Making sense of street chaos: an ethnographic exploration of homeless people's health service utilization

[Barriers and facilitators in accessing and using primary health care centers for people experiencing homelessness]

OBJECTIVE

To identify barriers and facilitators for the access and use of primary care centers for people experiencing homelessness.

DESIGN

Qualitative study, phenomenological theoretical-methodological approach. Between May 19 and July 27, 2023.

LOCATION

Besòs Primary Health Care Center and Gregal social dining (Besòs and Maresme neighborhood, Barcelona).

PARTICIPANTS

People experiencing homelessness attending the Gregal social dining and professionals from the Besòs Primary Health Care Center.

METHOD

Theoretical purposive sampling. Individual and group interviews and open non-participant observation. Thematic content analysis, triangulation by independent analysis of three members of the research team and triangulation of methods. Discourse saturation was achieved through variability of discourse and techniques.

RESULTS

Eleven individual interviews, three group interviews and two observations. Different barriers and facilitators were identified. These were classified into five categories: (1)concept and identification of people experiencing homelessness; (2)personal factors of people experiencing homelessness; (3)behaviors and attitudes of professionals; (4)structural factors related to health system regulation, anf (5)internal organizational factors of primary health care centers.

CONCLUSIONS

People experiencing homelessness face multiple barriers to access primary health care, although there are also facilitators such as trusting relationships and multidisciplinary and intersectoral work that can be enhanced from primary health care centers to contribute to health equity.

"Just a knife wound this week, nothing too painful": An ethnographic exploration of how primary care patients experiencing homelessness view their own health and healthcare

Community health needs assessments (CHNA) involving qualitative techniques help tailor health services to the specific needs of the population groups for whom they are designed. In light of increasing health disparities amongst people experiencing homelessness (PEH)-and to ensure the integration of their voices into a larger CHNA-this study used an ethnographic approach grounded in a social constructivist research paradigm to explore the perspectives of PEH attending a primary care and addiction service in Ireland on their priority health and healthcare needs. Participant observations and informal interviews were conducted with clients experiencing homelessness attending the service for three hours every Monday morning between October 2022 and April 2023. Field note data from active participant observation and informal conversations were collected, anonymised, and analysed using inductive thematic analysis in accordance with the Declaration of Helsinki and the researchers' institutional Research Ethics Committee. Three main themes emerged from the analysis: self-identified priorities, satisfaction with health services, and migrant health. Clients' priority concerns relate to their mental health and personal safety, strengthening ties with children and families, finding a sense of purpose, and feeling better physically. These challenges differ from those of the general population in terms of their severity observed both prior to and during experiences of homelessness, coupled with disproportionately high levels of loss, fear, pain, fatigue, social stigma and other barriers to accessing satisfactory housing. In terms of services, clients are satisfied with their ability to access primary care and harm reduction in a social environment where positive exchanges with friends and providers take place. Conversely, barriers to accessing mental health and addiction services persist including the internalised belief that one is beyond help, lack of access to information on available services and their entry requirements, and lingering stigma within a health system that treats addiction as separate to health. Moving forward, health practitioners may consider holding more regular and open conversations with clients experiencing homelessness about the care they are receiving, its rationale, and whether or not changes are desired that can be safely made. The health needs of migrants and asylum seekers entering homelessness in Ireland are urgent and should be prioritised in future research.

[Stigma in homelessness and health care: reflections from a Housing First program in Barcelona, Spain]

The experience of homelessness is associated with strong stigmatization processes, which are often reflected in the treatment received from professionals and the healthcare system itself. This article aims to analyze the experiences of participants in a program for homeless individuals in Barcelona called Primer la Llar within the healthcare system, and how the stigma they suffer affects the care processes. This program follows the Housing First model, a social intervention that proposes providing housing without preconditions to individuals with long histories of street living, who suffer from severe mental disorders and/or addictions. Based on individual interviews with 20 participants conducted between 2016 and 2020, it is observed that in certain cases, entering the program, having housing availability, support from professionals, and the development of their own strategies had positive effects on improving their health, although they continue to perceive discriminatory attitudes in some medical settings. It is suggested that the transformation regarding stigmatization be understood broadly, affecting individuals, institutions, and society as a whole.

Diagnosis and management of tuberculosis infection in inclusion health populations in London

BACKGROUND

Tuberculosis in the UK is more prevalent in people with social risk factors- e.g. previous incarceration, homelessness - and in migrants from TB endemic countries. The management of TB infection is part of TB elimination strategies, but is challenging to provide to socially excluded groups and the evidence base for effective interventions is small.

METHODS

We evaluated a TB infection screening and treatment programme provided by a peer-led service (Find&Treat) working in inclusion health settings (e.g. homeless hostels) in London. IGRA (interferon-gamma release assay) testing and TB infection treatment were offered to eligible adults using a community-based model. The primary outcome was successful progression through the cascade of care. We also evaluated socio-demographic characteristics associated with a positive IGRA.

RESULTS

42/312 (13.5%) participants had a positive IGRA and no one had evidence of active TB. 35/42 completed a medical evaluation; 22 started treatment, and 17 completed treatment. Having a positive IGRA was associated with previous incarceration and being born outside of the UK.

DISCUSSION

Provision of TB infection diagnosis and management to this socially excluded population has several challenges including maintaining people in care and drug-drug interactions. Peer-support workers provided this service safely and effectively with appropriate support. Further work to generate data to inform risks and benefits of treatment for TB infection in this group is needed to facilitate joint decision making.

Priority healthcare needs amongst people experiencing homelessness in Dublin, Ireland: A qualitative evaluation of community expert experiences and opinions

In light of evidence that housing-related disparities in mortality are worsening over time, this study aimed to explore the perspectives of experts working in homeless health and addiction services on priority healthcare needs amongst people experiencing homelessness in Dublin, Ireland, a city facing problematic increases in homelessness. As part of a larger qualitative study, a series of semi-structured interviews were carried out with 19 community experts followed by inductive thematic framework analysis to identify emergent themes and sub-themes relating to priority healthcare needs. At the societal level, community experts identified a need to promote a culture that values health equity. At the policy level, accelerating action in addressing health inequalities was recommended with an emphasis on strategic planning, Housing First, social support options, interagency collaboration, improved data linkage and sharing, and auditing. At the health services level, removing barriers to access will require the provision of more and safer mental health, addiction, women-centred, and general practice services; resolved care pathways in relation to crisis points and multi-morbidity; expanded trauma-informed education and training and hospital-led Inclusion Health programmes; and outreach programmes and peer support for chronic disease management. The voices of people experiencing homelessness, including representatives from specific homeless groups such as migrants, youth, and the elderly, must be thoroughly embedded into health and social service design and delivery to facilitate impactful change.

