Background
Methods
○ Socio-demographic factors: ● Age ● Gender ● Ethnicity ○ Socioeconomic factors: ● Social Class ● Unemployment ● Familial and social network influences ○ Psychological Factors: ● Perceived susceptibility. ● Perceived Severity ● Knowledge about illness and information seeking behaviour. ● Belief in the effectiveness of healthcare. ● Belief in the effectiveness of self-care ● Stressful Life Events. ● Perceived benefits and costs of obtaining healthcare. ○ The Organization of Healthcare: ● Distance from Surgery ● Appointments Systems. ● Doctor Initiated Consultations. ● Access to Emergency Departments. |
Participant ID | Sex | Age | Hx IV Drug Use | Hx of Benzo Abuse | Hx Alcohol Misuse | Hx of Methadone Treatment | Hx Mental Ill Health | Hx HIV | Hx Hep C | Hx of being in care | Ethnicity | Housing |
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | M | 33 | Y | Y | Y | Irish | Hostel | |||||
2 | M | 35 | Y | Y | Y | Y | Y | Irish | Hostel | |||
4 | F | 33 | Y | Irish | Hostel | |||||||
5 | M | 48 | Y | Y | Y | Y | Y | Irish | Hostel | |||
6 | M | 63 | Y | Y | Y | Irish | Hostel | |||||
10 | M | 30 | Y | Y | Irish | Hostel | ||||||
13 | M | 31 | Y | Y | Y | Irish | Hostel | |||||
18 | F | 34 | Y | Y | Y | Y | Y | Irish | Hostel | |||
19 | M | 31 | Y | Y | Y | Y | Irish | Hostel | ||||
21 | M | 23 | Y | Y | Y | Y | Y | Y | Irish | Hostel | ||
23 | F | 21 | Y | Y | Irish | Hostel | ||||||
26 | F | 31 | Y | Y | Y | Irish | Hostel | |||||
27 | M | 23 | Y | Y | Y | Y | Y | Y | Irish | Hostel | ||
28 | F | 28 | Y | Y | Y | Y | Irish | Hostel | ||||
30 | F | 45 | Y | Irish | Hostel | |||||||
33 | M | 39 | Y | Y | Y | Y | Y | Y | Irish | Rough Sleeper | ||
34 | M | 32 | Y | Y | Y | Y | Y | Irish | Hostel | |||
39 | M | 31 | Y | Y | Y | Irish | Hostel | |||||
40 | M | 37 | Y | Y | Y | Y | Y | Irish | Rough Sleeper | |||
41 | F | 25 | Y | Y | Y | Y | Irish | Hostel | ||||
42 | M | 49 | Y | Y | Y | Y | Y | Y | Irish | Hostel | ||
43 | M | 31 | Y | Y | Y | Irish | Hostel | |||||
45 | F | 50 | Y | Y | Y | Irish | Hostel | |||||
46 | M | 31 | Y | Y | Y | Y | Irish | Hostel | ||||
50 | M | 30 | Y | Y | Y | Y | Irish | Hostel | ||||
53 | M | 42 | Y | Y | Y | Irish | Hostel | |||||
54 | M | 37 | Y | Y | Y | Y | Irish | Rough Sleeper | ||||
60 | M | 38 | Y | Y | Y | Y | Y | German | Rough Sleeper | |||
61 | F | 40 | Y | Y | Y | Y | Y | Irish | Hostel | |||
62 | M | 36 | Y | Y | Y | Irish | Hostel | |||||
63 | F | 24 | Y | Y | Y | Irish | Hostel | |||||
64 | F | 44 | Y | Y | Y | Y | Irish | Hostel | ||||
65 | M | 37 | Y | Y | Y | Y | Irish | Hostel | ||||
66 | F | 35 | Y | Y | Y | Y | Irish | Hostel | ||||
67 | M | Irish | Hostel | |||||||||
68 | F | 30 | Y | Y | Y | Y | Irish | Hostel | ||||
69 | M | 37 | Y | Y | Irish | Hostel | ||||||
70 | M | 45 | Y | Y | Y | Irish | Hostel | |||||
71 | M | 26 | Y | Y | Y | Irish | Hostel | |||||
72 | M | 39 | Y | Y | Y | Irish | Hostel | |||||
73 | F | 20 | Y | Y | Y | Irish | Hostel | |||||
74 | M | 40 | Y | Portugal | Hostel | |||||||
75 | F | Y | Y | Y | Y | Y | Y | Irish | Hostel | |||
76 | M | 23 | Y | Irish | Hostel | |||||||
77 | M | 59 | Y | Y | Y | Irish | Rough Sleeper | |||||
78 | F | 48 | Y | Y | N | Y | Y | Irish | Hostel | |||
79 | M | 53 | Y | Y | N | Y | Y | Eastern Europe | Hostel |
Results
Delayed presentation for treatment. (39 sources/75 references).
