Abstract

This integrative review systematized the factors that influence access to mental health services for the Homeless Population (HP) in harmful use of alcohol and other drugs in the Psychosocial Care Network (RAPS) in Brazil by categorizing the factors into access “barriers” and “facilitators”. We selected 13 corresponding articles and subsequently assessed their methodological quality. We identified 19 access barriers and 22 access facilitators, observing a convergence and complementarity of the factors identified, with no disagreements between authors. Although there are specific barriers and facilitators related to substance use, most are connected to HP’s conditions and lifestyles or how services address the HP. Discrimination, bureaucratic rigidity of services, and a lack of intra- and intersectoral integration were identified as significant barriers. On the other hand, Street Outreach Clinics and practices such as harm reduction and matrix-based support emerged as notable facilitators, adapting to patients’ needs. Future studies should explore specific factors and the relationships between these factors.

Key words:
Homeless population; Health Services Accessibility; Mental Health Services; Substance-Related Disorders

Introduction

Guiding access to mental health care in the Psychosocial Care Network (RAPS) for the Homeless Population (HP) who engage in the harmful use of alcohol and other drugs requires recognizing the complex factors that permeate the lives of these service users and their interactions with the network and its services. Among the multiple factors that complicate this relationship are barriers and facilitators affecting these individuals’ access to services, which is imperative to guide more inclusive and effective public policies and health practices.

The HP is defined as a heterogeneous population group. However, it is characterized as a group that lives in extreme poverty, with weak or broken family ties, without conventional housing, and uses urban public spaces as a place of residence and sustenance. Some may use shelters or hostels to spend the night, which does not exclude them as the HP¹1 Brasil. Decreto nº 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União; 2009..

The National Survey on the Homeless Population revealed the profile of these individuals as predominantly male (82%), racialized (67% Black), and with incomplete primary education (63.5%)²2 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Rua aprendendo a contar: pesquisa nacional sobre a população em situação de rua. Brasília: MDS, Secretaria de Avaliação e Gestão da Informação, Secretaria Nacional de Assistência Social; 2009.. These and other structural determinants of health, such as social class, gender identity, and migration, contribute to the health inequalities observed in unequal societies such as Brazil³3 Galvão ALM, Oliveira E, Germani ACCG, Carmo LO. Determinantes estruturais da saúde, raça, gênero e classe social: uma revisão de escopo. Saude Soc 2021; 30(2):e200743.^,44 Theodoro M. A sociedade desigual: racismo e branquitude na formação do Brasil. Rio de Janeiro: Zahar; 2022..

Regarding the HP’s health, mental health conditions stand out as one of the main demands for treatment. In the National Survey mentioned above, 17% of respondents reported having a history of psychiatric hospitalization and 28% having spent time in recovery homes or clinics related to the harmful use of alcohol and other drugs²2 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Rua aprendendo a contar: pesquisa nacional sobre a população em situação de rua. Brasília: MDS, Secretaria de Avaliação e Gestão da Informação, Secretaria Nacional de Assistência Social; 2009.. Martins et al.⁵5 Martins ALJ, Souza AA, Silva GDM, Dantas ACMTV, Marinho RA, Fernandes LMM, Oliveira AMC, Magalhães Júnior HM, Paes-Sousa R. Access to health and social protection policies by homeless people during the COVID-19 pandemic: a mixed-methods case study on tailored inter-sector care during a health emergency. Frontiers Public Health 2024; 12:1356652. present the main complaints of this population as mental and behavioral disorders due to the use of multiple drugs, alcohol use-related disorders, and schizophrenia. Mental health-related issues appear as a motivation for these people to end up living on the streets, along with unemployment, family conflicts, and, to a lesser extent, other health issues²2 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Rua aprendendo a contar: pesquisa nacional sobre a população em situação de rua. Brasília: MDS, Secretaria de Avaliação e Gestão da Informação, Secretaria Nacional de Assistência Social; 2009.^,55 Martins ALJ, Souza AA, Silva GDM, Dantas ACMTV, Marinho RA, Fernandes LMM, Oliveira AMC, Magalhães Júnior HM, Paes-Sousa R. Access to health and social protection policies by homeless people during the COVID-19 pandemic: a mixed-methods case study on tailored inter-sector care during a health emergency. Frontiers Public Health 2024; 12:1356652.. Furthermore, data from the federal government’s Single Registry for Social Programs (CadÚnico), which identifies the registered population living in poverty and extreme poverty, identified the use of alcohol and other drugs in 29% of the HP in Brazil⁶6 Martins ALJ, Souza AA, Fernandes LdaMM, Oliveira AMC, Cordeiro JC, Oliveira AF, Magalhães Júnior HM. A interface entre as políticas públicas para a população em situação de rua: revisão integrativa. Cien Saude Colet 2023; 28(8):2403-2416..

