Health Problems, Healthcare Service Utilisation and its Health Problems, Healthcare Service Utilisation and its Associated Factors Among the Homeless In Malaysia: A Associated Factors Among the Homeless In Malaysia: A Systematic Review Systematic Review

Background : Homelessness is a growing concern since it affects many individuals worldwide. Homeless people are vulnerable to health problems but tend to underutilise health services. Despite being a worldwide concern, there is little research on health issues and healthcare utilisation among homeless people in Malaysia. Methodology : Three databases were used to search for relevant articles: Scopus, Web of Science, and PubMed. Studies published between 2011 and 2021 that examined the health problems and health service utilisation among homeless adults in Malaysia were considered. Manual searches in reference lists and grey literature were also performed to add reports. Data were extracted manually. The authors conducted a descriptive analysis and narrative synthesis. Results : A total of seven articles ful ﬁ lled the pre-determined inclusion and exclusion criteria. Three themes emerged from the studies: health problems, healthcare service utilisation, and associated factors of healthcare services utilisation. Of the seven articles, reported health problems included drug abuse, alcohol abuse, HIV-positive status, mental health problems, oral health, and other chronic diseases. All included articles reported none to under-utilised health care services. The associated factors of health care utilisations were ﬁ nancial issues, low levels of self-care awareness, feeling embarrassed, low health literacy, and poor social support. Conclusion : Evidence shows that the homeless suffer from a range of health problems. Poor health care utilisations among the homeless are a signi ﬁ cant issue, with several associated factors contributing to that worrying scenario. Future studies among homeless people are needed to provide more information, especially about their health care utilisations. In addition, effective multi-agency interventions are required to address health vulnerabilities.


Introduction
H omelessness affects an increasing number of people worldwide, posing a challenge to policymakers and service providers. According to various United Nations estimates, between 100 and 150 million people worldwide are homeless in various ways [1]. This figure is concerning because the homeless population is prone to various health issues due to their sleeping arrangements. Moreover, they are a marginalised community with limited access to and utilisation of health care services [2].
Homelessness is not a new issue in Malaysia. Even neighbouring countries such as Indonesia and other Southeast Asian countries are experiencing this issue [3,4]. Despite the lack of government data on homelessness in Malaysia and the fact that definitions and measurements differ from nation to country, current country estimates reveal a significant prevalence. In Malaysia, homeless people usually consist of elderly men who are single and jobless [5]. According to the fourth edition of the Dewan Bahasa Pustaka Dictionary, a homeless person, or gelandangan in Malay, is defined as not having permanent employment or dwelling [6].
Homelessness is associated with many problems such as poor health, mental problems, and violence related to sleeping conditions and living surroundings [7]. Studies from England and Ethiopia showed that substance abuse and malnutrition are common among homeless people [8,9]. However, in Malaysia, the prevalence of health problems amongst the homeless population, whether physical or mental, may differ from that in other countries due to differences in treatment coverage and support services available and differences in family support systems and cultural responses to illnesses. Furthermore, the homeless population is one of the groups of people who are frequently overlooked or excluded from obtaining assistance due to a lack of precise standards or policies that define their requirements and fate [10].
Even essential services can be out of reach regarding health care access and utilisation for homeless people [10]. A survey conducted in the USA showed low earnings, a lack of health insurance, poor accessibility, and stigma and discrimination contribute to poor engagement with healthcare services among homeless individuals [11]. In addition, a local study in Malaysia reported that low awareness and health care utilisation can lead to delayed recognition and treatment of the signs and symptoms of a disease, resulting in higher rates of emergency visits and hospitalisation [12].
The government subsidises the healthcare system in Malaysia for all Malaysian people [13]. In addition, certain groups of people, such as the disabled and the disadvantaged, are also eligible for free treatment [3]. However, getting treatment from government facilities can be difficult for homeless people due to time and financial constraints. Given that issue, government and non-governmental organisations (NGOs) have worked well together to assist homeless individuals, especially on health issues. Although most NGOs are renowned for assisting with basic daily needs like food, some NGOs provide free healthcare and run outreach programs for marginalised people [14]. Even if such programs do not address all of the issues homeless people face, they will help alleviate the load on marginalised and homeless people.
Even though health issues are a significant focus of homelessness research, and there is a considerable body of literature on health and health service utilisation among homeless persons, little is known about the situation in Malaysia. Thus, this systematic review aimed to gather information from available studies conducted in Malaysia regarding health problems and healthcare service utilisation among homeless groups.

