RESUMO
BACKGROUND: Stigma and discrimination are widely recognised as core social determinants of health. There is a gap in understanding how to intervene at societal and systems level to address stigma. This study aims to theorise how particular care and support systems shape experiences of stigma as it relates to homelessness, and to then develop systems-level interventions. METHODS: We present findings from an ongoing longitudinal ethnographic study, which started June 2022, in south London. Data collection included interviews with people managing, delivering, and using homelessness services (n=41 interviews, two focus groups); participant observation across a range of service settings (>70 h, principally in five sites), and documentary analysis. Participants and research sites gave informed consent. The study was framed by Bourdieu's social practice theory, which structures data collection and analysis around the power and resources individuals have within particular social contexts. We did the analyses using thematic and grounded approaches to qualitative data. FINDINGS: We found that across homeless and health services there was in-depth awareness of stigma and discrimination, but that, collectively, we are "stuck in a rut" in responding to stigma. A proximate challenge was limited clarity and agreement across systems on the nature of the issues involved. A deeper analysis also suggested specific organisational structures and ways of thinking within homelessness and health systems that limit collective discussion and agreement on social and systemic responses to stigma. We also collected data on how stigma was experienced, delineating different forms of stigma and discrimination and where and how they take shape, focusing on enacted, anticipated, and internalised stigma. We also explored how stigma was actively managed and overcome, and how different intersections of systems of inequality produce varying forms of stigma and discrimination. INTERPRETATION: Our study provides insight into how stigma and discrimination could potentially be addressed systemically within homelessness and health systems. The existing collective awareness of stigma and discrimination offers specific opportunities for generating systemic change. Study limitations include the focus on one geographic area of the UK, although we reflect on how our findings could be generalised to other settings. FUNDING: UK Research and Innovation.
