"Just a knife wound this week, nothing too painful": an ethnographic exploration of how homeless clients attending an urban primary care and addiction service view their own health and healthcare

This study used an ethnographic approach grounded in a social constructivist research paradigm to explore the perspectives of people in homelessness attending a primary care and addiction service on their priority health and healthcare needs. Participant observations and informal interviews were conducted with homeless clients attending the service for three hours every Monday morning between October 2022 and April 2023. Field note data from active participant observation and informal conversations were collected, anonymised, and analysed using inductive thematic analysis in accordance with the Declaration of Helsinki and the researchers institutional Research Ethics Committee. Three main themes emerged from the analysis: self-identified priorities, satisfaction with services, and migrant health. Clients priority concerns relate to their mental health, maintaining ties with children and families, navigating complex romantic relationships, finding meaningful activities, and feeling better physically. These challenges differ from those of the general population in terms of their severity observed both prior to and during experiences of homelessness, coupled with disproportionately high levels of loss, fear, injury, pain, disability, fatigue, and isolation. In terms of services, clients are satisfied with their ability to access primary care and harm reduction in a social environment where positive exchanges with friends and providers take place. Conversely, barriers to accessing mental health and addiction services persist including the internalised belief that one is beyond help, lack of access to information on available services and their entry requirements, and lingering stigma within a health system that treats addiction as separate to health. Moving forward, health practitioners may consider holding more regular and open conversations with homeless clients about the care they are receiving, its rationale, and whether or not changes are desired that can be safely made. The health needs of migrants and asylum seekers entering homelessness in Ireland are urgent and should be prioritised in future research.