Access to Healthcare for People Experiencing Homelessness: A Scoping Review

doi:10.21203/rs.3.rs-1430496/v1

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Access to Healthcare for People Experiencing Homelessness: A Scoping Review

https://doi.org/10.21203/rs.3.rs-1430496/v1

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Background: People experiencing homelessness (PEH) have poorer physical and mental health than the general population. They are also more likely to have less access to healthcare. These processes of access can be better understood using Levesque’s access framework which addresses both supply (service provision) and demand (user abilities).

Methods: Following the Joanna Briggs Institute (JBI) guidelines, electronic peer-reviewed databases were searched in February 2022 for studies published since 2000 related to access to healthcare for PEH ages 16 and older in the UK and Ireland. Retrieved articles were screened and those eligible were selected for data extraction. Qualitative and quantitative studies were included.

Results: Fifty-six papers out of 538 identified were selected and aliased. Six main themes were identified: staff education, flexibility of systems, service coordination, patient preparedness, complex health needs and holistic care. These relate to the Levesque access framework.

Conclusions: Improving access to healthcare for PEH requires changes to how services are provided and how service-user abilities are supported.

Homelessness

healthcare access

United Kingdom

Ireland

People experiencing homelessness (PEH) have poorer health than the general population. Mortality rates are much higher and morbidity trends show that infections, mental health, cardiovascular and respiratory conditions are more prevalent among homeless populations (Aldridge et al., 2018). Premature ageing and frailty are more common (Rogans-Watson et al., 2020) and PEH are also disproportionately affected by mental health issues. One study concluded that self-harm rates among PEH was 30 times higher than that of their housed counterparts (Barrett et al., 2018). PEH have higher rates of hospital readmission, with one study reporting the rate of PEH having an emergency readmission as 2.49 times higher than their housed counterparts (Lewer et al., 2021).

Despite this, PEH are known to have poorer access to healthcare, as described by Julian Tudor Hart’s ‘Inverse Care Law’. This explains that the availability of medical care tends to vary inversely with the need for it in the population served (Haggerty et al., 2020, Tudor Hart, 1971). PEH are frequent attenders at emergency departments but relatively low users of primary and preventative health services, which may indicate that health is often not a priority until a crisis point is reached (Ni Cheallaigh et al., 2017, Keogh et al., 2015).

Access to healthcare for PEH has been highlighted as a priority for research, both in the United Kingdom (UK) and Ireland (Jagpal et al., 2020, Bergin, 2010). Prior to this scoping review, a preliminary search was conducted to ensure that there are no reviews published or in in progress on the topic of access to healthcare for PEH in the UK and Ireland. The databases searched were Medline, Joanna Briggs Institute (JBI) Evidence Synthesis and the Cochrane Database (Medline, Cochrane, JBI). Therefore, this scoping review was conducted to provide a broad insight into the evidence available concerning access to healthcare for PEH, specifically within the UK and Ireland.

Objectives

The objective of this scoping review was to assess the evidence from the published literature addressing access to healthcare for people experiencing homelessness in the UK and Ireland. Conclusions will highlight the main findings from all research in the review in order to make recommendations to improve access. The main question was:

What does the literature tell us about factors influencing access to healthcare for people experiencing homelessness in the United Kingdom and Ireland?

A protocol was designed prior to starting this scoping review, according to JBI recommendations (Peters et al., 2020). This included background, eligibility criteria and methods for search strategy, evidence selection, data extraction, analysis and presentation. It was not published or registered.

Eligibility criteria were decided using the Population, Concept, Context (PCC) framework. The population included literature considering adults (16 and older) who are experiencing homelessness using either of the first 4 sub-categories of the FEANTSA framework, that is, two roofless sub-categories and the first two sub-categories of houseless (as indicated in Fig. 1). This included people who are sleeping on streets or staying in short term accommodation.

The concept is access to healthcare, including primary and secondary healthcare as well as specific services. Levesque’s access framework was used for theoretical understanding, it describes a two-way relationship in which service-user and provider both play a part (Levesque et al., 2013).

