Abstract

The number of homeless people (HP) has been increasing in recent years. Government actions have been implemented to improve the living conditions for this population, especially those focused on health care. This study has as research question: What are the healthcare strategies of services and programs being offered to the homeless population in Brazil? Its objective is to analyze the health care strategies adopted by services and programs offered to the homeless population in Brazil. To achieve this purpose, a search was conducted in the Virtual Health Library (VHL), Latin American and Caribbean Literature in Health Sciences (Lilacs), and Scientific Electronic Library Online (SciELO) databases, resulting in 21 articles. The analysis revealed the scope and challenges of the health care networks, indicating drug use as the main reason for seeking the services, with the Street Clinics (CnaR, Consultório na Rua) being an important service capable of promoting the creation of links between the HP and other sectors. of health. The importance of networking and the complexity of population health care were recurring topics in the discussions, as they deal with actions aimed at vulnerable and stigmatized people, showing needs and singularities in the way of living in society.

Key words:
Homeless population; Health; Health assistance

Introduction

The existence of people who make the streets their space for survival is a common reality in Brazil. This phenomenon is justified by the constitution of the Brazilian society. The latter was founded from a slave-owning, racist and violent colonial process, with no reparatory measures after its end, leaving major fissures in the way the country organizes itself economically and culturally¹1 Paixão DS, Rocha RVS, Rodrigues ILS. A psicologia da libertação e o aquilombamento da população em situação de rua em Salvador/BA: reflexões através do Programa Corra pro Abraço. Bol Conjunt (BOCA) 2021; 15(14):9-20.^,22 Calmon TVL. As condições objetivas para o enfrentamento ao COVID-19: abismo social brasileiro, o racismo e as perspectivas de desenvolvimento social como determinantes. Rev NAU Soc 2020; 11(20):131-136.. Social and economic inequalities are striking, with thousands of people living on the streets¹1 Paixão DS, Rocha RVS, Rodrigues ILS. A psicologia da libertação e o aquilombamento da população em situação de rua em Salvador/BA: reflexões através do Programa Corra pro Abraço. Bol Conjunt (BOCA) 2021; 15(14):9-20.^,22 Calmon TVL. As condições objetivas para o enfrentamento ao COVID-19: abismo social brasileiro, o racismo e as perspectivas de desenvolvimento social como determinantes. Rev NAU Soc 2020; 11(20):131-136.. The Institute for Applied Research³3 Instituto de Pesquisa Econômica Aplicada (Ipea). Estimativa da população em situação de rua no Brasil [Internet]. 2012. [acessado 2023 jun 11]. Disponível em: https://repositorio.ipea.gov.br/bitstream/11058/10074/1/NT_73_Disoc_Estimativa%20da%20populacao%20em%20situacao%20de%20rua%20no%20Brasil.pdf
https://repositorio.ipea.gov.br/bitstrea... estimated that in March 2020 there were 221,869 people living on the streets in Brazil. This means that a heterogeneous group, made up of thousands of people, lives in extreme poverty. These people live, temporarily or permanently, in public places and degraded areas or in shelters for temporary overnight stays or temporary housing, with interrupted or weakened family ties⁴4 Brasil. Presidência da República. 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; 24 dez..

Living on the streets, permeated by joy, intelligence, hard work and a sense of community, also reveals a series of deprivations of rights. Their lives are marked by unpredictability. On the streets, they are exposed to climate changes, aggression and food insecurity, among other situations. Often, the use of psychoactive substances becomes a strategy to deal with adversity⁵5 Souza TP, Macerata I. A clínica nos consultórios na rua: territórios, coletivos e transversalidades. Ayvu Rev Psicol 2015; 1(2):3-23.^,66 Genonádio A, Tedesqui NSB, Aires, S. COVID-19 e a população em situação de rua: práticas e cuidados desenvolvidos em Salvador - BA. In: Lima M, Coutinho D, Bustamante V, Aires S, Patiño R, organizadores. Pensar junto/fazer com. Salvador: Edufba; 2021. p. 425-439..

