Obstacles and possibilities in guaranteeing tuberculosis treatment for homeless people: systematic review and meta-synthesis

Abstract

We aimed to synthesize the evidence from qualitative studies on the experiences of tuberculosis treatment among people living on the streets. We conducted a systematic review with meta-synthesis, searching for studies in ten databases from January to June 2023. We identified 3,801 publications, five of which were included in the study. This meta-synthesis reflects the barriers faced by the people living on the streets during tuberculosis treatment. These barriers originate from drug use, prejudice, lack of a support network, difficulties in accessing health establishments, and the low prioritization of treatment. Furthermore, there are issues with service resolution and accessibility, which often neglect the unique needs of these individuals. In contrast, comprehensive and humanized care, decentralized to primary health care, characterized by coordinated practices and family support, promotes access to treatment and strengthens connections with healthcare teams.

Keywords
Tuberculosis; Health vulnerability; Systematic review

Resumo

Objetivou-se sintetizar as evidências de estudos qualitativos sobre as experiências de tratamento para tuberculose das pessoas em situação de rua. Conduziu-se uma revisão sistemática com metassíntese cuja busca de estudos ocorreu em dez bases de dados, de janeiro a junho de 2023. Identificaram-se 3.801 publicações, das quais cinco foram incluídas. Esta metassíntese refletiu as barreiras enfrentadas pela população em situação de rua durante o tratamento da tuberculose, originadas por uso de drogas, preconceito, ausência de rede de apoio, dificuldades para deslocamento aos estabelecimentos de saúde, não priorização do tratamento e baixa resolutividade dos serviços, que, muitas vezes, negligenciam as singularidades das pessoas atendidas. Em contrapartida, o cuidado integral e humanizado; descentralizado à atenção primária à saúde; e balizado por práticas articuladas e vinculadoras apoiadas pela família promoveu adesão ao tratamento e vinculação às equipes.

Palavras-chave
Tuberculose; Vulnerabilidade em saúde; Revisão sistemática

Resumen

El objetivo fue sintetizar las evidencias de estudios cualitativos sobre las experiencias de tratamiento para la tuberculosis de las personas sin hogar. Se realizó una revisión sistemática con metasíntesis, cuya búsqueda de estudios tuvo lugar en diez bases de datos, de enero a junio de 2023. Se identificaron 3.801 publicaciones, de las cuales se incluyeron cinco. Esta metasíntesis reflejó las barreras enfrentadas por la población sin hogar durante el tratamiento de la tuberculosis, originadas por el uso de drogas, los prejuicios, la ausencia de una red de apoyo, las dificultades para el desplazamiento a los establecimientos de salud y la no priorización del tratamiento, además de la baja capacidad de resolución de los servicios que, muchas veces, son negligentes con sus singularidades. En contrapartida, el cuidado integral y humanizado descentralizado de la atención primaria de la salud, delimitado por prácticas articuladas y vinculadoras apoyadas por la familia, promovió adhesión al tratamiento y vínculo con los equipos.

Palabras clave
Tuberculosis; Vulnerabilidad en salud; Revisión sistemática

Introduction

Tuberculosis (TB) is a persistent global health priority, having for years been the leading cause of death from a single infectious agent in the world, surpassed only by COVID-19¹ during the pandemic period. The occurrence of TB is linked to socio-economic issues and local specificities, being more recurrent in poor countries with high levels of social inequality². In 2022 alone, it is estimated that there were 10.6 million cases of TB in the world¹.

It is well known that aspects such as homelessness, malnutrition, low schooling, and barriers to access and connection to health services have a negative influence on the occurrence of the disease, as well as worse treatment outcomes. With this in mind, it is clear that the homeless population (HP) is more susceptible to becoming ill with TB and needs proximal and specific care by health professionals, considering the vulnerable contexts in which they live^3,4.

The national literature already points to the existence of practices permeated by prejudice in health services and the weaknesses linked to government strategies for TB control among HP^3,4. Due to the overlapping vulnerabilities imbricated in the experience of these individuals, specifically in the context of TB care, people living on the street were more frequently experiencing re-entry after treatment interruption, loss to follow-up, and death due to TB^5-7.

