REVIEW PROTOCOL

ACCESS TO HEALTH CARE FOR HOMELESS WOMEN: A SCOPING REVIEW PROTOCOL

Nathália de Souza Monezi1, Maira Libertad Soligo Takemoto2, Renata Soares Luz1, Fernanda Mota Rocha1, Isabela Oliveira de Almeida1, Bruno Pereira da Silva1,3, Débora de Souza Santos1

1 State University of Campinas, São Paulo, SP, Brazil

2 State University of Botucatu, São Paulo, SP, Brazil

3 Federal University of Acre, Cruzeiro do Sul, AC, Brazil

ABSTRACT

Objective: To analyze, within the scientific literature, the strategies for accessing healthcare services and the paths taken by homeless women in their search for health care, based on a preliminary scoping review. Method: The protocol was developed following the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist. It has also been registered with the Open Science Framework. The proposed approach involves conducting a search in relevant databases, importing the retrieved articles into the Rayyan software, removing duplicates, and reviewing titles, abstracts, and full texts. Studies eligible for inclusion will include cohort studies, surveys, interviews, focus groups, observations, case series, and case studies. The results will be presented in a narrative format and summarized in tables.

Keywords: Women’s Health; Homeless People; Health Services; Access to Health Services; Systemic Racism.

INTRODUCTION

The homeless population is the result of individual, familial, economic, social, and political transformations that occur in low-, middle-, and high-income countries(1-2). In 2013, Portugal, with approximately 10 million inhabitants, had about 5,000 homeless individuals. In the United States, during the same year, with a population of 320 million, the figure reached 610,042(3). In São Paulo, Brazil, in 2015, there were 15,905 homeless individuals among an estimated population of 12 million(4). By 2019, São Paulo's total population had grown to 12.25 million, while the number of homeless people had increased to 24,344. Of this group, 96.7% were Brazilian and 3.3% were foreigners, with 85.5% identifying as male and 14.5% as female. In terms of racial demographics, 68.6% were black or mixed race, 26.1% were white, 2.4% were indigenous, 1.1% were of Asian descent, and 1.8% did not identify or did not provide information(5). 

This population faces profound social invisibility, discrimination, hunger, poverty, violence, extreme weather conditions, and a relentless search for shelter in places like bridges, overpasses, parks, vacant lots, and public shelters(6).

Women, often victims of poverty, low educational attainment, unstable housing, and domestic violence, are frequently forced to leave their homes and jobs, seeking refuge in shelters, philanthropic institutions, or on the streets(7). While homeless, they face significant barriers to accessing health care, compounded by intersecting factors such as race, class, and sexual orientation(8). Although women represent a minority compared to men in this situation, they encounter unique challenges, including violence—particularly sexual violence—when using psychoactive substances (PAS) in hidden spots known as mocós(9). To generate income, many resort to criminal activity or sex work, which helps fund PAS consumption and offers some protection against the insecurities and vulnerabilities of street life(10-11). 

Living on the streets poses severe health risks, especially when associated with PAS use, sex work, unintended pregnancies, and exposure to violence(12). Access to healthcare services is influenced by factors such as the availability of infrastructure and professionals, the initial reception at health facilities, and the quality of care provided(13). To address health inequities, Brazil’s Ministry of Health established Psychosocial Care Centers (CAPS) in 2002 and Street Outreach Clinics (CdR) in 2013(14-15). In addition to these services, a 2023 study involving nurses practicing Advanced Practice Nursing (APN) in Rio de Janeiro communities highlighted the critical role of nursing in expanding health care delivery, leading to significant improvements for vulnerable groups. Research showing the role of nursing in overcoming challenges when caring for vulnerable populations is of paramount importance(16). 

Scoping reviews, recognized for their relevance, synthesize evidence to systematically map available knowledge, identify gaps, and deepen understanding of specific topics(17). A 2022 study on homeless women revealed knowledge gaps that contribute to health inequities, underscoring the need for further scientific investigation(18).

Thus, this scoping review protocol aims to analyze, within the scientific literature, the strategies for accessing health care services and the pathways taken by homeless women, considering their historical and social challenges(19). The objectives, inclusion criteria, and analytical methods were predefined and documented in a previous protocol(20), following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist(21). The protocol has been registered with the Open Science Framework (OSF) under DOI 10.17605/OSF.IO/A9NFC.

METHOD 

Study type

This protocol outlines a scoping review, developed based on the JBI methodology(17) and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist,(21) with the protocol registered in the Open Science Framework (OSF)(22-23).

