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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)