Studies carried out in Korea⁸, Ethiopia⁹ and United States of America¹⁰ confirm the high burden of TB among people living on the streets when compared to the rest of the population. In Brazil, a study that analyzed the follow-up of HP during TB treatment showed that the chance of cure for this population is 50% lower, while the loss to follow-up and death due to TB were, respectively, 2.9 and 2.5 times higher when compared to the general population¹¹.

Therefore, it is essential to know the reality and experiences of this population in order to deconstruct the barriers to access and linkage of this group to health services and actions⁷. Thus, it is necessary to promote spaces for dialogues that contribute to creating a fairer reality based on guaranteeing rights and better health conditions for all people¹².

Following this rationale, understanding the perception of the people living on the streets regarding TB treatment can contribute to the planning of more equitable and effective health actions, as well as to community control of the disease. This can be crucial for promoting individualized care, based on the singularities of each person who is ill. Therefore, the aim of this study was to synthesize evidence from qualitative studies on the TB treatment experiences of HP.

Materials and methods

Design

This is a systematic review anchored in the meta-aggregating (or meta-synthesis) approach proposed by the Joanna Briggs Institute (JBI) through the JBI Manual for Evidence Synthesis, which offers guidance on preparing and conducting systematic reviews of qualitative evidence¹³. This approach allows for the creation of generalizable statements in the form of recommendations to guide professionals and policymakers in their decision-making¹⁴.

Preliminarily, in order to identify previous systematic reviews on the topic and avoid duplication, as well as wasting human resources, an initial search was carried out in the databases: Cochrane, PubMed Central/Medical Literature Analysis and Retrieval System Online (MEDLINE), International Prospective Register of Systematic Reviews (PROSPERO), Database of Abstracts of Reviews of Effects (DARE) and in the JBI Evidence Synthesis, according to the guidelines¹³.

This search was carried out in January 2023 and, in total, 42 literature reviews were identified, of which only two addressed the topic in question in this study. Based on this selection, the full text of the studies found was read and it was found that none of the two studies investigated the topic proposed here in a comprehensive manner, specifically at a global level (supplementary figure); therefore, it was decided to continue with this systematic review.

Thus, this study was guided by the eight stages recommended by the JBI for the design of the methodological path, namely: (i) formulation of the research question; (ii) definition of inclusion and exclusion criteria; (iii) search and location of studies; (iv) selection of studies; (v) assessment of the quality of studies; (vi) data extraction; (vii) analysis and synthesis of data; and (viii) presentation and interpretation of results¹³.

In accordance with the guidelines recommended by the JBI¹³, this review was registered with PROSPERO under protocol number CRD42022384749. The purpose of this registration was to avoid duplicate research with the same scope. It should also be noted that the presentation of this study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist, which supported the report of this systematic review¹⁵.

Formulating the research question

To structure the research question, we used the mnemonic: population (P), phenomenon of interest (I) and context (Co) – PICo, in order to obtain a clear and meaningful question. Initially, we established: P – adult people with TB (≥18 years); I – experience of TB treatment; and Co – people living on the streets. Thus, the following question was established: “what are the experiences of adult people living on the streets in relation to TB treatment?”.

Inclusion and exclusion criteria

The inclusion criteria were original studies with qualitative data in which the participants were considered and/or self-declared people living on the street and had a current and/or a previous diagnosis of TB, as long as they had experienced TB treatment at some point in their life. Duplicate studies, those not available in full, those that did not answer the research question, and/or those that did not meet the inclusion criteria were excluded.

There was no time frame, as no previous research on the subject was identified. Therefore, all articles published up to December 2022 were considered, due to the period of the database search (January to June 2023). Unlike informed in PROSPERO, we opted not to make language restrictions in the selection, noting that in the case of materials in a language not mastered by the authors, translation tools were used.

Locating and selecting studies

In the first phase of searching for and locating the studies to make up this review, we identified keywords and initial terms that were registered on the platforms: Descritores em Ciências da Saúde/Medical Subject Headings (DeCS/MeSH). This initial search aimed to ensure the use of controlled descriptors, most used in indexing scientific communications, to develop a comprehensive strategy.

