Homeless households are a serious public housing concern in India, mainly persistent in urban India. Several challenges, including livelihood and health challenges, are common among homeless individuals. The present slide describes challenges related to accessing outpatient care among homeless women in India.

1. Assessing the barriers of public outpatient
service utilization among Homeless
women: An exploratory study in Kolkata
Margubur Rahaman
Research Fellow,
International Institute for Population Sciences (IIPS),
Mumbai

2. Background
 Almost 1.8 million individuals are homeless in India,
mostly concentrated in urban areas with poor living status
(Census of India, 2011).
 The wave of dual burden of vulnerabilities —livelihood
and health are found to be high among them (Ritchey et
al. 1991).
 Sex-selective violence and morbidities high among the
females, which upsurges their demand for outpatient
care, and suitability public healthcare services (PHS)
high due to socio-economic vulnerability (Das et al. 2018).
 During access of PHS, they faces several barriers, which
are significantly varies with population, space, and time.

3. 83200
69798
39190
38339
22820
20298
20107
19287
19077
0 20000 40000 60000 80000 100000
Kanpur Nagar
Kolkata
Surat
Mumbai
Allahabad
Jaipur
Rangareddy
Thane
Mumbai Suburban
Number of Homeless population
Source: Authors' calculation using Census of India,
2011

4. Source : Roy & Siddique, 2018

5. Spatial display of the study area

6. Profile of homeless population, Kolkata district
Indicators Total Female
Average family
size 6 persons -
Females 21.7% -
Under-6
population 3.7% 3.1%
SCs/STs
population
2.4% 6.2%
Literacy rate 25.3% 17.8%
Workforce
participation rate 64.4% 62.2%
Main workers 75.4% 61.4%
Source: Authors calculation using Census of India,
2011

7. Research gap & need for study
 Most of the previous studies explored socio-economic
background, livelihood and health vulnerabilities, and
health seeking behaviours of the homeless individuals.
 However, little studies has focused on to contextualized
the health care choice and perceived obstacles.
 Therefore, the present study aims to explore the the
barriers of public outpatient service utilization among
homeless women.
 The present study will be supported to frame the
population-centric health care systems.

8. Research questions and hypothesis
 What are the homeless women's perspectives on
facilitators and barriers to receiving outpatient health
care?
 We hypothesized that the choice and barriers of using
outpatient care service varies with individuals.

9. Data & Methods
 The present study used primary data, which was collected
during May-June, 2022 in Kolkata municipal corporation
(KMC).
 The present study used time and location sampling to
select the sample. We have conducted 18 in-depth
interviews (IDIs) to draw the information from the women
with at-least one chronic diseases . We terminated
interviewing when we reached saturation, that is, when we
stop getting new information (Taylor & Bogdan, 1998).
 Further, five key interviews (KIIs) including chief of the
homeless cluster (1), doctor (1), pharmacist (1), and NGO
workers (2) also conducted to understand the key
challenges to access the healthcare facilities among the
homeless women. Open-ended questionnaires used to
conduct systematic interview, which covered healthcare.
 Using the grounded theory method (Glaser & Strauss,
1967), content analysis applied to framing the research
outcomes.

10. Results & findings
% Mean (SD)
Age 35.6 (10.6)
Marital status (currently
married)
72.2%
Duration of homelessness 1.3 years
Religion (Hindu) 77.7%
Social group (Don’t know) 50%
Work participation (in 1
month prior to the survey)
83.3%
Number of chronic diseases
1-2 88.8%
2+ 55.5%
Descriptive statistics of the IDIs, homeless
women, KMC, May-June, 2022

11. Percentage distribution of outpatient care utilization
by types of health care service, Homeless women,
KMC
33.3
5.6
61.1
0
10
20
30
40
50
60
70
Public Private Other
Note- public facility includes health post/sub centers, primary health center, community health center, district
hospital/ sub-district hospital and Govt. AYUSH hospital; private facility includes private hospital/nursing home,
private clinic (OPD based service), NGO/charity/trust/church-run hospital, and private AYUSH hospital; and other
facility includes pharmacy/drugstore, home visit, mobile healthcare unit and others
Source- Authors calculation, Primary survey in KMC during May-June, 2022