Mental health care focused on the needs arising from the use of alcohol and other drugs is one of the priority points in the care of the HP. In the Unified Health System (SUS), health services are provided in the Psychosocial Care Network (RAPS), which includes specific services like the Psychosocial Care Centers for Alcohol and Drugs (CAPS-AD) and the Street Outreach Clinic (eCR) teams⁷7 Brasil. Ministério dos Direitos Humanos e da Cidadania (MDHC). População em Situação de Rua. Diagnóstico com base nos dados e informações disponíveis em registros administrativos e sistemas do Governo Federal. Brasília: MDHC; 2023.. These services must be guided by the SUS principles to guarantee comprehensive, universal, and equitable access to health.

The National Policy for the Homeless Population (PNPSR) reinforces the State’s obligation to guarantee the HP broad, simplified, and safe access to programs and services that make up public policies, including health¹1 Brasil. Decreto nº 7.053, de 23 de dezembro de 2009. Institui a Política Nacional para a População em Situação de Rua e seu Comitê Intersetorial de Acompanhamento e Monitoramento, e dá outras providências. Diário Oficial da União; 2009.^,88 Brasil. Portaria nº 3.088, de 23 de dezembro de 2011. Institui a Rede de Atenção Psicossocial para pessoas com sofrimento ou transtorno mental e com necessidades decorrentes do uso de crack, álcool e outras drogas, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2011., considering that 18% of the HP mentioned impediments to receiving care in the health network²2 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Rua aprendendo a contar: pesquisa nacional sobre a população em situação de rua. Brasília: MDS, Secretaria de Avaliação e Gestão da Informação, Secretaria Nacional de Assistência Social; 2009.. However, the literature points to persistent barriers to these individuals’ access to SUS services⁶6 Martins ALJ, Souza AA, Fernandes LdaMM, Oliveira AMC, Cordeiro JC, Oliveira AF, Magalhães Júnior HM. A interface entre as políticas públicas para a população em situação de rua: revisão integrativa. Cien Saude Colet 2023; 28(8):2403-2416.^,99 Oliveira AL, Guizardi F. A construção da política para inclusão de pessoas em situação de rua: avanços e desafios da intersetorialidade nas políticas de saúde e assistência social. Saude Soc 2020; 29(3):e190650.^,1010 Valle FAAL, Farah BF, Carneiro Junior N. As vivências na rua que interferem na saúde: perspectiva da população em situação de rua. Saude Debate 2020; 44(124):182-192.. Regarding the challenges faced in caring for the HP in RAPS, an integrative review study mentions stigma, inflexible protocols, insufficient integration of the healthcare network, and lack of co-accountability, for example¹¹11 Wijk LB, Mângia EF. Atenção psicossocial e o cuidado em saúde à população em situação de rua: uma revisão integrativa. Cien Saude Colet 2019; 24(9):3357-3368..

If we consider the principle of equity as a guiding characteristic of the SUS, we should consider access to health equity as a process of permanent transformation¹²12 Barros FPC, Sousa MF. Equidade: seus conceitos, significações e implicações para o SUS. Saude Soc 2016; 25(1):9-18.. However, such transformation only becomes effective when a proper understanding of the factors that affect service user access exists.

This study aimed to gather the main published contributions on the subject and identify gaps in the field of care for these individuals, mainly to organize the results of studies on the access of HP who use alcohol and other drugs to the Mental Health Services of the Brazilian RAPS from an integrative literature review, focusing on the access barriers and facilitators. Moreover, the study used criteria to assess the quality of the selected articles, allowing a discussion of the results found with greater reliability of the information presented.

Methods

This integrative review study’s guiding question was: “What are the barriers and facilitators to accessing Brazilian mental health services for homeless individuals who engage in harmful use of alcohol and other drugs?”.

In order to answer this question, a bibliographic survey was conducted in September and October 2023 on the SciELO, LILACS, and PubMed platforms in English, Portuguese, and Spanish, using the descriptors The HP, Homeless population, People living on the street, Psychosocial Care Center, Access, CAPS, RAPS, Street Outreach Clinic, and Alcohol and Drugs, using the Boolean operators “AND” and “OR”.

The articles located were subject to the following inclusion criteria: (i) Full articles with open access; (ii) Articles available in English, Spanish, and Portuguese; (iii) Articles with results related to Brazil. The following were excluded: (i) Articles repeated in the databases or duplicated within the same database; (ii) Experience reports and integrative, systematic, or scoping literature review articles; (iii) Technical notes; (iv) Theses and dissertations.

The articles were first selected by reading the title and abstract of the article to see if they had characteristics related to the guiding question of the research. After this first stage of exclusion, those whose information answered the guiding question of the research or supporting elements that would do it were read in full. In the end, those who answered our question or opened a broad discussion on the topic remained for analysis of the results.

All steps were conducted independently by two evaluators. When disagreement occurred, the article was presented to a third evaluator to result in a consensus on its exclusion or inclusion in the study.