In addition, previous research was carried out in the Biblioteca Virtual em Saúde (BVS) and MEDLINE, with a view to analyzing the main non-controlled terms included in the most recent papers published on the subject. In the end, the terms/descriptors selected were “homeless persons”, “homeless youth”, “homelessness, tuberculosis”, and “latent tuberculosis”.

Then, to be used in the respective libraries and electronic databases, the terms were associated with each other, in both Portuguese and English, using the Boolean operators “AND” and “OR”, according to the specifics of each database that we considered. With the help of a librarian, the databases were listed to allow for a greater variety of sources and to guarantee quality in the selection of studies; a total of ten databases were used (frame 1).

Frame 1
Library and databases, according to search strategies and filters.

Database	Search strategy	Search filters
Scientific Electronic Library Online (Database 1)	[Todos os índices] (“pessoas em situação de rua”) OR (“homeless persons”) OR (“jovens em situação de rua”) OR (“homeless youth”) OR (sem-abrigo) OR (homelessness) AND (tuberculose) OR (tuberculosis) OR (“tuberculose latente”) OR (“latent tuberculosis”)	Not applicable
Web of Science (Database 2)	“pessoas em situação de rua” (All Fields) OR “homeless persons” (All Fields) OR “jovens em situação de rua” (All Fields) OR “homeless youth” (All Fields) OR sem-abrigo (All Fields) OR homelessness (All Fields) AND tuberculose (All Fields) OR tuberculosis (All Fields) OR “tuberculose latent” (All Fields) OR “latent tuberculosis” (All Fields)	Document type: article Category: social work or health care sciences services or nursing or primary health care
Scopus (Elsevier) (Database 3)	(TITLE-ABS-KEY (“homeless persons”) OR TITLE-ABS-KEY (“homeless youth”) OR TITLE-ABS-KEY (homelessness) AND TITLE-ABS-KEY (tuberculosis) OR TITLE-ABS-KEY (“latent tuberculosis”))	Not applicable
Cumulative Index to Nursing & Allied Health Literature (Database 4)	“pessoas em situação de rua” OR MH “homeless persons” OR “homeless persons” OR “jovens em situação de rua” OR “homeless youth” OR “sem-abrigo” OR “homelessness” AND “tuberculose” OR “tuberculosis” OR MH “tuberculosis, mycobacterium” OR “tuberculose latente” OR “latent tuberculosis” OR MH “tuberculosis, latent”	Availability: full text
Latin American and Caribbean Health Sciences Literature via Biblioteca Virtual em Saúde (Database 5)	[Título, resumo, assunto] (“pessoas em situação de rua”) OR (“homeless persons”) OR (“jovens em situação de rua”) OR (“homeless youth”) OR (sem-abrigo) OR (homelessness) AND (tuberculose) OR (tuberculosis) OR (“tuberculose latente”) OR (“latent tuberculosis”)	Availability: full text
Medical Literature Analysis and Retrieval System Online via Biblioteca Virtual em Saúde (Database 6)	[Título, resumo, assunto] (“pessoas em situação de rua”) OR (“homeless persons”) OR (“jovens em situação de rua”) OR (“homeless youth”) OR (sem-abrigo) OR (homelessness) AND (tuberculose) OR (tuberculosis) OR (“tuberculose latente”) OR (“latent tuberculosis”)	Availability: full text Study type: qualitative research
Base de Dados de Enfermagem (Nursing Database) via Biblioteca Virtual em Saúde (Database 7)	[Título, resumo, assunto] (“pessoas em situação de rua”) OR (“homeless persons”) OR (“jovens em situação de rua”) OR (“homeless youth”) OR (sem-abrigo) OR (homelessness) AND (tuberculose) OR (tuberculosis) OR (“tuberculose latente”) OR (“latent tuberculosis”)	Availability: full text
Index Psi Periódicos via Biblioteca Virtual em Saúde (Database 8)	[Título, resumo, assunto] (“pessoas em situação de rua”) OR (“homeless persons”) OR (“jovens em situação de rua”) OR (“homeless youth”) OR (sem-abrigo) OR (homelessness) AND (tuberculose) OR (tuberculosis) OR (“tuberculose latente”) OR (“latent tuberculosis”)	Availability: full text
Índice Bibliográfico Español en Ciencias de la Salud via Biblioteca Virtual em Saúde (Database 9)	[Título, resumo, assunto] (“pessoas em situação de rua”) OR (“homeless persons”) OR (“jovens em situação de rua”) OR (“homeless youth”) OR (sem-abrigo) OR (homelessness) AND (tuberculose) OR (tuberculosis) OR (“tuberculose latente”) OR (“latent tuberculosis”)	Availability: full text
Pan American Health Organization via Biblioteca Virtual em Saúde (Database 10)	[Título, resumo, assunto] (“pessoas em situação de rua”) OR (“homeless persons”) OR (“jovens em situação de rua”) OR (“homeless youth”) OR (sem-abrigo) OR (homelessness) AND (tuberculose) OR (tuberculosis) OR (“tuberculose latente”) OR (“latent tuberculosis”)	Availability: full text

