Experiences of the homeless accessing an inner-city pharmacy and medical student-run clinic in Johannesburg

Background Mental and physical health problems are both contributory factors and drivers of homelessness. Adding to this, the homeless encounter numerous barriers when accessing healthcare services. Aim The aim was to determine the experiences of the homeless when accessing healthcare services and the reason why they visit Trinity Health Services (THS). Setting Trinity Health Services, a student-run clinic (SRC) based at an inner-city church in Johannesburg, South Africa, provides free acute healthcare services to the homeless. Methods This qualitative study comprised three focus group discussions (FGDs) with the homeless who access services provided by the church. Those who had previously visited THS on at least one occasion were invited to participate in FGDs. The FGDs were audio-taped and transcribed verbatim. The data were analysed thematically using Tesch’s eight steps. Results Three themes were identified. The first theme, homelessness affecting health, explains how limited access to food, ablution facilities and shelter negatively impact their well-being. This led to the second theme, health needs, where tuberculosis, influenza, sexually transmitted diseases and dental infections were identified as ailments occurring frequently. The need for healthcare services was explicit, yet participants were reluctant when accessing healthcare services as they faced stigma and discrimination. The third theme, THS in addressing health needs, denotes the value of THS in the community it serves where they were treated with compassion and empathy. Conclusion The needs of this homeless community as well as the role played by THS were clearly identified. However, THS provides limited services, and integration with existing healthcare services is essential.

Introduction healthcare services are provided by healthcare students under the supervision of licensed healthcare professionals. However, it differs from other clinical exposures as in these clinics the healthcare students are responsible for the management of clinics (Holmqvist et al. 2012;Simpson & Long 2007).
It was found through patient feedback that the homeless were appreciative of the quality of care received at SRCs; however, they raised concerns regarding waiting and operational periods of these clinics (Ellett, Campbell & Gonsalves 2010;Mischell et al. 2017). Feedback from patients and community members assists in identifying the healthcare needs that can be addressed by a SRC (Buchanan & Witlen 2006). Thus, this study was motivated by the need to obtain patient feedback to determine the value of a SRC to the community it serves. The aim of this study was to determine the experiences of the homeless when accessing healthcare services and the reasons for their visiting Trinity Health Services (THS).

Description of the setting
Trinity Health Services is a SRC operating on alternate Monday nights from an inner-city church in Braamfontein, Johannesburg. The church provides, apart from meals to the homeless community through a soup kitchen, toiletries (toothbrushes, toothpaste and soap), blankets and second-hand clothing (see Figure 1). The need for healthcare services in the community was recognised by two medical students from the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, who were volunteering in the soup kitchen (Johnston, Egan & McInerney 2018). Initially, basic first aid services were provided but over time this expanded to more comprehensive acute care. The most common conditions seen and managed at the clinic were related to the respiratory, predominately upper and lower respiratory tract infections, and digestive systems, including dental caries (Johnston, McInerney & Miot 2019). The clinic comprises three consultation rooms and a pharmacy. It is staffed by pharmacy and medical students as well as pharmacists and doctors who work together to provide healthcare services (see Figure 1). Patients in need of further care are referred to nearby public healthcare facilities.
The community served by the clinic has become increasingly dependent on the services provided, yet there is little information describing their experiences when accessing healthcare and the reasons for their attending THS.
Therefore, the research question asked was: why do the homeless seek help from the clinic and what were their experiences of the services it provides?
This qualitative study formed part of a larger body of research which aimed to describe the establishment and investigate the various factors affecting the sustainability of THS. A component of this was to establish the value of the clinic from the homeless communities' perspective and various stakeholders. Stakeholders are groups and/or individuals having a vested interest in THS and were identified as the church, university, pharmacy and medical students, supervising professionals and the homeless community.

