“I would protest if they ever stopped coming out here”: How street medicine services support ontological security by building trust among a community sample of unsheltered patients in Bakersfield, California

1. Introduction

1.1. Unsheltered homelessness

Between 2018 and 2024, homelessness in the United States increased by nearly 40 %, including a 41 % rise in unsheltered homelessness (Pillai, Saunders, & Rudowitz, 2025). On a single night in 2024, more than 771,000 people were experiencing homelessness, including over 274,000 living unsheltered - both record highs, marking the most severe levels ever documented (Colburn et al., 2024; Pillai et al., 2025). Unsheltered homelessness refers to individuals residing in locations not intended for human habitation - such as streets, encampments, tents, or vehicles - and is often associated with greater exposure to environmental hazards, violence, and instability compared to sheltered settings (de Sousa, Henry, & Khadduri, 2024, December; Richards & Kuhn, 2022). The majority of people experiencing unsheltered homelessness reside in Southern and Western states, with California most heavily affected, reflecting broader regional disparities in housing costs, safety nets, and service availability (Pillai et al., 2025). Research consistently shows that unsheltered populations face disproportionate burdens of chronic disease, severe mental illness, and substance use compared to sheltered or housed counterparts, underscoring the urgent need for targeted health interventions (Garcia, Manji, Underriner, & Reid, 2022, April; Ra et al., 2021; Richards & Kuhn, 2022).

1.2. Healthcare needs among people experiencing unsheltered homelessness

People experiencing unsheltered homelessness (PEUH) face persistent barriers to healthcare, including stigma, rigid appointment structures, lack of insurance, transportation challenges, and mistrust of providers (Withers, 2011). As a result, care is often delayed until conditions are advanced, driving higher costs, frequent emergency department (ED) use, and prolonged hospital stays: nearly one-third of people experiencing homelessness are hospitalized annually - four times the U. S. average - and those with co-occurring substance use disorders are twice as likely to revisit the ED within 72 h (Lin et al., 2015; Zhang et al., 2021). Reliance on the ED as a primary access point reflects gaps in preventive and primary care as well as structural barriers that limit timely, appropriate treatment (Vohra et al., 2022).

These structural and interpersonal barriers translate into markedly poor health outcomes. PEUH experience significantly higher morbidity and mortality (Roncarati et al., 2018), with an average life expectancy 17.5 years shorter than the general population (Romaszko et al., 2017). Approximately one-quarter have a serious mental illness, and co-occurring conditions compound complexity and costs (Vohra et al., 2022). Daily exposures to harsh weather, violence, inadequate nutrition, and lack of safe shelter further worsen health outcomes (Bedmar et al., 2022). Negative encounters in clinical settings - characterized by stigma and perceived lower quality of care - deter engagement and leave conditions untreated among unhoused populations (Bagget et al., 2010; Purkey & MacKenzie, 2019; Reilly et al., 2022). Collectively, these factors underscore the need for alternative care models that are flexible, consistent, and responsive to the realities of unsheltered life (Kaufman et al., 2024; Lynch et al., 2022; Ramirez et al., 2022).

1.3. Street medicine

Street medicine, established in the 1990s, delivers healthcare directly to PEUH in their own environments - such as encampments, riverbeds, and city street - rather than in traditional clinical settings (Feldman et al., 2023; Withers, 2011). With over 60 teams operating across California (Callaghan, 2024), street medicine emphasizes trust-building and sustained engagement as prerequisites for effective care. Teams typically include physicians, nurse practitioners, physician assistants, nurses, and community health workers (Buller, 2023; Feldman, 2023; Tito, 2023). This model integrates medical and social services to reduce health disparities by meeting patients where they are, offering nonjudgmental care, and fostering dignity and inclusion (Frankeberger et al., 2022).

As of October 2023, the Centers for Medicare & Medicaid Services (CMS) began reimbursing street medicine through the creation of a new billing designation, Place of Service (POS) code 27. This update formally acknowledges outdoor locations - such as sidewalks, encampments, and other nontraditional spaces - as legitimate sites for delivering healthcare to PEUH (Keck School of Medicine of USC, 2023).

1.4. Landscape in Bakersfield, California

Located in Kern County in California’s Central Valley, Bakersfield is one of the state’s ten largest cities, with a population of over 400,000 (City of Bakersfield, n.d.-b). Homelessness remains a pressing concern, with the 2025 Point-in-Time (PIT) count identifying 2606 unhoused individuals countywide, 46.5 % sheltered and 53.5 % unsheltered (Bakersfield Kern Regional Homeless Collaborative [BKHRC], 2025). Among respondents, 9.4 % reported a serious mental health condition, 17.8 % of unsheltered individuals reported medical conditions, and about 25 % reported a substance use disorder, primarily in the unsheltered cohort. Despite these complex care needs, only 22.3 % reported having health insurance (BKHRC, 2025).

Currently, there are two organizations providing street medicine services in Kern County - Clinica Sierra Vista and Akido Labs, which have been operating for 6 and 2 years, respectively (Lara, 2024; Morley, 2023). While PEUH reside across the city of Bakersfield, a community of multi-generational PEUH reside in encampments along the Kern River Parkway (Image 1). In 2018, Bakersfield, California passed Measure N for the PSVS to fund Code Enforcement to engage in encampment abatements throughout the city (City of Bakersfield, n.d.-a) (Image 2). Consequently, PEUH frequently encounter Code Enforcement agents charged with destroying their encampments and disposing of all their worldly possessions, creating pervasive worry, mistrust, and anger (Image 3).

Image 1.

