Review Article - (2023) Volume 12, Issue 4
Received: 04-Jul-2023, Manuscript No. JNC-23-104829;
Editor assigned: 07-Jul-2023, Pre QC No. P-104829;
Reviewed: 21-Jul-2023, QC No. Q-104829;
Revised: 03-Aug-2023, Manuscript No. R-104829;
Published:
31-Aug-2023
, DOI: 10.37421/2167-1168.2023.12.597
Citation: Tshitangano, Takalani Grace, Mnkandla
Mayibongwe Mkhaliphi Abel and Mudau Azwinndini Gladys.
"Healthcare Seeking Behaviours of Homeless Substance
Users: Scoping Review." J Nurs Care 12 (2023): 597.
Copyright: © 2023 Tshitangano TG, et al. This is an open-access article distributed under the terms of the creative commons attribution license which permits
unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.
Substance use continues to be a public health problem globally as it is associated with health issues, such lung or heart disease, stroke, cancer or mental health conditions. About 15% of South Africans uses substances and worsened during COVID-19 pandemic, with 0.02% being homeless. Substance use among homeless people is associated with sexually transmitted infections and a high level of morbidity and mortality, with the average life expectancy of homeless men living more than ten years on the street being 45-47 years old. Good health seeking behaviour is an important element of prevention, early diagnosis, and management of disease conditions, reducing cost, disability and death. This scoping review aimed to assess the healthcare seeking behaviors of homeless substance users during COVID-19 lockdowns. This review was conducted following PRISMA guidelines, where electronic databases such as consulting newspaper articles, credited website published reports and journals under Google Scholar. A total of 47 articles published in English between 2017 and 2022 were consulted, only using 27 for results synthesis. Results indicate difficult to access healthcare and only admission in hospitals as emergency cases. Factors associated with health seeking behaviors include lack of identification documents and address and stigma. Since many of studies addressing this topic were conducted in Europe and India, there is a need to explore healthcare seeking behaviors of homeless substance users during the COVID-19 lockdowns, in South Africa to inform strategies to improve healthcare utilization.
COVID-19 • Healthcare seeking behaviors • Homeless • Substance users • Health promotion
Substance use continues to be a public health problem globally. Peacock et al. assert that in 2015, the estimated prevalence among the adult population was 18.3% for heavy episodic alcohol use in the past 30 days; 15.2% for daily tobacco smoking and 3.8%, 0.77%, 0.37%, and 0.35% for past-year cannabis, amphetamine, opioid and cocaine use, respectively. European regions had the highest prevalence of heavy episodic alcohol use and daily tobacco use. The age-standardised prevalence of alcohol dependence was 843.2 per 100,000 people; for cannabis, opioids, amphetamines and cocaine dependence it was 259.3, 220.4, 86.0 and 52.5 per 100,000 people, respectively. High-Income North America region had among the highest rates of cannabis, opioid, and cocaine dependence [1]. According to Peacock et al., substanceattributable mortality rates were highest for tobacco (110.7 deaths per 100,000 people), followed by alcohol and illicit drugs (33.0, and 6.9 deaths per 100,000 people, respectively) in 2015. The South African Community Epidemiology Network on Drug Use (SACENDU) highlight that at least 15% of the South African population are homeless substance users. Cases of people recorded in about 94 centers have increased from 9 394 to 10938, which is about 0.10% of substance users, accessing treatment in the 2021/2022 fiscal year, posing a huge percentage of substance users who are not accounted for.
According to Arde, prevalence of homeless substance users climaxed amid the COVID-19 pandemic in 2020, where it was above 60% in Durban. The Human Sciences Research Council (HSRC) estimates that approximately 100,000 to 200,000 people are homeless in South Africa. Most of the homeless people have been vulnerable to communicable diseases, with substance users contributing to HIV at 9.56% and TB at 1.8%. Homelessness contributes to severity of COVID-19 as symptoms of fever and flu are more favorable in places with low temperatures such as the streets. This poses a huge risk of infection and succumbing to the disease if improper strategies are taken or challenges towards accessing healthcare are not addressed Studies have shown that homeless people have a high level of morbidity and mortality. The average life expectancy of homeless men living more than ten years on the street is 45-47 years old. Attaining good health seeking behaviour is an important element of prevention, early diagnosis, and management of disease conditions. It helps in reducing cost, disability, and death from diseases. However, the health seeking behaviour of homeless substance users is not clear [2]. This scoping review is necessary to examine novel findings, identify and analyze any gaps in knowledge from specific studies. Relationships with other studies regionally and globally will be explored. Specific objectives entail to:
• Describe health seeking behaviors of homeless substance users.
• Describe the determinants of health seeking behaviors among
homeless substance users.