Microsoft Office Excel was adopted to compile the results of the selected articles. The following information was recorded for all articles: article title, authors, journal, and year of publication; methodological aspects of the studies (place of study, unit of analysis [national, regional or local], study objectives, temporality [study period], type of design, and results’ analysis method), and the article’s conclusion. Finally, the article’s evidence was recorded regarding barriers and facilitators of access for the HP who use alcohol and other drugs to Brazilian mental health services, which allowed us to answer the guiding question of the current study.

Finally, the final selected articles¹³13 Vale AR, Vecchia MD. "UPA é nós aqui mesmo": as redes de apoio social no cuidado à saúde da população em situação de rua em um município de pequeno porte. Saude Soc 2019; 28(1):222-234.

14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.

15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.

16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.

17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.

18 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.

19 Lima HS, Seidl EMF. Consultório na Rua: percepção de profissionais e usuários sobre redução de danos. Psicol Pesq 2017; 11(2):33-41.

20 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848.

21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.

22 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.

23 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.

24 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.^-2525 Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP. Street clinic: the care practices with users of alcohol and other drugs in Macapá. Esc Anna Nery 2019; 23(1):e20180261. were evaluated per their methodological quality, adapting the validated methods of Downs and Black²⁶26 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998; 52(6):377-384. and Patias and Hohendorff²⁷27 Patias ND, Von Hohendorff J. Critérios de Qualidade para Artigos de Pesquisa Qualitativa. Psicol. Estud 2019; 24:e43536. for non-experimental studies, using 12 evaluation items, namely: (i) Title consistent with the study presented; (ii) Abstract summarizes the main elements of the study (problem, objective, method and main results); (iii) Introduction includes a description of the study topic, with a critical and relevant review of theoretical and empirical literature; (iv) Objectives described clearly and align with the development of the article; (v) Clarity in the presentation of results, with consistency between excerpts and themes/categories presented, demonstrating the researcher’s understanding of the results; (vi) Methodological design described coherently as per the qualitative design used in the study; (vii) Discussion with description of the study findings, with the leading results summarized and discussed according to a theory, model or previous research; (viii) Well-defined sample definition criterion; (ix) Data collection instruments appropriate to the article’s objective; (x) Study limitations clearly defined and reported; (xi) Description of the main contributions to the area or discipline and to public policies, with practical application and suggestions for new studies; (xii) Results consistent with the data presented. For each of these categories, the value “1” was computed when the criterion evaluated was found, and “0” when absent. The computed score value was “1” when the criterion was not applied. The closer to the total value (12/100%), the better the quality of the study.

Results and discussion

Figure 1 presents the selection steps for structuring the review, in which we initially identified 972 articles. We removed 595 duplicate articles (61.2%) based on the exclusion criteria, along with 32 documents selected in the search identified as literature review articles, technical notes, theses, or dissertations (3.3%), resulting in 345 articles. After this stage, 332 articles were excluded after reading the title, abstract, or full text (34.2%), leaving 13 articles (1.3%) comprising the final review.

Chart 1 shows the methodological quality of the selected articles, assessed from the adaptation of validated methods²⁶26 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998; 52(6):377-384.^,2727 Patias ND, Von Hohendorff J. Critérios de Qualidade para Artigos de Pesquisa Qualitativa. Psicol. Estud 2019; 24:e43536.. Considering the 12 evaluation criteria already displayed in the methods section, five articles were classified with a value above 90%, two with values between 70% and 89%, and six between 50% and 69%. The primary limitations identified in the studies are related to the lack of description of the main contributions to the area or discipline, public policies with practical application and presentation of suggestions for new studies, lack of well-defined criteria for sample definition, and lack of a well-defined presentation of the study’s limitations. The general characteristics of the articles are shown in Chart 2.

Among the articles analyzed, one (7.7%) conducted an international comparative analysis between mobile services for assisting the HP in Portugal, the USA, and Brazil. Twelve (92.3%) were developed at the municipal level. All 13 (100%) articles were qualitative research, with multiple methodologies and analysis instruments, published in national (Brazilian) journals and dated between 2015 and 2022. Four articles (30.8%) did not reveal the months in which the data were collected, which compromised the evaluation of some results (Chart 2).

Regarding the articles’ objectives, all those selected directly or indirectly aimed to evaluate therapeutic itineraries, the production of care for the HP, and the barriers that interfere with these individuals’ access to health services (Chart 2).

Some of the selected articles did not directly address the access of the HP to municipal health services that specifically address mental healthcare for the HP who use alcohol and other drugs. Even so, positive and negative characteristics related to access to health services in general were identified in all the selected articles, categorized in the current article as “barriers” or “facilitators” (Chart 3).

The following paragraphs will present and discuss, by category, the access barriers and facilitators of the HP who use alcohol and other drugs harmfully to mental health services provided by the Brazilian RAPS from the most cited to the least cited factors.

Access barriers

Discrimination

The discrimination category was identified in most articles through themes such as racism, stigma, and prejudice directed at the HP¹³13 Vale AR, Vecchia MD. "UPA é nós aqui mesmo": as redes de apoio social no cuidado à saúde da população em situação de rua em um município de pequeno porte. Saude Soc 2019; 28(1):222-234.

