People who are homeless are often socially isolated and may have experienced rejection and/or discrimination from their family, communities, and institutional authority figures, including health care providers (Flaskerud & Strehlow, 2008; Irestig, Burström, Wessel, & Lynöe, 2010; Ramsay, Hossain, Moore, Milo, & Brown, 2019; Wen, Hudak, & Hwang, 2007). Frequent rejection from family and society creates a sense of shared social identities between those experiencing homelessness, as well as long-lasting impressions of rejection (Maniglio, 2009; Skosireva et al., 2014). It also intensifies mistrust of others, including those in positions of authority such as health care providers. This can lead to ambivalence and resistance to change health behaviors or seek self-sufficiency, contributing to a diminished well-being and prolonged or chronic homelessness (Byrne et al., 2017; Prochaska, Wright, & Velicer, 2008).
Poor health is closely associated with homelessness, with high rates of both chronic and acute health problems such as pneumonia, tuberculosis, hepatitis C, cardiovascular disease, cancer, diabetes, HIV/AIDS, asthma, and obesity (Beijer, Wolf, & Fazel, 2012; Jones et al., 2009; Lebrun-Harris et al., 2013; Schanzer, Dominguez, Shrout, & Caton, 2007; Wiersma et al., 2010). The complexity of the health issues combined with the barriers to health care often experienced by those who are homeless has resulted in higher morbidity and mortality rates than in the general population, including homelessness as an independent risk factor for death (Metraux, Eng, Bainbridge, & Culhane, 2011; Morrison, 2009). Persons who are homeless also experience unmet health care needs because of an inability or delays in getting care, resulting in more frequent use of hospital emergency departments (EDs) than housed patients, increasing the cost of health care for all and further burdening health systems (Hwang et al., 2013; Tadros, Layman, Brewer, & Davis, 2016).
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