Methodology
Focus group discussions (FGDs) were conducted with the homeless visiting the church to gain an in-depth understanding of their experiences of healthcare services they access. The inclusion criteria were patients who had previously visited THS on at least one occasion and were aged 18 years or older. A convenience sampling method was employed: those meeting the inclusion criteria and were present at the soup kitchen when FGDs were held were invited to participate. The facilitator of FGDs was an experienced qualitative researcher (H.T.). The researcher (D.J.) observed these FGDs.
The facilitator provided a participant-information sheet and explained the purpose of the study to all the participants. The participants signed an informed consent to participate in the FGD and a separate consent was obtained for voice recording. The FGDs were audiotaped and transcribed verbatim. Ethics approval was obtained from the Human Research Ethics Committee of the University of the Witwatersrand, Johannesburg (M170953).
Three FGDs, each with six participants were held, totalling 15 men and three women. The higher number of men who participated is congruent with the demographics of those attending the clinic (Johnston et al. 2019). This is attributed to THS operating after hours and women are more likely to access shelters that close at sunset. The predominant common language spoken by the homeless at the soup kitchen and THS was English. The FGDs varied in duration from 58 min to 75 min.
The facilitator of the FGDs explained to the participants that they could disclose information they were comfortable with sharing and were not expected to reveal personal information relating to their health. Participants were also requested to keep information discussed in the FGD confidential and not to discuss it with others afterwards. They were asked both primary and probing questions outlined in Table 1.
The data were analysed thematically using Tesch's eight steps (Creswell 2014). The researchers reviewed the audio recordings and transcriptions repeatedly to gain a thorough understanding of the data. Initial codes were induced and grouped into categories. Categories were reviewed to determine the emerging themes.
The source of the statement was confirmed using an annotation system, FGDs were numbered (H1-H3); followed by the participant number (#1-6), the gender of the participant (M: male; F: female) and employment status (E: employed; UE: unemployed).

Ethical consideration
Participants of the focus group discussions (FGDs) were provided with a participant information sheet, and the facilitator provided an explanation about the purpose of the study. The participants signed an informed consent form to participate in the FGD and a separate consent form for voice recording. The FGDs were audiotaped and transcribed verbatim. Ethical approval was obtained from the Human Research Ethics Committee of the University of the Witwatersrand, Johannesburg (M170953).

Trustworthiness
Trustworthiness of study was ensured through addressing the 'credibility', 'transferability', 'dependability' and 'confirmability' (Guba & Lincoln 1981). The credibility was confirmed through member checking and peer debriefing. The FGDs were conducted by the same facilitator. Before coding commenced transcriptions were checked for accuracy.
The coding system and transcription were revised until consensus was reached between researchers. A thick description adds to the 'transferability' of the findings to other SRCs and health services the homeless seek. However, THS to our knowledge is the only SRC serving the homeless in South Africa and the findings may be difficult to compare to those SRCs internationally as the services available to these communities differ considerably between countries. The 'dependability' refers to consistency of the findings if repeated. Data saturation, defined as the point at which the gathering of more information no longer revealed a new insight, was reached after the third FGD. The 'confirmability' denotes the awareness of the researchers bias to ensure neutrality. H.T. and P.M. were not involved in THS. While, D.J. was the responsible pharmacist of Trinity Pharmacy and could not suspend her involvement in THS. She was however aware of her personal bias at all times and the above-mentioned measures were taken to safeguard the trustworthiness of the findings.

Findings
Three themes emerged from FGDs (see Figure 2). The first theme, homelessness affecting health, explains how homelessness affects health. This led to the second theme, health needs, referring to the prevailing ailments in the community contributing to their health needs as well as their experiences when accessing existing healthcare services. The third theme, THS in addressing health needs, refers to the value of this SRC to the community it serves.

Homelessness affecting health
There were three categories contributing to this theme: food and nutrition, ablution facilities, as well as shelter and belongings. These categories elucidate the link between homelessness and health. The homeless frequent soup kitchens for food or may resort to eating from dustbins. There are few ablution facilities in the vicinity and they cannot afford toiletries, resulting in poor hygiene practices. Many of the homeless reside on the streets as they cannot afford to stay in a shelter. Exposed to the cold wet weather, they frequently become sick. Furthermore, their belongings, such as important documents, medication, clothes and blankets, were often stolen.