• Source: the authors.

In order to ensure the greatest scope in the search and selection process, all the databases were accessed through the Federated Academic Community (CAFE), via the journal portal of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), which is a program that brings together Brazilian teaching and research institutions and allows unrestricted access to a greater number of contents available in each database.

In the second phase of this study, the articles were searched for in the databases by implementing the strategies developed (frame 1). Initially, the search and selection process was conducted by reading the title and abstract and then reading the full text of the articles selected in the previous stage. Finally, in the third stage, the reference lists (reverse search) of all the studies retrieved and included in the final review sample were selected.

Evaluation of the quality of the studies

With the aim of assessing the quality of the studies, the JBI Critical Appraisal Checklist for Qualitative Research was used, consisting of ten items¹⁶. This checklist has criteria for analyzing theoretical and methodological coherence, such as the adoption of references and principles in data collection and analysis. Only articles that scored 70% or more—i.e., met at least seven items—were included, as established in previous studies^17,18.

Data extraction, analysis and synthesis

For organizing the data from the included studies, we employed the qualitative data extraction tools developed by JBI. Initially, a table was constructed containing the following information: authors, year of publication, country, participants, context, collection procedure, data analysis method and/or software, theoretical framework, and score received in the JBI Critical Appraisal Checklist for Interpretive & Critical Research.

For each finding (literal extract from the authors), an illustration (quote from the participant) was presented¹⁶. Each extracted finding was assessed by the reviewers as to the degree of congruence between the finding and the illustration presented¹⁶, which could be: unequivocal – findings accompanied by an indisputable illustration; equivocal – findings accompanied by an illustration that could be contested; and unsupported – findings not supported by the data¹⁶.

Meta-aggregation followed three steps, according to the JBI: (i) extraction of findings included with an accompanying illustration and allocated level of reliability; (ii) creation of categories for unequivocal and equivocal findings with at least two per category; and (iii) development of one or more synthesized findings from at least two categories¹⁶. The process was presented in a summary table and visually represented by an explanatory figure.

In order to guarantee the rigor of the review, it is certified that the entire process of searching, selecting, extracting, evaluating, and synthesizing the studies and results was carried out independently by two researchers and that any disagreements that arose were resolved through discussions with a third evaluator, until a consensus was reached between them. The data relating to the articles identified and analyzed was saved in an open repository, Mendeley Data®¹⁹.

Results

A total of 3,801 publications were identified in the literature for reading titles and abstracts, of which only five were included in the final sample of this systematic review^20-24. In the reverse search, 139 publications were identified, but none met the postulated inclusion criteria. As recommended by the PRISMA checklist, the selection process was described in the flowchart shown in figure 1.

Figure 1
Flowchart of the selection process for the studies encompassed in this systematic review

As for the characteristics of the articles, in terms of origin, the studies were carried out in Brazil (n=2)^20,21, Japan (n=2)^23,24 and United States of America (n=1)²², and were published in Portuguese (n=2)^20,21, English (n=2)^23,24 and Japanese (n=1)²². The JBI Critical Appraisal Checklist for Interpretive & Critical Research scores ranged from 90% (n=2)^20,21, 80% (n=2)^22,23, and 70% (n=1)²⁴. In all, the study population totaled 97 homeless people (frame 2).

