Responding to Homelessness, Multiple Exclusion and Stigma: Developing a Complex Public Health Intervention Approach

Background Stigma refers to people being 'marked' in society's eyes as lesser, unworthy or disgraced, and then consequently experiencing discrimination. This stigma that often focuses on people who are homeless, and how that intersects with drug use, mental health and other identities and experiences, is widely understood as a cause of ill-health through being a persistent barrier to accessing support and services and through creating conditions and experiences that deny or limit the determinants of health.

Stigma scholarship increasingly emphasises the role of care systems and social context in producing stigma. Numerous studies have drawn attention to how stigma is experienced within health care settings. There is in turn a wide literature exploring how systems of criminalisation of drugs or regimes of welfare benefits can be understood to generate stigma. In consequence, stigma can be understood as a phenomena experienced across different settings and that emerges from long-running structural processes.

Rationale for the study Whilst there is increasing understanding of the social aspects of stigma and their complexity, theory that delineates specific pathways by which particular experiences relate to social factors is still limited. Indeed, social theory on stigma can be characterised as having a 'gap': understanding of micro-scale interactions is rich, and there is increasing analysis of macro-scale influences, but little understanding of how these levels interact. In the absence of such theory there is little to guide empirical research and then public health interventions that could address these dimensions of stigma.

Corresponding to the social theory gap, interventions to address stigma at a social level are limited. Current evidence indicates short-term impact from individual and inter-personal level interventions to prevent stigma in health care settings, but little progress in developing interventions seeking coordinated change at multiple levels. Stigma scholars and policymakers agree that we need new theory, interventions and evaluation methods to respond to the systemic nature of stigma.

Overlapping with the specific debate on stigma, public health is increasingly seeking to develop 'complex systems interventions', which could provide a route to thinking of how to respond to the social roots of stigma. A complex system intervention approach could seek change across multiple overlapping systems to enable, in combination, access to care, social support and housing, and consequently significant impact on health and welfare.