How do health system factors (funding and performance) impact on access to healthcare for populations experiencing homelessness: a realist evaluation

BACKGROUND

People experiencing long-term homelessness face significant difficulties accessing appropriate healthcare at the right time and place. This study explores how and why healthcare performance management and funding arrangements contribute to healthcare accessibility or the lack thereof using long-term homeless adults as an example of a population experiencing social exclusion.

METHODS

A realist evaluation was undertaken. Thirteen realist interviews were conducted after which data were transcribed, coded, and analysed.

RESULTS

Fourteen CMOCs were created based on analysis of the data collected. These were then consolidated into four higher-level CMOCs. They show that health systems characterised by fragmentation are designed to meet their own needs above the needs of patients, and they rely on practitioners with a special interest and specialised services to fill the gaps in the system. Key contexts identified in the study include: health system fragmentation; health service fragmentation; bio-medical, one problem at a time model; responsive specialised services; unresponsive mainstream services; national strategy; short health system funding cycles; and short-term goals.

CONCLUSION

When health services are fragmented and complex, the needs of socially excluded populations such as those experiencing homelessness are not met. Health systems focus on their own metrics and rely on separate actors such as independent NGOs to fill gaps when certain people are not accommodated in the mainstream health system. As a result, health systems lack a comprehensive understanding of the needs of all population groups and fail to plan adequately, which maintains fragmentation. Policy makers must set policy and plan health services based on a full understanding of needs of all population groups.

A qualitative exploration of older people's lived experiences of homelessness and memory problems - stakeholder perspectives

BACKGROUND

The numbers of older people experiencing both homelessness and memory problems are growing, yet their complex health, housing and care needs remain undelineated and unmet. There is a critical gap in understanding what can improve the care, support and experiences of this group. In this qualitative study we explore how stakeholders understand memory problems among older people in the context of homelessness and consider what they judge gets in the way of achieving positive outcomes.

METHOD

We conducted reflexive thematic analysis of qualitative interviews (n = 49) using a semi-structured topic guide, with 17 older people (aged ≥ 50 years) experiencing memory problems and homelessness, 15 hostel staff and managers, and 17 health, housing and social care practitioners. We recruited participants from six homelessness hostels, one specialist care home and National Health and Local Authority Services in England.

RESULTS

We identified four overarching themes. The population is not taken seriously; multiple causes are hard to disentangle; risk of exploitation and vulnerability; and (dis)connection and social isolation. The transience and lack of stability associated with homelessness intensified the disorienting nature of memory and cognitive impairment, and those providing direct and indirect support required flexibility and persistence, with staff moving beyond traditional roles to advocate, provide care and safeguard individuals. Memory problems were perceived by frontline staff and older people to be overlooked, misinterpreted, and misattributed as being caused by alcohol use, resulting in pervasive barriers to achieving positive and desired outcomes.

CONCLUSIONS

Efforts to meet the needs of older people living with memory problems and experiencing homelessness and future interventions must reflect the complexity of their lives, often in the context of long-term alcohol use and current service provision and we make suggestions as to what could be done to improve the situation.

Impact of Harm Reduction Treatment with or without Pharmacotherapy on Polysubstance Use among People Experiencing Homelessness and Alcohol Use Disorder

OBJECTIVES

A prior randomized controlled trial showed behavioral harm reduction treatment for alcohol use disorder (AUD), or HaRT-A, was effective in improving alcohol outcomes and quality of life for people experiencing homelessness and AUD when provided with or without pharmacotherapy (ie, extended-release naltrexone). Because nearly 80% of the sample also reported baseline polysubstance use, this secondary study tested whether HaRT-A also positively impacted other substance use.

METHODS

In the parent study, 308 adults with AUD and homelessness were randomized to receive HaRT-A plus intramuscular injections of 380-mg extended-release naltrexone (HaRT-A + extended-release naltrexone), HaRT-A plus placebo (HaRT-A + placebo), HaRT-A alone, or community-based services as usual (control). In this secondary study, we used random intercept models to detect changes in other substance use after exposure to any of the HaRT-A conditions. For less prevalent behaviors, outcomes included past-month use (cocaine, amphetamines/methamphetamines, opioids). For more prevalent behaviors (polysubstance, cannabis), outcomes were past-month use frequency.

RESULTS

Compared with controls, participants who received HaRT-A showed significantly reduced 30-day frequency of cannabis use (incident rate ratio = 0.59, 95% CI = 0.40-0.86, P = 0.006) and polysubstance use (incident rate ratio = 0.65, 95% CI = 0.43-0.98, P = 0.040). No other significant changes were detected.

CONCLUSIONS

Compared with services as usual, HaRT-A is associated with reduced cannabis and polysubstance use frequency. The benefits of HaRT-A may thus extend beyond its impact on alcohol and quality of life outcomes to positively reshape overall substance use patterns. A randomized controlled trial is needed to further investigate the efficacy of such combined pharmacobehavioral harm reduction treatment for polysubstance use.

Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

Background

Adequate housing is a basic human right. The many millions of people experiencing homelessness (PEH) have a lower life expectancy and more physical and mental health problems. Practical and effective interventions to provide appropriate housing are a public health priority.

Objectives

To summarise the best available evidence relating to the components of case-management interventions for PEH via a mixed methods review that explored both the effectiveness of interventions and factors that may influence its impact.

Search Methods

We searched 10 bibliographic databases from 1990 to March 2021. We also included studies from Campbell Collaboration Evidence and Gap Maps and searched 28 web sites. Reference lists of included papers and systematic reviews were examined and experts contacted for additional studies.

Selection Criteria

We included all randomised and non-randomised study designs exploring case management interventions where a comparison group was used. The primary outcome of interest was homelessness. Secondary outcomes included health, wellbeing, employment and costs. We also included all studies where data were collected on views and experiences that may impact on implementation.

Data Collection and Analysis

We assessed risk of bias using tools developed by the Campbell Collaboration. We conducted meta-analyses of the intervention studies where possible and carried out a framework synthesis of a set of implementation studies identified by purposive sampling to represent the most 'rich' and 'thick' data.

