1. Do people experiencing homelessness have equitable access to primary care?
In the chapter on Public Health, we asked you to consider the challenges that go along with experiencing homelessness during a pandemic outbreak. We saw that people were often living in congregate settings, like emergency shelters, without reliable access to healthy food, fresh water, and hygiene facilities. These factors created conditions that led people experiencing homelessness to be particularly vulnerable in these emergency times. For instance, during the COVID-19 outbreak people experiencing homelessness were over 20 times more likely to be admitted to hospital for COVID-19, over 10 times more likely to require intensive care, and over 5 times more likely to die within 21 days of their first positive test result (Richard et al., 2021).
There is a well-recognized truth that vulnerability during a pandemic is often rooted in vulnerability that pre-existed before the pandemic. This tells us that people who experience homelessness were at high risk during COVID-19 because they already had complex underlying issues. Before you begin this section, we encourage you to pause and reflect on the question of whether people experiencing homelessness have equitable access to primary care, and if you believe they do not (as we have not so subtly hinted at) why do you think their access might be inequitable?
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When you think about primary care, such as Family Physicians and Nurse Practitioner led clinics, what might come to mind is our universal health care system. There is often a misconception that because we have “free health care” in Canada, that everyone has the same access to it. However, there is a long history of research that shows people who experience homelessness often have very poor health (Chiu, Redelmeier, Tolomiczenko, Kiss, & Hwang, 2009; Daiski, 2007; Frankish, Hwang, & Quants, 2005; Guirguis-Younger, McNeil, & Hwang, 2014; Hwang, 2001; Jaworsky et al., 2016; Khandor et al., 2011; Kelly & Caputo, 2007).
What we see when we look at these health outcomes is a pattern. If most people who experience homelessness are in poor health, there must be some common factor that explains why. The explanation cannot be found exclusively in biomedical factors, such as genes and predisposition to certain health conditions. These no doubt play a role in poor health, but they do not provide a full account of why there is a connection between people experiencing homelessness and having multiple chronic health conditions. In order to do this – to understand the reasons why we see this relationship emerge – we have to consider the social determinants of health. This concept should be familiar to you from previous chapters, as it is an underlying foundational concept for understanding homelessness. Before we move through the remainder of the section, we invite you to watch this video that expands upon the social determinants of health and situates them within a Canadian context.
The social determinants of health help provide a more nuanced picture of human health, beyond individual level factors. We can see their importance when we think about why people who experience homelessness are often in poor health compared to the housed population. Dr. Stephen Hwang, who has studied the relationship between health and homelessness extensively, explains that there are many barriers to accessing care that exist. Liu and Hwang (2021) have argued that the upstream causes of poor health for people experiencing homelessness include extreme poverty, harsh living environments, trauma, and structural barriers to care, while the downstream causes include infectious diseases, heart disease, substance use disorders, and suicide. You can see a graphic depiction of these barriers in Fig. 1: Interventions to improve health outcomes among homeless people. In the video that follows, Dr. Hwang explains these barriers further.
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Dr. Stephen Hwang: Do people experiencing homelessness have equitable access to primary care?
In this video, Dr. Stephen Hwang argues that by any means that we can define the term equity, people who experience homelessness do not have equitable access to primary health care. He notes that there are several barriers that exist, such as competing obligations and needs, a lack of transportation, not having a phone or computer to communicate, and having previous negative encounters that lead to health care avoidance. Dr. Hwang notes that the health care system is set up to incentivize practitioners to care for people who are well and well-off, who require only brief visits, and who have less complex health needs than those who are more disadvantaged. This video is 3:28 in length and has closed captions available in English.
Key Takeaways – Dr. Stephen Hwang: Do people experiencing homelessness have equitable access to primary care?
- By any means that we can define the term equity, people who experience homelessness do not have equitable access to primary health care.
- There are several barriers or impediments that people who experience homelessness face in trying to access primary care.
- Seeking health care may be a lower priority than obtaining other necessities, such as food and shelter.
- There are practical issues, such as lacking transportation to appointments, and not having a telephone or computer to book appointments or receive follow-up communication.
- There are barriers related to care-seeking behaviour, as many people report discriminatory and suboptimal care related to their low socioeconomic status. These negative encounters can lead to health care avoidance.