Defaulting from treatment prior to completion. (33 Sources/78 references)
Low usage of Primary Care Services. (22 sources/50 references)
High (often described as inappropriate) usage of Emergency Departments (ED).
Poor compliance with medication (10 sources/30 references).
Avoidance of Psychiatric Services. (10 sources/ 17 references)
Participant ID | Gender | Description (note ages are estimates which can be unreliable in homeless population) | Where met |
---|---|---|---|
3 | F | 30-40 yo. hostel dwelling Intravenous Drug User (IVDU) | Focus Group |
7 | F | 30-40yo. Hostel dweling underweight. | Food Hall |
8 | M | 30-40yo IVDU rough sleeper | Street Outreach |
9 | M | 20-30yo IVDU rough sleeper with schizophrenia. | Drop In Centre |
11 | M | 30-40yo IVDU rough sleeper | Street Outreach |
12 | F | 20-30yo Hostel dweling. IVDU | Food Hall |
14 | F | 40-50 yo. Hostel dweling. Non Irish female socially isolated | Food Hall |
15 | M | 40-50yo. hostel dwelling Drug User | Focus Group |
16 | F | 30-40yo ex IVDU. History (hx) of HIV | Drop In Centre |
17 | F | 40-50yo ex IVDU. Hx of HIV | Drop In Centre |
20 | F | 20-30yo Junior doctor in hospital | Focus Group |
22 | F | 20-30yo Junior doctor in hospital | Focus Group |
24 | F | 20-30yo Junior doctor in hospital | Focus Group |
25 | M | 40-50yo Hostel dweling with history of mental illness and alcoholism | Drop In Centre |
29 | F | 20-30 yo. IVDU Rough Sleeper. Hx of Endocarditis and malnourished. | Street Outreach |
31 | M | 40-50 yo. Hostel dwelling, ex- IVDU | Focus Group |
32 | M | 40-50 yo. Homeless street drinker and rough sleeper. Unwell. | Street Outreach |
35 | M | 40-50 yo. Hostel dweling IVDU. Malnourished and unwell. | Drop In Centre. |
36 | M | 50-60 yo. Hostel dweling IVDU. Lot of medical issues. | Focus Group |
37 | M | 30-40 yo. Hostel dweling IVDU. | Focus Group |
38 | M | 40-50 yo. Hostel dweling ex IVDU. | Focus Group |
44 | M | 30-40 yo. Hostel dweling IVDU. | Drop In Centre |
47 | M | 50-60 yo. Rough sleeper, street drinker. | Street Outreach |
48 | M | 60-70 yo. Hostel dweling. Street drinker. | Food Hall. |
49 | F | 40-50 yo. Hostel dweling. Hx of severe anorexia | Street Outreach. |
51 | F | 20-30 yo. Hostel dweling. Ex IVDU. | Focus Group |
52 | M | 60-70 yo. Rough Sleeper. | Street Outreach. |
55 | F | 20-30 yo. Rough Sleeper. IVDU. Severe arthritic condition. | Street Outreach. |
56 | F | 20-30 yo. Rough Sleeper. From outside Dublin. Socially Isolated. | Street Outreach. |
57 | M | 50-60 yo. Rough Sleeping. Hx of schizophrenia. | Street Outreach. |
58 | M | 30-40 yo. Hostel dwelling. IVDU. | Street Outreach. |
59 | M | 20-30 yo. Rough Sleeper. IVDU. From outside Dublin. | Street Outreach. |
80 | M | 30-40 yo Hostel dwelling IVDU. | Drop In Centre. |
81 | F | 30-40 yo. Hostel dwelling IVDU. | Drop In Centre. |
82 | M | 40-50 yo. Hostel dwelling IVDU. | Drop In Centre. |
83 | M | 20-30 yo. Hostel dwelling IVDU. | Drop In Centre. |
84 | F | 20-30 yo. Hostel dwelling IVDU. | Drop In Centre. |
85 | M | 30-40 yo. Hostel dwelling IVDU. | Drop In Centre. |
86 | M | 20-30 yo. Hostel dwelling IVDU. Malnourished. Unwell. | Drop In Centre. |
