Exploring the factors that prevent or facilitate palliative care at ‘home’ for adults experiencing structural vulnerability: a scoping review

Abstract

Background

While most people express a preference to be cared for and die at home, not all people have access to a safe or stable home. Government policies often position home death as a proxy measure of quality end-of-life care, yet structurally vulnerable populations, including those who are precariously housed, homeless, or living in supportive or transitional housing, are frequently excluded from this possibility. This scoping review aims to summarize the current literature on the factors that facilitate or prevent palliative care at ‘home’ for structurally vulnerable adults.

Methods

We conducted a scoping review following Joanna Briggs Institute’s (JBI) methodology, searching eight academic databases and relevant grey literature sources. Studies were eligible for inclusion if they were published in English, and addressed three core eligibility criteria: housing status, health status, and high-income country context. Data were extracted and analyzed using narrative synthesis and thematic analysis.

Results

A total of 33 studies were included. Five overarching themes influenced the ability to remain at home at end-of-life: systemic complexity, financial resources, value systems, social supports, and education and training. The review highlights how systemic barriers, including restrictive housing and healthcare policies, fragmented care structures, and stigmatization, limit opportunities for home-based care. Notably, narrow definitions of home and dominant cultural values about appropriate places to die further constrained access to palliative care in non-traditional settings. At the same time, flexible, community-based models and strong relational supports were identified as facilitators of dying in place.

Conclusion

This review underscores that people experiencing structural vulnerability are too often denied the choice of where they die. Addressing inequities in end-of-life care requires policy reforms that support flexible service models and recognize diverse forms of home, including shelters, transitional housing, and supportive housing, as legitimate places of care and dying. Findings provide an evidence base to inform equity-oriented policies aimed at expanding end-of-life options for structurally vulnerable populations.

Registration

A protocol for this review was registered in the Open Science Framework registries: 10.17605/OSF.IO/X8TJ7.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-026-02777-3.

Background

The ability to be cared for and die at home has become a cornerstone of the modern hospice and palliative care movement [1–3]. Home-based palliative care not only provides a familiar and comforting environment for patients and family members but studies have shown that if given a choice the majority of people would prefer to die at home, where they feel most connected to the people and places that are meaningful to them [4, 5]. Thus, supporting people’s preference to die at home has become a proxy measure for quality palliative care [6–9].

While policies that promote dying at home have gained momentum, people who experience structural vulnerability have been largely overlooked [10, 11]. That is, not all people who are dying have a safe and secure home, revealing that such policy directives are based on assumptions about who is in need of palliative care and thus, reinforcing a model of care that may be inaccessible for certain population groups. In particular, people impacted by intersecting structural inequities (i.e., racism, classism, ageism) and who experience social disadvantages like homelessness and poverty, are known to face disproportionate barriers in accessing palliative care, or any care, particularly as they approach end-of-life [12–15]. Research demonstrates that if access to palliative care by structurally vulnerable populations does occur, it tends to be very late in the illness trajectory [13, 14, 16–18]. Research with people who experience structural vulnerability shows that intertwined with other barriers to care (e.g., navigating complicated health/social care systems with limited resources), the willingness to seek out and accept care at the end-of-life is highly dependent upon who is providing such care and where [13, 14, 19, 20]. People who experience structural vulnerability often avoid seeking medical care out of mistrust of health professionals, lack of culturally safe care, and not being believed or deemed worthy by providers to receive care [21, 22]. Care in hospitals is often avoided because of the stigmatization, social exclusion, and power imbalances experienced within these spaces that evoke feelings of discomfort, fear, and anxiety [9, 23, 24]. Considering the above mentioned barriers, providing people who experience structural vulnerability the option to be cared for and die at ‘home’ - defined here as receiving quality palliative care by people they trust in the places they feel safe and prefer to die - is critically important.

As part of the first phase of a larger Canadian ethnographic study examining dying at ‘home’ in contexts of inequity (CIHR, Supporting Vulnerable and Marginalized Older Adults to be Cared for and to Die at ‘Home’ - PJT-186033), a scoping review of the literature was completed. The research question guiding the scoping review was: What are the factors that facilitate or prevent the provision of palliative care at ‘home’ among people who experience structural vulnerability? The scoping review results, contained herein, are being used to inform the team’s ongoing ethnographic research and builds on our previous research, suggesting that strategies to support people who are structurally vulnerable to be cared for and die at ‘home’ would significantly improve quality of life, care, and death, if the right supports were put in place [25, 26].