- The health care system, in general, makes it easier to deliver care to people who are well and well-off. There are financial incentives for running a practice where patients receive quick care and have no complex health problems, which is not consistent with providing care for the most disadvantaged.
There are many obstacles that people who experience homeless face in accessing primary care. Research from the Niagara region of Ontario found that some of the commonly identified barriers include challenges finding a primary care provider, lack of affordability, poor therapeutic relationships, systemic issues, and transportation / accessibility issues (Ramsay, Hossain, Moore, Milo, & Brown, 2019). Stigma and discrimination are particularly prevalent issues that people who experience homelessness face in health care encounters, particularly if they use drugs and/or have mental illness (Paradis-Gagné, Pariseau-Legault, Villemure, & Chauvette, 2020).
Our own research using narrative interviews with 53 people experiencing homelessness or housing vulnerability in a small Ontario town showed that only 28% had a primary care provider locally, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all (Gilmer & Buccieri, 2020). This research also indicated that participants frequently sought out care in emergency departments because they were unable to access the primary care they needed in the community. When trying to get primary or emergency medical care, the participants largely felt they were discriminated against and treated poorly because they had, or were perceived to have, mental illness, chronic pain, and/or addiction issues (Gilmer & Buccieri, 2020). These findings are supported by Magwood et al., (2020) who have also found that health care practitioners may be reluctant to care for patients with lived experience of homelessness, indicated stigma and bias are barriers that lead to inequitable primary health care access.
We would like to invite you to learn more about our research in this featured reading published in the Journal of Primary Care & Community Health. Here we examine the relationship between primary care access and homelessness in a small town.
Featured Reading:
Gilmer, C., & Buccieri, K. (2020). Homeless patients associate clinician bias with suboptimal care for mental illness, addictions, and chronic pain. Journal of Primary Care & Community Health, 11.
Stigma and discriminatory treatment are often linked to chronic pain, as people who seek treatment in primary care settings may be viewed as engaging in drug-seeking behaviour. This has the effect of decreasing their access to medical treatments and results in multiple visits or fractured health care, as they try to find a health care provider who can help. For instance, researchers in Calgary examined primary care clinic records and found that patients who were experiencing homelessness visited at a rate 2.02 times higher than those who were housed (Rivera et al., 2018). These findings may indicate that these patients had higher health care needs, and also that their needs were not being fully met when they visited their primary care provider.
In a study of 1,287 people with mental illness involved in a Housing First program in three Canadian cities, researchers found that 43% reported moderate to severe chronic pain that interfered with daily activities (80%), sleep (78%), and social interactions (61%) (Vogel et al., 2017). Chronic pain was associated with increasing age, major depressive disorder, mood disorder with psychotic features, panic disorder, post-traumatic stress disorder, and increased suicidality (Vogel et al., 2017). Among participants who reported experiencing chronic pain, 64% had sought medical treatment, 56% were treated with prescription drugs, and 38% used illicit drugs as a form of pain relief (Vogel et al., 2017). When people are not able to receive health care that meets their needs, they may seek out alternative measures. In the next video, Dr. Abe Oudshoorn identifies and discusses three challenges he has observed with primary care for patients experiencing homelessness.
Dr. Abe Oudshoorn: Do people experiencing homelessness have equitable access to primary health care?
In this video, Dr. Abe Oudshoorn shares his passion for equitable health care access and argues that the challenges with primary care for people experiencing homelessness are system-wide and multifactorial. First, he notes, people may become disconnected from their primary care provider due to conflict over care or due to their own relocation. Second, they may face discrimination from care providers that can be a barrier to seeking out future health care supports. Finally, when people who experience homelessness lack a foundation of primary care they may receive episodic care, such as at community health centres or emergency shelters, which lacks the continuity needed for ongoing treatments and medication monitoring. Dr. Oudshoorn concludes that what is needed is to reconnect people experiencing homelessness with a stable foundation of primary care. This video is 3:29 in length and has closed captions available in English.
Key Takeaways – Dr. Abe Oudshoorn: Do people experiencing homelessness have equitable access to primary health care?
- The challenges with primary care for people experiencing homelessness are system-wide and multifactorial. They include disconnection, discrimination, and the patchwork of services people receive.