87 | M | 20-30 yo. Hostel dwelling IVDU. | Drop In Centre. |
88 | F | 40-50 yo. Ex hostel dwelling – now housed. Ex IVDU. | Drop In Centre. |
89 | F | 40-50 yo Hostel dwelling. Ex IVDU. | Drop In Centre. |
90 | M | 20-30 yo. Hostel dwelling IVDU. Came from outside Dublin. | Street Outreach. |
91 | M | 20-30 yo. Rough Sleeping. IVDU. | Street Outreach. |
92 | M | 20-30 yo. Rough Sleeping. IVDU. Came from outside Dublin. | Street Outreach. |
93 | M | 20-30 yo. Rough Sleeping. IVDU. Came from outside Dublin. | Street Outreach. |
94 | M | 30-40 yo. Rough Sleeping. Street Drinker. | Street Outreach. |
95 | M | 20-30 yo. Hostel Dwelling. IVDU. | Street Outreach. |
96 | M | 20-30 yo. Rough Sleeping. IVDU. Deaf. | Street Outreach. |
97 | M | 20-30 yo. Hostel dwelling. | Street Outreach. |
98 | M | 20-30 yo. Hostel dwelling. | Street Outreach. |
99 | M | 40-50 yo. Hostel dwelling. | Street Outreach. |
100 | M | 30-40 yo. Hostel dwelling. IVDU. | Street Outreach. |
101 | F | 30-40 yo. Hostel dwelling. IVDU | Street Outreach. |
102 | M | 40-50 yo. Hostel dwelling. Moldovan. | Street Outreach. |
103 | M | 20-30 yp. Rough Sleeper. IVDU. Domestic violence. | Street Outreach. |
104 | M | 30-40 yo. Rough Sleeping. History of repeated violent behaviour. | Street Outreach. |
105 | M | 30-40 yo. Hostel dwelling. | Street Outreach. |
106 | M | 40-50 yo. Rough Sleeping. Street Drinker. Polish. | Street Outreach. |
107 | F | 20-30 yo. Rough Sleeping. IVDU. Came from outside Dublin. | Street Outreach. |
1108 | M | 40-50 yo. Rough Sleeping. Eastern European. | Street Outreach. |
109 | M | 20-30 yo. Hostel dwelling. Eastern European. | Street Outreach. |
110 | F | 40-50 yo. Couch surfing. Ex IVDU. | Food Hall. |
111 | F | 20-30 yo. Couch Surfing. Ex IVDU. | Food Hall. |
112 | F | 40-50 yo. Hostel dwelling American. | Food Hall. |
113 | M | 40-50 yo. Hostel dwelling. IVDU. | Food Hall. |
114 | F | 30-40 yo. Hostel dwelling. IVDU. | Food Hall. |
115 | M | 30-40 yo. Hostel dwelling. Ex IVDU. | Food Hall. |
116 | F | 40-50 yo. Rough sleeping. IVDU. | Food Hall. |
117 | M | 40-50 yo. Rough sleeping. Street Drinker. | Food Hall. |
118 | M | 20-30 yo. Hostel dwelling .Recent rough sleeper. Ex IVDU. | Food Hall. |
119 | M | 30-50 yo. Hostel dwelling. | Food Hall. |
120 | M | 20-30 yo. Hostel dwelling. | Food Hall. |
121 | M | 20-30 yo. Hostel dwelling. IVDU. | Food Hall. |
122 | M | 30-40 yo. Hostel dwelling. Ex IVDU. | Food Hall. |
123 | M | 20-30 yo. Disliked doctors. | Food Hall. |
124 | F | 20-30 yo. Hostel dwelling IVDU. | Food Hall. |
125 | M | 60-70 yo. Ex homeless. Ex drinker. | Food Hall. |
126 | M | 50-60 yo. Hostel dwelling. Mental Illness. | Food Hall. |
127 | M | 40-50 yo. Ex Homeless. Ex IVDU. | Focus Group. |
128 | M | 30-40 yo. Hostel dwelling Ex IVDU. | Focus Group. |
129 | F | 20-30 yo. Hostel dwelling. Ex IVDU. | Focus Group. |
130 | M | 40-50 yo Hostel dwelling Ex IVDU. | Focus Group. |
131 | M | 30-40 yo. Hostel dwelling. IVDU. | Focus Group. |
132 | F | 40-50 yo. Hostel dwelling. IVDU. | Focus Group. |
133 | M | 40-50 yo. Hostel dwelling. Ex IVDU. | Focus Group. |
134 | M | 30-40 yo. Junior hospital doctor. | Focus Group. |
