Tackling the needs of the homeless: a controlled trial of health advocacy

The objective of the present study was to assess the effectiveness of a health advocate's casework with homeless people in a primary care setting in terms of improvements in health‐related quality of life (QoL). The impact of the health advocacy intervention was assessed in a quasi‐experimental, three‐armed controlled trial. Homeless people moving into hostels or other temporary accommodation in the Liverpool 8 area of the UK and patients registering at an inner‐city health centre as temporary residents were allocated in alternating periods to health advocacy (with or without outreach registration) or ‘usual care’ over a total intake period of 3 years. Health‐related QoL outcomes were assessed using three independent self‐report measures: the Life Fulfilment Scale; the Delighted–Terrible Faces Scale; and the Nottingham Health Profile. Out of the 326 homeless people who were given baseline questionnaires at registration, 222 (68%) returned usable questionnaires. Out of these individuals, 171 (77.0%) were traceable at follow‐up, and 117 (68.4%) follow‐up questionnaires were returned. The majority of respondents (n = 117) were women (72%) who were under 30 years of age (74%), white British (91%), and single (63%) or separated (23%), many of whom were living with their children (41%) in either women's refuges (30%) or family hostels (25%). Improvements in health‐related QoL were greatest in people recruited and supported by a health advocate early in their stay in temporary housing, in comparison with those in the control group given ‘usual care’ at the health centre. The model of streamlined care for patients with complex psycho‐social needs is shown to be a worthwhile and effective option for primary healthcare providers.     

Self‐reported health,healthcare service use and health‐related needs: A comparison of older and younger homeless people

The number of older homeless people with a limited life expectancy is increasing. European studies on their health‐related characteristics are lacking. This study compared self‐reported health, healthcare service use and health‐related needs of older and younger homeless people in the Netherlands. It is part of a cohort study that followed 513 homeless people in the four major Dutch cities for a period of 2.5 years, starting from the moment they registered at the social relief system in 2011. Using cross‐sectional data from 378 participants who completed 2.5‐year follow‐up, we analysed differences in self‐reported health, healthcare service use, and health‐related needs between homeless adults aged ≥50 years (N = 97) and <50 years (N = 281) by means of logistic regression. Results show that statistically significantly more older than younger homeless people reported cardiovascular diseases (23.7% versus 10.3%), visual problems (26.8% versus 14.6%), limited social support from family (33.0% versus 19.6%) and friends or acquaintances (27.8% versus 14.6%), and medical hospital care use in the past year (50.5% versus 34.5%). Older homeless people statistically significantly less often reported cannabis (12.4% versus 45.2%) and excessive alcohol (16.5% versus 27.0%) use in the past month and dental (20.6% versus 46.6%) and mental (16.5% versus 25.6%) healthcare use in the past year. In both age groups, few people reported unmet health‐related needs. In conclusion, compared to younger homeless adults, older homeless adults report fewer substance use problems, but a similar number of dental and mental problems, and more physical and social problems. The multiple health problems experienced by both age groups are not always expressed as needs or addressed by healthcare services. Older homeless people seem to use more medical hospital care and less non‐acute, preventive healthcare than younger homeless people. This vulnerable group might benefit from shelter‐based or community outreach programmes that proactively provide multidisciplinary healthcare services.     

Dutch homeless people 2.5 years after shelter admission: what are predictors of housing stability and housing satisfaction?

Housing stability is an important focus in research on homeless people. Although definitions of stable housing differ across studies, the perspective of homeless people themselves is generally not included. Therefore, this study explored the inclusion of satisfaction with the participant's current housing status as part of the definition of housing stability and also examined predictors of housing stability with and without the inclusion of homeless person's perspective. Of the initial cohort consisting of 513 homeless participants who were included at baseline in 2011, 324 (63.2%) were also interviewed at 2.5‐year follow‐up. To determine independent predictors of housing stability, we fitted multivariate logistic regression models using stepwise backward regression. At 2.5‐year follow‐up, 222 participants (68.5%) were stably housed and 163 participants (51.1%) were stably housed and satisfied with their housing status. Having been arrested (OR = 0.36, 95% CI: 0.20–0.63), a high level of somatisation (physical manifestations of psychological distress) (OR = 0.52, 95% CI: 0.30–0.91) and having unmet care needs (OR = 0.77, 95% CI: 0.60–0.99) were negative predictors of housing stability. Having been arrested (OR = 0.43, 95% CI: 0.25–0.75), high debts (OR = 0.45, 95% CI: 0.24–0.84) and a high level of somatisation (OR = 0.49, 95% CI: 0.28–0.84) were negative predictors of stable housing when satisfaction with the housing status was included. Because inclusion of a subjective component revealed a subgroup of stably housed but not satisfied participants and changed the significant predictors, this seems a relevant addition to the customary definition of housing stability. Participants with characteristics negatively associated with housing stability should receive more extensive and individually tailored support services to facilitate achievement of housing stability.     

