Chapter 6: Strengthen the role and impact of ill health prevention

Women who may be described as presenting with multiple and complex need often will have experiences that may include homelessness, drug and alcohol misuse, mental and physical health problems, cycles of violence and abuse, and chronic poverty. Often when we talk about women in the terms of their 'need', it suggests that the issues stem from the individual rather than from deficits in the system, or because of trauma or adverse childhood experiences. 

The Lankelly Chase Foundation has adopted the term 'severe and multiple disadvantage', Lankelly Chase Foundation. (2016). The Lives behind the numbers, to describe the clustering of serious social harms such as homelessness, contact with the criminal justice system, substance misuse and mental ill health. The term describes a type of disadvantage that most others do not experience, and which recognises the social nature of disadvantage.
(Duncan M and Corner J. (2012). Severe and Multiple Disadvantage. A Review of Key Texts. Lankelly Chase Foundation)

Acknowledging that people experience multiple social harms is important, as it highlights the intensity of the experience and that the solutions are very different to if there was only one presenting issue.

For some women, experiencing multiple disadvantage means they do not fit neatly into existing services. 

This has led to women who are most in need of support having to struggle to navigate a complex system and either obtain help late or not at all, often falling between the gaps of what is on offer. For example, women are under-represented in official homelessness counts which utilise the concept of 'literal homelessness', which includes sleeping rough, using hostels or other emergency accommodation.
(Fitzpatrick, S., Bramley, G., & Johnsen, S. (2013). Pathways into multiple exclusion homelessness in seven UK cities. Urban Studies, 50(1), 148-168.)

Research has also found that women tend to make less use of homelessness services, postponing entering the system until sources of informal support have run out.
(Mayock P & Bretherton J. (2016). Women's homelessness in Europe (pp. 127-154). London, England: Palgrave Macmillan)

In 2017, a comprehensive health needs assessment focusing on homelessness and multiple complex need was completed by Gateshead Council. The study identified that although most of those experiencing homelessness are male, the number of women exposed to homelessness is growing, especially within some of the types of homelessness.
(Harland J. (2017). Gateshead Homelessness and Multiple and Complex Needs Health Needs Assessment. Gateshead: Gateshead Council.)

Distinct patterns occur within women's reason and reaction to homelessness compared to that of men. For women the most common are physical or mental health problems and escaping a violent relationship.
(Mackie P (2014) Nations Apart: Experiences of Single Homeless People Across Britain.) 

Interviews with homeless women conducted by Crisis showed that over 20% became homeless to escape violence from someone they knew, Public Health England. (2018). Evidence review: Adults with complex needs (with a particular focus on street begging and street sleeping), and McGrath's participants described coercive and controlling relationships that often included severe violence.
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review))

Health outcomes for women experiencing homelessness are significantly worse, with life expectancy being lower than that of men. 

Women are more likely to be 'hidden homelessness' and engage in coping strategies such as sofa surfing or returning to a relationship to avoid rough sleeping.139 One of McGrath's participants, "Tracey", described the inherent danger associated with sofa surfing: 'Once you owe something, they can take anything'.
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

The Communities and Local Government (CLG) Homelessness Inquiry received evidence that 28% of homeless women have formed an unwanted sexual partnership to get a roof over their heads, and 20% have engaged in prostitution to raise money for accommodation. The evidence identified high levels of vulnerability within the female homeless population, mental ill health, drug and alcohol dependencies, childhoods spent in care, experiences of sexual abuse and other traumatic life experiences are all commonplace. The inquiry also identified that services do not always cater for the specific needs of vulnerable females, so women may be less likely to engage with services.
(Department for Communities and Local Government (2016) Communities and Local Government Committee: Homelessness. Third Report of Session 2016-17.)

McGrath's research highlights how the multiplicity of issues that women face, which compound each other into complex situations, are often faced by services that can only tackle one issue at a time. Key to women's wellbeing is their ability to rely on social networks, which is typically severely impaired.
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

The STAGE project brings together charities (Changing Lives, The Angelou Centre, Ashiana, GROW, A Way Out, Together Women, Basis and Women Centre) to provide trauma informed support across North East and Yorkshire for women who have been groomed for sexual exploitation.
(STAGE (2022) Experiences of accessing healthcare amongst women who have experienced sexual exploitation.)

