The health concerns of people experiencing homelessness are aggravated, or possibly caused, by the fact that many encounter barriers to accessing formalized health care services beyond emergency rooms. Statistics demonstrate the lack of formalized care that homeless persons receive. A study in Germany found that 90% of homeless people are “urgently in need of medical treatment (Trabert, 1997, p. 378). In a large American study (Burt et al., 1999) it was found that of the sample of homeless persons involved, 24% required treatment from a physician but were unable to obtain this treatment. Similarly, in a French survey of 838 homeless persons (Kovess & Mangin Lazarus, 1999), only 53% of those who were experiencing an active psychiatric condition were accessing formal care.
The barriers to care are many, and vary with the local context, but generally include social isolation. Social isolation is both a causal factor and an outcome of experiencing homelessness. In a phenomenological study of the experiences of homeless men, Lafuente (2003) found that homeless men are socially isolated in that they experience rejection both from within (i.e. rejection of one’s self) and from others. This social isolation, and the level of social isolation, is predictive of not receiving regular formalized health care (Gallagher, Andersen, Koegel & Gelberg, 1997). The mechanisms that link social isolation to a lack of accessing regular care include the development of a mistrust of health professionals and an unwillingness to disclose personal information. Additionally, by being isolated from society, people who are experiencing homelessness will have a decreased knowledge of the available services and the means of accessing these services.
Competing demands or priorities, also referred to in psychology as the hierarchy of needs, may prevent homeless persons from taking the time to access formalized health care services. Kushel, Gupta, Gee and Haas (2006) found that housing instability, taken as a proxy for competing demands, was associated with having no usual source of formalized health care. This finding is identical to previous work that measured ‘competing demands’ directly as an independent variable (Gallagher, Andersen, Koegel & Gelberg, 1997). Homelessness is a chaotic experience in which individuals struggle to meet their basic needs. Homeless persons need to simultaneously find food, shelter, and clothing, attend appointments, obtain transportation, obtain or maintain an income, and attend to their acute health care needs. If one’s time is consumed simply trying to survive, dealing with health concerns may be seen as a luxury and not attended to until they become completely unmanageable and threaten this ability to survive. Additionally, the length of time required to receive health care services compounds the issue of competing demands, and links directly to the third issue of prohibitive bureaucratic structures.
For homeless Canadians, a major barrier is the lack of personal identification, including the lack of a health card. Within the turbulent existence of a homeless person, identification is frequently lost or stolen, and is difficult to replace due to complicated procedures, the requirement of having other identification to replace missing identification, and fees charged for replacement. Another barrier is the accessibility of health centres that specifically serve homeless persons, such as community health centres or shelter-based health centres, as they are often only open during business hours. Additionally, these centres often have complicated intake procedures to ensure that people are not receiving care from more than one physician. These intake procedures may be too complicated or too prohibitive for people who are living a chaotic life, dealing with mental illness, or dealing with addictions. For example, these intake processes may involve multiple scheduled visits, with a population for whom keeping scheduled appointments may be difficult. Lastly, there is often a cost involved in transferring health records from previous sources of care to the current physician, a process that is often a mandatory step before care is available.
In addition to these other barriers, homeless persons frequently experience negative attitudes from health care providers. These negative attitudes have been identified as the primary barrier that homeless persons face in obtaining health care services (Ensign & Panke, 2002). Negative attitudes do not go unnoticed, with one Canadian study showing that 40% of homeless persons felt they had received less-than-ideal care, and 1/3 had been treated rudely when using emergency rooms (Crowe & Hardill, 1993). Studies have shown time and again that homeless persons face disrespect, stigma, prejudice, dehumanization, judgmentalism, being ignored, and insensitivity from health care professionals.