14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.

15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.

16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.

17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^-1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,2020 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848.

21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.

22 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.

23 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.

24 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.^-2525 Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP. Street clinic: the care practices with users of alcohol and other drugs in Macapá. Esc Anna Nery 2019; 23(1):e20180261.. These barriers are related to prejudice based on stereotypes about these individuals, discriminatory and exclusionary actions regarding the use of alcohol and other drugs, poverty, poor hygiene conditions, and the racial marker of this mostly Black population²2 Brasil. Ministério do Desenvolvimento Social e Combate à Fome (MDS). Rua aprendendo a contar: pesquisa nacional sobre a população em situação de rua. Brasília: MDS, Secretaria de Avaliação e Gestão da Informação, Secretaria Nacional de Assistência Social; 2009.^,55 Martins ALJ, Souza AA, Silva GDM, Dantas ACMTV, Marinho RA, Fernandes LMM, Oliveira AMC, Magalhães Júnior HM, Paes-Sousa R. Access to health and social protection policies by homeless people during the COVID-19 pandemic: a mixed-methods case study on tailored inter-sector care during a health emergency. Frontiers Public Health 2024; 12:1356652.. The notion of ethnicity/race identified in this context is a sociopolitical construct that reveals markers of social inequalities and injustices, reflecting on the distribution of power between social groups, with a recognized impact on health conditions and access to services²⁸28 Barata RB. Como e por que as desigualdades sociais fazem mal à saúde. Rio de Janeiro: Editora Fiocruz; 2020..

Discrimination in health services can contribute to social humiliation¹³13 Vale AR, Vecchia MD. "UPA é nós aqui mesmo": as redes de apoio social no cuidado à saúde da população em situação de rua em um município de pequeno porte. Saude Soc 2019; 28(1):222-234., produce a feeling of inferiority in the HP¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057., weaken the relationship of trust between individuals and health services, jeopardize social ties, and generate fear of being poorly served or not being recognized in services¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.. This fear is based on the discrimination process experienced in an even more severe way by the HP who use alcohol and other drugs, which results in a double stigma¹⁵15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.. From a prohibitionist logic outlook, the person who engage in harmful use of alcohol and other drugs is recognized as sick or criminal. This stigma prevents people from seeing the subject beyond drugs and establishing forms of agency for this use²⁹29 Fiore M. O lugar do Estado na questão das drogas: o paradigma proibicionista e as alternativas. Novos Estud CEBRAP 2012; 92:9-21..

Stigmatization involves reducing the social identity of homeless individuals to a position of discredit and inferiority due to the imposition of the perspective of those who conform to the current social norms, which legitimizes social exclusion and discrimination and establishes barriers to equal access to services since those who are stigmatized are not seen on an equal footing with “normal” people³⁰30 Goffman E. Estigma: notas sobre a manipulação da identidade deteriorada. 4ª ed. Rio de Janeiro: LTC; 2008..

This stigmatized identity influences the homeless person’s self-perception and the perception of healthcare providers. The stigma associated with homeless individuals, rooted in sociohistorical distinctions of normality and deviance³⁰30 Goffman E. Estigma: notas sobre a manipulação da identidade deteriorada. 4ª ed. Rio de Janeiro: LTC; 2008., erects significant barriers to equitable access to healthcare services. This stigma is perpetuated by society and healthcare institutions, discouraging the HP from seeking healthcare for fear of discrimination and receiving inadequate treatment.

Racism appears in a veiled manner in the health service, and workers may not realize that they are practicing it, as it is a “subtler” violence that can be characterized as institutional violence¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057., which sometimes manifests itself in the refusal of care²¹21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.^,2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142. or a police-like attitude of professionals towards service users¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.. The situations mentioned in health services, as a space for reproducing social relationships, refer to racism’s structural and institutional conceptions. In other words, they result from the social structure and materialize in institutions³¹31 Almeida S. Racismo estrutural. São Paulo: Sueli Carneiro; Ed. Jandaíra; 2020.^,3232 Kalckman S, Santos CG, Batista LE, Cruz VM. Racismo institucional: um desafio para a equidade no SUS? Rev Saude Soc 2007; 16(2):146-155.. Thus, institutional racism compromises the quality of care and the professional-service user relationship, limits individuals’ access, and weakens the principle of equity in the SUS³²32 Kalckman S, Santos CG, Batista LE, Cruz VM. Racismo institucional: um desafio para a equidade no SUS? Rev Saude Soc 2007; 16(2):146-155..

Service rigidity

This category encompasses several aspects that influence and result in barriers to access by the HP who use alcohol and other drugs to health services, including the dissonance between the lifestyles of the HP and how care is offered by health services, or even the difficulty or lack of consideration of the lifestyles of this population when considering the services offered or the need to adapt care provision¹³13 Vale AR, Vecchia MD. "UPA é nós aqui mesmo": as redes de apoio social no cuidado à saúde da população em situação de rua em um município de pequeno porte. Saude Soc 2019; 28(1):222-234.