- People experiencing homelessness may become disaffiliated with their primary care Physician and/or Nurse Practitioner. This creates a disconnection from the foundation of primary care.
- This may result because the patient was fired by their care provider such as for having a substance use issue.
- The patient may become disconnected by moving around to different cities or neighbourhoods.
- Studies consistently show that the largest barrier to health care for people experiencing homelessness is having previous negative experiences where they were discriminated against and treated poorly.
- Often this discrimination occurs in emergency settings but has also been found in primary care settings.
- People may lose their foundation of primary care if they have had negative experiences at any point in the health care system.
- Without primary care, people experiencing homelessness often get episodic care, such as at an emergency shelter or community health centre. They may see different practitioners in each setting, with no continuity of care.
- This lack of continuity is challenging for medication monitoring and may result in multiple different diagnoses.
- What is needed is to reconnect people experiencing homelessness with a stable foundation of primary care.
When we asked the researchers whether people experiencing homelessness have equitable access to primary care, they all said no. There are many barriers to primary care that exist, as we have seen. People may have difficulty finding a primary care provider, staying connected after moving around or losing housing, and may face discrimination when seeking treatment and medication for conditions such as chronic pain, mental illness, and/or addiction. There are also many barriers to primary care that result from institutional biases within our health care system. In the two videos that follow Dr. Rebecca Schiff and Dr. Alex Abramovich speak about racism, homophobia, and transphobia as barriers in our health care system that prevent equitable access for many people experiencing homelessness.
Dr. Rebecca Schiff: Do people experiencing homelessness have equitable access to primary health care?
In this video, Dr. Rebecca Schiff argues that people who experience homelessness are one group, like those living in rural and remote communities, who lack equitable access to primary health care. She notes that we must consider intersectionality, such as discrimination in our health care system related to being Indigenous, visibly homeless, and/or a substance user. Dr. Schiff notes that in addition to having poor access to primary care, people who experience homelessness may also have a range of factors that make it more challenging for them to advocate for themselves. This video is 2:18 in length and has closed captions available in English.
Key Takeaways – Dr. Rebecca Schiff: Do people experiencing homelessness have equitable access to primary health care?
- People who experience homelessness are amongst many groups of Canadians who do not have equitable access to primary care, such as those living in rural, remote, and isolated communities.
- We must also consider intersectionality issues related to racism and discrimination in our health care system.
- People face discrimination in the health care system on the basis of being Indigenous, appearing to be homeless, and being a person who uses substances and is perceived to be drug-seeking.
- People who experience homelessness have poor access to primary care, which can be further complicated by factors of discrimination based on race, appearance of substance use, mental illness, and/or developmental disability. These factors can also make it more difficult for patients to advocate for themselves.
Dr. Alex Abramovich: Do people experiencing homelessness have equitable access to primary health care?
In this video, Dr. Alex Abramovich explains that LGBTQ2S+ individuals, particularly those experiencing homelessness, do not have equitable access to primary health care. He notes that many of our health services are not population-specific, nor prepared to appropriately respond to the health care needs of these patients. Within mainstream primary care, LGBTQ2S+ patients may feel unsafe and not know how their physician will respond to them. Dr. Abramovich argues that few specialized clinics exist and those that do often have long waitlists, which is particularly problematic and increases risk of suicidality for trans-identified individuals seeking support for medical transitions. Dr. Abramovich concludes a lot more work needs to be done to improve access to appropriate and timely health care for LGBTQ2S+ persons, including those experiencing homelessness. This video is 3:40 in length and has closed captions available in English.
Key Takeaways – Dr. Alex Abramovich: Do people experiencing homelessness have equitable access to primary health care?
- LGBTQ2S+ individuals, particularly those experiencing homelessness, do not have equitable access to primary health care.
- Many of our health care services are not population-specific nor prepared to appropriately respond to the health care needs of LGBTQ2S+ individuals.
- When seeking mainstream health care, these patients may not know what to expect or how the physician will respond to them. This is particularly challenging for trans-identified individuals seeking support around medical transition.
- Many LGBTQ2S+ youth have reported not having a primary care physician and not feeling safe in primary care settings.
- Clinics that specialize in LGBTQ2S+ health care often have long wait times. This is particularly challenging for trans individuals, as it delays access to hormones and surgery at a crucial time in their lives, which can increase risk of suicidality.