Homelessness—‘It will crumble men’: The views of staff and service users about facilitating the identification and support of people with an intellectual disability in homeless services

People with an intellectual disability (ID) face significant health inequalities and barriers to accessing appropriate support, which are made worse if the person is also homeless. An important barrier is that services may not recognise that the person has ID. This qualitative study explored the views of staff members and service users about the identification and support needs of homeless people with ID and the role of an ID screening questionnaire as a way to help improve service provision. Semi‐structured interviews were conducted with 16 staff members and 8 service users from homeless services in the South East of Scotland between March 2017 and 2018. Thematic analysis identified four themes: ‘not diagnosed or declared’, which explored the barriers to support due to the person's ID not being identified by others or disclosed by the person; ‘It will crumble men’, which reported on the additional challenges faced by homeless people with ID; ‘disabling environment’ which identified the ways in which organisations can make support difficult for people with ID to access; and ‘It's not against them, it's to help them’ which explored the benefits and issues associated with screening for ID in homeless services. The results identified the complex support needs likely to be experienced by many homeless people with ID and suggested a number of implications for practice. First, the screening tool was seen as having a number of benefits, if used where there is a process to provide the person with further specialist assessment and support. Second, staff members identified a need for training in relation to identifying and supporting this group of people. Third, the screening tool was seen as a way to help provide information about the prevalence and needs of people with ID, in order to inform and shape policy, service development, and delivery.     

Impediments to community‐based care for people ageing with intellectual disability in rural New South Wales

The emerging phenomenon of ageing with an intellectual disability has become subject to an increasing research focus in recent years. However, there remains little knowledge regarding the specific impediments that community workers face in supporting this cohort. The aims of the current study were to identify the major factors that, direct care staff believe, have most impact upon individuals ageing with an intellectual disability in the community. A three‐round Delphi project was conducted across rural areas of New South Wales in Australia with 31 disability support workers to gain their perspectives on the main impediments facing a person ageing with intellectual disability. The 2010 study identified that the issue of ageing with an intellectual disability was presenting significant problems for community‐based service delivery to this group of people. The panel identified 25 different impediments to the provision of support. A thematic analysis of the items indicated three main themes of ‘funding’, ‘training’ and ‘access to services’. By identifying these impediments to supporting people ageing with an intellectual disability in the community, both services and government funding bodies have the ability to plan to overcome both current and future problem areas. This identification of impediments may facilitate individuals to receive more appropriate assistance, which in turn may lead to an improved quality of life and maintenance of a community‐based placement rather than premature admission to the congregate‐care system. This study is particularly timely, given that Australia is in the midst of implementing a National Disability Insurance Scheme, and is an opportunity for all levels of government to agree on the mechanisms to appropriately assist individuals with an intellectual disability to continue to be supported in the community as they age.     

The impact of transitional programmes on post‐transition outcomes for youth leaving out‐of‐home care: a meta‐analysis

Youth residing in out‐of‐home care settings have often been exposed to childhood trauma, and commonly report experiencing adverse outcomes after transitioning from care. This meta‐analysis appraised internationally published literature investigating the impact of transitional programme participation (among youth with a baseline age of 15–24 years) on post‐transition outcomes of housing, education, employment, mental health and substance use. A comprehensive search of sociology (e.g. ProQuest Sociology), psychology (e.g. PsycInfo) and health (e.g. ProQuest Family Health) electronic abstraction databases was conducted for the period 1990–2014. Search terms included ‘out‐of‐home care’, ‘transition’, ‘housing’, ‘education’, ‘employment’, ‘mental health’ and ‘substance use’. Nineteen studies, all from the United States, met the inclusion criteria and were included in the meta‐analysis. Living independently and homelessness were the most commonly described housing outcomes. Rates of post‐transition employment varied, while rates of post‐secondary education were low. Depression and alcohol use were commonly reported among transitioning youth. Findings of the meta‐analysis showed that attention should be given to the potential benefit of transitional programme participation on outcomes such as housing, employment and education. Moderator analyses showed that these benefits may differ based on study design, sample size and sampling unit, but not for mean age or gender. Detailed and rigorous research is needed internationally to examine the characteristics of transitional programmes resulting in more successful outcomes for youth, and whether these outcomes are sustained longitudinally.     

