Abstract

Introduction

The existence of people on the streets is a social phenomenon that takes on new expressions in contemporary society, particularly in large urban centers (Hwang et al., 2009Hwang, S. W. et al. Multidimensional social support and the health of homeless individuals. Journal of Urban Health, New York, v. 86, n. 5, p. 791-803, 2009.). This social group which inhabits public parks or public/philanthropic shelters, experiences precarious work situations, living conditions and poor social integration (Vannucchi, Barros, 2009Vannucchi, A. M. C.; Barros, J. O. População em situação de rua: identificando necessidades para políticas públicas de inclusão social. In: Silveira, C.; Carneiro Junior, N.; Marsiglia, R. M. (Org.). Projeto inclusão social urbana: nós do centro: metodologia de pesquisa e de ação para inclusão social de grupos em situação de vulnerabilidade no centro da cidade de São Paulo. São Paulo: Fundação Arnaldo Vieira de Carvalho: Faculdade de Ciências Médicas da Santa Casa de São Paulo, 2009. p. 61-90.; Vieira, Bezerra, Rose, 1992Vieira, M. A. C.; Bezerra, E. M. R.; Rosa, C. M. M. População de rua: quem é, como vive, como é vista. São Paulo: Hucitec, 1992.).

Living on the streets is a problem that goes beyond homelessness. Having a home means having roots, identity, security, a sense of belonging and a place of emotional well-being (Editorial, 2008THE PLOS MEDICINE EDITORS. Homelessness is not just a housing problem. PloS Medicine, San Francisco, v. 5, n. 12, 2008. Editorial. Disponível em: <http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000003>. Acesso em: dd mmm. aaaa.
http://journals.plos.org/plosmedicine/ar... ).

The transformations experienced by Western societies, through the processes of social exclusion and inclusion have produced different groups, more or less marginalizing the population on the streets (Castel, 1997Castel, R. A dinâmica dos processos de marginalização: da vulnerabilidade à "desfiliação". Caderno CRH, Salvador, v. 10, n. 26/27, p 19-40, 1997.; Nascimento, 1994Nascimento, E. P. Hipóteses sobre a nova exclusão social: dos excluídos necessários aos excluídos desnecessários. Cadernos CRH, Salvador, v. 7, n. 21, p. 29-47, 1994.).

The heterogeneity of social groups within the composition of the downtown area of São Paulo is too big. In this area of the city people co-exist on the streets, women and transvestites in prostitution, and lower middle classes occupying houses and apartments, are often interspersed with slums and Bolivian migrant worker workshops, among others. Depending on the location, the neighborhood can also be made up of housing units built by the government, with poor structural conditions, rapidly deteriorating and with a history of violence, delinquency and organized crime. There are also small slums and upper-class neighborhoods (Silveira, Amaral, Marsiglia, 2009Silveira, C.; Amaral, D. P.; Marsiglia, R. M. Aspectos metodológicos sobre as intervenções junto aos segmentos sociais em situação de vulnerabilidade social: contribuição para a formação de redes sociais. In: Silveira, C.; Carneiro Junior, N.; Marsiglia, R. M. (Org.). Projeto inclusão social urbana: nós do centro: metodologia de pesquisa e de ação para inclusão social de grupos em situação de vulnerabilidade no centro da cidade de São Paulo. São Paulo: Fundação Arnaldo Vieira de Carvalho: Faculdade de Ciências Médicas da Santa Casa de São Paulo, 2009. pp. 45-59.; Frúgoli Junior, 1995Frúgoli Júnior, H. São Paulo: espaços públicos e interação social. São Paulo: Marco Zero, 1995.).

People on the streets are among the most marginalized groups in society. Even among them there are differences across their individual trajectories, such as length of stay on the streets and their particular life strategies (Martins, 1997Martins, J. S. Exclusão social e a nova desigualdade. São Paulo: Paulus, 1997.; Carneiro Junior et al., 1998Carneiro Junior, N. et al. Serviços de saúde e população de rua: contribuição para um debate. Saúde e Sociedade, São Paulo, v. 7, n. 2, p. 47-62, 1998.; Hwang et al., 2010Hortale, V. A.; Pedroza, M.; Rosa, M. L. G. Operacionalizando as categorias acesse e descentralização na análise de sistemas de saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 16, n. 1, p. 231-239, 2000.).

