The way of life of the unhoused people as an enhance for COVID-19 care

Modo de vida de población en situación de calle como potenciador del cuidado de COVID-19

ABSTRACT

Objective:

To analyze the way of life of the unhoused people to enhance health care in the pandemic.

Methods:

A qualitative, interdisciplinary research, with participant observation and 24 interviews with the unhoused people. Empirical categories and bibliographic search on this population and COVID-19 guided simple actions aimed at care.

Results:

The group at greatest risk for COVID-19 use drugs compulsively; starves constantly; discontinues drug treatment for tuberculosis, HIV, and diabetes; has underdiagnosis of Depression; has difficulty sheltering and uses inhaled drugs. This way of life increases the risk of worsening COVID-19 and brings great challenges to health services. Several proposals to guide care considered these results and the new routine caused by the pandemic.

Final considerations:

The way of life of the studied population increased their vulnerability in the pandemic, as well as the perception of risk of disease transmission by the population in general.

Descriptors
Homeless Persons; Coronavirus Infections; Social Vulnerability; Primary Health Care; Life Style

RESUMEN

Objetivo:

Analizar el modo de vida de la población en situación de calle (PSC) para potenciar el cuidado en salud en la pandemia.

Métodos:

Investigación cualitativa, interdisciplinaria, con observación participante, y 24 entrevistas con población en situación de calle. Categorías empíricas y búsqueda bibliográfica sobre dicha población y COVID-19 determinaron propuestas simples orientadas al cuidado.

Resultados:

El grupo más vulnerable a COVID-19 usa drogas compulsivamente, pasa hambre, interrumpe tratamiento médico para tuberculosis, VIH y diabetes; tiene subdiagnóstico de depresión, dificultad para hallar refugio y usa drogas inhalantes. Dicho modo de vida incrementa el riesgo de agravamiento del COVID-19, imponiendo mayores desafíos a los servicios de salud. Diversas propuestas de orientación del cuidado consideraron estos resultados y las nuevas rutinas impuestas por la pandemia.

Consideraciones finales:

El modo de vida de la población estudiada incrementó su vulnerabilidad en pandemia, así como la percepción de riesgo de transmisión de la enfermedad a la población en general.

Descriptores:
Personas sin Hogar; Infecciones por Coronavirus; Vulnerabilidad Social; Atención Primaria de Salud; Estilo de Vida

RESUMO

Objetivo:

Analisar o modo de vida da População em Situação de Rua para potencializar o cuidado em saúde na pandemia.

Métodos:

Pesquisa qualitativa, interdisciplinar, com observação participante e 24 entrevistas com população em situação de rua. Categorias empíricas e busca bibliográfica sobre essa população e COVID-19 pautaram proposições simples voltadas ao cuidado.

Resultados:

O grupo de maior risco para COVID-19 faz uso compulsivo de drogas; passa fome constantemente; interrompe tratamento medicamentoso para Tuberculose, HIV e Diabetes; tem subdiagnóstico de Depressão; tem dificuldade de abrigamento; usa drogas inalatórias. Esse modo de vida aumenta risco de agravamento da COVID-19 e impõe maiores desafios aos serviços de saúde. Diversas propostas para orientar o cuidado levaram em conta esses resultados e a nova rotina impressa pela pandemia.

Considerações Finais:

O modo de vida da população estudada ampliou sua vulnerabilidade na pandemia, bem como a percepção de risco de transmissão da doença pela população em geral.

Descritores:
Pessoas em Situação de Rua; COVID-19; Vulnerabilidade Social; Atenção Primária à Saúde; Estilo de Vida

INTRODUCTION

The COVID-19, a disease caused by the SARS-CoV-2 coronavirus, has already caused infections, deaths, and financial loss throughout the planet. Factors such as age, smoking and having certain comorbidities can increase the risk of developing the severe form of the disease, while the difficulty of accessing highly complex health services for patients with severe conditions increases the likelihood of death⁽¹⁾. Precautions such as handwashing with soap and water, use of hand sanitizer, social distance (#Stayhome!), and healthy eating are efficient ways to prevent infection⁽¹⁾. However, taking simple actions in the daily lives of people that have an income and housing proved to be exhaustive, and quite challenging for the most vulnerable. On the other hand, such recommendations are unfeasible for those without a home, income, or access to sufficient food and potable water.

This aspect of the pandemic proves that it is not limited to numbers, drugs, technologies, or vaccines. Particularities on social inequalities^(2-3), ethics⁽⁴⁾, behaviors, cultures, ways of life are essential to face it properly^(3,5), mainly because its effects can be perpetuated in the post-pandemic given the economic crisis triggered by it.

The emergence of COVID-19 reflects inequality because although its spread is democratic, the population’s unequal conditions cause different risks of illness and death. In this sense, despite reaching universal numbers, the phenomena are distinctive, therefore, Human science’s contribution is essential in this context⁽⁶⁾.

