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Introduction
People experiencing homelessness (PEH) are defined as people who, regardless of their sociodemographic background, lack housing or shelter. In Portugal, it is estimated that approximately 9,604 PEH, according to the National Strategy for the Integration of PEH 2025-2030 1. This population is more susceptible to chronic conditions and severe health issues 2-4. Regarding musculoskeletal (MSK) conditions, they are particularly vulnerable to bacterial infections in soft tissues, traumatic injuries, fractures, and chronic pain 5, which are globally significant causes of disability, early workforce withdrawal, presenteeism, and absenteeism 6,7.
Despite the high costs associated with treating MSK conditions, particularly in PEH due to comorbidities, necessary interventions and priorities are often not reflected in available healthcare services 8. Recommended practices such as patient-centered care, addressing psychosocial factors, providing education about conditions, and promoting self-management 9 are frequently overlooked. MSK health is not solely about the absence of physical impairments; it also encompasses mental well-being and the ability to live independently and comfortably, underscoring the critical role of physiotherapy 10.
However, PEH exhibit higher rates of missed physiotherapy appointments compared to the general population, leading to reluctance among physicians to prescribe physiotherapy 11. Reports of stigmatization and discrimination - including perceived lack of interest by healthcare professionals, interactions influenced by appearance, inadequate communication, and biases related to time management or assumptions of drug-seeking behavior - are significant barriers to accessing healthcare 12-15. Such experiences foster feelings of shame and dehumanization, resulting in delays in seeking care and reduced use of primary and specialized healthcare services, even in severe cases 14,16,17.
In Portugal, there is no specific data on discrimination or inequity in healthcare access for PEH. However, broader evidence highlights stigma surrounding mental health issues, which are often associated with homelessness 11. Additionally, financial constraints contribute to inequities in healthcare access, which were exacerbated during the COVID-19 pandemic 18,19. Consequently, PEH are more likely to use emergency hospital services while underutilizing primary or specialized care, hindering timely and appropriate management of MSK conditions 3,20.
To address these barriers, the literature suggests offering physiotherapy in shelters to eliminate obstacles such as time, cost, and discomfort 21 and encouraging voluntary interactions between healthcare professionals, students, and PEH to improve awareness and sensitivity 22-24. Improving MSK health in this population can contribute to better employability and access to housing, education, and healthcare 25. This study aimed to understand the improvements in physiotherapy students’ attitudes toward PEH by involving them in a program designed to enhance MSK health in PEH, implemented in shelter homes.
Methodology
The study was conducted at the (a social support center), an institution dedicated to supporting PEH and other vulnerable populations. The center provides various services, including health support, meals, personal hygiene, and recreational activities. The sessions of the project were held twice a week at previously defined times, considering the internal organization of the institution.
The sessions were led by students from the Bachelor’s Degree in Physiotherapy at the (Institution Name), under the supervision of a fourth-year student who possessed the necessary competencies to conduct interventions with PEH. The primary challenge was aligning the institution's schedule with the academic timetables of the physiotherapy students. The project lasted for 3 months, with weekly sessions conducted between February 26 and May 31, 2023.
Recruitment and Intervention
Student recruitment was carried out through an informational video and an online form, resulting in the selection of nine students to participate in the study. These students were equally divided among the second, third, and fourth years of the Bachelor’s Degree in Physiotherapy.
The recruitment of PEH was managed by the fourth-year student in charge. During 2 weeks of activities conducted at the institution, the participants were informed about the project. Those expressing interest were provided with informed consent forms.
The intervention consisted of active sessions combining strength training, aerobic training, and educational components focusing on promoting MSK health and the role of physical exercise. The program was adjusted due to limited resources at the center and was designed to respect the conditions and needs of participants. The educational program addressed topics such as the neurophysiology of pain, the importance of physical exercise, common MSK conditions, and associated risk factors. Sessions were conducted over 3 months, from February to May 2023 9, 26-29.
Measurement Instruments
To evaluate physiotherapy students’ attitudes toward HIs, the Escala de Atitudes Face à População em Situação de Sem-Abrigo (EAFPSSA) was used. This questionnaire comprises 17 items divided into three domains: behavioral, emotional, and cognitive 30. The scale was applied to students at the beginning and end of the project, enabling the assessment of changes in their attitudes toward the target population. The data collection was conducted using an online survey on the Microsoft Forms platform, chosen for its ability to facilitate an open survey process and asynchronous data collection.