The scoping review is a methodology used to map the literature within a specific field of knowledge, enabling an assessment of the scope of existing research as well as the identification of gaps and opportunities for further investigation(24).

The guiding review question is: What are the strategies for accessing health care and the pathways to health services for homeless women as identified in the global scientific literature? The SPIDER strategy was employed to formulate this question(25) (Figure 1).

Figure 1 - Mnemonic for developing the guiding question. Campinas, SP, Brazil, 2023

Search strategy

After formulating the research question, controlled and uncontrolled descriptors were selected, and the search strategy for the information resources was designed and developed with the assistance of a librarian.

The terms used in the search strategy were identified from the Health Sciences Descriptors (Descritores em Ciências da Saúde [DeCS]) and Medical Subject Headings (MeSH), in both Portuguese and English.

Documenting the search strategies is an essential tool for the scientific validation of a scoping review, as it facilitates understanding and evaluation of subsequent stages(19). The information resources utilized in this protocol include: Virtual Health Library (VHL), with no filter for specific databases, encompassing Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Health Sciences Literature (LILACS), Nursing Database (BDENF - Enfermagem), Puerto Rico, São Paulo State Health Secretariat, and the Coleciona SUS repository; PubMed; EBSCOHost; Scopus. Studies published between 2010 and 2022 were included, with no language restrictions. However, publications in languages other than Portuguese will be sent for translation. All the resources are presented in Figure 2 below:

Figure 2 - Search strategy across information resources. Campinas, SP, Brazil, 2023

Study selection

The condition under study is access to healthcare services, with the population including homeless women (cisgender, transgender, and transvestite). Cisgender and transgender men were excluded.

This review will consider studies employing qualitative, quantitative, mixed-method approaches, and reviews, while excluding dissertations, theses, and gray literature. Eligible studies must have been published between 2010 and 2022. To be selected for analysis, studies must include terms related to “Health” and/or “Homeless Women” or healthcare services such as “Primary Care” or “Mobile Health Services”.

A thorough reading will be conducted to classify information that addresses the guiding review question.

Data extraction (selection and coding)

The identified studies will be imported into the Rayyan software, where duplicate entries will be removed. Subsequently, two independent, blinded reviewers will evaluate and select studies based on the eligibility criteria(26). In case of disagreements, a third reviewer will resolve the conflicts.

The methodological quality of the studies will be assessed to ensure their internal validity and minimize risks of bias. Data extracted from the articles will be recorded in an Excel® spreadsheet, including the following details: author; year of publication; journal; study design; setting; participants (age, sex, city/state, sample size, risks, and other relevant characteristics); recruitment procedures; follow-up or study duration; exposure(s) of interest (independent variable) - type, frequency, intensity, and duration; dependent variable (outcome); results; outcome measurements - scales or tools used for measurement; data analysis methods; appropriate effect size measures, such as risk proportion, relative risk ratio, odds ratio, p-value, 95% confidence intervals; reviewer comments.

Data synthesis strategy

A qualitative synthesis of the selected studies will be conducted, detailing sample characteristics and grouping narratives. Additionally, information regarding authorship, country, year, title, journal, and study participants will be synthesized. These details will be organized into a descriptive table. The studies will be grouped in a way that facilitates a clearer understanding of the conditions experienced by homeless women.

Expected results

The review aims to map and synthesize data on the strategies for accessing and the pathways to healthcare services utilized by homeless women. The goal is to identify the health needs of this vulnerable group, thereby contributing to the strengthening of health equity policies. Furthermore, the review seeks to promote the development of strategies for ongoing health education to improve the quality of care provided.

ACKNOWLEDGMENT

The authors express their gratitude to the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP), the Graduate Program in Nursing (PPG-Enf) of the School of Nursing (FEnf) at the University of Campinas (Unicamp), and to librarian Ana Paula de Morais e Oliveira from the Library of the School of Medical Sciences (FCM) at Unicamp.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

FUNDING

This research was supported by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES). Process No.: 23038.003069/2023-68.

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Submission: 26-Dec-2023

Approved: 28-Oct-2024

Editors:

Ana Carla Dantas Cavalcanti (ORCID: 0000-0003-3531-4694)

Paula Vanessa Peclat Flores (ORCID: 0000-0002-9726-5229)

Cláudia Maria Messias (ORCID: 0000-0002-1323-0214)

Corresponding author: Nathália de Souza Monezi (nathaliamonezi@gmail.com)

Publisher:

Escola de Enfermagem Aurora de Afonso Costa – UFF

Rua Dr. Celestino, 74 – Centro, CEP: 24020-091 – Niterói, RJ, Brazil

Journal email: objn.cme@id.uff.br