Main Results

We included 64 intervention studies and 41 implementation studies. The evidence base was dominated by studies from the USA and Canada. Participants were largely (though not exclusively) people who were literally homeless, that is, living on the streets or in shelters, and who had additional support needs. Many studies were assessed as having a medium or high risk of bias. However, there was some consistency in outcomes across studies that improved confidence in the main findings.

Case Management and Housing Outcomes

Case management of any description was superior to usual care for homelessness outcomes (standardised mean difference [SMD] = -0.51 [95% confidence interval [CI]: -0.71, -0.30]; p < 0.01). For studies included in the meta-analyses, Housing First had the largest observed impact, followed by Assertive Community Treatment, Critical Time Intervention and Intensive Case Management. The only statistically significant difference was between Housing First and Intensive Case Management (SMD = -0.6 [-1.1, -0.1]; p = 0.03) at ≥12 months. There was not enough evidence to compare the above approaches with standard case management within the meta-analyses. A narrative comparison across all studies was inconclusive, though suggestive of a trend in favour of more intensive approaches.

Case Management and Mental Health Outcomes

The overall evidence suggested that case management of any description was not more or less effective compared to usual care for an individual's mental health (SMD = 0.02 [-0.15, 0.18]; p = 0.817).

Case Management and Other Outcomes

Based on meta-analyses, case management was superior to usual care for capability and wellbeing outcomes up to 1 year (an improvement of around one-third of an SMD; p < 0.01) but was not statistically significantly different for substance use outcomes, physical health, and employment.

Case Management Components

For homelessness outcomes, there was a non-significant trend for benefits to be greater in the medium term (≤3 years) compared to long term (>3 years) (SMD = -0.64 [-1.04, -0.24] vs. -0.27 [-0.53, 0]; p = 0.16) and for in-person meetings in comparison to mixed (in-person and remote) approaches (SMD = -0.73 [-1.25,-0.21]) versus -0.26 [-0.5,-0.02]; p = 0.13). There was no evidence from meta-analyses to suggest that an individual case manager led to better outcomes then a team, and interventions with no dedicated case manager may have better outcomes than those with a named case manager (SMD = -0.36 [-0.55, -0.18] vs. -1.00 [-2.00, 0.00]; p = 0.02). There was not enough evidence from meta-analysis to assess whether the case manager should have a professional qualification, or if frequency of contact, case manager availability or conditionality (barriers due to conditions attached to service provision) influenced outcomes. However, the main theme from implementation studies concerned barriers where conditions were attached to services.

Characteristics of Persons Experiencing Homelessness

No conclusions could be drawn from meta-analysis other than a trend for greater reductions in homelessness for persons with high complexity of need (two or more support needs in addition to homelessness) as compared to those with medium complexity of need (one additional support need); effect sizes were SMD = -0.61 [-0.91, -0.31] versus -0.36 [-0.68, -0.05]; p = 0.3.

The Broader Context of Delivery of Case Management Programmes

Other major themes from the implementation studies included the importance of interagency partnership; provision for non-housing support and training needs of PEH (such as independent living skills), intensive community support following the move to new housing; emotional support and training needs of case managers; and an emphasis on housing safety, security and choice.

Cost Effectiveness

The 12 studies with cost data provided contrasting results and no clear conclusions. Some case management costs may be largely off-set by reductions in the use of other services. Cost estimates from three North American studies were $45-52 for each additional day housed.

Authors' Conclusions

Case management interventions improve housing outcomes for PEH with one or more additional support needs, with more intense interventions leading to greater benefits. Those with greater support needs may gain greater benefit. There is also evidence for improvements to capabilities and wellbeing. Current approaches do not appear to lead to mental health benefits. In terms of case management components, there is evidence in support of a team approach and in-person meetings and, from the implementation evidence, that conditions associated with service provision should be minimised. The approach within Housing First could explain the finding that overall benefits may be greater than for other types of case management. Four of its principles were identified as key themes within the implementation studies: No conditionality, offer choice, provide an individualised approach and support community building. Recommendations for further research include an expansion of the research base outside North America and further exploration of case management components and intervention cost-effectiveness.

The perspectives of homeless people using the services of a mobile health clinic in relation to their health needs: a qualitative study on community-based outreach nursing

Background

Significant social and health issues are associated with homelessness. Negative experiences with the healthcare system are also frequent and cause people experiencing homelessness to avoid health services.

Aims

The purpose of this study was to (1) explore participants' health needs concerning outreach nursing services and (2) describe the perceptions and preferences of people who access this form of community-based intervention.

Methods

We conducted a critical ethnography with semi-structured interviews of 12 people experiencing homelessness who receive the services of a nurse-led mobile clinic, and 60 hours of observation during the provision of these services.

Results

Our results describe the perspectives of people experiencing homelessness in three main categories: (1) worrisome health and social needs, (2) non-use of healthcare and (3) what connects us to health services.

Conclusions

Timely access to healthcare is an important issue for people experiencing homelessness. Nurse-led clinics meet needs that go far beyond health issues.

Caregiving Needs Are Unmet for Many Older Homeless Adults: Findings from the HOPE HOME Study

BACKGROUND

The homeless population is aging, with early onset of cognitive and functional impairments. It is unclear whether older homeless adults receive caregiving assistance that could prevent long-term disability.

OBJECTIVE

We describe characteristics of older homeless-experienced adults with caregiving need and determine factors associated with having unmet need.

DESIGN AND PARTICIPANTS

Cross-sectional analysis of a longitudinal study, Health Outcomes in People Experiencing Homelessness in Older Middle Age (HOPE HOME), examining health, life course events, and functional status among older homeless-experienced (i.e., currently and recently homeless) adults. We recruited 350 homeless adults (July 2013-June 2014) and an additional 100 (August 2017 to July 2018) in Oakland, California; this study includes 303 participants who completed caregiving interviews.

MEASUREMENTS

We defined caregiving need as difficulty with activities of daily living (ADLs), instrumental activities of daily living (IADLs), falls, Short Physical Performance Battery (SPPB) score < 10, or Modified Mini-Mental State (3MS) exam impairment. We defined unmet need as having caregiving need and reporting not receiving caregiving assistance in the last 6 months. Using logistic regression, we analyzed associations between respondent characteristics and unmet caregiving need.

