DOI: https://doi.org/https://doi.org/10.57187/s.3659
A recent report by the European Social Policy Network indicated that the number of people experiencing homelessness increased over the last decade in most European countries [1]. Homelessness has a major impact on health. People experiencing homelessness are disproportionately affected by mental health [2, 3], substance-use [4] and physical health issues (e.g. dermatological [5], metabolic [6], injuries [7]). Their management of these conditions is complicated by a lack of medical follow-up [8], and challenges with other needs to support self-management [9]. Many people experiencing homelessness lack regular primary care providers, which leads to increased use of emergency rooms (ER) for care [10, 11]. In addition, health-associated costs are higher among people experiencing homelessness than housed people [12]. These often-multiple difficulties typically lead to a reduced life expectancy in this population. For instance, in the Netherlands, a study showed that at age 30, life expectancy was lowered by 11 years in homeless women and 15.9 years in homeless men when compared to the general population [13].
Switzerland is not without people experiencing homelessness, but little data concerning their health is available. It is estimated that about 250 individuals are homeless in Lausanne, the capital of Vaud Canton [14]. No estimate is available for the other, smaller towns and cities. Very few studies have explored health of people experiencing homelessness in Switzerland: in the German-speaking part, one study described that 96% of 338 people experiencing homelessness surveyed suffered from mental health conditions [15], and two described the inpatient management as well as their demographics and clinical characteristics [16, 17]. In Geneva Canton, one study reported high adherence to tuberculosis screening programmes [18], and another a higher rate of COVID-19 infections among people experiencing homelessness than the general population [19].
In certain European countries and in North America, besides quantitative epidemiological research, qualitative research has explored health needs, barriers to healthcare and healthcare experiences of people experiencing homelessness. In these studies, they acknowledged the impact of their social situation on their health [20, 21]. Despite important health-related needs, they reported prioritising other needs (e.g. finding food and shelter) over their health [20–26]. People experiencing homelessness often face negative interactions with healthcare professionals [20, 22, 27], resulting in further challenges in accessing healthcare. Furthermore, they expressed difficulties navigating healthcare systems [22, 24, 26].
Taken together, both qualitative and quantitative findings document important health inequities that affect people experiencing homelessness: a high burden of health-related problems and reduced access to care compared to non-homeless individuals. Most of this research was conducted in English-speaking countries (United States, Canada and the United Kingdom). It is important to examine to what extent these findings are transferable to other countries, given differences in healthcare and social systems. Moreover, a call to better understand and characterise homelessness has been made in Switzerland [29]. In response, this study aimed to provide a comprehensive assessment of the health needs, expectations and healthcare experiences of people experiencing homelessness in Vaud Canton (French-speaking; 826,380 residents, constituting approx. 9.4% of the Swiss population [30]), by using both quantitative and qualitative methods among people experiencing homelessness and homeless-serving sector professionals. This was a secondary study of a larger research project aimed at developing and testing a complementary medicine intervention for people experiencing homelessness in French-speaking Switzerland [31]. The present study had the following aims:
We used a triangulation design with a convergence model [32]. Quantitative data collection was first conducted followed by qualitative interviews. Both methods had the same priority. We then compared both quantitative and qualitative findings and interpreted our results according to both methods. This design provides more information on the topic at hand than could have been garnered using a single method, while reinforcing the validity of results [33–35].
The study was conducted in French-speaking Vaud Canton of Switzerland. It has been reported that there are 250 people experiencing homelessness in Lausanne [14], so we set out to recruit at least 125 participants.
In total, 288 people experiencing homelessness were invited to participate in the study; 128 of them provided informed consent to participate and completed the questionnaire. After verification, 5 participants were subsequently excluded (3 had duplicates and 2 did not meet the inclusion criteria), leading to a final sample of 123 participants. For the qualitative interviews, for people experiencing homelessness we selected a quota sample according to health insurance status and residency status, while ensuring that the sex proportions of the sample were representative of those in the target population. For homeless-serving sector professionals, we selected a quota sample according to professions (i.e. night watcher in shelters; social/healthcare workers), again ensuring representative sex proportions. In addition, we aimed to recruit at least one homeless-serving sector professional from each of the ten institutions included in the parent research project. For both homeless-serving sector professionals and people experiencing homelessness, recruitment occurred until reaching data saturation in each sampling category.
Inclusion criteria for people experiencing homelessness were:
Exclusion criteria were:
Inclusion criteria among homeless-serving sector professionals were:
Recruitment was conducted over a 10-week period (May to August 2022) across 10 different homeless-serving institutions (six emergency night shelters, a community health centre and three day shelters) in four cities in Vaud Canton (Lausanne, Yverdon-les-Bains, Vevey and Nyon). Potential participants were recruited through flyers describing the study and were approached by the research team who provided information to interested people experiencing homelessness. The research team provided active paper-pencil administration of the questionnaires to the participants. The questionnaire content was adapted according to professionals involved with people experiencing homelessness and an association specialised in making written content accessible (Lire et Écrire). Then, it was translated and back-translated into 12 languages (English, Spanish, Italian, Portuguese, Romanian, Serbian, Albanian, Literary Arabic, Turkish, Bulgarian, Mandarin, Russian) by research team staff and medical students who were fluent in both French and each translation language. As the questionnaires were researcher-administered, the research team used them in languages they understood (French, English, Arabic, Portuguese). When participants spoke a language not understood by the research team (such as Romanian), a community interpreter assisted them. Completing the questionnaires took approximately 40 minutes. All participants provided signed written informed consent. The qualitative interviews were conducted by a member of the research team with experience in qualitative research (EH, a PhD candidate; JN, a Master’s level medical student; VG, a PhD) under the supervision of author VG. Qualitative interviews were conducted using an interview guide (one for people experiencing homelessness, one for professionals involved with people experiencing homelessness; both are provided in the appendix) with open-ended questions and probes to explore the experiences and health needs of people experiencing homelessness. Qualitative interviews were conducted until data saturation was reached, i.e. when no new ideas were expressed in the interviews. The mean interview duration was 45 minutes. The homeless participants received a 10 CHF (~11 USD) grocery gift card for completing the questionnaire and an additional 20 CHF (~22 USD) one for taking part in the qualitative interview. The study was conducted in accordance with the Declaration of Helsinki, and all procedures were approved by the local ethics committee on human research (project number: ID 2022–249).