The Unhoused People (UP) in Brazil is characterized by extreme poverty, irregular food habits, poor hygiene, sleep deprivation, exposure to weather variations⁽⁷⁾, poor search for public services, and difficulty in accessing them^(7-8) and most of them are not covered by social inclusion programs⁽⁷⁾, all of which are conditions for the contagion and worsening of the disease. Furthermore, the great uncertainties about their daily lives and the spread of partial “truths”⁽⁹⁾ about UP, hinder effective public policies.

The high prevalence of tuberculosis, HIV/AIDS, Hepatitis, psychiatric comorbidities, high-risk pregnancies, mouth problems, abuse of alcohol and other drugs in UP in the Brazilian context⁽⁷⁾ are also factors that increase their vulnerability in coping with COVID-19, as well as causing an additional challenge to SUS, requiring management between health and social assistance. UP still faces the difficulty of recognizing its rights and citizenship.

This article comes from the concern among researchers and health professionals of a Consultório na Rua (CnaR) (Clinic on the Street), in deepening the knowledge on the way of life of UP to reflect on health care in times of pandemic.

The CnaR is characterized by multi-professional teams, integrated with Atenção Primária em Saúde (APS) (Primary Health Care), who work in an itinerant way aimed at expanding the offer of comprehensive and adequate care to UP’s demands and needs.

The motivation for the research comes from the clinical complexity of UP, the severity of this pandemic, and the need for extra precautions in conditions of greater risk and vulnerability, making the work of health professionals even more challenging.

It was made possible because we conducted a broader, recently concluded qualitative research that investigates health care for UP. The set of results stimulated reflections on care at COVID-19 times, starting with the following questions: how to contribute with new perspectives and actions to cope with COVID-19 with this vulnerable population? How can the production of meaning about the way of life of the UP enhance the provision of care?

Other studies have already addressed the imbrication between the way of life or lifestyle and health, whether related to adolescence⁽¹⁰⁾, the unhoused crack user⁽⁹⁾, or the health-disease process of UP⁽¹¹⁾. Given the polysemy of the term “way of life”⁽¹²⁾, in this research it is understood as to how people experience the world, separating themselves between specific groups, through behavioral characteristics, language, habits, routines, and patterns of consumption.

The human sciences enable us to share unique experiences, where each one is important and allow us to think in a precise way its effects⁽⁶⁾. Thus, mitigating actions to face the pandemic benefit from both collective and individual sensitivities. Knowledge from the area of Human and ​​Social Sciences was essential to stop devastating epidemics⁽³⁾, considering that they are not exclusively biological, but also social phenomena⁽⁵⁾. Poverty and inequality demand not being restricted to the knowledge of the medical and exact sciences.

OBJECTIVE

Analyze the way of life of the unhoused people, to enhance health care in the COVID-19 pandemic.

METHODS

Ethical aspects

This research followed CNS/MS no. 510 resolutions, of 04/07/2016, and CNS/MS no. 466, of 12/12/2012 and was approved by the Research Ethics Committees (CEP) of the Escola Nacional de Saúde Pública Sergio Arouca and the Municipal Health Department and Civil Defense of Rio de Janeiro.

Study design and type

This is a descriptive-exploratory study, of a qualitative approach, comprehensive and Heideggerian phenomenological perspective, interdisciplinary character, reflective posture, following the recommendations of the Standards for Reporting Qualitative Research (SRQR). Interviews with the UP assisted by the CnaR and participant observation about this care carried out from 03/2017 to 09/2018, a period before the SARS-CoV-2 pandemic were used.

Study setting and participants

The interviewee was approached at a Family Health Clinic in the city of Rio de Janeiro, in the CnaR waiting room, as the area used by the UP went through an intense incursion of public security with an outcome of sudden shootings. The selection of patients was made by CnaR professionals, accompanied by the researcher to present the research and, upon agreement, the patient and researcher went to a private room with guaranteed privacy. No specific criterion or standard was used in this process of choosing the interviewees, instead, participant observation helped to include patients in their multiplicity, with no intention of representativeness, but rather of diversity.

All respondents were over 18 years old and were attended by the CnaR, which counts on a Social Worker, Nurse, Doctor, Dentist, Psychologist, Nursing Technician, and Social Agents. Tuberculosis patients still in the infectious phase were excluded, as the interview was conducted in a closed room.

Data collection and organization

The participant observation was carried out together with the CnaR’s work in the following spaces: reception, waiting room, CnaR’s office, procedure room, area (shacks, drug use settings, streets, UPA, Hospitals, social facilities, others) and team meetings.