Code Enforcement agents approach an encampment along the Kern River Parkway, preparing for abatement that will displace residents and disrupt their access to safety, stability, and community.

Image 2.

After an encampment sweep, the belongings of displaced residents lie in a bulldozed heap - personal property reduced to debris, awaiting disposal in a garbage truck.

Image 3.

Graffiti scrawled across an underpass in the Kern River Parkway voices unhoused residents' anger and frustration toward Code Enforcement in the wake of repeated encampment sweeps.

1.5. Ontological security and homelessness

Giddens (1991) posits that human beings possess a fundamental psychological need for ontological security – a sense of continuity, order, and stability in one’s self-identity and surrounding environment. This security is cultivated through trust in routine, relationships, and one’s material surroundings, enabling individuals to maintain a coherent narrative of the self amidst the uncertainties of modern life. Expanding upon Giddens’ concept, Dupuis and Thorns (1998) identify four central components of ontological security: material and social constancy, the capacity to establish and maintain daily routines, privacy and freedom from surveillance, and the opportunity for self-actualization and positive identity formation.

While early applications of ontological security theory focused on homeownership, including but not limited to countries like New Zealand and the United States, as a critical foundation for its development (Dupuis & Thorns, 1998; Saunders 1984; Saunders 1986), more recent research has extended this framework to examine how homelessness disrupts ontological security (Chamberlain & Johnson, 2018; Goldshear et al., 2023; Padgett, 2007; Rosenberg et al., 2021; Stonehouse et al., 2020; Watt, 2018). For PEUH, the absence of a stable dwelling often undermines trust in the self, others, and social system - thereby eroding both material and emotional stability. Rosenberg et al. (2021) described ontological insecurity as encompassing impermanence, punitive place rules, constant surveillance, and lack of control—conditions frequently experienced by unhoused individuals in public spaces. Similarly, Padgett (2007) discussed how homelessness threatened ontological security across intersecting material and non-material domains including emotional, psychological, relational, and identity.

A growing body of research documents how homelessness deepens ontological insecurity by eroding individuals’ social inclusion, agency, and capacity for decision-making (Henwood et al., 2018). These vulnerabilities are further exacerbated by traumatizing experiences associated with rough sleeping and state-sanctioned interventions such as encampment sweeps (Goldshear et al., 2023; Stonehouse et al., 2020). Stonehouse et al. (2021) found that many individuals entered homelessness after experiencing early-life adversity that prevented the development of ontological security prior to housing loss. Homelessness, in turn, intensified their ontological insecurity, as participants faced continual exposure to environments devoid of safety, autonomy, and resources (Gould et al., under review; Stonehouse et al., 2021). Even when participants transitioned into housing, material constancy alone was often insufficient to repair the non-material domains of ontological security (Stonehouse et al., 2021). Feelings of social exclusion and fractured self-identities frequently persisted, consistent with earlier findings that housing alone may not rebuild the nonmaterial dimensions of ontological security (Chamberlain & Johnson, 2018; McNaughton & Sanders, 2007; Padgett, 2007). This persistent sense of ontological insecurity further compromised the physical and mental health of PEUH.

In North American and public health contexts, ontological security has primarily been explored among housing and vulnerable subpopulations, including justice-involved individuals (Rosenberg et al., 2021), people living with serious mental illness (Henwood et al., 2020; Padgett et al., 2007), and sex workers (McNaughton et al., 2007). A smaller but emerging body of literature has examined the concept in relation to mental health and public health interventions, particularly in the context of the COVID-19 pandemic (Edwards et al., 2024; Oakes, 2023; Zhang et al., 2022). However, there remains a significant gap in research exploring ontological (in)security as a mechanism shaping engagement in healthcare and behavioral health services, particularly among PEUH.

PEUH face numerous barriers to accessing traditional healthcare, including rigid clinic schedules, lack of transportation, limited access to phones or secure storage for medications, stigma and bias from providers, and conditional or fragmented care (Fig. 1). Street medicine emerged as a direct response to these systemic obstacles, offering low-barrier, patient-centered care in the environments where PEUH live. Despite its growing implementation, research on patient experiences with street medicine remains limited, particularly in underserved regions. To date, there is no published data on how individuals experiencing homelessness in Bakersfield, California, perceive or engage with street medicine services.

Fig. 1.

Comparison of care models: street medicine fosters ontological security, improving healthcare engagement and health outcomes among unhoused patients, while traditional healthcare systems reinforce ontological insecurity, driving healthcare disengagement and poorer health.

1.6. Study aims

This study conducted an in-depth qualitative investigation exploring how the street medicine model in Bakersfield, California, shapes participants’ access to care, motivation for engagement, and overall health outcomes.

2. Methods

2.1. Study design: constructivist grounded theory

This study aimed to explore the acceptability of street medicine as an alternative healthcare delivery model by collecting data from PEUH actively receiving such services in Bakersfield, California. We conducted qualitative interviews with 10 PEUH (n = 10) who were patients of local street medicine teams in Bakersfield, CA between March 2025 and May 2025. Our research team included a master’s candidate and research staff (PB), a postdoctoral researcher (SSG), and faculty members (ANSH, RNB, and BC), with ANSH acting as the Principal Investigator. Throughout the course of the study, we reviewed the SRQR (standards for reporting qualitative research) to detail aspects of our team composition, research design, results, and analytic strategy [Appendix A]. We used constructivist grounded theory to explore the perspectives and experiences of PEUH who received integrated healthcare services through the street medicine service delivery model (Charmaz, 2016).