The last census, in 2011, listed 14,478 people on the streets in the city of São Paulo, of which 47% stayed overnight in public places and 53% in municipal or philanthropic shelter. There has been an increase of 65% in the past 10 years of the number of people in this population in São Paulo. Administrative districts with the highest number of people living on the street are those who are in the "central area" of the city, with St. Cecilia, Cathedral and the surrounding neighborhoods having a higher concentration of this population, amounting to 16% (Prefeitura do Município de São Paulo e Fundação Escola de Sociologia e Política de São Paulo, 2012SÃO PAULO. Prefeitura Municipal; FUNDAÇÃO ESCOLA DE SOCIOLOGIA E POLÍTICA DE SÃO PAULO. Censo da população em situação de rua da municipalidade de São Paulo (2011): principais resultados. São Paulo, 2012.).

Taking the people on the streets as a social issue for health care is relevant because their living conditions that determine health-illness care is a very different process, requiring new technical health care arrangements and public policy (Carneiro Junior, Jesus, Crevelim, 2010Carneiro Junior, N.; Jesus, C. H.; Crevelim, M. A. A Estratégia Saúde da Família para a equidade de acesso dirigida à população em situação de rua em grandes centros urbanos. Saúde e Sociedade, São Paulo, v. 19, n. 3, p. 709-716, 2010.).

In order to develop public policies aimed at this population, the Brazilian government issued the Decree 7,053/2009 establishing a national policy for the people on the streets, aimed at building institutional and social mechanisms to promote intersectoral programs and actions ensuring access to public goods and effective citizenship (Brazil, 2009BRASIL. Presidência da República. Casa Civil. 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, Brasília, DF, 24 dez. 2009. p. 16.).

The purpose of this article is to describe the sociodemographic characteristics, health status and access to services of a homeless sample living in downtown São Paulo, and compare these features to those observed among the most socially vulnerable residents, living in the same area.

Methodology

This article used results from "Social Inequalities in health and access to services for groups with varying degrees of vulnerability and social exclusion living in downtown São Paulo," a household survey carried out in 2008 that included four groups: residents living with social vulnerability; residents living without social vulnerability; Bolivian immigrants; and people living on the streets.

For the group of people living on the streets, we selected for convenience, three city shelters situated in downtown São Paulo, with 642 places for adults, 532 (83%) occupied by men and 110 (17%) women. A sample of 251 individuals was included. All women (78) present in the three shelters were included. For men, a systematic sample of 173 individuals was obtained. Data was collected in a single day by a team of 30 interviewers.

The sample of residents living in a socially vulnerable area was obtained in three stages. All census tracts in the central area were classified according to the São Paulo Social Vulnerability Index, developed by the SEADE Foundation, based on socioeconomic data and types of households. 25 census sectors were randomly selected among those classified as medium, high or very high social vulnerability. Households that occupied these 25 sectors were listed, 40 addresses (20 + 20 reserves) were drawn in each of the sectors through a systematic procedure. Only one of the residents aged 18 or over in each household was randomly selected. It included 487 residents with social vulnerability. The collection was done in a month by a team of trained interviewers.

A structured questionnaire containing demographic data, history, lifetime on the street, discrimination, social support, health status, alcohol consumption, tobacco or drugs use, violence and access to health services was applied. The data was submitted to double typing and processed with SPSS 17 software.⁹9 SPSS v17 is a paid software developed and marketed by IBM that allows processing and statistical analysis of research data. A database can be created and entered in the software itself or imported from other software. The processing and analysis are performed through commands.

The research project was approved by the Research Ethics Committee of, the Irmandade da Santa Casa de Misericórdia de São Paulo with 061/07 protocol. All participants signed the informed consent form (ICF).

Results

Table 1 shows the sociodemographic characteristics of the sample population consisting mainly of adult males, non-white (non-white category includes: black, brown and native yellow, whitch are and the color classes used by IBGE), those with low educational level, living without a partner, with a monthly income lower than 1/2 (half) the minimum wage (R$207.00 at the time of the survey) and those working outside of the labor market.

Table 2 shows the amount of time on the street and the reasons that led to this situation. One-third of respondents were in this situation for over five years while another third has been on the street for less than a year. For most, the reasons for homelessness are precarious financial conditions and the absence of family. Those with families are separated from them by personal choice or for other unspecified reasons. Almost all respondents stated the intention to get out of this situation.