Twenty-four interviews were carried out, starting from a previous script, but conducted openly, with the possibility of the speeches’ free flow, allowing the phenomenon to be expressed in the language itself. The assumption is that the narrative is only (and everything) what you have, since you do not have access to the “facts”, to what was experienced. Thus, considering that the narrative comes from the experience shared with the other, we take the contents of the interviews as narratives, by recognizing the role of the report in the establishment of social phenomena.

As a measure to expand the possibilities to cope with the current pandemic by the UP, a bibliographic search was made on UP and COVID-19 on national and international bases, finding 33 documents for analysis published until 07/2020.

Research data before the pandemic, supported by a bibliographic review on SARS-CoV-2, enabled the production of this article on how to enhance the health care of UP in coping with COVID-19.”

Data analysis

Besides the data resulted from the transcription of the interviews’ audios, the researchers’ field diary was also used. With this, the reading of the material and the grouping into units of meaning began, using the phenomenological narrative method⁽¹³⁾ that enables the dialogical description between the subjects, making it historical, unique and collective. From the grouping of data, the following empirical categories were created on the UP way of life: work/income, benefit, illness, living on the street, hunger, support network, shelter, drugs, feelings. These categories were used to support the construction of actions that could enhance the fight against COVID-19.

It was supported by Evans-Pritchard’s ethnographic approach⁽¹⁴⁾ of “not taken-for-granted” by adopting the categories that make sense to them, reflecting on the question: “How does the narrator count?”. This methodology that opposes and put together the narratives (among themselves), is effective in the sense of providing not a “finished truth”, but a “probable version” (and refutable) among so many, like the principle of scientific thought. In the presentation of the results, fragments of these ipsi literis narratives are marked with quotation marks in the description of the analyzes.

Based on the bibliographic review and the empirical categories of this study, we propose simple actions to enhance/improve the care of UP.

RESULTS

Impressions and sociodemographic characteristics

Of the 24 people interviewed, 14 were male and 10 were female. Most were adults (30 to 60 years old), greater among the 40 to 50 age group, ranging from 20 to 66 years. The black race was predominant and 1/3 of the white race, was a caboclo (mestizo of white with Indigenous) individual. All were born in the Southeast Region, the great majority (83%) from the State of Rio de Janeiro. About schooling, 1/3 was illiterate or finished the first cycle of elementary school and half had a high school or college degree.

Although this was a group of adult age, the frequency of people using a pacifier or wearing strigs with a pacifier hanging from it, caught our attention and, although there was no information on sharing this object, hygiene did not seem to be adequate. The use of vocabulary in the diminutive or staggering language by some, compatible with an infantile behavior, was also remarkable in this research.

In the context of the pandemic, guidance on cleaning and not sharing pacifiers is important, an object that is rarely cited in the COVID-19 guidelines for coping with UP. Furthermore, infantilized patients deserve greater emphasis on guidance to avoid contamination and worsening of the disease.

The feeling of researchers in the face of certain risky and harmful situations of housing allows us to assume about the range of the vulnerability concept, especially when we are faced with an exposed and precarious way of life: the vulnerability of vulnerability. The current pandemic leaves no hesitation about the need to increase shelter offerings, an alternative for access to potable water, and that these obstacles may aggravate the confrontation of COVID-19 in UP, as well as the suffering of CnaR professionals.

Dealing, hunting, and scavenging represent the main work, and income activities for this group (62.5%); followed by informal workers (street vendors, peddlers, bricklayers, car watchers, crafts); beneficiaries, retirees, and pensioners; pleading and “begging” and some did nothing at all, they lived from objects and food donations, without any active attitude of seeking some pay. This way of life, work, and income source described by the UP have direct implications for the pandemic. Social isolation has an incisive impact on this form of livelihood, given that non-essential activities have been suspended and the urban circulation has slowed down, implying greater restrictions among a population with no minimum living conditions. The recyclable collection activity itself can facilitate the infection by COVID-19.

Benefit and Unhoused People

The UP often refers to social benefits as not being easy to obtain or the amount being insufficient to leave the streets, however, most do not consider it as a right:

It is very difficult to get the money you have the right to. (Subject 9)

The thing is that the amount of the benefit is not enough to pay for housing and live off the street. (Subject 2)

It is a shame. (Subject 4)

I do not agree with the donation of food, clothing, everything, by Evangelicals, because they [UP] need to take responsibility for getting food, getting clothes, everything. (Subject 8)

The little understanding of being a person with rights, plus the lack of information and digital access, increase the barriers to seek the coronavoucher benefit⁽¹⁵⁾ created in the context of the pandemic, making it unlikely to get it.

Health Problems of the Unhoused People

The health problems under treatment at the time of the interview were: Tuberculosis (TB) (25%), HIV (17%), skin problems (17%), substance addiction (17%), mental illness (17%), Diabetes (8%), other STIs (8%), respiratory diseases (8%), flu (8%), eye problems (8%), epilepsy (4%), mouth problems (4%). Symptoms compatible with a diagnosis of depression were very present in the interviews, mainly related to drug use, family breakups, deaths of relatives and lonely daily life. However, it was opted not to include it in the description above, as it was not mentioned voluntarily as a health problem. However, depression appears as an important underestimated health problem among UP, little contemplated by health services and undertreated, despite the suffering caused.