135 | F | 20-30 yo. Junior hospital doctor. | Focus Group. |
136 | F | 30-40 yo. Junior hospital doctor. | Focus Group. |
137 | M | 30-30 yo. Junior hospital doctor. | Focus Group. |
138 | F | 20-30 yo. Junior hospital doctor. | Focus Group. |
139 | F | 20-30 yo. Junior hospital doctor. | Focus Group. |
140 | F | 20-30 yo. Junior hospital doctor. | Focus Group. |
141 | M | 30-40 yo. Junior hospital doctor. | Focus Group. |
142 | F | 20-30 yo. Junior hospital doctor. | Focus Group. |
External barriers
Generative Structures. Structures Exerting Influence Prior to becoming homeless ● Poverty ○ Dysfunctional Familial Background (23 sources/71 references). ○ Substance Misuse (8 sources/10 references). ○ Negative Experiences of Authority (35 sources/70 references). ○ Illiteracy (4 sources/4 references). ● Mental Illness (14 sources/22 references). Structures Exerting Influence upon becoming homeless ● Insecurity of Accommodation. (10 sources/19 references). ● Need to Prioritise Survival over Health (35 Sources/99 references). ● Chaotic Nature of Homelessness (26 sources/56 references). ● Ubiquity of Early Death in Homelessness (17 sources/39 references). ● Ubiquity of Violence in Homelessness (26 sources/78 references). ● Substance Misuse (42 sources/107 references). ● Negative Experience of Authority (35 sources/70 references). | |
External Barriers ● Physical Barriers ○ Distance (6 sources/6 references) ● Administrative Barriers ○ Complexity of application processes for medical care. (12 sources/15 references) ○ Appointment Systems (16 sources/26 references) ○ Queues (18 sources/ 37 references) ○ Policies for Management of addiction when queuing (20 sources/48 references) ○ Authoritative Rules of Service (16 sources/39 references) ● Communicative Barriers ○ Absence of Information (10 sources/19 references) ○ Conversations of Exclusion. (36 sources/172 references) ● Attitudinal Barriers ○ Stigma & Discrimination (35 sources/222 references) | |
Internalised Barriers Cognitive Barriers ● Fatalistic Cognitions (18 sources/47 references) ● Denial Cognitions (18 sources/45 references) ● Presumption of Poor Treatment due to personal past experience or due to hearing of other people’s’s negative experiences (15 sources/33 references) ● Presumption of Discrimination Cognitions (11 sources/33 references) ● Self Blame Cognitions (12 sources/37 references) ● Competing Priorities Cognitions. (35 sources/99 references) Emotional Barriers ● Fear (35 sources/96 references) ● Hopelessness (18 sources/36 references) ● Embarrassment (11 sources/30 references) ● Low self-esteem (8 sources/20 references) |
Administrative Barriers
Communicative barriers
The benzo conversation
The distrustful conversation
The blaming conversation
The assertiveness conversation
Attitudinal deterrents and barriers
Internalised barriers
Fear
Hopelessness
Embarrassment
Low self-esteem
Generative mechanisms for homeless people’s HSU
Generative factors preceding homelessness
Generative factors taking effect while homeless
Discussion
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Several authors have noted homeless people displaying fatalistic attitudes [51].