- A lot more work needs to be done to improve access to appropriate and timely health care for LGBTQ2S+ persons, including those experiencing homelessness.
What do you think?
In a review of administrative health data for 2,085 transgender individuals in Ontario, Dr. Abramovich and his team (2020) found that these patients are more likely than cisgender patients to live in lower-income areas, experience chronic health conditions such as asthma, diabetes, chronic obstructive pulmonary disease, and HIV. How do you think experiencing homelessness might make it even more difficult for transgender individuals to get the health care they need? What measures could we take to improve this population’s access to primary health care?
We have considered a number of barriers that people experiencing homelessness face in accessing primary care. In response to these barriers, researchers and care providers have also sought out ways to increase accessibility. For instance, Ramsay et al., (2019) found that health care access can be enhanced for this population through community health care outreach, implementing measures to foster positive relationships, and engaging shelters in coordinating health care. As we have seen, traditional health care settings may not be welcoming spaces for people experiencing homelessness. In the next set of videos, Dr. Tim Aubry and Dr. Kelli Stajduhar discuss how communities are using mobile outreach teams as a way to increase access to primary care.
Dr. Tim Aubry: Do people experiencing homelessness have equitable access to primary care?
In this video, Dr. Tim Aubry explains that people who experience homelessness often do not have a family doctor and consequently lack equitable access to primary care. He notes that as a response to this, many cities have developed teams of health care practitioners who offer outreach in shelters, service agencies, and on the street. Dr. Aubry notes that shelters have evolved into health, mental health, and addictions service hubs and while this fills a need, it is also problematic as it goes against the Housing First philosophy of integrating people into the broader community. This video is 3:15 in length and has closed captions available in English.
Key Takeaways – Dr. Tim Aubry: Do people experiencing homelessness have equitable access to primary care?
- People who experience homelessness typically do not have equitable access to primary care, nor a family doctor.
- In response, many cities have a group of health care professionals come together to do outreach in shelters, service agencies, and on the street as a crisis response kind of primary care.
- Over the past 20 years, we have seen the evolution of shelters, to now include primary care, mental health services, and addictions support programs. They have become service hubs, which responds to a need but is problematic.
- Embedding health care in the homelessness sector is not consistent with the Housing First philosophy that people should be integrated into the community.
Dr. Kelli Stajduhar: Do people experiencing homelessness have equitable access to primary care?
In this video, Dr. Kelli Stajduhar explains that people who experience homelessness may be able to access primary care through practitioners or walk-in clinics, but that these environments often do not feel safe for people who have experienced trauma, violence, discrimination, and who may use substances. Likewise, in the absence of primary care, seeking support in an emergency room may also feel unsafe. Dr. Stajduhar argues that people who experience homelessness are cared for everywhere in our health care system, so it is important all health care practitioners understand key aspects such as harm reduction, trauma and violence informed care, the social determinants of health, and cultural humility and safety. She concludes by discussing the work of mobile primary palliative outreach teams in cities across Canada, who work on providing upstream care to people in a way that is low barrier and meets them where they are at. This video is 5:37 in length and has closed captions available in English.
Key Takeaways – Dr. Kelli Stajduhar: Do people experiencing homelessness have equitable access to primary care?
- People who experience homelessness can sometimes access primary care through practitioners and walk-in clinics, but these spaces do not always feel like safe spaces to those who have experienced trauma, violence, discrimination, stigmatization, and who may also use substances.
- Some people have primary care, and it is fine, but many people do not have equitable access.
- When primary care services are not available, people will often turn to emergency departments, which are also not necessarily safe places for those experiencing homelessness or structural vulnerability.
- People who experience homelessness and/or other kinds of inequities are cared for everywhere in our health care system, so all health care providers should understand some fundamental keys.
- They must understand harm reduction, trauma and violence informed care, and how the social determinants of health such as housing, transportation, and food security come into play when caring for patients experiencing homelessness.
- We all need to understand cultural humility and cultural safety, and how this is key to good primary care.
- Mobile palliative care teams work across Canada to provide low barrier care to people where they are at. The services are not limited to people who are near death but also include an upstream focus informed by safe street nursing practices.
- Examples include PEACH team in Toronto, CAMPP team in Calgary, PORT team in Victoria, and PCOAT in Edmonton.
