Homeless population in India

Homeless households are a serious public housing concern in India, mainly persistent in urban India. Several challenges, including livelihood and health challenges, are common among homeless individuals. The present slide describes challenges related to accessing outpatient care among homeless women in India.

1. Assessing the barriers of public outpatient service utilization among Homeless women: An exploratory study in Kolkata Margubur Rahaman Research Fellow, International Institute for Population Sciences (IIPS), Mumbai

2. Background Almost 1.8 million individuals are homeless in India, mostly concentrated in urban areas with poor living status ( Census of India, 2011). The wave of dual burden of vulnerabilities —livelihood and health are found to be high among them ( Ritchey et al. 1991) . Sex-selective violence and morbidities high among the females, which upsurges their demand for outpatient care, and suitabilit y public healthcare services (PHS) high due to socio-economic vulnerability ( Das et al. 2018 ). During access of PHS, they faces several barriers, which are significantly varies with population, space, and time.

3. Source: Authors' calculation using Census of India, 2011

4. Source : Roy & Siddique , 2018

5. Spatial display of the study area

6. Profile of homeless population, Kolkata district Indicators Total Female Average family size 6 persons - Females 21.7% - Under-6 population 3.7% 3.1% SCs/STs population 2.4% 6.2% Literacy rate 25.3% 17.8% Workforce participation rate 64.4% 62.2% Main workers 75.4% 61.4% Source: Authors calculation using Census of India, 2011

7. Research gap & need for study Most of the previous studies explored socio-economic background, livelihood and health vulnerabilities, and health seeking behaviours of the homeless individuals. However, little studies has focused on to contextualized the health care choice and perceived obstacles. Therefore, the present study aims to explore the the barriers of public outpatient service utilization among homeless women. The present study will be supported to frame the population-centric health care systems.

8. Research questions and hypothesis What are the homeless women's perspectives on facilitators and barriers to receiving outpatient health care? We hypothesized that the choice and barriers of using outpatient care service varies with individuals.

9. Data & Methods The present study used primary data, which was collected during May-June, 2022 in Kolkata municipal corporation (KMC). The present study used time and location sampling to select the sample. We have conducted 18 in-depth interviews (IDIs) to draw the information from the women with at-least one chronic diseases . We terminated interviewing when we reached saturation, that is, when we stop getting new information (Taylor & Bogdan , 1998). Further, five key interviews (KIIs) including chief of the homeless cluster (1), doctor (1), pharmacist (1), and NGO workers (2) also conducted to understand the key challenges to access the healthcare facilities among the homeless women. Open-ended questionnaires used to conduct systematic interview, which covered healthcare. Using the grounded theory method (Glaser & Strauss, 1967), content analysis applied to framing the research outcomes.

10. Results & findings % Mean (SD) Age 35.6 (10.6) Marital status (currently married) 72.2% Duration of homelessness 1.3 years Religion (Hindu) 77.7% Social group (Don’t know) 50% Work participation (in 1 month prior to the survey) 83.3% Number of chronic diseases 1-2 88.8% 2+ 55.5% Descriptive statistics of the IDIs, homeless women, KMC, May-June, 2022

11. Percentage distribution of outpatient care utilization by types of health care service, Homeless women, KMC Note- public facility includes health post/sub centers , primary health center , community health center , district hospital/ sub-district hospital and Govt. AYUSH hospital; private facility includes private hospital/nursing home, private clinic (OPD based service), NGO/charity/trust/church-run hospital, and private AYUSH hospital; and other facility includes pharmacy/drugstore, home visit, mobile healthcare unit and others Source- Authors calculation, Primary survey in KMC during May-June, 2022

12. Theme 1: Availability of services and competing Needs Most of the knew of availability of outpatient care services where they could get medical care and most said lack of services was not the main barrier to care, unless serious health complications few of them sought treatment. They have preferred generally nearby pharmacy for outpatient care. As Roshni (name changed) said- “ It’s not hard to get medical care once a women decides to get up and go, when we feel very serious maternity complication then we try to visit public health services ”.

13. Theme 2: Availability of public service but accessibility is matter While availability may not have been a issue, access to public outpatient care is expressed as time overriding process. As a daily wage worker, they are not willing to receive outpatient care from public services through a channel like enrolment, waiting, and routine visits. Other commonly reported obstacles to care were limited clinic hours and backlog. Ruma said- “ We are homeless women generally engages with 3D work, and we have not time to getting care from public facilities because of time constraints and demeaning livelihood”.

14. Theme 3: Acceptability of services Women talked openly about how being both poor and homeless situation affect the treatment receive, some said the experience was sufficiently disrespectful to actually deter them from seeking care. As Komla explained- “I won’t like to face disrespectful treatment from time-bound public health process, therefore I generally like home remedy or preferred nearby local quack practitioners. “

15. Theme 3: socio-economic backwardness Majority of them recognizes fever as the major feature of malaria but their knowledge of what causes it, symptoms and sign was poor. All perceived malaria as simple disease that mothers should be comfortable to apply home based remedy. Religious beliefs did not prevent mothers from seeking hospital care. but some are aware of mothers that rely on Holy water and prayer to treat malaria. The study observed poor knowledge of mothers of malaria; cultural beliefs in home remedy and poverty are issues that affect malaria outcome. 

16. C onclusion According to the findings, the majority of women received their outpatient care in unsafe facilities. Institutional level barriers are found to be more important than individual level barriers in the poor utilisation of safe health care services. Furthermore , access to outpatient care was significantly impacted by the respondent's dwelling, socio-economic background and living status. Based on the findings of the current study, a multi- sectoral approach is helpful to cover the homeless population under the safe outpatient services.

17. Limitations A key limitation is that  the interviewee can give limited or even misleading answers . Also, the data obtained cannot be generalized to the population . These limitations can be dissipated by combining in-depth interviewing with other methods.

18. References Kar , S. K. (2021). Indian perspectives on homelessness and mental health.  Homelessness and Mental Health , 99. Roy, A., & Siddique , G. (2018). Homeless people in West Bengal: a district-level study.  Space and Culture, India ,  6 (3), 110-133 . Kolb, S. M. (2012). Grounded theory and the constant comparative method: Valid research strategies for educators.  Journal of emerging trends in educational research and policy studies ,  3 (1), 83-86 . Strauss, A., & Corbin, J. M. (1997).  Grounded theory in practice . Sage . Bhattacharya, P., & Priya , K. R. (2022). Stakeholders facilitating hope and empowerment amidst social suffering: A qualitative documentary analysis exploring lives of homeless women with mental illness.  International Journal of Social Psychiatry ,  68 (4), 908-918 . Das, M., Angeli , F., Krumeich , A. J., & van Schayck , O. C. (2018). The gendered experience with respect to health-seeking behaviour in an urban slum of Kolkata, India.  International journal for equity in health ,  17 (1), 1-14 . Ritchey, F. J., La Gory, M., & Mullis, J. (1991). Gender differences in health risks and physical symptoms among the homeless.  Journal of Health and Social Behavior , 33-48.