An exploration of mental healthcare inequality for people experiencing homelessness

Abstract

People experiencing homelessness face profound mental health inequalities. This thesis explores these inequalities through two complementary qualitative studies.
Chapter 1 presents a systematic review, synthesising findings from 57 qualitative papers exploring how people experiencing homelessness perceive mental health services. Using meta-ethnography, 22 interpretive metaphors and seven higher level themes were developed: stigma and dehumanisation, distrust and mistrust, trauma, power, lack of understanding of homelessness, intersectionality, and intergenerational poverty. The synthesis culminates in a conceptual model illustrating how factors operate at multiple ecological levels, driving three overarching mechanisms of inequality: avoidance of care, exclusion from care, and the creation of setting conditions for poor mental health. The review highlights the need to move beyond reductive, panacea-driven approaches and calls for iterative reforms across service, policy, and cultural domains, including trauma-informed, relationship-based, and culturally competent care.
Chapter 2 complements these findings by exploring healthcare professionals’ perspectives on barriers to care using reflexive thematic analysis. Three interrelated themes were developed: (1) Deemed “undeserving”: how stigma shapes systems of exclusion, (2) Systemic misfit: how standard service models disengage those with complex needs, (3) How to make care possible in impossible systems – relational practice as resistance. Clinicians face substantial challenges in providing mental healthcare to people experiencing homelessness in the context of structural stigma, exclusionary systems, and a lack of trauma-informed approaches. Specialist services attempt to fill the gap through flexible, inclusive, and relational care, but are overburdened and unsustainably stretched.
Together, these studies offer a systems-level understanding of mental health inequalities in the context of homelessness. The findings emphasise the need for cross-sector collaboration, integrated and flexible service models, long-term investment, and structural reform. This thesis contributes to theoretical and practical understandings of mental health inequality and provides a framework for engaging with complexity and designing more inclusive care for marginalised populations.

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Identifiers

ORCID for Elizabeth Grace Bodley Scott: orcid.org/0000-0002-3594-6942

ORCID for Nick Maguire: orcid.org/0000-0003-4295-8068

ORCID for Stephanie Barker: orcid.org/0000-0002-2886-4113

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