Homelessness is associated with high risks of morbidity and premature death. Many interventions aimed to improve physical and mental health exist, but do not reach the population of persons experiencing homelessness. Despite the widely reported unmet healthcare needs, more information about the barriers and facilitators that affect access to care for persons experiencing homelessness is needed. A systematic integrative review was performed to explore experiences and needs of health‐ and social care for persons experiencing homelessness. The following databases were searched: AMED, ASSIA, Academic Search Complete, CINAHL, Cochrane library, Nursing and Allied Database, PsycInfo, PubMed, Scopus and Web of Science Core Collection. Twenty‐two studies met the inclusion criteria of empirical studies with adult persons experiencing homelessness, English language, and published 2008‐2018. Fifty percent of the studies were of qualitative and quantitative design, respectively. Most studies (73%) were conducted in the United States (n=11) and Canada (n=5). The analysis resulted in three themes Unmet basic human needs, Interpersonal dimensions of access to care, and Structural and organizational aspects to meet needs. The findings highlight that persons in homelessness often must prioritize provision for basic human needs, such as finding shelter and food, over getting health‐ and social care. Bureaucracy and rigid opening hours, as well as discrimination and stigma, hinder these persons’ access to health‐ and social care.
Homelessness is an increasing problem worldwide (EU, 2013; US, 2018), and previous research highlights that persons experiencing homelessness are disproportionately affected by physical and mental illness, substance abuse and long‐term burden of chronic diseases compared to housed persons (van Dongen et al., 2019; Lebrun‐Harris et al., 2013; Lewer et al., 2019). Homeless populations, that is, individuals without permanent housing who may live on the streets; stay in a shelter, mission, single room occupancy facilities, abandoned building or vehicle; or in any other unstable or non‐permanent situation (US, 2018), face huge health inequities across a wide range of health conditions (Aldridge et al., 2018). Persons experiencing homelessness are three times more likely to report chronic diseases with asthma, COPD, epilepsy and heart problems being prevalent (Lewer et al., 2019). Older persons (>50) experiencing homelessness have multiple health problems that remain unaddressed by healthcare services, often lack social support and do not explicitly express their own healthcare needs (van Dongen et al., 2019), resulting in higher use of acute care. The excess mortality associated with considerable social exclusion, such as homelessness, is extreme (Aldridge et al., 2018; Fazel, Geddes, & Kushel, 2014; Slockers, Nusselder, Rietjens, & van Beeck, 2018), that is, the mortality rate is nearly eight times higher than the average for men and 12 times higher for women (Aldridge et al., 2019, 2018), with an average age for death at 52 years.
The origins of homelessness are multi‐faceted, both on individual and structural levels, for example the ageing population (van Dongen et al., 2019; Fazel et al., 2014), changes in the housing market with shifts in family structures (NBHW, 2017), migration (EU, 2013), rising costs for housing (NBHW, 2017) and poor health (van Dongen et al., 2019; Fazel et al., 2014; Lewer et al., 2019). A growing body of research concludes that homelessness is associated with heavy costs for society with regards to public health, social and legal services (Basu, Kee, Buchanan, & Sadowski, 2012; Fuehrlein et al., 2015; Larimer et al., 2009; Mitchell, Leon, Byrne, Lin, & Bharel, 2017; Suh et al., 2016). However, the samples in the studies often consist of highly selected subgroups, like individuals with a certain specific diagnosis or demographic criteria like ethnicity or gender orientation, making comparisons and inferences challenging. At the same time, tri‐morbidity, defined as a combination of poor physical health, poor mental health and drug or alcohol misuse (Hewett, Halligan, & Boyce, 2012) is a suggested characteristic in long‐term homelessness, further illustrating the complexity of designing and providing health‐ and social care interventions for persons experiencing homelessness.
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