Driving forces for home‐based reablement; a qualitative study of older adults’ experiences

As a result of the ageing population worldwide, there has been a growing international interest in a new intervention termed ‘reablement’. Reablement is an early and time‐limited home‐based intervention with emphasis on intensive, goal‐oriented and interdisciplinary rehabilitation for older adults in need of rehabilitation or at risk of functional decline. The aim of this qualitative study was to describe how older adults experienced participation in reablement. Eight older adults participated in semi‐structured interviews. A qualitative content analysis was used as the analysis strategy. Four main themes emerged from the participants’ experiences of participating in reablement: ‘My willpower is needed’, ‘Being with my stuff and my people’, ‘The home‐trainers are essential’, and ‘Training is physical exercises, not everyday activities’. The first three themes in particular reflected the participants’ driving forces in the reablement process. Driving forces are intrinsic motivation in interaction with extrinsic motivation. Intrinsic motivation was based on the person's willpower and responsibility, and extrinsic motivation was expressed to be strengthened by being in one's home environment with ‘own’ people, as well as by the co‐operation with the reablement team. The reablement team encouraged and supported the older adults to regain confidence in performing everyday activities as well as participating in the society. Our findings have practical significance for politicians, healthcare providers and healthcare professionals by contributing to an understanding of how intrinsic and extrinsic motivation influence reablement. Some persons need apparently more extrinsic motivational support also after the time‐limited reablement period is completed. The municipal health and care services need to consider individualised follow‐up programmes after the intensive reablement period in order to maintain the achieved skills to perform everyday activities and participate in society.     

Improving health literacy in a Japanese community population—A pilot study to develop an educational programme

Objective

Although a growing number of interventional studies on health literacy have been conducted recently, the majority were designed in clinical settings, focusing mainly on functional health literacy. This study evaluated a programme designed to improve health literacy in a community population, with a scope of going beyond functional health literacy.

Methods

In collaboration with an Approved Specified Nonprofit organization (NPO), we evaluated a five‐session programme designed to provide basic knowledge on health‐care policy and systems, current issues in health care in Japan, patient roles and relationships with health‐care providers and interpersonal skills. In total, 67 of 81 programme participants agreed to participate in the study, and 54 returned the completed questionnaires at baseline and at follow‐up. Health literacy and trust in the medical profession were measured at baseline and at follow‐up. Participants’ learning through the programme was qualitatively analysed by thematic analysis.

Results

Quantitative examinations of the changes in health literacy and degree of trust in medical professionals between the baseline and follow‐up suggested that health literacy significantly improved after implementing the programme. The thematic analysis of participants’ learning throughout the programme suggested that they not only acquired knowledge and skills but also experienced a shift in their beliefs and behaviours.

Discussion

Providing individuals who are motivated to learn about health‐care systems and collaborate with health‐care providers with the necessary knowledge and skills may improve their health literacy, which could enable them to maintain and promote their health and that of their family and other people around them.     

Needs of homeless people coping with psychiatric problems: findings from an innovative advocacy project

In this article the authors report on the self-perceived needs of 40 homeless people who are coping with psychiatric problems. These people were among 207 with psychiatric problems participating in an innovative advocacy project based outside the formal mental health system. Compared with domiciled participants, the homeless participants had more accentuated and somewhat different major daily living needs in the areas of income and benefits, housing, legal services, employment, and health care. On the basis of these findings, the authors draw implications for social work practice with homeless people coping with psychiatric problems.     

