Introduction
Despite the high prevalence of cancer risk factors among people experiencing homelessness (PEH), such as environmental exposure and unhealthy behaviours, their access to health care remains significantly obstructed.1–3 These obstructions require a differentiated understanding of PEH’s needs and barriers to accessing mainstream health and social care services. This editorial identifies key issues of the cancer care pathway for PEH and outlines barriers that must be addressed to ensure equitable access to cancer care for this underserved community.
Homelessness and cancer
Recognising homelessness as a complex social issue driven by multiple factors, including loss of the social safety net, mental health issues, and lack of affordable housing, is important in understanding structural barriers that PEH face when accessing health and social care services. These barriers are often perpetuated by experiences of discrimination and stigmatisation towards PEH in said services, creating hard-to-break cycles of instability and vulnerability, resulting in health disparities.2, 4
Cancer is the second leading cause of death within PEH.5 However, mainstream healthcare systems across Europe are poorly equipped to meet PEH’s specific needs, and the available healthcare services tend to be fragmented without the flexibility required to accommodate the often unpredictable conditions of PEH’s lives.2, 3 Once diagnosed with cancer, PEH face numerous challenges. For instance, a lack of income and stable address may disqualify PEH from health insurance and continuous care, leading to fragmented healthcare experiences.2 Difficulties in organising and attending appointments, adhering to complex medication regimens, and coping with chronic pain further hinder effective disease management.6 On top of this, the stress experienced when living under insecure housing conditions can be exacerbated by the physical and emotional burden of cancer, as cancer diagnosis is associated with increased feelings of isolation and depression.7 Such challenges underscore the need for tailored healthcare strategies that address not only the medical but also the social and psychological needs of PEH fighting cancer.
Facilitating access to cancer screening
Screening programmes are pivotal in early detection and improving cancer survival rates, yet such programmes remain disproportionately inaccessible to people without stable housing. PEH are less likely to be enrolled in health programmes that routinely offer screening tests such as mammograms, colonoscopies, and skin cancer tests.1, 8 Receiving invitations for scheduled screenings or follow-up appointments is extremely difficult without a fixed address. Moreover, daily needs for food and shelter and low awareness of cancer symptomatology may lead PEH to deprioritise cancer screening opportunities.3
Mobile health clinics and targeted outreach programmes have effectively addressed these accessibility barriers to cancer screening for PEH.9 These initiatives can facilitate essential screening services directly to places that PEH frequently visit, such as shelters, soup kitchens, and community day-care centres. They can eliminate the need for transportation and offer flexible service hours. Integrating screening services with other social support services can further boost participation rates.10 For example, offering cancer screening during PEH’s regular visits to day-care centres or shelters to receive food or basic medical care creates multiple touchpoints for engagement, raising the likelihood of early cancer detection. An essential factor for participation in low threshold screening programmes is the developed trust in the healthcare providers who work in these services.2, 11 Their efforts to build strong relationships are critical as they not only help break down barriers of distrust but also enhance the effectiveness of these initiatives by encouraging ongoing participation in screening programmes and ensuring that individuals adhere to recommended follow-up treatments and diagnostic tests after initial screenings.
Cancer care challenges
The unpredictability often inherent in PEH’s lives magnifies the difficulty of managing a complex health condition like cancer.12 However, cancer treatment often requires a coordinated approach over an extended period, involving various specialists and consistent monitoring and adjustments to treatment plans. Maintaining this level of contact with a healthcare team is challenging for this community, and medical records may not be centrally managed, leading to fragmented care and repeated diagnostics, which can delay critical treatment.12 In addition to logistical and systemic barriers, social stigma and discrimination in healthcare settings can deter PEH from seeking and continuing treatment.2 This stigma may manifest as biased attitudes held by healthcare professionals towards PEH, often based on misconceptions about homelessness and associated behaviours, such as substance use.4 For instance, a healthcare provider might assume that PEH will not follow treatment recommendations and, consequently, may not explain treatment options thoroughly or offer follow-up support. Discrimination can also be seen in the prioritisation of services where individuals perceived as ‘less likely to benefit’ may receive a lower standard of care or experience longer waiting times.
Tackling these challenges requires an integrated approach that considers the medical aspects of cancer treatment and the social determinants of health that significantly impact PEH.13 One auspicious practical solution may include providing Health Navigation services to help PEH navigate fragmented healthcare systems.14 Health navigators are key in empowering PEH by improving their health literacy, enabling informed health decision-making, promoting active participation in their care, and thus, fostering more inclusive support.
Practical recommendations
Active counselling and health education are fundamental. Therefore, healthcare professionals should engage actively in counselling, offering clear, accessible information about the importance of cancer screening and treatment. This effort can be bolstered through direct interactions in shelters or social or community centres in collaboration with local charities and healthcare programmes.15 Maintaining proactive communication with patients who may lack stable contact points and encouraging them to make frequent visits is vital to consistent care. Also, involving health navigators can significantly aid PEH in navigating the complex cancer screening and treatment process. These navigators can assist with scheduling appointments, filling out paperwork, supporting transportation to facilities, and coordinating health care across the different services, as a crucial linkage between PEH and the healthcare system.14 Additionally, developing integrated care pathways that include not only cancer care but also psychosocial support and support with immediate needs (e.g., housing and food) can address the broader health needs of PEH.
To further enhance accessibility, healthcare providers should adopt low-threshold services that deliver care directly where PEH communities usually are. Incorporating trauma-sensitive care in settings where PEH seek assistance or help provides an environment conducive to addressing the complex needs of PEH without overwhelming them. Opening resources and expanding training and education for healthcare professionals are critical steps towards reducing stigma and discrimination, ensuring that all staff can offer empathetic and informed support. Policymakers should incentivise healthcare providers to deliver outreach in these non-traditional settings, emphasising the importance of financial support and sustainability for these programmes. They often operate with limited resources yet provide essential services to a high need population. Additionally, coordinating social and health services and building trusting relationships between medical and social staff and PEH is vital, promoting a cohesive approach to care that respects and addresses PEH’s challenges.
Conclusion
An integrated and person-centred approach that extends beyond traditional medical pathways is required to engage with the social determinants of health that disproportionately impact PEH. Coordinating medical and social services through innovative and multidisciplinary approaches such as Health Navigation and advocating for targeted policy reforms is a possible way to overcome health disparities in cancer care that this marginalised community often encounters. This effort will improve the cancer care continuum for PEH and enhance their overall health and social outcomes.
Notes
Provenance
Commissioned; not externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2024