Methods

A scoping review was conducted to identify and synthesize existing literature on the facilitators and barriers to dying at ‘home’ for adults experiencing structural vulnerability. This review followed the Joanna Briggs Institute’s (JBI) methodology for scoping reviews [27] and is reported following the PRISMA extension for Scoping Reviews (PRISMA_ScR) [28]. The protocol for this scoping review was developed a priori and was registered in the Open Science Framework registries (10.17605/OSF.IO/X8TJ7). Initially, ‘home’ was specified according to the established definitions from Canada’s National Housing Strategy and focused on three types of housing (emergency shelter housing; transitional housing; supportive housing). This definition of ‘home’ was based on previous research suggesting that loss of housing or eviction occurs most frequently in these settings for people experiencing structural vulnerability [4] who are also on a palliative trajectory [14]. However, after pilot-testing this definition, no single framework encompassed the full spectrum of housing and home environments relevant to this population. Thus, the definition was expanded to include a broader range of housing status (see Table 1).

Table 1.

Eligibility criteria

	Inclusion Criteria	Exclusion Criteria
Population	Focused on adults who are 35 + and experiencing housing insecurity and chronic illness. Palliative trajectory for the purposes of this scoping review is indicated by acknowledgement of provision of end-of-life care. This may include those experiencing chronic substance use and/or mental illness that is likely to cause death, and /or living with health conditions including cardiovascular disease, cancer, respiratory disease, endocrine disorders, HIV, hepatitis C, or end stage liver disease.	Studies were excluded if they focused on youth or pediatric populations, people with disabilities without reference to housing insecurity and serious illness, or the general population without attention to structural vulnerability. Studies were also excluded if they considered women as a vulnerable group in isolation; however, women were included if they met the criteria for housing insecurity and health status outlined above. In addition, studies focused on homeowners, those living in congregate housing, or those receiving homecare services were excluded.
Concept	Palliative Care at Home - ‘Home’ in this instance is specified according to established definitions from Canada’s National Housing Strategy but was further expanded on to include a diverse range of housing facilities, service models and living arrangements. These encompassed, but were not limited to, social model hospices, “home” settings, transitional housing facilities, assisted living facilities, permanent supportive housing, street-based and mobile palliative care teams, night shelters, homeless hostels, encampments, rough sleeping, hospices, hospitals, clinics, shelters, single-room occupancy hotels, and day centres.	Studies were excluded if they focused on the concept of aging in place without explicit discussion of dying in place or dying. We also excluded studies that addressed healthy aging rather than end-of-life contexts, as well as studies on advance care planning that did not specifically mention death or dying. Studies examining bereavement were excluded unless they explicitly framed bereavement as part of palliative care. Finally, studies that addressed Indigenous palliative care facilitators and barriers were excluded if they did not mention place.
Context	High Income Countries - Countries that are member states of the United Nations, have some form of social housinga and are considered high-incomeb according to the World Bank’s definition. High income countries based on this definition will include: Australia, Austria, Belgium, Canada, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Malta, Netherlands, New Zealand, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, South Korea, Spain, Sweden, Switzerland, United Kingdom, and the United States.	Countries not mentioned in inclusion criteria section.
Study and publication characteristics	Must be written in English. Empirical studies were limited to original research published scholarly journals. Commentaries, editorials, reviews, and syntheses were disaggregated into their contributing articles, which were then screened for inclusion.	Publication in languages other than English. Publications not containing primary research.

^aCountry was named/listed in one of the social housing reports by either UNECE (2015) or OECD (2020), indicative of social housing within the country. ^b A high-income economy is defined by the World Bank as a country with a gross national income per capita of US$13,845 or more in 2022, calculated using the Atlas method

Inclusion/exclusion criteria

The three primary concepts guiding this search were: housing status, health status, and country. Inclusion and exclusion criteria and more detailed definitions for each of these concepts can be found in Table 1. If an article met our criteria for housing and health status as defined above, we considered the population included in the article as structurally vulnerable.

Information sources and search strategy

The search strategy was developed by a librarian (ZP) with extensive expertise in conducting scoping reviews. Exploratory searches were first conducted in Medline and Academic Search Complete using three key concepts: housing status, health status and country. Following this, comprehensive searches were conducted, on February 10, 2024, in Medline, CINAHL, Sociological Abstracts, Social Work Abstracts, Academic Search Complete, Scopus, Web of Science Core Collection, and CENTRAL (see Table 2). The complete search strategies for all databases can be found in Appendix A [see Additional file 1].

Table 2.