Demographic variables. A set of 11 items assessed sociodemographic variables including age, sex, nationality, residence permit, education, health insurance and ETHOS-Light typology (1. living rough; 2. sleeping in emergency accommodation; 3. living in accommodation for the homeless; 5. living in non-conventional housing) [36].
Quality of life. Participants’ quality of life (QoL) was assessed with the WHOQOL-BREF scale, a validated 26-item questionnaire which measures satisfaction across four domains: physical (7 items); psychological (6 items); social (3 items); environmental (8 items) [37]. A percentage rating was computed for each domain, with scores ranging from 0 (lowest QoL) to 100 (highest QoL).
Psychological distress. Levels of psychological distress were assessed with the validated Kessler scale (K6). This scale screens for mental illness symptoms over the past 30 days [38]. It includes 6 items evaluating the feelings associated with anxiety, depression and restlessness. Participants were asked to indicate how often they experienced each feeling on a scale from 0 (never) to 4 (all the time). The scores were summed to give a total score ranging from 0 to 24. According to the literature [39], the score can be used to indicate low-grade (0 to 7), moderate (8 to 12) and serious (13 to 24) psychological distress. A score greater than 13 indicates serious mental illness.
Health-related needs and use of healthcare services. Health-related needs were assessed with an open-ended question asking participants to indicate their main health problem. An additional item asked participants to report which healthcare services they had used in the last six months.
Likelihood and difficulty of accessing healthcare. Participants’ likelihood of accessing care and the degree of difficulty they face when accessing healthcare services when necessary were assessed with four items adapted from the Theory of Planned Behaviour [40]. Specifically, participants were asked to indicate their likelihood of accessing healthcare services for physical and psychological problems on a Likert scale from 1 (likely) to 7 (unlikely). In addition, participants were asked to indicate their difficulty in accessing healthcare services for physical and psychological problems on a Likert scale from 1 (easy) to 7 (difficult).
We conducted semi-structured interviews with people experiencing homelessness, using an interview guide to explore health-related experiences (e.g. “What is it like when you visit healthcare services”), needs (e.g. “How well do you think the care you receive meets your health needs?”) and expectations (e.g. “What could be done to improve healthcare in your opinion?”). To complement this data, we conducted semi-structured interviews with homeless-serving sector professionals, exploring their perceptions of the health needs of people experiencing homelessness (e.g. “In your view, what are the reasons for people experiencing homelessness to visit the healthcare system?”), their experiences (e.g. “In your opinion, what is it like for people experiencing homelessness when they need to visit healthcare?”) and expectations (e.g. “In your opinion, which structure would be the most appropriate for people experiencing homelessness to receive care?”). Both interview guides are provided in the appendix.
The questionnaire data was recorded in REDCap© by a research assistant (JN). A second researcher (EH) double-checked data entry to minimise errors. Descriptive statistics were used to summarise the data (e.g. proportions, means, standard deviations). Descriptive statistics were performed using IBM SPSS (version 27) by the first author (LS) under the supervision of the last author (VG).
The data was analysed using inductive conventional content analysis with a comparative process [41, 42]. The interviews were recorded and then transcribed verbatim by a professional transcriptionist. To develop the two codebooks, two researchers (EH, PhD candidate, and LS, a medical doctorate candidate) with experience in qualitative research completed initial coding independently. The researchers pooled their codes to reduce redundant, idiosyncratic or common codes to generate a comprehensive codebook. A third senior researcher (VG, a PhD, Privat-Docent tested the codebook and provided feedback, resulting in codebook adaptations. Then, three researchers (EH, VG and LS) triple-coded 10% of the interviews until an inter-judge agreement of at least 80% was obtained. A single researcher (LS) conducted focused coding on the rest of the interviews and explored overarching topic areas using Atlas.ti software version 9.0.3.
The study was conducted in accordance with the Declaration of Helsinki and all procedures were approved by the local ethics committee (project number: ID 2022—249).
In total, 123 people experiencing homelessness completed the quantitative questionnaires. The mean age of participants was 41.2 years (SD: 12.2) and most (91%) were men (table 1). The majority was from Europe (52%) and did not hold a Swiss residence permit (62%). Health insurance coverage was reported by 49% of the participants. Most participants usually slept in emergency shelters (60%).
Table 1Demographic characteristics of participants (n = 123).
| Age | Age in years, mean and SD | 41.2 | 12.2 |
| Missing, n and % | 2 | 2.46% | |
| n | % | ||
| Sex | Male | 112 | 91% |
| Female | 11 | 9% | |
| Nationality | European | 64 | 52% |
| Non-European | 51 | 41% | |
| Residence status | No residence permit | 76 | 62% |
| B (residence foreign national’s permit) | 10 | 8% | |
| Swiss | 8 | 7% | |
| N (permit for asylum seekers) | 5 | 4% | |
| Other* | 4 | 3% | |
| C (settled foreign national permit) | 3 | 2% | |
| Did not know | 10 | 8% | |
| Did not want to answer | 3 | 2% | |
| Missing | 4 | 3% | |
| Education | Compulsory education | 30 | 24% |
| High school level | 30 | 24% | |
| General professional apprenticeship | 24 | 20% | |
| College education | 19 | 15% | |
| Did not finish school | 18 | 15% | |
| Did not want to answer | 2 | 2% | |
| Has health insurance | Yes | 60 | 49% |
| No | 60 | 49% | |
| Did not know | 1 | 1% | |
| Did not want to answer | 1 | 1% | |
| Missing | 1 | 1% | |
| Ethos Light typology | Emergency shelter | 74 | 60% |
| Sleeping rough | 25 | 20% | |
| Non-conventional accommodation** | 7 | 6% | |
| Sleeping at relative’s place | 7 | 6% | |
| Lost their home | 4 | 3% | |
| Refugee shelter | 3 | 2% | |
| Institution | 1 | 1% | |
| Did not know | 1 | 1% | |
| Did not want to answer | 1 | 1% |
* G and L permits (respectively, cross-border commuter permit and short-term residence foreign national permit).