Interviews and Participant Observation showed the frequent discontinuation of health treatments because of compulsive drug use, as will be explored below. The profile of UP illnesses, the number of patients with comorbidities and interruptions in treatment raise the potential for more severe development of COVID-19 and deserve increased CnaR surveillance among the most vulnerable ones.

Way of life: living on the street

Half of the interviewees have lived for long years on the street (from 5 to over 30), while the other half lives going back and forth to the street. Of these, four respondents had been unhoused for less than a year.

In this back and forth between housing (family/shelters) and the street, going home is motivated by weight loss, lack of food, and worsening health conditions due to discontinuation of the medication. This speech was very frequent among the interviewees:

I go home, I go back to the streets, I go home, I go back to the streets. (Subject 23)

After losing weight I go home. (Subject 5)

Because the street is not a place for me. It is a place to come and go, not to live. (Subject 20)

The new social dynamic that calls for isolation for 14 days due to the possibility of infection may increase issues about this way of life. This can create embracement barriers in shelters and homes, increasing homelessness and decreasing the chances of recovering the UP’s health status, besides risking family members.

For almost all (23), the street has nothing good, being described by some with the following words: “difficult”, “a lot of dirt”, “no friends”, “place of deprivation”, “hunger”, “being cold”, “I live in need” or that there are places and people who help and others who discriminate, or even that the street is full of drug relapses and impossibilities.

Way of life: hunger and support networks

Three people said they did not feel hungry on the street due to the help of people, shops, and religious entities. Some move to places where there is “food that passes”, in analogy to the distribution of food by groups or individuals to UP. Those who said they do not feel hungry, do not use or make moderate use of drugs, managing to organize receiving meals by local shop owners.

Those who said they were hungry (88%) sometimes resort to the same strategies described above but compared this situation with intensive drug use. Seven respondents stated that all money is for drugs (crack) and not for food.

As the cost of drugs such as crack or hard liquor is low, less than the cost of a meal, getting a small amount of money urges the person to stop any profitable activity and buy the drug. Two frequent reports are:

[When] I don’t eat, then it’s just drugs, drugs, drugs, drugs, drugs, I try to use more drugs, more drugs to feed the hunger . (Subject 7)

It is from the garbage that I take my food too. When I can’t [get money]. (Subject 16)

Thus, hunger is described as “very bad”, “suffering” and most believe that they need help because otherwise, they will not eat for several days, causing dizzying weight loss. As “addiction that overcomes hunger”, getting help or going home are the only ways that several respondents find to eat.

Regarding support networks established on the street, it was almost unanimous that no one is trusted on the street, not even the UP itself. The absence of interpersonal support was exposed as a deep feeling of loneliness and distrust, especially related to drugs. Emblematic phrases translate this feeling:

The more I know the human being, the more I miss my dog . (Subject 4)

You only have friends when you have something to offer. (Subject 13)

Without support from each other, other support networks mentioned were family, health professionals, partners, childhood friends, residents/Shop owners in the neighborhood.

For those who live on the street, hunger is mitigated by shop owners, religious entities, health services and people in the neighborhood, however, closing shops, reduced operation of restaurants, and reduced circulation of people in quarantine impairs the supply of this basic need, besides increasing feelings of loneliness and helplessness. The mobilization to provide meals by actors with a greater role in society, including social assistance and health professionals, represents a simple, but essential and differential action in maintaining lives and facing SARS-CoV-2.

Way of life: shelter

Difficulties and inadequacies reported by the UP about staying in shelters, which we can compare in the context of the pandemic are strict discipline; bad conditions; lack of structure and hygiene; activities restricted to games. For those who seek abstinence, shelters are sometimes seen as permissive to the use of drugs, sometimes as places where one cannot even talk about the subject. This conflicting relationship between the UP and shelters is described with the following expressions: “it does not recover anyone”, “not worth it”, “like a jail”. Those who had a positive experience, thought that shelter is good for “elderly people”, for “getting off the street” or for those who “have no alternative”.

The pandemic increased the risk for UP and its health requirements increased the need for shelter to provide adequate conditions (access to potable water, soap, food, less weather exposure) for the prevention of contagion and social distancing. However, the participant observation, carried out before the pandemic, already showed that the shelters resented admitting patients with health problems because they did not have the structure to support them. This fact becomes more relevant, especially since COVID-19 may cause a sudden deterioration.