2.2. Selection of participants: sampling and recruitment strategies

This research examined patient perspectives on receiving street medicine services. We recruited participants receiving services from two local street medicine teams operating in Bakersfield, California, using convenience sampling between March 2025, to May 2025. Study eligibility included being 18 years of age or older, resident of Bakersfield, California, had received street medicine services in the past 6 months, were English-speaking, and willing and able to provide informed consent. PB accompanied the street medicine teams on rounds to invite patients directly to participate and also provided flyers for distribution by team members to their patients. Three patients were recruited from the first street medicine team, and seven patients were recruited from the second street medicine team.

Participants were recruited from two street medicine programs operating in Bakersfield, California. Team 1 was operated by a for-profit street medicine entity and did not serve as a training site for students or residents. Clinical services for Team 1 were primarily delivered by advanced practice providers and case managers, with physician oversight provided remotely.

Team 2 was embedded within a federally qualified health center (FQHC) and functioned as a clinical training site for a family medicine residency program and an addiction medicine fellowship, as well as a rotation site for medical students. This team consistently included an onsite physician (MD) during outreach and emphasized trainee education alongside service delivery.

Despite these organizational and staffing differences, both teams shared a common street medicine model, including low-barrier, patientcentered care delivered in unsheltered settings; a harm reduction–oriented approach; continuity of outreach locations and schedules; and training influenced by the same street medicine training program. In participant interviews, patients did not describe meaningful differences in care approach, relational dynamics, or service philosophy between the two teams. As a result, patient perspectives were analyzed collectively. We note, however, that the study was not designed to compare team-level differences, and patient interviews were not structured to systematically elicit contrasts between teams.

This population was intentionally selected for the study given their heightened exposure to structural barriers, such as lack of transportation, geographic isolation, limited or no insurance coverage, inflexible clinic hours, and lack of ID or documentation; social marginalization, and healthcare disconnection (Aldridge et al., 2018; Hughes, 2024; Ramsay et al., 2019; Wille et al., 2017), making them uniquely positioned to describe the acceptability and impact of alternative care models like street medicine.

We used constructivist grounded theory and theoretical sampling to continue participant recruitment until no new themes emerged in the qualitative interviews (Charmaz, 2016). This resulted in a final sample of 10 participants. Throughout the data collection process, participants introduced emerging theoretical categories, such as relationship building with street medicine providers, health literacy promotion, particularized trust (i.e., placing trust in specific targets, such as friends, relatives, or acquaintances that have been built upon pre-existing social ties) (Alesina & La Ferrara, 2002; Uslaner, 2002), and overall acceptability, which were further explored in subsequent interviews. Data collection concluded once no new categories were identified and existing concepts were well developed, indicating that saturation had been reached (Ligita et al., 2020).

2.3. Data collection: semi-structured interviews

The interview sessions were conducted in-person and via HIPAA-compliant Zoom calls, according to participants’ preferences between March 2025, and May 2025. We developed and followed a semistructured interview guide based on the Theoretical Framework of Acceptability (Sekhon et al., 2017) [Appendix B: Interview Guide]. The Theoretical Framework of Acceptability includes seven constructs of acceptability: burden, opportunity cost, intervention coherence, self-efficacy, perceived effectiveness, affective attitude, and ethicality (Sekhon et al., 2017), which help identify potential barriers to acceptability and guide adaptations to support successful adoption and sustained use of an intervention. This framework was applied to the current study to examine the acceptability of street medicine and which components of its practice enhance patient engagement, mitigate structural barriers and medical mistrust, and advance health equity among structurally vulnerable individuals experiencing unsheltered homelessness.

The semi-structured interview guide questions [Appendix B] were piloted and refined internally within the research team (PB - ANSH). We met on a weekly basis to review data collection and participant recruitment. During these team meetings, we continued our iterative review and revisions to the interview guide as interviews progressed and new themes emerged. This process facilitated exploration of theoretically relevant areas and elicited richer, more nuanced responses from participants (Charmaz & Thornberg, 2020; Ligita et al., 2020). For example, although the qualitative interview questions were designed to explore the acceptability of street medicine services, participant narratives consistently expressed strong endorsement of this care model.

All interviews were conducted by a single member of the research team (PB), who employed open-ended prompts and follow-up questions to encourage participants to elaborate on topics they introduced. Using a non-directive approach in the interviewing process supported the emergence of additional, unanticipated perspectives, allowing for a rich participant-driven exploration.

Audio recordings of interview sessions were uploaded and transcribed verbatim using the digital transcription platform Otter.ai and subsequently reviewed by research staff to ensure accuracy. Anonymized and sanitized transcripts were securely uploaded to HIPAA-compliant Box for team access and collaborative analysis. During the initial analytic phase, team members independently reviewed the transcripts and annotated emerging ideas. As data collection progressed, the team reached consensus on theoretical saturation when newly emerging insights coincided with previously observed patterns. This study was approved by the Human Subjects Institutional Review Board of California State University, Bakersfield (Protocol #25–53).

2.4. Data analysis: constructivist grounded theory

Data analysis was conducted in two phases: Preliminary and In-Depth.

2.4.1. Phase 1: preliminary data analysis for theoretical saturation

To ensure theoretical saturation, PB kept detailed notes throughout each of the interviews to further examine emerging themes and identify new ones. After that, PB manually coded sections of the interview based on the seven domains of the Theoretical Framework of Acceptability (TFA). This allowed her to iteratively revise the semi-structured interview guide to saturate emerging themes. After each interview, PB would address (via interview questions or probes) new or emerging themes that in the previous interview, in the following participant’s interview, and analyze similarities and differences in responses. We conducted this preliminary analysis to ensure that the scope of data collected from the interviews was analyzed for emerging theoretical categories to ensured that we achieved theoretical saturation for TFA domains as well as new themes that emerged from the semi-structured interviews. This ongoing preliminary analysis showed that while data were saturated with TFA domains, the semi-structured interview guide had facilitated the emergence of unanticipated thematic categories that were beyond the scope of the TFA framework.

