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This submitted article is based on partial data from the Health and Use of Health Care Services by Shelters Users research, taking advantage of the sequential synergy of qualitative and quantitative research strategies. The quantitative research involved 192 respondents, while the qualitative research involved 30 communication partners. The article aims at finding out the relationship between selected health characteristics of the shelter population and their impact on the use of health care services. The article presents data from the quantitative research that are further illustrated by qualitative data. The data were analysed using descriptive statistical methods, a Fisher's exact test, a Wilcoxon test and a Proportion Matching Test. The relationship between mental health and use of health care services (especially in the case of women) has been proven. Homeless people who do not use any health care services are, on average, for a longer period in temporary housing; whereas those who rated their health as more serious used health care services more frequently. In the conclusion, the authors present the implications for social work that resulted from the survey.

ABSTRAKT

Předložený článek je založen na dílčích údajích z oblasti zdravotní péče a využívání služeb zdravotní péče obyvateli azylových domů, s využitím sekvenční synergie kvalitativních a kvantitativních výzkumných strategií. Kvantitativní výzkum zahrnoval 192 respondentů, zatímco kvalitativní výzkum zahrnoval 30 komunikačních partnerů. Cílem článku je zjistit vztah mezi vybranými zdravotními charakteristikami populace z azylových domů a jejich dopadem na využívání zdravotnických služeb. Článek představuje údaje z kvantitativního výzkumu, který je ilustrován kvalitativními údaji. Data byla analyzována pomocí popisných statistických metod, Fisherova exaktního testu, Wilcoxonova testu a testu shody proporc. Vztah mezi duševním zdravím a využíváním služeb zdravotní péče (zejména u žen) byl prokázán. Bezdomovci, kteří nevyužívají žádné zdravotnické služby, jsou v prozatímním ubytování v průměru déle; zatímco ti, kteří považovali své zdraví za důležitější, využívali služby zdravotní péče častěji. V závěru autoři prezentují možné dopady na sociální práci, které vyplynuly z výzkumu.

KEYWORDS:

· Health

· health care services

· shelter users

· homelessness

· social work

KlÍČOVÁ SLOVA:

· Zdraví

· služby zdravotní péče

· obyvatelé azylových domů

· bezdomovectví

· sociální práce

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Introduction

Homelessness is an extreme form of poverty and a highly topical problem experienced worldwide. From foreign (and also Czech) studies, we know that the health status of homeless people living in shelters is very often worse both at a psychological and physical level than that of the majority population (e.g. Brem & Seeberger, 2010 ; Fitzpatrick-Lewis et al., 2011 ) and health problems tend to deepen with increasing age (e.g. Barták, 2011 ; Frey, 2013 ). A number of studies also describe the co-morbidity of individual diseases in this target group (see, for example, Brem & Seeberger, 2010 ). A number of research surveys, e.g. Baggett, O'Connell, Singer, and Rigotti ( 2010 ), suggest that homeless people do not often use health care services even if they experience acute health problems. This paper aims at identifying the relationship between the selected (health) characteristics of shelter residents and their impact on their use of health care services. To achieve its objective, the paper delivers: (a) the categorisation and systematisation of findings from foreign research on barriers to access to health care for homeless people; (b) verification of hypotheses based on the results of foreign research; and (c) illustration and deepening of knowledge from the quantitative research through data obtained from the qualitative research.

Theoretical foundation

The theoretical foundation of the submitted article rests on two principal axes: the health status of the homeless shelter 1 residents and the use of health care services by this population.

Health status of the homeless shelter population

Fitzpatrick-Lewis et al. ( 2011 ) surveyed the health status of 1,192 residents of shelters, hostels and night shelters. 85% of the persons stayed in chronically poor health conditions, and almost 50% had been diagnosed with some medical or mental condition. Beijer, Wolf, and Fazel ( 2012 ) focused on the incidence of tuberculosis, C-type jaundice and HIV in homeless people using night shelters and regular shelters by analysing data from 43 published surveys (59,736 homeless people). Prevalence of tuberculosis ranged from 0.2% to 7.7%, for C-type jaundice from 3.9 to 36.2% and for HIV from 0.3 to 21.1%. Folsom et al. ( 2002 ) note the incidence of diabetes, arthritis, and hypertension.

Folsom et al. ( 2002 ) talk about the high incidence of psychiatric diagnoses, namely depression and schizophrenia, in homeless people living in shelters. These two diagnoses were up to four times more prevalent amongst the shelter population compared with the majority population. The so-called SEEWOLF-Study 2 (Bäuml, Brönner, Baur, Pitschel-Walz, & Janh, 2017 ) emphasises a higher risk of depression, schizophrenia or anxiety disorders in the homeless population. A total of 232 randomly selected individuals took part in the study, out of whom 80% were men and 20% were women. The results of the study showed that approximately two thirds of the surveyed individuals suffered from a mental illness, but usually from multiple illnesses at a time.

