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Access to Health Services

strength of evidence

Considerable reliable evidence

Cost effectiveness

Insufficient evidence available

Impact

Multiple high quality studies show a positive impact

What is this intervention?

Access to health services for people who are homeless is complex and sometimes requires delivery through unconventional means. Interventions may provide access through mobile street outreach or through health professionals attending a non-traditional setting such as a hostel or shelter. Individuals may have multiple and complex needs relating to their mental and physical health requiring enhanced care.

People who are homeless have comparably poorer mental and physical health than the general population. This means that they have a greater need for access to health services, but many people experiencing homelessness do not regularly see a doctor.

The reasons for this lack of engagement with health services are multifaceted. Firstly, in countries without a free healthcare system, people who are homeless may not be able to afford to visit a doctor. They may prioritise food and shelter over their health needs. Secondly, correspondence with health services can be difficult without a phone or permanent address. Thirdly, the individual may experience prejudice and discrimination when trying to access health services, or fear these attitudes and therefore avoid health services.

What is its goal?

Access to basic health care services is as a fundamental human right. Through regular and appropriate contact with health care professionals, morbidity and other outcomes related to ill health are reduced. Access to health services is more complicated for people who are homeless and therefore interventions are needed to reduce the barriers to healthcare faced by homeless people. Individuals who are homeless are also more likely to have multiple and complex health needs, such as mental ill health and substance misuse, which will require a specialist approach.

Access to appropriate healthcare represents much more than improved health outcomes. The empowerment and self-esteem associated with health autonomy is a central aspect of quality of life. Interventions provide access to healthcare that is appropriate to the specific needs and circumstances of homeless people.

What does the evidence tell us?

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Programmes that attempt to improve access to health services for people who are homeless show positive effects on housing and employment outcomes. These findings should be considered cautiously, however, because they are based on a single study.

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Where does the evidence come from?

Of the five studies included in this summary, four were conducted in North America and a case-control study was conducted in France. Three types of study designs are included in this summary:

  • one systematic review (containing one RCT and four observational studies)
  • 3 RCTs (n=1,288)
  • one case-control study (n=221).

Four studies measured one outcome in their evaluation of health access programmes (80%), one study measured two outcomes (10%), and one study measured three outcomes (10%). Of these, four measured outcomes relating to health and substance misuse, two measured access to services, one measured outcomes related to housing stability, and one measured the effects of access to health services on employment and income.

The effectiveness of interventions to increase access to health services was measured across this range of outcomes at various time points. The longest follow-up of participants was 24 months.


Which groups does it affect?

Various

The participants included in the summarised programmes were varied. The majority of studies included participants who have or had a recent history of mental illness and veterans. Other participants who appeared less frequently in this category of programmes were women and girls, families, participants with substance misuse issues, and participants with complex needs including a dual diagnosis.

Which outcomes does it affect? 

Access to services

In the RCT included in the systematic review, participants had improved access to a primary healthcare provider compared to those who did not receive the intervention. Conversely, within this same review, an observational study that compared integration of primary care and other services for people who are homeless did not observe any difference in access to primary care between the two groups.

Health and Substance Misuse

For outcomes related to health and substance misuse, the benefits of these interventions are generally inconclusive. One RCT conducted with 358 participants demonstrated that the intervention led to significant improvements on both health and substance abuse measures during a two-year follow-up. A case-control study found that access to services in a shelter facility could control and prevent respiratory diseases in people experiencing homelessness. However, although a large RCT conducted with 720 participants found that participants who were involved in the access to services intervention remained engaged in substance-misuse treatment at three months, symptoms of addiction at longer-term follow-ups did not differ significantly between the groups. Furthermore, one RCT conducted across 210 families reported no difference in mental distress for homeless mothers who received access to the intervention compared to those who did not.

Housing Stability

Information around housing stability was sparse in these interventions; however, one RCT conducted with 358 participants demonstrated that the intervention led to significant improvements on housing measures during the two-year follow-up.

Employment

Only one study reported on employment outcomes. This RCT indicated that access to health interventions led to improved employment outcomes at a two-year follow-up.

Cost

Cost data are available, but there are no cost effectiveness studies. A large RCT on 720 veterans experiencing homelessness reported various findings related to the cost of the intervention. This study did not find significant differences in the treatment conditions considered.

considerations for IMPLEMENTATION

Combine access to health services with other support

If you are implementing access to health services, consider how best to combine traditional medical interventions with wider housing and non-housing support. Of note are the wider benefits of secure housing, adequate health information, independent living skills, and social opportunities. Multi-disciplinary teams help provide this holistic support and colocation of housing services with mental health, physical health and substance misuse support helps improve coordination and accessibility for service users.

Collaborate with other agencies

Partnership working between agencies and individual staff is essential. Ensure protocols for joint working and data collection and sharing are streamlined. Key stakeholders – from policy makers to staff members – should share an understanding of appropriate outcomes and align their approaches to overcoming the barriers to healthcare.

Adapt intervention to meet service users’ needs

Enable your team to offer service users personalised, 1-2-1 support programmes tailored to reflect the user’s situation, age and preferences. Staff should also be aware that many service users will have been through traumatic experiences. In countries without socialised healthcare, there need to be routes to securing this access as soon as possible.

Build trust with service users

Enable staff to cultivate trust and rapport with service users to promote engagement with health services. There are several ways to build trust, including:

  • Meeting service users at a location that suits them, e.g. outreach services on the street or in a housing programme
  • Taking a long-term, assertive approach to engagement
  • Recognising that service users are often more open to engagement at crisis points
  • Using a network of support and continuous engagement

If your service covers rural areas, staff need to consider carefully how and where to arrange care to minimise geographical barriers. This will require special attention and resourcing.

Design interventions with users in mind

Try to integrate new health and wellbeing interventions into existing services to promote engagement. Service users are more likely to engage if the intervention fits with their existing routines.

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