2.4.2. Phase 2: in-depth analysis

We found that the TFA was unable to comprehensively capture the nuances of our patients’ complex realities shaped by homelessness, poverty, and co-morbidity. In order to address this methodologically, we conducted an in-depth analysis using constructivist grounded theory. Constructivist grounded theory (CGT) methods allowed us to engage in iterative analysis and cross-data comparison to generate a conceptual framework (Charmaz, 2021). This methodology facilitated the generation of theories and explanations that were directly rooted in participants’ subjectivities, narratives, and experiences (Charmaz, 2016).

The study team discussed preliminary findings before we conducted in depth data analysis using CGT methods. This led to development of the initial codebook using CGT. The codes in this codebook were not restricted to TFA domains but instead were generated from the data. This allowed us to comprehensively capture themes participants had introduced. We then applied this initial codebook to 3 transcriptions to examine whether the themes were capturing the data, and iteratively revised this codebook based on application to transcript [Appendix C: Codebook]. We imported transcripts to Atlas.ti (Version 26) to conduct the analysis. A two-person (ANSH-PB) team independently analyzed the transcripts and met weekly with SSG to discuss codes, themes, and theoretical categories and synthesize emerging theories from transcripts. Through weekly meetings, we developed audit trails, applied and revised the codebook, reviewed observations and deviations, developed early memos, and engaged in triangulation.

During data analysis meetings with the PI, final analytic memos were developed to document themes and categories arising from intersecting codes and to facilitate comprehensive, co-constructed interpretation. Our iterative review process continued across several study team meetings until consensus of themes and theoretical categories was achieved. Upon constructing theories emerging from theoretical categories related to social and material consistency, self-perception, and health routines, we found that our findings were well situated within the corpus of literature on ontological security and its domains.

To summarize, the data were collected and iteratively analyzed during data collection using TFA. When TFA was unable to capture the nuance in the data, we used CGT to conduct the in-depth analysis. Ontological security and its domains emerged from the CGT methods – we did not enter the data analysis process with ontological security in mind nor analyze the data using this lens.

3. Results

The analytic sample included a total of 10 participants residing in Bakersfield, California. Participants were majority female (n = 6; 60 %) and Latine (n = 7; 70 %). Most were experiencing chronic unsheltered homelessness for over 12 months (n = 7; 70 %) with 3 participants reporting that they were recently housed within the past 6 months after experiencing chronic unsheltered homelessness. All participants were current patients of one of two street medicine teams operating in Bakersfield, California. Authors assigned pseudonyms to participants to protect their privacy.

We constructed five primary themes from emerging categories within the data: street medicine services fostered social and material constancy, promoted positive self-appraisal through unconditional positive regard, restored autonomy and trust via privacy and control, and enabled the development of health routines and reduced health anxiety through consistent, reliable care.

3.1. Street medicine team members engaged with participants in a reliable and consistent manner, building trust in social relationships

In the context of street medicine, patients reported consistent access to team members, providers’ predictable and respectful interactions, and the team’s responsiveness to their urgent needs. This contributed to a sense of social constancy, which was characterized by reliability, trust, and safety in the patient-provider relationship.

Several participants described how street medicine providers consistently showed up and followed through on their commitments. Consistency fostered a sense of reliability helped build trust in a context where many had long struggled to trust others at all. For individual patients like Christina, it was the street medicine team’s steady presence and follow-through that allowed her to begin letting her guard down and rebuild trust in people.

“They do what they say they are going to do. I don’t like many people, but they are good at what they do. They take care of the stuff we talk about and make sure I get what I need.” - Christina

Beyond being a reliable source of services, Christina also points to the consistent quality of street medicine services. For her, the consistency extended to their competence and commitment to meeting patient needs.

Similar to Christina, several participants felt that consistency played a key role in shaping, relying, and depending on street medicine services support. It reinforced patient confidence that they could access the care and resources they needed when they needed it.

“Too easy [to access street medicine services]. I know what day they are coming, and I have [street medicine team]. I can call [street medicine provider] if I need something. She always answers, so I’ve never worried about if I can’t see them because they come every week.” - Ana

“I think this is easier for me. They come to me. I can call my nurse anytime, and he will be out here the same day. When I would call [redacted], he would take care of anything I called him for. He’s never too busy to come and see me.” - Amanda

Street medicine fosters social constancy through consistent across various domains of social service provision including days of availability, competence, commitment to meeting patient needs, and patient-provider interactions. Social constancy emerging from this consistent care played a key role in helping patients build trust and a sense of stability in their relationships with care providers.

3.2. Street medicine provided resources that contributed to building trust in the durability of available material resources among patients

In street medicine, material constancy was reflected in the consistent, non-contingent provision of basic necessities - such as food, water, hygiene supplies, and medication for opioid use disorder (MOUD) - and reliable access to material resources like vital documents and social benefits. Participants emphasized that receiving these supports without conditions fostered trust and served as a crucial entry point for engaging with care. An interview with our patient, Amanda, highlighted her engagement with the street medicine team extended beyond streetbased care.

