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Conteúdo (article):

Determinantes Sociais da Saúde para Pessoas Idosas em Situação de Rua: uma revisão de escopo.


Social determinants of health among older homeless people: a scoping review.


Antônio Batista Silva (https://orcid.org/0000-0002-3874-9290)1
Hugo Moura de Albuquerque Melo (https://orcid.org/0000-0001-8072-337X)2
Beatriz de Lourdes Santos Chagas (https://orcid.org/0000-0003-2356-1786)3
Anna Karla de Oliveira Tito Borba (https://orcid.org/0000-0002-9385-6806)4
Danielle de Andrade Pitanga Melo (https://orcid.org/0000-0003-2340-3796)5
1Mestrando em Gerontologia, Centro de Ciências da Saúde da Universidade Federal de Pernambuco – UFPE. Recife, Pernambuco, Brasil. antonio.batista191@gmail.com
2 Professor Doutor no Programa de Pós-Graduação em Gerontologia, Centro de Ciências da Saúde da Universidade Federal de Pernambuco –UFPE. Recife, Pernambuco, Brasil. Hugo.amelo@ufpe.br
3Mestranda em Psicologia, Centro de Filosofia e Ciências Humanas, CFCH – UFPE. Recife, Pernambuco, Brasil..
4Professora Doutora no Programa de Pós-Graduação em Gerontologia, Centro de Ciências da Saúde da Universidade Federal de Pernambuco –UFPE. Recife, Pernambuco, Brasil. anna.tito@ufpe.br
5 Professora Doutora no Programa de Pós-Graduação em Gerontologia, Centro de Ciências da Saúde da Universidade Federal de Pernambuco –UFPE. Recife, Pernambuco, Brasil. danielle.pitanga@ufpe.br

RESUMO:
Objetivo: Mapear e analisar os estudos que abordam os determinantes sociais da saúde para pessoas idosas em situação de rua. Método: Trata-se de uma revisão de escopo elaborada de acordo com estrutura metodológica do Joanna Briggs Institute. A pesquisa foi realizada nas bases de dados: Apa Psycnet, LILACS, Medline/PubMed, Scopus, Web of Science e Embase e também na literatura cinzenta: Google Acadêmico; Cochrane Library; Catálogo de Teses e Dissertações (CAPES); Cybertesis e NDLTD. Resultados: No total foram encontradas 658 referências e a amostra final resultou em quatro estudos. Os impactos para a população idosa em situação de rua estiveram presentes em todos os artigos e relacionados diretamente com os determinantes sociais da saúde. Conclusões: Evidenciou-se que questões socioeconômicas, falta de apoio familiar, desemprego, ausência de habitação adequada e demandas de saúde mental são os determinantes sociais da saúde mais presentes do público estudado e impactam diretamente nas condições de saúde de pessoas idosas em situação de rua.
Palavras-chaves: determinantes sociais da saúde; pessoas idosas; pessoas em situação de rua.

ABSTRACT
Objective: To map and analyze studies addressing the social determinants of health among older homeless people. Method: We conducted a scoping review guided by the methodological framework proposed by the Joanna Briggs Institute. Searches were undertaken of the following databases: Apa PsycNET, LILACS, Medline/PubMed, Scopus, Web of Science and Embase. We also searched for grey literature using Google Scholar, The Cochrane Library, Catalogue of Theses and Dissertations (CAPES), Cybertesis and NDLTD. Results: A total of 658 references were retrieved. After screening the final sample consisted of four studies. Impacts on older homeless people were mentioned in all the articles and directly related to social determinants of health. Conclusions: The findings show that the main social determinants of health affecting older homeless people were socioeconomic problems, lack of family support, unemployment, lack of adequate housing and mental health issues, having a direct impact on the health of this group.
Keywords: social determinants of health; older people; the homeless.