12. Theme 1: Availability of services and competing
Needs
 Most of the knew of availability of outpatient care
services where they could get medical care and most
said lack of services was not the main barrier to care,
unless serious health complications few of them sought
treatment.
 They have preferred generally nearby pharmacy for
outpatient care.
 As Roshni (name changed) said-
 “It’s not hard to get medical care once a women decides
to get up and go, when we feel very serious maternity
complication then we try to visit public health services”.

13. Theme 2: Availability of public service but
accessibility is matter
 While availability may not have been a issue, access to
public outpatient care is expressed as time overriding
process. As a daily wage worker, they are not willing to
receive outpatient care from public services through a
channel like enrolment, waiting, and routine visits.
Other commonly reported obstacles to care were limited
clinic hours and backlog.
 Ruma said-
“ We are homeless women generally engages with 3D
work, and we have not time to getting care from public
facilities because of time constraints and demeaning
livelihood”.

14. Theme 3: Acceptability of services
 Women talked openly about how being both poor and
homeless situation affect the treatment receive, some
said the experience was sufficiently disrespectful to
actually deter them from seeking care.
 As Komla explained-
“I won’t like to face disrespectful treatment from time-
bound public health process, therefore I generally like
home remedy or preferred nearby local quack
practitioners. “

15. Theme 3: socio-economic backwardness
 Majority of them recognizes fever as the major feature
of malaria but their knowledge of what causes it,
symptoms and sign was poor. All perceived malaria as
simple disease that mothers should be comfortable to
apply home based remedy.
 Religious beliefs did not prevent mothers from seeking
hospital care. but some are aware of mothers that rely
on Holy water and prayer to treat malaria.
 The study observed poor knowledge of mothers of
malaria; cultural beliefs in home remedy and poverty
are issues that affect malaria outcome.

16. Conclusion
 According to the findings, the majority of women
received their outpatient care in unsafe facilities.
 Institutional level barriers are found to be more
important than individual level barriers in the poor
utilisation of safe health care services.
 Furthermore, access to outpatient care was significantly
impacted by the respondent's dwelling, socio-economic
background and living status.
 Based on the findings of the current study, a multi-
sectoral approach is helpful to cover the homeless
population under the safe outpatient services.

17. Limitations
 A key limitation is that the interviewee can give
limited or even misleading answers. Also, the data
obtained cannot be generalized to the population.
These limitations can be dissipated by combining in-
depth interviewing with other methods.

18. References
 Kar, S. K. (2021). Indian perspectives on homelessness and mental
health. Homelessness and Mental Health, 99.
 Roy, A., & Siddique, G. (2018). Homeless people in West Bengal: a district-
level study. Space and Culture, India, 6(3), 110-133.
 Kolb, S. M. (2012). Grounded theory and the constant comparative method:
Valid research strategies for educators. Journal of emerging trends in
educational research and policy studies, 3(1), 83-86.
 Strauss, A., & Corbin, J. M. (1997). Grounded theory in practice. Sage.
 Bhattacharya, P., & Priya, K. R. (2022). Stakeholders facilitating hope and
empowerment amidst social suffering: A qualitative documentary analysis
exploring lives of homeless women with mental illness. International Journal
of Social Psychiatry, 68(4), 908-918.
 Das, M., Angeli, F., Krumeich, A. J., & van Schayck, O. C. (2018). The
gendered experience with respect to health-seeking behaviour in an urban
slum of Kolkata, India. International journal for equity in health, 17(1), 1-14.
 Ritchey, F. J., La Gory, M., & Mullis, J. (1991). Gender differences in health
risks and physical symptoms among the homeless. Journal of Health and
Social Behavior, 33-48.