Review protocol
This study was guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) review protocol, which was explicitly designed for systematic reviews and meta-analyses [15].

Inclusion criteria
Articles were included if they were a full empirical journal article, published in English and Malay, and published between 2011 and 2021.

Study selection and data search
Related articles were identified by searching Scopus, Web of Science, and PubMed databases. The keywords used were "homeless" OR "homelessness" OR "homeless people" OR "houseless" AND "health problem" OR "health" OR "health status" OR "disease" OR "illness" OR "comorbid" OR "sickness" OR "ill" AND "health service utilisation" OR "health service" OR "healthcare" OR "health delivery" OR "health service use" OR "health-seeking" OR "health facilities" AND "Malaysia". Following the removal of duplicates, two reviewers examined the titles and abstracts of all identified studies independently to identify those that met the selection criteria.

Quality appraisal
The quality of the selected articles was evaluated using the Mixed Methods Appraisal Tool (MMAT) (Supplementary File 1). Articles with an MMAT score of 80% were selected (Table 1). Any disagreement was resolved with the third reviewer.

Data extraction and synthesis
Following the initial search, the authors created a standardised form to extract the following data: (1) study year and location, (2) study population, (3) study type, (4) health problem, (5) health service utilisation, and associated factors.
This systematic review used a narrative synthesis encompassing quantitative and qualitative data analysis. The quantitative analysis included all quantitative and quantitative data from mixed-method studies. The findings, such as statistical outcomes from the quantitative analysis, were thoroughly described.
In the qualitative analysis, the findings were described using a thematic analysis. To generate relevant themes, the authors used Braun and Clarke's sixphase framework consisting of data familiarisation, code generation, theme search, theme review, theme definition and write up [16]. The selected articles were divided into two groups (i.e., health problems and health service utilisation among the homeless). The associated factors of each health problem and health service utilisation were then described separately. Finally, quantitative and qualitative findings of the selected articles were merged using a narrative approach for the overall results.

Basic description
A total of 7 articles were selected and analysed to identify the health problems and associated factors of health service utilisation (Fig. 1). Most of the study designs were qualitative studies (n ¼ 4), and the rest were cross-sectional studies (n ¼ 3). The sample size in this systematic review ranged between 15 and 315 respondents. The characteristics and the main findings of the final articles included in this systematic review are summarised in Table 1.

Health problems
The seven articles that measured the health problem reported a range of illnesses. The reported illnesses were drug abuse (n ¼ 4), alcohol abuse (n ¼ 3), psychological problems (n ¼ 2), HIV positive (n ¼ 2), oral health (n ¼ 2) and other chronic diseases (n ¼ 1).

Health service utilisations
All the articles (n ¼ 7) in this systematic review reported that the homeless had not or under-utilised the available healthcare services. One article reported that only 57.5% of the respondents in the study utilised health care services for general medical conditions. Two articles studied oral health among the homeless found that 16.7% and 63.8% of the respondents in the studies never sought any dental treatments. Three articles reported that the respondents had not utilised any health care services at all. The paper by Aizuddin et al. stated that the respondents (42.5%) used their own money to pay for the services [21].

Associated factors of health service utilisations
The majority of the articles stated that finance was the main reason for the lower usage of health service utilisations. The other factors were low levels of self-care awareness, feeling embarrassed, low health literacy, and poor social support.