This context generates several impacts on their lives and directly influences their health-disease processes, and also the possibility of access to health services. In 2009, the National Policy for the Homeless Population (PNPR, Política Nacional para a População em Situação de Rua) was established through Presidential Decree n. 7,053/20094. The PNPR seeks to ensure that the homeless population have broad, simplified and safe access to health, social assistance and housing networks. However, the complexity involved in accessing and maintaining the homeless population in the health services is recognized, whether due to the specificities that the vulnerability of life offers or the social stigma and structural racism that impact the way these people are perceived and treated in services⁶6 Genonádio A, Tedesqui NSB, Aires, S. COVID-19 e a população em situação de rua: práticas e cuidados desenvolvidos em Salvador - BA. In: Lima M, Coutinho D, Bustamante V, Aires S, Patiño R, organizadores. Pensar junto/fazer com. Salvador: Edufba; 2021. p. 425-439..

Considering the decentralized management of the Brazilian Public Health System (SUS, Sistema Único de Saúde) and the possibility of private sector participation in many actions, several complementary programs and services, mainly in primary health care, attend to this population. Therefore, the objective is to analyze the health care strategies developed in services and programs aimed at the homeless population in Brazil. Therefore, this study’s guiding question is: What are the health care strategies of services and programs aimed at the homeless population?

Method

The methodological choice was a systematic literature review - the unfolding of a review whose objective is to characterize political actions aimed at homeless people (HP)⁷7 Queiroz D, Veras R, Genonádio A, Costa Filho A. A população em situação de rua: as estratégias de planejamento intersetorial para o cuidado em saúde. NTQR 2022; 13:e707.. A question was formulated and, using systematic and explicit methods, it was possible to identify, select and critically evaluate relevant studies, collect and analyze data from the material in this review.

The studies followed the updated recommendation of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, as shown in the update flow diagram model⁸8 Galvão TF, Andrade TS, Harrad D. Principais itens para relatar revisões sistemáticas e meta-análises: a recomendação PRISMA. Epidemiol Serv Saude 2015; 24(2):335-342.. The guiding question was: What are the health care strategies of services and programs aimed at the homeless population?

PRISMA helps researchers to improve the reporting of systematic reviews and meta-analyses. It consists of a checklist and a four-step flowchart that organizes and guides the reporting of reviews, offering greater transparency to the data collection and analysis process. The analyzed documents belong to the public domain, originating from higher education institutions and research centers, with the aim of demonstrating which projects and proposals are developed, within the scope of health, for and with the homeless population in Brazil.

The searches were carried out in March 2023, in the following databases and portals: Virtual Health Library (VHL), Latin-American and Caribbean Literature in Health Sciences (Lilacs) and Scientific Electronic Library Online (SciELO). The following Boolean descriptors and operators (in capital letters) were used: homeless population AND health AND project OR program.

After inserting the descriptors, the results totaled 337 documents - 199 in the VHL, 70 in Lilacs and 68 in SciELO. The inclusion criteria in the analysis were: full-text and peer-reviewed articles, published in the last ten years in Portuguese and related to the topic.

After the researchers read the titles, descriptors and abstracts, those that did not correspond to the research objective were excluded. Of the 199 studies in the VHL, 179 were excluded, leaving 20; of the 70 in Lilacs, 41 were excluded, leaving 29; and of the 68 in SciELO, 47 were excluded, leaving 21. Among the articles found in the VHL, 6 were excluded due to appearing in duplicate in other databases, and another 6 were excluded in SciELO, totaling 12 duplicate articles and excluded in these databases.

Therefore, 58 studies were read in full by the researchers. Articles that did not deal with services and actions aimed at the HP in the health field were excluded at this stage. Of the 58, ten were excluded from VHL, 22 from Lilacs and cinco from SciELO because they did not correspond to the research objective. Hence, in total, 21 texts were included in the study, five from VHL, six from Lilacs and ten from SciELO. Figure 1 depicts the selection steps for the analyzed documents.

Chart 1 shows the included articles, depicting the title, year of publication, authors, place of publication, methodology used and category of analysis.

The process of organizing and validating the categories had the assistance of a third researcher. After the initial categorization of the results, they were presented and discussed by the other authors and a third researcher, thus defining the final study categorization. In the next section, we will describe how the assessed studies are related to these categories and subsequent discussion.

Results and discussion

The analysis of the 21 articles that constituted the database of this study (Chart 1) indicated that publications on the topic are concentrated in the Southeast region, with emphasis on the state of Rio de Janeiro (six articles). Most of the studies constitute qualitative research, using different data collection and analysis techniques.

