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

Abstract

Background Homeless people have poor health and mortality indices. Despite this they make poor usage of health services. This study sought to understand why they use health services differently from the domiciled population. Methods Ethnographic observations were conducted at several homeless services, in Dublin. This was supplemented with 47 semi-structured interviews with homeless people and two focus groups of homeless people and hospital doctors. A critical-realist approach was adopted for interpretation of the data. Results Homeless people tended to present late in their illness; default early from treatment; have low usage of primary-care, preventative and outpatient services; have high usage of Emergency and Inpatient services; and poor compliance with medication. They tended to avoid psychiatric services. A number of external barriers were identified. These were classified as physical (distance) administrative (application process for medical care; appointments; queues; the management of addiction in hospital; rules of service; and information providing processes); and attitudinal (stigma; differing attitudes as to appropriate use of services. A new form of barrier, Conversations of Exclusion was identified and described. Internalised barriers were identified which were in nature, either cognitive (fatalistic, denial, deferral to future, presumption of poor treatment or discrimination, self blame and survival cognitions) or emotional (fear; embarrassment, hopelessness and poor self-esteem). Generative mechanisms for these factors were identified which either affected participants prior to homelessness (marginalization causing hopelessness, familial dysfunction, substance misuse, fear of authority, illiteracy; mental health; and poor English) or after becoming homeless (homelessness; ubiquity of premature death; substance misuse; prioritization of survival over health; threat of violence; chaotic nature of homelessness; negative experiences of authority; and stigma. Conclusions An explanatory critical realist model integrating the identified generative mechanisms, external and internalised barriers was developed to explain why the Health service Utilization of homeless people differs from the domiciled populations. This new model has implications for health service policy makers and providers in how they design and deliver accessible health services to homeless people.

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

“…Despite increased morbidity and mortality, engagement with healthcare often occurs at crisis point, where those experiencing homelessness use accident and emergency services rather than primary care [21], with high cost implications [22,23]. Avoidance of mental health services and problems taking medication as required are also reported by those experiencing homelessness, often due to a range of external barriers [24]. Recent austerity measures and funding cuts to services have resulted in reduced services, and services discharging people more quickly [6,[25][26][27], making access to health care and problematic substance use treatment more challenging.…”

“…Twelve Step programmes such as Alcoholics Anonymous or Narcotics Anonymous have a spiritual orientation and advocate complete abstinence although participants take part in various activities including attending meetings and getting a 'sponsor'. These were discussed in five papers[24,61,65,71,79]. wanna be able to help somebody.…”

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

“…They experience feelings of inadequacy and lack of professional con dence and display an unwelcoming attitude toward patients. (13,(26)(27)(28)(30)(31)(32)(33)(34) As a result, patients do not feel comfortable and choose not to seek care at an appropriate time (eg seeking care early from a GP before a condition gets worse and acute care is needed). (13,26,31,(35)(36)(37) The outcome of not seeking care when the care environment is not welcoming becomes a new context which leaves patients instead to seek care only when the need is emergent and out of desperation, and at a later stage than ideal and at a setting that is available (such as the ED).…”

“…(13,(26)(27)(28)(30)(31)(32)(33)(34) As a result, patients do not feel comfortable and choose not to seek care at an appropriate time (eg seeking care early from a GP before a condition gets worse and acute care is needed). (13,26,31,(35)(36)(37) The outcome of not seeking care when the care environment is not welcoming becomes a new context which leaves patients instead to seek care only when the need is emergent and out of desperation, and at a later stage than ideal and at a setting that is available (such as the ED). (13,31,33,35,38) This results in the need for the health system to provide more care at a later stage and more intensive care and it generates poorer health outcomes and higher overall costs to the health system.…”

“…(2,11) While these are common experiences, it is important to stress that they happen to varying degrees and sometimes not at all. (11) The majority of research exploring access to healthcare for homeless populations has focused on individual level factors and particularly on why, whether and how individuals experiencing homelessness do or do not access healthcare (3,(12)(13)(14)(15)(16)(17)(18)(19)(20). A focus on individual level factors is illuminating but without understanding and balancing this with health system factors there is a risk that responsibility for accessing services is inappropriately placed with the individual (21,22).…”