Living in Canada’s biggest city, the homelessness crisis is undoubtedly an unfortunate social determinant of health that is of great concern. In Toronto, approximately 5000 people are homeless on any given night. In my experience as a Technologist, I often had patients arrive for x-rays and CT scans who arrived battered, dirty, and often in an altered state of consciousness. Oftentimes, these patients arrived overnight and sleeping. Although not much conversation took place in the interaction, the same care was provided, despite the condition they arrived in.
Homeless individuals have a high burden of illness and are at increased risk for premature death, but factors such as the daily struggles to meet basic needs, lack of health insurance, mental illness, and addictions can limit homeless people’s ability to access health care services appropriately. (Wen, 2007).
In addition to this, despite Canadians having access to universal healthcare, a study by Khandor, et. al (2011) identified of the 366 study participants, only 124 had a health card (which serves as proof of health insurance coverage in the province of Ontario). The two main causes of these participants not having a health card was a result of either it being lost or stolen. The result of not having a health card was a decrease in seeking health care with a primary physician or at a healthcare facility. Not having a family doctor was associated with key indicators of health care access and health status, including increasing duration of homelessness, lack of proof of health insurance coverage, and having a chronic medical condition. (Khandor et al., 2011). One way to improve access to primary care for the homeless population would be providing low-threshold health care services that use alternative physician billing systems that do not require patients to have or show their health card in order to obtain care. (Khandor et al., 2011).
Due to the limitations in visiting a family doctor, many homeless people go to emergency rooms to seek medical care. In the 2011 study, 145 (40%) of the 366 participants reported being discriminated against by a health care professional in the 12 months before the survey. (Khandor et al., 2011). In a 2007 study conducted by Wen et al., participants described encounters experienced in a health care environment – which were feelings of being ignored, rushed, brushed aside, or treated rudely. Of the 17 participants, 13 felt as though their experiences were of unwelcomeness, as acts of discrimination. (Wen, 2007). One particular participant felt he was treated differently because he was homeless and that the stereotypical attributes of a homeless person was that he was being a “freeloader”. This recurring experience of feeling unwelcome in the healthcare environment resulted in participants having a strong distrust of health care workers and a desire to avoid health care institutions at almost any cost. (Wen et al., 2007).
In an attempt to curve these negative experiences, an increasing effort is being made by nursing and medical schools to improve the preparedness for students working with homeless populations by offering community rotations or clinical placements in homeless health care settings. It has been reported that students completing a clinical elective that included lectures, journaling and rotations in settings providing health care to homeless people (e.g. emergency shelters, drop-in centres, etc.) had improved attitudes towards homeless populations. (McNeil et al., 2013). Often, the clinical experience a nurse or doctor receives doesn’t account for social and structural factors that affect the health of the homeless population. (McNeil et al., 2013). While interviewing participants in a study conducted by McNeil et at.:
[Homeless clients] have so many little things involved. When you’re in the hospital, you don’t think about food. You don’t think about clothing. You don’t think about shelter… You know they’re safe. You know everything’s taken care of. You know they’ll take their medication. You don’t even think about it. With these guys, just getting a prescription filled is 2 days of work.’ (Nurse, 6)
‘I was running a psychiatric programme where people came in during the day and went home at night. All of those people were housed… They were well enough to get on the bus and come to a programme. If you’re connected up to [the psychiatric programme] and miss three appointments, they discharge you. They don’t bother asking if the person has bus tickets or are they well enough to come to get on a bus… People don’t have bus tickets… They’re not going to buy bus tickets and, nine times out of ten, they’re not well enough to get to the hospital.’ (Nurse practitioner, 1)
These two accounts alone put things into perspectives when assessing the limitations experienced by the homeless population. Simple things many of us take for granted are much more difficult for those without housing. Without getting to this level of honesty and communication with a patient who is homeless, would often result in the patient not obtaining the required medication or treatment needed to recover from an illness.
Additionally, when the trust is not built between patient and health care worker, it often results in patients not seeking out care until chronic illnesses worsen. This is also the cause of homeless people having poorer health than the general population and often experience a disproportionate burden of acute and chronic health issues, including concurrent mental health and substance use disorders. (Khandor et al., 2011). The combination of feeling unwelcome in a health care setting and the difficulty in obtaining the necessary means to healing results in some homeless people not seeking health care at all. It has been shown that the longer one is homeless, the more priority they place on their essential needs (ie: food and shelter), rather than non-urgent health care such as preventative care and care in the early stages of illness. (Khandor et al., 2011).
Source: Medicine on the Margins, Health Services the Homeless
Resources
Khandor, E., Mason, K., Chambers, C., Rossiter, K., Cowan, L., & Hwang, S. W. (2011, May). Access to primary health care among homeless adults in Toronto, Canada: Results from the Street Health Survey. Open medicine : a peer-reviewed, independent, open-access journal. Retrieved March 19, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148004/
Liu, M., & Hwang, S. W. (2021, January 14). Health Care for homeless people. Nature News. Retrieved March 20, 2022, from https://www.nature.com/articles/s41572-020-00241-2
McNeil, R., Guirguis-Younger, M., Dilley, L. B., Turnbull, J., & Hwang, S. W. (2013, April 10). Learning to account for the social determinants of health affecting homeless persons. Wiley Online Library. Retrieved March 19, 2022, from https://onlinelibrary.wiley.com/doi/full/10.1111/medu.12132
O'Carroll, A. (2017, July 17). Medicine on the margins, health services the homeless | Austin O'Carroll | tedxha'pennybridge. YouTube. Retrieved March 20, 2022, from https://www.youtube.com/watch?v=GiwRSPY_JqI
Wen, C. K., Hudak, P. L., & Hwang, S. W. (2007, April 6). Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters - Journal of General Internal Medicine. SpringerLink. Retrieved March 19, 2022, from https://link.springer.com/article/10.1007/s11606-007-0183-7
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