Rosenthal, Diana Margot; (2024) Barriers and facilitators to optimising health outcomes and accessing health care services among under 5s experiencing homelessness in temporary accommodation (U5TA) in England: a case study of a local authority in East London. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

Background: Child homelessness is a growing global public health crisis. These children have a higher life-long risk of developing chronic conditions, repeated cycles of homelessness and adverse childhood experiences. Under 5s experiencing homelessness in temporary accommodation (U5TA) are especially vulnerable because the first five years of life are crucial for optimising growth, health, and ~90% of brain development. However, few studies have focused exclusively on this marginalised group, lacking comprehensive evidence across the various types of temporary accommodation (TA) they can experience. // Aims: To better understand barriers and facilitators to accessing health care services and optimising health outcomes among U5TA in England and the additive impact experience of the COVID-19 pandemic. Methods: London Borough of Newham (LBN) was the population under consideration because LBN has the highest number of children living in TA (1 in 11) and poverty (1 in 2) in England. I conducted five research phases: a 1) scoping review; 2) community-based study utilising citizen science with mothers of U5TA (the experts by experience); 3) cross-sectional survey of families experiencing homelessness during the pandemic; 4) qualitative study with relevant cross-sector professionals; 5) triangulation of findings to co-develop multi-level recommendations.// Results: Triangulated data identified multiple concurrent housing hazards, which made these unsuitable environments for U5TA and their families, e.g., overcrowding, dampness/mould, poor/inadequate kitchen/toilet facilities, infestations/vermin, structural problems/disrepair, and frigid temperatures. Living in TA was an independent predictor of poor parental mental health: the odds of more severe depressive (OR: 3.14, 95%CI:1.61–6.13) and anxiety (OR: 2.46, 95%CI:1.27–4.75) symptoms were higher for parents/carers living in TA than those residing in non-TA. Additional factors associated with living in TA and poorer mental health included duration of tenure in TA, immigration status, financial and food insecurity, and inadequate housing. Cross-sector professionals described adverse pandemic effects on U5TA—developmental delays and regression. Triangulated data also highlighted that U5TA experienced various difficulties accessing health care services due to affordability, availability, accessibility, accommodation, and acceptability, i.e., the 5A’s of access. Furthermore, the pandemic exacerbated pre-existing systemic barriers by the reduction of in-person services, digital poverty, language discordance, and inability to register and track U5TA, rendering some invisible to services and heightening poor care continuity. // Conclusion: These novel mixed-methods findings demonstrated interrelated, multi-level barriers for this population outweighed the few existing facilitators before and during the pandemic. Results demonstrated that housing is a fundamental component of health care—both are inextricably linked—safe and suitable housing are prerequisites for “optimal health and wellbeing.” Thus, as a first-line response, priority actions should include reducing the time families reside in TA and implementing a child-centred TA Standards Framework. Poor parental mental health and poor child health outcomes were frequently prevalent among U5TA and their families. This necessitates co-located mental health and housing support within settings already accessed by U5TA and trauma-informed care training for all staff working with families in TA. Lastly, service barriers should be addressed through co-produced tailored solutions and policies targeting emergency preparedness and the 5A’s of access including digital exclusion.

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