Table 4 Qualitative Studies
Author, year Country | Title | Objective | Population/Setting | Exposure | Patient Experience Measure | Key findings related to patient experience measures and/or outcomes |
|---|---|---|---|---|---|---|
Davis, 2012 [30] US | ‘‘Because Somebody Cared about Me. That’s How It Changed Things’’: Homeless, Chronically Ill Patients’ Perspectives on Case Management | To study the perspectives of enrollees in an intensive case management program focused on decreasing admissions among frequently admitted patients at a public hospital in order to understand | PEH N = 11 Outpatient intensive case management program | Hospital outpatient case management program | FTF interviews | Participants in the case management program identified their prior social isolation as unhealthy and valued two distinct aspects of the program: feeling cared for through their relationships with case managers and receiving assistance with navigation of medical systems and social services. Participants identified each as important contributors to their improved health |
Gunner, 2019 [45] UK | Provision and accessibility of primary healthcare services for people who are homeless: a qualitative study of patient perspectives in the UK | To explore the perspectives of individuals who are homeless on the provision and accessibility of primary healthcare services | PEH N = 22 Homeless shelters and a Specialist primary healthcare centre for people who are homeless (SPHCPH) | No specific health service exposure | FTF semi-structured interviews | PEH perceived the model of care at the SPHCPH to be best practice. Mainstream services were associated with negative experiences and inequality in access. Barriers to access highlighted included the denial of registration, fragmented services, poor continuity of care, stigma and discrimination and a lack of awareness on the complexity of healthcare needs for PEH |
Henderson, 2022 [33], US | Experiences of Adult Men Who Are Homeless Accessing Care: A Qualitative Study | The purpose of this study was to describe the perceptions of homeless individuals related to their health and experiences accessing care | PEH N = 16 Emergency homeless shelter for men | No specific health service exposure | Focus groups n = 2 | Three themes identified; (1) men who are homeless experience bias throughout their health care and interpersonal relationships; (2) the best care is person-centred and considers patients’ priorities; (3) care coordination resources are inadequate PEH experience access to healthcare as transactional, opting for convenient episodic care as a means of avoiding poor care coordination, power imbalances and stigma. PEH want their priorities to be considered and care to be person-centred. PEH have complex needs and desire assistance in care coordination and navigation of the healthcare system to ensure their needs and priorities can be met |
Hirst, 2021 [46], UK | Benefits of GP care in outreach settings for people experiencing homelessness: a qualitative study | To explore PEHs’ experiences of GP care in community outreach settings in UK; and to seek staff/volunteers’ views on the strengths and weaknesses of GP community outreach services | PEH N = 22 Drop-in day-centre and Food Drop-in | GP Outreach Service in different community settings Primary Healthcare | FTF semi-structured interviews | Across all settings, GP outreach services helped facilitate access to medical care for PEH. High value was placed on the positive physical, social and organisational environment of GP outreach services. Compared to mainstream services, outreach services were perceived as comfortable, safe, engendered a sense of belonging, convenient and integrated as they brought several services together. PEH valued outreach services as they felt listened to, and time was dedicated to building a therapeutic relationship |
Lamanna, 2018 [34], Canada | Promoting continuity of care for homeless adults with unmet health needs: The role of brief interventions | To examine diverse stakeholder perspectives on the role of a brief intervention in supporting continuity of care, using qualitative methods for their strength in studying phenomena that have not been well documented | PEH N = 22 People with Lived Experience of Homelessness n = 8 Coordinated Access to Care for Homeless People (CATCH) programme | Brief Interventions—CATCH programme Primary Healthcare | Focus groups n = 3 Semi structured interviews n = 29 | Findings suggest that brief interdisciplinary interventions can promote continuity of care by offering low-barrier access, timely and responsive service provision, including timely connection to long-term services and supports, appropriate individualised services and effective coordination of services. Although brief interdisciplinary interventions were perceived to promote access, timeliness and coordination of care for this population with complex health and social needs, gaps in the local service delivery context can present persisting barriers to care comprehensiveness and continuity |