14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.^-1515 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.^,1717 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^,2121 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.^,2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.. A study showed that the HP depend on other services, such as food and shelter, which have rigid and inflexible arrival and departure times, which means that these individuals do not have autonomy over their time²¹21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744..

Furthermore, the lack of a daily routine linked to precise times and a clock or calendar can prevent the HP from organizing the day and time of their appointment, for example, leading to a lack of temporal orientation²²22 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.. The daily demands of these individuals require agility and are very different from the needs of the general population, which requires strategies for operationalizing health services from the perspective of equity³³33 Engstrom EM, Lacerda A, Belmonte P, Teixeira MB. A dimensão do cuidado pelas equipes de Consultório na Rua: desafios da clínica em defesa da vida. Saude Debate 2019; 43(n. esp. 7):50-61..

Six articles¹⁵15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.^,1717 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^,1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,2121 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.^,2323 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408. highlighted the bureaucratic administrative logic or excessive bureaucracy, emphasizing the requirement for identification documents or an SUS card to receive care¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^,1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,2121 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.^,2323 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.. This practice contradicts national legislation, which provides that comprehensive health care must be provided regardless of the presentation of documents proving domicile or registration in the SUS registry³³33 Engstrom EM, Lacerda A, Belmonte P, Teixeira MB. A dimensão do cuidado pelas equipes de Consultório na Rua: desafios da clínica em defesa da vida. Saude Debate 2019; 43(n. esp. 7):50-61..

The lack of flexibility in service rigidity was highlighted as a barrier to access. Some of the situations described were related to flows, rules, and times for appointments and tests that often do not include the lifestyles of the HP and are inflexible¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^,2121 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744., evidencing the service’s inability to adapt to the HP’s needs¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.. Low-threshold services are an essential driving force for adequate care for those who use alcohol and other drugs. Active and unrestricted support by an eCR, support during a crisis at CAPS-AD, or social reintegration programs with flexible organizational methods and schedules are possible by establishing a subjective position regarding the harmful use of drugs³⁴34 Lancetti A. Contrafissura e plasticidade psíquica. São Paulo: Editora Hucitec; 2015..

The institutional concept of services centered on the physical structure¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.^,1616 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408. is a barrier to access. It shows an explicit separation between life within the services and life on the street as if these spaces were disconnected¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.. This hurdle is related to another complication, which concerns the conceptions of the service’s territorial action, often based on arbitrary lines drawn on the map or with the delimitation of the service’s action within its institutional walls¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408., without considering the possibilities of external action, such as active search and planned actions in the street environment. In this regard, there is often an understanding in SUS services of territorialization based only on geographic and administrative divisions, leaving aside the concept of territory that encompasses its fluidity and intrinsic relationship with the ways of life of the people who inhabit it³⁵35 Tetemann EC, Trugilho SM, Sogame LCM. Universalidade e Territorialização no SUS: contradições e tensões inerentes. Textos Contextos 2016; 15(2):356-369..

Imposed abstinence is highlighted as another barrier to access to health services¹⁵15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.^,2323 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.. It is essential to highlight that it is also related to the category of discrimination based on the reproduction of stigmas that permeate drug users. There is a perceived disconnection between the provision of some health services and the guidelines of the Ministry of Health, which provides for action under the logic of harm reduction. From this perspective, we should recognize that some people cannot, are unable, or do not wish to stop using, and, therefore, the aim should be to reduce the risks associated with use without necessarily intervening in supply or consumption³⁶36 Brasil. Portaria nº 1.028, de 1 de julho de 2005. Determina que as ações que visam à redução de danos sociais e à saúde, decorrentes do uso de produtos, substâncias ou drogas que causem dependência, sejam reguladas por esta Portaria. Diário Oficial da União; 2005..

Furthermore, care is denied to the HP because they are not accompanied by a mobile team, such as the eCR, or because they have been referred by another service, whether a health or social assistance facility²³23 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.. Although this barrier reflects service rigidity, it is also related to the discrimination that the HP experience. Situations like this disregard the SUS doctrinal principles of universality and equity.

Services weaknesses

In the category of service weaknesses, some barriers identified were due to the inability or ineffectiveness of services to conduct network coordination, whether between the intrasectoral or intersectoral network, also considering the lack of integration and misalignment alignment of care among the stakeholders that make up these networks¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.

17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^-1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408..

In this regard, one of the articles highlights that although CAPS is the main instrument for implementing RAPS, this policy is not confined to CAPS alone and must be implemented by establishing a network with well-defined referral flows that contribute to the comprehensive care of service users²⁴24 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408..

Other factors identified includes structural and human resource deficiencies¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,2525 Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP. Street clinic: the care practices with users of alcohol and other drugs in Macapá. Esc Anna Nery 2019; 23(1):e20180261., which were shown as barriers and weakened the work process and the provision of care, besides the physical distance between health services and the places the HP occupy²¹21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744..