In this video, Dr. Stajduhar makes the important point that all health care providers need to be aware of how to care for patients experiencing homelessness in a way that is respectful and accounts for the barriers they face. The research supports her position. In a critical ethnography with 12 outreach Nurses who work with people experiencing homelessness, researchers found that there is a need to raise awareness among health care providers about the ethical, clinical, and organization issues of these patients particularly in relation to the ways in which they are stigmatized and excluded from health care settings (Paradis-Gagné, Pariseau-Legault, Villemure, & Chauvette, 2020).
As an alternative to more traditional clinic-based care, mobile outreach allows health practitioners to meet people where they are. In an article that provides a critical history of outreach nursing in Canada, Hardill (2007) notes that street nursing, or nursing outreach to people experiencing visible homelessness, has become an established specialty in Canada, as in America, Great Britain, Europe, and Australia with roots tracing as far as the early 1700s when the Grey Nuns made visits to those who were ill and poor in what is now known as Quebec. In her memoir, “A knapsack full of dreams” respected Toronto Street Nurse Cathy Crowe (2019) writes about the career trajectory that led her to street nursing, and shares frustration over larger structural issues, like the lack of affordable housing, that contribute to poor health outcomes for the people she treats. In this video, Her Nurse Hands, she speaks firsthand about her career as a Street Nurse in Toronto.
Mobile outreach is a critically important approach for reaching people who are experiencing unsheltered homelessness and are disconnected from social services and health care agencies. Sometimes health care is provided directly in shelters or drop-in centres that support people experiencing homelessness. What do you think some of the benefits and drawbacks are of having health care services located in homelessness agencies? Dr. Naomi Thulien and Dr. Tim Aubry speak about this issue in the next two videos.
Dr. Naomi Thulien: Do people experiencing homelessness have equitable access to primary health care?
In this video, Dr. Naomi Thulien argues that the reasons people who experience homelessness do not have equitable access to health care are complex. She notes that finding a primary care physician is difficult for everyone, but that those who experience homelessness also tend to have urgent health care needs that require same day emergency care. She cites health care clinics located within homeless sector agencies as being a source of health care, but also notes that as people move into housing, they often no longer want to access care in these locations. This video is 1:24 in length and has closed captions available in English.
Key Takeaways – Dr. Naomi Thulien: Do people experiencing homelessness have equitable access to primary health care?
- The reasons people experiencing homelessness do not have equitable access to health care are complex.
- Even for housed individuals, it is difficult to find primary care practitioners.
- People who experience homelessness often have urgent health needs and may require same day care. When primary care takes too long, they may seek help at an emergency room.
- People experiencing homelessness may not have a phone and, if they do, may not have time to communicate with a primary care office over the phone.
- There are some excellent health care services located within the homelessness sector but as people become housed, they often no longer want to access them.
Dr. Tim Aubry: Housing stability as long-term health care
In this video, Dr. Tim Aubry explains that having health care services located in shelters can be problematic in the long run because it sets up a parallel system of health care. Instead, he argues, we should take a Housing First approach that moves away from a treatment-first perspective and focuses on housing people before addressing health, mental health, and/or addictions issues they may be experiencing. This video is 2:32 in length and has closed captions available in English.
Key Takeaways – Dr. Tim Aubry: Housing stability as long-term health care
- In the long run, having health care services located in shelters can be problematic because it sets up a parallel system rather than integrating people into the main primary health care system.
- Endemic in our social service systems that work with people experiencing homelessness has been a treatment-first perspective, that we need to fix people’s addictions and mental health before they can have their own housing.
- Housing First turned that perspective around and said we should start with housing and once people have stability, work on any other health, mental health, and/or addictions issues they are experiencing.
Dr. Thulien and Dr. Aubry both recognize the urgent health care needs of many people who experience homelessness but also caution that having health care directly in shelters may not be what people want after they are housed. In the chapter on Policy, Politics, and Housing in Canada we looked at Housing First, the idea that people are housed before needing to demonstrate they have met ‘housing-readiness’ requirements. Researchers have studied Housing First to see whether it helps people obtain and stay connected to primary health care after being housed. Unfortunately, this does not seem to be the case. Whisler et al., (2021) found that there was no significant improvement in primary care retention for Housing First participants compared to people not receiving the housing intervention. These findings suggest that while housing is a critically important social determinant of health, it is not enough just to get people housed. More targeted interventions are needed to actively help those who want health care to be able to access it without barriers.
