Social justice considerations for occupational therapy: The role of addressing social determinants of health in unstably housed populations

Abstract

BACKGROUND:

Populations of those experiencing homelessness in the United States expand beyond those living in shelters and on the streets. Many individuals living in poverty experience housing instability, as well as refugee populations who experience deprivation of social resources due to displacement. These populations are significantly affected by social determinants of health (SDOH).

OBJECTIVE:

A current policy and literature review was completed to assess prominent SDOH impacting unstably housed populations in the United States, including refugees, encountered in occupational therapy practice. Review of evidence-based practice to address SDOH was completed to provide recommendations for practitioners across healthcare settings.

RESULTS:

A review of policy and its impact on those experiencing housing instability or recently resettled identifies several significant barriers to full occupational performance and health management. Several specific occupational therapy interventions exist to address these barriers and are in alignment with current practice.

CONCLUSION:

Occupational therapy practitioners across practice settings should consider how current housing status and social determinants of health may impact their clients’ occupational performance and ability to manage health conditions.

Keywords

Homelessness poverty refugee

1 Introduction

In the United States, an individual is most commonly identified as homeless if “they lack adequate, fixed, night-time residence” [1]. However, the National Health Care for the Homeless council characterizes homeless as “extreme poverty coupled with a lack of stable housing,” increasing the scope of who may be considered as experiencing homelessness. Occupational therapy has traditionally addressed the needs of those experiencing homelessness by working directly in shelter settings [2, 3]. Limiting this focus to shelter settings may prevent needed services from being delivered to individuals experiencing housing instability. Populations who may experience unstable housing and are at a higher risk to be impacted by Social Determinants of Health (SDOH) include those living in extreme poverty and refugee populations. In order to best address the needs of those experiencing unstable housing and displacement, occupational therapy practitioners would benefit from adopting a social justice perspective. Those impacted by SDOH may be encountered by occupational therapy practitioners in all practice settings, and may not receive as much benefit from services provided if interventions are not adapted to address these needs. Understanding and applying evidence-based interventions within occupational therapy practice allows practitioners to address SDOH and factors impacted by housing status.

Social justice and social determinants of health are not new concepts within health care. As the result of increasingly challenging life experiences of clients, there is growing awareness among healthcare professionals of how contextual factors influence a person’s ability to care for themselves and live healthily and independently in the community. Since its inception, occupational therapy has considered the “whole person” when identifying strengths and barriers to occupational performance, including contextual factors, supports, and resources. Therefore, it is natural for the occupational therapy profession to use a social justice framework to develop effective and relevant interventions. Attention to social justice within daily occupational therapy practice can improve outcomes for those experiencing any type of homelessness, including those living in extreme poverty and refugee populations. By occupational therapy practitioners addressing social justice issues within a diverse range of practice settings, practitioners have the opportunity to potentially prevent and mitigate the effects of homelessness.

2 Social justice in occupational therapy practice

While many definitions of social justice exist, the term is commonly identified as “encompass[ing] several interrelated concepts, such as equality, empowerment, fairness in the relationship between people and the government, equal opportunity, and equal access to resources and goods” [4]. The United Nations states, “in short, justice derives from equality of rights for all peoples and the possibility for all human beings, without discrimination, to benefit from the economic and social progress disseminated and secured through international cooperation” [5]. Social justice has become a concept used frequently within international and national health and social services programs, politics, and community development as the world becomes more global, and economic disparities grow greater. For occupational therapy practice, social justice provides a broad view of the interrelationship of equity, contexts, and access to opportunity and tangible resources.

The American Occupational Therapy Association [AOTA] Statement on Health Disparities states that practitioners “have the knowledge and skills in evaluating and intervening with individuals and groups who face physical, social, emotional, or cultural challenges to participation” [6]. Further, the AOTA Code of Ethics regarding the principle of justice states “as occupational therapy personnel, we work to uphold a society in which all individuals have an equitable opportunity to achieve occupational engagement as an essential component of their life” [7]. Within occupational therapy practice, Wilcock and Townsend define the term occupational justice as the “denial of opportunities to engage in purposeful activities necessary for health and well-being” [8, 9].

It is likely that within day-to-day practice, practitioners are innately addressing occupational justice issues by increasing opportunities for occupational engagement. However, practitioners may not routinely and explicitly address or identify social justice issues that may result in impediment to occupation, or to even engaging in occupational therapy services [10]. Wilcock and Townsend identify the difference between occupational and social justice, stating “social justice addresses the social relations and social conditions of life, occupational justice addresses what people do in their relationships and conditions for living” [11]. Practitioners may believe that social conditions are more appropriately addressed by other health and service providers. However, disparities and inequities are embedded in the contexts in which our clients live and can significantly impact quality of life [8 , 11]. Although there are practitioners that work in settings specifically designed to address these barriers, social justice barriers and SDOH may impede a person from participating in occupational therapy services in more traditional health care settings. In traditional health care settings, individual and systemic interventions are required to mitigate these barriers, and occupational therapy practitioners can make significant contributions.

3 Housing stability and poverty

3.1 Housing instability and homelessness

Healthy People 2020 identifies there is no standard definition of housing instability, however frequently includes: having trouble paying rent, overcrowding, moving frequently, staying with relatives, or spending the bulk of household income on housing [13, 14]. The National Health Care for the Homeless council also includes if a person’s housing arrangement is for economic reasons and is unstable (e.g. a disagreement or other scenario could result in being asked to leave) [15]. It is difficult to identify the number of people experiencing housing instability in the U.S., however, 83 percent of those experiencing poverty are identified as severely cost burdened by housing, indicating risk for becoming homeless [13, 14].

The World Bank defines poverty to be “pronounced deprivation in well-being and comprises many dimensions. It includes low incomes and the inability to acquire the basic goods and services necessary for survival with dignity. Poverty also encompasses low levels of health and education, poor access to clean water and sanitation, inadequate physical security, lack of voice, and insufficient capacity and opportunity to better one’s life” [16]. The American Psychological Association identifies that “socioeconomic status (SES) encompasses not just income but also educational attainment, financial security, and subjective perceptions of social status and social class” [17]. Those living in poverty face social justice issues such as access to adequate or equal material resources and education, and social participation. Poverty is a global issue, with half of the world’s poorest households living within 5 countries [18].