The context is the geographical nature of the limitations for this review, limiting to UK and Ireland. The review was confined to the UK and Ireland because of the similarities in their healthcare systems and excluded other jurisdictions because healthcare system dissimilarities. A location specific scoping review adds value to this body of evidence as it allows researchers to understand the impact of culture and health services in the selected countries. The results of this scoping review may contribute to further research design in this wider context.

This review considered both qualitative and quantitative research. Methodology was not a limiting factor, and all methods were included. Literature reviews that meet the eligibility criteria were included if the review was published after 2000 after an initial search showed most papers would be included in this date range but excluded some that would not be applicable to current health systems. Opinion and commentary papers were not included.

The literature search was finalised in February 2022. Key terms were entered into four databases: Medline, CINAHL, Web of Science and EMBASE. The key terms used were homelessness, healthcare access and United Kingdom (UK) or Ireland (Table 1). The exact synonyms for each of these were slightly different for each database as some databases have relevant subject headings and key phrases. The key terms were finalised in discussion with a subject librarian after several initial searches.

Table 1

– Medline Search Terms
1	Homeless Persons/ or homeless.mp. or Homeless Youth/	13089
2	homelessness.mp.	6053
3	houseless.mp.	12
4	roofless.mp.	18
5	Health Services Accessibility/ or health access.mp.	82890
6	access to health service*.mp.	2645
7	health services access*.mp.	82901
8	United Kingdom/	240693
9	England/	91969
10	Scotland/	25700
11	Wales/	14822
12	Northern Ireland/ or Ireland/	24290
13	1 or 2 or 3 or 4	14866
14	5 or 6 or 7	84989
15	8 or 9 or 10 or 11 or 12	380332
16	13 and 14 and 15	81

All papers from these searches were saved into EndNote and duplicates removed (Endnote, 2013). The final list was then transferred to Rayyan to facilitate the screening of titles and abstracts during the selection process (Rayyan, 2016). Two reviewers did a blind independent screen of all papers using the predetermined eligibility criteria to make decisions. Conflicts were resolved through discussion with an additional reviewer.

Data extraction and charting was completed by one reviewer using headings from the JBI manual. These were used for initial data charting with three papers as a sample and then edited slightly to suit the objectives of this scoping review. The full text of 88 papers was data-charted and 32 papers were excluded during this process. After data-charting, results were coded. These codes were then written and grouped into themes, with agreement from two reviewers.

Four databases produced 647 results in total (Fig. 2). There were 81 from Medline, 303 from CINAHL, 220 from Web of Science and 43 from Embase. These results were all downloaded to Endnote and duplicates removed, leaving 538 individual papers. When these papers were transferred to Rayyan, 453 were excluded based on title and abstract screening using eligibility criteria. Then, the full text of 88 papers were read and 32 more excluded. This resulted in 56 papers to be included in this scoping review (Appendix 1).

The 56 selected papers included four that did not meet the agreed inclusion criteria but were included following researcher discussion as they were service evaluations that would add to the evidence as they offer insight into access to dental and pharmaceutical healthcare for PEH.

Characteristics of Evidence

The final results included 36 articles from England, 7 from Ireland, 7 from Scotland, 1 from Northern Ireland and 3 reporting on the broader UK. The final two were literature reviews that did not specify geographical location. Although this is not fully representative, it gives an overview of the general situation across the UK. Most studies took place in cities which limits the transferability of the results to rural areas. This is most noticeable for Ireland, where the only research included is from Dublin.

The participants were mostly PEH with 7 papers including health professionals. The sex of the PEH was reported in 20 studies. Fifteen had more male participants than female, 4 had more female and one had equal numbers of both.

The most common data capture method was semi-structured interviews with 22 papers reporting on results from interviews. Focus groups were used in 5 studies and questionnaires in 3. Other data collection methods used included freedom of information requests, surveys, census and observation. The health focus of the studies was varied and broad. The most common foci were dental hygiene, nursing intervention and end of life care.