** E.g. mobile homes, squatting, temporary structures, camp.
Mean scores for QoL domains ranged from 48.2 (SD: 21.1, range: 0–100) for environmental QoL to 68.3 (SD: 20, range: 6–100) for psychological QoL (table 2). Participants reported mean scores of 65.3 (SD: 20.5, range: 6–100) for physical QoL and 53.8 (SD: 27.2, range: 0–100) for social QoL.
Table 2Participants’ quality of life (QoL) scores (n = 123). Potential values are in range 0 to 100, with higher values denoting better QoL.
| QoL domain | Domain 1 | Domain 2 | Domain 3 | Domain 4 |
| Physical | Psychological | Social | Environmental | |
| Min = 6; max = 100 | Min = 6; max = 100 | Min = 0; max = 100 | Min = 0; max = 100 | |
| n | 123 | 122 | 123 | 122 |
| Score, mean | 65.3 | 68.3 | 53.8 | 48.2 |
| Score, standard deviation | 20.5 | 20 | 27.2 | 21.1 |
In total, 50% of the participants reported low levels of psychological distress, 33% reported moderate levels of psychological distress and 17% reported high levels of psychological distress.
There was an average of 1.56 (SD: 0.95) health issues per participant among those reporting at least one health issue. About a third (31%) of participants reported having no issues, followed by musculoskeletal (27%) and psychiatric (15%) problems. Participants reported various chronic conditions, including cardiovascular conditions (9%).
As for their use of healthcare services over the previous six months, 25% reported not having used any. Conversely, 31% mentioned using ER, 27% reported using the canton’s community health centre for underserved populations and 19% reported having consulted nurses in homeless shelters. Finally, only 7% reported having seen a general practitioner in the last 6 months (table 3).
Table 3Current health issues and recent contact with healthcare providers (n = 123).
| n | % | |
| Current health issues | ||
| None | 34 | 31% |
| Osteoarticular problems (including back pain) | 30 | 27% |
| Dental problems | 17 | 15% |
| Psychiatric (including substance misuse) | 16 | 15% |
| Cardiovascular problems | 10 | 9% |
| General conditions | 9 | 8% |
| Dermatological problems | 7 | 6% |
| Respiratory problems | 5 | 5% |
| Gastrointestinal problems | 5 | 5% |
| Surgical problems | 5 | 5% |
| Diabetes | 4 | 4% |
| Ophthalmological problems | 4 | 4% |
| Headache | 3 | 3% |
| Neurological and neurosurgery | 3 | 3% |
| Non-specific symptoms | 2 | 2% |
| Angiological problems | 2 | 2% |
| Other (does not fit any of the conditions above) | 1 | 1% |
| Did not provide answer | 13 | 12% |
| Healthcare providers seen in last six months | ||
| None | 31 | 25% |
| Pharmacist | 44 | 36% |
| Emergency room | 38 | 31% |
| Community health centre* | 33 | 27% |
| Shelter nurse | 23 | 19% |
| Dentist | 21 | 17% |
| University walk-in clinic | 18 | 15% |
| Psychologist/ Psychiatrist | 17 | 14% |
| Specialist | 15 | 12% |
| Social ambulance service | 9 | 7% |
| General practitioner | 8 | 7% |
| Surgeon | 6 | 5% |
| Other | 4 | 3% |
* The canton’s only community health centre providing care to underserved populations.
When asked to assess their likelihood of visiting healthcare when needed, most participants (57%) responded that they would likely visit healthcare services if they presented a somatic problem in the following two months, whereas only 37% said they would do so for psychological health problems. When asked to assess how difficult it would be for them to visit healthcare for physical concerns, 20% considered it difficult. As for seeking care for mental health problems, 25% felt that it would be difficult for them (table 4). Interestingly, 39 participants (32%) reported finding it difficult to reach out to the healthcare system for either psychological issues, somatic issues or both.
Table 4aLikelihood and difficulty accessing care.
| Likelihood/difficulty | n | Mean | Median | Mode | SD | Missing | |||||||||||||||
| Likelihood of using healthcare for a physical health issue | 123 | 2.62 | 1.00 | 1.00 | 2.20 | 0 | |||||||||||||||
| Likelihood of using healthcare for a psychological health issue | 122 | 3.89 | 4.00 | 4.00 | 2.61 | 1 | |||||||||||||||
| Difficulty seeking physical care | 123 | 3.19 | 2.00 | 1.00 | 2.39 | 0 | |||||||||||||||
| Difficulty seeking psychological care | 121 | 3.79 | 4.00 | 1.00 | 2.49 | 2 | |||||||||||||||
Table 4bIntention (in the following 2 months) to access care, using a Likert scale (n = 123).
| 1 (likely) | 2 | 3 | 4 | 5 | 6 | 7 (unlikely) | |||||||||||||||
| n | % | n | % | n | % | n | % | n | % | n | % | n | % | ||||||||
| If I were to present a physical health issue (e.g. pain or injury), I would seek help through healthcare | 70 | 57% | 5 | 4% | 10 | 8% | 15 | 12% | 2 | 2% | 5 | 4% | 16 | 13% | |||||||
| If I were to present a psychological health issue (e.g. feeling desperate or anxious), I would seek help through healthcare | 45 | 37% | 5 | 4% | 8 | 7% | 11 | 9% | 7 | 6% | 6 | 5% | 40 | 33% | |||||||
Table 4cBehaviour (in the following 2 months) accessing care, using a Likert scale (n = 123).
| 1 (easy) | 2 | 3 | 4 | 5 | 6 | 7 (difficult) | ||||||||||||||
| n | n | % | n | % | n | % | n | % | n | % | n | % | ||||||||
| If I had to visit a healthcare professional for a physical health issue, it would be … | 50 | 15 | 12% | 12 | 10% | 11 | 9% | 3 | 2% | 7 | 6% | 25 | 20% | |||||||
| If I had to visit a healthcare professional for a psychological health issue, it would be … | 41 | 10 | 8% | 7 | 6% | 12 | 10% | 8 | 7% | 12 | 10% | 31 | 25% | |||||||
A subset of the sample of people experiencing homelessness (n = 18; 72% men) and homeless-serving sector professionals (n = 13; 62% women) completed qualitative interviews. Four topic areas emerged from the analysis:
The themes that emerged from the analysis are summarised in table 5.