Follow‐up care in cancer: adjusting for referral targets and extending choice

Background Over recent years, several initiatives have impacted on the referral of patients to secondary care, most notably targets for urgent referral in suspected cancer and the patient choice agenda. At the same time, improved long‐term survival in cancer has increased numbers attending follow‐up, doubts about the effectiveness of specialist follow‐up have emerged, and alternative models of follow‐up have been tested. Aim The aim of the study was to explore patient and carer perspectives on the flexibility and responsiveness of cancer services. This article focuses on findings relating to referral, subsequent outpatient appointments and cessation of outpatient follow‐up. Methods Issues were explored in a qualitative study using face‐to‐face interviews with a purposive sample of 54 people affected by cancer. Data were analysed concurrently with data collection, using qualitative analysis software. Findings The study gave rise to a number of salient themes. Links were identified between three of these: choice and responsiveness during referral; the flexibility and responsiveness of outpatient appointment systems; and negotiating cessation of follow‐up. It appeared that policy on urgent referrals might be adversely affecting practice relating to appointment systems and the continuance of follow‐up. Discussion and conclusions Hospital‐based cancer follow‐up is being given decreasing priority because of doubts about effectiveness and a target‐driven focus on referral. This is impacting on patients, who may value outpatient follow‐up as a ‘safety net’ but have difficulties in obtaining appointments, and may be discharged without negotiation or adequate support. For these reasons, new forms of flexible/responsive aftercare are urgently needed.     

Kickin’ Asthma: School‐Based Asthma Education in an Urban Community

BACKGROUND: In urban communities with high prevalence of childhood asthma, school‐based educational programs may be the most appropriate approach to deliver interventions to improve asthma morbidity and asthma‐related outcomes. The purpose of this study was to evaluate the implementation of Kickin’ Asthma, a school‐based asthma curriculum designed by health educators and local students, which teaches asthma physiology and asthma self‐management techniques to middle and high school students in Oakland, CA. METHODS: Eligible students were identified through an in‐class asthma case identification survey. Approximately 10‐15 students identified as asthmatic were recruited for each series of the Kickin’ Asthma intervention. The curriculum was delivered by an asthma nurse in a series of four 50‐minute sessions. Students completed a baseline and a 3‐month follow‐up survey that compared symptom frequency, health care utilization, activity limitations, and medication use. RESULTS: Of the 8488 students surveyed during the first 3 years of the intervention (2003‐2006), 15.4% (n = 1309) were identified as asthmatic; approximately 76% of eligible students (n = 990) from 15 middle schools and 3 high schools participated in the program. Comparison of baseline to follow‐up data indicated that students experienced significantly fewer days with activity limitations and significantly fewer nights of sleep disturbance after participation in the intervention. For health care utilization, students reported significantly less frequent emergency department visits or hospitalizations between the baseline and follow‐up surveys. CONCLUSIONS: A school‐based asthma curriculum designed specifically for urban students has been shown to reduce symptoms, activity limitations, and health care utilization for intervention participants.     

Evaluating a low‐intensity cognitive behavioural program for young people in regional Australia

NewAccess is a low‐intensity cognitive behavioural program which was recently trialled for the first time in Australia for clients aged under 18. Given that accessing support earlier tends to result in better outcomes for people with mild‐to‐moderate mental health issues, having NewAccess available for young people has the potential to reduce the likelihood of mild‐to‐moderate mental health concerns developing into more serious, or chronic mental illness over time for some clients, while also freeing up resources for those with more severe support needs. This mixed methods approach presents the findings of an independent evaluation of the program delivered out of two regional headspace centres in 2017‐2019. From an initial sample of 165 young participants aged between 12 and 25, 109 completed the program. Of those who completed the program 60 were under the age of 18. The standardised assessment and outcome measures indicated a very good response to the program, with the majority showing significant improvements in their depression, anxiety and psychological distress scores. The overall ‘reliable improvement’ and ‘recovery rates’ were 64.2% and 72.3% respectively. Overall, the results indicated this program was an acceptable and efficacious intervention for young people in rural settings, when delivered in a ‘youth‐friendly’ service environment.     

Supportive housing for chronically homeless individuals: Challenges and opportunities for providers in Chicago,USA

Chronically homeless individuals often have extensive health, mental health and psychosocial needs that pose barriers to obtaining and maintain supportive housing. This study aims to qualitatively explore supportive housing providers’ experiences and challenges with housing chronically homeless individuals and examine opportunities to improve supportive housing systems of care. In 2014, we conducted qualitative in‐depth interviews with 65 programme administrators and case managers of supportive housing programmes in Chicago, IL. Data were analysed using an inductive thematic content analysis. Analysis revealed four themes that capture the primary challenges faced by housing providers: housing priorities, funding cuts, co‐ordinated entry and permanency of housing. Housing for the chronically homeless has been prioritised, yet service providers are being expected to provide the necessary services to meet the needs of this population without commensurate funding increases or agency capacity. Additionally, case managers and administrators discussed the tension over housing tenure and the permanency of supportive housing. Findings provide qualitative insight into the challenges providers face implementing supportive housing for chronically homeless individuals.     

