Addressing the health needs of the homeless

Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study

Background

Homeless and unstably housed individuals face barriers in accessing healthcare despite experiencing greater health needs than the general population. Case management programs are effectively used to provide care for this population. However, little is known about the experiences of providers, their needs, and the ways they can be supported in their roles. Connect 2 Care (C2C) is a mobile outreach team that provides transitional case management for vulnerable individuals in a major Canadian city. Using an ethnographic approach, we aimed to describe the experiences of C2C team members and explore their perceptions and challenges.

Methods

We conducted participant observations and semi-structured interviews with C2C team members. Data analysis consisted of inductive thematic analysis to identify themes that were iteratively discussed.

Results

From 36 h of field observations with eight team members and 15 semi-structured interviews with 12 team members, we identified five overarching themes: 1) Hiring the right people & onboarding: becoming part of C2C; 2) Working as a team member: from experience to expertise; 3) Proud but unsupported: adding value but undervalued; 4) Team-initiated coping: satisfaction in the face of emotional strain, and; 5) Likes and dislikes: committed to challenges.

Conclusions

A cohesive team of providers with suitable personal and professional characteristics is essential to care for this complex population. Emotional support and inclusion of frontline workers in operational decisions are important considerations for optimal care and program sustainability.

Developing an Embedded Nursing Service within a Homeless Shelter: Client's Perspectives

This phenomenological case study of a newly developed nursing service, embedded within a homeless shelter in the South East of England, uses semi-structured to elicit experiences and perceptions of clients within the service. Participants (n = 6) were interviewed using a semi-structured approach and identified three broad themes: impact of previous healthcare experiences, benefits of embedding healthcare within the shelter, and future service development. The study illuminates the diversity and complexity of healthcare needs of homeless people, as well as offers a unique insight into the service user’s perception of the service.

Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

Objective

The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.

Design

A realist review.

Data sources

Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019.

Eligibility criteria for selecting studies

The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.

Analysis

Inductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory.

Results

Systematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention.

Conclusions

With homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

A theory based evaluation of an intervention to promote positive health behaviors and reduce social isolation in people experiencing homelessness

Homelessness adversely affects an individual's ability to access healthcare, opportunities for social interaction and recreational activities such as physical activity. This study aimed to evaluate the impact of a community-based physical activity and peer support intervention on the health and wellbeing of homeless participants. This study employed semi-structured interviews to investigate the perceived impact of the Street Fit Scotland intervention on the health and wellbeing of 10 homeless adults. Interviews were audio recorded and transcribed verbatim. A thematic analysis was conducted. Participants reported that their health and wellbeing had improved since attending the intervention. This was attributed to improvements in self-esteem, social interaction and mental wellbeing. Participants generally felt that their physical activity had increased since attending Street Fit Scotland, and a number of individuals reported that they were making healthier choices with regards to health behaviors. A theory of change logic model was developed that demonstrated how each component of the intervention influences the observed and intended outcomes. Attendance of Street Fit Scotland had positive effects on participant's health and wellbeing, particularly concerning self-esteem, health behaviors, social interaction, and physical activity. More efforts should be made to evaluate small-scale interventions that are reaching vulnerable population groups.

Assessing Impact of Community Health Nurses on Improving Primary Care Use by Homeless/Marginally Housed Persons

This study invited a cross-sectional sample of 112 homeless/marginally housed adults in New Haven, CT to respond to a structured survey questionnaire. Seventy-six individuals responded. Among them, 39 (51%) had utilized primary care services during the preceding 2 years. Multivariate logistic regression analysis adjusting for age, sex, ethnicity, housing status, health insurance status, and self-reported health status found that having utilized primary care services was significantly associated with having regular contact with a community health nurse. This finding indicates that community health nurses may have a significant influence in increasing primary care service utilization by homeless and marginally housed individuals.

Gardening for the mental well-being of homeless women

PURPOSE

To explore the perceptions of homeless women regarding their experience in a shelter-based garden project to promote mental wellness. Participants planted and tended the vegetable garden and prepared and ate the fruits of their labor.

DESIGN

A qualitative descriptive design with a conventional content analysis of narrative data.

METHOD

Data were gathered in semistructured interviews. Participants were homeless daytime shelter guests who had participated in at least eight gardening sessions over 4 weeks. The project was started in the fall of 2010 and the interviews were conducted over 2 months in the summer of 2011.

FINDINGS

Two polarized themes were identified in the narratives, clustering around negative and positive thoughts. The "dark" theme centered on marginalization and the oppressiveness of shelter life. The "light" theme centered on stress relief, feeling socially included, and personal change.

CONCLUSION

The gardening experience interrupted the participants' negative ruminations, offering stress relief and elements of social inclusion and self-actualization. Gardening is an inexpensive and positive intervention for a population with a high incidence of mental illness and distress.

[Meanings and practices associated with health and illness among the homeless in Salvador, Bahia State, Brazil]

This article aimed to analyze the practices and meanings associated with health and illness among homeless people in Salvador, Bahia State, Brazil. A qualitative anthropological study was conducted with participant observation and semi-structured interviews with 13 subjects 30 to 66 years of age. The results point to extremely precarious living and health conditions among the homeless. The narratives emphasize frequent violence. The main health problems were substance abuse, HIV/AIDS, mental disorders, and dental, dermatological, and gastrointestinal problems. Among other meanings, health was associated with the capacity to cope with everyday difficulties. Meanwhile, illness was identified as a state of weakness that hindered the struggle for survival. Homeless people only turned to health services when their health problems were serious and urgent. In conclusion, the study showed the need for specific policies to improve living conditions and access to healthcare for this population.