Table 3 deals with the perception of discrimination and the social support network of the respondents. The vast majority of respondents feel discriminated against, particularly, with the homeless situation. The reason is that the lack of hygiene, physical appearance and physical or mental disability. About two-thirds feel unsafe walking in downtown at night. The majority does not have friends or relatives living nearby and do not identify institutions to whom they can turn to if they have a problem. In the shelter, 40% identify social workers as people who support them, while 22% say they cannot count on anyone; however, 60% say they feel good in the shelter.

The situation of health and exposure to violence are presented in Table 4. Most respondents considered themselves as having fair or poor health, but 45% report having good or very good health. Only 30% think that their health conditions interfere with everyday activities. The experience of attacks in the last month was reported by 46% of respondents, of which 16% reported physical or sexual assaults, in the shelter or on the street itself. The assaults were committed by homeless or other people living on the streets. About 10% reported having suffered abuse by the police.

As for risk of exposures: 57% are smokers; 34% consume alcohol, of which 18% reported consuming more than six drinks at a time and 19% answered yes to three or four questions from the CAGE¹⁰10 The instrument CAGE (Cut down, Annoyed by criticism, Guilty and Eye-opener) is used as a screening for alcohol abuse or dependence (CASTELLS, FURLANETTO, 2005). questionnaire (hazardous drinking). About one-third reported ever having used marijuana; 10% to 14% reported the use of inhaled cocaine, crack, or amphetamine; 8% reported sniffing perfume, glue, loló (solvents) and other inhaled drugs; 5% reported the use of injectable drugs, LSD or ecstasy.

Table 5 shows the access to health services. Most respondents are always looking for the same service and two-thirds seek primary care centers. Only 20% reported seeking emergency room when they have health problems. About 42% reported health problems in the week preceding the interview. Of these, 62% sought care at a health facility and 95% had their needs met. The most popular services were the primary care centers. Only 19% had sought the emergency room. Most evaluated the care they received as good or very good (84%).

Among those who had health problems, but did not seek treatment, 43% considered it unnecessary and 22% resorted to self-medication. Only 5% said it was due to lack of money and 8% claimed that the service would be time consuming.

Hospital admissions were reported by 21% of respondents and 7% had never been to a dental appointment. Of the rest, 49% had not had a dental appointment for three years or more and 26% less than a year. About two-thirds of women reported a Pap smear in the past three years and 42% reported mammogram in the past two years.

Discussion

The demographic profile of the surveyed individuals is similar to the last census of the population living on the streets in the city of São Paulo. This population group is predominantly male, with an average age of 40, "non-white", with schooling up to elementary school and coming from the Southeast zone, specific to the state of São Paulo (São Paulo, 2012SÃO PAULO. Prefeitura Municipal; FUNDAÇÃO ESCOLA DE SOCIOLOGIA E POLÍTICA DE SÃO PAULO. Censo da população em situação de rua da municipalidade de São Paulo (2011): principais resultados. São Paulo, 2012.). Similar profiles are reported in studies conducted in Canadian cities, in Glasgow, Scotland, and Los Angeles, and the United States (Hwang et al., 2009Hwang, S. W. et al. Multidimensional social support and the health of homeless individuals. Journal of Urban Health, New York, v. 86, n. 5, p. 791-803, 2009.; Morrison, 2009Morrison, D. S. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. International Journal of Epidemiology, London, v. 38, n. 3, p. 877-883, 2009.; Teruya et al., 2010Teruya, C. et al. Health and health care disparities among homeless woman. Women & Health, Philadelphia, v. 50, n. 8, p. 719-736, 2010.; Palepu et al., 2012Palepu, A. et al. Quality of life themes in Canadian adults and street youth: who are homeless or hard-to house: a multi-site focus group study. Health and Quality of Life Outcomes, London, v. 10, p. 93, ago. 2012.).