The conclusions from papers were mostly similar, providing corroboration of themes. One notable difference was that 2 sources suggested that main services should be altered or improved rather than creating and using specialised services for PEH (Dawes et al., 2017, Anderson and Ytrehus, 2012). One of these noted the issue that dedicated homeless services may not provide patients with specialist health services (Dawes et al., 2017), while the other study concluded that reintegration into mainstream services created more challenges (Anderson and Ytrehus, 2012).

Six themes were identified, namely staff education, flexibility of systems, service coordination, patient preparedness, complex health needs and holistic, patient centred care. These themes explore factors that influence access for PEH in the UK and Ireland.

Staff Education

The attitudes and knowledge of staff and their impact on access were and mentioned in 29 papers included in this review. Education was noted in most of these papers as a tool to improve both knowledge and attitudes of staff in both healthcare and hostel settings.

Education for health professionals was highlighted by both health professionals and PEH. Two papers used Freedom of Information requests to conclude that education on homelessness in English Healthcare Trusts was minimal if present at all (Read, 2008, Lucas et al., 2018). One paper suggested that medical students should receive homeless specific education during their training (Paisi et al., 2020a). PEH emphasised the need for staff to be educated and aware of the complexities they faced and to offer ‘realistic advice’ and ‘simple explanations’ (Gunner et al., 2019, Rae and Rees, 2015, Chaturvedi, 2016).

Education for hostel staff was also requested, with aims to improve understanding of health needs and knowing when to escalate and refer patients to appropriate health services (Shulman et al., 2018, Jenkins and Parylo, 2011, Melvin, 2004, Taylor et al., 2007). This is challenging as PEH tend to have complex health needs and their disease trajectory is often difficult to predict (Traynor, 2019).

Several authors concluded that both healthcare and hostel staff should have a better understanding of navigating the health systems available for PEH, allowing them to signpost and direct PEH to appropriate services (Paisi et al., 2019a, Jenkins and Parylo, 2011, Schneller, 2012, Paisi et al., 2020b).

One paper presented data in a narrative form, with the aim of producing an emotive response from the reader, allowing them to gain an empathetic understanding of the experiences of PEH and their struggle in accessing healthcare. The author used this technique to educate the reader and remove the idea of PEH being ‘hard to reach’ but that services are ‘hard to reach’ for PEH. This was the only example where the author explicitly aimed to challenge readers attitudes and perceptions (Fordham, 2015).

Flexibility of Systems

The need for systems to be flexible and accommodating for PEH is the most common theme throughout, mentioned in 33 of the papers. Several authors specifically mentioned flexibility as a facilitator for access to healthcare for PEH, while others discussed the negative consequences of rigid systems. Key properties included location of services, appointments, and GP registration.

The physical location of services was mentioned most often, featuring in 18 papers. In some cases, the services were mobile or outreach groups bringing the service to PEH rather than expecting them seek it out. In one case this was done using a GP-led bus that drove to areas where PEH would be and then invited for health consultations (O'Carroll et al., 2017). Outreach and mobile approaches resulted in higher uptake or screening, vaccinations, and other health interventions (Neale and Kennedy, 2002, Gray, 2007). Location of services in relation to each other was also emphasised, highlighting that access to all services may be easier if they are ‘all under one roof’ (Mc Conalogue et al., 2021, Dawes et al., 2017). However, authors acknowledged that having all services under one roof might lead to PEH missing out on specialist care that would be available if regular referral routes were used (Dawes et al., 2017).

Rigid, individual appointment times were criticised in the results of several articles, suggesting instead that periods of time be set aside for homeless services. This would provide PEH, hostel staff or support workers with a window of opportunity to arrive at the health centre rather than a specific time slot. The flexibility around appointments also included giving out longer appointment times as many PEH have complex health needs that require longer than a usual GP time slot (Mills et al., 2015, Jenkins and Parylo, 2011).