RESULTS

Among 303 participants, the mean age was 61.3 ± 5.0 years; 73% were men and 82% were Black. Eighty-one percent had caregiving needs, and in 82% of those, their caregiving needs were unmet. Better self-rated health (AOR 2.13, CI [1.02-4.46], p = 0.04) and being a man (AOR 2.30, CI [1.12-4.69], p = 0.02) were associated with higher odds of unmet need. Moderate or high-risk substance use (AOR 0.47, CI [0.23, 0.94], p = 0.03) was associated with lower odds of unmet need.

CONCLUSIONS

Older homeless-experienced adults have high prevalence of unmet caregiving need. Interventions that increase caregiving access for homeless-experienced individuals may help avoid poor health outcomes and costly long-term-care needs due to untreated disabilities.

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

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 United Kingdom (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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08265-y.

Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco's Mission District: a qualitative study

Background

People experiencing homelessness have unique health needs and barriers to medical and behavioral health care (mental health, substance use disorder, and overall well-being) compared to housed people. It remains unclear why many people experiencing homelessness do not access care when community-based homeless health care resources are available at low or no cost. This qualitative study examined perspectives of people experiencing homelessness and staff members at community-based homeless health and service organizations in San Francisco’s Mission District on unmet medical and behavioral health needs and barriers to accessing care.

Methods

We conducted 34 interviews between September and November 2020: 23 with people experiencing homelessness and 11 with staff at community-based homeless health and service organizations in the Mission District. Qualitative interviews were transcribed, coded, and analyzed using the Framework Method on NVivo Qualitative Data Analysis Software.

Results

Both staff and homeless participants reported unmet and common health needs of mental illness, physical injury and disability, food and nutrition insecurity, and substance use disorder. Barriers to care included negative prior health care experiences, competing priorities, and provider turnover. Recommendations for improving services included building more trust with people experiencing homelessness by training clinic staff to treat patients with respect and patience and expanding clinical outreach and health education programs.

Conclusions

People experiencing homelessness face many different health needs and barriers to care, some of which community-based organizations have the ability to address. These findings can help inform future strategies for homeless health care programs to identify and target the specific unmet health needs and barriers to care of people experiencing homelessness in their communities.

PROTOCOL: Exploring the effect of case management in homelessness per components: A systematic review of effectiveness and implementation, with meta-analysis and thematic synthesis

This is the protocol for a Campbell review. The objectives are as follows: To carry out a mixed methods review to summarise current evidence relating to the components of case-management interventions for people experiencing homelessness.

Emergency department utilisation by homeless children in Dublin, Ireland: a retrospective review

INTRODUCTION

Despite increasing prevalence, European family homelessness remains under-researched.

METHODS

A retrospective review was performed of homeless children attending a paediatric emergency department in Dublin, Ireland, from 1 January 2017 to 31 December 2020. Comparison was made with a random cohort of 1500 non-homeless paediatric attendances in 2019. Homelessness was defined using the European Typology of Homelessness and Housing Exclusion, including those with addresses of no fixed abode, government homeless accommodation and certain residential settings. The objectives were to compare presentations between homeless and non-homeless children. We were interested in determining differences regarding demographics, healthcare utilisation, clinical presentation and outcomes.

RESULTS

Of 197 437 attendances 3138 (1.59%) were homeless. Compared with the non homeless, homeless children were less likely to be ethnically Irish (37.4% vs 74.6%, p<0.001) or have been born in Ireland (82.3% vs 96.2%, p<0.001). Irish Travellers (3% vs 0.8%), Roma (22.5% vs 2.4%) and black (21.1% vs 4.2%) ethnicities were over-represented (p<0.001) in the homeless cohort.Homeless children were younger (age <12 months: 26% vs 16%; p<0.001), less likely to be fully vaccinated (73.6% vs 81.9%, p<0.001) and have registered general practitioners (89.7% vs 95.8%, p<0.001). They were more likely to represent within 2 weeks (15.9% vs 10.5%, p<0.001), and use ambulance transportation (13.2% vs 6.7%, p<0.001). Homeless children had lower acuity presentations (triage category 4-5: 47.2% vs 40.7%, p<0.001) and fewer admissions (5.9% vs 8.4%, p<0.001) than non-homeless children.

DISCUSSION

Infants, Irish Travellers, Roma and black ethnicities were over-represented in homeless presentations. Homeless children had increased reliance on emergency services for primary healthcare needs.

A peer-delivered intervention to reduce harm and improve the well-being of homeless people with problem substance use: the SHARPS feasibility mixed-methods study

BACKGROUND

For people experiencing homelessness and problem substance use, access to appropriate services can be challenging. There is evidence that development of trusting relationships with non-judgemental staff can facilitate service engagement. Peer-delivered approaches show particular promise, but the evidence base is still developing. This study tested the feasibility and acceptability of a peer-delivered intervention, through 'Peer Navigators', to support people who are homeless with problem substance use to address a range of health and social issues.

OBJECTIVES

The study objectives were to design and implement a peer-delivered, relational intervention to reduce harms and improve health/well-being, quality of life and social functioning for people experiencing homelessness and problem substance use, and to conduct a concurrent process evaluation to inform a future randomised controlled trial.

DESIGN

A mixed-methods feasibility study with concurrent process evaluation was conducted, involving qualitative interviews [staff interviews (one time point), n = 12; Peer Navigator interviews (three or four time points), n = 15; intervention participant interviews: first time point, n = 24, and second time point, n = 10], observations and quantitative outcome measures.

SETTING

The intervention was delivered in three outreach services for people who are homeless in Scotland, and three Salvation Army hostels in England; there were two standard care settings: an outreach service in Scotland and a hostel in England.

PARTICIPANTS

Participants were people experiencing homelessness and problem substance use (n = 68) (intervention).

INTERVENTION

This was a peer-delivered, relational intervention drawing on principles of psychologically informed environments, with Peer Navigators providing practical and emotional support.

MAIN OUTCOME MEASURES

Outcomes relating to participants' substance use, participants' physical and mental health needs, and the quality of Peer Navigator relationships were measured via a 'holistic health check', with six questionnaires completed at two time points: a specially created sociodemographic, health and housing status questionnaire; the Patient Health Questionnaire-9 items plus the Generalised Anxiety Disorder-7; the Maudsley Addiction Profile; the Substance Use Recovery Evaluator; the RAND Corporation Short Form survey-36 items; and the Consultation and Relational Empathy Measure.

