The access of the homeless persons with tuberculosis to the health care: an integrative review
Authors: Virgínio de Oliveira Annelissa Andrade , Oliveira Rita de Cassia Cordeiro de , Barbosa Khivia Kiss da Silva , Mendonça Ana Valéria Machado , Sousa Maria Fátima de , Sá Lenilde Duarte de 
Published: April 2017

Introduction: The Tuberculosis (TB) keeps being a big public health problem in the world, having the poverty, the bad life condition, the bad income distribution, the social iniquity and the disability on the health system as a substrate to its maintenance.

Objective: To identify the scientific knowledge produced under the access to the health service of the homeless person sick by TB.

Method: Integrative literature review conducted from April to June, 2016, having as inclusion criteria: publications written in Portuguese, English or Spanish, published from 1990 to 2015, indexed on the data basis: LILACS, SciELO, MEDLINE and Web of Science and portals Virtual Health Library (VHL) and MEDLINE/PubMed, that had the text completely available online. As searching strategy was used the Boolean operator AND, with the descriptors: Tuberculosis, health services accessibility; homeless persons. To obtain the information that answered the research guideline question was elaborated a form that contemplated the following items: identification, theme, descriptors or key-words, abstract, introduction, method, results, discussion, conclusions and references. The search resulted in 51 articles that, observed with the inclusion and exclusion criteria, resulted in 10 complete articles. The data analyzes was made in qualitative terms, summarized in three categories: I) Specific characteristics of the homeless people access to the health services to tuberculosis diagnostic and treatment; II) Access difficulty to the health care: factors related to homeless people and factors related to health services; III) Strategies to overcome the access difficulties of the homeless person (HLP)  to the health care.

Results: pointed that the homeless people have a higher risk to get sick by TB, presenting TB incidence rate 10 to 20 times higher than the general population. Many obstacles that limited those people access to the health services were identified. Many times they presented difficulty to identify the appropriated place to search for assistance and not always this place had the opened doors to this social group. Another important finding treats about the low adhesion to the TB treatment, because treating about the search for health care, the homeless people are less inclined to search the health services, seen that living on the street implies in a daily fight for survival. To those people, the sickness treatment has a lower priority than the meal obtaining, the searching for shelter, or the search for a job.

Discussion: It was observed that by the fact to be exposed to many risk factors, such as: alcoholism, chemical dependence, environmental exposition, inadequate sleeping accommodations, crowed shelters, stress, psycho disturbs, poverty, HIV infection, weak nutrition, affected immunity through the pre-existent conditions, lack of access to health services, cognitive affection and the adverse effects to the health by the lack of home, the homeless people have high risk to get sick and the high TB mortality rate if compared to the general population. Thus it is evident the serious problem that this disease represents to this specific group, justifying urgently the necessity of specific actions to the TB control in this population. The most important element during the TB elimination will be a significant decreasing of the agglomerations, on the poverty and the barriers to the health care. To increase the access to the health care is essential on the homeless population TB control. It is necessary to highlight that when health services that attends their necessity are provided, the homeless individuals will access to the health care at the same rhythm as the general population.

Conclusion: It is necessary that the health actions break the strictly technical caring barriers and include the psychosocial and educative perspective in all the health care process to homeless people with different conformations due to the individuals’ singularities and their scenarios. Thus, the search by the more integral care and, therefore, more efficient possible, it is wait that be included on the health team daily work, routines and process to a systematic search for the health necessities, and developed abilities to recognize the adequacy of the offers to the specific context, in which is given the meeting from the individual and the team.

Keywords: Tuberculosis; health services accessibility; homeless persons.