McCallum, 2019 [47], UK | Using always events to derive patient-centred quality improvement priorities in a specialist primary care service providing care to a homeless population | To determine if the Always Events (AE) concept is an acceptable and feasible method for deriving patient-centred QI priorities in a specialist primary care service providing care to PEH | PEH N = 20 Drop-in clinics at a specialist homeless general practitioner service | No specific health service exposure Primary Healthcare | Interviews ‘Always Events’ (AE) is a validated QI method | Nine AEs were generated, five fitted the criteria to be used as metrics for future QI projects. These were ‘I always want…’ to be seen, the staff to be approachable and responsive, to feel safe while waiting to be seen, my privacy to be valued and clear information on how service works. The AE method is an acceptable and feasible tool for generating QI targets that can lead to improvements in care for this vulnerable group |
Meehan et al. 2023 [48], USA | Previous Health Care Experiences’ Influence on Health Care Perceptions Among Residents in Six Homeless Shelters in Seattle, Washington, July–October 2021 | To describe where residents of homeless shelters in Washington receive healthcare, and to examine their perceptions of healthcare and experiences of healthcare | PEH N = 68 Participants all residents across 6 homeless shelters | No specific health service exposure | Semi-structured interviews n = 25 Focus groups n = 8 groups with 43 participants | Findings indicated that residents received healthcare from a variety of settings, with varying frequency. Onsite clinics at homeless shelters and community homeless clinics were most commonly used, but also ED and urgent care and pharmacies Key elements shaping health experiences that emerged from the data were ability access healthcare, level of clear communication from health facilities and staff, ease of securing timely follow up care, experiences of respect or stigma/discrimination. Positive, neutral and negative perceptions of healthcare experiences were identified |
Moore, 2011 [49] Australia | Complex health service needs for people who are homeless | To examine the perceptions and experiences of homeless people in relation to their health service needs as well as those of service providers involved with their care | PEH N = 20 ED in an acute hospital | No specific health service exposure | Semi structured interviews | Six key themes were identified from interviews: complexity of care needs, respect for homeless people and co-workers, engagement as a key strategy in continued care, lack of after-hour services, lack of appropriate accommodation and complexity of services |
Moore-Nadler, 2020 [50] US | Storytelling to capture the health care perspective of people who are homeless | To explore the perceptions of health care experiences by people who are homeless in Mobile, Alabama, while also considering their own thoughts and beliefs regarding the interviews | PEH N = 16 Homeless day shelter, Mobile | No specific health service exposure | Semi structured interviews | The following themes were identified: social determinants of health, compromised systems, professionalism, dehumanisation, engagement, and downward trajectory The experiences described and themes identified indicate a breakdown in therapeutic relationships between homeless individuals and health care providers, contributing to the continuing destabilisation common in this population |
Nicholas, 2016 [31], Canada | The Experiences and Perceptions of Street-Involved Youth Regarding Emergency Department Services | How do Street Involved (SI) youth experience and navigate ED services? What components of ED services foster accessibility and engagement of SI youth? What components of ED services limit accessibility and engagement of SI youth? | PEH N = 42 Health care and service providers in the EDs or community agencies serving SI youth, | Acute and Emergency care | FTF interviews Focus groups n = 7 | Street Involved (SI) youth often perceived suboptimal care and experienced long waiting periods that led to many avoiding or prematurely exiting the ED. Service gaps appeared to have a negative bearing on their care and health outcomes. Negative interactions and serious health implications periodically left SI youth at heightened risk of long-term and serious health and psychosocial outcomes |
