Date of Award

May 2015

Degree Type


Degree Name

Doctor of Philosophy



First Advisor

Rachel Schiffman

Committee Members

Kathleen Sawin, Peninnah Kako, Gwat-Yong Lie, Michelle Gehring


Chronically Unsheltered Homeless, Homeless Women, Individual and Family Self-Management Theory, Personal Hygiene, Self-Management





Stephanie L. Durfor

The University of Wisconsin, Milwaukee, 2015

Although the subpopulation of chronically unsheltered homeless women is a small percentage of the overall homeless population, this vulnerable group of women is very high risk for poor health status and negative health outcomes. Unsheltered homeless women are significantly higher risk for assault, physical/mental disorders, and substance/ alcohol abuse compared to women residing in shelters or transitional housing. In the midst of a challenging physical and social environment, chronically unsheltered homeless women must manage their personal hygiene on a daily basis.

The purpose of the current study was to gain an in depth understanding of the personal hygiene self-management (PHSM) of chronically unsheltered homeless women. Guided by the Individual and Family Self-Management Theory (IFSMT), narrative inquiry was used to answer the following research questions: (1) What was the experience of chronically unsheltered homeless women in personal hygiene self-management? (2) What personal hygiene self-management behaviors did chronically unsheltered homeless women report carrying out? and (3) Can the PHSM experience of chronically unsheltered homeless women be mapped on to the IFSMT?

Purposive, snowball sampling resulted in the recruitment of a final sample size of 10 participants ranging in age from 36 to 77 years old (median age was 57.5 years). Time living outdoors for the women ranged from 2 to 53 years (median time living/sleeping outdoors was 10 years). Recruitment took place in a mid-size, coastal city in Southern California with a year-round mild climate.

Data collection was obtained through semi-structured interviews. Within-case analysis profiled the experiences of each individual woman. Cross-case analysis searched for similarities and differences across all ten of the women. Following cross-case analysis five common themes emerged: Maintaining Safety, Blending In, Managing Sleep, Sustaining Health, and Problem-solving.

Living in fear on a regular basis required the women to constantly be concerned for their safety. Maintaining their safety was the most serious challenge the women faced while living/sleeping outdoors and was a prevalent theme across all participants. Blending in with the general public was a theme across the women which posed some challenges. The women worked hard to blend in with the general public because the consequences of not blending in were negative. The positive outcomes of blending in included the ability of the women to have an easier time navigating around town, reduced their experience of being stereotyped or judged by the public for being a homeless person, and contributed to a reduction in the overall fear and stress the women experienced on a daily basis. Quality of sleep was an ongoing challenge for the majority of the women. The sleep challenges the women faced were related to safety concerns and nocturnal urinary frequency. Self-management behaviors carried out by the women were related to sleep locations and guarded sleep time.

Prevention or treatment of health conditions with limited resources was an ongoing challenge for the women yet many of them were able to find ways to sustain their health. Natural remedies were generally preferred as they were typically cheaper and viewed as safer by the women. With limited means and a challenging environment in which the women lived and slept required them to be resourceful in self-managing their personal hygiene. The women were creative in problem-solving their needs.

Findings determined PHSM of chronically unsheltered homeless women in the current study supported the concepts and relationships of the IFSMT. Despite living and sleeping in harsh, unsafe conditions, all ten of the women were successful in their personal hygiene self-management and sustaining their physical health. Although some chronically unsheltered homeless women performed certain personal hygiene behaviors to prevent the development of or reduce the severity of a health problem, a significant finding was the women primarily engaged in PHSM to be able to blend in with the general public. These behaviors were performed in order to improve their quality of life.

Establishing trusting relationships with the women was crucial to the recruitment of participants and completion of the study. One recommendation is to establish trust and rapport with chronically unsheltered homeless women prior to the launch of a study. Recommendations for further research include exploring PHSM in different geographical areas especially areas with inclement weather, gender-differences in PHSM among the homeless population, and a community-based participatory research approach. Implications for practice should include interdisciplinary services based on trauma-informed care. Assisting chronically unsheltered homeless women to enroll in the Affordable Care Act would provide the women with necessary healthcare resources, especially dental care. Policy implications involve homeless shelters offering daily showers to the unsheltered population with services tailored to the specific needs of homeless women. Programs to assist chronically unsheltered homeless women in gaining access to permanent housing could potentially address several of their PHSM issues such as keeping clean, managing their sleep, and toileting needs. Living inside, the women would no longer have the stigma of being homeless therefore they would blend in more with the general public and potentially increase their sense of safety.

Included in

Nursing Commons