The use of health care services by shelter residents

In individual surveys, a number of barriers related to the use of health care services by homeless people were pointed out. The first range of these barriers was a poor mental state. Gelberg, Andersen, and Leake ( 2000 ) mention three areas of barriers to the use of health care services by homeless people, namely the long-term situation of homelessness, mental problems and substance abuse. The positive impact on use of health care services occurred when an individual had positive experience with a GP and therefore held the perception of a GP as a regular source of care and support. The authors emphasise that the availability of health care services was not as important to people in shelters as their quality. Salize et al. ( 2001 ) also point to the barrier of visiting a physician when one's issue is related to a mental illness. The researchers carried out the research with 102 probands suffering from some kind of a mental illness. Most of them identified a visit of health care services as problematic and did not use it.

The second important factor influencing the use of health care services was the existence of social support. For example, the research by Hwang et al. ( 2009 ) (carried out on 544 respondents) demonstrates the relationship between social support and the scope of a social network with better mental and physical health; the research by McCormack and MacIntosh ( 2001 ), based on the experience of 11 homeless people living in shelters, established an anchored theory of strategies that the homeless people use to acquire, maintain and restore health. The model points to three paths leading to health. Such paths are socially influenced, directly by the family and its beliefs, and indirectly by values and beliefs in a particular society. Similarly, for example, Constantino, Yookyung, and Crane ( 2005 ) emphasise the importance of a social support network, in particular accompaniment to health care services. The women who had an accompaniment and a self-help group available to them demonstrated a reduced emotional distress and an increased use of health care services.

The third identified factor that had an impact on the use of health care services was the duration of stay in a temporary accommodation. Baggett et al. ( 2010 ) conducted a study of 966 homeless people who were long-term users of night shelters and shelters. 73% of the respondents pointed out that they were a subject to unmet health care needs, including the inability to receive medical or nursing care (32%), difficulty in receiving prescribed medication (36%), problematic access to mental health treatment (21%), problematic access to eyewear (41%) as well as a problematic access to dental care (41%). A long-term life away from ‘home’ was identified as a significant predictor of unmet needs; other factors included insufficient nutrition, poor sight, and the absence of health insurance.

The fourth factor influencing the use of health care services is the severity of physical problems. Compared with the above-mentioned factors, this factor has a consolidating impact on the use of health care services. For example, Gelberg et al. ( 2000 ) tried to find out in their study the factors predicting the use of health care services by homeless people living in shelters. They emphasise that there is a high percentage of homeless people with high blood pressure (as much as 81%) and with a positive tuberculosis test (78%) who use health care services. On the contrary, the use of health care services is relatively low in people with visual impairment (33%), skin diseases or walking difficulties (44%) (see also Hwang et al., 2009 ; Beijer et al., 2012 ).

The fifth factor having an effect on the use of health care services is the perceived quality of health care services. In relation to this topic, Martins ( 2008 ) carried out a study aimed at understanding the experience of homeless shelter users with medical services. The method used was qualitative research based on in-depth interviews with 15 shelter residents. Barriers to access to health care have been identified during the research, including: condemnation, ‘labelling’ and stigmatisation, lack of systematic medical care for homeless people, feeling of ‘invisibility’ in relation to healthcare providers, lack of respect when providing treatment, and ultimately the creation of ‘underground movements’ in the area of provision of resources related to medical care.

Similarly, Lyon-Callo ( 2000 ) presents the results of his three-year ethnographic study from a homeless shelter and describes the barriers this group had when trying to access health care services. The first barrier is the concept of homelessness presented by mass media, which is reflected in the view of homeless people in health care services. The prevailing view is that homeless people are to blame for their situation. In addition, Laberge ( 2000 ) points out the barrier of homeless people’s access to health care services in the form of symbolic exclusion. Homeless people, as a result of the symbolic exclusion, can be perceived as being guilty of their own medical situation, as people who are dirty, as those the doctors are squeamish about treating. These perceived attitudes of physicians trigger reluctance to seek health care services and feelings of shame in homeless people.

Methodology of the research

The paper objective has been achieved through the presentation of partial data of a research survey focused on the health of the population of homeless shelters and the use of health services, which took place in 2018. The research used the sequential synergy of qualitative and quantitative research strategies. The aim of the research was to identify the key factors that, according to different shelter user categories, affect their health and to determine the impact of these factors on the residents’ health and their use of health care services. The qualitative research was comprised of 30 semi-structured interviews with shelter residents (17 women and 13 men), which were then analysed using Grounded Theory by K. Charmaz. The quantitative research was comprised of a questionnaire used with 192 respondents.

The paper is based on outputs from the quantitative part of the research; the data from the qualitative part is used to illustrate and elaborate the interpretation of the quantitative data in more detail. The hypotheses for the quantitative research were determined on the basis of the study of professional literature (see The Theoretical Foundation section) and on the basis of a qualitative investigation, which preceded the quantitative research, and within which we examined the themes and relationships between individual variables in the respondents’ narrations that we decided to verify in the hypotheses.

H1: There is a relationship between mental health and the use of health care services.

For operationalisation purposes, we defined mental health as health self-assessed on a four-point scale and the use of health care services as the frequency of use over a 6-month period.

H2: There is a relationship between the existence of social support, one's health condition and the use of health care services.

For operationalisation purposes, we defined the existence of social contacts (family, roommates (or housemates), friends, shelter staff) perceived by a person from a shelter in relation to going to see doctors as being supportive. The health status was again self-assessed on a four-point scale, and the use of health care services was defined as the frequency of use over a 6-month period.