Additionally, a supplementary section with six open-ended questions was included in the final survey to assess students’ perceptions at the end of the project. These questions prompted students to reflect on their perceptions of PEH, how their participation in the project contributed to their academic and professional development, how it shaped their perception and interaction with PHE, and the role of physiotherapy in the context of homelessness. The final survey was distributed on May 20, 2023, with a submission deadline of June 2, 2023. Each student could respond only once to each question. The collected survey data were stored exclusively by the student responsible, in a secure folder on their personal computer, ensuring data confidentiality and protection.
Data Analysis
Quantitative data analysis was performed using Microsoft Excel for descriptive statistics and SPSS for inferential analysis. The Wilcoxon non-parametric test was used to compare students’ initial and final data.
Additionally, qualitative analysis was conducted on the open-ended responses collected at the end of the program, using the thematic inductive analysis framework described by Braun and Clarke 31: familiarizing yourself with your data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; producing the report. This analysis focused on students’ reflections on the project, their interaction with PEH, and the program's impact on their academic and professional development.
Results
During the recruitment of students, 75 were contacted, of whom 13 volunteered to participate (17.33%). Of the nine selected volunteers, all participated in every scheduled session and completed the project.
Regarding PEH, 17 individuals were contacted during the recruitment weeks, and eight participated in the sessions (50%). Of these eight, three completed the initial evaluation (37.5%). However, no participant completed the program. Of the 20 planned sessions, 14 were conducted (70%), 5 were canceled due to the absence of participants, and 1 due to a lack of available spaces (a situation that had been anticipated). Consequently, it was impossible to evaluate the program’s impact on mental health and work capacity for the participants.
In EAFPSSA, no statistically significant changes (p < 0.05) were observed in any of the evaluated dimensions (Table 1). However, the goal was achieved, with 80% of the students responding positively (three or below in the questions for the Emotional and Cognitive dimensions, and three or above in the Behavioral dimension) in 11 out of 17 questions, with the Emotional dimension standing out as the goal was met in all its questions.
Table 1.Descriptive and inferential analysis of students’ responses across behavioral, cognitive, and emotional domains as measured by the Escala de Atitudes Face à População em Situação de Sem-Abrigo (EAFPSSA), before and after participation in the intervention
The qualitative analysis allowed for the exploration of students’ perceptions of PEH, as well as the impact of participating in the project on how students interact with these individuals and view the role of physiotherapists in this context.
Overall, students tended to perceive these individuals as people, with one student anonymously stating: “Perhaps I should start with the word itself: people. I unconsciously judged them long before knowing them.” Additionally, subthemes were identified regarding their perception of PEH, including being excluded by society, having a desire to change, possessing the same rights and values as others, and feeling discouraged.
When analyzing the impact of project participation, the following themes were identified: improvement in the quality and quantity of communication with PEH, impact as citizens, reduction of fear towards PEH, appreciation of the psychosocial domain, better understanding of the context of homelessness, and gaining flexibility skills. Two statements highlight this impact: “These people became visible to my eyes” and “Eliminating certain stigmas or, in a way, discrimination by avoiding approaching them to avoid giving money, for example.”
Regarding the influence on academic and professional training, students highlighted the positive impact in terms of citizenship, the development of psychosocial and communication skills, as well as the appreciation of knowledge in the field of intervention with vulnerable populations. Participation was considered a relevant complementary experience to the academic curriculum, enhancing specific skills and contributing to a more humanized and flexible approach in professional practice.
Discussion
Although no significant improvements were observed in the results obtained through the ATHPS, achieving the goal of 80% positive responses in 11 out of 17 questions reinforces the positive impact of this project on students’ attitudes toward PEH. Notably, the emphasis on the theme “People” as the main perception of the students aligns with Axis No. 1 of the National Strategy for the Integration of PEH 2025-2030, which highlights the promotion of a unified and inclusive concept of PEH 32. This alignment suggests that the project successfully achieved its purpose of raising awareness and educating students about the realities of PEH, while also providing physiotherapy services, as recommended in the literature 21-24. These quantitative outcomes gain further depth when interpreted alongside the qualitative data, which shed light on the students’ evolving perceptions and experiences throughout the intervention.
Thematic analysis revealed that students began to perceive PEH as individuals with history, uniqueness, and value. This shift in perception aligns with the principles of humanized care, namely, respect for dignity, empathy, and relational communication 33. The dehumanization of care, often linked to service fragmentation and procedural routinization, can be countered through experiences like this one, which provide training and bring students closer to the lived reality of PEH, promoting person-centered practices 22,34,35. Furthermore, due to the shortage of human resources, involving volunteers in real contexts has been identified as a strategy to overcome structural and organizational barriers in the provision of care to vulnerable populations 33.
