Digital Health Fails Women Experiencing Homelessness, Landmark Study Finds

As health systems around the world race to move appointments, prescriptions, and medical records onto smartphones and web portals, a quiet assumption has taken hold: that digital tools automatically make health care more accessible, more flexible, and more empowering for everyone. A new qualitative longitudinal study, published in the International Journal for Equity in Health, challenges that assumption head-on. Researchers followed nine women experiencing homelessness in London, England, and found that digital health technologies, far from levelling the playing field, can introduce new layers of exclusion for people already pushed to the margins of society. The study introduces and applies the concept of eHealthism, an interpretive lens that exposes how digital health systems can shift responsibility for health onto individuals while ignoring the brutal realities of their daily lives.

The research team, led by Sophie Nadia Gaber of Uppsala University and University College London, together with Elisabet Mattsson, Anna Klarare, Jenny Eriksson Lundström, and Penny Rapaport, worked in collaboration with the Women’s Advisory Board for Inclusion Health, a group of women with lived experience of homelessness. This was not a token consultation. Women with lived experience contributed to the study design and recruitment processes, co-produced study materials, supported the analysis and interpretation of the findings, and helped shape the final recommendations. The study was approved by the UCL Research Ethics Committee, with additional approval from the Swedish Ethical Review Authority, and all participants gave written informed consent, with pseudonyms used to protect confidentiality.

Methodologically, the study is notable for its longitudinal, narrative design. Rather than capturing a single snapshot, the researchers gathered data through narrative interviews and participant observations with the nine women over time, allowing them to trace how engagement with digital health shifted as circumstances changed. The data were analysed using a three-phase phenomenological-hermeneutic approach inspired by the narrative and interpretation theory of Paul Ricoeur, a framework that moves from naive surface reading of the women’s accounts toward deeper critical interpretation of what those accounts reveal about structure, power, and exclusion. This approach is well suited to a population whose interactions with institutions are often fragmented, transient, and shaped by trauma.

The participants themselves reflected the complexity of homelessness in England today. The study situates its work within inclusion health, a field dedicated to addressing the extreme health inequities experienced by socially excluded groups, and the researchers used the European Typology of Homelessness and Housing Exclusion, known as ETHOS, to frame the diverse housing situations women navigate. The women’s stories were collected in partnership with a third-sector organisation, underscoring a key finding of the research: for people experiencing homelessness, the boundaries between health care, social care, and charitable support are porous, and digital tools must function across all of these systems, not just within the National Health Service.

From their analysis, the researchers identified three central themes. The first, framed as taking care of my health on my own terms, with or without digital tools, revealed that the women were not digitally helpless. Many used smartphones, searched for health information online, and managed appointments where they could. But they did so on their own terms, prioritising survival, safety, and autonomy. Digital engagement was often contingent on battery access, data credit, stable connectivity, and the emotional bandwidth to navigate clunky systems. When the technology demanded more than their circumstances allowed, the women simply opted out, not from apathy but from rational triage under conditions of scarcity.

The second theme, when digital tools are not enough, I still need support, cuts to the heart of the eHealthism critique. Digital health systems increasingly assume that patients can self-manage: book online, read results on a portal, complete symptom checkers, and follow app-based care plans. The women in this study showed that such self-management presumes a stable life, digital literacy, and relational support that many simply do not have. When a portal password was lost, when a phone was stolen or broken, or when an online form required information they did not have, the digital pathway became a wall rather than a door. What they needed, repeatedly, was a person: someone to help, explain, advocate, and accompany them through systems designed for the digitally fluent and the securely housed.

The third theme, digital health can work, but it’s not the same as seeing someone face-to-face, captures a tension that resonates far beyond this study’s participants. The women acknowledged genuine benefits of digital tools, including flexibility and the ability to reach services without travelling across an unfamiliar and sometimes hostile city. Yet they consistently described remote interactions as thinner, less trusting, and less therapeutic than in-person encounters. For women whose histories often include trauma, the embodied presence of a trusted clinician was not a luxury but a precondition for disclosure and care. A video call could not replicate the safety of a familiar face, and the researchers argue that treating digital contact as equivalent to in-person care risks mistaking convenience for quality.

Building on these themes, the study’s most significant theoretical contribution is a three-layer conceptual framework of exclusion mechanisms in eHealthism. The individual layer encompasses the personal capacities, resources, and circumstances that shape whether someone can engage with digital health at all. The relational layer captures the interpersonal dynamics of trust, support, and continuity that determine whether digital tools are used well or abandoned. The contextual layer refers to the structural conditions, housing instability, poverty, violence, and institutional fragmentation, that constrain every other layer. Together, the researchers argue, these layers challenge two dominant assumptions of digital health policy: that health is primarily an individual responsibility, and that digital access universally empowers. eHealthism, in this framing, describes how digital health can moralise health behaviour and blame individuals for non-engagement while the systems themselves remain blind to exclusion.

The practical implications are concrete. The researchers propose recommendations for inclusion health that centre on meaningful choice in hybrid care, meaning that patients must be able to choose between digital and face-to-face pathways rather than being forced into whichever option the system prefers to offer. They also call for ongoing, trauma-informed relational support, recognising that a one-off digital skills session is insufficient for people whose lives are marked by instability and whose trust in institutions must be rebuilt repeatedly. For the National Health Service and third-sector organisations alike, the message is that digital inclusion is not achieved by handing someone a device or a login; it requires sustained relationships, flexible service design, and honest acknowledgement that for some patients, the digital route will never be the right one.

The study arrives at a moment when digital health expansion is accelerating globally, from NHS app-first strategies to telehealth booms elsewhere, and its findings speak to a much broader population than the nine women who shared their stories. Refugees, people with severe mental illness, older adults with dementia and related conditions, and anyone else at risk of social exclusion face overlapping versions of the same barriers. By grounding its analysis in the lived narratives of women experiencing homelessness, and by co-producing both the research and its recommendations with a Women’s Advisory Board for Inclusion Health, the study models the very relational, choice-based approach it advocates. Its central warning is stark but constructive: if digital health is to advance health equity rather than deepen disparity, policymakers must abandon the fantasy of universal digital empowerment and design hybrid systems that meet people where they actually are, with or without a smartphone in hand.

Subject of Research: Digital health engagement and exclusion among women experiencing homelessness

Article Title: eHealthism in inclusion health: a qualitative longitudinal study with women experiencing homelessness

Article References: Gaber, S. N., Mattsson, E., Klarare, A., Lundström, J. E., Rapaport, P., & in collaboration with the Women’s Advisory Board for Inclusion Health (2026). eHealthism in inclusion health: a qualitative longitudinal study with women experiencing homelessness. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03061-0

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03061-0

Keywords: eHealthism, digital health, homelessness, inclusion health, health equity, women's health, qualitative research, narrative interviews, hybrid care, trauma-informed care, eHealth, social exclusion