H3: There is a relationship between the duration of a person’s stay in temporary accommodation and the use of health care services.

The duration of stay in temporary accommodation was operationalised as the total duration of the stay in a shelter, hostel and on the street. The use of health care services was defined as the frequency of use over a 6-month period.

H4: There is a relationship between the severity of physical problems and the use of health care services.

The severity of physical problems was self-assessed on a four-point scale and the use of health care services was again defined as the frequency of use over a 6-month period.

H5: There is a relationship between the quality of health care services and their use.

The quality of health care services was operationalised as an assessment of perceived physicians’ attitude to homeless people on a four-point scale. The use of health care services was defined as the frequency of use over a 6-month period.

The respondents were selected on the basis of a quota sampling. The quota was set at 5% of the population of homeless people living in shelters in the Czech Republic. According to the Statistical Yearbook in the area of labour and social affairs (MoLSA, 2016 ), in 2015, 3,659 clients over 18 years old used shelters. Our research survey involved 192 individuals (i.e. 5.2% of the population) from 7 different regions (that is territorial-administrative units in the Czech Republic) out of a total of 14. The regions included in the survey were drawn; the respondents involved were selected using a purposeful sampling through an institution (a particular homeless shelter). 55% ( n = 106) of the respondents were women. The average age of the respondents was 44 years and each respondent had an average of 2 children (who did not necessarily have to live in the shelter with them). 64% ( n = 123) of the respondents were not employed, 17% (n = 33) reported that they had jobs (and the rest of the respondents did not answer the question). 55% ( n = 106) of respondents said they had experienced ‘serious’ injuries or surgeries, 43% ( n = 83) of respondents said they should be on medication but only 36% ( n = 69) of them regularly took it. 33% ( n = 63) of the respondents said they had the experience of drug addiction. The average length of the respondents’ stay on the street was 8.5 months; the average length of the respondents’ stay in the hostel was 12.6 months and the average length of their stay in the shelter was 16 months. 57% ( n = 109) of the respondents were living in the homeless shelter for the first time, and 38% ( n = 73) of the respondents repeatedly stayed in such a facility.

The data were obtained using a self-designed questionnaire, which consisted of 25 mostly scale-based questions. 3 The questions in the questionnaire were thematically inspired by findings from the qualitative research. The design of the questions was peer reviewed and piloted with two homeless people who lived in a shelter at the time. The questionnaire’s limitation in relation to the research results is that it is not a standardised questionnaire, which may negatively affect its reliability as a research tool. The method of assisted administration of the questionnaire was used to fill out the questionnaire. A social worker and/or a researcher assisted with the completion of the questionnaires. If a social worker acted as an administrative assistant, he/she was trained beforehand regarding the meanings of individual questions and the data anonymization (the questionnaires were collected and put in an envelope which was immediately sealed after the data collection). The reason for these measures was to make sure that the data would be influenced as little as possible by the presence of a social worker in the research. Within the possible limits of the data obtained, it may be necessary to reflect on the fact that the data originated on the basis of the self-assessment of communication partners who could misunderstand a question, not respond to it, or try to make a better impression within a certain social desirability. Another limitation of the research is that despite the fact that we randomised the respondents by choosing regions involved in the research, the sampling of respondents was purposeful, that is, non-random, which could have negatively affected the data validity. The limitation in relation to the research results is the fact that as part of the data processing, we clustered the data that could have affected the results.

The data was analysed using descriptive statistical methods, the Fisher's exact test (Agresti, 1990 ), the Wilcoxon test (Bauer, 1972 ), and the Newcombe’s Proportion Matching Test ( 1998 ).

The entire research has conformed to the Ethical Principles in Human Research adopted by the American Psychological Association (APA, 2010 ). Each communication partner and respondent was asked to sign an informed consent in both stages of the research (that is within the qualitative and quantitative stages). The informed consent provided the research participants with all the necessary research essentials: research objectives, further data handling, data anonymization 4 , researchers’ discretion 5 , voluntary participation in research (the research participants had a possibility to withdraw from the research at any time as well as to refuse to answer any question). Taking into account the fact that the research target group can be considered a vulnerable human subject, we emphasised to keep a non-judging and respectful attitude to each of the respondents. Moreover, we also emphasised the necessity of their understanding of all information about the research, their rights (see above), and all asked questions. We also tried to create the environment of safety and trust and to provide the respondents enough time for their answers to the questions. (see Miovský, 2006 6 ).

Results

The following text presents the results relating to individual hypotheses. In relation to the research results, it is necessary to mention the acquired data and its interpretation cannot be generalised to the whole population of homeless people nor to the population of homeless people living in a shelter in the Czech Republic.

H1: There is a relationship between mental health and the use of health care services.

A total of 18% ( n = 35) of the respondents reported that their mental status was ‘very good’, 59% ( n = 113) of the respondents reported that it was ‘good’, 20% ( n = 38) of the respondents perceived it as being ‘poor’, and 3% ( n = 6) of the respondents thought that their mental state was ‘very poor.’ A total of 68% ( n = 131) of the respondents reported that they went to see a doctor regularly, 28% ( n = 54) of the respondents did not go to see a doctor at all, and 4% ( n = 7) of the respondents did not answer the question.