• Explore challenges faced by homeless substance users while
accessing healthcare service
This scoping review was done to justify the mini-dissertation study for a master of public health degree.
The methodology of this scoping review guided by PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta- Analyses extension for Scoping Reviews) guidelines being comprised of 20 key points. This entails addressing sections such as protocol validation, eligibility criteria, information sources, search strategy, selections of sources, data charting, data items, critical appraisal and synthesis of results.
Protocol validation
A copy of this study’s proposal was submitted and approved through the decision of the executive faculty of health sciences higher degree committee of the university of Venda on 14 August 2022.
Eligibility criteria
Going through various sources of information, it is key to screen articles on whether they are relevant to the study purpose. Sources consulted were supposed to be written in English and published between 2017 and 2023 [3]. Inclusion and exclusion criteria guide the eligibility of each literature to be used as stated in Table 1.
| Inclusion criteria | Exclusion criteria |
|---|---|
| Used Google Scholar (GS), Newspaper Articles (NA), Credited Website Published Reports (CWPR) | Studies published before 2017 |
| Studies published between 2017 and 2023 | Lack of full text reference |
| Only studies involving healthcare seeking behaviors of homeless substance users, social determinants of health affecting substance users and challenges they usually faced | Reports not published by accredited institutions |
Table 1. Inclusion and exclusion criteria.
Information sources
Online databases were used to provide information validated by certified publishers. Of late sources require recognition for them to be appraised to provide usable data through eligibility assessments. Online sources such as Newspapers Articles (NA), Credited Website Published Reports (CWPR), journals and books under Google Scholar (GS) were consulted [4]. Google scholar consisted of several articles from science direct, SagePub, BioMed central, MDPI, springer and national library of medicine. Credited website published reports entail reports from programmes which are published in governing institutions such as Western cape government, National Institute for Communicable Diseases (NICD) and World Health Organization (WHO).
Search strategy
Search terms on healthcare seeking behaviors were used to consult sources, for example via Google Scholar. Three sets of search terms were used based on the objectives of the study.
• Health, seeking, behavior, homeless [5].
• Determinants, health, seeking, behavior homeless.
• Challenges, experienced, homeless, accessing healthcare.
After using these search terms, about 33,885 of articles came up. About 17,532 remained after customizing based on years as from 2017 till 2023.
Selection of sources evidence
Whilst reviewing 17 532 articles by abstract, 15742 were included after removing 1,790 duplicates. After going through titles, 1,232 articles were excluded remaining 14,510. Further on using the eligibility criteria, 25 were included and 14485 being excluded, with an added 2 included to make them 27 in total. The PRISMA flow diagram below shows the details of selection (Figure 1).
Figure 1. PRISMA based flow diagram.
Data charting
Results from the review were systematically extracted by the principal researcher (Mayibongwe Mnkandla) and summarized in a table of evidence. Source coding was employed to group literature from similar journals and credited websites, as per inclusion and exclusion criteria [6]. Criteria for data extraction was authors, year, title, source, study approach, sample size, setting and objectives. These are recorded in an Excel spreadsheet Insert file 1, describing how each contributed to the objectives. Data was presented to address each objective. A thorough check of the data extracted was done by a core data extractor (Dr Ndumiso Tshuma). The study supervisors verified the data extraction.
Data items
Data extraction variables were based on the study objectives as follows:
• What is the healthcare seeking behavior of homeless substance users?
• What determinants are associated health seeking behaviors of homeless substance users?
• What are the challenges faced by homeless substance users in seeking healthcare services?
Definition of variables:
• Determinants in this study were individual characteristics associated with the health seeking behavior of homeless substance users.
• Health seeking behaviors in this study meant services utilized categorized as formal and informal platforms offering healthcare services such as hospitals, clinics, community healthcare workers, traditional herbs, and personal beliefs.
• Challenges faced entail barriers which limited or inhibited utilization of healthcare services such as stigmatization, marginalization, stereotyping, emotional and physical factors.
Critical appraisal
Articles selected were not limited to the study approach either quantitative, qualitative, or mixed methods, all types of information sources were selected [7]. No further critical appraisal was done.
Synthesis of results
A scoping review of the literature entailed reviewing different literature and synthesizing them under three topics to address the study objectives as presented in the next section.
Literature review sources consulted are sorted below under Table 2 determining the number of references with findings related to each objective.
| Objectives | Number of studies |
|---|---|
| Healthcare seeking behaviors of homeless substance users | 11 |
| Determinants influencing health seeking behaviors of homeless substance users | 6 |
| Challenges in accessing healthcare services | 10 |
Table 2. Sources relating to review of objectives search terms.