In the U.S., poverty is defined as “making less than $12,400 per year,” and does not include additional benefits such as supplemental nutrition assistance program (SNAP) benefits [19]. Twenty-five percent of individuals with a disability live below the poverty threshold, compared with 10 percent of the general population [19]. Falling within this category are individuals receiving Social Security Income (SSI) due to disability; receiving on average $550 per month [20]. Individuals whose sole income is SSI have a median annual income of $6,600 per year, which is well below the US poverty threshold.

There is no community in the United States in which a person working full-time at minimum wage or relying solely on disability benefits can afford at two-bedroom apartment listed for fair-market rent [21]. In the US, one-quarter of renter households are considered extremely low income and cannot afford their rent [21]. Affordable housing is considered to be housing priced at no more than one-third of an individual’s income; for those relying on SSI benefits affordable rent is significantly lower than the average rent for a one-bedroom apartment in most major cities [21]. The availability of subsidized housing for low-income renters is limited. Lists in most major cities are closed or have waits up to 10 years, severely limiting access to affordable housing for most individuals and families in poverty [21]. Lack of access to affordable housing can cause individuals and families to forgo other necessities in order to pay for rent and may eventually result in the individual or family becoming homeless. The strictness of the HUD definition of homelessness limits eligibility of those experiencing housing instability for housing programs, thus requiring individuals to experience street or shelter homelessness before becoming eligible [1].

3.2 Refugee resettlement

Refugees comprise another sub-population of those experiencing housing and social instability in the U.S. Every day, over 28,000 individuals across the globe are forced to flee their native country because of persecution, war, violence, or natural disaster [22, 23]. These individuals, better known as refugees, face an array of challenges as they seek a safer livelihood and integrate into a new community. Refugees have often experienced social injustices in their home country prior to coming to the United States (US). Although distinct from natural United States (US) citizens experiencing homelessness or housing instability, refugees may present with similar occupational engagement challenges due to their transition into a new community and the necessity to learn new social customs and roles in their country of resettlement. Like individuals living in poverty, without appropriate supports, refugees may be at a greater risk for exacerbation of health conditions.

The United States has accepted over 3 million refugees since 1975, and, unlike most developed countries, prioritizes admission of refugees with significant health conditions [24, 25]. To reach the United States, refugees undergo a vetting process for up to 36 months [24]. Following acceptance and arrival, refugees receive support from a resettlement agency for ninety days. Resources are provided by the agency to address housing, develop or improve English language skills, and navigate health care [24]. Once this period of support concludes, many refugees are left with a gap of resources as they continue to adjust. Refugees are at a significant risk for isolation, particularly in the initial stages of resettlement. Daily activities that are commonplace in American culture, such as riding buses or other public transportation systems, may be unfamiliar to refugees, preventing community mobility and exposure to necessary resources [26].

Although refugee status does not indicate economic status, 18 percent of non-citizens residing in the US also live below the poverty threshold [19]. Refugee populations are also more likely to be low-income than US-born populations, and refugees’ ability to earn equal to the US median household income has decreased [27]. Recent refugees are more likely to live in low-income status and receive public benefits [27]. Similarly, to native-born citizens experiencing housing instability, refugee populations present with a specific set of social justice challenges that occupational therapy practitioners are well-positioned to address.

4 Connecting social determinants of health, poverty, and housing instability

The Center for Disease Control (CDC) defines social determinants of health as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” [28]. The World Health Organization (WHO) and the CDC each categorize and emphasize various social determinants of health somewhat differently, however, each organization is in agreement that social determinants of health are the primary cause of health inequities across communities. Social determinants of health are especially relevant to occupational therapy, as they affect occupational performance and engagement.

Poverty and social determinants of health are both causal and correlational. It is this interplay, if unaddressed, that continues the cycle of poverty. Although a single health care provider may not be able to fully resolve the inequities experienced by their clients, consideration of these is important as they affect health care outcomes and a person’s overall quality of life. Important social determinants of health that fall within the domain of occupational therapy practice include: chronic health conditions, access to medical care, literacy and health literacy, employment status, food and nutrition, transportation, and social/community supports [29].

4.1 Chronic health conditions and access to basic medical care

Individuals living in poverty are not only more likely to have chronic health conditions but are more likely to have multiple chronic conditions [30, 31]. Individuals living in poverty overall report poorer physical and mental health than the general population and have higher rates of diabetes, heart disease, arthritis, and depression [30, 31]. Poverty is additionally associated with higher mortality rates, especially for those diagnosed with diseases such as cancer and HIV [30, 31]. There are multiple factors in the relationship between poverty and chronic health conditions. Having a lower income increases exposure to risk factors for health, but also those in poverty have decreased access to preventative and ongoing health services that might address and mitigate these risk factors [30, 31]. The existence of chronic conditions can limit a person’s ability to work, as individuals may have difficulty working full-time hours due to symptoms or the need to attend multiple medical appointments. Additionally, those with chronic conditions may be unable to sustain more physically demanding jobs, such as working in construction or maintenance, making it more difficult to find employment. Decreased access to health care may cause those with chronic conditions to experience a more significant health event, such as a heart attack or stroke, resulting in a significant disability that can prevent a return to work. Without additional resources or supports, these events can result in individuals and families moving into poverty. For refugees, unaddressed chronic health conditions may serve as an additional barrier for community integration, as it may further contribute to isolation during a time when access to resources is integral to assimilation [23]. In a study of geriatric refugees, common co-morbidities included hypertension, decreases in vision, arthritis, and low back pain, suggesting that longer-term care and follow-up visits were necessary for the well-being of this population [23].

People with a usual source of health care have better health outcomes, fewer disparities, and overall lower costs [32]. However, 18 of the 50 states in the US have not expanded Medicaid coverage under the Affordable Care Act (ACA), resulting 2.5 million adults who are considered poor falling into “coverage gaps” and unable to access or afford health insurance [33]. Additionally, those who work part-time or at minimum wage may not be eligible for work sponsored health care plans, and in states without ACA expansion, do not qualify for Medicaid benefits. Thus, those who are more at risk for chronic conditions are less able to access preventative and ongoing health care to minimize risks or manage conditions once diagnosed. Those experiencing housing instability are more likely to forgo routine check-ups and lack usual sources of care [34].

