Abstract
Improving the sexual health of homeless young people in hostels Background Eighty-six thousand young people are estimated to have approached Local authorities in the United Kingdom because of homelessness or risk of homelessness in the 2016/17 period. Young people under 25 years are known to have higher rates of Sexually Transmitted Infections than any other groups and although the rates of teenage and unintended pregnancy in under 20-year olds have reduced in recent years, there is still room for improvement, especially in deprived areas. Little is known about the sexual health needs of homeless young people. The aim of this study was to improve homeless young people’s sexual health because of the high risk within this vulnerable community of Sexually Transmitted Infections and unintended pregnancy. This thesis explores the knowledge and attitudes towards sexual health and contraception use of homeless young people accommodated in hostels in London. A review of policy, homelessness, young people, sexual health and underpinning research in middle or high-income countries was undertaken. Despite limited evidence overall, current and past trauma and abuse were noted to be of significance, and revealed the need for further research. Research design: A constructivist theoretical framework was used to underpin an ethnographic case study following Burawoy’s extended case method. To reveal new knowledge about young people’s attitudes about sexual health, semi-structured interviews with a purposeful sample of 29 homeless young people and five key workers were conducted, audio recorded and transcribed verbatim. Insider observations of the participants in their natural settings and during hostel residents’ meetings over a five-month period were also carried out and documented. This amounted to a total of 48 hours of observation undertaken in the research setting (ranging from 1.5 – 5 hours per session). Data analysis was thematic, guided by Braun and Clarke’s thematic framework and QSR International’s Nvivo 10 Software. Findings: Analysis of data from the young people and their key workers, observations and documentation highlighted three significant themes. These were overarching, and not expected; they related to attending to the basic physical, emotional and mental needs of this population before sexual health can be effectively addressed. The themes were: risks and extreme vulnerability to danger, exploitation, shame, and mental illness; relationship and communication difficulties; and a consequent emergence of a culture of homelessness. Analysis of demographic data added significant detail to the findings which included gender differences, sexual health and service awareness, and ethnicity. These themes represent new knowledge and understanding regarding the complex needs of homeless young people. The study provides new insight into the lives of these young people who, due to their extreme vulnerability and the harshness of their circumstances, have to prioritise basic requirements before attending to the higher cognitive aspects of living. Consequently, an emergent model and cycle of care arose from the data, both are proposed for practice so as to enhance the outcomes for homeless young people. Implications for practice: Homeless young people require specialist delivery of sexual health care, in safe surroundings. This should focus initially on an assessment of their ‘current state of being’, through to establishment of trusting relationships between staff and young people and ongoing vulnerability awareness. A multidisciplinary approach is required with mutual shared learning across the disciplines, and support for key workers in addressing sexual health amongst the population. Only then can a reliable sexual health risk assessment be undertaken which will address the individual support requirements to achieve screening and contraceptive care for this group.