In the evaluation of the results, the exact Fisher’s test was used, which showed existing dependence between the above variables ( p-value = 0.0250). The dependence is statistically significant in women ( p-value = 0.0233). However, the significance was not confirmed in men ( p-value = 0.5854). As part of our further data processing, we ranked ‘very good-good’ as ‘good mental health’ and ‘poor-very poor’ as ‘poor mental health’ and then we compared them with each other. The results showed that people with bad psychological health are less likely to seek the help of any physician (the proportion is 65% ( n = 89) versus 88% ( n = 36), p-value = 0.0037). The difference between groups is even greater in the case of women only (65% ( n = 50) versus 91% ( n = 22), p-value = 0.0138). In the case of men, the significance was not confirmed ( p-value = 0.2203). The research findings can be also illustrated using the statements of the communication partners from the qualitative part of the research. ‘When I had the depression and such, I wouldn’t go to see a doctor at all’ (CP 8). ‘Well, those anxieties … they prevented me from going to the doctor’ (CP 6). ‘I had different worries back then … I mean those in my mind’ (CP 3).

H2: There is a relationship between the existence of social support, health status and the use of health care services.

As a result, 38% ( n = 73) of the respondents reported that someone was there to help them to access and use health care services; 60% ( n = 115) of the respondents stated that nobody helped them, and 2% ( n = 4) of the respondents did not respond to the question. The respondents reported that the greatest amount of assistance was received from their family members and from the social workers of the shelter where they live (41%, n = 79). A total of 14% ( n = 27) of the respondents thought that their overall health was ‘very good’, 65% ( n = 125) of the respondents were of the opinion that it was ‘good’, 18% ( n = 35) of the respondents thought it was ‘poor,’ and 3% ( n = 5) of the respondents believed that their overall health was ‘very poor’.

The Test of Equal Proportions was used to test the hypothesis. The users of shelters who are helped by social workers in 87% ( n = 26) of cases evaluate their health as ‘good’ or ‘very good.’ On the other hand, only 73% ( n = 24) of the users of shelters, who are helped by family members when in need of a visit to a physician, evaluate their health as ‘good’ or ‘very good.’ However, the difference in proportion is not significant ( p-value = 0.2919). Despite the fact that a statistically significant relationship has not been demonstrated, the results of the qualitative research illustrate that social support is perceived as an important factor in the use of health care services. ‘When it’s needed … I mean that they accompany you to the doctors, otherwise I wouldn’t go to that doctor on my own … if you need it, they will support you’ (CP 10). ‘I needed to be accompanied because I was completely weak and didn’t feel like going anywhere, so I needed accompaniment’ (CP 6).

H3: There is a relationship between the length of stay in temporary accommodation and the use of health care services.

The average length of stay on the street was 8.5 months for respondents, the average length of stay in a hostel was 12.6 months, and the average length of stay in a shelter was 16 months (to illustrate the data, 57% ( n = 109), of the respondents stayed in a shelter for the first time, and 38% ( n = 73) of the respondents stayed in a shelter repeatedly). The Wilcoxon rank sum test was used to compare the length of stay in temporary accommodation between different groups of respondents who said they were using (or not using) health care services. Differences in the length of stay in the street ( p-value = 0.2403), hostel ( p-value = 0.7608) or in the shelter ( p-value = 0.2134) did not prove to be statistically significant. For homeless people who do not use any health care services, a median length of stay in temporary housing was a total of 38 months and those who responded that they were using health care services had a median length of stay of 18.75 months in temporary housing. Therefore, the results at the threshold of statistical significance ( p-value = 0.0714) show that the length of stay in temporary housing is higher in people who do not use health care services. The above-mentioned result of the quantitative survey is illustrated by the statement of one of the communication partners in the qualitative part of the research:

I’ve been homeless for four years now … one has poor quality food because doesn’t have money … sometimes you sleep outdoors, with mould and bed bugs in a homeless shelter but the longer you live in such environment, the more you get used to it and the harder it is for you to go to the doctor. You are ashamed too … and plus, you have other worries, you worry where to sleep … trying to secure some certainty … just that health is secondary … (CP 17).

H4: There is a relationship between the severity of physical difficulties and the use of health care services.

14% ( n = 25) of the respondents stated that their physical condition was ‘very good,’ 63% ( n = 115) of the respondents reported that their physical condition was ‘good,’ 19% ( n = 34) of the respondents thought it was ‘poor,’ and 4% ( n = 8) of the respondents called their condition ‘very poor.’

To show the statistical significance of the relationship between the severity of physical difficulties and the use of health care services, the exact Fisher's test was used ( p-value = 0.0015). As part of our further data processing, we ranked a cluster of values ‘very good-good’ as ‘good physical health’ and ‘poor-very poor’ as ‘poor physical health’ and compared them with each other. The results show in only 63% ( n = 85) of cases that people with good physical health seek the help of a physician. People who evaluate their health as poor claim to seek medical help in 93% ( n = 39) of cases. The difference is huge and very statistically significant ( p-value = 0.0152). The results also show that men tend to seek help from physicians less frequently (the difference between the clusters of men and women is 56% ( n = 27) versus 90.9% ( n = 20)), but the difference is also significant in case of men ( p-value = 0.0058). The results of the quantitative survey are illustrated by the statements of the communication partners from the qualitative part of the research. They show that when a serious health problem arises, the doctor’s visit is necessary and sometimes is also a question of life and death: ‘When it’s serious, you just go to see a doctor. For example, I’ve had serious problems with my heart … you have no choice then … ’ (CP 22). ‘I had pneumonia … they thought I was gonna die, I had it in cold print that I was gonna die … it wasn’t about choosing anymore whether to go or not to go to see a doctor … ’ (CP 29).