Healthcare seeking behaviors of homeless substance users
In New York, Sakai-Bizmark et al. noticed that homeless youths do utilize hospital services when facing challenges with their health such as accidents, diarrhea, Tuberculosis (TB) and fever, facing longer time in hospitalization compared to housed youths. Similarly, statistics demonstrate that the homeless people are admitted to a hospital five times more than the public and stay under care much longer. In addition, Marks et al. indicate that homeless people often obtain their care in hospital emergency departments, partly due to their inability to pay for medical services [8]. Rahmawati’s case study in India observes the number of homeless substance users rising in the emergency department seeking chronic TB therapy. In support of Sakai-Bizmark' findings on formal healthcare services, Jean’s survey on healthcare professions interactions with the homeless, realize the use of shelter-based clinics in designated stations for the homeless. On the contrary, the CDC noted that people experiencing homelessness often lack ready access to the medical care required to make an early diagnosis of TB disease.
Other types of healthcare services used by homeless substance users are community healthcare workers, Feldman et al. who provide street medicine to improve utilization of hospital services. In addition, Rogers et al. highlight that various treatment services were provided to homeless substance users through health promotion including the distribution of masks and training substance users on how to cover their mouths and noses when coughing or sneezing, during COVID-19 pandemic. These community healthcare workers are also consulted by homeless adults from jail to bridge the gap between hospitals and homelessness according to Abbott et al. Van Hout and colleagues realized that mobile outreach services to drug spots by community healthcare workers to reduce harm is also well utilized according to Iqbal et al. On the contrary, studies show that homeless people are not receiving preventive and primary care, which is known to substantially lower overall healthcare costs. According to Harmon, homeless people are often faced with reduced access to private and public services and vital necessities such as healthcare and dental services [9]. Preventative measures play an effective role in infection control, although countries such as Sweden view social distancing as inadequate in containing COVID-19 virus on a personal basis.
Stacy et al. record cases of the homeless having to use selfmedication obtained from over-the-counter facilities to treat themselves. Although sometimes they use unknown substances such as drugs to help themselves relieve feeling the symptoms of the sickness they will be undergoing. Rogers et al state that various treatment measures emerged during COVID-19 pandemic with other homeless substance users preferring traditional medicine and unknown substances [10]. African traditional remedies sprung up with some individuals from Tanzania endorsing Umhlonyane to be effective in treating COVID-19, including the Madagascan president. However, Minister of Health in South Africa dismissed effectivity of umhlonyane against COVID-19 as it was not approved by the South African Health Products Regulatory Authority (SAHPRA).
Most studies cited here were conducted in Europe and regionally in Africa, with none from South Africa. Thus, there is essence in exploring different types of healthcare services used by homeless substance users during COVID-19 lockdowns in South Africa.
Determinants influencing health seeking behaviors of homeless substance users
Using Natural Language Processing (NLP), Patra et al. were able to extract social determinants which influence the healthcare seeking behaviors of homeless substance users are level of education, poverty, and social support. Amongst these three, Johnston et al. realize that resource allocation from less essential healthcare services to primary healthcare helps alleviate severity of a pandemic. It is key to keep the economy abreast to cater for all population groups amid a pandemic. Therefore, Briginshaw et al. discover that reduction of methadone price from authorities to accommodate institutions acquiring it for mitigating risks linked with substance users in controlled facilities. All these measures were to try and provide social protection for homeless individuals, although COVID-19 relief packages were less accessible for homeless substance users.
Another influencing social determinant of health was the level of education. After investigating literacy levels amongst the homeless and vulnerably housed in Canada, depictions are that high literacy levels are associated with beneficial use of formal healthcare services according to Farrell and colleagues. However, studies show that a higher number of substance users do not know their education status. Thus, according to Germishuys et al., approximately 52%, 32%, 15% and 0.001% homeless substance users in the city of Tshwane do not know their education status, have not attained matric, have reached matric and reached tertiary level, respectively. This represents a low education level community amongst homeless substance users [11]. Thus, in support of Farrell and colleagues and Germishuys’ cohort, depictions of low healthcare services are linked to this population group. However, less linkage is made regarding preferred healthcare services accessed amid a novel pandemic combining different social determinants of health such as accommodation and level of education. This brings about research to be done on addressing age and level of education in determining the level to which the pandemic was perceived and influencing which services to utilize or not.
According to Giljam-Enright et al, in South Africa the three major SDH that influence the choice of healthcare services consulted in low socio-economic settings are level of education, availability of social protection, and distance from location to healthcare services provided by Eastern Cape Department of Health. The determinants from other provinces are not clearly available in literature. Therefore, to address health inequalities in each provincial setting, specific relatable SDH influencing healthcare seeking behaviors of homeless substance user ought to be described and understood.