The STAGE briefing brings together the learning from this work with the aim of influencing systemic change. It highlights that the findings from the experiences of women involved in the study are not isolated occurrences but indicative of wider systemic issues across the health sector that fail to address the needs of women who have experienced significant trauma, discrimination and exploitation. Our systems need to be able to respond to meet the needs of girls and women with severe and multiple disadvantage. 

Evidence from STAGE (2022) shows that women who have experienced sexual exploitation are more likely to experience poor health outcomes and often struggle to access healthcare services because of a lack of recognition or understanding of their needs.
(STAGE (2022) Experiences of accessing healthcare amongst women who have experienced sexual exploitation.)

Similarly to the issues highlighted in McGrath's research, many of the women in the STAGE study reported negative experiences and having to overcome barriers when accessing GP and dental practices. Barriers include identification, cost, accessibility (for example if the women have had to move to escape violence), no recourse to public funds, no fixed abode, in addition to the practicalities of accessing an appointment by ringing the surgery at a precise time, without a phone, or with a pay as you go mobile. For women with complex issues, it may have taken a lot of courage to make that step to ask for help and the experience of making an appointment and navigating a triage assessment by the receptionist can feel like a negative experience. The healthcare issues of this group of women are not easily covered in a 10 minute appointment as it may have been a while since they were able to access services. As a result of these barriers, many women resort to attending A&E departments where often additional barriers may be faced. 

McGrath's participant "Beckie" stated: "Services are invisible. So hard to find". "Carrie" commented: "You have to keep telling your story over and over. Why can't they keep it all on file?".
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

High staff turnover was an issue, as women valued relationships built with individuals and were unwilling to retell their story or start again with someone who did not know them. To help address some of these barriers, staff at the Queen Elizabeth hospital in Gateshead are trained in identifying women who are experiencing severe and multiple disadvantage and require a trauma informed approach. This can be identified from the moment that someone books into the department. In addition, within A&E there is a 'Peer Navigator' post linked to the Alcohol Care Team, who can provide more specialised trauma informed support and ensure safeguarding pathways are followed, with referrals to community services where needed.

Awareness and understanding of complex issues, such as sexual exploitation, has been identified as making a big difference in the way women are treated, managed and supported. 

For this group of women, their presenting physical health problems are often viewed by health professionals as due to their 'life choices'. Where women have been subjected to exploitation, gynaecological issues are very common, but barriers to access services may be felt from fear of judgement, repercussion or re-traumatisation. Healthcare provision provides an opportunity to ask explorative questions to identify vulnerability, rather than seeing contraception, although it is important, as the only solution. 

57.1% of the women supported by STAGE had a dual diagnoses of substance misuse and mental ill health. Women who experience addiction often struggle to access the mental health support they need, yet the underlying cause of both the poor mental health and addiction is often unresolved trauma. Therefore, it is vital that women can access trauma responsive support. Many women experiencing complex and multiple disadvantage may require mental health services. However, the STAGE report identifies concerns that women may in fact be experiencing post-traumatic stress disorder (PTSD) rather than personality disorder and are therefore possibly being mis-diagnosed. Being labelled as having emotionally unstable personality disorder is felt by women to be a dismissive diagnosis, which they feel unable to challenge.
(STAGE (2022) Experiences of accessing healthcare amongst women who have experienced sexual exploitation.)

In Gateshead, the need for trauma-based interventions is widely recognised, and we are fortunate that Recovery Connections, (one of the organisations that make up the substance misuse service, Gateshead Recovery Partnership) have accessed funding to embed specialist trauma counsellors within the substance misuse treatment system. McGrath's participant "Carrie" reiterated the importance of this: "We need the help with what we're going through now to be able to deal with what's happened in the past. You can't deal with the past if you don't deal with the present".
(McGrath, J., Crossley, S.J., Lhussier, M., & Forster, N. (2023) Social capital and women's narratives of homelessness and multiple exclusion in northern England International Journal of Health Equity (under review).)

The national 10-year drug strategy, 'From harm to hope: A 10-year drugs plan to cut crime and save lives',142 and subsequent increased investment in substance misuse treatment systems provides the opportunity to consider how the needs of women with severe and multiple disadvantages can be better met and barriers to service access can be overcome. This may be through women's specific sessions or venues, an assertive outreach approach or innovative delivery of healthcare services focussing on women's health.