After reading the articles, it was possible to group them according to the health care strategies adopted by programs that attend to HP in Brazil. For Minayo¹⁰10 Minayo MCS, organizadora. Pesquisa social - teoria, método e criatividade. Petrópolis: Vozes; 2021., one of the functions of content analysis is to search for answers to the questions that were asked. In this process, creating categories is recommended by collecting content, ideas and/or common expressions to be better presented and discussed. Thus, three main categories were identified for the analyses, as shown in Chart 2.

HP’s access to the Healthcare Network

The first category deals with the HP’s access to the health network, including service strategies and the challenges encountered in this area.

Ordinance N. 4,279, of December 30, 2010, establishes the guidelines for the organization of the Health Care Network (RAS, Rede de Atenção à Saúde) in the Unified Health System (SUS, Sistema Único de Saúde ) in Brazil. The RAS is defined as “organizational arrangements of health actions and services, of different technological densities, which integrated through technical, logistical and management support systems, seek to guarantee comprehensive care.”¹¹11 Brasil. Presidência da República. Portaria 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; 31 dez. (p.1). From this perspective, health services are organized into two main levels:

1. Primary health care (PHC): generally represented by Basic Health Units (BHUs) that offer routine consultations, exams, integrative health practices, workshops, among other activities. PHC is characterized by being close to people, preventing diseases and promoting health and quality of life, ensuring comprehensive health care in territories¹¹11 Brasil. Presidência da República. Portaria 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; 31 dez..

2. Specialized care: characterized by more complex actions and consisting of secondary (medium complexity) and tertiary (high complexity) care. Specialized services such as outpatient clinics, hospitals, emergency care units and polyclinics are present in medium complexity. Large hospitals with cutting-edge technology and research development are found in high complexity¹¹11 Brasil. Presidência da República. Portaria 4.279, de 30 de dezembro de 2010. Estabelece diretrizes para a organização da Rede de Atenção à Saúde no âmbito do Sistema Único de Saúde (SUS). Diário Oficial da União 2010; 31 dez..

In this category, the studies had the following focuses: HP access to the care network; barriers and challenges that arise in this access; and coordination between health services and public policies aimed at this population. Regarding the access to the health care network, most studies highlighted Primary Care, mainly because it is seen as the HP’s gateway to health services, through the Street Clinics.

Paiva and Guimarães¹²12 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408. evaluated several services offered by the Psychosocial Care Network (RAPS, Rede de Atenção Psicossocial) for the HP: Family Health Support Center (NASF, Núcleo de Apoio à Saúde da Família); Street Clinic teams; Community Center; Family Health Strategy Unit (ESF, Unidade de Estratégia de Saúde da Família ); Psychosocial Care Center for Alcohol and Drug use (CAPS-AD, Centro de Atenção Psicossocial para Álcool e Drogas) type II and type III; CAPS type III; 24-hour Emergency Care Unit (UPA, Unidade de Pronto Atendimento); and Psychosocial Care Unit located in a General Hospital.

Similarly to other authors¹³13 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.

14 Araújo E. Funcionamentos de instituições em cenas de uso de crack: um estudo etnográfico. Trab Educ Saude 2019; 17(2):e0019529.^-1515 Viana LS, Oliveira EN, Costa MS, Aguiar CC, Moreira RM, Cunha AA. Política de redução de danos e o cuidado à pessoa em situação de rua. Rev Eletr Saude Mental Alcool Drog 2020; 16(2):57-65., Paiva and Guimarães¹²12 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 illicit drug use by the HP, showing that prior to the “supposed crack epidemic” this population remained invisible within the scope of RAPS. However, as a result of this epidemic, the authors state that the creation of projects and policies aimed at the HP was more of a control and stigmatization strategy than a health strategy itself. In the lack of assistance and the absence of public policies, the HP seeks social support from entities and people linked to non-governmental organizations, communities and religious groups, which, in most cases, have a charitable nature, which obscures the right to health.