“Before I moved into this place [transitional housing], they would see me on the streets. They would even bring out bug spray in the summertime. I was taking the shot [Sublocade] out there on the streets. They got me on that.” - Amanda

For patients like Amanda, the material resources provided by street medicine were firmly situated in the environmental contexts of living outside during the summer in Bakersfield. Consistently, and non-contingently receiving resources that met key needs, contributed to a sense of trust in street medicine providers and their material constancy. Further, street medicine served as an entry point into treatment for Amanda where she received a once-monthly extended-release injectable formulation of buprenorphine (Sublocade) to treat her opioid use disorder.

Yet another patient, Jordan, described the challenges of managing priorities, especially housing, and that the support from her case manager alleviated the intense pressure of navigating through several goals. Noting that she could rely on her case manager to fulfill the commitments discussed, contributing to the trusted bond.

“They provide case management. My case manager is awesome. She literally helps me get my Social Security and helped get me into housing. She also helped me try and get my GA [General Assistance]. She does way more than she has to and she’s awesome about it. She makes the time and makes sure she gets everything we talked about done. I struggle to get a lot of things done and she helps get it taken care of for me.” - Jordan

Jordan also points to the ways in which street medicines’ material resources contribute to alleviating patients’ cognitive burden of navigating disjointed social services. In these ways, material constancy extends beyond the direct resources that patients receive from street medicine via linkage and case management.

Christina highlighted that receiving basic needs items, such as food, without the expectation of further engagement with the street medicine team, provided a sense of trust and familiarity that contributed to her willingness to engage in additional services.

“I would see them giving out lunches and stuff. So, I would go and get that. But it took me a while to actually get any medical care. I went up to them one day, and he handed me lunch and asked if I needed anything else. I said no, and he said that’s okay, but to take the lunch anyway if I wanted it. I remember thinking, ‘he’s kind of cool.’” - Christina

Beyond being a reliable source of services, Christina also points of to the consistent quality of street medicine services. Participants like Christina found street medicine services to be non-contingent, as they could access essential resources such as food, hygiene, or harm reduction supplies without being required to accept treatment. In this way, street medicine services fostered a sense of material constancy, as these non-contingent services were consistent, responsive to the social and environmental realities of unhoused individuals and tailored to their specific risk contexts. By providing competent and coordinated linkage and case management, street medicine helped alleviate the cognitive burden placed on patients as they attempted to navigate complex, fragmented social service systems.

3.3. Street medicine empowered patients to exercise privacy and control via practices such as consent, shared decision-making, and confidentiality

Several participants discussed how street medicine providers encouraged their autonomy and self-determination through the practice of shared decision-making, encouraging patients to collaborate with providers during the clinical interaction. Jose described how having control over his healthcare needs was imperative to his continued engagement with the street medicine team. The ability to engage in services that were best aligned with his level of comfort fostered a sense of empowerment and autonomy.

“With street medicine, I’m allowed to decide what I am and am not comfortable with. I like the doctors and the team so I keep seeing them.” - Jose

Amanda expressed that she felt safe expressing her readiness to engage in treatment interventions with the street medicine team, as she perceived that they empowered her to exercise a high level of control due to the non-contingent care service delivery model.

“If there is something I don’t think I can do or I know I won’t follow through on, I will tell them … I feel like I have a good relationship with them to tell them the things I don’t think I can do. Which is a big step for me.” - Amanda

Since she did not fear judgment or discharge from care due to non-adherence/limited engagement, Amanda felt she was able to be honest about her capacity, ability, or willingness to adhere to treatment recommendations. Notably, she pointed to this being “a big step” implying a stark difference between other forms of clinical care.

In street medicine, shared decision-making is a respectful, collaborative process where providers listen, adapt care to the complex realities of unhoused patients’ lives, and communicate health information clearly to support their patients to make informed, confident choices. Anthony and Christina described the importance of shared decision-making regarding their healthcare needs. When provided with information and reassurance related to addressing their needs, the participants expressed their willingness to engage in treatment recommendations when they recognized the significance and process of the next steps.

“Like they [conventional healthcare provider] would tell me I needed lab work and just expect me to get it done. But I didn’t know why I needed it or how to do it. With [street medicine provider], he tells you need lab work done, and then he tells you why you need it, and then he tells you how it’s going to get done. It’s better when something is explained to me.” -Anthony

“I had been ignoring having a mammogram for nine years. He [street medicine doctor] got me into doing it. Now that I feel comfortable, I am able to do it. It can be scary, especially when [breast cancer] runs on both sides of your family. I had been putting that off for a long time. I would tell them [the street medicine team] I don’t want to do it, or I can’t do it, and they would tell me what the process is and what I need to expect. Which helped me feel a lot more comfortable to actually get it done.” - Christina

Multiple participants shared that street medicine providers respected their privacy and sought to create safety for confidential disclosures in public encampment spaces.

“It is open, and people are around, but if you ask them for privacy, they will take you where no one else is. When I wanted to talk about my drug use, I asked to move away from other people, and they did that for me. It felt laid-back and chill.” - Jose

For Jose it was important that the street medicine team honored his request to discuss substance use in private. He felt this enhanced his comfort and willingness to freely discuss his goals for addiction treatment.

Ana and Christina described how street medicine teams to create privacy even in open settings with a high volume of patients. Street medicine team members honored patients’ privacy and the sensitive nature of their disclosures by delivering services away from their immediate environment. Additionally, health status was never disclosed to patients’ significant others to ensure privacy and confidentiality, unless patients provided their written consent:

“They do a great job of making sure everything is private. He won’t talk about your business if other people are around. I’ve never been worried about that. I actually think it’s the most respected and decent care I’ve received.” - Ana

“We go to private areas when we are talking about stuff. He won’t even tell your significant other about what is going on. Unless you put something in writing, your information stays between you and him.” - Christina

Despite operating in public spaces, the street medicine team actively safeguarded patient privacy by holding conversations out of earshot, honoring confidentiality, and handling sensitive health information with care. Shared decision-making further empowered patients to exercise control over their health goals and care planning.