INTRODUCTION

Brazil’s older population is growing at an unprecedented rate and is projected to become increasingly significant. According to the 2022 census conducted by the Brazilian Institute of Geography and Statistics (IBGE), the older population increased by 15.1% between 2012 and 2021, while the population aged under 30 decreased by 5.4%. Currently, people aged 30 years and over account for 56.1% of the total population(1).
Population ageing in Brazil and around the world has led to significant changes in demographic profiles over time, especially across the different age groups. However, although demographic transition is a universal phenomenon, its effects differ across world regions and between countries in the same region. The demographic transition began in the 19th century in first world countries, starting much later in Latin America and the Caribbean. This is particularly worrying since the latter regions face high levels of poverty and social inequality(2).
Ageing is a multidimensional process that is strongly influenced by social factors. Successful aging can depend on childhood and adulthood experiences. Public policies should therefore focus not only on old age, but also on promoting favorable social conditions throughout the course of human development, ensuring healthy development and quality ageing(3).
Public policies in Brazil have addressed social issues related to inequality and health inequities, emphasizing the concept of social determinants of health (SDH). This concept stresses the importance of living conditions and public policies for the promotion of health. Historically, SDH have reflected an increasingly comprehensive understanding of health, recognizing the profound influence of both national and global social, economic and environmental conditions(4).
Among the various conceptual approaches to SDH, the National Commission on Social Determinants of Health adopts the Dahlgren and Whitehead model due to its relative simplicity and graphic clarity, which makes it easily understandable by different audiences. The model organizes SDH into layers, incorporating elements of analysis such as age, gender, genetic factors, diet, leisure and information. These layers are divided into an inner layer related to individual factors and an outer layer that encompasses macro-determinants(5).
According to the Commission, SDH are social, economic, cultural, ethnic/racial, psychological and behavioral factors that influence the occurrence of health problems and associated risk factors in a population. The World Health Organization (WHO) defines SDH as follows:
“The conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems” (6) .

According to the Ministry of Health, there is a notable lack of in-depth research exploring SDH and associated dynamics among the homeless population(7). According to Decree 7053 (23 December 2009), the homeless are a diverse group with common characteristics, including extreme poverty, broken or weakened family ties and lack of conventional housing, leading to the use of public spaces on a temporary or permanent basis for housing and survival(8). The UN provides a broader definition, stating that homelessness is not just the deprivation of physical shelter, but rather an extreme violation of the right to housing, security, health and protection(9).
Brazil has witnessed a significant increase in the number of homeless people, who, according to data from the Institute for Applied Economic Research (IPEA), accounted for 3.2% of the country’s population in 2022(10). The presence of older persons living on the streets is a worrying reality, as ageing progressively reduces the body\'s ability to defend itself against external threats. This makes the body more vulnerable to these threats and slows its response, increasing the need for specialized assistance and care(11).
In a study of SDH among the homeless, Nascimento et al (12) highlighted the influence of macro-level structural factors such as the dismantling of services and funding shortages, as well as barriers that hamper the effectiveness of intersectorality and integration of health services targeting this population.
In a study conducted in the municipality of Porto Alegre, Mattos et.al(13) found that older homeless people perceived a deterioration in their health due to their vulnerable situation. Common health conditions in old age, such as heart disease and diabetes, become chronic and more severe in this context. Participants also reported difficulties in accessing health services and obtaining continuous care. Despite national health service guidelines on the monitoring of this population in primary care services, the interviewees reported barriers such as stigma, prejudice and adverse conditions.
In this respect, a study of older homelessness in Montreal highlighted that social determinants play a crucial role in the health of vulnerable populations. In the case of older people, vulnerability can result in degrading living conditions and poor health due to extreme poverty and social exclusion, meaning that many older homeless persons live "life on the edge", subject to various risks(14).
Another study of homeless older people in three countries (England, the USA and Australia) revealed that most interviewees already had physical and mental health problems before living on the streets. However, lack of medical care, unhealthy living conditions and adversity aggravated these illnesses. In addition, mental health deteriorated significantly due to the absence of a safe environment, social isolation and homelessness, intensifying depression and anxiety(15) .
Understanding the characteristics and particularities of homeless older people is essential, given that this group faces extreme vulnerability and various risks. SDH include limited access to health care and difficulties involved in care provision(6). These people are therefore more susceptible to illness due to their life circumstances. Thus, illness is not restricted only to physical aspects, but is rather a reflection of the entire life trajectory of an individual. Health is largely influenced by the conditions in which individuals are born, live, work and age(16.
SDH vary within and across world regions. Specifically regarding the determinants affecting homeless people, a major research effort is underway to develop a global framework for conceptualizing and measuring homelessness to think about and share effective care approaches and intervention methodologies(17).
Although there is a broad body of research on homelessness, studies focusing on older homeless people remain scarce. A scoping review is a research method with a variety of objectives. In this study, this method was used to identify emerging literature in areas where there is a lack of in-depth research(18). The following guiding question was therefore formulated: How do studies characterize social determinants of health among older homeless people? The aim of this scoping review was to map existing studies addressing SDH among older homeless persons.
Reviewing existing literature based on the mapping of these concepts can help detect gaps in knowledge. This review attempts to synthesize current knowledge to provide a basis for future primary studies.