Individuals covered by Medicaid may experience additional barriers to accessing care despite having insurance. Medicaid beneficiaries are disproportionately affected by lack of reliable transportation, longer wait times in doctor’s offices, and difficulty getting to appointments as compared with those with private or work sponsored insurance [35 –37]. Those who are covered by Medicaid report barriers to accessing primary medical care such as: inability to take time off work, difficulty reaching their providers on the phone, feeling discriminated against, and forgetting their appointments [35 –37].

Although refugee populations have access to multiple streams of health coverage (Medicaid, Children’s Health Insurance Program, and options under the ACA), quality of health care treatment remains an ongoing challenge [38]. In an interview with eighteen refugees, barriers reported include: “lack of language supports, difficulties with accessing specialty care, unfamiliarity with referral procedures, limited information on where to find services, confusion about the roles of different health professionals, and overall difficulties with navigating the healthcare system” [25]. Refugees with disabilities were found to have additional disadvantages in addressing health and accessing needed services [38].

4.2 Literacy and health literacy

Once a person is able to access basic medical care, they may continue to experience difficulty in managing their health due to issues with literacy and health literacy. Those of lower socio-economic status and/or those with a poorer health status from chronic mental and physical conditions are more likely to have decreased reading and comprehension skills than the general population [39]. Illiteracy is defined as the ability to read/write or at lower than a 4th grade level; low literacy is the ability of adults to read, write and comprehend information at a 5th to 8th grade reading level [39]. Health literacy is specific to how well an individual can read, interpret, and comprehend health information [39]. As many as 50 percent of adults in the United States lack the basic reading and math skills to function effectively in the health care environment, and limited literacy is one of the strongest predictors of an individual’s health status [39]. Individuals with literacy problems are overall less knowledgeable about their health and have higher hospitalization rates, likely due to difficulty understanding and implementing health strategies and recommendations [39]. Although refugees are provided with initial resources for gaining English language skills, barriers persist while navigating medical appointments, accessing specialty healthcare providers, and receiving education from providers to manage health conditions [25]. In a study by Campbell et al., evidence suggested that language barriers led to poorer mental health outcomes and dependence on others [40].

Increasing access to health services can improve health outcomes. However, these outcomes may be limited if the health care is not delivered in a way that is understandable to the patients or in a way for the person to feel capable of implementing them.

4.3 Unemployment and under-employment

Unemployment and under-employment is another cause of poverty and housing instability. The established federal minimum wage is $7.25 an hour, resulting in an annual income slightly above the poverty threshold ($15,080) for a full-time worker, and this amount has not increased in the past 10 years [41]. Despite growth in the job market since the most recent recession almost 50 percent of US workers identify themselves as “under-employed,” meaning their current jobs did not require the level of skill or training they have received, resulting in lower wages than they felt they were capable of earning [42]. Twenty-two percent of part-time workers report this is “not by choice,” and are unable to find full-time work; 14 percent of part-time workers who work year-round fall under the poverty threshold [43, 44]. Compared with 65 percent of the general population, only 17.9% of individuals with disabilities were employed, and are more likely to be employed part time [43]. This puts individuals with disabilities and chronic health conditions at an economic disadvantage: those who rely solely on SSI live within the poverty level, and those who attempt to return to work are more likely to work part-time, which also falls within or near poverty levels. Refugees who have higher employment and educational histories are often able to achieve employment at the same rate as natural US citizens [27]. However, some subgroups and those with less education find employment at lower rates than the general US population, and women within these sub-groups are particularly affected which limits overall household income [27, 45]. Successful transition to employment relies on overall ability to integrate within a new community and health status of the refugees [27]. Those who are affected by other SDOH will have more difficulty transitioning into full-time employment.

4.4 Food and nutrition

In addition to needing food for survival, there is a clear link between a person’s diet and their overall health [46]. However, an estimated 12.3% of American households were considered food insecure in 2016, meaning they lacked access to enough food for an active, healthy life for all household members [47]. Those living at or below poverty levels or single parent homes were more likely to be food insecure [47]. Food insecurity may be a result of environment, finances, and/or health knowledge. Those who live in food deserts live in communities that lack access to affordable fruits, vegetables, whole grains, low-fat milk, and other foods that encompass a healthy diet [48]. Individuals may be additionally limited in their ability to access affordable and nutritious foods because they do not have easy transportation to markets or grocery stores; this is especially true in urban and low-income communities [49]. Low income individuals and families and those experiencing homelessness and housing instability commonly rely on meal programs and food pantries in which they are not able to choose the foods they eat [50].

Even if individuals and families are able to access foods, they may be limited in their ability to purchase supplies for meal preparation and healthy cooking [51]. They may also not have the knowledge of how to prepare certain healthy foods, and due to limited resources, cannot purchase foods they are unsure if they like or how to properly prepare [51]. Those experiencing housing instability may have additional difficulty with consistent access to kitchens in order to prepare meals. Limited literacy can impede a person’s ability to learn and try new recipes, and may limit experimentation with new, healthy foods. Similarly, small pilot studies have revealed challenges with food management and budgeting issues in the refugee community due to unfamiliar food choices and the lingering impact of pre-settlement food deprivation [52]. The ability to eat healthily includes having access to nutritious foods and the ability to prepare healthy meals; both are an important consideration when addressing social determinants of health.