3.4. Unconditional positive regard from street medicine providers supported building positive self-appraisal among patients

In street medicine, unconditional positive regard is a philosophy and practice centered on the inherent dignity and worth of all human beings regardless of their circumstances or choices. In turn, unhoused patients receive care without judgment or conditions.

Maria described that she felt socially abandoned and excluded, especially from the traditional healthcare system. She explained:

“I actually feel blessed. Because there are no services out here for anybody, at all. You don’t see anybody out here for the homeless. There is nobody out here for us. No medical, this is a first. So yeah, you can’t really say anything bad about it. He actually reaches out more than anyone else does.” - Maria

For Maria, the street medicine team’s willingness to provide services in their social environment (encampment) created a sense of worth for her. The perceived status and authority of physicians served to further reiterate the importance of the doctor’s commitment to unhoused patients.

Amanda discussed how her experiences of dehumanization as an unhoused person with opioid use disorder created multiplicative harm and social exclusion.

“The doctors and nurses understand me. Before, people just used to see me as a drug addict. I always felt like people didn’t like me. I feel good here, and I trust they will take care of me.” - Amanda

Amanda felt that the street medicine team did not reduce her to these identities and treated her with dignity and respect, leading her to “feeling good” and developing a positive sense of self.

Ana and Daniela emphasized how the street medicine team prioritized relational aspects of care, taking time to know patients as individuals and treating them with respect and compassion - an approach that contributed to their development of a positive self-appraisal and a newfound sense of being “important.”

“For me, personally, they have become like family. They really get involved with you, and they care. They remember your name, and they remember your dog’s name. They really become like family … Like, most people don’t treat us well out here. He came in and treated us with respect, and it seemed like he really cared, so it made it easy to keep going. Again, they just make you feel important.” - Ana

“I don’t like going to the doctor. With [redacted], he makes it comfortable. He don’t come at you like a patient, he comes at you like a friend. He acts like somebody that’s concerned. He don’t judge us. When code enforcement comes out here, they look down on us and talk badly about us or whatever, but [redacted] don’t. His team don’t. They don’t look at us differently because of our living situation. I think that’s what makes it a lot more comfortable for people to come and see him.” -Daniela

Such interactions were particularly impactful given the participants’ broader context of social exclusion as PEUH and the targeted social violence they often experience during encampment sweeps.

Participants in this study were often interacting with very few individuals, most of whom were public safety actors such as code enforcement. These interactions were marked by violence and dehumanization, often resulting in total erasure of participants lives by discarding their belongings, identifying documents, and medications. In stark contrast, the unconditional positive regard from street medicine expressed via interactions such as remembering participants names or the pets was deeply affirming to their sense of self and humanity. It allowed participants the opportunity to reappraise themselves positively by making them feel valued and important.

Valeria, shared a similar experience, highlighting how the physician’s unconditional positive regard - expressed through kindness, approachability, friendliness, and nonjudgmental and dignity-affirming care - was emotionally validating, contributing to her sense of comfort and worth:

“He makes it comfortable and chill. So, I didn’t have time to worry about it because, off the bat, he was nice and made me feel comfortable. He don’t look at us like homeless people. He looks at us like friends. And that makes us feel better.” - Valeria

In summary, the street medicine team’s nonjudgmental, relationshipcentered approach fostered a renewed sense of self-worth, restored trust in healthcare, and strengthened patients’ self-efficacy and motivation to engage in their care.

3.5. As ontological security improved, patients built health routines that improved their health outcomes

Jordan discussed how the street medicine team’s commitment to social constancy and unconditional positive regard supported the development of health routines and promoted patient activation, ultimately contributed to improved health outcomes:

“How friendly they are. They are devoted to their job. That’s what makes it worth it. They care and treat you like they care, so it makes it worth it to come back and see them. Since I started seeing them, my health has been better, my heart has been better, and it’s easier to take care of all of this.” - Jordan

They also emphasized consistently being seen at the same time by the street medicine team was critical to establish reliability. Several patients, including Christina, echoed how a consistent and reliable schedule facilitated engagement in integrated healthcare services by building trust in street medicine providers and services:

“[It is] extremely easy [to be seen by a provider]. They show up and I show up, and it gets done. It’s really good for us on the [encampment site]. More people should be able to get this.” - Christina

Building upon trust, several participants discussed how the consistency and reliability of the street medicine teams enabled them to establish weekly routines aligned with the team’s schedule, offering a sense of structure and stability in a world often experienced as chaotic and beyond their control. This regularity not only fostered trust, but also empowered individuals like Robert and Daniela to build health routines and reassert agency over their well-being:

“It’s been very easy. We know when Thursday comes, we are getting up and coming over here. I’ve never had any issues getting something I need from them. That’s something that’s important to me.”- Robert

“They come out early, but I like that. I know when Thursday comes around, I need to get up and walk to see them. It helps me start my day honestly.” - Daniela

Several participants who had previously struggled to follow through with treatment guidance and attend medical appointments emphasized that the consistency, reliability, and unconditional positive regard demonstrated by the street medicine team fostered a strong sense of trust. This relational foundation, in turn, enabled participants to establish greater adherence to health routines, including improved follow-through with treatment recommendations, follow-up care, and regular appointment attendance:

“Over the time of me going to see him, I built that trust with him. I trust the places he sends me to because I trust him. I trust he knows what he’s doing, and if he says I need to go see someone for my health, I’m going.” - Daniela