Another flexibility issue is GP registration, a prospective patient may require identification and proof of address to register with a GP, which is often not possible for PEH (Gunner et al., 2019, Mc Conalogue et al., 2021).

Service Co-ordination

Service co-ordination was highlighted as a factor that influence access to health services. It was mentioned in 24 articles included in this review. This included poor discharge planning, fragmentation of services, poor communication, lack of understanding of who is responsible for the health of PEH, difficult referral processes, and poor links between health systems and hostels or shelters (Whiteford and Simpson, 2015, Rae and Rees, 2015, Paisi et al., 2019a, Dawes et al., 2017, Taylor et al., 2007). A small number of authors noted the positive impact of good signposting, where staff have an awareness of other available and relevant services and can direct PEH in the direction of support that will be helpful for them (Johnsen et al., 2021).

Discharge processes and transitions between services have a considerable impact on access for PEH. Poor communication or difficult discharge paperwork at transition stages was linked to patients falling through gaps in the system and losing access to healthcare (Dawes et al., 2017, Gunner et al., 2019). Some authors suggested a solution may be continuation of care planning and sharing notes between services (Smith et al., 2018, Webb, 2018).

Accountability for PEH is lacking, causing them to be passed between services with no-one taking on responsibility for their care (Traynor, 2019, Shulman et al., 2018, Rae and Rees, 2015). Some papers highlighted the positive impact of a specialised role of district/public health nurse to fill this position. However, positive outcomes were noted to depend upon the individual who carried out the role (Poulton et al., 2006).

Relationship and links between staff from different services was a facilitating factor for access to healthcare. This was often referring to relationship between hostel or shelter staff and healthcare providers as well as wider networks (Taylor et al., 2007).

Patient Preparedness

Authors discussed the preparedness of patients for accessing healthcare. This included the awareness of need and desire to access healthcare, as well as the knowledge and ability to do so.

Negative experience of healthcare services was a barrier mentioned in most of the papers included in this review. This led to attachments to certain services and fear of relocation (Paisi et al., 2020a, Smith et al., 2018). Negative experiences included both social and physical setbacks, such as bad interactions with healthcare staff or side effects from medication (Shah et al., 2019). One article suggested that providing an informal, flexible setting with non-judgemental staff and confidentiality would help to remove barriers that PEH had due to past negative experiences (Johnsen et al., 2021).

The ability to perceive health need is often lacking among this vulnerable group. Negative experiences may impact health beliefs and expectations and therefore the patients ability to perceive health need. In some cases, PEH were in denial that they had any health needs (Chaturvedi, 2016), while other results stated that seeking healthcare is often not be a priority for PEH (Coles and Freeman, 2016). This is mainly when the health concern is not at crisis point, resulting in preventative and primary health services having low attendance from PEH (Rae and Rees, 2015).

While PEH may not always perceive or prioritise their own health needs, healthcare staff should still strive for patient autonomy. One article recommended asking patients what health support they want (Ungpakorn and Rae, 2020). Improving autonomy can also include self-treatment of wounds and encouraging medication compliance (Morton, 2017, O'Carroll and Wainwright, 2019). Another author emphasised the importance of empowerment and control over one’s health choices (Paisi et al., 2020b). Empowerment and autonomy improve a patients ability to engage, however, perception of health need and desire for care can impact how much autonomy patients are given (Levesque et al., 2013).

Knowledge of healthcare systems and services were identified as barriers to access for PEH (Paisi et al., 2019a, Gunner et al., 2019, Paisi et al., 2020b). This included knowledge of mainstream services as well as specialist services (Smith et al., 2018, Dawes et al., 2017). There is also a lack of knowledge about preventative healthcare, such as health screening and health education (Swabri et al., 2019).