Therefore, our proposal for the implementation of the telehealth modality by the CnaR to shelters, with the intervention of workers in shelters and a careful evaluation of the face-to-face service indications or directing to emergency assistance, has multiple benefits. This new type of assistance requires increased articulation with social assistance (shelters, popular motels) and the use of remote communication technology. It enables to improve shelter conditions, reduce the risk of contamination by reducing the circulation of professionals and UP and support workers in shelters with guidance on contagion and management of compulsive drug use. Another advantage is the existence of specialized human resources for its implementation, which is a major challenge nowadays, and requires low investment in infrastructure to expand access and improve health actions and results.

Way of life and drug use

All interviewees had already used or were using drugs, with some using several types. The most used drugs were crack, cocaine, cachaça (distilled alcoholic beverage from sugar cane). Those with less use: paint thinner/glue, inhalant drugs, ecstasy.

The effects reported as deleterious are linked to the feeling of loss in general. In the context of the pandemic, the losses refer to health, self-esteem to the family. Drug addiction impairs self-care, diet and regular use of medications. Furthermore, it makes you lose weight, causes panic, causes loss of money, family relationships, employment, dignity. Self-image is distorted because the person is often dirty, has bad teeth, feels messy, while other respondents see the drug as a companion or cheap:

I will die [...] if I am just seeking for crack, I am already scrawny, I am skin and bone. (Subject 17)

As I was very disappointed with the human being, the drug became my company. (Subject 1)

In the pandemic context, factors related to the use of drugs reported, aggravated using inhaled drugs, corroborate the inclusion of UP as a population at risk.

Feelings of those who live on the street

Feelings from the experience of being unhoused were loneliness, sadness, fear, deception, and distrust. The suffering told by the UP is mainly related to drug use and the way of life itself. The research revealed peculiarities of this population, lack of housing, family relationships, friendship, formal employment, access to basic care, self-esteem and feeling of importance and dignity. The decrease in people walking around and the closing of shops, as a mitigation measure for contagion, may have intensified the suffering experienced by UP.

To affirm self-loneliness, whether for being unhoused or concerning life’s problems, the expression “it is just me and God” is repeated. God is always considered to be present, even when everyone else is missing or in the deepest loneliness, there is also an allusion to the inadequacy of the system, as can be observed in the following narratives:

I have nothing, man. I only have Jesus. (Subject 8)

I can’t fit in either hell or heaven. (Subject 15)

The fear of dying, whether because of violence, interruption of health treatment or drug use, is part of the UP’s life. There was also a fear of being cared for in unknown health services, of suffering prejudice for being a drug user and for being an unhoused person.

Many express fears of the consequences of violence against the UP: suffering “cowardice” or being the target of eradicating squads. The emptying of the streets allows episodes of violence against this population, increasing feelings of insecurity and causing conditions of anxiety disorder, panic, paranoia, or other symptoms of mental suffering.

COVID-19 and population at risk

Among the UP there is a group with a converging way of life, those who use drugs compulsively are also constantly starving, interrupting medications for diseases, have hygiene problems, are afraid of dying and have more difficulty staying in shelters. These people also have in common the use of crack (the most prevalent drug among compulsive users), whose smoke can worsen the aggression of the users’ respiratory tract. It is conceivable that this group is the most vulnerable in the context of the pandemic and imposes the greatest challenges on health professionals, since their way of life can lead to the weakening of the body and the worsening of COVID-19. Furthermore, they are ways of life associated with prejudice and discrimination by society in general, especially in the context of a shortage of intensive care units and artificial respirators.

APS as the ideal locus for rapid and wide-reaching strategies provides new possibilities for intersectoral action for UP, with CnaR having a major role. This increase of assistance through Tele-medicine aims to mitigate contagion, enhance care and optimize the clinical diagnosis of COVID-19 in UP and is already authorized by the Ministry of Health⁽¹⁶⁾.

The increase in the context of stress due to the pandemic can lead to greater compulsive use of drugs by UP. The proposed assistance modality also helps to reduce the feeling of anxiety, loneliness, and helplessness, with the potential to alleviate this psychological suffering.

For those with a riskier and more vulnerable way of life in the circumstances of COVD-19, but without the possibility of shelter, regardless of the reason (personal refusal or professional contraindication), extra attention from the CnaR is recommended.

Paradoxically, the UP way of life has increased its vulnerability in the pandemic and, it can be fully understood by third parties as a risk of disease transmission, increasing prejudice against it. And so, in a sudden way, the pandemic may have struck both ways against this population.

DISCUSSION

The World Health Organization⁽¹⁷⁾ (WHO), in the event of a pandemic, recommends active engagement of health services with patients under different conditions. The similarity of symptoms (cough, fever, dyspnea) of TB with COVID-19 makes differential diagnosis difficult. Furthermore, interrupting treatment for TB suggests a worse prognosis for COVID-19. People living with advanced HIV (or without antiretroviral treatment) and with diabetes are at increased risk of infections or complications associated with COVID-19⁽¹⁷⁾. Smoking increases the susceptibility to be infected through the contact of fingers with lips, besides impairing lung function, making it difficult to fight the disease, recommending greater care for smokers⁽¹⁷⁾.