Even when compared to other socially vulnerable populations residing in the center of a metropolis, the group of individuals on the streets showed conditions of extreme vulnerability and social exclusion. They have uncertain role in the labor market, characterized by odd jobs and unemployment. Among those some enjoy a monthly income but a large part lived on less than half the minimum wage. This data is compatible with those observed in the census and in other studies in urban cities (Sao Paulo, 2012SÃO PAULO. Prefeitura Municipal; FUNDAÇÃO ESCOLA DE SOCIOLOGIA E POLÍTICA DE SÃO PAULO. Censo da população em situação de rua da municipalidade de São Paulo (2011): principais resultados. São Paulo, 2012.; Teruya et al., 2010Teruya, C. et al. Health and health care disparities among homeless woman. Women & Health, Philadelphia, v. 50, n. 8, p. 719-736, 2010.; Palepu et al., 2012Palepu, A. et al. Quality of life themes in Canadian adults and street youth: who are homeless or hard-to house: a multi-site focus group study. Health and Quality of Life Outcomes, London, v. 10, p. 93, ago. 2012.).

A small portion of respondents presented a circumstantial reason for being homeless, such as health treatment in the capital or temporary jobs. Most attributed their condition to economic problems, removal/lack of family relationships motivated by disagreements, unemployment or use of alcohol or drugs. Similar reasons appeared in studies of other cities (Editorial, 2008THE PLOS MEDICINE EDITORS. Homelessness is not just a housing problem. PloS Medicine, San Francisco, v. 5, n. 12, 2008. Editorial. Disponível em: <http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000003>. Acesso em: dd mmm. aaaa.
http://journals.plos.org/plosmedicine/ar... ; Palepu et al., 2012Palepu, A. et al. Quality of life themes in Canadian adults and street youth: who are homeless or hard-to house: a multi-site focus group study. Health and Quality of Life Outcomes, London, v. 10, p. 93, ago. 2012.; Hudson et al., 2010Hudson, A. L. et al. Health-seeking challenges among homeless youth. Nursing research, New York, v. 59, n. 3, p. 212-218, 2010.).

The perception of discrimination is extremely high among the group living on the streets, widely surpassing those residents reported living with social vulnerability (16%) in the downtown area of the city. Among the reasons indicated, the group identifies their condition of living on the street as the main reason for discrimination. There is also an overlap of other forms of racial, generational and sexual orientation. Milburn et al. (2010Milburn, N. G. et al. Discrimination and mental health problems among homeless minority young people. Public Health Reports, Washington, DC, v. 125, p. 61-67, jan. 2010.) studied adolescents living on the streets in Los Angeles, finding racial discrimination values ranging from 12% in whites and 42% among Latino immigrants. In the group studied racial discrimination was reported by 36% of respondents.

About a third of respondents felt discriminated against them in health services. Although the proportion is high, it was the lowest among the areas surveyed. In Toronto, discrimination in the health services accounted for 40% of the homeless respondents (Khandor et al., 2011Khandor, E. et al. Access to primary care among homeless adults in Toronto, Canada: results from the street health survey. Penn Medicine, Philadelphia, v. 5, n. 2, p. 94, 2011.).

The feeling of insecurity on the streets is indeed high among this group living on the streets (65%), but much lower than those residents who reported social vulnerability (96%) or residents without social vulnerability (78%).

Much of respondents live alone and when there is company, there is no relationship. Many of them report having children, with whom they have contact sporadically. There are few who participate in political and social activities promoted by targeted entities for this population.

Respondents highlight social workers, who work in the shelters, as people who they can tell if they have problems or difficulties in daily life. In a survey conducted in four Canadian cities, the authors identified conflicting perceptions between negative and positive aspects related to shelters among the participants. Among the negative aspects appeared the restrictions imposed by the regulations, conflicts with the teams, lack of privacy and interference with aspects of everyday life. The positives that were mentioned were having a roof over their head, or being housed (Palepu et al., 2012Palepu, A. et al. Quality of life themes in Canadian adults and street youth: who are homeless or hard-to house: a multi-site focus group study. Health and Quality of Life Outcomes, London, v. 10, p. 93, ago. 2012.).

The absence or weakness of social ties have deleterious effects on the physical and mental health of the person and increases the probability of suffering new attacks (Hwang et al., 2009). Living on the street means an accumulation of disadvantages that translate into: greater social discrimination, lack or limitation of ties, sense of insecurity, lack of trust in people and institutions, exposure to numerous health risks, unhealthy behaviors, increase in mortality and a lower life expectancy (Morrison, 2009Morrison, D. S. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. International Journal of Epidemiology, London, v. 38, n. 3, p. 877-883, 2009.; Dibben et al., 2011Dibben, C. et al. Differences in 5 year survival after a homeless or housed drugs-related hospital admission: a study of 15-30 years old in Scotland. Journal Of Epidemiology And Community Health, London, v. 65, p. 780-785, set. 2011.).