H5: There is a relationship between the quality of health care services and their use.

The shelter users who have evaluated a physician's attitude to homeless people as good or rather good visit physicians in 75% ( n = 111) of cases, compared with 52% ( n = 12) of those who have evaluated a physician’s attitude as bad or rather bad. This difference is significant ( p-value = 0.04). Similarly, if we ask directly whether a physician's attitude affects their willingness to go and see a physician, then clients who claimed that the physician's attitude affected them positively actually go to doctors more often (in 79% cases, n = 27), and vice versa, clients who claimed that the physician’s attitude affected them negatively go to doctors in 63% cases ( n = 21). The difference is smaller than in the first comparison and is not statistically significant ( p-value = 0.49).

We examined the quality of health care services in each respondent group, namely the group of respondents that considered the distance to a doctor’s office to be an important factor of the doctor’s visit as well as the group of respondents that considered money the most important factor.

Given the implicit importance, that is, the connection between evaluation of health care services and attendance, the most important factor appears to be the physician’s attitude (the difference is 75% of attendance ( n = 111) vs. 52% of attendance ( n = 12)). If, on the contrary, we consider the explicit importance declared by clients, the most important factor is money (the difference is 90% of attendance ( n = 37) vs. 52% of attendance ( n = 14)).

Several communication partners in the qualitative part of the research described their negative experiences with physicians who showed an oppressive attitude toward the homeless.

Well, I’ll tell you that when I did everything, the doctors did their best to help me … now, some doctors … I’ll tell you directly when you’re at the rock bottom, collecting social benefits, some doctors behave horribly. You're just a waste of time for them, which is terrible. I have experienced it a few times. (CP 6).

Discussion of the research results and implications for social work

The research results show, also as part of the reflection of the research limitations presented in its methodology, that there is a relationship between mental health and the use of health care services. The results show that people with a bad mental state are less likely to use health care services. The implications for social work therefore include:

The use of social work methods with regard to the comorbidity of a disease with an emphasis on mental health

In homeless shelter practice, there is a need to purposefully and specifically develop methods of social work that promote mental health and fulfil the requirement for the need for the multidimensional support of homeless people. This need, according to Hwang, Kirst, et al. ( 2009 ), arises due to the complexity of the needs resulting from interdependence and multiplication of the problems of this target group, including health related problems. One of the methods that can address the complexity of the needs and the comorbidity of disease is case management. According to Walsch and Holton ( 2008 ), case management makes it possible to provide people with complex problems with services in a timely and appropriate manner.

In this context, it may be interesting to note that 60% of the respondents answered that nobody was there for them. In this context, it should be mentioned that a number of researches considered the existence of social support in the use of health care services as crucial (see, e.g. Constantino et al., 2005 ; Hwang et al., 2009 ). The implication for social work therefore includes:

The importance of social support and accompaniment in supporting the use of healthcare

Social support has proven to be an important factor supporting the use of health care services. The level of this support intended for shelter residents is rather low and needs to be systematically developed. Wright and Tompkins ( 2006 ) draw attention to the importance of peer accompaniment in the area of health care for homeless people. One of the successful practices is the activity of the Groundswell organisation in London, which set up the ‘Homeless Health Peer Advocacy.’ It is a programme focused on accompanying homeless people to health care facilities. The accompanying people are volunteers who have experience with homelessness themselves. The provided assistance helps overcome personal, systemic, and practical barriers to access to health care.

The results, therefore, show that homeless people who do not use health care services have spent, on average, a longer period of time in temporary accommodation (see also Baggett et al., 2010 ). The result corresponds with the results of the qualitative part of the research, where the communication partners themselves stated that after a certain period of homelessness health ceases to be a priority and is replaced by survival as the main priority. A long-term stay ‘on the street’ or in different forms of temporary housing was linked by communication partners to negative emotional distress aroused by insecurities about accommodation, fear of security and the necessity to provide basic life needs. The implication for social work therefore includes:

The need for rapid reintegration into housing

The need for housing stabilisation as a prerequisite for improving the health situation is also emphasised by research of the Housing First model, which according to Busch-Geertsema ( 2013 ) is based on the principle of normalisation of living conditions, individualisation of support and transition from support focused on a place to a more individualised support. The Housing First addresses what homeless people identify as their first priority, which is housing (Stefanic & Tsemberis, 2007 ). According to Fitzpatrick-Lewis, the provision of permanent housing leads to a reduction in substance abuse and to the increased use of health care services (see also Larimer et al., 2009 ) as well as to improvement of the quality of mental health (Smith, 2005 ). However, the data collected from the research also show that 64% of the respondents are unemployed. In this context, it seems necessary to direct the support provided under Housing First, not only on the area of health but also on the job acquisition that could subsequently be an important factor in maintaining housing after the programme’s end.