The socio-demographic heterogeneity and the morbidity profile of the UP highlighted in this research, endorsed by others^(7-8,18), show similarities with those of greater risk from COVID-19⁽¹⁷⁾. Sometimes it is not the disease itself, but the non-persistence in treatment that implies greater severity. Moreover, the very common behavior of the UP to deny, not perceive/recognize symptoms, and to discontinue medications^(7-8,18), makes it a highly vulnerable population. This knowledge intends to approach the care of these people, given the sudden worsening, however, it allows strategic actions in situations of greater risk.

Another aspect closely associated with UP is the compulsive use of drugs^(7-9,18), which was mentioned by all interviewees, even those who have been abstinent for years. This behavior emphasizes other factors such as hunger, weight loss, interruption of medications for disease control, decreased self-care, social stigma, feelings of sadness, low self-esteem, fear and lack of control over their lives. And they all act as potentiators of serious cases in COVID-19^(16,19-20). In analogy to smoking, the same concerns fall on respiratory drug users, such as crack, marijuana, inhalant drugs, paint thinner, cocaine.

Revised guidelines in technical documents^(21-22), such as not sharing personal items, cleaning them before and after use and housing as a single proposal, do consider the UP way of life, even disagreeing with him.

The current pandemic has shown social stigma and discriminatory behavior against people with greater contact with viruses⁽¹⁹⁾. The association of UP with dirt and failures of all kinds⁽⁸⁾, boosted by current concerns, causes an increase in prejudice and violence against it.

The United Nations⁽²⁰⁾ (UN) has reported a three-fold increase in symptoms of depression and anxiety related to the pandemic and people with mental illness are at specific risk. Increased consumption of alcohol and other drugs is another concern of specialists⁽²⁰⁾ and issues involving mental health and well-being of UP have been little discussed in the current context⁽²³⁾. In this regard, the UN⁽²⁰⁾ underlines actions that reduce loneliness and protect and promote the human rights of people with serious mental health problems and psychosocial disabilities, since they are often neglected in major emergencies⁽²⁰⁾. The deficiency in the consolidation of fundamental social rights in countries like Brazil, added to social policies that reinforce the exclusion of these rights⁽¹¹⁾, produces misery, unemployment, violence, lack of access to health and education⁽⁸⁾. The counterproposal is to produce knowledge, actions and social policies consistent with the social needs of those in exclusion.

Remote health activities, both for COVID-19 and Mental Health and Psychosocial Support demands, enhance and integrate⁽²⁴⁾ the care provided to the UP and are included in the recommendations of several organizations^(16,19-20).

The precariousness of the UP routine requires specific policies to guarantee adequate living conditions, access to health care⁽¹⁸⁾ and care practices that absorb the unexpected⁽²⁴⁾ and consider important aspects of their lives^(8-9,11,24). The research broadly reinforces this recommendation, especially in this global emergency since epidemics are social and biological phenomena. From this perspective, Segata⁽⁶⁾ emphasizes that the Social and Human Sciences have inputs and tools to help in this matter, especially because even a simple recommendation like “soap and water saves lives” needs to be contextualized.

In this perspective, we remember that hard technologies are not always insufficient to solve complex social problems⁽⁵⁾. Moreover, the UP is known to have no access to potable water regularly, soap is superfluous and “#Stayhome!” presupposes having a home.

Any recommendation, even with fundamentals, is insufficient because to be implemented it is necessary to consider different contexts⁽³⁾ and research can support these actions.

Considering that the characteristics (sociodemographic, morbidity, way of life) of UP are also mentioned by other studies^{(7-9,11,17,24)}, the actions proposed in this article are likely to be adopted by other health services with similar purposes however, some limitations need to be recognized.

Study limitations

The study was carried out with UP in an area with a high prevalence of cracolândias (Crackland), because the crack has “good price and quality”, according to interviewees. In this sense, the categories presented here may be related to this specificity of the research, deserving further investigations in places with a lower drug offering.

Another limitation is that the way of life can differ between UP and the pandemic may have changed the ways of living, but the probability is that it has changed to greater risks.

The proposals listed for coping with COVID-19 were thought of as quick responses, through simple actions, but they require engagement, commitment, and team leadership. However, the telehealth with shelters, as an enhancer of care, needs professionals able to work in this new model and surveillance, to prevent the shelters from becoming spots of new outbreaks and prejudice. In this regard, the telehealth can also be a differential, promoting guidance from health professionals to prevent this counter effect.