METHOD

Protocol and Registration

We conducted a scoping review following the recommendations contained in the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis, which propose the following steps: 1) definition of the review question; 2) inclusion criteria; 3) search strategy; 4) selection of evidence sources; 5) data extraction and analysis; and 6) presentation of the results(19). This review was also conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extended to Scoping Reviews (PRISMA-ScR) statement(19).
The review protocol was registered on the Open Science Framework (OSF) platform (identifier: DOI 10.17605/OSF.IO/CXTYK at https://osf.io/cxtyk/).

Selection Criteria
The guiding question was formulated based on the PCC mnemonic(19), as follows: Population: older people; Concept: social determinants of health; and Context: homeless. The participants were homeless people aged 60 and over. The eligibility criteria were guided by the research question: How do studies characterize Social Determinants of Health among older homeless people?
The following types of studies were included: 1) Studies addressing homeless people specifically focusing on older persons, based on the definitions adopted by Brazil’s Statute for the Elderly and the WHO; 2) Concept: studies involving and considering Social Determinants of Health, where this approach is underpinned by the principle that social inequalities and socioeconomic conditions influence population health; 3) Studies involving homeless people focusing specifically on older persons. No exclusion criteria were applied. Given the review type and characteristics, no date, language or country restrictions were applied in order to make the search as comprehensive as possible.
Information sources
Searches were performed of the following databases: Latin American and Caribbean Center on Health Sciences Information (LILACS), PubMed, Scopus, Web of Science, Embase and APA PsycNET. A search of relevant grey literature was also performed of Google Scholar, Cybertesis, Networked Digital Library of Theses and Dissertations (NDLTD), CAPES Catalogue of Theses and Dissertations and The Cochrane Library.

Search Strategy
The search strategy was designed by the authors by consensus to identify the likely sources of evidence published in the databases and grey literature. An initial search of PubMed was undertaken to identify keywords and synonyms in the following controlled vocabulary: MeSH, DeCS and Emtree. The terms were then adjusted for each database and grey literature database. The keywords were tested from September 2023 to January 2024.
Using the Boolean operators “AND” and “OR”, a uniform plan was created and validated by three researchers. Two of the researchers had knowledge on the topic and the third was well-versed in the method. The following keywords were used: "Social Determinants of Health", "Socio-Economic Determinants of Health", "Structural determinants of health", "Homeless Persons", "Housed Persons", "Street People", "Homelessness", "Aged" and "Aged, 80 and over". The latter was used to filter out studies specifically involving people Aged 80 and over, since the keyword "Aged" covers studies with people aged up to 79. The associations with the Boolean operators were "AND" and "OR", and the procedure was adapted to each database and grey literature database.
The searches were undertaken on 13 January 2024. To ensure that the review was as comprehensive as possible, we also examined the reference lists of the studies included in the review. Box 1 shows the search strategy used in each of the databases.
Box 1