The results also show that there is a dependence between the severity of physical health problems and the use of health services (see also Beijer et al., 2012 ). Homeless people who rated their health as worse / more serious used health care services more often. In relation to the data from the qualitative research part, it would be worthwhile to discover which types of health care services are used by homeless people, given that communication partners in the qualitative research have reported that they were particularly emergency care services. Communication partners have also stated that they only used such services when their health problems became more urgent or more serious. It seems that the preventive use of health care services is rather lower in the case of shelter users (see Kushel, Perry, Bangsberg, Clark, & Moss, 2002 ). The preventive use of health care services is rather absent; therefore social work with shelter residents should focus on promoting health prevention.

The research participants perceived the seeking of medical help as a significant barrier and held an oppressive view of physicians when the physicians associated these individuals with a situation of homelessness; see also Martins ( 2008 ), Lyon-Callo ( 2000 ) a Laberge ( 2000 ). The implication for social work therefore includes:

Changes in the medicalisation meta-narrative of homelessness through anti-oppressive social work

The need for an anti-oppressive approach is related to the prevailing medicalisation meta-narrative of homelessness based on a socially shared view of homeless people as weak, lazy, handicapped, and prone to psychological and social problems (Swick, 2005 ), thus ignoring the multidimensional conditionality of homelessness.

The above stated is also related to another instrument of anti-oppressive social work, which is advocacy in the sense of defending the rights of recipients of social work. In the broader sense, it means the promotion of rights of whole disadvantaged groups when compared with the general public. In the narrower sense, it means the promotion of rights of specific people at different system levels (Dominelli, 2010 ). Through this instrument, the right to housing for homeless people, the right to a provision of intelligible information from the authorities, or the right to dignified and respectable treatment in health care facilities can be defended.

Conclusion

The article aims at finding out about the relationship between the selected (health) characteristics of the shelter residents and their impact on the use of health care services. Based on these research results, we have formulated implications for the practice of social work with homeless people. The methods of social work used in working with homeless people should respect the multidimensionality of the needs of this target group of clients, develop and support social support resources beyond the context of social services, strive for rapid reintegration into permanent housing, and mitigate oppressive mechanisms to which homeless people are exposed by society.

Acknowledgements

This research was partially supported by the NPU II Project LQ1602 ‘IT4Innovations excellence in science’ provided by the MŠMT of Czech Republic.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Kateřina Glumbíková is an assistant professor at the Faculty of Social Studies at the University of Ostrava. In her dissertation thesis she dealt with the topis of reintegration of single mothers living in shelters into permanent forms of living. Her research interest focuses on reflexivity in social work with families and relationship-based approach in social work with families.

Alice Gojová is an associate professor at the Faculty of Social Studies at the University of Ostrava. In teaching and research she is interested in the topic of community social work and social work with families.

Michal Burda is a junior researcher at the Institute for Research and Applications of Fuzzy Modeling, University of Ostrava, Czech Republic. He obtained his Ph.D. degree in computer science and applied mathematics from VSB-Technical University in Ostrava. His research interests focus on data mining, fuzzy logic in expert systems and statistics.

Pavel Rusnok received amasters degree from the Czech Technical University (CTU) in mathematical engineering in 2008. Now he is assistant researcher at Institute for Research and Applications of Fuzzy Modeling at Ostrava University, where he is finishing his PhD in applied mathematics. His research interests include fuzzy logic, statistics, data mining and machine learning.

Radka Poláková is an employee of the University of Ostrava. Her research is focused on algorithms for global optimisation (especially differential evolution) and started in 2008. She was also a member of Biostatistics centre on the university. She is placed on the second and third rank with an optimisation algorithm on the Black Box Optimization Competition organised as part of Genetic and Evolutionary Computation conference in 2016 and 2018, respectively. Her algorithm won a part for constrained problems of optimisation competition held on CEC2017 world congress in San Sebastian. Her h-index on Scopus equals to 8.

Additional information

Funding

This research was partially supported by the NPU II Project LQ1602 ‘IT4Innovations excellence in science’ provided by the Ministerstvo Školství, Mládeže a Tělovýchovy (MŠMT) of Czech Republic.

Notes

1 In the Czech Republic, a shelter is described in the Act No. 108/2006 on Social Services, Section 57 as follows: ‘Shelters provide temporary residential services to persons in an unfavourable social situation associated with a loss of housing.’ The law on social services for shelters lays down the following basic (mandatory) activities: ‘(a) the provision of food or assistance in catering, (b) accommodation, (c) assistance in the application of the rights, legitimate interests and in obtaining clarity in personal affairs.’ The law on social services (No. 108/ 2006 ) further provides that ‘the provision of social services in shelters shall be made by payment … ’ The stay in a shelter is limited, most often for a period of one year.