RESULTS

The Supporting Harm Reduction through Peer Support (SHARPS) study was found to be acceptable to, and feasible for, intervention participants, staff and Peer Navigators. Among participants, there was reduced drug use and an increase in the number of prescriptions for opioid substitution therapy. There were reductions in risky injecting practice and risky sexual behaviour. Participants reported improvements to service engagement and felt more equipped to access services on their own. The lived experience of the Peer Navigators was highlighted as particularly helpful, enabling the development of trusting, authentic and meaningful relationships. The relationship with the Peer Navigator was measured as excellent at baseline and follow-up. Some challenges were experienced in relation to the 'fit' of the intervention within some settings and will inform future studies.

LIMITATIONS

Some participants did not complete the outcome measures, or did not complete both sets, meaning that we do not have baseline and/or follow-up data for all. The standard care data sample sizes make comparison between settings limited.

CONCLUSIONS

A randomised controlled trial is recommended to assess the effectiveness of the Peer Navigator intervention.

FUTURE WORK

A definitive cluster randomised controlled trial should particularly consider setting selection, outcomes and quantitative data collection instruments.

TRIAL REGISTRATION

This trial is registered as ISRCTN15900054.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 14. See the NIHR Journals Library website for further project information.

A population level study of SARS-CoV-2 prevalence amongst people experiencing homelessness in Wales, UK

Introduction

Prior research into the prevalence of SARS-CoV-2 infection amongst people experiencing homelessness (PEH) largely relates to people in communal forms of temporary accommodation in contexts where this type of accommodation remained a major part of the response to homelessness during the COVID-19 pandemic. Little is known about the prevalence of SARS-CoV-2 amongst PEH more broadly, and in a policy and practice context that favoured self-contained accommodation, such as Wales, UK.

Objective

Describe the prevalence of SARS-CoV-2 amongst PEH in Wales, UK, using routinely collected administrative data from the Secure Anonymised Information Linkage Databank.

Methods

Routinely collected data were used to identify PEH in Wales between 1st March 2020 and 1st March 2021. Using SARS-CoV-2 pathology testing data, prevalence rates were generated for PEH and three comparator groups: (1) the not-homeless population; (2) a cohort 'exact matched' for age, sex, local authority and area deprivation; and (3) a matched comparison group created using these same variables and Propensity Score Matching (PSM). Three logistic regressions were run on samples containing each of the comparator groups to explore the effect of experiencing homelessness on testing positive for SARS-CoV-2.

Results

The prevalence of SARS-CoV-2 infection amongst PEH was 5.0%, compared to the not-homeless population at 5.6%. For the exact matched and PSM match comparator groups, prevalence was 6.9% and 6.7%, respectively. Logistic regression found that SARS-CoV-2 infection was 0.9 times less likely amongst PEH compared to people not experiencing homelessness from the general population. The odds of SARS-CoV-2 infection for PEH was 0.75 and 0.73 where the 'not-homeless' comparators were from the exact match and PSM samples, respectively.

Conclusion

Our analysis revealed that a year into the COVID-19 pandemic, the prevalence of SARS-CoV-2 amongst PEH in Wales was lower than the general population. A policy response to homelessness that moved away from communal accommodation may be partly responsible for the reduced SAR-CoV-2 infection amongst PEH.

Experiences of Adult Men Who Are Homeless Accessing Care: A Qualitative Study

INTRODUCTION

Homeless individuals experience increased rates of chronic physical and mental health conditions. They also experience difficulty accessing care and poor health outcomes compounded by social and economic factors, such as housing insecurity, unemployment, and limited social support. The purpose of this study was to describe the perceptions of homeless individuals related to their health and experiences accessing care.

METHOD

Qualitative descriptive methods and content analysis were used to gather, analyze, and interpret the data and identify themes.

RESULTS

Three themes were identified: men who are homeless experience bias throughout their health care and interpersonal relationships, the best care is person-centered and considers patients' priorities, and care coordination resources are inadequate.

DISCUSSION

The housing needs of homeless individuals are best contextualized by their health and social needs. In addition, their priorities must be taken into consideration to develop culturally congruent services that are appropriate and effective care for this population.

Sharing the burden of treatment navigation: social work and the experiences of unhoused women in accessing health services in Santa Cruz

This paper explores the challenges faced by unhoused women in accessing general and reproductive health care services in Santa Cruz, CA. Semi-structured interviews with women experiencing houselessness were conducted in Santa Cruz, CA with a focus on their narrative experiences as patients. The overwhelming majority of participants expressed appreciation for clinics that provided support through longer hours, alternative therapies, and appointment reminders. Overall, the interviews indicated that women who had access to a social worker were much more likely to report improved access to satisfactory treatment. These findings suggest that there is not a tangible lack of healthcare services for unhoused women in the local community, but rather a burden of treatment navigation caused by a dearth of information on how to access care. The interviews suggest that this burden can be reduced with social work interventions and service centers that offer health navigation support. By adapting theories of the "burden of treatment," we argue that additional attention must be paid to overcoming the "burden of treatment navigation." For related reasons, we suggest that increasing the availability of social workers would concretely improve health outcomes for unhoused women.

The Long-Term Effects of a Housing First Intervention on Primary Care and Non-Primary Care Physician Visits Among Homeless Adults with Mental Illness: A 7-Year RCT Follow-Up

BACKGROUND

Housing First (HF)-based interventions have been implemented in North America and beyond to help people exit homelessness. The effect of these interventions on access to primary and specialist care services is not well-defined. This study assesses the long-term effects of an HF intervention for homeless adults with mental illness on primary care physician (PCP) and non-primary care physician (non-PCP) visits.

METHODS

This is a secondary analysis of the At Home/Chez Soi study, a randomized trial of HF for homeless adults with mental illness in Toronto, Canada. High-need (HN) participants were randomized to HF with assertive community treatment (HF-ACT) or treatment as usual (TAU). Moderate needs (MN) participants were randomized to HF with intensive case management (HF-ICM) or TAU. The primary outcomes were the incidence and the number of visits to a PCP and non-PCP over 7-years post-randomization, compared to the 1-year pre-randomization.