Frame 2
Summary of the characteristics of the studies encompassed by this systematic review.

ID	Author/year	Country	Participants	Context	Data collection procedure	Analysis methods	Theoretical framework	%*
1	Hino et al., 202220	Brazil	24 homeless people with TB	Basic health unit and street clinic	Semi-structured interview	Thematic analysis	Social determination of the health-disease process	90
2	Zuim; Trajman, 201821	Brazil	19 homeless people hospitalized for TB	TB reference hospital	Semi-structured interview and medical records review	Content analysis	Health care system Model	90
3	Connors et al., 201722	United State of America	10 homeless people with TB	Shelter	In-depth interview	Thematic analysis aided by MaxQDA	Not reported	80
4	Kawatsu et al., 201323	Japan	8 homeless people who underwent directly observed treatment (DOT) in PHC	Public health center	In-depth interview	Interpretative content analysis	Not reported	80
5	Nagahiro et al., 200724	Japan	26 homeless men who underwent DOT	Health clinic	Semi-structured interview, participant observation and medical records review	Not reported	Not reported	70

• ^*
  Percentage referring to the score on the JBI Critical Appraisal Checklist for Interpretive & Critical Research.

The four categories of analysis elicited, based on descending aggregation, two synthesis themes: “Homeless people face individual, social and programmatic challenges that hinder adherence to tuberculosis treatment” and “Humanized and comprehensive care, decentralized to primary health care (PHC), based on articulated and binding practices supported by the family, promotes greater adherence to tuberculosis treatment” (frame 3).

Frame 3
Data aggregation process of the studies that made up this systematic review.

Findings	Category	Themes
Drug abuse is an obstacle to adherence to treatment20-22	Drug use, prejudice, lack of a support network, difficulty in getting to services and lack of prioritization of treatment hinder adherence to treatment	Care strategies to create a bond must take into account that homeless people face individual, social and programmatic challenges that make it difficult to adhere to TB treatment
Prejudice is a barrier to follow-up in services20,22
Lack of a support network is a barrier to treatment adherence20
Daily commuting to services is an obstacle to treatment20
There is a lack of prioritization of TB treatment21
Neglect of care by health professionals20,21	Services with low resolution, that neglect people's needs and do not create a bond can lead to loss of follow-up treatment
Drug side effects are seen as a difficulty20,21
Non-binding practices lead to discontinuity of care21
The perception of the service's low resolutiveness is a barrier to adherence21
Creating a bond is a strategy for adherence20,21	Attention anchored in humanized and comprehensive care, based on binding practices, enables the successful outcome of TB treatment	There is an urgent need to strengthen humanized and comprehensive care in primary health care, based on articulated and binding practices supported by the family, in view of its potential for adherence to TB treatment
The street clinic teams facilitate treatment20
Humanized care contributes to adherence and encourages self-care23,24
Treatment encourages people to stop abusing drugs20
The desire to return to family life serves as support for adherence to treatment20	Articulated care, decentralized to primary health care and supported by the affected person's family, promotes greater adherence to TB treatment
The street clinic teams facilitate treatment20
Coordination between points in the health care network facilitates bonding21
DOT conducted in PHC is efficient23

The list of synthesis themes generated from the meta-aggregation showed two possible treatment outcomes: “loss to follow-up” or “adherence to treatment”, depending on the phenomena and elements that are present in people’s reality. Thus, the experience of treatment in this population varies according to the contexts that touch homelessness, reflecting on adherence to TB treatment or loss to follow-up (figure 2).

Figure 2
Representation of the relationship between the thematic categories identified in this systematic review.

Discussion

This review was able to shed light on the experiences of HP with TB, in order to uncover situations linked to adherence or loss of follow-up to the treatment to which they had access. It emerged that people living on the streets face individual, social and programmatic challenges that make it difficult for them to adhere to TB treatment. However, humanized and comprehensive care in PHC, based on articulated and binding practices, promoted greater adherence to treatment.