Table 5Qualitative results (18 people experiencing homelessness and 13 homeless-serving sector professionals).
| Themes and subthemes | Example quote | |
| Experiences in healthcare | Health issues: same as those reported in the quantitative strand | “In general, it [the consultation’s reason] is for my polyarthritis” (participant 9) |
| Emergency rooms as means of accessing healthcare | “I went to the ER because I could not wait 2 weeks to see my general practitioner” (participant 12) | |
| Positive perspectives | “Honestly I have a good opinion about doctors, I always have received good care” (participant 7) | |
| Barriers to seeking healthcare | Lack of health insurance | “The doctor doesn’t want to see me because I lost my health insurance because I lost my permit. So, I don’t have the right to obtain medications!” (participant 9) |
| Delays for appointments in the existing community health centre | “They say ‘No, no, it’s in three weeks’ time’ or something. But if I am sick now, I cannot wait three weeks.” (participant 2) | |
| Fear | “We were scared: [University hospital] and so on!” (participant 12) | |
| Health not being a top priority | “We tell ourselves, ‘It’s going to pass’” (participant 13) | |
| Economic reasons | “Due to lack of means we hesitate” (participant 3) | |
| Ways to overcome said barriers | More medical care | “More medical help [is required] not only for me, but the others too” (participant 5) |
| Developing more community health centres | “Based on the [community health centre] and develop, make small ones” (professional 12) | |
| The importance of drop-in services | “Instead of giving them appointments […] that the visit could be done at the time of the request” ( professional 5) | |
| When the social situation makes people sick | Impact on health of people experiencing homelessness | “To be concerned about where to eat, concerned about employment, it’s quite a lot for the head” (participant 16) |
| Impact on healthcare use of people experiencing homelessness | “I have a general practitioner, but […] it’s been 3–4 times I have missed the appointments because of the night shelter… I hadn’t slept all night! […] So, I had to visit the ER.” (participant 12) | |
The first topic area reported by both people experiencing homelessness and homeless-serving sector professionals related to the health issues commonly faced by people experiencing homelessness. Consistent with quantitative findings, participants (both groups) reported that people experiencing homelessness faced the following health problems: musculoskeletal (e.g. participant 9: “In general, for my polyarthritis”) and psychiatric (e.g. professional 7: “There are psychiatric disorders, that’s obvious”).
Consistent with quantitative findings, people experiencing homelessness and homeless-serving sector professionals reported people experiencing homelessness using ER to seek care, for practical reasons, “I went to the ER because I could not wait 2 weeks to see my general practitioner” (participant 12), or as an entry point into the healthcare system, “In the ER. […] From there, they decide if I need to stay at the hospital or not.” (participant 11). Conversely, very few of the people experiencing homelessness reported seeing a general practitioner.
Additionally, some participants reported seeking care via the canton’s community health centre, as well as through outreach programmes in emergency shelters. Both groups generally reported positive perceptions of people experiencing homelessness of those: “[Community health centre] is helping me for the medicines” (participant 10).
When accessing healthcare, most people experiencing homelessness reported positive interactions with the staff: “I have a good opinion about doctors” (participant 7). Some, although rarer, reported negative experiences: “Last time I went to [university hospital], they told me ‘You always come here’” (participant 5).
Overall, people experiencing homelessness reported being satisfied with their care: “The healthcare system works fine in my opinion” (participant 3). In fact, frequently people experiencing homelessness considered their healthcare experiences in Switzerland better than the ones they had in other countries: “In [other country], everything about healthcare is complicated! […] But Switzerland it’s not like that: they take care of you right away.” (participant 18).
Still, people experiencing homelessness reported encountering various barriers to accessing healthcare. Most of them expressed that their difficulties in receiving care stemmed largely from lacking health insurance: “The doctor doesn’t want to see me because I lost my health insurance because I lost my permit. So, I don’t have the right to obtain medications!” (participant 9). Some people experiencing homelessness reported that a lack of financial resources was an obstacle to healthcare access. Participant 3 said: “Due to lack of means we hesitate [to visit healthcare]”.
Since there is only one community health centre for underserved populations in Vaud Canton, located in Lausanne, participants (both groups) reported limited appointment availability and long waiting times due to the high number of patients. Participant 2 explained: “It’s in three weeks’ time or something. But if I am sick now, I cannot wait three weeks.” In addition, homeless-serving sector professionals reported many difficulties of people experiencing homelessness in getting there: “We send people to Lausanne to the [community health centre] […] but the people don’t go because it’s far and they have to take the train” (homeless-serving sector professional 3).
Furthermore, some professionals and participants reported that it is common for people experiencing homelessness to fear the healthcare system and providers, which prevented them from seeking care, emphasising the importance of trust in their care providers, for instance because of dreading being judged by the staff: “Another thing that’s holding you back is the judgement” (participant 13). Both groups expressed that some people experiencing homelessness were afraid of being reported to the authorities, “Because we were undeclared workers, see, we were scared: [university hospital] and so on!” (participant 12), or of being admitted against their will, “They fear doctors: those are people […] who have experienced involuntary hospitalisation” (professional 5).
In addition, according to most of the homeless-serving sector professionals, seeking healthcare was not a top priority for people experiencing homelessness, who prioritised other, more immediate needs. Professional 6 explained: “Where to eat, where to sleep, how to protect themselves from aggression [...], these are people’s first priorities, and in fact, health comes second, third, fourth, fifth”. One of the contributors to this lack of prioritisation seems to be poor health literacy; participant 13 explained: “We tell ourselves ‘It’s going to pass, we’ll see’ and being no doctor, having not taken any tests, we don’t know what’s going on in the body and finally, generally when we tell ourselves ‘Well, I am going to go now’, it may already be too late.”
