An exploration of access to healthcare for women experiencing homelessness in Northern Ireland

Abstract

Background
People experiencing homelessness (PEH) have poorer health than the general population. Morbidity and mortality rates are higher, and inequalities are more marked for women experiencing homelessness (WEH) (Aldridge et al., 2018, Ivers et al., 2019). The inverse care law describes the inverse relationship between the availability of good medical care and the need for it in the population served, meaning that those who most need healthcare are more likely to struggle with accessing it (Tudor Hart, 1971). This same trend is still true for socially vulnerable populations, such as PEH (Haggerty et al., 2020).
In Northern Ireland (NI), the post-conflict political and social context impacts deprivation, health, and homelessness. There has been no published peer-reviewed research considering homelessness and health in the NI context since 2007 (Collins and Freeman, 2007). Therefore, this research will add considerable value to the research body and could be used to practically influence change in policy and actions in NI.
A scoping review was published in 2022 exploring access to healthcare for PEH in the UK and Ireland, the findings from which informed the next steps of the research. The identified literature gaps were; WEH representation in research, stakeholder representation such as health professionals, and research that considered access to health services outside of urban centres.
Therefore, the following research question was constructed: ‘What is the nature of access to healthcare for women experiencing homelessness in Northern Ireland and how can it be improved?’

Methodology
I used qualitative methods to answer the research question, including both interviews and workshops. Using semi-structured interviews, I interviewed 19 participants including WEH (10), and hostel staff (6) and healthcare staff (3). The hostel and healthcare staff were interviewed online due to COVID-19 restrictions at the time of data collection, while the WEH were interviewed in person in their hostels once restrictions were lifted. Following the interviews, I held two workshops, the first was hosted at Queen’s University Belfast (QUB) and had 13 participants involved in developing and undertaking policy or healthcare education. The second workshop was hosted in the University of Limerick and had 21 participants representing health practitioners and housing support from across the island of Ireland. Data were analysed following the phases of Reflexive Thematic Analysis (Braun and Clarke, 2022a).

Results
The resulting themes constructed from the interviews and workshops provided a picture or story of what access to healthcare looks like for WEH in NI and how it can be improved. In summary, WEH are vulnerable, and have complex health and social care needs which impact on their ability to access healthcare. Their awareness or capacity for awareness of their own needs and available services is limited. These complexities need to be understood by systems and service providers to provide an educated, tailored approach. The findings link closely with trauma-informed practice (TIP) principles of safety, trust, choice, collaboration, empowerment and cultural consideration. The approach should be unified from government level, and it should be holistic, flexible, and coordinated. Trusting relationships between WEH and hostel staff should be nurtured and valued, and resources should be managed creatively to ensure best possible use of funding. Finally, people with lived experience of homelessness (PLEH) should be involved in every aspect of service commissioning, design, delivery, and evaluation, ensuring those who use and need the services are heard during decision making processes.

Discussion and Conclusions
The acronym ‘INvEST’ provides a summary of five principles to improve access to healthcare for WEH in NI. This acronym can be applied to local service planning across NI when designing services for WEH. The five principles are Involve, Network, Educate, Support and Tailor. They suggest that PLEH should be involved throughout the service design process, the network, pathways and communication between services should be improved, education about homelessness should be provided at all levels for healthcare staff, WEH should be supported in various ways when accessing health services, e.g reminders for appointments or a buddy system, and finally, services should be tailored to suit the needs of WEH.
Further application from this research includes constructing a modified version of Levesque’s access framework that is tailored to inclusion health populations, such as WEH. It could include additions such as capabilities, feedback loops, advocacy, trauma and transience. Further consultation from stakeholders could inform a finalised modified framework for inclusion health populations.

Thesis is embargoed until 31 December 2024.

Date of Award	Dec 2023
Original language	English
Awarding Institution	Queen's University Belfast
Sponsors	Northern Ireland Department for the Economy
Supervisor	Nigel Hart (Supervisor) & Diarmuid O'Donovan (Supervisor)