A number of situations in the daily life of HP corroborate the loss of follow-up to TB treatment, such as: drug use^20-22, prejudice^20,22, lack of a support network²⁰, difficulties in accessing services²⁰ and treatment not being prioritized²¹, as well as the low resolutiveness of services²¹, the failure to create bonds²¹ and neglect of homeless’ needs^20,21. The sum of these vulnerabilities, especially the programmatic ones, reduces the possibility of a cure^22-24.

In this sense, ensuring visibility and giving a voice to the experiences of homeless people regarding access, use, permanence and linkage to health services are fundamental actions to provide a broader understanding of the health-disease process. It is essential to (re)understand the aspects that make these people weak and vulnerable, with a view to guaranteeing the human right to health and enabling the transformation of the unjust reality they experience on a daily basis²⁵.

The present findings concur with a literature review that included studies from various Brazilian states and found that the entry of people experiencing homelessness into health services is hampered by structural barriers in the health care network (HCN). This scenario is mainly supported by the existence of prejudice and stigma during reception and the lack of documentation and proof of address, which is sometimes a condition required for PHC²⁶.

A study carried out in a Colombian city found that homeless persons with TB suffer greater stigma when compared to other people with TB, reinforcing the obstacles they face on a daily basis²⁷. In addition, a study of 543 people living on the streets in Texas, United States of America, showed a higher chance of death, which may be related to the stressors of poverty, associated comorbidities and difficulty or lack of access to health services²⁸.

These findings point to the urgent need to prioritize the timely diagnosis and treatment of TB in this population, which is known to be vulnerable²⁹. In this sense, the implementation of measures that protect them individually and collectively and that promote diagnosis and adequate treatment must be established^29,30. It is therefore necessary to consider the dimensions that go beyond the biological being²⁹, considering the social and structural elements that determine HP illnesses.

However, health services are often unaware of the particularities of this population. This fact supports the production of hygienist and medicalizing actions, of a punctual nature, based on a one-cause model²⁹. This scenario is amplified in the context of social assistance policies, which reveal the lack of coordination between sectors, the discontinuity of current programs aimed at homeless people and the prevalence of policies with a punitive and isolating content^29,31.

It is natural that just trying to understand these contexts of vulnerability and the experience of people living on the streets in relation to their health does not in itself solve the problem of inequality and social marginalization. However, we must believe that research represents a tool for knowledge and social denunciation that can bring visibility and prompt action to create more universal and equitable public policies^29,31.

In addition, this review identified that care anchored in humanized and comprehensive care^20,23,24, articulated between the services of the HCN²¹ and decentralized to PHC services^20,23, with the support of families²⁰ to promote the linking of homeless people to health facilities^20,21 enabled greater adherence to TB treatment among homeless people and, consequently, the successful outcome of a cure.

This meta-theme is validated by a study which showed the potential of joint action between basic health units, street clinic teams, psychosocial care centers and social assistance professionals³². This articulation has facilitated access to services, mainly due to the welcoming, humanization, bonding and proximal care based on the integrality and uniqueness of people³².

The street clinic is the Brazilian strategy of care for homeless persons in PHC and is anchored in dialog with the other services of the HCN within the scope of the Brazilian National Health System (SUS)³². In the context of TB, considering the importance of adherence to drug treatment lasting six months, strategies supported by the doctrinal principles of the SUS—universality, equity and comprehensiveness—which enable longitudinal care, are fundamental for adherence and cure³³.

The Brazilian Ministry of Health recommends the following strategies to promote adherence to TB treatment in homeless people: (i) material incentives; (ii) access to housing; (iii) person-centered health care; and (iv) socio-educational practices involving the community³⁴. In addition, there is a need to articulate the strategies and the various social actors³³, covering all the needs of the HP, especially given the vulnerability of this public.

A study conducted in the United States of America reported a successful experience with a community-based program run by community health workers and nurses³⁵, in which people living on the streets were offered proximal care with regular follow-up throughout their TB treatment. The care was adapted to the health needs of the public, so that, in the end, the treatment completion rate was 91.8%³⁵.