In response to the reported barriers, both groups agreed that people experiencing homelessness needed better access to medical care. Participant 5 reported, “More medical help [is required]”; in particular both groups expressed the need for more mental health care: “I would like to find a good doctor for my depression” (participant 6). To improve access to healthcare for people experiencing homelessness, the professionals suggested developing more community health centres like the existing one. Professional 12 suggested: “Based on the [community health centre] and develop, make small ones”. In addition, the professionals valued drop-in services, “Instead of giving them appointments […] that the visit could be done at the time of the request” (professional 5), and outreach programmes, “What’s working best is that the medical staff comes to the person” (professional 6).
The barriers reported above were commonly related to the social and economic determinants of health of people experiencing homelessness, which had direct and indirect consequences on their health. People experiencing homelessness commonly linked their social situation with their use of healthcare services. Participant 2 explained: “Normally nobody with diarrhoea goes to the ER but when you don’t have a home, you have to run all day.” They also reported the impact their social situation had on their health, by causing homelessness-specific conditions: “The mattress, you see, that’s the problem. Scabies is transmissible, and so are bedbugs.” (participant 12). Finally, people experiencing homelessness expressed how the social situation affected their mental health; participant 16 explained: “To be concerned about where to eat, concerned about employment, it’s quite a lot for the head”; this was so severe that one of them even stated that these struggles have led him to suicidal ideations: “If I don’t see a place to stay, if I cannot sleep: I can end my life” (participant 10).
To the best of our knowledge, this is the first study describing the healthcare needs, experiences and expectations of people experiencing homelessness in Western Switzerland.
In line with a previous Swiss study [15], we found a high prevalence of serious mental distress among people experiencing homelessness, with 17% high risk psychological distress, more than 3-fold higher than in the general Swiss population over 15 years of age according to the Swiss Health Survey, although defined with a different screening instrument [43]. A meta-analysis including studies from high-income countries (for instance US, UK and Germany) reported the prevalence of mental illnesses among the homeless to be 76.2%, mainly alcohol use disorders (36.7%) followed by drug use disorders (21.7%) and schizophrenia-spectrum disorders (12.4%) [44]. Our study reported lower results. This might be because the K6 Score does not consider psychotic disorders nor substance misuse but is more a screening tool. More research to characterise mental health of people experiencing homelessness in Switzerland is needed. As reported in other countries, QOL scores of people experiencing homelessness were lower than in the general population [45]. No WHOQOL data was available for the Swiss general population for comparison, but our results are much lower than those in Denmark [46]. Although this comparison requires caution, these findings suggest that, as elsewhere, people experiencing homelessness in Switzerland are at risk of experiencing lower QoL than the general population. Moreover, consistent with previous studies [22], both groups reported that homelessness has a considerable negative impact on the health of people experiencing homelessness and is a major driver of healthcare use patterns.
Most participants in our sample did not have residence permits. This can be explained by the fact that emergency shelters cater for the most precarious section of Swiss society (lack of social assistance and subsidies). To reduce those structural health inequities, policies need to act on social determinants of health. Programmes such as Housing First have shown promising findings in terms of improving QoL, mental health and need for inpatient care [47–50]. In Switzerland, Housing First research is just beginning [51]. Moreover, as reported elsewhere [10, 11], our findings suggest that people experiencing homelessness may be more likely to seek care in ER settings due to lack of other options: 31% reported visiting the ER over the previous six months, which is slightly more than the general Swiss population: the Swiss Health Observatory reported in 2016 that approximately 20% of the Swiss population of this age visited the ER at least once over one year [52]; this rate is higher when the patients are from abroad and similar to those identified in our study. In Switzerland, although health insurance is mandatory, undocumented people often lack insurance coverage, limiting their care outside ED. Although some emergency care might be needed, it does not replace follow-up. Strengthening the ambulatory care network of people experiencing homelessness via primary care physicians showed good outcomes in Canada [8]. In Australia [53], the implementation of a psychiatric outreach programme has shown positive outcomes on emergency psychiatric visits. Therefore, addressing social determinants of health via Housing First combined with actively providing outreach psychiatric and primary care programme appear to be two areas for action.
Inconsistent with past international literature documenting negative experiences in healthcare [54–56], homeless participants reported mostly positive healthcare experiences. In fact, some people experiencing homelessness reported previous negative healthcare experiences in other countries and considered their care to be better in Switzerland. Consistent with the literature, people experiencing homelessness in our study seemed to place a lower priority on seeking healthcare compared to other, more pressing needs [22]. Additionally, although not evaluated in the current study, people experiencing homelessness typically have low levels of health literacy [57], which could lead to lower healthcare expectations. In Lausanne, the canton’s main city (where the majority of people experiencing homelessness are found), there are targeted ways for people experiencing homelessness to access healthcare: via Medecins du Monde’s outreach programme and the community health centre. Despite these, 32% of people experiencing homelessness encounter difficulties in accessing care. Our qualitative findings provide insights into the barriers to healthcare. Mainly, people experiencing homelessness noted that a lack of health insurance prevented them from accessing healthcare. In addition, in line with previous research, our qualitative findings report other barriers faced in accessing care [23, 27, 58], namely financial resources, fear of healthcare providers and settings, and prioritisation of immediate primary needs over health. One of the major contributors to the fear of healthcare is the fact that most of our sample (62%) reported not holding a valid Swiss residence permit. Finally, part of the difficulty was attributed to an insufficient number of community health centres, resulting in delays in obtaining appointments.