Our current primary health care system is not accessible to many people who experience homelessness. We have seen that mobile outreach and shelter-based health care are approaches used to reach people experiencing unsheltered or emergency sheltered homelessness. However, while important strategies, these approaches do not solve the underlying issue that mainstream health care is discriminatory and inaccessible to a large number of people who have complex health problems. Does the solution then lie in creating a separate system, or does it mean we should improve the system we have to make it more equitable? Dr. Bernie Pauly and Dr. Abe Oudshoorn share their views in the next two videos.
Dr. Bernie Pauly: Do people experiencing homelessness have equitable access to primary care?
In this video Dr. Bernadette [Bernie] Pauly explains that if we want to build a better response to homelessness, we need to develop a system that is accessible and streamlined, where people do not have to go to multiple places, fill out multiple forms, and tell their story multiple times. She notes that many people who experience homelessness do not have a primary care practitioner. While she identifies community health centres as being helpful for promoting equity, she is also clear to note that they are often not integrated into the larger primary care system and are not available in every community. Dr. Pauly cites multiple inequities people experiencing homelessness face when navigating primary care, such as a lack of transportation, competing care responsibilities, hours that are not in line with their availability, and stigmatization. She concludes that while primary care practitioners may recognize the roots causes of poor physical and mental health as being a lack of housing, food, and income, they are not well-equipped to address the social determinants of health. This video is 5:42 in length and has closed captions available in English.
Key Takeaways – Dr. Bernie Pauly: Do people experiencing homelessness have equitable access to primary care?
- If we want to build a better response to homelessness, we need to create a system that is accessible and streamlined, where people do not have to go to multiple places, fill out multiple applications, tell their story multiple times, and then wait. That is not an integrated system of care.
- Many people experiencing homelessness do not have a primary care physician.
- Community health centres, that specialize in inner-city health, are helpful but not necessarily integrated into the rest of the primary care system.
- Inner city health centres address equity issues but are not available in every community.
- There are multiple inequities that people experiencing homelessness face when trying to navigate primary care.
- They may have limited access due to a lack of transportation, service hours that do not match their availability, and a lack of access to a phone.
- Some people may be caring for others, such as children or other family members and prioritizing their own health care is difficult.
- People who experience homelessness often face stigma in the health care system and may not feel safe discussing their circumstances, particularly if there are children in their care.
- Health care providers are not well-equipped to address the social determinants of health. Even the best practitioner cannot fix the root causes of a lack of housing, food, and income.
- Practitioners often recognize the importance of advocating for housing and income, and some have written prescriptions for housing to demonstrate their own lack of ability to address the causes of these patients’ poor physical and mental health.
Dr. Abe Oudshoorn: The need to enhance Canada’s existing health care system
In this video, Dr. Abe Oudshoorn argues that it is not advisable to create an alternative system of health services attached to people’s housing status, but rather that we should ensure people experiencing homelessness receive quality care by making improvements to our current health care system. He notes there are several steps we can take to fix our primary care system, including legislation that prevents primary care practices from firing patients, attaching better funding and supports such as integrating social workers into care teams, and coordinating care across teams for patients who relocate. Dr. Oudshoorn concludes that there is a perception that because Canada’s health care system is public people have equal access, but that the health outcomes demonstrate this to be untrue. Poor health outcomes are not individual failures but rather the predictable result of a system that is not designed to be flexible to meet people’s diverse needs. This video is 4:14 in length and has closed captions available in English.
Key Takeaways – Dr. Abe Oudshoorn: The need to enhance Canada’s existing health care system
- It is not advisable to create an alternative system of health services for people experiencing homelessness, because once a person is housed, they will have to return to the homelessness sector to see their care provider.
- We need to ensure people experiencing homelessness have access to the same quality of primary care as housed individuals, rather than the current patchwork.
- We need to fix our current primary health care system so that people can continue to access it regardless of their housing status.
- There are multiple ways of enhancing our current system, such as looking at legislation around the ability of primary care practices to fire their patients and attaching and funding better supports in primary care services such as integrated social workers as part of the care team.