A barrier identified is the lack of a system that enables more concrete and immediate responses to service user demand¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202., evidencing that resources in the health network are lacking at the appropriate time for service user demand now and then. The impersonal provision of procedures was also pointed out as a barrier¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202., identifying that the services operate predominantly based on biomedical logic without considering the social determinant of health³⁷37 Silva L, Bicudo V. Determinantes sociais e determinação social do processo saúde-doença: discutindo conceitos e perspectivas. In: Santos TVC, Silva LB, Machado TO, organizadores. Trabalho e saúde: diálogos críticos sobre crises. Rio de Janeiro: Mórula; 2022. p. 115-131.. We should emphasize the relevance of organizing care based on technical guidelines and include the interests and desires of the subjects to whom the care is directed¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202..

Another barrier highlighted was interpersonal violence, both between service users and between service users and health service workers, which stems from the relationships established in these environments¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.. Finally, the last barrier concerns a weak health communication process with the service’s public, which can generate a lack of knowledge about the services¹⁵15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161., their functions, the care offered, and how to access them.

Access facilitators

Relational

Regarding relational facilitators, the relationship between service users and workers or services was highlighted in nine articles¹⁵15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.^,1616 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.

19 Lima HS, Seidl EMF. Consultório na Rua: percepção de profissionais e usuários sobre redução de danos. Psicol Pesq 2017; 11(2):33-41.

20 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848.

21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.^-2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.^,2525 Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP. Street clinic: the care practices with users of alcohol and other drugs in Macapá. Esc Anna Nery 2019; 23(1):e20180261. and the listening and receptive attitude of professionals in six works¹⁵15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.^,1717 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.

18 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.

19 Lima HS, Seidl EMF. Consultório na Rua: percepção de profissionais e usuários sobre redução de danos. Psicol Pesq 2017; 11(2):33-41.^-2020 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848.^,2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142., revealing themselves as crucial soft technology healthcare tools³⁸38 Merhy EE. Saúde: a cartografia do trabalho vivo. São Paulo: Hucitec; 2002., considering the relevance of a non-judgmental reception that considers the subjects’ reality.

Another facilitator was the mediation of other professionals or coordination between eCR professionals and professionals from other services²²22 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408. to promote access, considering the personal “partnerships” established among service workers. While presented as a facilitator, this situation also exposes access barriers by indicating that service user access sometimes relies on informal and non-institutionalized arrangements. This attempt to build arrangements with some professionals in the health network can be interpreted as a favor, and despite being strategic or even subversive in guaranteeing service user access to the SUS, it does not ensure care continuity and does not solve the problems of the homeless access to the SUS³⁹39 Fraga PVR. "Tá normal! tá normal! a saúde chegou": etnografia da atuação do Consultório na Rua de Belo Horizonte nas cenas de uso [dissertação]. Belo Horizonte: Instituto René Rachou; 2022..

The active search for service users is identified as access facilitator¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.. It is one of the Family Health Strategy (ESF) activities, which refers to the service professional visiting the service user as a strategy to increase resolution, operating as a possibility of expanding access and promoting equity⁴⁰40 Brasil. Portaria nº 2.436, de 21 de setembro de 2017. Aprova a Política Nacional de Atenção Básica, estabelecendo a revisão de diretrizes para a organização da Atenção Básica, no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União; 2017.. This practice must be at the heart of CAPS assistance, which must organize care for people with mental health issues and their families based on an expanded notion of territory, consisting mainly of “people who live there, their conflicts, interests, friends, neighbors, family, institutions, and settings (church, religious services, school, work, and bar)”⁴¹41 Brasil. Ministério da Saúde (MS). Departamento de Ações Programáticas Estratégicas. Saúde mental no SUS: os Centros de Atenção Psicossocial. Brasília: MS; 2004..

The professionals’ negotiating stance with service users was described as access facilitator¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202. and is directly related to the receptive and listening posture to preserve and encourage the service user’s autonomy. This practice aligns with the SUS guidelines that point to harm reduction as a care strategy for service users of psychoactive substances (PAS), respecting their choices and autonomy in the care process with information, education, and counseling actions that contribute to adopting safer behaviors³⁶36 Brasil. Portaria nº 1.028, de 1 de julho de 2005. Determina que as ações que visam à redução de danos sociais e à saúde, decorrentes do uso de produtos, substâncias ou drogas que causem dependência, sejam reguladas por esta Portaria. Diário Oficial da União; 2005.. This posture incorporates the recognition of the service user as a subject in their healthcare process to establish standards for conducting their lives¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202..

Finally, recognizing the service as a place of protection was identified as a facilitator of access¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.. Regarding life on the streets, vulnerability to the risk of violence is part of everyday life, which generates insecurity and fear of sleeping, directly affecting the quality of sleep and well-being. In this sense, recognizing services as a place of protection favors access and the permanence and continuity of care in health services.