A significant portion of the group on the street (55%) considered their health fair, poor or very poor, reflecting the precarious living conditions. Compared to downtown residents, both in areas with and without social vulnerability, this group reported a higher proportion of subjects with fair health, poor or very poor (18% and 39%, respectively). In a sample of homeless in the city of Ghent, Belgium, 40% reported a fair, poor or very poor health status, compared to 34% of the general population (Verlinde et al., 2010Verlinde, E. et al. Unique health care utilization patterns in a homeless population in Ghent. BMC Health Services Research, London, v. 10, p. 242, ago. 2010.).

Physical violence adds to the prejudiced actions of violence and discrimination suffered in the daily lives of people living on the streets. Physical violence suffered in public parks often repeats itself in institutionalized spaces such as shelters, not leaving these people safe spaces to ensure their physical and mental integrity.

The proportion of smokers observed is high surpassing residents with social vulnerability (50%). The proportion of those who refer alcohol consumption is lower for the group on the street (34% versus 52%); however, the risk consumption is almost three times more common in this group. Consumption in life of illicit drugs is more frequent among the group on the street, for all considered drugs.

In a sample of people living on the streets in Toronto, they recorded 36% of alcohol use, similar to the rate observed in São Paulo; and 46% of drug use, a higher rate than that reported in this study (Hwang et al., 2009Hwang, S. W. et al. Multidimensional social support and the health of homeless individuals. Journal of Urban Health, New York, v. 86, n. 5, p. 791-803, 2009.). In four studies in Detroit, alcohol abuse was reported in 11% of adolescents, reaching 57% among the elderly. Drug use ranged from 19% among adolescents, and 56% in the elderly (Tompsett, Fowler, Toro, 2009Tompsett, C. J.; Fowler, P.; Toro, P. A. Age differences among homeless individuals: adolescence through adulthood. Journal of prevention & intervention in the community, New York, v. 37, n. 2, p. 86-99, 2009.). The differences can be attributed to various factors such as the possibility of information omission in São Paulo, the fact that consumption is considered a crime in Brazil, there is less access, given the cost of acquisition, or even that the sample bias for the exclusive inclusion of homeless located in shelter in the present study.

Gelberg, Andersen and Leak (2000)Gelberg, L.; Andersen, R. M.; Leak, B. D. The behavioral model for vulnerable populations: application to medical care use and outcomes for homeless people. Health Service Research, Chicago, v. 34, n. 6, p. 1273-1302, 2000. proposed a behavioral model for vulnerable populations that may be useful in the analysis of access to health services. In this model access is seen as the result of predisposing factors that determine the propensity to seek services, facilitate or inhibit access and use of services sought, and the health needs that determine the search for care. The concept of access to health services is complex, highlighting three dimensions: availability - offering, accessibility - the service organization, and acceptability - user satisfaction (Aday, Andersen, 1992ADAY, L. A.; ANDERSEN, R. Marco teórico para el estudio del acceso a la atención médica. In: White, K. (Ed.). Investigaciones sobre servicios de salud: una antologia. Washington, DC: OPAS, 1992. p. 604-613. (Publicación Científica, n. 534).; Frenk, 1992Frenk, J. El concepto y la medición de accesibilidad. In: White, K. (Ed.). Investigaciones sobre servicios de salud: una antologia. Washington, DC: OPAS, 1992. p. 929-943.; Bronfman et al., 1997Bronfman, M. et al. Del "cuánto" el "por qué": la utilización de los servicios de salud desde la perspectiva de los usuarios. Salud Pública de México, México, DF, v. 39, n. 5, p. 442-450, 1997.; Hortale, Pedroza, Rose, 2000Hortale, V. A.; Pedroza, M.; Rosa, M. L. G. Operacionalizando as categorias acesse e descentralização na análise de sistemas de saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 16, n. 1, p. 231-239, 2000.; Mendoza-Sassi, Bérua, 2001Mendoza-Sassi, R.; Bérua, J. V. Utilización de los servicios de salud: uma revisión sistemática sobre los factores relacionados. Cadernos de Saúde Pública, Rio de Janeiro, v. 17, n. 4, p. 819-832, 2001.; Travassos, Martins, 2004Travassos, C.; Martins, M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cadernos de Saúde Pública, Rio de Janeiro, v. 20, p. 190-198, 2004. Suplemento 2.; Marsiglia, Carneiro Junior, 2009Marsiglia, R. M.; Carneiro Junior, N. Disponibilidade, acessibilidade e aceitabilidade do PSF em áreas metropolitanas. In: Cohn, A. (org.). Saúde da família e SUS: convergências e dissonâncias. Rio de Janeiro: Beco do Azougue; São Paulo: CEDEC, 2009. p. 95-112.).