Findings of this study should be interpreted in the light of several limitations. First, participants who completed the quantitative questionnaire were recruited in institutions serving the people experiencing homelessness (convenience sampling); therefore, the sample may not be representative of the whole homeless population that includes those not using or accessing homeless services. It is also possible that the sample might be prone to bias as people experiencing homelessness agreeing to participate in the study may differ from those who declined in their health needs and characteristics. Next, our quantitative study includes self-reported data, which can involve reporting bias with respect to social desirability. We limited this bias by having the research team administer the questionnaire to people experiencing homelessness, using professional translators to ensure understanding, and using validated scales. Next, we used triangulation with the quantitative and qualitative data to enhance trustworthiness. Moreover, findings describe health needs, expectations and experiences of people experiencing homelessness in Vaud Canton, which limits the generalisability of findings, although most findings align with previous national and international research. Finally, the number of people experiencing homelessness in Vaud Canton was unknown and 250 was an estimate dating back to 2018 in Lausanne alone that did not use a standardised methodology. In addition, while the Kessler scale is a good tool for assessing psychological distress, our study did not assess substance misuse and psychotic disorders which are reported as the most frequent among the homeless population [44]. Hence, the prevalence of mental distress reported in our study surely underestimates the psychiatric disorders among people experiencing homelessness. Finally, 91% of our sample were men. This could be explained by the recruitment taking place in homeless shelters of Vaud Canton in which the population is composed of men in majority (86.3%) [59]. Our results are similar to those reported in other Swiss studies [60].
Our study makes an important contribution to the existing literature by being the first to describe the health needs, experiences and expectations of people experiencing homelessness in Western Switzerland. Our findings indicate that people experiencing homelessness in Switzerland are subject to common homelessness-associated health conditions. Unlike previous findings from the international literature, our results highlight rather positive perspectives of people experiencing homelessness about the healthcare system, although access to healthcare remains challenging for people experiencing homelessness in Switzerland. In addition, our study highlighted specific needs and perspectives of people experiencing homelessness in Switzerland about health that influence their healthcare use. Concrete public health actions need to be undertaken such as: (1) the development of novel interventions to provide enhanced medical care to this population to address psychiatric and somatic care; and (2) the creation of public policies that act upon the socioeconomic determinants of health to improve the health of this population in Switzerland.
The authors thank Nuno Miranda and Julie Bridevaux for the transcriptions of the qualitative interviews.
Authors’ contributions: Conceptualisation: VG, PB, CB. Methodology: VG, PB, CB. Formal analysis: VG, LS, EH. Investigation: EH, JN, VG. Resources: VG, PB. Data curation: VG, LS. Writing – Original draft preparation: LS. Writing – Review and editing: EH, LS, JN, LH, TAV, SC, DC , CL, CLo, CB, PB. Supervision: VG, PB, CB. Project administration: PB. Funding acquisition: VG, PB, CB.
This research project was funded by the Leenaards Foundation, project 6071.9.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflict of interest related to the content of this manuscript was disclosed.
1. Commission staff working document: Confronting Homelessness in the European Union. Towards Social Investment for Growth and Cohesion - including implementing the European Social Fund 2014-2020. 2013. https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=celex%3A52013SC0042
2. Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014 Oct;384(9953):1529–40. doi: https://doi.org/10.1016/S0140-6736(14)61132-6
3. Knörle U, Gutwinski S, Willich SN, Berghöfer A. [Associations of mental illness and homelessness: results of a secondary data analysis at a Berlin health center for the homeless]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2022 Jun;65(6):677–87.
4. Baggett TP, Chang Y, Singer DE, Porneala BC, Gaeta JM, O’Connell JJ, et al. Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. Am J Public Health. 2015 Jun;105(6):1189–97. doi: https://doi.org/10.2105/AJPH.2014.302248
5. Moretti DF, Dory É, Favrat PB, Winterton DN. Berger Jé. Précarité et problèmes cutanés. Rev Med Suisse. 2015;•••:5.
6. Bernstein RS, Meurer LN, Plumb EJ, Jackson JL. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. Am J Public Health. 2015 Feb;105(2):e46–60. doi: https://doi.org/10.2105/AJPH.2014.302330
7. Topolovec-Vranic J, Ennis N, Colantonio A, Cusimano MD, Hwang SW, Kontos P, et al. Traumatic brain injury among people who are homeless: a systematic review. BMC Public Health. 2012 Dec;12(1):1059. doi: https://doi.org/10.1186/1471-2458-12-1059
8. Khandor E, Mason K, Chambers C, Rossiter K, Cowan L, Hwang SW. Access to primary health care among homeless adults in Toronto, Canada: results from the Street Health survey. Open Med. 2011;5(2):e94–103.
9. Campbell RB, Larsen M, DiGiandomenico A, Davidson MA, Booth GL, Hwang SW, et al. The challenges of managing diabetes while homeless: a qualitative study using photovoice methodology. CMAJ. 2021;193(27):E1034–41. doi: https://doi.org/10.1503/cmaj.202537
10. Capp R, Rosenthal MS, Desai MM, Kelley L, Borgstrom C, Cobbs-Lomax DL, et al. Characteristics of Medicaid enrollees with frequent ED use. Am J Emerg Med. 2013 Sep;31(9):1333–7. doi: https://doi.org/10.1016/j.ajem.2013.05.050
11. Abramson TM, Sanko S, Eckstein M. Emergency Medical Services Utilization by Homeless Patients. Prehosp Emerg Care. 2021;25(3):333–40. doi: https://doi.org/10.1080/10903127.2020.1777234
12. Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in New York City. N Engl J Med. 1998 Jun;338(24):1734–40. doi: https://doi.org/10.1056/NEJM199806113382406
13. Nusselder WJ, Slockers MT, Krol L, Slockers CT, Looman CW, van Beeck EF. Mortality and life expectancy in homeless men and women in Rotterdam: 2001-2010. PLoS One. 2013 Oct;8(10):e73979. doi: https://doi.org/10.1371/journal.pone.0073979
14. Le nombre de sans-abri suisses augmente. Le Temps 17 nov 2018 https://www.letemps.ch/suisse/vaud/nombre-sansabri-suisses-augmente
15. Briner D, Jäger M, Kawohl W, Baumgartner-Nietlisbach G. [Mental Disorder and Self-Rated Health Among Homeless People in Zurich - First Epidemiological Data from Switzerland]. Psychiatr Prax. 2017 Sep;44(6):339–47.
16. Lauber C, Lay B, Rössler W. Homelessness among people with severe mental illness in Switzerland. Swiss Med Wkly. 2005 Jan;135(3-4):50–6.