Acting from the perspective of equity

Equity is one of the doctrinal principles of the SUS, conceived from the need to reduce inequalities in access to health services⁴²42 Brasil. Lei 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set.. In the category that addresses action from the perspective of equity, we identified strategies that can operate as facilitators of access for the HP; among them, the possibility of itinerancy with deployment of services to the territory was pointed out in five articles¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,2222 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.

23 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.^-2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408., which dialogues with the category of active search, from the establishment of a service deployment to the place where service users stay.

Another facilitator identified is referral systems within the health network (intrasectoral)¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.^,2525 Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP. Street clinic: the care practices with users of alcohol and other drugs in Macapá. Esc Anna Nery 2019; 23(1):e20180261. and the capacity for intersectoral coordination, establishing partnerships between different public policies¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,2121 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408., thus enabling a network of alliances and agreements for the care of the HP. Considering that poverty and social exclusion are the central axes for thinking about HP’s health, the need to implement structural and intersectoral public policies is fundamental for a concrete process of guaranteeing rights and overcoming the ills that violently affect these bodies³⁹39 Fraga PVR. "Tá normal! tá normal! a saúde chegou": etnografia da atuação do Consultório na Rua de Belo Horizonte nas cenas de uso [dissertação]. Belo Horizonte: Instituto René Rachou; 2022..

The capacity to incorporate the unpredictable or unplanned based on the demand and desire of service users¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^,1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,2020 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848., the flexibility of services with the possibility of adapting flows and protocols based on the recognition of the HP’s lifestyles¹⁷17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.^,2020 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848., the capacity to respond to the request for care on demand²²22 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142., operate as facilitators based on equitable practices that consider the different access needs.

The characteristic of being an open-access service²²22 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142., referring to the care of the person based on walk-in demand, is identified as a facilitator that contributes to the opportunity for care without the need to establish a prior referral.

Assistance-related

Regarding care aspects, twelve of the thirteen selected articles point to the role of mobile teams as facilitators of access¹⁴14 Oliveira JAS, Furtado LAC, Andreazza R. (In)visibilidades das violências na produção do cuidado com as pessoas em situação de rua. Interface (Botucatu) 2022; 26:e220057.

15 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.

16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.

17 Friedrich MA, Wetzel C, Camatta MW, Olschowsky A, Schneider JF, Pinho LB, Pavani FM. Barreiras de acesso à saúde pelos usuários de drogas do consultório na rua. J Nurs Health 2019; 9(2):e199202.

18 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.

19 Lima HS, Seidl EMF. Consultório na Rua: percepção de profissionais e usuários sobre redução de danos. Psicol Pesq 2017; 11(2):33-41.

20 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848.

21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744.

22 Wijk LB, Mângia EF. O cuidado a Pessoas em Situação de Rua pela Rede de Atenção Psicossocial da Sé. Saude Debate 2017; 41(115):1130-1142.

23 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101.

24 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.^-2525 Bittencourt M, Pantoja PVN, Silva Júnior PCB, Pena JLC, Nemer CRB, Moreira RP. Street clinic: the care practices with users of alcohol and other drugs in Macapá. Esc Anna Nery 2019; 23(1):e20180261. when moving to offer care on-site, exemplified in these articles through eCRs’ work.

Another important aspect highlighted as a facilitator refers to multidisciplinarity, interprofessionality, or integration between different professional categories¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,2020 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848.^,2424 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408., identified as a potentiating factor of the offers based on the possibility of integrated action from several knowledge domains for the construction of plural care prepared to address the different problems and needs of people living on the streets.

In contrast to the imposed abstinence shown as a barrier in the services rigidity, the offer from the perspective of harm reduction and specific offers for care concerning the use of alcohol and other drugs¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890.^,1818 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69. were indicated as facilitators of access, as they recognize this subject in their needs and provide care to the extent that the subject allows, considering the service user’s knowledge. The available car for the team’s deployment is a physical structure that facilitates access to services for the HP¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890..

The provision of care from the perspective of comprehensive healthcare¹⁶16 Borysow IC, Conill EM, Furtado JP. Atenção à saúde de pessoas em situação de rua: estudo comparado de unidades móveis em Portugal, Estados Unidos e Brasil. Cien Saude Colet 2017; 22(3):879-890., access to oral health²⁰20 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848., recognizing the HP’s difficulties to maintaining satisfactory oral hygiene due to substandard living conditions, and the provision of medications are also identified as facilitators²⁰20 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848., also considering the possibility of dispensing medication to the HP without the requirement for an identification document. Another facilitator was workers’ technical knowledge about sexually transmitted infections (STIs) and drugs¹⁸18 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69., contributing to an efficient care approach for the HP.