Contributions to Nursing, Health or Public Policy

In the context of Public Health, the present study can contribute to maintaining lives in the face of the pandemic, through low investment actions. These actions aim to improve the care of vulnerable populations and reduce infection, by reducing the circulation of professionals and UP. Furthermore, the research reinforces the view of the UP as citizens of law and the dialogue with health professionals at a time of great challenge. This will provide solidarity and reflective elements for the disruption of only prescriptive care and a greater role for workers who are experiencing different fears and sufferings.

Specifically, about nursing professionals, we believe that this article’s content will bring additional benefits to their practices, given the kind of their practice, which presupposes closer and continuous contact with the patient.

New multidisciplinary and interdisciplinary studies are recommended to enable the deepening of the plurality of the way of life, belief, values, and culture of the subjects for the participatory transformation in the health-disease process and support in the creation of health actions.

FINAL CONSIDERATIONS

The depreciation of the diversity of conditions, identities, values, and beliefs, besides the predominance of the knowledge of biomedical sciences in health, reduces the complexity of the subjects of care, the interpretation of their demands, and the ways of supporting them.

Our perspective was to share new ways of providing care to a highly vulnerable population, by overcoming health actions guided only by the disease and its biological determinations. We aim to add and enhance in care the context of life and the unique psychic processes of people, enabling actions thought in an interdisciplinary way.

We hope that these reflections will be useful in highlighting the contributions of qualitative research in response to the pandemic.

• FUNDING
  The research that enabled this article was funded by the Development and Innovation Program in Public Health of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation (ENSP-016-FIO-17).