The propensity to seek services usually increases with age, is lower in men and higher among individuals with less education and lower income for curative services, but for this same group, the search for preventive practices is low. The perception of discrimination, little or no trust in institutions and the instability of social ties in this group can function as factors that hinder the effective pursuit of health services. On the other hand, the existence of a public health system with universal access and a greater emphasis on primary care could facilitate the access and use of services, even for marginalized groups. Finally, the health needs expressed by the self-health assessment above, shows that exposure to situations of aggression, the use of drugs, alcohol and tobacco, presuppose this population to a greater need to search for care.

The type of service that was most sought by the homeless was provided by primary care centers and emergency units, and the primary care centers were reported twice as much by the group living on the streets compared to residents with social vulnerability. About 80% reported always seeking the same services when they have a health problem, this aspect did not differ in the residents with social vulnerability. This data did differ from those previously published which pointed to low utilization of primary care in the group living on the streets and almost exclusive use of emergency services. Even in the UK, which has a national health system, barriers were identified in this population group such as access to GPs (General Practitioners). However, the homeless in the city of Ghent in Belgium, consulted a GP more often than emergency services, which is in line with this study (Verlinde et al., 2010Verlinde, E. et al. Unique health care utilization patterns in a homeless population in Ghent. BMC Health Services Research, London, v. 10, p. 242, ago. 2010.).

When looking at the prevalence of health problems in the week preceding the interview, the rate for the homeless in São Paulo were extremely high, reaching about 42% of respondents (three times higher than that observed in residents with social vulnerability). This high prevalence is expected to the unpredictable living conditions and numerous harmful exposures of this group.

Among those living in the streets, approximately 40% of the individuals who reported having had a health problem did not seek care. The reasons given were self-medication and that they did not deem it necessary to search for service. For the group of residents with social vulnerability the proportion of non-demand was lower (25%) but the allegations were similar. The lower rate of demand for the group living on the street, probably, reveals: a lower valuation of health problems, fatalistic attitude toward health problems, lack of knowledge of their rights regarding the use of services, avoidance attitude towards previous discrimination and prejudice experiences, less pressure for attendance resulting from lack of inclusion in the labor market, and predominance of men in this patient subset. Similar data were observed among the homeless in Toronto (Khandor et al., 2011Khandor, E. et al. Access to primary care among homeless adults in Toronto, Canada: results from the street health survey. Penn Medicine, Philadelphia, v. 5, n. 2, p. 94, 2011.).

When exploring the dimension "of health services" in the population census of the homeless, the majority of respondents disclose not have health problems, although they state separately injuries related to falls, fights with pedestrians as well as respiratory problems; often mentioning the use of the emergency room for these situations (São Paulo, 2012SÃO PAULO. Prefeitura Municipal; FUNDAÇÃO ESCOLA DE SOCIOLOGIA E POLÍTICA DE SÃO PAULO. Censo da população em situação de rua da municipalidade de São Paulo (2011): principais resultados. São Paulo, 2012.). This data does not coincide with those found in the literature, probably due to the methodological differences in the questions or the existence of differences between the people on the streets, homeless or not.

Among those who sought health services, 95% of their needs were met, thereby demonstrating that despite the barrier factors, individuals had access. This high rate of attendance may reflect greater access for sheltered individuals, assuming the intermediation of the staff and professionals at the shelter assist in obtaining care. For those who had their needs met, the care received was considered good or very good in 84% of the cases. This high degree of satisfaction may result from the simple fact of having achieved compliance or, also, means a lower level of expectation on the part of these individuals, suggesting lower standards.