Entry and re‐entry into informal care‐giving over a 3‐year prospective study among older people in Nairobi slums,Kenya

This paper analyses data from a 3‐year prospective study to understand the factors associated with becoming a caregiver to a person with a chronic illness and examines the dynamics among caregivers over time. A total of 1485 participants were drawn from a study conducted in the slums of Nairobi, Kenya. Two waves of data collected in 2006 for the baseline and a follow‐up in 2009 were used. Information on the demographic, self‐reported health and socioeconomic characteristics such as education, sources of livelihood and employment status was used. Age was a significant factor in becoming a caregiver, but there were no significant differences by gender or marital status. New caregivers and those with more than one care‐giving episode had a higher socioeconomic position than non‐caregivers. Caregivers also had poorer health compared with non‐caregivers, highlighting the association between being a caregiver and negative health outcomes. Additionally, having cared for someone with a HIV‐related illness compared with other chronic conditions increased the likelihood of subsequently caring for another person in need of long‐term care. This may be due to the heterosexual mode of HIV transmission in sub‐Saharan Africa, hence clustering of infection within family or married couples. This finding draws attention to the need to provide timely interventions to caregivers for people with HIV‐related illness who are likely to end up providing care to multiple care recipients. Furthermore, there is a need to enhance the indispensable contribution of informal caregivers through incorporating their role within the continuum of care for effective HIV and AIDS management. Overall, informal caregivers to persons with chronic illnesses perform the tasks of care‐giving without any formal support from health or social services. Therefore, it is crucial to initiate policies and programmes to ease the burden of care that is borne by informal caregivers.     

Self‐directed community services for older Australians: a stepped capacity‐building approach

Consumer‐directed care (CDC) is increasingly widespread among aged care service options in Organisation for Economic Co‐operation and Development (OECD) countries. However, the evidence base regarding the programmatic and contextual factors that affect the outcome of CDC interventions is surprisingly small. This paper reports on a self‐directed care approach for older Australians with complex care needs. A multi‐methods longitudinal comparative cohort study was employed comprising 4 survey tools and 56 semi‐structured interviews. Participation rates were around 20%. A total of 185 (98 in the intervention and 87 in the control group) older people and carers were recruited at baseline. Eleven months later, 109 participants (59 in the intervention and 50 in the control group) completed the repeat measure. Attrition rates were around 40%. Data collection occurred between July 2010 and April 2012. The data suggest that intervention group participants were likely to be more satisfied with the way they were treated (P = 0.013), their care options (P = 0.014), the ‘say’ they had in their care (P < 0.001), the information they received regarding their care (P = 0.012), what they were achieving in life (P = 0.031), that the services changed their view on what could be achieved in life (P = 0.020) and with their standard of living (P = 0.008). The evaluation suggests that while only a very small segment of older people is interested in a voucher or cash option, a substantially larger group would like to have greater say over and more direct access to their care, without, however, assuming administrative and financial responsibilities. The paper concludes that a stepped capacity‐building approach to CDC may improve the acceptability of CDC to older people and generate synergies that improve older people's care outcomes.     

Health status and utilisation of the healthcare system by homeless and non‐homeless people in Vienna

This case–control study describes the health situation, internal and external resources, and utilisation of healthcare facilities by a marginalised population consisting of homeless people in Vienna, Austria, compared with a non‐homeless control population. Among the homeless group, participants lived in halfway houses (70%) or permanent housing (30%) in Vienna. Personal interviews were conducted in July 2010 with 66 homeless individuals, and their data were compared with data from non‐homeless subjects from the Austrian Health Interview Survey using conditional logistic regression. Compared with the control group, homeless persons suffered more often from chronic diseases (P < 0.001) and rated their health considerably lower than the comparison group (P < 0.001). Homeless people suffered significantly more often from psychiatric disorders, respiratory diseases, hypertension (P < 0.001), digestive system diseases (P = 0.002) and heart diseases (P = 0.015) in comparison with the control group. Additionally, among homeless and non‐homeless individuals, the former more often consulted a general practitioner in a period of 28 days (P = 0.002). A significantly greater proportion of homeless people did not have any teeth (P = 0.024) and smoked significantly more (P = 0.002). The results demonstrate deficits in the areas of health, health behaviour, and individual and social resources of homeless people, even though homeless people seek medical care at a higher rate than controls. Continuing health promotion projects for this high‐risk group and the strengthening of social resources are recommended.     