Learning from peers about health behaviour and available services was acknowledged as a facilitator for improving access to healthcare (Jagpal et al., 2019, Mills et al., 2015, Paisi et al., 2019b). Having a peer advocate or chaperone was recommended and supported by both staff and PEH. This model improved PEH attendance at appointments and helped with understanding during consultations (Paisi et al., 2020a, Hebblethwaite et al., 2007, MacLellan et al., 2017, Cameron et al., 2009).

Complex Health Needs

Several papers highlighted the issue of the complexities of health needs for PEH. Authors concluded that PEH have more complex needs than the general population and are more likely to experience comorbidities (Keogh et al., 2015, McKenzie et al., 2019). Some authors focused on end-of-life care for PEH, highlighting the unpredictability of death and disease trajectory for PEH (Traynor, 2019, Shulman et al., 2018) which may be exacerbated by low use of preventative health services and presenting with advanced illnesses (O'Carroll and Wainwright, 2019, Rae and Rees, 2015). Some authors explored the complexity and vulnerability linked to high prevalence of mental instability and disjointed lifestyles (Shah et al., 2019). Two papers highlighted the increased vulnerability when overlapped with other needs such as motherhood or learning disabilities (Fordham, 2015, Hebblethwaite et al., 2007). Other papers highlighted specific health concerns linked to homelessness, such as Hepatitis C, sexually transmitted illnesses, and alcohol use (McGregor et al., 2018, Hewett et al., 2011, Lambert et al., 2019).

Illicit drug use was mentioned in several papers as an added complexity with PEH, making accessing healthcare more difficult for PEH and creating issues for staff when treating them (Fountain et al., 2003, O'Carroll and O'Reilly, 2008). Some PEH described a connection between their substance misuse and mental health needs but were required to be ‘clean’ from substance use before they could access mental health services, meaning they could not access services when they felt they needed it (Mc Conalogue et al., 2021). Illicit drug use also affects use of services after arrival, one hospital-based study concluded that withdrawal symptoms should be managed upon arrival to A&E to ensure access to healthcare was optimal (Schneller, 2012). Another author mentioned the issue of storing some drugs in hostels, sometimes causing PEH to miss out on medication that the general population could store safely (Webb, 2018). Harm reduction healthcare also featured, with authors discussing providing water for injection and needle exchange (Harris et al., 2020, Fountain et al., 2003).

Holistic, Person-Centred Care

Several articles highlighted the importance of addressing needs in a holistic, person-centred manner (Neale and Kennedy, 2002). This included providing practical support alongside healthcare to fulfil basic needs such as hunger and shelter and to assist or encourage accessing other social or healthcare services (Wyatt, 2017, Cameron et al., 2009).

Person-centred care (PCC) is an evolving concept with frameworks that allow better understanding of the outcomes and aspects within PCC (McCormack and McCance, 2006, Santana et al., 2018). The results of this scoping review included papers that discussed the need for human connection, relationship, trust, and the need for PEH to feel listened to (Ungpakorn and Rae, 2020, Schneller, 2012, Hebblethwaite et al., 2007). These are all aspects of the therapeutic relationship highlighted in PCC frameworks (Doherty and Thompson, 2014).

Cost of health products was discussed in two papers, one in relation to contraception and one in relation to dental health products. These papers highlighted the importance of making these products free to PEH (Paisi et al., 2019b, Shah et al., 2019). These papers were the only two to broach affordability, suggesting that affordability is not a usual barrier to access for PEH in the UK and Ireland.

Levesque Access Framework

It is of interest to note that these themes overlap with and relate to aspects of Levesque’s access framework (Fig. 3).

Three of the themes (Staff Education, Flexibility and Co-ordination) link with the service accommodations from Levesque’s framework, one theme (Patient Preparedness) pertains to the abilities of the service-user and the final two themes (Complex Health needs and Holistic, Person Centred Care) are more exclusive to access for PEH specifically but can be explored alongside Levesque’s framework (Levesque et al., 2013).

