How can health care systems effectively deal with the major health care needs of homeless people?

Summary

The issue

Homeless people have poorer physical and mental health than the general population, and often have problems obtaining suitable health care. This synthesis has critically reviewed the international literature pertaining to the health care needs of homeless people in countries with relatively well-developed health care systems. It does not deal with the causes and prevention of homelessness, but focuses on the evidence of effective treatment for the types of ill health from which homeless people often suffer.

Findings

Homeless people constitute a heterogeneous population characterized by multiple morbidity (primarily alcohol and drug dependence, and mental disorders) and premature mortality. The problems need to be addressed by many measures, requiring a focused primary health care system and multiagency cooperation.

There is evidence that behavioural interventions for mental health problems, drug and alcohol dependence, and sexual risk behaviour can empower homeless people, and lead to lasting health gain, as well as helping in treatment retention. Effective interventions for drug dependence include pharmaceutical treatment, hepatitis B vaccination, advice about safe injection and access to needle exchange programmes. There is an emerging evidence base for the effectiveness of supervised injecting rooms for homeless intravenous drug users and for the peer distribution of naloxone in reducing drug-related deaths. Early evaluation of medically supervised injecting centres (MSICs) would suggest they have the capacity to reduce the incidence of drug-related deaths, stop the increase in reported hepatitis B and C infections, reduce the risks involved in injecting, increase the likelihood of starting treatment for drug dependence, reduce public sitings of discarded syringes, and do not increase theft and robbery.

Policy considerations

Access to primary health care is a pre-requisite for effective treatment of health problems among homeless people. This will require addressing barriers to provision such as lack of health insurance. Cultural barriers due to stigma or lack of knowledge among health service staff can be addressed by relevant training activity. Barriers to effective multiagency cooperation need to be addressed in order for homeless people get access to medical and behavioural interventions, re-housing and financial support.