4.5 Transportation

Transportation can be a significant barrier to health management. Unreliable or lacking transportation can limit the ability to access health services and nutritious and affordable foods. Low-income individuals are more likely to spend more per month on transportation than the general population, as they are unable to buy longer-term transportation passes at lower prices [53]. Individuals who are low income and refugees face similar challenges when relying on public transit to access health and social services [54, 55]. In all major US cities, those using public transportation have a longer commute than those who travel by car, and low-income individuals identify length of time to get to the doctor as a barrier to accessing health services [35 , 57]. Those living in rural areas also identify transportation as a major barrier to seeking health care, and two-thirds of people with disabilities who report transportation problems had annual incomes below $35,000 [58, 59]. Limited transportation not only leads to more frequent rescheduled or missed appointments, but often delays care and medication use [55]. Those who identify transportation and finances as barriers to health also have self-rated higher levels of stress and lower levels of health [60]. Lack of transportation highly affects those who most need to access health care, and those with the need to frequently see medical providers may be limited in their ability to follow-up and get routine prescriptions filled. Those who travel longer distances or have longer commutes to their providers may be unable to work as much as needed due to the time needed to manage their health or may have to make the choice between their health and employment.

4.6 Social and community supports

The existence and benefit of social and community supports are affected by socio-economic status. Supports can decrease stress and provide a pathway for economic mobility and stability. However, those living in poverty often do not receive these benefits from their support systems. Overall, adults living in poverty have smaller social networks and experience less social support and is especially true for those who live in rural areas [61]. If a person’s social supports are also living in poverty, they are less of a protective factor against stress and consequences of long-term hardship, and do not affect a person’s economic stability, [62, 63].

Although some refugees are connected with others through refugee resettlement organizations, this population is especially susceptible to the incidence of social isolation. Additionally, newly resettled refugees are faced with challenge of adapting to or learning best ways to socialize in new cultural settings [64]. Without the appropriate skills or connections to social networks, refugee populations are at risk for losing access to resources needed to thrive in their new communities.

Availability of support also impacts overall health status. Older adults who identified needing more support report poorer health more often than those who were satisfied with the supports available [65, 66]. Those with more functional limitations also report overall less social contact than their peers [65, 66]. Living alone with limited social support is associated with higher hospital re-admission rates and higher mortality rates following a stroke or heart attack, independent of the severity of the incident [67, 68]. Social supports have a significant influence on health status, which increases the older or more health vulnerable a person becomes. Those who have supports, but whose supports face similar economic barriers to do not receive the same benefits of these social networks than do those that are not living in poverty. Consideration of the availability and types of supports available to individuals are critical in addressing social justice and health needs.

5 The role of OT in addressing social determinants of health

Social justice issues, such as poverty and social determinants of health, can significantly impact a person’s quality of life. Occupational therapy is a client-centered profession which seeks to implement whole-person care and identify factors influencing healthful participation in life’s activities. Thus, it is critical for occupational therapy practitioners to consider the contextual and societal barriers that may impede a person from full participation. Social determinants of health may be exacerbating the health conditions that have led the person to occupational therapy services. Addressing social justice issues is well within the scope of occupational therapy practice and is more than appropriate to include in interventions, both individual and population-based. Outlined further are recommended strategies and ways occupational therapy practitioners can address social justice needs through direct intervention and within their practice settings.

5.1 Evaluation and intervention

Occupational therapy practitioners should consider social determinants of health in their evaluation process and when developing their occupational profile of individuals they are working with [29, 69]. In regard to refugee populations, an occupational profile would be invaluable in identifying cultural values, traditions, and roles that provide a more authentic and deeper picture of clients’ activities of daily living. Once an appropriate profile is created, practitioners can better address the instrumental activities of daily living (IADL) that are impacted by a person’s socioeconomic and housing status. This can be achieved by occupational therapy practitioners acquiring skills and strategies to teach clients how to learn and use public transportation, improve health and medication management, prepare meals and grocery shop, and engage in community and self-advocacy [29].

For occupational therapy practitioners treating those in poverty, there may be unique barriers when applying typical strategies to improve activities of daily living [ADLs] or IADL routines. Examples of barriers include: a client may be unable to install adaptive equipment into rental properties; a temporary home may lack environmental accessibility; a client may lack necessary caregivers who can assist with ADLs or IADLs; and, a lack of financial means to pay for additional services. Direct skill building with clients that considers contextual barriers presented by poverty and housing status is more effective than traditional interventions and may mitigate the effects of these barriers. For example, a practitioner may help identify safe alternatives to complete ADLs when a person is unable to keep adaptive equipment in a shared and crowded living arrangement.

Several evidence-based occupational therapy interventions exist to target health disparities and focus on occupational skill development. Living Better with What You Have focuses on occupational skill development to address food insecurity issues for individuals living in poverty to “explore, examine, create, and develop skills for managing food resources,” versus focusing only on nutritional education [70]. The OPTIMAL program focuses on developing health management skills for those with multiple co-morbidities within a primary health care setting, which may make rehabilitation services more accessible and reduce the burden on low-income individuals to access health care in multiple locations [71, 72]. The Let’s Go! program focuses on low-income older adults in urban in areas, increasing their skills in using community and public transit [73]. The outcomes of this program not only address transportation barriers among older adults, but increases social and leisure engagement, which are tied to health and well-being [73]. Health Care Survival Skills is a group co-led by participants and an OT to develop health care skills for persons with disabilities [74]. Similarly, Our Peers –Empowerment and Navigational Support is designed to increase independence in self-management skills [74]. Lifestyle Redesign^® has been effectively implemented in settings serving low income adults to address chronic health needs (75, 76). The Resilient, Empowered, Active Living with Diabetes [REAL Diabetes] program was developed to address low-income young adults with diabetes, and demonstrated effectiveness in management of diabetes symptoms (77). Each of these evidence-based programs could be adapted to address specific communities or clients individually and provide a basis for introducing these interventions into practice settings.

Although not unique to occupational therapy practice, permanent supportive housing has demonstrated improved outcomes for chronically homeless adults for housing stability and overall health outcomes [78 –80]. Occupational therapy can play an effective role in developing skills for adults experiencing homelessness or recently housed through direct interventions [3 , 81–85]. Individual evaluation can inform the inter-professional team regarding the needs of clients as they transition into housing, and group and individual intervention can address specific skills to increase functional skills and quality of life (3, 81–85). In some programs, occupational therapy practitioners can support clients in navigating the housing process and make recommendations on appropriate housing (such as completing paperwork to support the need for an accessible unit) [86].