Addressing staff education, knowledge and attitudes impacts several domains of the Levesque access framework, suggesting it is a vital component when improving access to healthcare. Education could improve approachability, with staff better educated about how to communicate effectively with PEH and get important information across. Acceptability could also be addressed by improving attitudes and professional values. Interpersonal qualities can also be improved by education: these would contribute to the appropriateness aspect of access.

The flexibility theme links distinctly with availability and accommodation, showing that practical, structural factors impact hugely on access. The approachability aspect relates to this theme as well, where location of services turns into outreach, increasing the chances of patients being able to approach the services.

Service Co-ordination is encompassed within Levesque’s appropriateness aspect. Coordination and continuity of services increase appropriateness of service provisions and improve efficiency as patients can be directly referred to the service they require rather than starting the access process again.

Both knowledge of health systems and peer support impact on all patient abilities outlined in Levesque’s framework. These include the abilities to perceive, seek, reach, pay and engage. The ability to pay does not feature in the articles reviewed. This may be due to the geographical limitations where all papers are from the UK and Ireland where welfare systems and the National Health Service means this population do not need to pay for healthcare out of pocket.

The final two themes, complex health needs and holistic, patient centre care do not link with service provisions or service-users’ abilities to access but instead affect the entire process of access. The complexities of health needs can be acknowledged in the first box in Levesque’s access framework, ‘health care needs’, impacting each step along the way. While holistic, patient centred care may transform one journey of access into several to meet the needs of a patient who needs access to more than one service.

The geographical transferability of the results of this scoping review is limited. The majority of included studies are England based almost all are based in cities. Solutions for improving access to healthcare for PEH may differ across the UK and strategies that work for big cities may not work for homeless populations in smaller urban or rural areas. The studies focus mostly on men experiencing homelessness and there is a relatively small number of health professionals’ voices included. Studies focusing on women and other stakeholders in other parts of the UK would add greatly to the research body. This review also excludes the second two sub-categories of houseless in the ETHOS typology (Fig. 1) i.e. migrant accommodation and people due to be released from institutions. Accessing health services for these groups presents a different set of challenges and will need to be explored separately (Hiam et al., 2019, Hu et al., 2020).

Service provision can be improved by educating healthcare and hostel staff. Learning about homelessness and developing skills in communicating effectively with this population should improve attitudes and the distribution of information. The education should also increase knowledge of what services are available and how to signpost appropriately. Services could also introduce structural change, such as providing flexible appointment services in appropriate locations. Patient abilities must also be considered to improve access to healthcare for this population. The results suggest that patient’s abilities are improved with the addition of peer support. This may be through positive experiences of peers or having a formally assigned peer to attend appointments with.

The themes relate to Levesque’s access framework with the notable lack of affordability and ability to pay, potentially due to the geographical limits on the review. The final two themes must be included alongside Levesque’s framework when considering this vulnerable population. PEH have complex health needs, which creates a deeper need for access to services but also can hinder the entire process. PEH must also receive holistic care, meaning that PEH may be on several access journeys at the same time, trying to access healthcare, social care, or housing.

A&E	Accident and Emergency
ETHOS	European Typology of Homelessness and housing exclusion
FEANTSA	European Federation of National Organisations working with the Homeless (French: Fédération Européenne d'Associations Nationales Travaillant avec les Sans-Abri)
GP	General Practice
JBI	Joanna Briggs Institute
PCC	Person Centred Care
PEH	People Experiencing Homelessness
UK	United Kingdom

Ethical Approval and Consent to Participate

Not applicable

Consent for publication

Not applicable

Availability of supporting data

Please contact author Miss Sarah McNeill ([email protected]) to request any supporting data

Competing interests

Authors declare no competing interests

Funding

This publication is part of a PhD project funded by Northern Ireland Department for the Economy

Authors' contributions

SM wrote the initial manuscript text. DOD and SM conducted the screening and selection process, with NH helping resolve disagreements. NH and DOD edited and reviewed the manuscript. All authors approved the manuscript.

Acknowledgements

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No competing interests reported.

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Access to Healthcare for People Experiencing Homelessness: A Scoping Review

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