2 SEEWOLF-Studie (Seelische Erkrankungsrate in den Einrichtungen der Wohnungslosenhilfe im Großraum München).

3 The questions used ranged from yes/no questions, for example: Do you take medications prescribed to you by your doctor? through multiple-choice questions, for example: What are the health care facilities you visit? (select one or more options) Options: general practitioner, ophthalmologist, emergency room, dentist, gynaecologist, psychiatrist, dermatologist, pulmonary doctor, ear-nose-throat; other (please specify), to questions where the respondents were asked to choose the degree of their agreement on the scale, for example: How do you rate your physical health? Scale: Very good – Good – Bad – Very bad.

4 There was no mention of the name of the person or the shelter where the survey took place in the questionnaire. In the final research report, the data are presented only as data summarised for the target group as a whole; data related to individual respondents is not stated in any outputs. The data presented in this form does not help to identify a particular person. Recordings of the qualitative interviews have been transcribed and then deleted in a way that even the voice of the respondent has not been stored. Any data leading to identification of the communication partner, third party, or organisation has been anonymised.

5 The researchers informed the participants the acquired information would not be passed to a third party outside the research team (primarily to the shelter staff). They also stated that they have a reporting obligation in case the participant would report very serious facts, such as grievous body harm to a third person.

6 The author presents an overview of the Czech Republic norms and requirements for ethics approval.

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References

1. Act No. 108/2006 on Social Services. [Google Scholar]

2. Agresti, A. (1990). Categorical data analysis. New York: Wiley. [Google Scholar]

3. American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org.lopes.idm.oclc.org/ethics/code/ [Google Scholar]

4. Baggett, T. P., O'Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet health care needs of homeless adults: A national study. American Journal of Public Health, 100(7), 1326–1333. Retrieved from https://www-ncbi-nlm-nih-gov.lopes.idm.oclc.org/pmc/articles/PMC2882397/ doi: 10.2105/AJPH.2009.180109 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

5. Barták, M. (2011). Bezdomovství v ČR: Zdravotní stav bezdomovců a jeho determinanty [Homelessness in the Czech Republic: Health status of homeless people and its determinants]. Ústí nad Labem: University of J. E. Purkyně in Ústí nad Labem. [Google Scholar]

6. Bauer, D. F. (1972). Constructing confidence sets using rank statistics. Journal of the American Statistical Association, 67, 687–690. doi: 10.1080/01621459.1972.10481279 [Taylor & Francis Online] , [Web of Science ®] , [Google Scholar]

7. Bäuml, J., Brönner, M., Baur, B., Pitschel-Walz, G., & Janh, T. (2017). Die SEEWOLF-Studie. Seelische Erkrankungsrate in den Einrichtungen der Wohnungslosenhilfe im Großraum München [SEEWOLF-Study. Mental illness rate in the institutions of the homeless assistance in the metropolitan area of Munich]. Freiburg: Lambertus. [Google Scholar]

8. Beijer, U., Wolf, A., & Fazel, S. (2012). Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: A systematic review and meta-analysis. The Lancet Infectious Diseases, 12(11), 859–870. Retrieved from http://www.sciencedirect.com.lopes.idm.oclc.org/science/article/pii/S1473309912701779 doi: 10.1016/S1473-3099(12)70177-9 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

9. Brem, D., & Seeberger, B. (2010). Alt und wohnungslos in Bayern – eine Untersuchung über Lebenslagen von älteren wohnungslosen Männern in betreuten Wohnforme [Old and homeless in Bavaria - an investigation on life situations of elderly homeless men in assisted living forms of housing]. Sozialer Fortschritt, 8(10), 209–219. doi: 10.3790/sfo.59.8.209 [Crossref] , [Google Scholar]

10. Busch-Geertsema, V. (2013). Housing First Europe: Final report. Bremen/Brussels: Housing First Europe. Retrieved from http://www.servicestyrelsen.dk/housingfirsteurope [Google Scholar]

11. Constantino, R., Yookyung, K., & Crane, P. A. (2005). Effect of a social support intervention on health outcomes in residents of a domestic violence shelter: A pilot study. Issues in Mental Health Nursing, 26(6), 575–590. Retrieved from http://www-tandfonline-com.lopes.idm.oclc.org/doi/abs/10.1080/01612840590959416 [Taylor & Francis Online] , [Google Scholar]

12. Dominelli, L. (2010). Social work in a globalizing word. Cambrigde, Malden: Polity Press. [Google Scholar]

13. Fitzpatrick-Lewis, D., Ganann, R., Krishnaratne, S., Ciliska, D., Kouyoumdjian, F., & Hwang, S. W. (2011). Effectiveness of interventions to improve the health and housing status of homeless people: A rapid systematic review. BMC Public Health, 11, 638. doi: 10.1186/1471-2458-11-638 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

14. Folsom, D. P., McCahill, M., Bartels, S. J., Lindamer, L. A., Ganiats, T. G., & Jeste, D. V. (2002). Medical comorbidity and receipt of medical care by older homeless people with schizophrenia or depression. Psychiatric Services, 53(11), 1456–1460. Retrieved from http://ps.psychiatryonline.org/doi/abs/10.1176/appi.ps.53.11.1456 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

15. Frey, R. (2013). Hilfen bei vorgealterten und älteren wohnungslosen Menschen [Help by older homeless people]. Sozialer Fortschritt, 62(13), 109–114. doi: 10.3790/sfo.62.4.109 [Crossref] , [Google Scholar]