Occupational therapy practitioners are well suited to address the needs of refugees, particularly in the stages of early resettlement. In a collaborative study that collected the perspectives of four individuals with a refugee background and one occupational therapist, the findings indicated that occupational therapy practitioners have the “potential to be a connector, matchmaker and translator” during efforts to improve community integration [87]. Activity analysis, environmental modifications, and occupational adaptation are a few tools that allow occupational therapists to develop appropriate interventions that address life skills, such as acquiring job opportunities, accessing community services, and cooking [88].

In a systematic review of qualitative studies of Australian programs that support refugees, community-based interventions allowed for participants to utilize pre-settlement skills to enhance their sense of social inclusion [89]. From community gardens to mentor programs, the possibilities of these exchanges prevent the development of maladaptive resettlement skills and renew meaning in daily occupations [89, 90].

5.2 Practice settings

Beyond the intervention, occupational therapy practitioners can address social determinants of health by examining their practice settings. Reviewing agency protocols and standards of care to determine where discrimination or barriers may exist allows the practitioner to suggest modifications and adaptations to make their services more accessible [91]. For example, strict late arrival policies may unfairly impact those that rely on public transportation, especially in areas where the transportation systems may be unreliable. Rules or staff responses to individuals who come with multiple bags or who appear disheveled can further marginalize those seeking services and may result in these individuals not returning. Identification of these barriers can allow practitioners to identify changes in practices or needed in-service trainings to make their settings more welcoming and accessible to those living within the constraints of poverty [91]. Programs such as the Language Services Documentation Tool can increase language access at health care facilities and also provides training to providers at facilities on working with those with English as a second language [74]. It is also recommended that practitioners use professional interpretation services when available to minimize errors and provide client-centered and comprehensive care [92]. It may require advocacy of the practitioner to ensure their practice setting offers language services, however, they can use federal and state legislation as support [92].

Health care sites may also consider hosting accessible health information days which address specific health needs, such as women’s health for women with disabilities or culturally directed to specific refugee groups in the community [74]. In areas with refugee populations or individuals living in substantial poverty, health care providers and facilities may develop outreach programs which provide services in locations central to the population, such as community centers, local churches, shelters, and refugee resettlement agencies [93]. Although these programs may not be able to provide the full breadth of services, this strategy can significantly increase access to health services and build relationships to increase further engagement. Within these settings, occupational therapy practitioners may also be able to provide more community-based programming, such as meal preparation classes using healthy low-cost and easy to access ingredients.

Within inpatient and sub-acute settings, identification of those living in poverty or experiencing housing instability and homelessness is important to determine realistic discharge recommendations and appropriate community referrals. An individual living in poverty who has limited or no social supports may be highly likely to become homeless after experiencing a stroke, if the discharge plan does not consider the client’s financial resources and existing supports for IADLs. This individual may need advocacy to have a longer hospital or rehabilitation stay in order to spend more time developing adaptive strategies and skills to return to independent living, or to develop a relationship with ongoing community supports and programs. Individuals who are homeless or unstably housed benefit from increased time in the hospital to recovery from illness or injury as they are often unable to rest and recuperate in shelter or unstable housing situations [94]. Without acknowledging or addressing these circumstances, individuals are more likely to return to the hospital and experience worse outcomes such as homelessness. Occupational therapy has been demonstrated to reduce hospitalizations, this could be further increased by using OT frameworks to identify and addresses SDOH and poverty [95]. Occupational therapy practitioners, through developing an occupational profile and understanding the person’s context, may be the provider to uniquely recognize these barriers and how they impact ADL and IADL. This knowledge supports the need for practitioners to advocate to the interdisciplinary team the varying circumstances and needs.

6 Conclusion

Understanding and addressing issues related to social justice are a critical part of occupational therapy practice. These issues affect all practitioners as clients impacted by social determinants of health require services across practice settings. Addressing social determinants of health in occupational therapy practice may prevent exacerbation of issues related to poverty and homelessness, through identification and development of skills to minimize the impact of these factors. Client-centered practice that addresses the unique needs of those who are experiencing unstable housing or living in poverty may also lead to more effective interventions in rehabilitation, as it provides individuals with strategies that are useful within their contexts, even if these contexts have limited resources. Occupational therapy practice has a unique role in understanding and addressing SDOH to increase quality of life across these populations.

Conflict of interest

None to report.

References

The U.S. Department of Housing and Urban Development [HUD]. The 2018 Annual Homeless Assessment Report (AHAR) to Congress: PART 1- point-in-time estimates of homelessness. Washington, D.C: HUD; 2019.

Parmenter

, Fieldhouse

, Barham

. An occupational therapy intervention service to hostels for homeless people: An overview. British Journal of Occupational Therapy. 2013;76(5):242–5. Available from: DOI: 10.4276/030802213X13679275042807.

Roy

, Vallee

, Kirsh

, Marshall

, Marval

, Low

. Occupation-based practices and homelessness: A scoping review. Canadian Journal of Occupational Therapy. 2017;84:98–110. Available from: DOI: 10.1177/0008417416688709.

Braveman

, Bass-Haugen

. From the Desks of the Guest Editors—Social justice and health disparities: An evolving discourse in occupational therapy research and intervention. American Journal of Occupational Therapy. 2009;63:7–12.

The International Forum for Social Development. Social justice in an open world: The role of the United Nations. Department of Economic and Social Affairs, Division for Social Policy and Development. NewYork: United Nations; 2006. Available from: https://www.un.org/esa/socdev/documents/ifsd/SocialJustice.pdf.

American Occupational Therapy Association. AOTA’s statement on health disparities. AJOT. 2006;60:679. DOI: 10.5014/ajot.60.6.679

American Occupational Therapy Association. Occupational therapy code of ethics (2015). AJOT. 2015; 69(Suppl. 3), 6913410030. https://dx-doi-org.web.bisu.edu.cn/10.5014/ajot.2015.696S03.

Townsend

, Wilcock

. Occupational Justice. In: Christiansen C & Townsend E, editors. Introduction to occupation: The art and science of living. Upper Saddle River, NJ: Prentice-Hall; 2004. p. 243-73.

