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Occupational Therapy Intervention for the Hygiene Needs of People who are Homeless—Wynne Scherf—December, 2004
Introduction (Purpose of the Review): Hygiene is one of many basic activities of daily living (ADL) that pose a challenge for people who
are homeless. As health professionals focusing on function, occupational therapists (OTs) are in a position to aid people who are homeless in
this sphere. However, in order to provide assistance, OTs must understand the specific needs and factors leading to difficulties. Therefore, the
purpose of this review was to examine the hygiene needs of people who are homeless, to determine the reasons for those needs, and to establish
the role of OT in addressing the issue of hygiene.
Evidence-Based Practice Question: What have occupational therapists done and/or what can they do to help people who are homeless with
issues of hygiene?
Criteria for Evidence Selection: Because of the paucity of literature in this arena, articles had only to meet the following two lenient criteria:
1) Addressed the hygiene needs of people who are homeless, even if only briefly, and 2) Printed in English. Articles about women and
published within the last five years were preferred, but studies were not excluded if they did not meet these standards.
Table Summarizing the Evidence:
Study
Design/
Level of
Reference
Data
Evidence
Collection
Baldwin,
D. M.
(1998)
Ensign, J.
(2000)
Power, R.,
& Hunter,
G. (2001)
Ethnographic
Participatory
Action
Research via
Interviews
(SemiStructured) &
Focus Groups
CrossSectional
Survey, &
Participatory
Action
Research via
Interviews &
Focus Groups
III
III
III
Sample & Size
Outcome/Intervention
Summary of Results
13 ♀ who were
homeless (@
some point
during the
study) &
mentally ill.
Stratified by
gender, age,
ethnicity, level
of function &
disability,
trackability,
service
utilization, &
coherence/
ability to
communicate.
In downtown LA between
1987 & 1990, participants
observed on daily routines;
frequency of observation
ranged from 1-2x per wk. to
1x/mo. Depending on
participant. Extensive field
notes taken on activities & on
things participants said. Indepth, audio-taped life history
interviews of ♀ who
consented.
Hypothesis that poor hygiene among
homeless ♀ is a purposeful deterrent to ♂
attackers (Baxter & Hopper, 1981, as cited
in Baldwin, 1998) appears to be false. ♀
on streets had very poor hygiene due to ↓
accessibility to bathrooms & showers & to
breakdown of physical & psychological
resources. The few available toilets
lacked privacy & were unreliable (e.g., no
toilet paper, plugged up). ♀ in shelters
usually had better hygiene than those on
street. ♀ ĉ own home tended to have best
hygiene. Hygiene for all fluctuated ĉ
physical & mental health.
20 adolescent
♀ who were
homeless
100 Big Issue
news-paper
vendors (all
home-less),
some paper
staff members
Semi-structured interview
covered ♀ self-care practice
& health-seeking behaviors.
3 focus groups (each ĉ same 6
participants) focused on
emergent themes from
interviews: 1) young ♀’s
health problems, reproductive
self-care, & health-seeking
behavior; 2) survival sex,
self-induced abortions, birth
control, & health care
barriers; and 3) meaning of
sexual relations, forced sex
experiences, & lessons from
being homeless.
Themes for questionnaire,
interviews, & focus groups
selected by expert panel on
homelessness & health. 100
vendors completed survey to
determine health promotion
concerns, 14 interviewed re:
social contacts. 5 focus
groups & 18 interviews (ĉ
vendors & staff) to illustrate
survey data.
Some related cleanliness ĉ self-esteem.
Took showers as often as possible, but
access to showers & soap/shampoo was
problematic. Some carried feminine
towelettes to wash genitals when shower
unavailable. Inability to keep clean led to
more frequent vaginal & urinary tract
infections. Hygiene especially difficult @
menstruation. Access to sanitary
pads/tampons & to bathrooms was
limited. Some stole pads/tampons. Many
ran out of underwear @ menstruation.
5/20 douched regularly if possible, while
all others recognized danger of douche.
15% of vendors identified maintenance of
personal hygiene (to avoid skin conditions
& parasites) as a key health concern of the
homeless (4th most commonly cited
concern). Yet, immediate, daily concerns
(i.e., money, family, & housing) were
prioritized over health. Common belief
that health info was available but
inaccessible. Interviews re: social
contacts indicated vendors might be in
valuable position for peer education.
