The Meaning of Homeless Women's Healthcare Experiences in Community-Based Settings: A Qualitative Systematic Review

Introduction: Homeless women are a growing portion of the overall homeless population with complicated health needs. Multifactorial issues related to societal stigma, economic burden, gaps in current policy, and medical complexity only exacerbate health care challenges in this population. Barriers exist outside the realm of health care that play a large role in homeless women accessing care even when it is available to them. Various interviews with homeless women have uncovered perspectives that speak to current social stigmas surrounding being homeless. Of note, even among health care professionals, homeless women have felt stigmatized for being homeless, have reportedly been treated disrespectfully, and have felt ignored by health care providers. The ability to shed light on what is meaningful to homeless women in their health care experiences along with barriers that impede their access to health services can guide healthcare providers in ways to improve access to and use of effective and impactful care for this vulnerable population.

Objective: This qualitative systematic review aimed to establish the best available evidence on the experiences of homeless women when accessing community-based health care services.

Inclusion criteria: This review included studies on homeless women, both previously or currently, aged 18 or older. The phenomena of interest were the meaning of homeless women’s health care experiences, including perspectives, narratives, and/or reflections, at any time during their period of homelessness. The review included health care services received by homeless women in community-based settings, shelter-based clinics, and/or mobile clinics. Qualitative data including, but not limited to, designs of phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research were considered.

Search strategy: A three-step search strategy was utilized to find both published and unpublished studies in the English language. Databases searched included Campbell Collaboration, CINAHL Complete, Cochrane Database of Systematic Reviews, EMBASE, Family and Society Studies Worldwide, Google Scholar, Joanna Briggs Institute, JSTOR, MEDLINE with full text, OpenGrey, ProQuest Dissertations and Theses, PsycArticles, PsychEXTRA, SCOPUS, Social Sciences Full text, Virginia Henderson Global Nursing e-Repository, and Web of Science. Two reviewers independently appraised the 24 included studies using the Joanna Briggs Institute (JBI) critical appraisal checklist for qualitative research. The studies were of moderate to high quality, mostly falling short in quality due to lack of informed consent or ethics approval from an appropriate professional body and a lack of statements mentioning the researchers and their influence on the research. Data were extracted from included papers using the standardized JBI data extraction tool.

Data synthesis: Two reviewers independently reviewed and pooled similar findings into categories. The two reviewers then collaborated in finalizing these derived categories to generate a meta-synthesis.

Results: Three synthesized findings were generated during the meta-synthesis: (1) Homeless women who access health care services at community-based settings feel as if their homelessness qualifies them as second-class citizens which impedes future access; (2) Homeless women have an expectation of therapeutic communication from their health care providers that, if lacking, can incite negative emotional responses, fear, and knowledge deficits; (3) Homeless women struggle to prioritize competing needs with limited resources such as transportation, time, and money, which influences their ability to access health care.

Conclusion: Overall, homeless women’s experiences with health care providers are poor and have negatively affected their desire to access health care in the future. The lack of compassion reported from health care providers questions the role of cultural competence and provider bias in the delivery of health care to homeless women. The women’s reflections on positive interactions with health care providers included therapeutic communication with active listening by the provider along with consideration of the unique life challenges these women face and how this may affect their ability to access the care required. Cultural competence and bias needs to be addressed in all health care provider curriculum specific to vulnerable populations such as homeless women. Clinical experiences providing direct care for these women can shed light on the type of advocacy needed to ensure equitable access to health care services.