Experiences of homeless women in accessing health care in community-based settings: a qualitative systematic review

ABSTRACT Introduction: Homelessness among women is on the rise in the US and continues to be a concern globally. The challenges homeless women face are unique and vast, yet how they experience health care can greatly affect their desire to access health care in the future. The ability to shed light on what is meaningful to homeless women in their health care experiences can guide the changes necessary to provide appropriate patient-centered, impactful care with the goal of increasing access by this vulnerable population. Objective: This review aimed to identify, appraise and synthesize existing qualitative 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 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, the designs of phenomenology, grounded theory, ethnography, qualitative description, action research and feminist research were considered. Methods: Using a three-step search strategy, databases of published and unpublished articles were searched from database inception to 2018. All included studies were assessed by two independent reviewers for methodological quality, and data was extracted and pooled using the JBI System for the Unified Management, Assessment and Review of Information. Findings were rated according to their level of credibility, categorized based on similarity in meaning, and subjected to a meta-synthesis. Two reviewers utilized a meta-aggregative approach. Results: A total of 196 qualitative articles were identified of which 24 were included after critical appraisal. Meta-synthesis generated three synthesized findings: (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, the lack of which can incite negative emotional responses, fear and knowledge deficits; (3) Homeless women with limited resources struggle to prioritize competing needs, such as transportation, time and money, which influences their ability to access health care. These synthesized findings were derived from 47 study findings that were subsequently aggregated into 10 categories. Of the 47 study findings, 32 were rated as unequivocal and 15 were rated as credible. The overall ConQual for each of the three synthesized findings was low due to common dependability issues across the included studies. A total of 454 participants were included. The included studies were published from 1997 to 2017. Conclusion: The review identified that homeless women's experiences when accessing health care in community-based settings, particularly in the US, have been poor and have negatively affected their desire to access health care in the future. The synthesized findings illustrate clear indicators for use of cultural competence and addressing provider bias in the delivery of health care to homeless women. This review also highlights the importance of understanding clinical experiences of providing direct care for these women in order to shed light on the type of advocacy needed to ensure equitable access to health care services. While this review uncovered issues with some global health care systems, the predominance of system constraints within the US highlights the need for health policy reform to improve the experiences of homeless women when accessing health care.