Selection of Evidence Sources
The studies were exported to the Rayyan® (20) and duplicate articles were removed. Then, in phase 1, two reviewers (A.B.S and B.L.S.C) independently performed blinded title/abstract screening of the retrieved studies, removing all articles that did not meet the inclusion criteria.
In phase 2, the full text of the articles were read by the two reviewers, who were blinded to each other’s assessment. Studies that met the eligibility criteria were selected. Any disagreements at this stage were resolved by the decision of a third reviewer.
Data collection
Data collection was performed following the guidelines set out in the JBI Manual(21). Descriptive mapping of the variables investigated by each study was undertaken using an instrument built into Microsoft® Excel® for Microsoft 365® MSO (Version 2312 Build 16.0.17126.20132) 64 bits. The data were presented in a table containing the following columns: study characteristics (author, year, country and objectives); concept characteristics: social determinants of health and impacts on homeless people.
Two reviewers (A.B.S and B.L.S.C) carried out a preliminary test to assess the viability of the data extraction forms, i.e. whether the proposed variables would result in the extraction of all relevant data needed for qualitative analysis. The study information included in phase 2 was extracted independently using Microsoft Excel® spreadsheets.

Characterization and analysis of the data from the studies
The individual characteristics of the selected studies are described in Table 2. The studies addressing SDH were published between 2017 and 2022, with one study being published in each of the following years 2017, 2020, 2022, and 2021. One study was undertaken in Australia(22), one in the USA(23) and two in Brazil (a master\'s thesis(24) and doctoral dissertation(25)).
All the articles contained findings linked to SDH that were shown to have an impact on the health of older homeless people, including financial insecurity, unemployment, lack of social and family support, use of psychoactive substances and lack of housing(23-26).
All the studies showed that living on the streets is a factor that adversely affects the health and way of life of older homeless persons, since the condition of ageing implies specific needs. In addition, older people tend to gradually lose their autonomy and capacity for self-care management(27).
The findings of the studies showed that older homeless people face difficulties in accessing health care, especially when it comes to continuity of care, and are more susceptible to developing chronic diseases. Box 2 provides a synthesis of the data from the studies selected for this scoping review.
Box 2

RESULTS

The searches of the databases and grey literature retrieved 658 references, 148 of which were removed because they were duplicates, resulting in a total of 510 articles that were eligible for title and abstract screening.
A total of 480 studies were excluded after title and abstract screening because they did not match the study objective, population, concept or context, and six were removed because they were not available on the databases (not open access). The reviewers disagreed on the assessment of 24 studies, resulting in a disagreement rate of 4.76%.
The disagreement rate was calculated based on the number studies where there were disagreements (24) and the total number of studies screened (504): 24/504 x 100 = 4.76 %. Despite the low rate of disagreement, it was necessary to seek assistance from a third reviewer, who excluded a further nine studies, leaving only 15 for full text screening.
A further 11 studies were excluded after full text screening: the studies by Parsell, et.al (2018) and Ye, et.al (2019)(28-34) do not address SDH, while the studies by Parsell et.al (2018), Carroll et.al (2023) and Tabuchi(26,35,36) do not include only elderly people living on the street. The studies by Schwarz et.al (2022) and Jones et.al (2015)(37-40) did not address SDH and the study population was not made up only of elderly people, resulting in a final sample of four studies, as shown in the flowchart below (Figure 1).
Figure 1

