Abstract
Background
Indigenous Peoples experiencing homelessness have a life expectancy that is thirty years shorter compared to their housed counterparts. For over a third, avoidable death may be prevented by timely and adequate delivery of primary health care. Given the prevalence of mental and physical health conditions exacerbated by homelessness, outreach health care has been identified as an effective method for improving healthcare delivery. However, little is known about the perspectives of the outreach health care workforce delivering care to Indigenous Peoples experiencing homelessness; and about the perspectives of Indigenous recipients of outreach health care provision for people experiencing homelessness.
Aim
This research aimed to synthesise existing qualitative evidence that explored the perspectives of outreach health care workforce delivery to Indigenous Peoples experiencing homelessness; and the perspectives of outreach health care uptake for Indigenous Peoples experiencing homelessness.
Methodologies
Critical Theory, Critical Race Theory, and Kaupapa Māori Methodologies informed the theoretical positioning. Critical Theory positioned the critique of Indigenous experiences within the historical and ongoing impact of colonisation. Critical Race Theory examined dominant cultural orientations, and Kaupapa Māori Methodologies centred Māori ways of knowing and doing as the experts in the critique of existing power structures.
Methods
This research employed a systematic review with meta-synthesis of qualitative data reported according to the ENTREQ (Enhancing transparency in reporting the synthesis of qualitative research) guidelines. A highly sensitive search of three electronic databases (CINAHL, Ovid-Emcare, Scopus), and a hand search of one database (Google Scholar) were conducted to identify studies that reported on the perspectives of outreach health care workforce who deliver health care to Indigenous Peoples experiencing homelessness; and the experiences of Indigenous recipients of outreach health care for people experiencing homelessness. Studies were included if they were published between 2003 and 2023 and published in the English language. Actor-Network theory was used to analyse the data. Data were extracted and analysed line-by-line deductively to identify both human and non-human (technology, ideas, animals) actors who comprise, enable, or disrupt the outreach healthcare network for Indigenous Peoples experiencing homelessness. Actors who had more than 9 relationships were conceived as central actors, while actors who had 5 to 8 relationships were considered secondary actors and actors with 0 to 4 relationships within the network were considered peripheral actors. The strength of a relationship between actors was informed by the number of codes assigned to a relationship. Relationships with thirteen to eighteen codes assigned were considered strong relationships, while relationships with 7 to twelve codes assigned were identified as moderate relationships. Relationships with 0 to 6 codes assigned were considered low.
Results
Two qualitative studies proved eligible. Meta-synthesis identified 16 actors comprising the outreach healthcare network for Indigenous Peoples experiencing homelessness. Central actors included outreach team and outreach health care. Secondary actors included health prevention, unhoused, healthcare continuity, research, general healthcare, health outcomes, housed, discrimination, disaffiliation, and advocacy. Peripheral actors included trust, person-centred care, Indigenous Peoples, and government. The actor outreach team was identified as a significant actor with ten relationships that enabled the network to function. Multi-disciplinary teams including nurses, cultural support, housing and social support services were pivotal to the effectiveness of outreach healthcare services. The actor outreach healthcare enabled the network to function, however, disruption occurred when service-use was conditional to the needs of outreach healthcare services. Traditional characteristics of outreach health care ensured access, these included free access, removal of administrative barriers and a mobile service. The actor Indigenous Peoples was identified as a peripheral actor despite their reported effectiveness in increasing service-uptake among Indigenous Peoples experiencing homelessness. Actor Indigenous Peoples did not impact on actors’ outreach healthcare, government, or research.
Conclusion
The actor network analysis confirmed Indigenous experiences of homelessness are diverse and that precipitant and maintenance factors differ between Indigenous and non-Indigenous Peoples experiencing homelessness. The United Nations Declaration for the Rights of Indigenous Peoples mandate governments address housing, health and wellbeing and cultural preservation for Indigenous Peoples. In Aotearoa New Zealand government must consider the specific needs of Māori. This is particularly important, given the predicted tidal wave of homeless expected in Aotearoa New Zealand, which is likely to disproportionately impact Māori. Future recommendations include the delivery of outreach healthcare provision with a focus on Indigenous governance, workforce development and relational funding models to achieve health equity for Indigenous Peoples experiencing homelessness.