“We have trust there. So, I know if I needed to go somewhere or do something, he tells me, it’s because it’s better for my health. I do what he tells me to do because I trust him. He hasn’t actually ever sent me to an appointment because I don’t think it’s something I need. But if he told me I needed to do it, I would.” - Valeria

In short, by offering consistent material and social support, shared-decision making, unconditional positive regard, and non-punitive care, street medicine services fostered patients’ ability to trust in the reliability of care providers. This sense of social and material continuity - coupled with the development of a positive self-identity - enhanced participants’ capacity to engage in health-promoting behaviors. As trust in their relationships with care providers and in themselves grew, participants were better able to establish and maintain health routines, including medication adherence, attending follow-up appointments, and engaging with preventive care. These routines, grounded in self-determined goals, contributed to improved physical and psychological well-being and meaningful, sustained engagement with healthcare systems (Fig. 1).

4. Discussion

This study highlights the powerful role of the street medicine healthcare delivery model in promoting ontological security among PEUH. Participants resoundingly endorsed street medicine services, underscoring how this model stands in sharp contrast to traditional healthcare systems and broader social interactions, which are often characterized by social violence, unpredictability, exclusion, and surveillance. Notably, participants described street medicine as a rare domain in which they felt safe, valued, and seen - a context that fostered the development of trust, agency, and a coherent sense of self.

Street medicine approaches were perceived by patients to mitigate the immediate harms of marginalization but actively supported participants in building ontological security across the four domains identified by Dupuis and Thorns (1998): material and social constancy, routine, privacy and autonomy, and positive self-identity. Despite living in settings marked by uncertainty and frequent displacement, participants experienced street medicine as a reliable and consistent source of care. The repeated presence of street medicine providers within participants’ own environments introduced continuity into otherwise fragmented lives, enabling the formation of health routines and long-term care engagement - even amid the instability caused by encampment sweeps (Goldshear et al., 2023). In addition to consistent and respectful interpersonal interactions, participants in our study emphasized the reliability of material supports - such as medications, wound care, hygiene supplies, and food - that were regularly provided by the street medicine team. This dependable access to both relational and tangible resources helped to restore a sense of control and predictability in participants’ daily lives. As Giddens (1991) asserts, a fundamental element of ontological security lies in the reliability of persons and things; our findings illustrate ways in which the street medicine model directly fulfilled this condition by offering stability in both human relationships and material provisions. In doing so, it created a foundation upon which PEUH could begin to rebuild trust in the world, develop routines, and reassert control in managing their health and well-being.

Importantly, participants emphasized that street medicine sites offered a rare reprieve from surveillance. Whereas public spaces and institutional settings often policed their presence and behavior, street medicine services respected participants’ privacy and autonomy, affording them greater control over if, when, how, and where care was accessed. The delivery of care within encampments - spaces described by participants as the closest thing they had to “home” - was especially meaningful. By meeting individuals where they were, both geographically and emotionally, street medicine teams fostered a sense of ownership and safety that was often absent in mainstream healthcare settings.

We found that the relational nature of street medicine was among its most transformative aspects. Participants spoke of team members with warmth and familiarity, frequently referring to them as “family” or “friends.” These relationships were described as non-contingent, rooted in unconditional positive regard and non-punitive interactions. Unlike many traditional providers, street medicine teams did not withhold care based on compliance, sobriety, or appearance. This non-judgmental ethos facilitated identity reconstruction, allowing participants to rebuild trust in others, see themselves beyond stigmatized labels, and engage with society in ways that affirmed their self-worth and dignity. These findings align with prior research suggesting that, for ontological security to be meaningfully built among PEUH, it must be accompanied by social inclusion and the restoration of a coherent, positive self-identity (McNaughton & Saunders, 2007).

Crucially, participants described how this newly established sense of ontological security enabled them to engage more confidently in health behaviors, pursue treatment goals, and sustain adherence. The consistent presence and provision of resources, reliability, and nonjudgmental approach of street medicine providers played a pivotal role in reducing fear and mistrust, thereby fostering patient empowerment and activation. These findings reinforce the notion that ontological security is a critical precondition for meaningful healthcare engagement, particularly for PEUH who have long faced exclusion and marginalization within institutional care systems. Our results closely align with Engel et al. (2021), who observed that enhancing ontological security among unsheltered people who use drugs (PWUD) may be associated with increased agency, optimism, and the capacity to make health-promoting decisions regarding substance use. This is further supported by previous research from Padgett (2007) and Rosenberg et al. (2021), both of whom underscore the central role of ontological security in promoting health and well-being among unhoused populations.

Furthermore, this study highlights the vital importance of the nonmaterial aspects of ontological security and how street medicine addresses the emotional, psychological, relational, and identity aspects of ontological security. This study extends upon the work of Chamberlain and Johnson (2018), McNaughton and Sanders (2007), Padgett (2007), and Rosenberg et al. (2021) by demonstrating the ways in which street medicine contributes to the restoration of ontological security through supportive, empowering social relationships and routine-based structures.