Challenges experienced by homeless substance users when accessing healthcare services
Studies have noticed various challenges faced by substance users when trying to access healthcare services. One such challenge is that homeless people may find it difficult to document their date of birth or their address, which are requisite to accessing health care. National law centre on homelessness and poverty, states that homeless people most likely misplace their luggage containing their Personal Unique Identification Documents (PUID), thus facing challenges in accessing various social services. Therefore, replacing such documents without proof of residency and other identification documents makes it close to impossible. However, a catch 22 is created where other states hold back birth certificates if photo IDs are not presented. This problem is insignificant in countries that have the National Health Insurance (NHI) offering free healthcare services such as the United Kingdom (UK) and the United States of America (USA), with 24 hour healthcare services.
Quite a significant number of studies highlighted stigmatization as a strong barrier from healthcare administration. Amanda recorded stigma for getting help whilst facing addiction problems is a challenge for substance users. In Sydney, jailed substance users who have just been released and are homeless, indicated stigmatization on being ex-convicts, using substances and residing in abandoned shelters. In support of Amanda and Abbott, substance users also face stigmatization termed as TB based stigmatization which has a major impact in their healthcare seeking behaviors when seeking TB aid. Dromi postulates homeless individuals prone to employ certain strategies of preserving dignity by limiting interactions with other people, thus resulting in systematic stigmatization. Therefore such key populations face umbrella stigmatization such as sexually transmitted infections and communicable diseases. In support of these findings, hammarlund and colleagues, after reviewing the World drug report in USA, figured out that homeless individuals are affected by internal and external forms of stigmatization in their decision-making process, influencing on whether to seek help or not when feeling seek.
O’Carroll and Wainwright describe barriers to healthcare services utilization faced by substance users to be physical in terms of distance to healthcare facilities, administrative systems in place, or attitudinal by healthcare administration [12]. Although findings by Jean observed community healthcare workers being mobile around the homeless and shelter-based clinics meant to reduce distance to actual hospitals, challenges are also faced when consulting these services.
Allen et al. noticed that substance users face system related barriers while trying to access healthcare services such as unfair treatment. Although equity is key in addressing public health problems, unfair treatment is noticed most of the time. Also, Purkey and MacKenzie highlight the issue of marginalization of the homeless and vulnerable housed when accessing respectful healthcare services in Ontario. Therefore, addressing equity has been part of the World Health Organization’s plan by addressing Social Development Goals (SDGs) through integrating healthcare strategies with the aim to address needs in high-risk populations. It has been discovered that due to workload, staff insecurity, poor documentation of homeless, clinics refuse to attend to homeless substance users, forcing a team of medical practitioners from the University of Pretoria to assist this key population group during the lockdown. Measures put in place to address systematic challenges through shelter and remote clinics, but Mahlase noted that the focus was feeding scheme and mitigation of HIV/AIDS spread amongst substance users, ignoring the actual needs of the homeless on site. Thus, also mentioning less empathy shown towards them by shelter workers.
Davis et al. present those psychological factors such as patientclinic relationships being vital in reducing challenges on substance users in seeking healthcare assistance in Cape Town, South Africa. In as much as this is relevant to Tuberculosis (TB) treatment, communicable diseases’ strategy of healthcare seeking is uniform towards most of them, and such gaps must be addressed among different communicable diseases due to their novelty and different pharmacological properties [13]. Matsuzaki et al confirm these findings too on their study as they perceived social support being a major barrier to care among illicit drug users. Even though the national strategic plan (2019-2024) of the national department of health in South Africa, has goals of developing sustainable interventions to ease access to health through improving client relationships, poor patientclinic relationships are still being witnessed. However, such structural barriers still need to be investigated in relation to any novel public health problem [14,15].
Sources consulted and used were only limited to between 2017 and 2023, thus limiting the synthesis of available literature. Literature reviewed could be further explored systematically.
This scoping review noted that much research studies about health seeking behavior of substance users has been conducted in Europe covering type of services consulted, determinants of choice of services and challenges faced. Thus, all the studies were not conducted in South Africa during COVID-19 pandemic. This scoping review has noted that, health seeking behaviors of homeless substance users, associated social determinants and challenges faced when accessing health care need to be explored further especially amid pandemics.
Conceptualization done by Mayibongwe Mkhaliphi Abel Mnkandla, Takalani Grace Tshitangano and Azwinndini Gladys Mudau. All authors reached agreed on publication of the manuscript, limiting authorship to all authors who participated in the reported.
No funding was received.
Obtained from all participant.
Data available upon request.
Best health Solutions and participants who provided data used in this study.
None declared by the authors.
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