DISCUSSION
The objective of this scoping review was to map and analyze studies addressing SDH affecting older homeless people. The findings show that research addressing homelessness, especially older homeless people, remains limited. However, despite the diversity of research methodologies and the fact that the studies were carried out in different countries, the similarities found between the studies indicate a consensus: SDH significantly affect the lives of older homeless people.
The study conducted in the USA(23) showed that older adults with neurodegenerative diseases have a greater propensity for homelessness, and that this condition is exacerbated by socioeconomic issues, lack of family support and unemployment. In this respect, Souza et.al (41) highlight that older homeless people tend to progressively perceive loss of autonomy, which tends to be aggravated by increased susceptibility to risks and chronic diseases and lack of adequate food and safety.
Two of the studies included in this review (24,25) were undertaken in Brazil, in the municipalities of Belo Horizonte and Porto Alegre. The findings show that the main factors influencing homelessness in the study in Belo Horizonte were family conflicts, unemployment, lack of financial support and impoverishment, while the leading factors in Porto Alegre were diminished financial resources to afford housing, domestic violence, broken family ties, use of psychoactive substances and unemployment.
These factors contributed to social vulnerability and are directly linked to SDH, considering that socioeconomic, cultural, political and environmental conditions affect population health(16). Broken family ties, unemployment, financial difficulties, impoverishment, domestic violence and the use of psychoactive substances are a reflection of social inequality and have a direct impact on health.
Despite economic differences between the countries, the findings of the studies in the USA and Brazil show similarities, especially regarding factors contributing to homelessness and the impact of these factors on the health of older homeless people.
When compared to other homeless groups, older people are more vulnerable and susceptible to a greater array of physical and mental health issues, including increased cognitive impairment and dementia and greater propensity towards the consumption of and dependence on psychoactive substances. In combination, these issues can affect elderly people’s ability make decisions to manage their lives(42).
The research undertaken in Australia(22) was the only study to take a gender-specific approach, focusing on needs and barriers to health services among older women living on the streets. The main SDH were domestic and family violence, financial insecurity, divorce and mental health issues. The direct health effects of homelessness were sexual violence, difficulty in obtaining specialist medical care, prejudice and stigma from health professionals, trauma resulting from injuries and depression.
In this respect, a study in New York with 141 homeless women found high rates of physical and sexual violence(43), while a study with homeless women in Los Angeles found that 13% had been raped and that this was one of the main reasons for seeking health services(44).
A study with homeless women aged between 20 and 61 living in São Leopoldo and Novo Hamburgo in the state of Rio Grande do Sul, Brazil corroborates the findings of the above study from the United States. The women reported having experienced various forms of violence, including rape and domestic violence. In addition, these women often have broken family ties and encounter difficulties accessing health care(45).
The findings of the above studies show that women are highly susceptible to various forms of violence and that vulnerability is exacerbated by factors such as advanced age, being female and homelessness, intensifying frailty and increasing the likelihood of threats to their safety.
In general, the findings of the selected studies show that older homeless people tend to have poor and deteriorating health, with all investigations showing that in one way or another SDH have adverse consequences for the lives of these people.
Being homeless is therefore associated with lower life expectancy and higher risk of mortality. In addition, people experiencing homelessness are more likely to use acute hospital services and less likely to access primary and preventive services, which can result in increased risk for later-stage diagnosis of disease(46).
Public policies should therefore prioritize the SDH approach to care for the homeless and greater attention needs to be paid to SDH that have an impact on the health of this group(47).
The main limitation of this scoping review was the fact that research on homelessness in Brazil and worldwide is in its infancy, especially when it comes to older homeless persons, meaning that the number of studies remains limited. Furthermore, the studies involving the population of interest did not address SDH.
While the small number of studies limited the scope of the discussion of this topic, we believe that this review achieved its objective and succeeded in mapping existing literature on the subject, since the focus of the scoping review to provide a broad overview on a topic, identify research gaps and clarify key concepts.
To minimize the limitations of the studies related to the homeless focusing on older persons, we adopted the following strategies during the review: use of as many keywords and databases as possible, inclusion of grey literature, and examination of the selected articles’ reference lists to identify relevant papers to include in the scoping review.
Thus, despite the limited number of studies, the scoping review was the appropriate choice of methodology for this study and was able to identify gaps in knowledge. We therefore believe that the main objective was achieved, and this study makes valuable contributions.

FINAL CONSIDERATIONS
This scoping review identified four studies with older homeless people that address SDH as aspects that directly influence the life and health of this population. The results also show that social issues involving economic, cultural and family aspects, among others, play a crucial role in accessing public health services, programs and policies.
It is important to emphasize that homeless people are not a homogenous group, and, although many aspects are common to this group, this phenomenon is influenced by an array of intersecting factors. Older persons are particularly susceptible to overlapping factors such as frailty due to age, aggravation of chronic diseases and gradual loss of autonomy and mobility, increasing social exclusion and further hampering access to basic rights such as housing and health.
This population is therefore particularly vulnerable, and the health of this group is often affected by precarious living conditions, characterized by the lack of the basic resources needed to survive and greater difficulty in accessing public health policies.
Finally, this study makes a significant contribution to the scientific community in the field of gerontology, demonstrating that older homeless people are a vulnerable group with specific needs that are exacerbated by ageing and highlighting the need for further studies.
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