Food and nutrition
The participants visited the daily soup kitchens provided by the church or other facilities in the surrounding areas. However, many reported to have eaten from dustbins when necessary. Some explained the pain they experienced from hunger: 'You never know how hunger is, how painful it is until you get hungry yourself.' (H2, #2, M, UE) Mixed views were expressed regarding the food they ate, most often soup, and how often they were provided with meals. However, all agreed that their diets lacked nutritional value as indicated in reply to this question asked by a participant: 'Where do you get a balanced meal if you have to beg for food?' (H1, #4, M, UE) Furthermore, those taking medication were often instructed to take it with food. This may lead to non-compliance to medical treatment if they have nothing to eat.

Ablution facilities
The homeless use public ablution facilities to wash themselves and their clothes. Because they have to wait in long queues to use ablution facilities, they found: 'It's very difficult on the street to get a bath every day.' (H1, #4, M, UE) In addition, there is only cold water, and they need to purchase their own toiletries and soap, which they cannot afford.

Shelter and belongings
Some participants slept in a shelter but were required to pay a fee. Many of the homeless cannot afford this fee, leaving them with no choice but to sleep on the pavements. This, in turn, affects their health as they are more prone to influenza and infections: 'When you sleep on top of a pavement … if it rains, you normally (have) some cardboard underneath and then you put a plastic on top … the rain overflows underneath the cardboard, and it's just there before you get wet. And then the thing is we catch "flu" or coldness during that process … there is only one part that is being affected, and that is the back bone (referring to the spine). So it absorbs or it catches that coldness, and then after that what happens, you're going to get a blocked chest.' (H3, #2, M, UE) They face many difficulties when finding shelter and keeping their belongings safe, such as identification documents and medication: 'The basic thing is somewhere to sleep and where my things such as my CV can be kept safe … You can't keep a prescription of medication for more than 3 days without losing it.' (H1, #1, M, UE)

Health needs
The theme 'health needs' was developed from two categories: prevailing ailments and accessing healthcare services.
The participants described frequently occurring ailments such as influenza, tuberculosis, sexually transmitted diseases and dental infections that necessitated treatment. The participants then explained their experiences when accessing healthcare facilities and the barriers encountered.

Prevailing ailments
Tuberculosis and drug/alcohol addiction were identified by the participants as the prevalent conditions amongst the homeless: 'The majority (of the homeless) are doing drugs and you have got to watch out they are bringing in TB [tuberculosis] and viruses and they smoke from each other's lips (as they share cigarettes), so TB it's a high risk on the streets.' (H2, #6, M, UE) This participant described the need for information about sexually transmitted infections and, in particular, using adequate protection to reduce their transmission: 'I will wish that it can be also more of a counselling in terms of sexually transmitted disease ... because in the street I don't think they exercise protection.' (H1, #5, M, UE) The need for healthcare was evident especially during the winter months when those residing on the pavements were exposed to extreme cold. Most participants stated that they had had flu, and one participant explained that flu vaccines were required to provide protection against influenza: 'During winter it's whereby we experience a high number of death rates on the street, due to the fact that people, they don't know their health state.' (H3, #4, M, UE) The necessity for dental service was evident. Participants explained that there were relatively few facilities offering this service, and adding to this many of the homeless cannot afford toothpaste and toothbrushes: 'Since I was born I have never been attended to by a dentist.' (H1, #6, M, UE) 'My brothers and sisters are losing … their teeth, based on certain food they eat and not being able to have toothpaste and toothbrush to keep them clean.' (H3, #2, M, UE) Diseases that the homeless present with were also described as 'hidden sicknesses' (H3, #6, M, UE), referring to people not knowing about their condition, and therefore '… they fail to come here to approach the doctors for their health issues' (H3, #4, M, UE).