Discussion
This review explored the available local literature that studies the critical issues of health problems, health services utilisation, and its associated factors among the homeless in Malaysia. The findings in this review showed a wide range of health problems suffered by the homeless and the underutilisation of health care services.
The health problems found in this review ranged from physical health to mental health issues. Drug and alcohol abuse became the most common health issue among these vulnerable groups. Studies from the USA and Nigeria found that the use of drugs and alcohol without control influenced the user's thinking, and that most would end up with adverse outcomes [23,24]. In addition, a study from South Africa showed that alcohol and drug use can lower inhibitions and impair judgement, resulting in risky sexual encounters such as having multiple sexual partners and lengthening sexual encounters [25]. These high-risk behaviours increased their risk of developing a chronic disease such as HIV positive [26]. As a result, homeless people in Malaysia are also at risk of the negative consequences of alcohol and drug abuse, which should be addressed as a priority.
The homeless person's mental health problem is also a significant finding in this review. The high prevalence of this problem might be due to the rough living conditions, including the trauma of victimisation, stress, and anger that could directly cause mental health problems in the long run. In addition, the lack of social support found in this review may result in people with this mental illness becoming homeless. Social support is essential for maintaining physical and psychological health [27].
Several medical problems found in this article might not describe the whole picture of the medical condition suffered by the homeless. For example, studies from Ghana and the USA reported that homelessness is closely related to poor hygiene and nutritional problems that increase the risk of developing other diseases such as skin infections, malnutrition, and much more [28e30]. Limited access to healthcare facilities also contributes to the undiagnosed medical condition that the homeless might suffer, especially in developing countries. As an example, according to a study from a neighbouring country, Indonesia, 89.2% of the homeless respondents could not reach health services due to the lack of facilities [3].
Low health service utilisation among the homeless in Malaysia is a concern. As described earlier, these vulnerable groups suffered a significant health problem that might result in severe complications if not recognised and treated earlier. This early recognition and treatment will only be successful if the homeless turn up at healthcare facilities. However, several factors found in this review, such as financial problems, lack of social support, and low awareness, will prevent them from taking the necessary health actions.
Even though the health services in Malaysia, especially in the government facilities, are relatively cheap, the homeless are still reluctant to seek any healthcare treatments. The cost for attending an outpatient clinic is only RM1, and RM5 for a specialist clinic fee. This scenario can be due to their focus on looking for a safer place to sleep and looking for money or food that is prioritised over seeing a doctor to check their health, as well REVIEW described in Maslow's hierarchy of need theory [31]. In addition, their perception of discrimination by the community also contributes to their reluctance to seek medical advice and treatment.
Contribution by government agencies and NGOs plays an important role in providing consistent health care services for the homeless. For example, a local study suggested a special welfare card with similar benefits for disabled people may help increase the utilisation of health care services among the homeless [21]. In addition, health education and awareness regarding the importance of helping those homeless may help in reducing the stigma and fear of discrimination among the homeless and the public. As an example, a multi-modal education seminar in an undergraduate nursing program in the USA showed a statistically significant decrease in stigma perceptions of the homeless [32].

Conclusion
Significant medical health problems suffered by the homeless in Malaysia need to be addressed by the respective stakeholders for early preventive action. The utilisation of health care services among this vulnerable group is still low in Malaysia. Several associated factors such as financial barriers, low social support, low awareness, and many more need to be addressed. Collaboration of all agencies such as the Ministry of Health, the Ministry of Women, Family and Community Development and the Ministry of Human Resources are crucial in providing better services to the homeless, especially in maintaining their good health despite their shortcomings in almost every aspect of life. For example, to address these issues among the homeless, a clear policy governing the homeless should be established. In addition, more research in the future focusing on this vulnerable group is needed to give a clearer picture of the actual situation faced by the homeless, especially on their health and utilisation of health services.

Funding
This research received no specific grant from any funding agency in the public, commercial, or notfor-profit sectors.