- Primary care services may need to be interconnected with other teams to ensure continual care and access to health records for patients who relocate.
- There is a presumption that because our health care system is a free public system that everyone has equal care access and experiences, yet the statistics on health outcome differentials are stark.
- Research has shown the average age of death for people experiencing homeless to be around 47 years of age.
- Barriers previously discussed, around disconnection, discrimination, and episodic care, create these outcomes. Health differentials are not an individual issue but rather the result of a system that is not designed to be flexible in meeting the needs of different people.
When people experience homelessness they often have many competing priorities, such as finding shelter and food, that take precedence over seeking health care. For that reason, it is essential that health care workers understand the challenges these individuals face and advocate for them to get the care they need. For instance, there have been calls from practitioners and people with lived experience for improved training to increase knowledge of patient needs and preferences (Magwood et al., 2020), which can begin during their educational training even before they enter the field (Hossain, Ramsay, Moore, & Milo, 2018).
Family Physicians, for instance, have the opportunity to be powerful vocal advocates for people experiencing homelessness within their local communities, and they can provide direct care while championing policy changes that address the underlying structural causes that lead to poor health (Andermann et al., 2020). Likewise, by virtue of the work they do, Nurses are in a unique position to advocate for patients that others might stigmatize or discriminate against (Crowe & Baker, 2007).
A statement from the Registered Nurses’ Association of Ontario (2004) indicates, “Nurses must be aware of homelessness and basic housing needs in each facet of their practice. This should include all three dimensions of housing which include: house (physical structure), home (social and psychological characteristics) and neighbourhood (physical location and available services). Part of this process will require education and a reflective review of our own beliefs and practices surrounding homelessness. Nurses also have a responsibility to educate the public and advocate on behalf of homeless individuals – for health.” In the next video, Dr. Kelli Stajduhar discusses the responsibility Nurses have to advocate for their patients, even when it feels uncomfortable to do so.
Dr. Kelli Stajduhar: Nursing as a form of advocacy
In this video, Dr. Kelli Stajduhar explains that people who experience homelessness are often discriminated against and stereotyped, and Nurses need to push back against situations where their colleagues are being judgemental or making assumptions. She argues that Nurses are positioned in places where they can engage in advocacy and that, while there may be different levels of comfort, instructors can help prepare nursing students by providing them with the capacity and confidence to do so. This video is 2:46 in length and has closed captions available in English.
Key Takeaways – Dr. Kelli Stajduhar: Nursing as a form of advocacy
- People who experience homelessness are often discriminated against and stereotyped.
- Nurses need to push back and speak out against situations where their colleagues are being judgemental or making assumptions about a patient.
- Nurses are positioned in places where they can engage in advocacy – on a large scale but also amongst their colleagues to support a patient.
- Nurses may have different levels of comfort in speaking up about disparities in treatment. Nursing instructors can help by preparing their students to have this capacity and confidence when they enter into practice.
In this section, we asked you to consider whether people who experience homelessness have equitable access to primary health care. The answer we received from every researcher we asked was a loud and resounding ‘no!’ We noted that people who experience homelessness often have a range of complex chronic health conditions, which is not a coincidence but rather the result of social determinants. The reasons people are often in poor health include a lack of housing, employment, social support, and proper nutrition. These factors are made worse by a lack of accessible primary health care.
We have seen in this section that there are many barriers to care, and that these include institutional racism, homophobia, and transphobia within our health care systems. Mainstream primary care clinics are often inaccessible and discriminatory spaces for people experiencing homelessness, particularly if they have chronic pain, mental illness and/or addictions. As an alternative, mobile outreach teams have been formed in many communities to offer basic health care measures to people on the streets. Some homelessness services, such as emergency shelters, also offer onsite health care which is a valuable, but short-term, solution. We have heard that rather than setting up parallel health care systems, we need to focus on improving our current primary care response so that it is accessible to everyone. One key way to do this is for Family Physicians and Nurses to be champions for their patients’ needs within their own practices and through broader policy reform.
Podcast: Do people experiencing homelessness have equitable access to primary care? (39:30)
Click the link below to listen to all of the researchers answer the question “Do people experiencing homelessness have equitable access to primary care?” in audio format on our podcast!