The research also informs about the disarticulation of RAPS, “which, instead of being integrated, has disconnected lines (sic) and isolated points formed by services that are barely known and ill-defined flows”¹²12 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408. (p. 13). These authors argue that this system is still anchored in the psychiatry- and asylum-related logic, given the strengthening and expansion of services such as Therapeutic Communities, in addition to care being centered in psychiatric hospitals. Add to this the fact that mental illness is associated with a deviation from morality, as well as social danger, under the stigma of “drug user” and “drug addict”, going against the logic of damage reduction.

The presence of the police is constant as a way of sanitizing these public spaces, in an attempt to make this population invisible. Araújo¹⁴14 Araújo E. Funcionamentos de instituições em cenas de uso de crack: um estudo etnográfico. Trab Educ Saude 2019; 17(2):e0019529. studied the relationship between the police and social assistance. For the author, this relationship feeds into the establishment and maintenance of stigmas in relation to the HP, justifying the violence on the part of the police. On the other hand, he places the CnaR Teams as members of a network of services and administrative districts. However, they have a supportive and humanized character, truly managing to perform the function of establishing links and bridges between the HP and other institutions in a less stigmatized and violent way.

Sharing this perspective, Viana et al.¹⁵15 Viana LS, Oliveira EN, Costa MS, Aguiar CC, Moreira RM, Cunha AA. Política de redução de danos e o cuidado à pessoa em situação de rua. Rev Eletr Saude Mental Alcool Drog 2020; 16(2):57-65. investigated the health work process through an intervention research on damage reduction practices at the Specialized Reference Center for Homeless People (CENTRO POP, Centro de Referência Especializado para Pessoas em Situação de Rua) and at the Psychosocial Care Center for Alcohol and Drug use (CAPS-AD) in a municipality in Ceará. The researchers concluded that the HP assistance involves complex care that requires moving away from stigmatized ideas regarding this population. They reinforced the articulation of these spaces with primary health care, considered a gateway to care more focused on the demands of the homeless people’s situation. This finding was made by most of the analyzed studies¹³13 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161.^,1414 Araújo E. Funcionamentos de instituições em cenas de uso de crack: um estudo etnográfico. Trab Educ Saude 2019; 17(2):e0019529.^,1616 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.^,1717 Couto JGA, Godoi H, Finkler M, Mello ALS. Atenção à saúde bucal da população em situação de rua: a percepção de trabalhadores da saúde da região Sul do Brasil. Cad Saude Colet 2021; 29(4):518-527..

For Rossi and Tussi¹³13 Rossi CCS, Tucci AM. Acesso ao tratamento para dependentes de crack em situação de rua. Psicol Soc 2020; 32:e170161., the primary health care network is not prepared to attend to the HP, since most services offer therapeutic approaches based on total abstinence, with the exception of CAPS-AD, which operates under the anti-prohibitionist perspective of damage reduction. The authors also concluded that Therapeutic Communities were the most accessed services for the care of HP who use drugs; however, the operating methodology of these services is religious, prohibitionist and characterized by the lack of adequate technical treatment.

The study by Lira et al.¹⁸18 Lira CDG, Justino JMR, Paiva IKS, Miranda MGO, Saraiva AKM. O acesso da população em situação de rua é um direito negado? REME 2019; 23:e-1157. was developed with professionals from the family health teams, UPA and the emergency room of a regional hospital. Their results highlighted the obstacles in providing care to HP in urgent and emergency services due to the requirement for an identification document, known address and SUS card. They even stressed the low number of professionals and the social devaluation they direct towards this population, creating difficulties in forming bonds.

In response to these difficulties and barriers in accessing health services, the authors indicate CAPS-AD and the Street Clinics as extremely important to provide access to the HP and their care, since the damage reduction methodology has an anti-prohibitionist and contributes to stimulating the subjects’ autonomy¹²12 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408.^,1616 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.^,1717 Couto JGA, Godoi H, Finkler M, Mello ALS. Atenção à saúde bucal da população em situação de rua: a percepção de trabalhadores da saúde da região Sul do Brasil. Cad Saude Colet 2021; 29(4):518-527.. CnaRs stand out in most of the analyzed articles, as a gateway for this population, often being the only service that HP effectively have access to and that acts as a bridge to other services in the network. Couto, Godoi and Melo¹⁷17 Couto JGA, Godoi H, Finkler M, Mello ALS. Atenção à saúde bucal da população em situação de rua: a percepção de trabalhadores da saúde da região Sul do Brasil. Cad Saude Colet 2021; 29(4):518-527. expanded the discussion on CnaR, drawing attention to the importance of oral health professionals in these spaces, as oral health appears among the most common problems of this population, and is also a frequently requested service.