The hospitalization rates over the past year were also high for this population, mainly composed of adults 40-59 years, reflecting once again, that health needs are closely related to poor living conditions of this population group. Several authors mention the increased risk of hospitalization for most people on the streets, even among the young (Hudson et al., 2010Hudson, A. L. et al. Health-seeking challenges among homeless youth. Nursing research, New York, v. 59, n. 3, p. 212-218, 2010.; Baggett et al., 2010BAGGETT, T. P. et al. The unmet health care needs of homeless adults: a national study. American Journal of Public Health, Oxford, v. 100, n. 7, p. 1326-1333, 2010.). The existence of a public health system with universal coverage and service delivery at all levels of complexity can ensure access even to groups with higher levels of social exclusion.

With regards to access to dental care, what draws attention is the proportion of people who have never received this type of care, almost 4 times higher among the homeless in comparison to residents in areas with social vulnerability. However, this ratio is lower than that what was observed for the Brazilian population in the same year, probably due to the wide range of services in the city of São Paulo and the existence of dental care in primary care centers (Peres et al., 2012Peres, K. G. et al. Redução das desigualdades sociais na utilização de serviços odontológicos no Brasil entre 1998 e 2008. Revista de Saúde Pública, São Paulo, v. 46, n. 2, p. 250-258, 2012.). As for the time from the last query, the situation of the population is very similar to that observed among residents of areas with social vulnerability in São Paulo. The group on the streets presents a worse situation in this respect; since almost 50% said that their last visit was three or more years ago. A national survey with elderly people on the streets, in the United States, found that 41% of their dental care needs were unmet (Baggett et al., 2010BAGGETT, T. P. et al. The unmet health care needs of homeless adults: a national study. American Journal of Public Health, Oxford, v. 100, n. 7, p. 1326-1333, 2010.).

Access to preventive screenings for breast cancer was similar in the group of women living on the street to the residents living in areas with social vulnerability, in downtown São Paulo. For cervical cancer screening, it was lower among the women on the streets. For the same year, the population of Brazilian women ages 25 years or more, the examination rates for Pap smear and mammography were 70% and 55% respectively. Among women living on the streets in the downtown region of São Paulo, the proportions were lower than the national average.

The focus on the specifics of this group and their internal differences seems to be the best way to understand their needs. The consideration of the specifics would include this group's complex needs and create projects that would completely address those needs, as a guideline of actions in health and social services aimed at greater social inclusion.

Social and health care policies require the government's: flexibility in ways to observe and understand this group's diversity, consider the various interested social groups in its design, and implementation of actions and services that will incorporate the diverse health needs, such as violence in public places or in private life, sexually transmitted diseases, chronic respiratory diseases, mental diseases, among others (Nakamura, 1996Nakamura, E. Algumas considerações antropológicas sobre o processo de urbanização e suas consequências sobre a saúde mental das crianças. Infanto - Revista de Neuropsiquiatria da Infância e Adolescência, São Paulo, v. 4, n. 1, p. 52-56, 1996.; Carneiro Junior, Silveira, 2003Carneiro Junior, N.; Silveira, C. Organização das práticas de atenção primária no contexto dos processos de exclusão/inclusão social. Cadernos de Saúde Pública, Rio de Janeiro, v. 19, n. 6, p. 1827-1835, 2003.; Silveira et al., 2009Silveira, C.; Carneiro Junior, N.; Marsiglia, R. M. (Org.). Projeto inclusão social urbana: nós do centro: metodologia de pesquisa e de ação para inclusão social de grupos em situação de vulnerabilidade no centro da cidade de São Paulo. São Paulo: Fundação Arnaldo Vieira de Carvalho: Faculdade de Ciências Médicas da Santa Casa de São Paulo, 2009.).

Decree No. 7,053/2009, which established the National Policy for the Homeless Population, meets this specific incorporation, with a benchmark of equity when it says that one of its principles is to "respect the social conditions and differences of origin, race, age, nationality, gender, sexual orientation and religion, with special attention to people with disabilities "(Brazil, 2009BRASIL. Presidência da República. Casa Civil. 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, Brasília, DF, 24 dez. 2009. p. 16.).

Implementing this policy will require state and civil society efforts to overcome this social reality, facing obstacles of various dimensions, such as the dynamic life of these individuals including: poor social background, fragmented social relationships without solidarity, fragile intersectoral joints, the capacity of the public administration, among others, limit, therefore, the possibility an effective policy.

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