This study underscores the critical role of the nonmaterial dimensions of ontological security - including emotional stability, psychological well-being, relational connectedness, and self-identity - in supporting PEUH to not only successfully prepare to transition out of homelessness but also to meaningfully engage in healthcare. While previous research has shown that housing alone often fails to address these deeper psychosocial needs (Chamberlain & Johnson, 2018; McNaughton & Sanders, 2007; Padgett, 2007; Rosenberg et al., 2021), our findings demonstrate that street medicine fills these gaps by fostering consistent, trusting relationships and a sense of inclusion and dignity within care interactions. Through its relational and non-punitive approach, street medicine helps counteract the stigma and shame that PEUH often carry, enabling the construction of a positive self-identity grounded in experiences of unconditional respect, consistency, and care. Participants described how these repeated, affirming interactions with street medicine providers helped restore their ability to trust people and institutions - a foundational shift that empowered them to re-engage with their health, set goals, and begin envisioning a different future. In doing so, street medicine addresses not only the material and medical needs of unsheltered individuals but also the profound social and psychological dislocations that “housing only” interventions often leave unresolved, thereby creating the necessary conditions for PEUH to reconnect with care systems, manage chronic health conditions, and build toward long-term stability and well-being.

Paired with Housing First and permanent supportive housing models, street medicine may support unhoused patients to navigate the transition from the streets to stable housing, while simultaneously addressing their complex medical and social needs. While most patients in this study were experiencing unsheltered homelessness, several continued to be seen by the street medicine team after entering transitional housing programs. The team’s ongoing care during this period of transition promoted social constancy, reinforcing trust and stability as patients moved from the streets toward more permanent housing.

By legitimizing and reimbursing care provided where PEUH live, POS 27 has the potential to expand the capacity, reach, and sustainability of street medicine programs. Our findings suggest that such policy shifts may have meaningful downstream effects on health by strengthening ontological security - fostering stability, trust, and consistent engagement with care - among individuals who have long been excluded from traditional healthcare systems. By supporting care models that meet PEUH in their own environments, this change addresses both structural and relational barriers to care, aligning reimbursement policy with evidence-based approaches to reducing health inequities.

To realize the full potential of the street medicine model, critical investments are needed across three domains: training, fiscal support, and policy change. Training should be embedded across all levels of medical and behavioral health education - including primary care, addiction medicine, addiction psychiatry, social work, and related fields - and include structured instruction in street medicine principles, shared decision-making, harm reduction, and unconditional positive regard. Structural investment in the continuity, provision, and expansion of street medicine services is an evidence-based approach to improving both current health status and long-term outcomes among PEUH. Public investment, as well as institutional commitments from hospitals and academic training centers, can expand program reach, facilitate re-engagement in healthcare, and strengthen health-related and daily routines for PEUH.

Sustained support for the practice will require leveraging new policy tools and funding mechanisms, including the CMS POS code 27, HRSA-funded residency street medicine training programs, and California Advancing and Innovating Medi-Cal (CalAIM) funding. CalAIM is a statewide initiative that uses Medicaid resources to address social determinants of health by providing non-clinical, community-based supports - such as housing navigation, tenancy-sustaining services, and intensive case management - that can be integrated into street medicine programs. Advocacy for Section 1115 waivers, modeled after California’s approach, could extend similar supports nationally, funding the case management and wraparound service components of street medicine for structurally vulnerable populations.

As exclusionary approaches to homelessness gain momentum - particularly following the Grants Pass decision, H.R. 1 (One Big Beautiful Bill), and the Ending Crime and Disorder on America’s Streets Executive Order (14321) - structural harm directed at PEUH is intensifying. Impending work and eligibility verification requirements risk wide-spread Medicaid disenrollment, not from ineligibility, but from systemic barriers such as lack of documentation, internet access, or stable contact information. These shifts threaten continuity of care and the financial viability of street medicine programs reliant on Medicaid reimbursement. In this context, care models that foster ontological security are more urgent than ever. By centering trust, reliability, and dignity, street medicine offers a promising path to mitigating harm, addressing inequities, and improving health and social outcomes for PEUH.

4.1. Limitations

This study has several limitations. First, participants were recruited through convenience sampling from two street medicine teams in Bakersfield, California, and their experiences may not reflect those of street medicine patients in other geographic or programmatic contexts. Although participants were recruited from two distinct street medicine programs, the study was not designed to examine differences in care model, approach, services, or personnel. Patient interviews did not consistently distinguish between teams, and therefore, team-level differences could not be systematically evaluated. Second, the small sample size, composed predominantly of Latine and female participants, limited our ability to explore how intersecting identities shape perceptions of the street medicine model. Given the disproportionate representation of Black individuals among PEUH, future research should examine how street medicine fosters ontological security across more diverse populations and settings. Third, while “control” emerged as a salient theme in participant narratives, we did not explicitly probe for it, limiting the depth of related findings. Fourth, our sample may overrepresent patients more engaged in care. This may have limited the representation of less favorable or critical perspectives of street medicine, which may be more likely from individuals who are less engaged in care. Finally, although saturation was achieved, our small sample size may have constrained the diversity of perspectives and limited the scope of insights captured from street medicine patients. Despite these limitations, this study offers valuable insights into how the street medicine model may support the development of ontological security, a key factor in healthcare engagement and participation among PEUH.

4.2. Conclusions

This study underscores the potential of the street medicine model to serve as a key mechanism for fostering ontological security among PEUH. Traditionally associated with housing and homeownership, the concept of ontological security can now be extended to include access to healthcare - particularly when delivered through relational, patient-centered models like street medicine. Our findings show that street medicine promoted trust with patients through: 1) consistent and continued social interactions (social constancy); 2) durable provision of basic material resources for health and wellness (material constancy); 3) empowering patients to exercise privacy (privacy and control); and 4) providing unconditional positive regard that supported patients in appraising themselves favorably (reducing negative self-appraisal). By addressing the various domains of ontological security, street medicine fostered trust with patients, which led to increased engagement in healthcare services as well as development and adherence to health routines.

Abbreviations

PEUH

People experiencing unsheltered homelessness

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ssmqr.2026.100711.