Date of Award

January 2024

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Benjamin Howell

Second Advisor

Alana Rosenberg

Abstract

Objectives: People with lived experiences of homelessness encounter barriers to accessing and maintaining appropriate healthcare. This project aims to: 1) identify how these barriers manifest in New Haven, CT; 2) examine the negative health and healthcare impacts such barriers may incur, including when people adapt to or try to overcome them; 3) examine the characteristics of positive experiences in accessing healthcare in order to inform future approaches to healthcare for this vulnerable population.

Methods: This study is a subanalysis of the Justice, Health, and Housing Study (JustHouHS) and draws on longitudinal, qualitative interviews with low-income New Haven residents who experienced homelessness (N=36) at any point during the study. Parts of interviews that discussed healthcare were coded using an open-coding technique until themes could be identified and analyzed.

Results: Our participants described a healthcare system with many barriers to accessing and maintaining care, as well as a lack of effective help in navigating them despite the need. They described having limited agency as well as assumptive, uncaring, and impersonal experiences that led to harm, mistrust, and a lack of engagement. This was most pronounced in regard to substance use, which disproportionately impacts this population. Prioritizing healthcare often came at the cost of other basic needs and vice versa, and economic precarity had a notable impact on healthcare engagement. Participants adapted or coped with healthcare barriers through available, creative,deceptive, or desperate ways. Finally, the study elicits how resources and providers that encourage, empower, meet them where they are, and step “outside” or go beyond the expectations of current systems positively impact their health and engagement with healthcare.

Conclusions: This study supports the idea that until the many barriers to accessing and maintaining care for unhoused populations are dismantled, healthcare systems and related resources have a responsibility for providing proactive, sufficient, and effective help in navigating them. Also, healthcare providers should consider how current approaches to care may have negative impacts specific to their unhoused patients, and make concerted efforts to listen, empathize, and understand their needs, being prepared to go above and beyond to provide equitable care. This can create environments of trust and support, which is especially important in addressing substance use and its disproportionate impact on our participants and this population. The study also argues for healthcare systems that are more flexible, forgiving, and which attempt to meet patients who are unhoused where they are, both literally and figuratively. It also supports the idea that basic needs, like housing, and social safety nets should be viewed as critical elements of one’s health and healthcare, not merely adjacent factors, and should be redundantly addressed. Finally, it highlights the importance many in this population place on their health, emphasizing the potential for healthcare engagement should the system improve its ability to embrace them.

Comments

This is an Open Access Thesis.

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