List of scholarly sources searched

Database Name	Platform	Dates of coverage
Medline	Ovid	1946 - February 10, 2024
CINAHL	EBSCOhost	1982 - February 10, 2024
Sociological Abstracts	ProQuest	1952 - February 10, 2024
Social Work Abstracts	EBSCOhost	1965 - February 10, 2024
Academic Search Complete	EBSCOhost	1887 - February 10, 2024
Scopus	Elsevier	1788 - February 10, 2024
Web of Science Core Collection including:	Web of Science
• Arts & Humanities Citation Index		1975 - February 10, 2024
• Book Citation Index – Social Sciences & Humanities		2005 - February 10, 2024
• Book Citation Index – Sciences		2005 - February 10, 2024
• Emerging Sources Citation Index		2005 - February 10, 2024
• Conference Proceedings Citation Index – Social Sciences & Humanities		1990 - February 10, 2024
• Conference Proceedings Citation Index – Sciences		1990 - February 10, 2024
• Science Citation Index -EXPANDED		1990 - February 10, 2024
• Social Sciences Citation Index		1990 - February 10, 2024
Cochrane Central Register of Controlled Trials	Ovid	1991 - February 10, 2024

A grey literature search was conducted concurrently, focusing exclusively on Canadian websites and databases to identify relevant white papers, frameworks, and reports [see Additional file 1: Appendix B].

Additionally, supplementary techniques, including forward and reverse citation chaining, were employed to capture any articles that may have been overlooked. Forward citation chaining was conducted using the Citation Chaser tool, and reverse citation chaining was conducted in Lens.org. The records were then added to Covidence for deduplication and screening in September 2024.

Study selection

Screening was conducted using Covidence software to ensure efficient data management and accurate reporting. Screening was carried out by two independent reviewers at both the title abstract and full-text level from a team of five (AB, AG, AS, KKM, KSm). Disagreements at each stage of the selection process were resolved through discussion or consultation with the study’s principal investigator (KS).

Data extraction

Data extraction was conducted in Covidence by two independent reviewers (AB, AS, and/or KSm) using a developed data extraction tool [see Additional file 1: Appendix C] with 25 categories. Categories included, but were not limited to, purpose, population, study methods, main findings, etc. Extracted data were then consolidated and discrepancies resolved through discussion among AB, AS, and KSm.

Analysis

Narrative synthesis methods and thematic analysis was used to identify relevant topics in the included articles. This approach focused on summarizing and interpreting patterns within the literature, rather than generating recommendations for practice or drawing conclusions about intervention effectiveness. Consistent with JBI scoping review guidance, no formal quality appraisal was conducted. Following the narrative synthesis approach outlined by Pope et al., [29] the analysis involved repeatedly reviewing the material, identifying key excerpts, and systematically organizing verbatim quotes related to the facilitators and barriers to dying at home for adults experiencing structural vulnerability. Thematic analysis was employed to identify key themes across the included articles in accordance with the reseach aims of the current review, which were reviewed and refined in consultation with co-authors. Key themes were synthesized and organized by comparing and contrasting similarities and differences across categories in an iterative process. The finalized extracts were coded using NVivo software [30] by members of the analysis team (AB, AS, KSm).

Results

3699 records were imported from the database searches into Covidence. Following deduplication, 2,031 records were screened at the title and abstract level. An additional 2577 records from the grey literature or citation chaining searches were also screened at the title or title-abstract level. A total of 135 records were evaluated at the full-text level, of which 65 were identified through database searches and 70 through supplementary searches. The final screening process resulted in the inclusion of 33 articles. The PRISMA flow diagram (Fig. 1) presents a detailed overview of the search and screening results.

Fig. 1.

PRISMA flow diagram

Description of included studies

Of the 33 studies (see Table 3), the majority were conducted in Canada (n = 16), followed by the United Kingdom (n = 7) and the United States (n = 7). Remaining studies were conducted in the Netherlands (n = 1), Australia (n = 1), and Sweden (n = 1). Most studies were qualitative (n = 24). Of the remaining nine studies, four employed mixed methods, two were reports, one focused on quality standards, and one utilized a framework design.

Table 3.