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The witnessing of many young deaths can lead to the development of a sense of living in the moment, taking 1 day at a time [52].
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Fear of aggression is recognised as a deterrent for use of services [63].
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It is recognised that homeless people often feel hopeless; in the control of external forces; and with no optimism as to their future prospects [64].
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Poor personal hygiene causing embarrassment has been recognised in the literature as a cause for avoidance of health services [33].
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Poorly drawn up rules of service can exacerbate this potential for anger and confrontation [38].
Model of HSU for homeless people
Predisposing Factors | Enabling Factors | Need | Health Behaviour | Outcomes |
---|---|---|---|---|
Traditional Domain | ||||
Demographics
Age Gender Marital Status.
Health Beliefs
Values Concerning health and illness Altitudes towards health services. Knowledge about disease
Social Structure
Ethnicity Education Employment Social Networks Occupation Family Size Religion |
Personal / Family Resources
Regular Source of Care Entitlement to free primary-care Income Social Support Perceived Barriers to Care
Community Resources
Residence Region Health Services Resources |
Perceived health
General Population health conditions
Evaluated Health
General Population health conditions |
Personal Health Practices
Diet Exercise Self Care Tobacco Use Adherence to care
Use of Health Services
Ambulatory Care Inpatient Care Alternative Healthcare Long-term healthcare |
Traditional & Vulnerable Domains
Health Status
Perceived Health Evaluated Health
Satisfaction with Care
General Satisfaction Technical quality Interpersonal aspects Coordination Communication Financial Aspects Time spent with clinical Access / Availability Convenience Continuity Comprehensiveness Administrative Hassle |
Vulnerable Domain | ||||
Social Structure
Country of birth Acculturation / Immigration / Literacy Sexual orientation
Childhood characteristics
Residential History (e.g. foster care, orphanages) / Homelessness Living Conditions Mobility (stability of home) Length of time in the community Criminal behaviour / Prison history History of abuse or neglect Mental Health Psychological resources (self esteem, social skills etc) Substance abuse |
Personal / Family Resources
Competing Needs Hunger Social Benefits Self Help Skills Ability to negotiate system Key worker Transport Telephone Information Sources
Community Resources
Crime rates Social Services resources |
Perceived health
Vulnerable Population health conditions
Evaluated Health
Vulnerable Population health conditions (e.g. TB, STD’s, and HIV, Hepatitis etc and substance abuse and mental health problems). |
Personal Health Practices
Food sources Hygiene Unsafe sexual practices |
Conclusions
Limitations of the research
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Firstly, this research was conducted in Dublin and care must be taken in transferring findings to other populations.
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Secondly, the researcher, was an insider in the field prior to commencing the research as a doctor who attended many of the homeless people encountered when in the research role. This may have limited their interactions and opinions Participants offered me.
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Thirdly, the researcher founded and worked in a number of specialised services for homeless people. This could bias his opinions of specialised services which were viewed in a favourable light within the research.
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Lastly, the researcher was sole coder and interpreter of the data collected during the research.