Paiva and Guimarães¹²12 Paiva IKS, Guimarães J. População em situação de rua e Rede de Atenção Psicossocial: na corda bamba do cuidado. Physis 2022; 32(4):e320408. concluded that CnaRs work includes building bonds, qualified listening, dialogical relationships, intersectorality, interdisciplinary work and sharing care. Despite the importance of the CnaR, there are still many challenges such as lack of material supplies; great effort by professionals to meet the users’ demands; lack of a dedicated room for the CnaR team; difficulties in intersectoral work and HP access to other RAPS services; fragility of the employment relationship of health professionals who work in this area, due to the lack of public tenders and career plans for the area.

For Wijka and Mângia¹⁶16 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 services provided by eCnaR can be considered intersectoral and the relationships developed in its setting are humanized and contribute to actions based on affection, being especially important because they deal with a vulnerable and stigmatized population.

The work of the Street Clinics (Consultório na Rua)

The second category addresses issues related to the work of the team that works at the Street Clinics, established as a result of the Street Population Movement to legitimize the principle of equity. Thus, in 2011, Ordinance N. 122¹⁹19 Brasil. Presidência da República. Portaria nº 122, de 25 de janeiro de 2011. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União 2011; 26 jan. was published, establishing the Street Clinic teams (eCnaR), which are linked to the Psychosocial Care Network (primary health care). These teams are multidisciplinary, as they deal with the diverse demands and needs of the assisted population. The eCnaR differential is the work the perform in loco, on the streets, with the challenge of promoting care and health actions for the HP. Moreover, the work of articulating the entire health network - BHUs, UPA, CAPS among other services - becomes essential to provide comprehensive care to these people. Intersectoral work is also common, due to the complexity of the phenomenon, making it necessary to develop plans together with the social assistance network¹⁹19 Brasil. Presidência da República. Portaria nº 122, de 25 de janeiro de 2011. Define as diretrizes de organização e funcionamento das Equipes de Consultório na Rua. Diário Oficial da União 2011; 26 jan..

Most of the analyzed studies highlight and make reference to the diverse experiences of eCnaRs spread across Brazil, both for their importance in promoting accessibility of the HP to other services, and a gateway to the care network as well as for the successful and effective work they carry out in the street spaces, promoting equity and guaranteeing the right to health. In this category, articles describing the work of CnaR were included, as an exclusive research locus.

Regarding the operation of the Street Clinics, some of the studies²⁰20 Alecrim TFA, Palha PF, Ballestero JGA, Protti-Zanatta ST. Advisory teams on the streets: a nurse's experience report. Rev Esc Enferm USP 2022; 56:e20220026.

21 Silva CC, Cruz MM, Vargas EP. Práticas de cuidado e população em situação de rua: o caso do Consultório na Rua. Saude Debate 2015; 39(Esp.):246-256.

22 Viegas SMF, Nitschke RG, Bernardo LA, Tholl AD, Borrego MAR, Soto PJL, Tafner DPOV. Quotidiano de equipes de consultório na rua: tecendo redes para a promoção da saúde. Esc Anna Nery 2021; 25(3):e20200222.

23 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.

24 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(Esp. 7):50-61.

25 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.

26 Machado MPM, Rabello ET. Competências para o trabalho nos Consultórios na Rua. Physis 2019; 28(4):e280413.

27 Marques LS, Costa JHM, Gomes MM, Silva MM. Saberes, territórios e uso de drogas: modos de vida na rua e reinvenção do cuidado. Cienc Saude Colet 2022; 27(1):123-132.^-2828 Camargo BP. Vivência em Consultório na Rua do Rio de Janeiro: a situação de rua sob uma nova perspectiva. Rev Bras Med Fam Comunidade 2016; 11(38):1269. mainly highlight the knowledge of the territory, the itinerant work and the promotion of HP accessibility to health services, whether through eCnaR itself or when it ensures the meeting of health needs (including social and legal assistance) in other services. This highlights interdisciplinary work and network, in addition to promoting the development of actions that are based on the promotion of health and equity, and the continuity of comprehensive care.

