Equalising cancer screening rates for people experiencing homelessness

The links between cancer, cancer screening and homelessness

Experiences of homelessness place a person at much higher risk of developing cancer, and evidence shows that cancer is among the leading causes of death for people experiencing homelessness. The extreme damage that homelessness causes to health, the exposure to cancer risk factors, and the inaccessibility of preventative healthcare all mean that measures to prevent and detect cancers should be a core healthcare initiative for people experiencing homelessness.

However, data from Homeless Link’s Unhealthy State of Homelessness report shows that just 29% of eligible homeless women had attended a breast screening in the previous three years, in contrast to 70% of the general population. Cervical screening rates were comparably reduced, with 38% of eligible people accessing screening in the previous three years as compared to 69% of the general population.

What is this resource?

This report, Cancer screening and homelessness, aims to join the dots on what works to improve cancer screening, including how the frontline homelessness sector can support increased uptake for people experiencing homelessness, identifying opportunities for joint work with screening teams and how each can lean on the other’s specialities to improve the screening experience.

The project also explores how system barriers currently support or prevent best practice, presenting a range of recommendations for policy-makers on how access to screening can be made more equitable for people experiencing homelessness.

System barriers

While improvements have been made to inclusion health outreach in recent years, structural and service-level barriers mean that tailored cancer prevention services are limited to the point of being ‘effectively non-existent'. Barriers include:

• Information systems not inviting people to screenings - typically a postal-only invitation system that will not reach people without a fixed address; unable to cope with people movement / changes in address; unable to target people experiencing homelessness
• Engagement risk and KPIs - people experiencing homelessness face barriers to continual healthcare engagement; multi-stage processes of screening and follow-up can carry a heightened risk of disengagement; perverse incentive not to work with people experiencing homelessness, as KPIs for practices are often based on time-sensitive diagnosis standards
• Inflexible practice - people experiencing homelessness benefit from flexible support; screening services can be rigid in their delivery, requiring fixed appointment times and attendance at a medical centre
• Non-system barriers such as negative experiences, fear and anxiety and a lack of knowledge and education around cancer prevention and screening also play a role.

Solutions

• Utilising the frontline - The trusting relationship between homelessness workers and the people they support enables them to play a vital role in health and social care support. Building healthcare into support planning and ensuring workers are equipped to hold conversations about health can have positive impacts on engagement.
• Consistent communication - flexibility within screening systems to register alternative forms of contact or maintain support through a named advocate or key worker.
• Time to build trust - ensuring screening teams have capacity to conduct assertive community engagement activities with high-risk groups through guaranteed hours and funding.
• Education - targeted Government programmes to promote and educate on screening, such as has happened in relation to TB, would be of worthwhile investment.
• Innovation - breakthroughs in self-testing could be of enormous benefit to people experiencing homelessness, and may allow key workers to more easily integrate conversations around screening into their support planning. Government should continue to invest in the testing and rollout of innovative approaches to screening and test their applicability for groups who are subject to health exclusion.
• Good practice - learning can be taken from existing infrastructure for outreach screening targeting excluded groups.