TacomaPierce
County
Health
Departmen
t (2004a,
2004b,
n.d.)
Informational
Handout
(2004a &
n.d.), Meeting
Proceedings
(2004b)
IV
N/A
N/A
Methicillin-resistant Staphylococcus
aureus (MRSA) is a type of S. aureas
resistant to penicillins & cephalosporin
antibiotics. While previously acquired
almost solely in health care settings,
recently people ĉ no risk factors have
acquired it in community settings
(community-acquired, or CA-MRSA).
Leads to infected cuts & hair follicles,
boils, fluid-filled blisters (impetigo), or
skin sores looking like infected insect
bites. People in congregate living settings
(e.g., people in homeless shelters) are @ ↑
risk. Spreads through contact ĉ skin &
body fluid (especially wound seepage) of
persons who are infected. Best prevention
methods: wash hands regularly,
clean/disinfect commonly-touched
surfaces, don’t share personal hygiene
items, change sheets regularly, keep
wounds covered ĉ clean bandages, & wear
clean clothes after showering. These are
all difficult for people who are homeless.
Summary of the Evidence: Most of the research is qualitative, involving the perspectives of people who are homeless. According to this
literature, hygiene is poor among people who are homeless, largely because of inaccessibility to hygiene facilities and products. Women who
are homeless face specific hygienic challenges surrounding menstruation. Some research suggests that more basic needs (e.g., food, shelter,
family, and money) are prioritized over hygiene and health. There is a body of literature (not included in this table) identifying the health risks
associated with poor hygiene among people who are homeless, but most of it is ten or more years old. There appears to be no literature
available on the role of the OT (or any other service provider) in addressing the hygiene needs of people who are homeless.
Implications for Consumers: People who are homeless are at risk for health problems (e.g., skin conditions, parasites) as a result of poor
hygiene. Women are especially vulnerable, with increased risk for vaginal and urinary tract infections. Poor hygiene also can negatively affect
persons’ ability to maintain personal relationships, acquire services, & attain employment.
Implications for Practitioners: Hygiene is a largely neglected ADL within the homeless population; furthermore, the research base indicates
that OT practitioners have not addressed this issue. Therefore, OTs working with people who are homeless should develop intervention plans
that include a focus on hygiene. OTs who already provide or have provided interventions related to hygiene should publish literature about the
elements and efficacy of their therapy.
Implications for Researchers: There is a shortage of any kind of research relating to the hygiene needs of people who are homeless, so any
types of studies would be informative. Updated studies on the current health risks as a result of poor hygiene would be valuable. Once
interventions addressing the hygiene needs of people who are homeless have been implemented, researchers should perform efficacy studies
regarding these interventions (preferably randomized, controlled trials).
Recommendations for Best Practice: Perhaps the most pressing issue related to hygiene that practitioners should address is the accessibility
to restroom facilities, hygiene products, and health information. To this end, therapists’ duties are twofold: 1) be sure that clients have
knowledge about current availability of these items, and 2) work to increase the accessibility of these items to clients. Therapists should
educate clients about the health risks and other negative consequences associated with poor hygiene. Therapists might also be able to train
leaders in the homeless community to serve as peer educators and role models.
References:
 Baldwin, D. M. (1998). The subsistence adaptation of homeless mentally ill women. Human Organization, 57(2), 190-198.
 Ensign, J. (2000). Reproductive health of homeless adolescent women in Seattle, Washington, USA. Women and Health, 31(2/3), 133-151.
 Power, R., & Hunter, G. (2001). Developing a strategy for community-based health promotion targeting homeless populations. Health
Education Research, 16(5), 593-602.
 Tacoma-Pierce County Health Department. (2004a, September). Community-Acquired Methicillin-Resistant Staphylococcus aureus (CAMRSA), Skin and Soft Tissue Infections (SSTI’s). (Available from the Tacoma-Pierce County Health Department, 3629 South D Street,
Tacoma, WA 98418-6813)
 Tacoma-Pierce County Health Department. (2004b, December). Community-Acquired Methicillin Resistant Staphylococcus aureus [CAMRSA]. Proceedings of the Comprehensive Mental Health outreach staff meeting, Tacoma, WA, USA.
 Tacoma-Pierce County Health Department. (n.d.). Living with MRSA (Methicillin-Resistant Staphylococcus aureus). (Available from the
Tacoma-Pierce County Health Department, 3629 South D Street, Tacoma, WA 98418-6813)