Accessing healthcare services
The need for healthcare services was explicit, yet participants were reluctant to access these (government clinics) services as they felt discriminated against: The stigma and discrimination the homeless face is contextualised in these two questions that a participant was frequently asked by healthcare professionals:

Trinity Health Services in addressing health needs
The homeless are welcomed by the church through the soup kitchen and healthcare services provided. This participant explained that the church felt like home and the people who access these services regularly have formed a community: '… [I]t's more like our home, our community …' (H3, #3, M, UE) Trinity Health Services was appreciated by the participants for the medical and pharmaceutical facilities provided. The value of the clinic to this community extends beyond these services forming the first two categories in this theme: treated with compassion, and respect and professionalism. The third category, expanding the services, describes unmet needs of the community and suggestions for the future services.

Treated with respect and compassion
The participants described the way they were treated in contrast to the stigma they so often faced when accessing other healthcare services: They also referred to the 'love and compassion' (H1, #4, M, UE) experienced at the clinic, which in turn motivated them to return to the clinic: 'Some other time you just wish that you can be sick forever so that you get that attention.' (H2, #2, M, UE)

Professionalism
The participants referred to the professionalism of those providing the services at THS. The privacy experienced during consultations and relationships formed between healthcare providers and patients were key components that contributed to this category.
The participants were aware that THS is a SRC and felt that this was to their advantage because the pharmacy and medical students spent more time with them and there was a 'double check' in place as the students presented to a supervisor:

Expanding the services
The clinic is open on specific evenings each month and offers limited services. Therefore, patients were frequently referred to public healthcare facilities for further care. The following comment explains the disadvantages of the referral system, as they return to the healthcare services where they are discriminated against: 'Most of the times it's unfortunate that they only have to take you to refer you somewhere else to these people whom we are complaining about.' (H1,#1,M,UE) Participants suggested that THS must be opened more frequently and needed to expand the services offered to include dentistry, social and psychological services, as well as health promotion:

Discussion
This study described the experiences of the homeless accessing care from a free SRC based at an inner-city church. However, their experiences extended beyond THS and explained the connection between being homeless and health as well as the need for such a clinic. Three themes emerged: homelessness affecting health, health needs and the role of THS in addressing health needs. Limited access to food, ablution facilities and shelter negatively affected the health of the homeless. Adding to this, the stigma and discrimination they faced at public health services adversely affected their mental and psychological health. They explained the challenges faced when accessing public healthcare services and the gap which THS has filled.
This study reports on the experiences of participants when accessing healthcare services. Although it may be difficult to confirm the accuracy of their descriptions, other studies have also reported the discrimination that the homeless face when accessing healthcare services in South Africa (Moyo, Patel & Ross 2015;Seager & Tamasane 2010;Wentzel & Voce 2012). Their negative experiences whilst accessing healthcare services could lead to non-compliance with treatment regimens, especially in the case of HIV-positive patients as described in these findings. This could result in treatment failure and the virus developing possible resistance to the medication.
The participants appreciated the services as well as the respect and compassion provided by the SRC. In addition, the participants described returning to the clinic when they were sick or waiting till the clinic was open again for seeking help. Student-run clinics have been shown to provide quality healthcare services that lead to positive patient outcomes (Berman et al. 2012;Butala et al. 2012;Der et al. 2001;Gorrindo et al. 2014;Hsu et al. 2003;Liberman et al. 2011 There were several instances when participants mentioned their referral to other clinics and hospitals for further care. An established relationship between the clinic and neighbouring facilities is needed to expedite the referral process. Gelberg, Andersen and Leake (2000) found that the homeless were more likely to seek help of healthcare services if they felt the need. Thus, the referral letter the patients receive could prompt them to seek further care. However, more research is needed to determine whether referred patients visit these facilities and the factors influencing their decision to access further care.
The gap, which THS fills, is clearly elucidated. However, the community calls for more assistance, perhaps beyond the scope and the capacity of the clinic. The clinic plans to incorporate dental services. There is also an urgent need for social and psychological services as well as skills development. The church and the university must consider including additional partnerships with government and non-government organisations extending beyond the scope of this SRC.

Conclusion
This homeless community described an urgent need for healthcare and the challenges faced when accessing the existing services. The compassion and empathy received by patients at THS created an environment conducive to healing where patients felt at ease, and trusting relations with healthcare providers were formed. However, THS provides limited services; thus, integration with existing healthcare and other services is essential to meet the needs of the community.