Another successful strategy, carried out in the United Kingdom, jointly between the National Health Service and charitable organizations, consisted of creating a residential respite service with housing, health care and social support for HP with TB³⁶. The use of this service was associated with a reduction in the risk of treatment failure compared to standard treatment (offered by outpatient services), as well as helping to reintegrate the individual into society³⁶.

These reported experiences provide theoretical and practical insights that can be used to support new and better practices that promote greater access and permanence for these people in health services. Regarding the comprehensive approach, it is necessary to establish specific public health programs for HP, with a multidisciplinary team, including doctors, nurses, social workers and psychologists, to offer personalized care^37,38.

It is also necessary to carry out regular screenings in shelters, mobile services and other places frequented by this population to identify suspected cases and provide rapid access to diagnostic tests and facilitate access to treatment facilities close to the areas where these people live or frequent^37,38. As far as health education is concerned, educational campaigns aimed at this audience should be promoted, using tools and accessible language^37,38.

It is essential to strengthen partnerships with non-governmental organizations, civil society and community services, fostering the creation of support networks that can collaborate with treatment and offer social support³⁴. TB in persons living on the streets cannot be approached in isolation and strategies must take into account individual, social and programmatic aspects⁷, aiming to mitigate the challenges faced by this population identified in this review.

About the limitations of this research, it is worth mentioning the possibility of missing studies due to the fact that the search strategy was used only in English and Portuguese. Other limitations of this systematic review include: the search strategies and/or databases may have been insufficient to capture additional studies, which could hinder a broad and in-depth analysis of the topic in question.

Nevertheless, it should be considered that this meta-synthesis has the potential to provide an important understanding of the subject, represented in this case by TB treatment among the people living on the streets. However, it should be emphasized that qualitative research, which was an integral part of this review, provides theoretical and contextual support on experiences restricted to a specific number of people, places and periods¹⁶. Thus, sociocultural particularities need to be considered.

Furthermore, this work is a starting point for (re)thinking the situations that produce and sustain the unjust reality that influences the health and living conditions of these people, given the situation of sub-humanity and deprivation of fundamental rights that they endure on a daily basis. In this sense, there is a battle to be faced in society, in which the SUS, through the reordering of actions and practices directed by this study, can be the protagonist.

Finally, it is important to emphasize that this research represents a relevant source of evidence, especially for public health, since it brings visibility to the health situation of an extremely vulnerable population from a perspective that has not yet been widely approached. By synthesizing the qualitative evidence, the aim was to identify foundations that help explain the obstacles faced by HP in accessing and being linked to health services.

Final considerations

This synthesis reflects the barriers faced by people living on the streets during TB treatment, caused by drug use, prejudice, lack of a support network, difficulties in getting to health services and not prioritizing treatment. On the other hand, comprehensive and humanized care, decentralized to PHC, based on articulated and binding practices supported by the family, promoted adherence to treatment and bonding with the teams.

This evidence, although small in number as a possible consequence of the invisibility of this population in the academic-scientific field, reinforces the essential need to guarantee a care logic that understands the contexts in which HP are inserted, in order to focus on situations that go beyond the biological dimension and guarantee overcoming the fragility experienced on a daily basis, with a view to achieving comprehensive actions and longitudinal care.

Supplementary Figure.
Flowchart of the search process for reviews in the main databases.

• Pavinati G, Lima LV, Hino P, Marcon SS, Magnabosco GT. Obstacles and possibilities in guaranteeing tuberculosis treatment for homeless people: systematic review and meta-synthesis. Interface (Botucatu). 2025; 29: e240625 https://doi.org/10.1590/interface.240625

• Funding
  This work was carried out with the support of the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brazil (CAPES) – Financing Code 001.

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Edited by

• Editor
  Denise Martin Coviello

• Associated editor
  Charles Dalcanale Tesser

Publication Dates

• Publication in this collection
  24 Mar 2025
• Date of issue
  2025

History

• Received
  01 Oct 2024
• Accepted
  20 Nov 2024