RESULTS

Of 575 enrolled participants, 527 (80 HN and 347 MN) participants were included in the analyses. HN participants who received HF-ACT had a significant reduction in the number of visits to a PCP compared to TAU participants (ratio of rate ratios (RRR): 0.66, 95% CI: 0.48-0.93) and a significant reduction in the number of non-PCP visits compared with TAU participants (RRR: 0.64, 95% CI: 0.42-0.97) in the 7-years post-randomization compared to the 1-year pre-randomization. MN participants who received HF-ICM had a significant increase in incident visits to a PCP compared to TAU participants (RRR: 1.66, 95% CI: 1.10-2.50). No effect of HF-ICM was observed on the incidence or number of non-PCP visits.

CONCLUSION

HF has differing effects on visits to PCPs and non-PCPs among homeless people with high and moderate needs for mental health supports. HF does not result in a consistent increase in PCP and non-PCP visits over a 7-year follow-up period. The At Home/Chez Soi study is registered with ISRCTN (ISRCTN, ISRCTN42520374).

Substance use disorder and homelessness among American Indians and Alaska Natives in California

American Indian and Alaska Native (AIAN) communities have higher rates of substance use than other racial and ethnic groups. Substance use disorder (SUD) is tied to the increased risk of experiencing homelessness. National policies have also led to the disproportionate rates of homelessness among AIAN communities. However, specific experiences related to the occurrence of SUD and homelessness among AIAN in California, as well as seeking and accessing SUD treatment, are not well understood. This study explored potential SUD risk and resilience factors for AIANs experiencing homelessness and their experiences when seeking services for SUD. Nineteen interviews were conducted in northern, central, and southern California. Thematic analysis was used for these data. The five primary codes were: (1) risk factors for SUD, (2) resilience related to SUD service seeking, (3) services available, (4) barriers accessing services, and (5) services needed. Based on the results, themes for risk were trauma, mental health, and community conditions. Themes for resilience were identified at individual and community levels and included personal motivation and community support and inclusiveness. Themes for services available were limited knowledge about service types and services' location. The themes for barriers accessing services were identified at internal and external levels, and included lack of readiness and transportation challenges, respectively. Themes for services needed included continuum of care, integrated care, and culturally sensitive services. Findings highlight the importance of addressing the potential risk factors and service needs of AIANs experiencing homelessness to provide comprehensive and culturally sensitive services to reduce substance use.

Doctor-patient interactions that exclude patients experiencing homelessness from health services: an ethnographic exploration

BACKGROUND

People experiencing homelessness have poor health indices and poor access to health care. Their health service utilisation (HSU) is typified by: late illness presentations; poor attendance rates at appointments; low usage of primary care services and outpatient departments; and high utilisation of emergency departments and inpatient services. Why people experiencing homelessness have these particular HSU patterns is poorly understood.

AIM

This research sought to explore barriers to health service usage for people experiencing homelessness.

DESIGN & SETTING

The authors conducted critical realist ethnography over 13 months in Dublin with people experiencing homelessness at four purposively chosen sites (a food hall, a drop-in centre, an emergency department, and an outreach service for rough sleepers).

METHOD

Ethnographic research was supplemented with focus groups of hospital doctors and people experiencing homelessness, and with 50 semi-structured interviews with people experiencing homelessness. The epistemological framework was critical realism.

RESULTS

One of the factors identified in the research as contributing to the HSU pattern of people experiencing homelessness was recurrent interactions between health professionals and patients, whereby patients were either excluded or discouraged from attending health services, or self-excluded themselves from services. These interactions were described as 'conversations of exclusion'. Four such conversations were described: 'the benzodiazepine conversation'; 'the mistrustful conversation'; 'the blaming conversation'; and 'the assertive conversation'.

CONCLUSION

There are certain recurrent interactions between people experiencing homelessness and doctors that result in the exclusion of people experiencing homelessness from health services.

'Money up in smoke': The financial benefits of smoking cessation may be more motivating to people who are homeless than potential health gains

INTRODUCTION

High rates of tobacco smoking among people who are homeless or living in temporary accommodation exacerbate poor health outcomes and financial disadvantage. There is limited research on this population's perceptions of smoking cessation benefits or support strategies.

METHODS

We conducted a cross-sectional survey of 68 male smokers living in a temporary accommodation hostel in Brisbane, Australia. The survey measured smoking and quit attempt history, perceptions of cessation aids and benefits of cessation, and awareness of the Intensive Quit Support program-a free Queensland government-funded program comprising 12 weeks of nicotine replacement therapy supplemented with weekly calls from Quitline.

RESULTS

Participants (56% aged ≤40 years) spent a high proportion of their income on smoking (median $80/week). Although the most commonly reported perceived benefit of smoking cessation was improved health, more participants were interested in a campaign promoting the financial savings of quitting rather than the health benefits. Twice as many participants reported the high cost of smoking-provoked thoughts of quitting than graphic health warning labels on cigarette packs (70.6% vs. 30.9%). Participants reported a high level of interest in e-cigarettes as a cessation aid. There was a low level of awareness but moderate level of interest in the Intensive Quit Support program.

DISCUSSION AND CONCLUSIONS

Smoking cessation campaigns promoting the financial savings of cessation may be more salient than health-focused campaigns among relatively young men who smoke and experience homelessness. There is a clear need for innovative, targeted strategies promoting smoking cessation among this population.

Healthcare inequities and barriers to access for homeless individuals: a qualitative study in Barcelona (Spain)

BACKGROUND

In Spain, homeless individuals have lower perceived quality of health than the rest of the population and their life expectancy is 30 years lower than the national average. While the Spanish health system provides universal access and coverage, homeless individuals do not access or use public care enough to maintain their health. The objective of this study is to determine if homeless individuals can access public health services in conditions of equality with the rest of the population, as established in healthcare legislation, and to better understand the causes of observed inequalities or inequities of access.

METHODS

A detailed qualitative study was carried out in the city of Barcelona (Spain) from October 2019 to February 2020. A total of nine open and in-depth interviews were done with homeless individuals along with seven semi-structured interviews with key informants and two focus groups. One group was composed of eight individuals who were living on the street at the time and the other consisted of eight individuals working in healthcare and social assistance.

RESULTS

The participants indicated that homeless individuals tend to only access healthcare services when they are seriously ill or have suffered some kind of injury. Once there, they tend to encounter significant barriers that might be 1) administrative; 2) personal, based on belief that that will be poorly attended, discriminated against, or unable to afford treatment; or 3) medical-professional, when health professionals, who understand the lifestyle of this population and their low follow-through with treatments, tend towards minimalist interventions that lack the dedication they would apply to other groups of patients.

