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

The research team, led by Federica Vernile and Michela Di Trani of Sapienza University of Rome, together with colleagues from the University of Naples Federico II, Tor Vergata University of Rome and Pegaso University, set out to explore a question that sounds simple but is not: what do care operators actually feel and think about their relationships with residents, with families, and with the organization around them? The problem is sharpened by a paradox at the heart of geriatric care. Developmental psychology is built on the idea that every stage of life carries goals for growth, but in the final phase of the lifespan those goals are difficult to identify and promote. When staff cannot see a developmental horizon for the people they care for, the work risks collapsing into routine bodily maintenance, and the emotional weight of that collapse lands on the operators themselves.

Italy offers a particularly interesting setting for this kind of investigation. The care of older adults there has traditionally been managed either by religious institutions or within the family, and the modern residential care home is a relatively recent arrival in that cultural landscape. That history matters, because it shapes expectations. Families may experience guilt and ambivalence about placing a parent in institutional care, while operators inherit a system whose cultural scripts about aging and family obligation were never designed for professionalized residential settings. The researchers wanted to understand how these cultural tensions play out in the semiotic processes, the meaning-making flows of signs and emotions, that organize daily relational life inside a nursing home.

Eighteen operators of a single retirement home took part in the study, with an average age of 45.4 years and a standard deviation of 12.3, meaning the group spanned a wide range of career stages and life experiences. The instrument was a narrative interview, deliberately open-ended, designed to gather the emotions of the operators regarding two distinct relational arenas: the psychodynamics of their relationships with patients, and the psychodynamics of the organizational processes that regulate the institution. The interviewer introduced herself as a psychologist-psychotherapist following a master’s program in psychogeriatrics, and asked participants to tell everything that came to mind about their daily work and about what contribution psychology could make to improve it. This single-stimulus format, borrowed from clinical tradition, invites free association rather than answers to pre-set questions, letting the emotional structure of the workplace surface in the language itself.

The analytical engine of the study was Emotional Textual Analysis, a mixed method developed by Italian psychologists Romolo Carli and Rosa Maria Paniccia and implemented here with the T-LAB software package. The method rests on a specific theoretical claim: that language is never emotionally neutral. The words people choose, and the ways those words cluster together in discourse, carry the traces of emotional dynamics that operate below conscious awareness. By treating interview transcripts as textual data and applying statistical procedures to the co-occurrence of words, the researchers could map the emotional dimensions of professional discourse without imposing predefined categories on it. In this sense the technique functions like a microscope for culture, revealing the shared affective organization of a work group that its members may themselves be unable to articulate directly.

The statistical output came in the form of multiple correspondence analysis, which positioned the textual material along underlying factors and grouped it into clusters of words. Three clusters emerged. The first concerned expectations addressed to psychology, capturing what operators hoped a psychological presence in the institution might provide. The second concerned the relationship with users, the residents themselves. The third concerned the relationship with families. These clusters were distributed along two factors that the authors interpret as organizing axes of the institution’s psychological culture: a first factor opposing psychological intervention to health intervention, and a second opposing the relationship with operators to family ties. In other words, the discourse of the care staff is structured around two fundamental tensions, one about whether their work is essentially clinical-psychological or essentially medical-physical, and one about where emotional bonds properly belong, with the professional community or with the residents’ kin.

What the researchers found within that structure is the study’s most provocative claim. The culture of psychological work in the nursing home, they report, conceives its purpose mainly through an individualistic approach, one that is constantly anchored to bodily care. Rather than imagining the elderly person as a subject with developmental potential, the dominant professional culture frames its task as attending to the body, hour after hour, day after day. This finding resonates with earlier research on dehumanization in health settings, which has shown how implicit representations of death and decline can erode the recognition of patients as full persons. When the endpoint of life is seen as developmentally empty, care risks becoming a sequence of physical procedures stripped of relational meaning, and the operators who perform those procedures are left carrying emotions that have nowhere to go.

The second major finding concerns the institution’s relational function. In relational terms, the authors conclude, the nursing home proposes itself as an emotional substitute for all the significant ties that existed before internment, and in doing so it violently breaks the bond between the family of origin and the patient. The word choice is deliberate and dramatic: the admission of an elderly parent into residential care is experienced not as a gentle transfer of responsibility but as a rupture, an abrupt severing of attachment relationships that the institution then attempts to replace. Operators find themselves cast into an emotional role, substitute family, for which their training and their professional identity have not prepared them. Meanwhile the third cluster of discourse, expectations addressed to psychology, suggests that staff sense this gap and wish for psychological support and intervention that the current, health-dominated culture of the institution does not adequately provide.

The implications of the study reach into practice and training. If the emotional structure of care work in nursing homes is organized around bodily care and individualistic intervention, then introducing psychologists into these settings is not simply a matter of adding a service; it requires transforming the professional culture itself. Training programs in psychogeriatrics, such as the one that framed this research at Sapienza University of Rome, aim to prepare practitioners to work with individuals and with contexts, both family and organizational. The study’s results argue that such preparation must address the emotional dynamics of the staff group, not only the needs of residents, because the two are inseparable. Burnout research on long-term care staff has repeatedly linked stress and inadequate social support to emotional exhaustion, and the present study adds a cultural dimension to that picture: the very way an institution defines the purpose of care shapes the emotional burden its workers must carry.

The research also carries a broader message about aging as a psychological and cultural question. The authors’ framing, echoed in their related work asking simply who the elder is, insists that old age is not a developmental void but a phase of life that demands its own meaning-making. Narrative approaches in psychology have shown how constructing continuity of identity through storytelling helps people navigate even traumatic transitions, and the transition into residential care is among the most disruptive an elderly person can face. If institutions are to serve residents well, they must recognize that breaking family bonds, however necessary in some circumstances, creates an emotional debt that must be acknowledged and worked through, both for the older person and for the operators who become the new attachment figures. This study, with its unusual method of listening to the emotions embedded in professional speech, offers a template for how care organizations might begin that work: by taking seriously what their own staff, in their own words, are already trying to tell them.

Subject of Research: The emotional and relational psychological culture of care operators in Italian elderly care homes

Article Title: The Psychological Culture of Operators in Italian Elderly Care Homes: An Emotional and Lifespan Perspective

Article References: Vernile, F., Di Trani, M., Capone, V., Leone, L., & Carbone, A. (2025). The Psychological Culture of Operators in Italian Elderly Care Homes: An Emotional and Lifespan Perspective. Trends in Psychology. https://doi.org/10.1007/s43076-025-00478-4

Image Credits: AI Generated

DOI: 10.1007/s43076-025-00478-4

Keywords: nursing homes, elderly care, care operators, Emotional Textual Analysis, aging, lifespan psychology, family bonds, organizational psychology, Italy, narrative interviews, psychogeriatrics, burnout