Paradis-Gagne, 2023 [51] Canada | Perceptions of mobile and acute healthcare services among people experiencing homelessness | (1) to explore the needs of people experiencing homelessness regarding outreach services and (2) to describe the perceptions and preferences of people who benefit from this outreach intervention | PEH N = 12 Mobile clinic outreach service | No specific health service exposure | Semi structured interviews | The core category that emerged from the data analysis was “Perception of Health Care” from the following subcategories: (1) Conflicting Relationships with Institutional Health Services; (2) Perception of Outreach Services; and (3) Recommendations from Mobile Clinic Users. Some PEH were satisfied with the care received in the public health system, while many have experienced dehumanising practices. Outreach services are a promising strategy to reach underserved populations. Findings highlight practices to personalise and adapt healthcare services and foster inclusive environments to better serve PEH |
Purkey, 2019 [29], Canada | Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care | To explore the experience of hospital-based healthcare for people who are vulnerably housed or homeless | PEH interviews N = 31 Agencies providing services to those who are vulnerably housed | Hospital-based Healthcare | Focus groups n = 6 Semi structured interviews n = 4 (in-person or telephone) Participant and lived experience survey a | Four themes were highlighted by participants: (1) experiences and consequences of stigma and shame when accessing healthcare; (2) lack of accountability of the healthcare system towards equity seeking populations; (3) inflexibility of the healthcare system; and (4) positive experiences that warrant discussion for what they teach us about potential improvements |
Saharan, 2021 [52], US | Sharing the burden of treatment navigation: social work and the experiences of unhoused women in accessing health services in Santa Cruz | To explores the challenges faced by unhoused women in accessing general and reproductive health care services in Santa Cruz, CA | PEH N = 5 Homeless Garden Project | No specific health service exposure | Semi-structured interviews | Women who had access to a social worker were much more likely to report improved access to satisfactory treatment. These findings suggest that there is not a tangible lack of healthcare services for unhoused women in the local community, but rather a burden of treatment navigation caused by a dearth of information on how to access care. The interviews suggest that this burden can be reduced with social work interventions and service centers that offer health navigation support |
Steward, 2016 [44], US | Priorities in the primary care of persons experiencing homelessness: convergence and divergence in the views of patients and provider/experts | To identify aspects of primary care important to persons familiar with homelessness based on personal experience or professional commitment, and to highlight where the priorities of patients and professionals dedicated to their care converge or diverge | PEH N = 26 Homeless service organisations and established board of homeless service users | No specific Health Service Exposure Primary Healthcare | Qualitative Exercise, card sort | Both groups gave high priority to accessibility, evidence-based care, coordination, and cooperation. Provider/experts endorsed patient control more strongly than patients. Patients ranked shared knowledge and the free flow of information about their care more highly than providers/experts |
Strange, 2018 [53], Australia | A general practice street health service: Patient and allied service provider perspectives | To explore patient and staff perspectives of a street-based, primary health service, to help identify factors influencing patient access and management | PEH N = 27 Freo Street Doctor (mobile open-access general practice service) | Street based and mainstream primary healthcare Primary Healthcare | Semi-structured interviews | Thematic analysis identified factors influencing patient willingness to access primary healthcare: doctor–patient empathy, better understanding of patient circumstances, fostering of social capital, facilitating referral pathways and supporting the transition to mainstream general practice as circumstances improve. Hospital discharge planning and follow-up were service continuity gaps |
Sturman, 2020a [35] Australia | ‘Genuine doctor care’: Perspectives on general practice and community- based care of Australian men experiencing homelessness | To explore the experiences and attitudes of homeless men regarding community-based healthcare, and general practice in particular, To identify the potential areas for improvement | PEH N = 20 Ozcare residential hostel for homeless men | Community based healthcare—in particular general practice Primary Healthcare | Focus groups n = 5 | Three key themes identified important aspects of client experiences: the relative invisibility and low salience of general practice compared to hospital-based emergency and inpatient services; discontinuity within community- based healthcare and across transitions between community-based and other healthcare; and inconsistent and unsatisfactory general practitioner responses to physical and psychological pain. Less prominent, themes were: generalist medical expertise and perceived conflicts of interest for health and social care providers |