‘We are always in some form of contact’: friendships among homeless drug and alcohol users living in hostels

Homeless drug and alcohol users are one of the most marginalised groups in society. They frequently have complex needs and limited social support. In this paper, we explore the role of friendship in the lives of homeless drug and alcohol users living in hostels, using the concepts of ‘social capital’ and ‘recovery capital’ to frame the analyses. The study was undertaken in three hostels, each in a different English city, during 2013–2014. Audio recorded semi‐structured interviews were conducted with 30 residents (9 females; 21 males) who self‐reported drink and/or drug problems; follow‐up interviews were completed 4–6 weeks later with 22 participants (6 females; 16 males). Data were transcribed verbatim, coded using the software package MAXQDA, and analysed using Framework. Only 21 participants reported current friends at interview 1, and friendship networks were small and changeable. Despite this, participants desired friendships that were culturally normative. Eight categories of friend emerged from the data: family‐like friends; using friends; homeless friends; childhood friends; online‐only friends; drug treatment friends; work friends; and mutual interest friends. Routine and regular contact was highly valued, with family‐like friends appearing to offer the most constant practical and emotional support. The use of information and communication technologies (ICTs) was central to many participants' friendships, keeping them connected to social support and recovery capital outside homelessness and substance‐using worlds. We conclude that those working with homeless drug and alcohol users – and potentially other marginalised populations – could beneficially encourage their clients to identify and build upon their most positive and reliable relationships. Additionally, they might explore ways of promoting the use of ICTs to combat loneliness and isolation. Texting, emailing, online mutual aid meetings, chatrooms, Internet penpals, skyping and other social media all offer potentially valuable opportunities for building friendships that can bolster otherwise limited social and recovery capital.     

Do models of care designed for terminally ill ‘home alone’ people improve their end‐of‐life experience? A patient perspective

Palliative care patients who live alone report greater psychological distress, and are less likely to die at home than those living with a family carer. However, there is a lack of research on the value of models of care that specifically address this disadvantage. This article describes the experiences of terminally ill ‘home alone’ people using one of two models of care aimed at maintaining participants’ need for independent living, focusing on the effect of these two models of care on their physical, social and emotional needs. Twenty six palliative care patients of Silver Chain Hospice Care, in Western Australia, were randomly assigned to either having a personal alarm or additional care‐aide hours in their home. An in‐depth qualitative study was conducted in two phases in 2010 using face‐to‐face interviews. The care‐aide model of care resulted in benefits such as easing the burden of everyday living; supporting well‐being; enhancing quality of life and preserving a sense of dignity; and reducing loneliness and isolation. The personal alarm model of care imparted a sense of security; provided peace of mind; and helped to deal with feelings of isolation. Participants in both groups felt that they could remain at home longer. By providing a safer, more secure environment through the use of a personal alarm or additional care‐aide hours, patients were able to continue their activities of daily living, could build a sense of ‘normality’ into their lives, and they could live independently through support and dignity.     

Oral health problems and support as experienced by people with severe mental illness living in community‐based subsidised housing – a qualitative study

The purpose of this study was to explore how persons with severe mental illness (SMI) experience oral health problems (especially dry mouth), and weigh the support they received in this regard from professionals and staff at community‐based congregate housing through a controlled intervention programme. Oral health problems and dry mouth are found in association with apathy and indifference, cognitive deficits, and long‐term medication with psycho‐pharmacological drugs. The present study describes the results from one part of a longitudinal intervention programme, which sought effective ways of mitigating dry mouth through increased support with oral health problems. This part consists of 67 informal interviews with ten participants in two community‐based urban housing projects between November 2006 and June 2007, with a follow‐up session in December 2007. Content analysis of the results yielded five categories: The shame of having poor dental health, history of dental care, experiences of self‐care, handling of oral health problems, and experiences of staff support. Poor oral health caused shame and limited participation in social activities. Participants avoided oral health issues by such circumventions as denial of a tooth ache or dental infections, or postponing oral problems with the hope that they would die away. Offers of support were frequently resisted because of unsatisfactory prior encounters with dental professionals and staff. Our findings suggest that self‐care needs to be facilitated in an unobtrusive manner with minimal staff involvement, and clients should be referred to dental care providers experienced in treating people with SMI.