CONCLUSIONS

The conclusions derived from this study convey the infrequent use of health services by homeless individuals for reasons attributable to the population itself, to healthcare workers and to the entire healthcare system. Accordingly, to reduce inequities of access to these services, recommendations to healthcare service providers include adapting facilities to provide more adequate care for this population; increasing sensitivity/awareness among healthcare workers; developing in situ care systems in places where the homeless population is most concentrated; and establishing healthcare collaboration agreements with entities that work with this population.

Expanding buprenorphine treatment to people experiencing homelessness through a mobile, multidisciplinary program in an urban, underserved setting

BACKGROUND AND OBJECTIVES

Inequities in access to buprenorphine treatment remain despite measures to increase access to treatment. "Begin the Turn," a low-barrier, multidisciplinary mobile care unit with access to outreach services, counseling, case management, and buprenorphine treatment addresses these disparities in an urban setting.

METHODS

Retrospective medical record review of patients during the initial 6 months of operation abstracted patient demographics and clinical data, including 10 categories of adverse childhood experiences (ACEs) using a total number of ACEs (ACE score) and measuring scores greater than or equal to 4 given higher risk of chronic disease states at this level. The study collected data in electronic data capture tools. The study assessed retention rates at 1, 3, and 5 months.

RESULTS

Among the 147 individuals who received care, the mean age was 39.6 years and median onset of opioid use was 21 years of age. Among study participants, 67.3% (n = 99) reported IV use, 91.9% (n = 135) reported previous experiences with addiction treatment, and 49.7% (n = 73) had previously suffered an overdose. Adverse Childhood Experiences surveys demonstrated a mean score of 4.6 (n = 141), with 63.1% (n = 89) having a score of 4 or greater. The percentages of patients retained in care at 1, 3, and 5 months were 61.2%, 36.6%, and 27.6%, respectively.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

The program serves a population with high rates of trauma and overdose. The program can serve as a model for treatment for this population.

Making healthcare accessible for single adults with complex needs experiencing long-term homelessness: A realist evaluation protocol

Background: Over the last several years, homelessness has increased in Ireland and across Europe. Rates have recently declined since the coronavirus disease 2019 (COVID-19) pandemic, but it is unclear whether emergency housing measures will remain in place permanently. Populations experiencing long-term homelessness face a higher burden of multi-morbidity at an earlier age than housed populations and have poorer health outcomes. However, this population also has more difficulty accessing appropriate health services. A realist review by the authors found that important health system contexts which impact access are resourcing, training, funding cycles, health system fragmentation, health system goals, how care is organised, culture, leadership and flexibility of care delivery. Using a realist evaluation approach, this research will explore and refine key system-level factors, highlighted in our realist review, in a local health care system. Aim: The aim of this study is to understand how funding procedures and health system performance management impact service settings, staff, providers and their ability to make services accessible to populations experiencing homelessness. Methods: A realist evaluation will be undertaken to explain how funding and health system performance management impact healthcare accessibility for populations experiencing homelessness. Data will be collected using qualitative and realist interview techniques and focus group methodology. Secondary data such as policy documents and budgets will utilised. The analysis will follow Pawson and Tilley's iterative phases starting with building an Initial programme theory, then data collection, data analysis, synthesis and finally building a refined programme theory. Conclusion: Building on a realist review conducted by the same research team, this study will further test and refine findings that explain how health system factors impact healthcare accessibility for populations experiencing homelessness. The study has the potential to inform policy makers, health planners and managers of contextual factors that can be modified to increase healthcare accessibility.

Pharmacist led homeless outreach engagement and non-medical independent prescribing (Rx) (PHOENIx) intervention for people experiencing homelessness: a non- randomised feasibility study

BACKGROUND

Homelessness and associated mortality and multimorbidity rates are increasing. Systematic reviews have demonstrated a lack of complex interventions that decrease unscheduled emergency health services utilisation or increase scheduled care. Better evidence is needed to inform policy responses. We examined the feasibility of a complex intervention (PHOENIx: Pharmacist led Homeless Outreach Engagement Nonmedical Independent prescribing (Rx)) to inform a subsequent pilot randomised controlled trial (RCT).

METHODS

Non-randomised trial with Usual Care (UC) comparator group set in Greater Glasgow and Clyde Health Board, Scotland. Participants were adult inpatients experiencing homelessness in a city centre Glasgow hospital, referred to the PHOENIx team at the point of hospital discharge, from 19th March 2018 until 6th April 2019. The follow up period for each patient started on the day the patient was first seen (Intervention group) or first referred (UC), until 24th August 2019, the censor date for all patients. All patients were offered and agreed to receive serial consultations with the PHOENIx team (NHS Pharmacist prescriber working with Simon Community Scotland (third sector homeless charity worker)). Patients who could not be reached by the PHOENIx team were allocated to the UC group. The PHOENIx intervention included assessment of physical/mental health, addictions, housing, benefits and social activities followed by pharmacist prescribing with referral to other health service specialities as necessary. All participants received primary (including specialist homelessness health service based general practitioner care, mental health and addictions services) and secondary care. Main outcome measures were rates of: recruitment; retention; uptake of the intervention; and completeness of collected data, from recruitment to censor date.

RESULTS

Twenty four patients were offered and agreed to participate; 12 were reached and received the intervention as planned with a median 7.5 consultations (IQR3.0-14.2) per patient. The pharmacist prescribed a median of 2 new (IQR0.3-3.8) and 2 repeat (1.3-7.0) prescriptions per patient; 10(83%) received support for benefits, housing or advocacy. Twelve patients were not subsequently contactable after leaving hospital, despite agreeing to participate, and were assigned to UC. Two patients in the UC group died of drug/alcohol overdose during follow up; no patients in the Intervention group died. All 24 patients were retained in the intervention or UC group until death or censor date and all patient records were accessible at follow up: 11(92%) visited ED in both groups, with 11(92%) hospitalisations in intervention group, 9(75%) UC. Eight (67%) intervention group patients and 3(25%) UC patients attended scheduled out patient appointments.

CONCLUSIONS

Feasibility testing of the PHOENIx intervention suggests merit in a subsequent pilot RCT.