Sturman, 2020b [36] Australia | ‘I just hope they take it seriously’: homeless men talk about their health care | To improve system responsiveness and patient outcomes, the perspectives of marginalised groups need to be understood—Men who experience homelessness | PEH N = 20 Ozcare residential hostel for homeless men, Brisbane, Australia | No specific health service exposure | Focus groups n = 5 | Participants in all groups expressed gratitude for health care provided in both hospital and community sectors for life threatening physical illness and trauma. However, negative experiences with health care were commonly reported.: dismissive care, care fragmentation, inconsistent medical management of pain and inadequate acknowledgement of psychological distress. These four themes relate to difficulty securing an effective ‘ticket of entry’ to health care |
Ungpakorn, 2020 [54], UK | Health-related street outreach: exploring the perceptions of homeless people with experience of sleeping rough | To understand how health‐related street outreach is perceived by homeless people with experience of sleeping rough | PEH N = 10 Drop‐in centres | Health-related street outreach Primary Healthcare | F2F Semi-structured interviews | Health‐related street outreach was perceived as being able to offer a human connection that reduced the sense of isolation and exclusion commonly experienced on the street. People with experience of sleeping rough felt it could overcome access barriers and provide a bridge to healthcare services. Crucially the right approach was defined by participants in terms of location, timing, the outreach team, and the verbal and non‐verbal styles used by outreach workers. Three main themes were found during the data analysis: A human connection, Street outreach as a bridge and the right approach |
Varley, 2020 [55] US | Exploring quality of primary care for patients who experience homelessness and the clinicians who service them: what are their aspirations? | To develop and evaluate an effective model of patient-centred, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients | PEH N = 36 VA and non-VA clinics Health Care for the Homeless Programs | Primary Healthcare | Semi-structured interviews (in person and over the phone) | Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction |
Warren, 2021 [56], UK | Developing an Embedded Nursing Service within a Homeless Shelter: Client’s Perspectives | To illuminate the diversity and complexity of healthcare needs of homeless people, as well as offers a unique insight into the service user’s perception of the service | PEH N = 6 An embedded nursing service within the homeless shelter | An embedded nursing service within the homeless shelter Primary Healthcare | Semi-structured interviews | Three broad themes were identified in this study; (1): impact of previous healthcare experiences; (2) benefits of embedding healthcare within the shelter and; (3) future service development. Experiences of discrimination, stigma and social exclusion impact how people experiencing homelessness view and access health services and how they perceive the nurse-led clinic within the homeless shelter they use. Narratives of those who use it give testament to the value of embedding nurse-led services within homeless support |
Whitley, 2013 [57], US | Fear and loathing in New England: examining the health-care perspectives of homeless people in rural areas | To elicit health-care beliefs, and examine overall health experience among a sample of current or recently homeless people in rural New Hampshire | PEH N = 13 Tri-County Community Action Programs | No specific health service exposure | Interviews | Despite a massive burden of disease and illness, many participants reported a strong and abiding aversion to doctors, hospitals and professional health care In contrast to this dislike of professional medical care, participants spoke more fondly of other organisations that provided social services, for example churches and homeless organisations. Three main themes discussed were: Aversion to professional health care, favourable attitudes to social and voluntary supports and popular health care: self-care and self-help |
Wise, 2013 [58] US | Hearing the Silent Voices: Narratives of Health Care and Homelessness | To gain understanding about the homeless person’s experience of health care | PEH N = 11 Homeless ministry in Knoxville | No specific health service exposure | Interviews | The four polar themes that emerged from the analysis—same/different, fair/unfair, freedom/barriers, and choice/no choice—highlighted the great divide between the health care experiences of those with a home and those without. All participants made it clear that their experience in the healthcare system could be understood only when their world was understood |