Mortality and barriers to healthcare among people experiencing homelessness in Paris: a mixed-methods study.

backgroundHomelessness is a global problem with significant public health implications. Persons experiencing homelessness (PEH) face poorer health outcomes and elevated risks of premature death compared to the general population. This is also true for PEH in France, despite the country’s system of universal health coverage. This study investigates 10-year mortality patterns among PEH in Paris and barriers to accessing healthcare.

methodsDeaths among PEH—including demographic information and causes of death, identified through active case finding by volunteers—were compared to those in the general population of mainland France. Percentages were standardized for the sex distribution of the PEH population, using data from the National Institute of Statistics and Economic Studies and the Epidemiology Centre on Medical Causes of Death. We conducted semi-structured interviews with 11 healthcare and social service providers to explore barriers to healthcare access for PEH, using a pre-existing theoretical framework to guide interviews and analysis.

resultsBetween 2014 and 2023, 1 559 PEH (89.4% men) died in Paris. The median age of death was 54 years (IQR: 46–63), younger than the general population’s median of 80 years (IQR: 67–88). Notably, 1184 (75.9%) died before age 65, compared to 19.5% in the general population. Most deaths (450, 68.1%) were due to disease, with circulatory diseases (128, 19.4%) and neoplasms (102, 15.4%) as most common causes, similar to the general population. Barriers to healthcare access were manifold. Acceptability was low due to mismatches between provider attitudes and practices and the needs of PEH. Availability was limited due to capacity constraints and poor interdisciplinary collaboration. Geographical accessibility, when services were far from PEHs habitual locations, reinforced reluctance to health care use. Affordability and administrative hurdles impeded access for the uninsured.

conclusionPEH in Paris die from the same diseases as the general population, but at a much younger age, despite universal health coverage. The earlier onset of disease and multiple healthcare access barriers suggest an urgent need for improved social support and integrated care. Above all, the provision of stable, affordable housing could both mitigate the health impacts of homelessness and tackle its root causes.