Alecrim et al.²⁰20 Alecrim TFA, Palha PF, Ballestero JGA, Protti-Zanatta ST. Advisory teams on the streets: a nurse's experience report. Rev Esc Enferm USP 2022; 56:e20220026. point out that knowledge of the territory is essential for the development of CnaR actions, as it contributes to organizing work processes and health surveillance. The authors highlight the special importance of the territory for HP.

On the street, the territory is dynamic and independent of geographic limits. It happens every day in places of passage, at points of fixation, in different forms of subsistence, in encounters and divergences. Thus, it is essential to consider the relationship that the individual establishes with this territorial space, understanding that given the difficulties, weaknesses and risks of each territory, it is essential to also know its potential and resources²⁰20 Alecrim TFA, Palha PF, Ballestero JGA, Protti-Zanatta ST. Advisory teams on the streets: a nurse's experience report. Rev Esc Enferm USP 2022; 56:e20220026. (p. 3).

Alecrim et al.²⁰20 Alecrim TFA, Palha PF, Ballestero JGA, Protti-Zanatta ST. Advisory teams on the streets: a nurse's experience report. Rev Esc Enferm USP 2022; 56:e20220026. and Viegas et al²²22 Viegas SMF, Nitschke RG, Bernardo LA, Tholl AD, Borrego MAR, Soto PJL, Tafner DPOV. Quotidiano de equipes de consultório na rua: tecendo redes para a promoção da saúde. Esc Anna Nery 2021; 25(3):e20200222. recommend that it is necessary to think about network and intersectoral interventions in the social, political and technical sectors of the health-disease process. Therefore, promoting health is related to living conditions, work, education, food, housing, safety, sleep/rest, leisure, among other issues, considering that social aspects often overlap with care demands. In this sense, many teams invest in cultural and leisure activities, such as cinema, toy library, drawing workshop, visits to tourist attractions and juggling workshops²⁰20 Alecrim TFA, Palha PF, Ballestero JGA, Protti-Zanatta ST. Advisory teams on the streets: a nurse's experience report. Rev Esc Enferm USP 2022; 56:e20220026..

Working on the street, therefore, must consider the challenges of the unpredictable and rely on the team’s flexibility and creativity, since it is not possible to strictly predict or organize the work routine. Furthermore, the CnaR teams deal with the double stigmatization of the homeless population, who suffer from illicit drug use, both from health services and from society in general. On the subject, the works of Machado and Rabello²⁶26 Machado MPM, Rabello ET. Competências para o trabalho nos Consultórios na Rua. Physis 2019; 28(4):e280413., Marques et al.²⁷27 Marques LS, Costa JHM, Gomes MM, Silva MM. Saberes, territórios e uso de drogas: modos de vida na rua e reinvenção do cuidado. Cienc Saude Colet 2022; 27(1):123-132., Camargo²⁸28 Camargo BP. Vivência em Consultório na Rua do Rio de Janeiro: a situação de rua sob uma nova perspectiva. Rev Bras Med Fam Comunidade 2016; 11(38):1269. and Lima and Seidl²⁹29 Lima HS, Seidl EMF. Consultório na Rua: Atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69. highlight the work on damage reduction, which is based on care in freedom, the user’s protagonism in the care relationship and respect for the subjects’ choices.

In this sense, Marques et al.²⁷27 Marques LS, Costa JHM, Gomes MM, Silva MM. Saberes, territórios e uso de drogas: modos de vida na rua e reinvenção do cuidado. Cienc Saude Colet 2022; 27(1):123-132. point out that the Street Clinics need to deal with the unpredictability of the service; consider the culture and knowledge of care settings; outline concrete problems and objectives that dialogue with different realities and subjects; use a participatory approach that guarantees the subjects’ protagonism; and understand the uniqueness of the relationship between the subject and their use practices.

Although the CnaR plays an important role as a gateway to the network and ensures care for the HP, in addition to the different potentialities in offering this service, some authors²³23 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.

