Access to healthcare for people experiencing homelessness in the UK and Ireland: a scoping review

Incontinence and homelessness

The fundamental principles of why specific people become homeless, can be grounded in a simple rationale or founded within sophisticated reasoning. For instance, people who suffer from substance abuse, addiction, alcohol, gambling, have mental health concerns or financial difficulties may be susceptible to homelessness. It is also identified that persons who experienced violence in their childhood or abuse by a partner are at a higher risk of becoming homeless. Homelessness knows no ethnic, cultural, religious or gender boundaries, and can impact all individuals' health and well-being. A health problem and worldwide phenomenon that affects all cohorts of the population, including the homeless, is urinary incontinence. The aim of this article is to increase the awareness of incontinence and highlight the impact it has on the lives of people that experience homelessness.

Healthcare and housing provision for a UK homeless community: a qualitative service evaluation

OBJECTIVES

Homelessness is both a significant determinant and consequence of health and social inequalities. To better meet healthcare needs, dedicated mental health and general nurses were implemented to deliver outreach healthcare to people experiencing homelessness in one United Kingdom (UK) county. During COVID-19, the UK Government also instructed local authorities to accommodate individuals sleeping rough and have a national target to end rough sleeping. This qualitative study explored experiences of this nurse-let outreach service and housing journeys during and beyond COVID-19 among people experiencing homelessness.

STUDY DESIGN

Face-to-face, narrative storytelling interviews were conducted via opportunistic sampling in community settings. Individuals with recent or current experiences of homelessness were eligible.

METHODS

Participants were informed about the study via known professionals and introduced to the researcher. Eighteen narrative interviews were conducted, transcribed, and analysed using reflective thematic analysis.

RESULTS

Individuals described complex journeys in becoming and being homeless. The nurse-led outreach service provided integral support, with reported benefits to person-centred and accessible care and improved outcomes in health and well-being. After being housed, individuals valued housing necessities and described new responsibilities. However, some participants did not accept or stay in housing provisions where they perceived risks.

CONCLUSIONS

Interviewed participants perceived that the dedicated nurse-led outreach service improved their access to care and health outcomes. In the absence of dedicated provisions, mainstream healthcare should ensure flexible processes and collaborative professional working. Local authorities must also be afforded increased resources for housing, as well as integrated support, to reduce social and health inequalities.

Real-time evaluation of a multi-agency TB-screening event for persons experiencing homelessness in a town with a low incidence of TB in England

Real-time evaluation (RTE) supports populations (e.g., persons experiencing homelessness (PEH) to engage in evaluation of health interventions who may otherwise be overlooked. The aim of this RTE was to explore the understanding of TB amongst PEH, identify barriers/facilitators to attending screening for PEH alongside suggestions for improving TB-screening events targeting PEH, who have high and complex health needs. This RTE composed of free-text structured one-to-one interviews performed immediately after screening at a single tuberculosis (TB) screening event. Handwritten forms were transcribed for thematic analysis, with codes ascribed to answers that were developed into core themes. All RTE participants (n=15) learned about the screening event on the day it was held. Key concerns amongst screening attendees included: stigma around drug use, not understanding the purpose of TB screening, lack of trusted individuals/services present, too many partner organizations involved, and language barriers. Facilitators to screening included a positive welcome to the event, a satisfactory explanation of screening tests, and sharing of results. A need for improved event promotion alongside communication of the purpose of TB screening amongst PEH was also identified. A lack of trust identified by some participants suggests the range of services present should be reconsidered for future screening events.

Best practice models for dental care delivery for people experiencing homelessness

People experiencing homelessness have been encountering significant barriers in accessing healthcare services, including dental care services. There are several definitions for homelessness: it includes people sleeping rough but also people living in temporary accommodation. These categories are dynamic and individuals often find themselves on a continuum oscillating between sleeping rough and living in temporary accommodation. Their health-seeking behaviours are shaped by their living arrangements; therefore, one single model of dental care service delivery might not capture the needs of all those experiencing homelessness within an area. The service models presented in this paper are based on primary care delivery, mobile dental units and community clinics. Each of these models presents advantages and disadvantages and consideration should be given to delivering these on a complementary basis to maximise access to dental care, regardless of where patients are on the continuum between sleeping rough and living in temporary accommodation.

People living in homeless hostels: a survey of health and care needs

People experiencing homelessness have extremely poor health outcomes and frequently die young. Many single homeless people live in hostels, the remit of which is to provide support to facilitate recovery out of homelessness. They are not usually designed to support people with high health or care needs. A cross-sectional survey was developed with, and completed by, hostel managers to explore and quantify the level of health and care needs of people living in their hostels. In total, 58 managers completed the survey, with information on 2,355 clients: 64% had substance use disorder, 56% had mental health issues, and 37.5% were in poor physical health. In addition, 5% had had more than three unplanned hospital visits in the previous month, and 11% had had safeguarding referrals submitted over the past year. Barriers to getting support and referrals accepted were highlighted, particularly for people with substance use disorder. Hostel managers identified 9% of clients as having needs too high for their service, while move-on options were scarce. Our study highlights significant unmet needs. Health and care services are not providing adequate support for many people living in hostels, who often have very poor health outcomes. This inequity needs to be considered and addressed as a matter of urgency.

Homelessness and health-related outcomes in the Republic of Ireland: a systematic review, meta-analysis and evidence map

Aim

To map existing research on homelessness and health in the Republic of Ireland, and to synthesize the evidence on housing-related disparities in health.

Methods

Peer-reviewed articles and conference abstracts published in English between 2012-2022 were retrieved from 11 bibliographic databases if they contained empirical data on homelessness and health in Ireland, and - in a subsequent screening stage - at least one measure of health disparity between the homeless and general populations. Reviewers extracted relative risks (RR), 95% confidence intervals (CI), and calculated pooled RR of comparable health disparities using pairwise random-effects meta-analyses.

Results

One hundred four articles contained empirical data on the health of homeless individuals residing in Ireland, addressing primarily substance use, addiction and mental health. Homelessness was associated with increased risk of illicit drug use (RR 7.33 [95% CI 4.2, 12.9]), reduced access to a general practitioner (GP) (RR 0.73 [CI 95% 0.71, 0.75]), frequent emergency department (ED) presentation (pooled RR 27.8 [95% CI 4.1, 189.8]), repeat presentation for self-harm (pooled RR 1.6 [95% CI 1.2, 2.0]) and premature departure from hospital (pooled RR 2.65 [95% CI 1.27, 5.53]).

Conclusions

Homelessness in Ireland is associated with reduced access to primary care and overreliance on acute care. Chronic conditions amongst homeless individuals are understudied.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10389-023-01934-0.