Housing Satisfaction of Psychiatric Patients in Different Forms of Housing-A Cross-Sectional Study in Berlin, Germany

The growing social problem of homelessness and precarious housing situations has negative effects on psychological outcomes and quality of life (QoL) for mentally ill people. Despite a large body of research on QoL among homeless mentally ill people, research on housing satisfaction as a specific QoL domain and important outcome variable for treatment interventions is scarce. The purpose of this cross-sectional study is to investigate housing satisfaction among psychiatric patients in various housing situations. Out of 1,251 patients that were treated in the targeted facilities during the admission period, 540 agreed to participate (43.2%). 123 participants were excluded from the analysis due to missing data, resulting in a sample of N = 417. Housing satisfaction data was assessed in a subjective screening and differences in satisfaction levels between housing status groups were analyzed. As hypothesized, more normative housing situations reported higher housing satisfaction. Homeless participants and those living in socio-therapeutic facilities were associated with more psychological and physical distress resulting from their housing situation than domiciled and flat-sharing participants. Problems of reducing homelessness and improving housing support are highlighted, as well as opportunities for improving support, particularly in therapeutic facilities.

[Housing Situation Among People with Substance Use Disorder in a Psychiatric Centre in Berlin, Germany - A Cross-Sectional Patient Survey]

OBJECTIVE

To investigate the housing situation, service use and substance use among patients with substance use disorders seeking psychiatric treatment.

METHODS

Structured interview among 540 psychiatric inpatients including day clinics in a psychiatric centre in Berlin, Germany.

RESULTS

Patients under instable housing conditions were significantly more often diagnosed with a comorbid psychotic disorder and were significantly younger when first psychiatric or substance use treatment occurred, on average before onset of homelessness.

CONCLUSION

Homelessness among people with substance use disorder seeking psychiatric treatment is associated with disadvantageous treatment factors such as early age of psychiatric treatment and comorbid psychotic disorders. Therefore, addressing social difficulties especially after inpatient treatment and close cooperation between different care providers should be of high importance among these groups.

[Homelessness and mental illnesses]

Wohnungslosigkeit ist Ausdruck ausgeprägter sozialer Exklusionsphänomene und trifft besonders häufig Menschen mit seelischen Erkrankungen. Hierbei gehen die Erkrankungen meist der Wohnungslosigkeit vorweg, wobei einige seelische Störungen erst infolge der Wohnungslosigkeit auftreten. International wurde eine Vielzahl therapeutischer Unterstützungsformen für wohnungslose Menschen mit seelischen Erkrankungen evaluiert mit vorwiegend aufsuchenden Behandlungsstrategien. Dies wird häufig kombiniert mit niedrigschwelliger Zurverfügungstellung von Wohnraum. Hierbei zeigen sich gute Effekte auf die Zeit des Verbleibs in Wohnungen und auf die Verbesserung psychiatrischer Symptome, allerdings keine ausreichenden Effekte auf Substanzgebrauchsstörungen. Möglichkeiten zukünftiger Projekte liegen am ehesten im Einbezug ehemals Betroffener und in der Verwendung digitaler Medien.

How accessible is healthcare for single adults experiencing long-term homelessness and complex needs? A realist evaluation protocol

Background: Over the last several years, homelessness has increased in Ireland and across Europe. Rates have recently declined since the coronavirus disease 2019 (COVID-19) pandemic, but it is unclear whether emergency housing measures will remain in place permanently. Populations experiencing long-term homelessness face a higher burden of multi-morbidity at an earlier age than housed populations and have poorer health outcomes. However, this population also has more difficulty accessing appropriate health services. A realist review by the authors found that important health system contexts which impact access are resourcing, training, funding cycles, health system fragmentation, health system goals, how care is organised, culture, leadership and flexibility of care delivery. Using a realist evaluation approach, this research will explore and refine key system-level factors, highlighted in our realist review, in a local health care system. Aim: The aim of this study is to understand how funding procedures and health system performance management impact service settings, staff, providers and their ability to make services accessible to populations experiencing homelessness. Methods: A realist evaluation will be undertaken to explain how funding and health system performance management impact healthcare accessibility for populations experiencing homelessness. Data will be collected using qualitative and realist interview techniques and focus group methodology. Secondary data such as policy documents and budgets will utilised. The analysis will follow Pawson and Tilley's iterative phases starting with building an Initial programme theory, then data collection, data analysis, synthesis and finally building a refined programme theory. Conclusion: Building on a realist review conducted by the same research team, this study will further test and refine findings that explain how health system factors impact healthcare accessibility for populations experiencing homelessness. The study has the potential to inform policy makers, health planners and managers of contextual factors that can be modified to increase healthcare accessibility.

Correlates of Depressive Symptoms among Middle-Aged and Older Homeless Adults Using the 9-Item Patient Health Questionnaire

This study investigates the screening for depressive symptoms among middle-aged and older homeless adults based on Patient Health Questionnaire-9 (PHQ-9) and examines the possible factors associated with their major depressive symptoms. A cross-sectional survey was employed, and research subjects included 129 homeless people aged 45 years old and over in Taipei Wanhua District and Taipei Main Station. We used a structured questionnaire and face-to-face interview conducted by three social workers to collect data in the analyses. The content of the questionnaire included an informed consent form, demographic characteristics, enabling and need factors of healthcare, and PHQ-9 of homeless people. Results revealed that 15.5% respondents were free of depressive symptoms, 16.3% had mild level (score 5–9), 31.8% had moderate level (score 10–14), 26.4% had moderately severe level (score 15–19), and 10.1% had severe level of depressive symptoms (score 20–27). Adopting a PHQ-9 score 10 as a cut-off point for major depressive symptoms, 68.3% of middle-aged and older homeless adults were the cases needing to be referred to healthcare settings for further recheck in the near future. A multiple regression analysis found gender, age, and usage of psychiatric outpatient care were associated with major depressive symptom occurrence. The female participants were less likely to have major depressive symptoms than the male participants (OR = 0.29, 95% CI = 0.09–0.96). The elderly participants were more likely to have major depressive symptoms than the aged 45–54 years (OR = 5.29, 95% CI = 1.44–19.41). Those participants who have ever used psychiatric outpatient care were significantly more correlated with the occurrence of major depressive symptoms than their counterparts (OR = 3.65, 95% CI = 1.46–9.09). The present study suggests that in the future health policy should eliminate the risk factors of depressive symptoms and improve mental healthcare access, to improve the health and wellbeing of the homeless population.

Supporting Primary Care Access and Use among Homeless Persons

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Background

People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group.

Methods

Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model.

Results

Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user’s perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people’s lives.

Conclusion

This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted. The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals’ complex lives.