Townsend

, Polatajko

. Enabling occupation II: Advancing an occupational therapy vision for health, well-being, & justice through occupation. Ottawa, ON: CAOT ACE; 2007.

10.

Synovec

, Braveman

. Integrating social justice into everyday practice: Considerations for occupational therapy. presentation at AOTA. 2018.

11.

Wilcock

, Townsend

. Occupational justice: Occupational terminology interactive dialogue. Journal of Occupational Science. 2000;7(2):84–6.

12.

Kushel

, Gupta

, Gee

, Haas

. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006;21(1):17–7. Available from: doi: 10.1111/j.1525-1497.2005.00278.x.

13.

Frederick

, Chwalek

, Hughes

, Karabanow

, Kidd

. How stable is stable? Defining and measuring housing stability. J Community Psychol. 2014;42(8):964–79.

14.

Resources [Internet]. Nashville, TN: National Health Care for the Homeless Council; 2019. Frequently asked questions [cited 2019 June 1]. Available from: https://www.nhchc.org/resources/general-information/faq/.

15.

Haughton

, Khandker

. Handbook on poverty and inequality. Washington, DC: World Bank; 2009. Available from: https://openknowledge.worldbank.org/handle/10986/11985.

16.

American Psychological Association. Disability and socio-economic status [Internet]. Washington, DC: American Psychological Association; 2019 [cited 2019 June 1]. Retrieved from https://www.apa.org/pi/ses/resources/publications/disability.

17.

Poverty [Internet]. Washington, DC: World Bank Group; 2019. Overview; 2019 April [cited 2019 June 1]. Available from: https://www.worldbank.org/en/topic/poverty/overview.

18.

Fontenot

, Semega

, Kollar

. Income and poverty in the United States: 2017. Washington, DC: U.S. Government Printing Office, U.S. Census Bureau, Current Population Reports; 2018. 203 p.

19.

Social security administration [Internet]. Baltimore, MD: Social Security Administration; July 2019. Monthly statistical snapshot; July 2019 [cited 2019 July 6]. Available from: https://www.ssa.gov/policy/docs/quickfacts/statsnapshot/.

20.

National Low Income Housing Coalition [NLIHC]. Out of reach: 2017. Washington, DC: NLIHC; 2017.

21.

USA for UNHCR [Internet]. Refugee Facts: What is a Refugee? 2018. Available from: https://www.unrefugees.org/refugee-facts/what-is-a-refugee/.

22.

Frost

, Morgan

, Allkhenfr

, Dearden

, Ess

, Albalawi

, et al. Determining Physical and Mental Health Conditions Present in Older Adult Refugees: A Mini-Review. Gerontology 2018 Aug 21:1-7.

23.

International Rescue Committee [Internet].Refugees in America. 2019. Available from: https://www.rescue.org/topic/refugees-america#how-are-refugees-vetted.

24.

Mirza

, Luna

, Mathews

, Hasnain

, Hebert

, Niebauer

, et al.Barriers to healthcare access among refugees with disabilities and chronic health conditions resettled in the US Midwest. J Immigr Minor Health. 2014;16(4):733–42.

25.

Trimboli

, Taylor

. Addressing the occupational needs of refugees and asylum seekers. Aust Occup Ther J. 2019 12/01; 2019/04;63(6):434–7.

26.

Capps

, Newland

. The integration outcomes of U.S. refugees.Washington, DC: Migration Policy Institute; 2015.

27.

Secretary’s advisory committee on health promotion and disease prevention objectives for 2020 [Internet].Washington, DC: HUD; 2010.

28.

American Occupational Therapy Association. Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy. 2014;68(Suppl. 1):S1–S48. Available from: 10.5014/ajot.2014.682006.

29.

Centers for Disease Control and Prevention [CDC]. Health disparities and inequalities report – United States, 2013. Atlanta, GA: CDC; 2017. Available from: https://www.cdc.gov/features/fooddeserts/index.html.

30.

World Health Organization [WHO]. Preventing chronic diseases: A vital investment. Geneva, SW: WHO; 2005. 200p. Available from: http://www.who.int/chp/chronic_disease_report/part2_ch2/en.

31.

Healthy People 2020: An opportunity to address the societal determinants of health in the United States; 2010 26 July [cited 2019 June 1]. Available from: http://www.healthypeople.gov/2010/hp2020/advisory/SocietalDeterminantsHealth.htm.

32.

Garfield

, Orgera

, Damico

. The coverage gap: Uninsured poor adults in states that do not expand Medicaid [Internet]. 2019 March [cited 2019 June 1]. Available from: https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/.

33.

Martin

, Winston

, Bazemore

, Jetty

, Petterson

, Kushel

. Adults with housing insecurity have worse access to primary and preventative care. The Journal of the American Board of Family Medicine. 2019;32(4):521–30. DOI: DOI: 10.3122/jabfm.2019.04.180374

34.

Allen

, Call

, Beebe

, McAlpine

, Johnson

. Barriers to care and healthcare utilization among the publicly insured. Med Care. 2017;55:207–14.

35.

Ford

, Turley

, Porter

, Shakespeare

, Wong

, Jones

, Steel

. Access to primary care for socio-economically disadvantaged older people in rural areas: A qualitative study. PLOS One. 2018;13:e0193952.

36.

Kaplan-Lewis

, Percac-Lima

. No-show to primary care appointments: Why patients do not come. Journal of Primary Care and Community Health. 2012;4:251–5.

37.

Mirza

, Heinemann

. Service needs and service gaps among refugees with disabilities resettled in the United States. Disabil Rehabil. 2012;34(7):542–52. DOI: 10.3109/09638288.2011.611211

38.

Bastable

, Gramet

, Jacobs

, Sopczyk

. Health professional as educator: Principles of teaching and learning. Sudbury, MA: Jones & Bartlett Learning; 2011.

39.

Campbell

, Mann

, Moffatt

, Dave

, Pearce

. Social determinants of emotional well-being in new refugees in the UK. Public Health. 2018;164:72–81.

40.

United States Department of Labor. Minimum wage laws in the states. Washington, D.C.: United States Department of Labor; 2018. Available from: https://www.dol.gov/whd/minwage/america.htm.

