The ulcer with no fixed abode: barriers in accessing venous healthcare for individuals experiencing homelessness and using intravenous drugs in Bristol

Why we undertook the work

People who are homeless and inject drugs have higher rates of cardiovascular (heart and artery) disease. There are currently no reported studies focused on venous (vein-related) disease, despite the risk of blood clots (deep vein thrombosis or DVT). DVTs can be deadly if left untreated. Damage to the veins is common in this patient group and can lead to chronic leg ulcers, pain, infection and swelling, which can be life-limiting and life-threatening. This is a health inequality and overstretching finite NHS resources. Diagnosis requires outpatient ultrasound scans prior to treatment (eg, blood thinning medication and/or surgery). These patients often do not attend these appointments, instead presenting at A&E with more critical health. This can result in delayed treatment, higher risk and greater NHS expense. Known barriers exist to accessing healthcare; however, the relevance of these to venous healthcare has not been explored previously. What we did: 15 individuals were recruited and interviewed in drop-in clinics in a charity and homeless GP practice in Bristol. Staff in these organisations have built rapport and are known to the participants so directed potential participants. Eligible participants had a history of venous disease, homelessness and injecting drugs. Semi-structured interviews were used to explore the barriers faced, which were then analysed into themes.

What we found

Five separate themes emerged: (1) competing priorities; (2) stigma; (3) practical barriers; (4) treatment limited to anticoagulation and/or compression stockings only; and (5) knowledge and understanding of own health. Barriers previously reported to healthcare utilisation also apply to venous healthcare including stigma, practical barriers and competing priorities to healthcare (eg, drugs or housing). Appropriate opioid substitution treatment (used to help individuals cope with withdrawal symptoms) reduces the need to earn money for drugs, which readjusts priorities towards healthcare. Specific barriers exist related to venous healthcare including: (1) venous ulceration and associated odour cause stigma and embarrassment; (2) treatment for chronic venous conditions is limited to compression with inherent barriers from required compliance; (3) harm reduction and homeless health services cannot refer individuals for specialist vascular review/imaging; and (4) poor knowledge in the target population of groin-related pathologies such as DVT contributes to delayed presentation.

What this means

Barriers exist to accessing venous healthcare with both acute (eg, DVT) and chronic (eg, ulceration) disease for individuals experiencing homelessness and using intravenous drugs. These barriers are exacerbated by poorly managed opioid substitution treatment. Venous ulceration causes stigma and embarrassment contributing to untimely healthcare utilisation. Treatment can be limited to compression and/or anticoagulation only and specialist vascular review/imaging cannot be requested directly by harm reduction and homeless health services. Vascular services need to consider how best to engage and serve this patient demographic to challenge this health inequality.

Click this link to read the unabridged article published in the Journal of Vascular Societies