Background
Methods
Study objectives
Study design
Data collection
Study participants
Data analysis
Ethics approval
Results
Providers (/11 interviews) | Clients (/3 interactionsa) | |
---|---|---|
Needs | ||
Medical services | 10 | 3 |
Addictions & mental health | 9 | 3 |
Allied health services | 8 | 2 |
Family medicine | 7 | 1 |
Urgent care | 2 | 0 |
Chronic disease management | 6 | 0 |
Social determinants of health | 4 | 3 |
Barriers | ||
Patient-level | 11 | 3 |
Emotional barriers | 11 | 3 |
Knowledge & priorities | 8 | 1 |
Provider-level | 5 | 3 |
Environment & discrimination | 4 | 2 |
Geographic location | 3 | 2 |
System-level | 11 | 3 |
Financial barriers | 7 | 2 |
Other structural barriers | 11 | 3 |
Needs for healthcare services
Medical services
Overwhelming mental health [needs], like multi, multi, multiple diagnosis, all at the same time, that result in behaviors that influence the relationships that the patients have with us. It’s not just mood disorders. There’s a lot of disorder issues that come about from substance abuse and in my population we have a significant population of individuals with mood and substance and thought disorder all at the same time, all overwhelmed, all not coping well in the system. (male provider 1)
Mental health is a huge part of our client concerns and one of the biggest barriers. It often is a real issue in being able to be effective in helping address their physical health concerns when the mental health concerns aren’t addressed first because you don’t get the same kind of response and cooperation… And that’s a big issue. (female provider 1)
Social determinants of health
I think that patients are much more complex than they are in a typical family practice… you’re not just addressing one of the determinants of health. I think you want to look at all of the determinants of health and see if you can make an impact on any of those as well. (female provider 2)
The other thing that they come to us for are issues around income, income security. So that often while they’re adults, [they’re] not necessarily eligible for significant income from Social Services. So we spend a lot of time to, to sort out what is their best access to, to a stable income. (male provider 1)
Barriers preventing access to healthcare services
Patient-level: emotional barriers
They’re already in a stressful situation in their life being homeless. The stress level is incredible so to throw in a health issue would just increase that stress more than they can possibly bear without support. They might be scared to go to the doctor in case something that they can’t handle arises. Lack of social support could also mean they feel like they have no one to lean on if they do get bad news… (female provider 3)
Most of our people have a fear of authority. Medical systems are structured to represent that. They're incredibly hierarchical and even physically they're set up to be daunting to get through… a lot of our clients will hide ailments and I think that just comes from a lifetime of fear of authority. (female provider 1)
The psychological barrier of having to walk in and say that you're homeless. Part of it is our fault, part of it is us turning around and feeling uncomfortable and projecting that when it happens. The other half is a definite, darker side of the medical community that turns around and goes ‘oh, is that what you are?’ (male client 1)
Patient level: patient knowledge and priority setting
I think one of the biggest gaps is looking at that point of access as to what really is their need and not placing on them that we think they need. Today it might be only about Joe's meal. He really doesn't care that his immunizations are not up to date. (female provider 4)
Provider-level: environmental barriers and discrimination
A lot of times they’ll go down to [clinic] and if they’re not waiting eight hours, they feel very outcast there. They don’t feel included. Staff can be very rude or judgmental to them there. I mean we had [another facility], they felt more comfortable there because it wasn’t as out of their comfort zone I guess you could say, as opposed to like you know when they go down to those nice brand new buildings. (female provider 7)
Discrimination [is a big problem]… If you were living in a shelter, no fixed address, then you’re poor, you work sex trade, you’re using drugs, you’re HIV positive, many, many things, you’re discriminated against even by healthcare. (female provider 6)
I ended up at the [urgent care center], yeah, I went there and then they says no, you’re really in trouble, your lungs. So they admitted to the [hospital] and the doctor there said ‘I’m admitting you’, he had all the papers. He comes back an hour later and said ‘what’s your address?’ I said the [shelter]. Then he says ‘well just a minute…’ He went and comes back and said ‘I, I looked at your vitals and you’ve come up such a long way since you were diagnosed five hours ago, that I’m going to let you go,’ at three in the morning… because I said I was staying at the [shelter], I’m pretty sure. (male client 6)
Attitude of staff is a barrier. The attitudinal issues that a staff has regarding the nature of who that patient is – that’s racism, bias, all that kind of stuff. Discrimination exists for the homeless population in general and the Aboriginal homeless population. I think that's a primary issue that generates how an individual accesses a system or turns away from a system after they've accessed it. The perception that they're not going to be treated well is part of a series of access barriers. (male provider 1).
System level barriers: financial barriers
Patients get here but then they request a ticket to go home either a taxi or a bus, so we struggle with our responsibilities for that. It shouldn't necessarily [be] a policy that should apply to everyone, it needs to be based on where they live, what the physical disability is, all that kind of stuff. (male provider 1)
System level barriers: other structural barriers
Identification is something that you often need when you go to clinics and a lot of our [clients] do not have ID - whether or not they even have Alberta Health Care cards with them or have even applied for their Alberta Health Care cards. We have a lot of out-of-province [clients] that come through, a lot of immigrants that come through so then that whole issue is do they even get access to certain types of care just due to not having the proper documents. (female provider 8)
[One organization] is only running from seven to three so if you're working during those hours you're out of luck. [Another provider] is fully open 24 hours a day but [they] triage according to urgent care levels so they may be waiting all night for a simple question. (female provider 3)
They're not terribly good self-advocates, and may not have the literacy or educational background to be able to navigate or interpret the medical system in a way that serves them well, so if someone tells them no at an entry point to a clinic or any other medical service, they just tend to back away and go rather than ask the question about whether there's another option or whether they've [been] misunderstood. (female provider 1)