In contrast to the weak health communication in the barriers, previously defined and publicized opening hours so that service users know how to seek the service¹⁸18 Lima HS, Seidl EMF. Consultório na rua: atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69. facilitates the HP’s access to healthcare. Quality of care received²¹21 Oliveira MA, Boska GA, Oliveira MAF, Barbosa GC. O acesso à saúde pela população em situação de rua da Avenida Paulista: barreiras e percepções. Rev Esc Enferm USP 2021; 55:e03744. is a differential that brings the population closer to the services, and matrix-based support²³23 Teixeira MB, Belmonte P, Engstrom EM, Lacerda A. Os invisibilizados da cidade: o estigma da População em Situação de Rua no Rio de Janeiro. Saude Debate 2019; 43(n. esp. 7):92-101. is a facilitator of access and reveals the potential for shared construction for intervention with people experiencing homelessness, considering overlapping vulnerabilities.

Finally, artistic and recreational activities²⁰20 Engstrom EM, Teixeira MB. Equipe "Consultório na Rua" de Manguinhos, Rio de Janeiro, Brasil: práticas de cuidado e promoção da saúde em um território vulnerável. Cien Saude Colet 2016; 21(6):1839-1848. are also shown as facilitators. Such actions may broaden the view of these subjects and their singularities, considering the biopsychosocial aspects, which can result in a better response to healthcare.

An important limitation of the results shown is that all studies are linked, to varying degrees, to therapeutic itineraries. Studies on therapeutic itineraries face significant limitations, as they often establish a directional nature supported by a negative health conception, partly due to how the respondents rebuild the itinerary⁴³43 Demétrio F, Santana ER, Pereira-Santos M. O Itinerário Terapêutico no Brasil: revisão sistemática e metassíntese a partir das concepções negativa e positiva de saúde. Saude Debate 2019; 43(n. esp. 7):204-221.. Furthermore, this approach does not usually achieve effective interdisciplinary and transdisciplinary integration, restricted by paradigms prioritizing the lack of disease as the leading indicator of health. Adopting broader theoretical perspectives and analytical frameworks that broaden the debate on a positive conception of health, the effectiveness of comprehensiveness, and the symbolic efficacy of care⁴³43 Demétrio F, Santana ER, Pereira-Santos M. O Itinerário Terapêutico no Brasil: revisão sistemática e metassíntese a partir das concepções negativa e positiva de saúde. Saude Debate 2019; 43(n. esp. 7):204-221. is necessary.

Conclusion

Although this integrative review specifically focused on understanding access to mental health services, the results pointed to barriers and facilitators primarily found in the HP’s access to health services in general, even considering the public that uses alcohol and other drugs. This indicates the recognition that the RAPS comprises diverse services that exceed CAPS and CAPS-AD’s work. This perspective becomes fundamental for us to think that the care of the HP who use alcohol and other drugs should be provided in an expanded and integrated manner.

Furthermore, it offers implications that the main barriers and facilitators of access for this public are instead related to the fact that they are homeless rather than to the harmful use of alcohol and other drugs. Among the 19 categorized barriers, only imposing abstinence was exclusively linked to the use of alcohol and other drugs. Among the 22 facilitators, only technical knowledge about drugs and the harm reduction approach were exclusive to use. Part of this result can be attributed to the limited scope of these articles, whose exclusive target audience is the HP. The relevance of studies that allow comparing or differentiating between circumstances and factors linked to the different social groups that access mental health is noted for the more precise identification of the differences and commonalities in access due to their condition of being homeless or the harmful use of alcohol and drug.

Regarding the results, we should underscore that the multiple contributions of the articles were convergent or added new factors to be considered in the study of access. No disagreements were found among the authors regarding the different barriers and facilitators. We expect that the categorization effort in this review will enable progress in the systematization and understanding of these factors linked to barriers and facilitators. Future studies are needed to deepen the analysis of specific factors and understand the relationships between these factors. Furthermore, research must focus on identifying these factors and studying strategies that seek pragmatic solutions to be implemented in healthcare in a feasible manner and with some urgency, considering the several pieces of evidence of barriers that prevent the fulfillment of HP’s right to equal access to healthcare.

Discrimination has been identified as a critical barrier to access. It adversely affects individuals’ self-perception and interaction with health services and reflects broader structural failures. These systemic failures prevent services from effectively and inclusively meeting the complex needs of these service users.

Street Outreach Clinics were highlighted as key facilitators in accessing health services, particularly because of their ability to adapt to service users’ lifestyles and needs. Their team stands out for its multidisciplinary composition and approach of listening and being receptive, which is essential to building a relationship of trust with service users. These results reinforce the importance of ensuring that all components of the Psychosocial Care Network (RAPS) are equipped to provide care that is accessible, ethically sound, equitable, and free of bias in order to truly meet the needs of the population served.

Finally, the study also points to the need for reforming health service flows, routines, and protocols to increase access and improve the quality of care. Adopting harm reduction strategies and implementing matrix-based support are promising practices that can guide care, particularly for vulnerable patients. These approaches enable more personalized and co-participatory care, which is crucial for treatment adherence and effectiveness. The coordination of the care network within and between sectors is also vital to meet the complex needs of this population, highlighting the importance of a holistic and empathetic approach within health systems.

References

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