24 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(Esp. 7):50-61.^-2525 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.^,2929 Lima HS, Seidl EMF. Consultório na Rua: Atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,3030 Silva LMA, Monteiro IS, Araújo ABVL. Saúde bucal e consultório na rua: o acesso como questão central da discussão. Cad Saude Colet 2018; 26(3):285. indicate limitations and difficulties in the development of the work. Friedrich et al.²⁵25 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. identified the following barriers to health care: stigmas, fragmented service network, bureaucracy of care processes, and lack of mental health resources/services. Despite recognizing the CnaR as an innovative strategy, efficient in the care and insertion of the HP in other services, it becomes insufficient, in the face of a network that is still compartmentalized, with rigid and bureaucratic processes. Lima and Seidl²⁹29 Lima HS, Seidl EMF. Consultório na Rua: Atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69. highlight the difficulties in developing services at the CnaR: prejudice, lack of supplies and aggressive action by the police force.

Silva et al.³⁰30 Silva LMA, Monteiro IS, Araújo ABVL. Saúde bucal e consultório na rua: o acesso como questão central da discussão. Cad Saude Colet 2018; 26(3):285., when investigating the oral health care of the HP, highlighted their stigmatization as “drug users, rebels, fugitives, among others” and the lack of training of health professionals to care for this population. These stereotypes contribute to obstacles to seeking care and non-adherence of the HP to treatment. The CnaRs face difficulties in carrying out dental procedures as they do not have a professional specialist in their teams, nor are reference services available to meet these demands. The authors understand that the eCnaR must be attentive to identifying oral health demands, as they are the ones who deal with this population on a daily basis. In this study, there was a weakness in the team’s knowledge on this topic, which could compromise attempts to construct flows for dental care for the HP. The authors³⁰30 Silva LMA, Monteiro IS, Araújo ABVL. Saúde bucal e consultório na rua: o acesso como questão central da discussão. Cad Saude Colet 2018; 26(3):285. recommend that teams undergo permanent education activities.

Finally, it is necessary to highlight the development of care technologies by CnaR teams that become differentials and define the work with the HP. Alecrim et al.²⁰20 Alecrim TFA, Palha PF, Ballestero JGA, Protti-Zanatta ST. Advisory teams on the streets: a nurse's experience report. Rev Esc Enferm USP 2022; 56:e20220026.; Silva, Cruz and Vargas²¹21 Silva CC, Cruz MM, Vargas EP. Práticas de cuidado e população em situação de rua: o caso do Consultório na Rua. Saude Debate 2015; 39(Esp.):246-256.; Machado and Rabello²⁶26 Machado MPM, Rabello ET. Competências para o trabalho nos Consultórios na Rua. Physis 2019; 28(4):e280413.; Camargo²⁸28 Camargo BP. Vivência em Consultório na Rua do Rio de Janeiro: a situação de rua sob uma nova perspectiva. Rev Bras Med Fam Comunidade 2016; 11(38):1269.; Lima and Seidl²⁹29 Lima HS, Seidl EMF. Consultório na Rua: Atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69. and Hallais and Barros³¹31 Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad Saude Publica 2015; 31(7):1497-504. identified that CnaR teams use the most basic but scarce resources in health services in general, which are human resources. According to the authors²⁰20 Alecrim TFA, Palha PF, Ballestero JGA, Protti-Zanatta ST. Advisory teams on the streets: a nurse's experience report. Rev Esc Enferm USP 2022; 56:e20220026.^,2121 Silva CC, Cruz MM, Vargas EP. Práticas de cuidado e população em situação de rua: o caso do Consultório na Rua. Saude Debate 2015; 39(Esp.):246-256.^,2626 Machado MPM, Rabello ET. Competências para o trabalho nos Consultórios na Rua. Physis 2019; 28(4):e280413.^,2828 Camargo BP. Vivência em Consultório na Rua do Rio de Janeiro: a situação de rua sob uma nova perspectiva. Rev Bras Med Fam Comunidade 2016; 11(38):1269.^,2929 Lima HS, Seidl EMF. Consultório na Rua: Atenção a pessoas em uso de substâncias psicoativas. Psicol Estud 2015; 20(1):57-69.^,3131 Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad Saude Publica 2015; 31(7):1497-504., CnaR professionals have empathetic listening skills and a singular embracement attitude, building bonds and horizontal relationships of care, understanding cases, based on the uniqueness of each subject, striving to include the HP without stigmatizing and revictimizing the users. This is the CnaR biggest hallmark, which allows the HP to feel embraced in their real needs, which is often related to “being seen and humanized”, ultimately producing the exercise of citizenship.