17. Lauber C, Lay B, Rössler W. Homeless people at disadvantage in mental health services. Eur Arch Psychiatry Clin Neurosci. 2006 Apr;256(3):138–45. doi: https://doi.org/10.1007/s00406-005-0616-4
18. Janssens JP, Wuillemin T, Adler D, Jackson Y. Screening for tuberculosis in an urban shelter for homeless in Switzerland: a prospective study. BMC Infect Dis. 2017 May;17(1):347. doi: https://doi.org/10.1186/s12879-017-2449-y
19. Baggio S, Jacquerioz F, Salamun J, Spechbach H, Jackson Y. Equity in access to COVID-19 testing for undocumented migrants and homeless persons during the initial phase of the pandemic. J Migr Health. 2021;4:100051. doi: https://doi.org/10.1016/j.jmh.2021.100051
20. Pendyal A, Rosenthal MS, Spatz ES, Cunningham A, Bliesener D, Keene DE. “When you’re homeless, they look down on you”: A qualitative, community-based study of homeless individuals with heart failure. Heart Lung. 2021;50(1):80–5. doi: https://doi.org/10.1016/j.hrtlng.2020.08.001
21. Heaslip V, Green S, Simkhada B, Dogan H, Richer S. How Do People Who Are Homeless Find Out about Local Health and Social Care Services: A Mixed Method Study. Int J Environ Res Public Health. 2021 Dec;19(1):46. doi: https://doi.org/10.3390/ijerph19010046
22. Omerov P, Craftman ÅG, Mattsson E, Klarare A. Homeless persons’ experiences of health- and social care: A systematic integrative review. Health Soc Care Community. 2020 Jan;28(1):1–11. doi: https://doi.org/10.1111/hsc.12857
23. Paudyal V, MacLure K, Buchanan C, Wilson L, Macleod J, Stewart D. ‘When you are homeless, you are not thinking about your medication, but your food, shelter or heat for the night’: behavioural determinants of homeless patients’ adherence to prescribed medicines. Public Health. 2017 Jul;148:1–8. doi: https://doi.org/10.1016/j.puhe.2017.03.002
24. McNeill S, O’Donovan D, Hart N. Access to healthcare for people experiencing homelessness in the UK and Ireland: a scoping review. BMC Health Serv Res. 2022 Jul;22(1):910. doi: https://doi.org/10.1186/s12913-022-08265-y
25. Klop HT, Evenblij K, Gootjes JR, de Veer AJ, Onwuteaka-Philipsen BD. Care avoidance among homeless people and access to care: an interview study among spiritual caregivers, street pastors, homeless outreach workers and formerly homeless people. BMC Public Health. 2018 Sep;18(1):1095. doi: https://doi.org/10.1186/s12889-018-5989-1
26. Cernadas A, Fernández Á. Healthcare inequities and barriers to access for homeless individuals: a qualitative study in Barcelona (Spain). Int J Equity Health. 2021 Mar;20(1):84. doi: https://doi.org/10.1186/s12939-021-01409-2
27. Kneck Å, Mattsson E, Salzmann-Erikson M, Klarare A; in collaboration with Women Advisory Board for Inclusion Health. “Stripped of dignity” - Women in homelessness and their perspectives of healthcare services: A qualitative study. Int J Nurs Stud. 2021 Aug;120:103974. doi: https://doi.org/10.1016/j.ijnurstu.2021.103974
28. Bell L, Whelan M, Fernandez E, Lycett D. Nurse-led mental and physical healthcare for the homeless community: A qualitative evaluation. Health Soc Care Community. 2022 Nov;30(6):2282–91.
29. Jackson Y, Wuillemin T, Bodenmann P. Santé et soins des personnes sans abri. Rev Med Suisse. 2016 Oct;12(533):1671–5. doi: https://doi.org/10.53738/REVMED.2016.12.533.1671
30. Federal Statistical Office. Population résidante permanente selon la catégorie de nationalité, l’âge et le canton, 3e trimestre 2022 - 1.1.2022-30.9.2022 | Tableau. Federal Statistical Office. 2022. https://www.bfs.admin.ch/asset/fr/23728335
31. Center for Primary Care and Public Health (Unisante), University of Lausanne, Switzerland. Homeless People in French-speaking Switzerland and Integrative Medicine: A Pilot Intervention in Music Therapy. clinicaltrials.gov; 2023 nov [cité 1 janv 2024]. Report No.: NCT05873491. Disponible sur: https://clinicaltrials.gov/study/NCT05873491
32. Östlund U, Kidd L, Wengström Y, Rowa-Dewar N. Combining qualitative and quantitative research within mixed method research designs: a methodological review. Int J Nurs Stud. 2011 Mar;48(3):369–83. doi: https://doi.org/10.1016/j.ijnurstu.2010.10.005
33. O’Cathain A, Thomas KJ, Drabble SJ, Rudolph A, Hewison J. What can qualitative research do for randomised controlled trials? A systematic mapping review. BMJ Open. 2013 Jun;3(6):e002889. doi: https://doi.org/10.1136/bmjopen-2013-002889
34. Palinkas LA. Qualitative and mixed methods in mental health services and implementation research. J Clin Child Adolesc Psychol. 2014;43(6):851–61. doi: https://doi.org/10.1080/15374416.2014.910791
35. Lingard L, Albert M, Levinson W. Grounded theory, mixed methods, and action research. BMJ. 2008 Aug;337 aug07 3:a567. doi: https://doi.org/10.1136/bmj.39602.690162.47
36. ETHOS Typology on Homelessness and Housing Exclusion. [cité 16 févr 2023]. Disponible sur: https://www.feantsa.org/en/toolkit/2005/04/01/ethos-typology-on-homelessness-and-housing-exclusion
37. Skevington SM, Lotfy M, O’Connell KA; WHOQOL Group. The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res. 2004 Mar;13(2):299–310. doi: https://doi.org/10.1023/B:QURE.0000018486.91360.00
38. Furukawa TA, Kessler RC, Slade T, Andrews G. The performance of the K6 and K10 screening scales for psychological distress in the Australian National Survey of Mental Health and Well-Being. Psychol Med. 2003 Feb;33(2):357–62. doi: https://doi.org/10.1017/S0033291702006700
39. Prochaska JJ, Sung HY, Max W, Shi Y, Ong M. Validity study of the K6 scale as a measure of moderate mental distress based on mental health treatment need and utilization. Int J Methods Psychiatr Res. 2012 Jun;21(2):88–97. doi: https://doi.org/10.1002/mpr.1349
40. Ajzen I. The theory of planned behaviour: reactions and reflections. Psychol Health. 2011 Sep;26(9):1113–27. doi: https://doi.org/10.1080/08870446.2011.613995
41. Chamaz K. Coding in Grounded Theory Practice. Constructing Grounded Theory : a practical guide through qualitative analysis. Los Angeles: Sage Publications; 2006.
42. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005 Nov;15(9):1277–88. doi: https://doi.org/10.1177/1049732305276687
43. Federal Statistical Office. Health - Pocket Statistics 2023 | Publication. Office fédéral de la statistique. 2023 [cité 4 avr 2023]. Disponible sur: https://www.bfs.admin.ch/asset/fr/24131868
44. Gutwinski S, Schreiter S, Deutscher K, Fazel S. The prevalence of mental disorders among homeless people in high-income countries: an updated systematic review and meta-regression analysis. PLoS Med. 2021 Aug;18(8):e1003750. doi: https://doi.org/10.1371/journal.pmed.1003750
45. Sun S, Irestig R, Burström B, Beijer U, Burström K. Health-related quality of life (EQ-5D) among homeless persons compared to a general population sample in Stockholm County, 2006. Scand J Public Health. 2012 Mar;40(2):115–25. doi: https://doi.org/10.1177/1403494811435493
46. Noerholm V, Groenvold M, Watt T, Bjorner JB, Rasmussen NA, Bech P. Quality of life in the Danish general population—normative data and validity of WHOQOL-BREF using Rasch and item response theory models. Qual Life Res. 2004 Mar;13(2):531–40. doi: https://doi.org/10.1023/B:QURE.0000018485.05372.d6
47. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet. 2014 Oct;384(9953):1541–7. doi: https://doi.org/10.1016/S0140-6736(14)61133-8
48. Collins SE, Taylor EM, King VL, Hatsukami AS, Jones MB, Lee CY, et al. Suicidality Among Chronically Homeless People with Alcohol Problems Attenuates Following Exposure to Housing First. Suicide Life Threat Behav. 2016 Dec;46(6):655–63. doi: https://doi.org/10.1111/sltb.12250
49. Tinland A, Loubière S, Boucekine M, Boyer L, Fond G, Girard V, et al. Effectiveness of a housing support team intervention with a recovery-oriented approach on hospital and emergency department use by homeless people with severe mental illness: a randomised controlled trial. Epidemiol Psychiatr Sci. 2020 Sep;29:e169. doi: https://doi.org/10.1017/S2045796020000785
50. Loubière S, Lemoine C, Boucekine M, Boyer L, Girard V, Tinland A, et al. Housing First for homeless people with severe mental illness: extended 4-year follow-up and analysis of recovery and housing stability from the randomized Un Chez Soi d’Abord trial. Epidemiology and Psychiatric Sciences. ed 2022;31:e14.
51. Garcia Gonzalez De Ara C, Morandi S, Lippuner M, Delmatti J, Golay P, Bonsack C. [Housing first : at home recovery of severe mental disorder]. Rev Med Suisse. 2017 Sep;13(575):1605–9.
52. Swiss Health Observatory. Le recours aux services d’urgences en Suisse. OBSAN. 2018 [cité 3 avr 2023]. Disponible sur: https://www.obsan.admin.ch/fr/publications/2018-le-recours-aux-services-durgences-en-suisse
53. James M, Greenhill M, Sullivan D. Introduction of a homeless health outreach team in Northern New South Wales: is acute service usage reduced? Australas Psychiatry. 2023 Aug;31(4):441–4. doi: https://doi.org/10.1177/10398562231164869
54. Purkey E, MacKenzie M. Experience of healthcare among the homeless and vulnerably housed a qualitative study: opportunities for equity-oriented health care. Int J Equity Health. 2019 Jul;18(1):101. doi: https://doi.org/10.1186/s12939-019-1004-4
55. Nickasch B, Marnocha SK. Healthcare experiences of the homeless. J Am Acad Nurse Pract. 2009 Jan;21(1):39–46. doi: https://doi.org/10.1111/j.1745-7599.2008.00371.x
56. Rae BE, Rees S. The perceptions of homeless people regarding their healthcare needs and experiences of receiving health care. J Adv Nurs. 2015 Sep;71(9):2096–107. doi: https://doi.org/10.1111/jan.12675
57. Farrell SJ, Dunn M, Huff J; Psychiatric Outreach Team; Royal Ottawa Health Care Group. Examining Health Literacy Levels in Homeless Persons and Vulnerably Housed Persons with Mental Health Disorders. Community Ment Health J. 2020 May;56(4):645–51. doi: https://doi.org/10.1007/s10597-019-00525-2
58. Omerov P, Craftman ÅG, Mattsson E, Klarare A. Homeless persons’ experiences of health- and social care: A systematic integrative review. Health Soc Care Community. 2020 Jan;28(1):1–11. doi: https://doi.org/10.1111/hsc.12857
59. Stadelmann S, Debons J, Samitca S. Profils et trajectoires des bénéficiaires des hébergements d’urgence dans le canton de Vaud en 2021. Centre universitaire de médecine générale et santé publique (Unisanté); 2022. https://www.unisante.ch/fr/formation-recherche/recherche/publications/raisons-sante/raisons-sante-338
60. Dittmann J, Dietrich S, Stroezel H, Drilling M, Young C, Roduit S. Ausmass, Profil und Erklärungen der Obdachlosigkeit in 8 der grössten Städte der Schweiz. 2022. https://www.centre-lives.ch/fr/bibcite/reference/104
The appendix is available in the pdf version of the article at https://doi.org/10.57187/s.3659.