This evolution in perspective was accompanied by a notable educational impact. Students reported developing essential competencies such as communication, empathy, adaptability, and a stronger appreciation for the social role of physiotherapists. These findings echo those of other studies on student-led clinics, which similarly highlight gains in professional identity and awareness when working with underserved populations 22-24,34, which show improved awareness of the role of health professionals among underserved populations. However, the only study specifically involving physiotherapy students to which we had access also reported no significant changes in objective attitude scales toward PEH 36. Additionally, in the study by Annapureddy et al. 35, training and education led to significant improvements in attitudes toward PEH, while the intervention itself did not result in further improvements beyond those gains - thus validating the methodological structure adopted in this project. In that study, which also involved voluntary student participation, it was found that students who volunteered already held significantly more positive attitudes toward PEH than those who did not, a factor that may have also influenced the intervention’s limited margin of effectiveness 35.
This possibility is further supported by our own data: only 17.3% of the contacted students chose to participate, for reasons that remain unclear. Nonetheless, the emergent themes illustrate the added pedagogical value of such experiences within academic curricula, particularly in cultivating psychosocial, communicative, and civic skills. These competencies are increasingly prioritized in frameworks such as the Recovery and Resilience Plan for promoting health equity in socially vulnerable settings 19.
In this context, the adoption of a mixed-methods design was crucial. Relying solely on quantitative results might have led to an underestimation of the project’s impact, while qualitative data alone could risk social desirability bias. The integration of both allowed for a more comprehensive interpretation, highlighting both the subjective growth of students and the persistent challenges in shifting ingrained attitudes.
While the intervention primarily targeted MSK health, the collected data and broader literature underscore the potential for physiotherapy to address a wide range of health needs among PEH. These include conditions and risk factors for circulatory diseases (like stroke and ischemic heart disease) and respiratory diseases, which are among the leading causes of premature death in Portugal. These can be primary focuses of physiotherapy care, as well as needing to be considered when treating people with MSK conditions, in consideration of safety and maximizing patient outcomes. These constitute areas in which physiotherapists are well qualified to provide added value 37-43.
Future projects could benefit from involving PEH in the design and implementation phases, thereby enhancing relevance and adherence 44,45. Additionally, fostering interdisciplinary collaboration between physiotherapists and other health professionals, including street medicine, shelter-based initiatives, or home-adaptation programs, may expand access and improve outcomes. Such efforts could also facilitate the development of creative, realistic, and context-sensitive health promotion strategies tailored to this population’s lived experiences 38,44.
Despite the project’s contributions, some limitations must be acknowledged. The inability to evaluate the program’s impact on PEH due to the absence of participants who met the adherence criterion (16 of 20 sessions) restricted the generalizability of findings. Although based on recommendations for effective MSK condition management (9, 26-29), this threshold proved overly ambitious in a preventive context, where PEH may prioritize basic needs over health interventions. Attendance was also affected by unmet primary needs and schedule conflicts with other institutional activities. These barriers, already documented in the literature 11, highlight the importance of developing more flexible and responsive strategies. Furthermore, the exclusion of low-adherence participants from data analysis further limited conclusions regarding direct outcomes for PEH. Regarding the students, only 17.3% of those contacted volunteered, a rate for which no objective justification was identified. These limitations reinforce the call for future studies to adopt adaptable designs, address systemic access issues, and focus on outcomes that hold tangible value for participants.
Conclusion
This project demonstrated a positive impact on students’ attitudes toward PEH, aligning with the objectives of the National Strategy for the Integration of PEH 2025-2030 and highlighting the importance of educational and awareness-raising initiatives in academic training. The data collected, both quantitative and qualitative, underscore the relevance of projects that foster psychosocial skills and a more humanized approach to professional practice. These findings emphasize the need to adapt future projects to the priorities and realities of PEH, ensuring greater flexibility and accessibility, while continuing to explore innovative ways to integrate engagement with vulnerable populations into academic curricula.
Acknowledgments
We would like to thank all the students and PEH involved in the project, as well as the Centro Social São Francisco Xavier da Cáritas Diocesana de Setúbal, for the opportunity to create and implement this initiative. We are also grateful to the Escola Superior de Saúde - Instituto Politécnico de Setúbal for their institutional support, and to the project supervisor for her valuable guidance throughout the study.
Statement of Ethics
This study did not require approval from an Ethics Committee. Nonetheless, all participants, including students and PEH, provided written informed consent to participate in the study and for the publication of this study before participation in the project.