Hallais and Barros³¹31 Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad Saude Publica 2015; 31(7):1497-504. found that listening is used in the CnaR as a political instrument, as it brings people together on equal terms, breaking with the colonizing knowledge-power constantly present in care relationships in health services.

Other initiatives

Among the categories of analysis, other initiatives were highlighted, which contribute to improving access and embracement of the HP in RAPS. Some innovative strategies were described in two analyzed articles³²32 Matraca MVC, Araújo-Jorge TC, Wimmer G. O PalhaSUS e a saúde em Movimento nas Ruas: relato de um encontro. Interface (Botucatu) 2014; 18(2):1529-1536.^,3333 Silva SS, Skalinski LM, Calmon TVL, Araújo GS, Nery JS. Coletivo Nós nas Ruas e Programa Corra pro Abraço: ações para o enfrentamento da COVID-19 em Salvador, BA, Brasil. Interface (Botucatu) 2021; 25(Supl. 1):e200690..

PalhaSUS was a project created for a doctoral study carried out at FIOCRUZ, based on popular health education with the aim of bringing Family Health teams and the population closer together³²32 Matraca MVC, Araújo-Jorge TC, Wimmer G. O PalhaSUS e a saúde em Movimento nas Ruas: relato de um encontro. Interface (Botucatu) 2014; 18(2):1529-1536.. For the authors³²32 Matraca MVC, Araújo-Jorge TC, Wimmer G. O PalhaSUS e a saúde em Movimento nas Ruas: relato de um encontro. Interface (Botucatu) 2014; 18(2):1529-1536., this experience denotes a real need for reflection on the incorporation of popular education and the arts in public health policies aimed at the HP.

Other actions presented by Silva et al.³³33 Silva SS, Skalinski LM, Calmon TVL, Araújo GS, Nery JS. Coletivo Nós nas Ruas e Programa Corra pro Abraço: ações para o enfrentamento da COVID-19 em Salvador, BA, Brasil. Interface (Botucatu) 2021; 25(Supl. 1):e200690. were the “Coletivo Nós nas Ruas” and the “Programa Corra pro Abraço”. The latter has existed since 2013, in Salvador, based on the damage reduction strategy, with the objective of promoting the citizenship of HP who use illicit drugs. The “Coletivo Nós nas Ruas”, created in 2020 by a group of teachers and students from UFBA and Uneb, formulated emergency strategies to fight COVID-19 aimed at the HP of the city of Salvador. For this purpose, they proposed the implementation of a Contingency Plan for the coronavirus pandemic (COVID-19) aimed at HP, with the aim of going beyond recommendations based on individualized or segregationist actions to pay attention to raising awareness among different social groups (civil society, academic community and management) in relation to the gaps that involve the complexity and social visibility of HP. The authors³¹31 Hallais JAS, Barros NF. Consultório na Rua: visibilidades, invisibilidades e hipervisibilidade. Cad Saude Publica 2015; 31(7):1497-504. defend intersectoral coordination between social actors and health workers from different areas who work with HP, especially health and social assistance teams.

Final considerations

The studies analyzed in this systematic literature review showed, for the most part, descriptions of the health services offered to HP. The discussions revolve around illicit drug use, pointing out the damage reduction strategy as a viable option for working with this population. Moreover, many reported the consequences of stigmatization, creating barriers both for patients’ access to health services and for humanized care from professionals who work in these spaces.

An important alternative strategy to the barriers and limitations that affect HP access to RAPS, highlighted by many articles, is the Street Clinic (Consultório na Rua), which has emerged as an important articulator between primary health care services and the assisted population. Through damage reduction, the Consultório na Rua team builds bonds, demystifies stigmas and contributes to the autonomy of this vulnerable population. Few studies, however, have demonstrated the effectiveness of intersectoral projects and programs.

It is concluded, therefore, that it is important to think about changes, given the current scenario, through a broad intersectoral contribution that involves actions aimed at the HP based on cultural, educational, social and health strategies, aiming at an adequate and comprehensive health practice.

This is a review study and its limitations are related to the use of descriptors and the choice of databases. Choosing other descriptors and databases could increase the number of identified studies. However, this study has the potential to reveal strategies that are being used, their barriers and challenges to promote health care for the homeless population in a comprehensive manner, ensuring their rights.

References

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