16. Gelberg, L., Andersen, R. M., & Leake, B. D. (2000). The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people. Health Services Research, 34(6), 1273–1302. Retrieved from https://www-ncbi-nlm-nih-gov.lopes.idm.oclc.org/pmc/articles/PMC1089079/ [PubMed] , [Web of Science ®] , [Google Scholar]

17. Hwang, S. W., Kirst, M. J., Chiu, S., Tolomiczenko, G., Kiss, A., Cowan, L., & Levinson, W. (2009). Multidimensional social support and the health of homeless individuals. Journal of Urban Health, 86(5), 791–803. Retrieved from http://link.springer.com.lopes.idm.oclc.org/article/10.1007/s11524-009-9388-x [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

18. Kushel, M. B., Perry, S., Bangsberg, D., Clark, R., & Moss, A. R. (2002). Emergency department use among the homeless and marginally housed: Results from a communitybased study. American Journal of Public Health, 92(5), 778–784. doi: 10.2105/AJPH.92.5.778 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

19. Laberge, D. (2000). L'errance urbaine [Urban wandering]. Sainte-Foy, Québec: Éditions MultiMondes. [Google Scholar]

20. Larimer, M. E., Malone, D. K., Garner, M. D., Atkins, D. C., Burlingham, B., Lonczak, H. S., … Marlatt, G. A. (2009). Health care and public service use and costs before and after provision of housing for chronically homeless people with severe alcohol problems. JAMA, 301(13), 1349–1357. doi: 10.1001/jama.2009.414 . http://onlinelibrary.wiley.com.lopes.idm.oclc.org/doi/10.1111/j.17544505.2006.tb01716.x/abstract [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

21. Lyon-Callo, V. (2000). Medicalizing homelessness: The Production of self-blame and self-governing within homeless shelters. Medical Anthropology Quarterly, 14(3), 328–345. Retrieved from http://onlinelibrary.wiley.com.lopes.idm.oclc.org/doi/10.1525/maq.2000.14.3.328/full doi: 10.1525/maq.2000.14.3.328 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

22. Martins, D. C. (2008). Experiences of homeless people in the health care delivery system: A descriptive phenomenological study. Public Health Nursing, 25(5), 420–430. Retrieved from http://onlinelibrary.wiley.com.lopes.idm.oclc.org/wol1/doi/10.1111/j.1525-1446.2008.00726.x/full doi: 10.1111/j.1525-1446.2008.00726.x [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

23. McCormack, D., & MacIntosh, J. (2001). Research with homeless people uncovers a model of health. Western Journal of Nursing Research, 23(7), 679–697. Retrieved from http://wjn.sagepub.com.lopes.idm.oclc.org/content/23/7/679.short doi: 10.1177/019394590102300704 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

24. Miovský, M. (2006). Kvalitativní přístup a metody v psychologickém výzkumu [Qualitative approach and methods in psychological research]. Grada: Praha. [Google Scholar]

25. MoLSA. (2016). Statistic yearbook from the area of work and social affairs. Retrieved from: https://www.mpsv.cz/cs/3869 [Crossref] , [Google Scholar]

26. Newcombe, R. G. (1998). Interval estimation for the difference between independent proportions: Comparison of eleven methods. Statistics in Medicine, 17, 873–890. doi: 10.1002/(SICI)1097-0258(19980430)17:8<873::AID-SIM779>3.0.CO;2-I [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

27. Salize, H. J., Horst, A., Dillmann-Lange, C., Killmann, U., Stern, G., Wolf, I., … Rössler, W. (2001). Needs for mental health care and service provision in single homeless people. Social Psychiatry and Psychiatric Epidemiology, 36(4), 207–216. Retrieved from http://link.springer.com.lopes.idm.oclc.org/article/10.1007/s001270170065 [Crossref] , [PubMed] , [Web of Science ®] , [Google Scholar]

28. Smith, J. (2005). Housing, homelessness, and mental health in Great Britain. International Journal of Mental Health, 34(2), 22–46. Retrieved from http://www.jstor.org.lopes.idm.oclc.org/stable/41345127 doi: 10.1080/00207411.2005.11043399 [Taylor & Francis Online] , [Google Scholar]

29. Stefanic, A., & Tsemberis, S. (2007). Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. The Journal of Primary Prevention, 28(3), 265–279. doi: 10.1007/s10935-007-0093-9 [Crossref] , [PubMed] , [Google Scholar]

30. Swick, K. (2005). Helping homeless families overcome barriers to successful functioning. Early Childhood Education Journal, 33(3), 195–200. doi: 10.1007/s10643-005-0044-0 [Crossref] , [Google Scholar]

31. Walsch, J., & Holton, V. (2008). Case management. In K. M. Sowers, & C. N. Dulmus (Eds.), Comprehensive handbook of social work and social welfare: Social work practice, Volume 3 (pp. 139–160). New Jersey: JohnWiley et Sons. [Crossref] , [Google Scholar]

32. Wright, N., & Tompkins, C. (2006). How can health services effectively meet the health needs of homeless people? British Journal of General Practice, 56(525), 286–293. Retrieved from http://bjgp.org/content/56/525/286.short [PubMed] , [Web of Science ®] , [Google Scholar]