REFERENCES

• ¹
  World Health Organization (WHO). Coronavirus disease (COVID-19) advice for the public[Internet] 2020[cited 2020 Jun 08]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public
  » https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public
• ²
  Silva FV. Enfermagem no combate à pandemia da COVID-19. Rev Bras Enferm. 2020;73(Suppl 2):e2020sup2. doi: 10.1590/0034-7167-202073
  » https://doi.org/10.1590/0034-7167-202073
• ³
  Chaparro L. A medicina não é suficiente: por que precisamos das ciências sociais para acabar com essa pandemia. In: Café História: história feita com clique[Internet]. 2020[cited 2020 Jun 01]. Available from: https://www.cafehistoria.com.br/ciencias-sociais-novo-coronavirus-pandemia/
  » https://www.cafehistoria.com.br/ciencias-sociais-novo-coronavirus-pandemia/
• ⁴
  Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. Lancet Infect Dis. 2020;20(6):631-3. doi:10.1016/S1473-3099(20)30190-0
  » https://doi.org/10.1016/S1473-3099(20)30190-0
• ⁵
  Shah H. Global problems need social science. Nature. 2020;577(7790):295. doi:10.1038/d41586-020-00064-x
  » https://doi.org/10.1038/d41586-020-00064-x
• ⁶
  Segata J. A importância das Ciências Humanas na pesquisa e combate às pandemias[Internet]. Instituto de Filosofia e Ciências Humanas (IFCH)/UFRGS. 2020[cited 2020 Jun 01] Available from: https://www.ufrgs.br/ifch/index.php/br/a-importancia-das-ciencias-humanas-na-pesquisa-e-combate-as-pandemias
  » https://www.ufrgs.br/ifch/index.php/br/a-importancia-das-ciencias-humanas-na-pesquisa-e-combate-as-pandemias
• ⁷
  Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual sobre o cuidado à saúde junto a população em situação de rua [Internet]. Brasília: MS; 2012[cited 2020 Jun 01]. Available from: http://189.28.128.100/dab/docs/publicacoes/geral/manual_cuidado_populalcao_rua.pdf
  » http://189.28.128.100/dab/docs/publicacoes/geral/manual_cuidado_populalcao_rua.pdf
• ⁸
  Halpern SC, Scherer JN, Roglio V, Faller S, Sordi A, Ornell F, et al. Vulnerabilidades clínicas e sociais em usuários de crack de acordo com a situação de moradia: um estudo multicêntrico de seis capitais brasileiras. Cad Saúde Pública. 2017;33(6):e00037517. doi: 10.1590/0102-311x00037517
  » https://doi.org/10.1590/0102-311x00037517
• ⁹
  Raup LM, Adorno RCF. Jovens em situação de rua e usos de crack: um estudo etnográfico em duas cidades. Rev Bras Adolesc Conflit. 2011;(4):52-67. doi: 10.17921/2176-5626
  » https://doi.org/10.17921/2176-5626
• ¹⁰
  Ferreira MA, Alvim NAT, Teixeira MLO, Veloso RC. Saberes de adolescentes: estilo de vida e cuidado à saúde. Texto Contexto Enferm. 2007;16(2):217-24. doi: 10.1590/S0104-07072007000200002
  » https://doi.org/10.1590/S0104-07072007000200002
• ¹¹
  Paiva IKS, Lira CDG, Justino JMR, Miranda MGO, Saraiva AKM. Direito à saúde da população em situação de rua: reflexões sobre a problemática. Ciênc Saúde Coletiva. 2016;21(8):2595-606. doi: 10.1590/1413-81232015218.06892015
  » https://doi.org/10.1590/1413-81232015218.06892015
• ¹²
  Braga GB, Fiúza ALC, Remoaldo PCA. O conceito de modo de vida: entre traduções, definições e discussões. Sociol. 2017;19(45):370-96. doi: 10.1590/15174522-019004521
  » https://doi.org/10.1590/15174522-019004521
• ¹³
  Moreira DA. O método fenomenológico na pesquisa. São Paulo: Pioneira Thompson; 2002.
• ¹⁴
  Evans-Pritchard EE. Os Nuer. São Paulo: Perspectiva; 1978.
• ¹⁵
  Presidência da República (BR). Lei Nº 13.982, de 02/04/2020 [Internet]. Dou, 02/04/2020, P. 1 - Edição Extra. [cited 2020 Jun 14] Available from: http://www.planalto.gov.br/ccivil_03/_ato2019-2022/2020/lei/l13982.htm
  » http://www.planalto.gov.br/ccivil_03/_ato2019-2022/2020/lei/l13982.htm
• ¹⁶
  Ministério da Saúde (BR). Gabinete do Ministro. Portaria Nº 467 de 20/03/2020 [Internet]. Dou, 23/03/2020, Edição: 56-B, Seção: 1 - Extra, Página: 1[cited 2020 Jun 10] Available from: http://www.in.gov.br/en/web/dou/-/portaria-n-467-de-20-de-marco-de-2020-249312996
  » http://www.in.gov.br/en/web/dou/-/portaria-n-467-de-20-de-marco-de-2020-249312996
• ¹⁷
  World Health Organization (WHO). Coronavirus disease (COVID-19) Q&As on COVID-19 and related health topics[Internet] 2020. [cited 2020 Jun 19]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub
  » https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub
• ¹⁸
  Aguiar MM, Iriart JAB. Significados e práticas de saúde e doença entre a população em situação de rua em Salvador, Bahia, Brasil. Cad Saúde Pública. 2012;28(1):115-24. doi: 10.1590/S0102-311X2012000100012
  » https://doi.org/10.1590/S0102-311X2012000100012
• ¹⁹
  World Health Organization (WHO). Risk communication and community engagement (RCCE) Action Plan Guidance Covid-19 preparedness and response [Internet]. 2020. [cited 2020 Jun 22] Available from: https://www.who.int/publications/i/item/risk-communication-and-community-engagement-(rcce)-action-plan-guidance
  » https://www.who.int/publications/i/item/risk-communication-and-community-engagement-(rcce)-action-plan-guidance
• ²⁰
  United Nations. Policy Brief: COVID-19 and the Need for Action on Mental Health[Internet]. 2020 [cited 2020 Jun 20]. Available from: https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf
  » https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf
• ²¹
  Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Recomendações para os profissionais no âmbito das equipes de consultório na rua referentes ao COVID-19[Internet]. 2020[cited 2020 Jul 10]. Available from: http://docs.bvsalud.org/biblioref/2020/05/1096382/recomendacoes-pop-rua-covid19-17abril2020.pdf
  » http://docs.bvsalud.org/biblioref/2020/05/1096382/recomendacoes-pop-rua-covid19-17abril2020.pdf
• ²²
  Ministério da Saúde (BR). Secretaria de Atenção Primária à Saúde. Prevenção ao Covid-19 no âmbito das equipes de consultórios na rua[Internet]. 2020[cited 2020 Jul 15]. Available from: https://www.unasus.gov.br/especial/covid19/pdf/54
  » https://www.unasus.gov.br/especial/covid19/pdf/54
• ²³
  Lima NNR, Souza RI, Feitosa PWG, Moreira JLS, Silva CGL, Rolim Neto ML. People experiencing homelessness: their potential exposure to COVID-19. Psychiatr Res. 2020;288:ID112945. doi: 10.1016/j.psychres.2020.112945
  » https://doi.org/10.1016/j.psychres.2020.112945
• ²⁴
  Koopmans FF, Daher DV, Acioli S, Sabóia VM, Ribeiro CRB, Silva CSSL. O viver na rua: revisão integrativa sobre cuidados a moradores de rua. Rev Bras Enferm. 2019;72(1):211-20. doi: 10.1590/0034-7167-2017-0653
  » https://doi.org/10.1590/0034-7167-2017-0653

Edited by

EDITOR IN CHIEF: Dulce Barbosa

ASSOCIATE EDITOR: Hugo Fernandes

Publication Dates

• Publication in this collection
  14 Apr 2021
• Date of issue
  2021

History

• Received
  31 July 2020
• Accepted
  04 Dec 2020