41.

Elejalde-Ruiz

. Nearly half of US workers consider themselves under-employed, report finds. Chicago Tribune [Internet]. 2016 June [cited 2019 June 1]. Available from: http://www.chicagotribune.com/business/ct-underemployment-survey-0629-biz-20160628-story.html.

42.

Bureau of Labor Statistics. Persons with a disability: Labor force characteristics summary, USDL-17-0857. Washington, DC: Bureau of Labor Statistics. 2017. Available from: https://www.bls.gov/news.release/disabl.nr0.htm.

43.

Semega

, Fontenot

, Kollar

. Income and poverty in the United States: 2016.Washington, DC: U.S. Department of Commerce, Economics and Statistics Administration; 2017. pp. 199.

44.

Hocking

. Working for citizenship: the dangers of occupational deprivation. Work. 2012;41(4):391–5. DOI: 10.3233/WOR-2012-1316

45.

U.S. Department of Health and Human Services (HHS) and U.S. Department of Agriculture (USDA). 2015–2020 dietary guidelines for Americans: 8th edition. Washington, DC: HHS and USDA; 2015 Dec.

46.

Coleman-Jensen

, Rabbitt

, Gregory

, Singh

. Household food security in theUnited States in 2016.Washington, DC: USDA, Economic Research Service. 2017. ERR-237.

47.

CDC Features [Internet]. Atlanta, GA: Centers for Disease Control and Prevention; 2019 July 8. A look inside food deserts; 2017August 21 [cited 2019 June 1].Available from: https://www.cdc.gov/features/fooddeserts/index.html.

48.

United States Department of Agriculture. Access to affordable and nutritious food: Measuring and understanding food deserts and their consequences.Washington, DC: U.S. Department of Agriculture, Economic Research Service; 2009. AP-036.

49.

Feeding America. From paycheck to pantry: Hunger in working America. Chicago, IL: Feeding America; 2014. Available from: https://www.oxfamamerica.org/explore/research-publications/from-paycheck-to-pantry-hunger-in-working-america/.

50.

Moshfegh

. Research to advance the understanding of the interrelationship of poverty and nutrition. Journal of the American Dietetic Association. 2007;107:1882–5.

51.

Nunnery

, Haldeman

, Morrison

, Dharod

. Food insecurity and budgeting among Liberians in the US: how are they related to socio-demographic and pre-resettlement characteristics. J Immigr Minor Health. 2015;17(2):506–12.

52.

Verbich

, El-Geneidy

. The pursuit of satisfaction: Variation in satisfaction with bus transit service among riders with encumbrances and riders with disabilities using a large-scale survey from London, UK. Transport Policy. 2016;47:64–71.

53.

Bose

. Refugees in Vermont: Mobility and acculturation in a new immigrant destination. Journal of Transport Geography. 2014;6(C):151–9.

54.

Syed

, Gerber

, Sharp

. Traveling towards disease: Transportation barriers to health care access. Journal of Community Health. 2012;38:976–93.

55.

Wallace

. The best cities for public transportation [Internet]. New York, NY: SmartAsset; 2019 June 17 [cited 2019 July 1]. Available from: https://smartasset.com/mortgage/best-cities-for-public-transportation.

56.

Kullgren

, McLaughlin

, Mitra

, Armstrong

. Nonfinancial barriers and access to care for U.S. adults. Health Services Research. 2012;47:462–85.

57.

Goins

, Williams

, Carter

, Spencer

, Solovieva

. Perceived barriers to health care access among rural older adults: A qualitative study. J Rural Health. 2005;21(3):206–13.

58.

Rosenbloom

. Transportation patterns and problems of people with disabilities. In: Field MJ & Jette AM, editors. The future of disability in America.Washington, D.C.: National Academies Press. 2007. pp. 519-60.

59.

Kamimura

, Panahi

, Ahmmad

, Pye Mu

. Transportation and other nonfinancial barriers among uninsured primary care patients. Health Services Research and Managerial Epidemiology. 2018;5:1–6.

60.

Evans

, Boxhill

, Pinkava

. Poverty and maternal responsiveness: The role of maternal stress and social resources. International Journal of Behavioral Development. 2008;32(3):232–37. Available from: DOI: 10.1177/0165025408089272.

61.

Henly

, Danziger

, Offer

. The contribution of social support to the material well-being of low-income families. Journal of Marriage and the Family. 2005;67:122–40.

62.

Moskowitz

, Vittinghoff

, Schmidt

. Reconsidering the effects of poverty and social support on health: A 5-year longitudinal test of the stress-buffering hypothesis. Journal of Urban Health. 2013;90:175–84.

63.

Smith

, Cornella

, Williams

. Working with populations from a refugee background: An opportunity to enhance the occupational therapy educational experience. Aust Occup Ther J. 2014;61(1):20–7.

64.

Pavela

. Functional status and social contact among older adults. Research on Aging. 2015;37:815–36.

65.

White

, Philogene

, Fine

, Sinha

. Social support and self-reported health status of older adults in the United States. American Journal of Public Health. 2009;99:1872–8.

66.

Redfors

, Isaksen

, Lappas

, Blomstrand

, Rosengren

, Jood

, Jern

. Living alone predicts mortality in patients with ischemic stroke before 70 years of age: A long-term prospective follow-up study. BMC Neurology. 2016;16:80.

67.

Park

, Hain

, Tappen

, Diaz

, Ouslander

. Factors associated with 30-day hospital readmissions among participants in a care transition quality improvement program. Journal of the Society for Social Work and Research. 2012;3:308–28.

68.

American Occupational Therapy Association. AOTA occupational profile template. American Journal of Occupational Therapy. 2017;71(Suppl. 2), 7112420030. Available from: DOI: 10.5014/ajot.2017.716S12.

69.

Schmelzer

, Leto

. Promoting health through engagement in occupations that maximize food resources. AJOT. 2018;72(4):7204205020p1-7204205020p9. DOI: 10.5014/ajot.2018.025866

70.

Garvey

, Connolly

, Boland

, Smith

. OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care: A randomized controlled trial. BMC Family Practice. 2015;16:59. DOI: 10.1186/s12875-015-0267-0

71.

World Health Organization. Access to rehabilitation in primary health care: An ongoing challenge. Geneva:World Health Organization; 2018. Available from: https://apps.who.int/iris/bitstream/handle/10665/325522/WHO-HIS-SDS-2018.40-eng.pdf.

72.

Mulry

, Papetti

, De Martinis

, Ravinsky

. Facilitating wellness in urban-dwelling, low-income older adults through community mobility: A mixed-methods study. AJOT. 2017;71:7104190030. Available from: DOI: 10.5014/ajot.2017.025494.

73.

Suarez

, Hammel

, Magasi

, Mirza

, Januszewski

. The role of social determinants in promoting health and participation equity and outcomes: Opportunities for occupational therapy. 2019 presentation at the American Occupational Therapy Association Annual Conference.

74.

Pyatak

, King

, Vigen

CLP

, Salazar

, Diaz

, Schepens Niemiec

, et al.Addressing diabetes in primary care: Hybrid effectiveness–implementation study of Lifestyle Redesign® occupational therapy. American Journal of Occupational Therapy. 2019;73:7305185020. DOI: 10.5014/ajot.2019.037317.

75.

Uyeshiro

, Collins

CER

. Lifestyle Redesign® for chronic pain management: A retrospective clinical efficacy study. American Journal of Occupational Therapy. 2017;71:710490040. DOI: 10.5014/ajot.2017.025502.

76.

Pyatak

, Carandang

, Vigen

CLP

, Blanchard

, Diaz

, Concha-Chavez

, et al.Occupational therapy intervention improves glycemic control and quality of life among young adults with diabetes: the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) randomized controlled trial. Diabetes Care. 2018;41(4):696–704. DOI: 10.2337/dc17-1634.

77.

Aubry

, Tsemberis

, Adair

, Veldhuizen

, Streiner

, Laitmer

, et al.One-year outcomes of a randomized controlled trial of Housing First with ACT in five Canadian cities. Psychiatric Services. 2015;66:463–9.

78.

Nelson

, Aubry

, Lafrance

. A review of the literature on the effectiveness of housing and support, assertive community treatment, and intensive case management interventions for persons with mental illness who have been homeless. American Journal of Orthopsychiatry. 2007;77:350–61.

79.

Tsemberis

, Asmussen

. From streets to homes. Alcoholism Treatment Quarterly. 1999;17:113–31.

80.

Helfrich

, Fogg

. Outcomes of a life skills intervention for homeless adults with mental illness. Journal of Primary Prevention. 2007;28:313. DOI: 10.1007/s10935-007-0103-y

81.

Helfrich

, Synovec

. Homeless and women’s shelters. In Brown C, Stoffel V,Munoz J, editors. Occupational therapy inmental health. 2nd ed. Philadelphia, PA: F.A.Davis. 2019.

82.

Gutman

, Raphael-Greenfield

. Effectiveness of a supportive housing program for homeless adults with mental illness and substance abuse: A two-group controlled trial. British Journal of Occupational Therapy. 2017;80:286–93. DOI: 10.1177/0308022616680368.

83.

Merryman

, Synovec

. Integrated care: Provider perceptions of occupational therapy services for homeless adults. WORK. 2019;In press.

84.

Thomas

, Gray

, McGinty

. A systematic review of occupational therapy interventions with homeless people. Occupational Therapy in Health Care. 2011;25(1):38–53. DOI: 10.3109/07380577.2010.52855

85.

American Occupational Therapy Association. Occupational therapy’s role in case management. American Journal of Occupational Therapy. 2018; 72(Suppl. 2), 7212410050. Available from: DOI: 10.5014/ajot.2018.72S206.

86.

Blankvoort

, Arslan

, Tonoyan

, Damour

, Mpabanzi

. A new you: A collaborative exploration of occupational therapy’s role with refugees. World Federation of Occupational Therapists Bulletin2018 07/03;74(2):92–8.

87.

Winlaw K

. Marking the connection: Why refugees and asylum seekers need occupational therapy services [Internet]. Occupational Therapy Now: Volume 19.4. Available from: https://www.caot.ca/document/5748/Making%20the%20connection%20Why%20refugees%20and%20asylum%20seekers.pdf.

88.

Mahoney

, Siyambalapitiya

. Community-based interventions for building social inclusion of refugees and asylum seekers in Australia: A systematic review. Journal of Social Inclusion [Internet]. 2017;8(2). Available from: https://josi.journals.griffith.edu.au/index.php/inclusion/article/view/1016.

89.

Suleman

, Whiteford

. Understanding occupational transitions in forced migration: The importance of life skills in early refugee resettlement. Journal of Occupational Science. 2013;20(2):201–10.

90.

Bonin

, Brehove

, Carlson

, Downing

, Hoeft

, Kalinowski

, et al. Adapting your practice: General recommendations for the care of homeless patients. Nashville, TN: National Health Care for the Homeless Council; 2010. Available from: http://www.nhchc.org/wp-content/uploads/2011/09/GenRecsHomeless2010.pdf.

91.

Harrison

, Mirza

. Occupational therapy across languages: Working with interpreters to ensure ethical and effective practice. OT Practice [Internet]. 2019 July [cited 2019 July 16]. Available from: https://www.aota.org/ /media/Corporate/Files/Publications/CE-Articles/CE_article_July_2019.pdf.

92.

Health Outreach Partners. National outreach guidelines for under-served populations. Oakland, CA: Health Outreach Partners; 2015. Available from: http://outreachpartners.org/clientportal/wp-content/uploads/2017/02/National-Outreach-Guideline-Full.pdf.

93.

National Health Care for the Homeless Council. Standards for medical respite programs. Nashville, TN: National Health Care for the Homeless Council; 2016. Available from: http://councilbackup.flywheelsites.com/wp-content/uploads/2011/09/medical_respite_standards_oct2016.pdf.

94.

Rogers

, Bai

, Lavin

, Anderson

. Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review. 2017;74:1–19. Available from: DOI: 10.1177/1077558716666981.