Characteristics of included studies

Authors	Year	Stated Purpose/ Research Question	Study Design	Main Sample & Mean Age (if provided)	Location
McCune et al.	2022	Examines the goals, desires, and expectations for end-of-life care for people living in Permanent Supportive Housing (PSH) in San Fransico, California	Qualitative	Permanent supportive housing residents (n = 17); 65 years	Permanent Supportive Housing	US
Stajduhar et al.	2024	This analysis explores barriers preventing people who experience social and structural inequity the option to die-in-place	Qualitative - Longitudinal	(1) Structurally vulnerable persons on palliative trajectory (n = 25); (2) Informal support persons/family caregivers (e.g., street family) (n = 25); (3) Community service providers (e.g., housing workers, medical professionals) (n = 69); plus 18 primary and 48 secondary participants from second study; total n = 135 (4) Key informants (e.g., managers, medical directors, executive directors) (n = 20	Single room occupancy hotels shelters supportive housing units living rough (tents, boats)	CA
Johnson & Light	2023	The question at the core of this study is: what are the living locations and transitions experienced by unhoused people with serious illness throughout palliative care treatment?	Mixed methods	Mobile palliative care clients patients on the HPC roster in the month of March across a three-year period (March 2019, March 2020, March 2021) (n = 75); 61 years	Street-Based Palliative Care Model	US
Santos Salas et al.	2023	The purpose of this study was to explore how a community-based nursing intervention could contribute to improving access to palliative care for people experiencing socioeconomic inequities living with life-limiting illnesses in an urban Canadian setting	Qualitative - Longitudinal	Palliative Care Outreach Advocacy Team (PCOAT) Patients (n = 25) Inclusion criteria were: living or having lived in precarious housing with a life-limiting illness, age of 18 or older and ability to provide consent and to communicate in English; 57 years	Palliative Outreach Team	CA
Jensen et al.	2023	The purpose of this study was to elicit the experiences of people receiving SMH care who are considered homeless by the government definition and explore their perceptions of key elements of care	Qualitative - Longitudinal / Case Study	SMH recipients (n = 3); 31–64	Social Model Hospice (SMH)	US
Hansford et al.	2022	Explore the ways in which socio-economic status impacts people’s experiences of, and attitudes towards, death, dying, and bereavement in the United Kingdom	Qualitative	(1) Bereaved individuals with experience of poverty at end-of-life or in bereavement (n = 14) (2) Professionals supporting individuals in low-income communities (n = 15)	Social or privately rented housing (individuals with low income).	UK
Johnson et al.	2023	The paper identifies the health experiences of older adults with severe conditions living in and moving through temporary avoidance hotels during the COVID-19 pandemic. What were the palliative care provider accounts of COVID-avoidance hotels as a care site for older homeless patients?	Mixed methods - Longitudinal	Populations experiencing homelessness during onset of COVID-19 (n = 14); 57 years. Patient charts were included in the sample if the patient was both: (1) above 45 years of age and (2) lived in hotels or motels for at least one day between 11 March 2020, and 1 September 2021	COVID avoidance hotels	US
Vihvelin et al.	2022	The purpose of this study was to gain insight into preferences for the EOL and end-of-life care for people experiencing homelessness	Qualitative	Current or previous experience of homelessness; a diagnosis of advanced disease/progressive life-threatening illness	Assisted living, tent, hotel room, shelters	CA
Armstrong et al.	2021	To evaluate a model embedding palliative specialists, trained as homelessness champions, into hostels for two half-days a month to provide support to staff and residents and facilitate a multidisciplinary approach to care	Qualitative	Four hostels and two palliative care teams took part in this study homelessness champions, hostel staff and hostel managers	Hostels and Palliative Care teams	UK
Stajduhar et al.	2020	To describe family caregiving in the context of structural vulnerability, to understand who these caregivers are, and the unique challenges, burdens and barriers they face. The purpose is to promote the inclusion of these family caregivers, and their experiential knowledge, to generate findings that may inform the development of more equitable programmes and policies	Qualitative	1) Support persons for people experiencing structurally vulnerability who were on a palliative trajectory (n = 25) [for this analysis - the larger study had 2 other participant groups)	Home, shelter, transitional housing, clinic, hospital, palliative care unit, community-based service centre and outdoor settings	CA
Purkey & MacKenzie	2019	To explore the experience, goals, fears, and hopes surrounding death in the setting of homelessness or vulnerable housing	Mixed methods	Persons with experience of homelessness (n = 31)	Homeless, shelters, precarious housing situations	CA
de Veer et al.	2018	The objective of this paper is to give insight into the extent people experiencing homelessness have access to good palliative care in the Netherlands	Qualitative	People experiencing homelessness at the end-of-life, as well as with professionals who were close to them at the end-of-life. 19 case studies with a total of 52 participants; 60 years	Night-care shelters	Netherlands
Wales et al.	2018	To identify and describe factors that physicians perceive to influence a patient’s likelihood of dying at home and investigate how these factors interact with patient socioeconomic status	Qualitative	Physicians whose clinical practice is focused on providing palliative care services to individuals at home. The area served by the palliative care centre has nearly equal distribution between income quartiles but incudes neighbourhood clusters of both low- and high-income household	“Home” - subjective based on patient’s perception (palliative care unit, house, subsidized housing etc.)	CA
Hutt et al.	2018	Three authors convened a National Program and Policy Development Forum to define the key structural, clinical, and policy elements required to improve care.	Qualitative - Longitudinal	Community and veteran affair leaders; Forum participants (n = 13)	Homeless	US
Shulman et al.	2018	To explore the views and experiences of current and formerly homeless people, frontline homelessness staff (from hostels, day centres and outreach teams) and health- and social-care providers, regarding challenges to supporting homeless people with advanced ill health, and to make suggestions for improving care	Qualitative	Single homeless people (n = 28), formerly homeless people (n = 10), health- and social-care providers (n = 49), hostel staff (n = 30) and outreach staff (n = 10	Homeless Hostels Day Centres	UK
Hakanson et al.	2016	We explored the conditions and practices of palliative care from the perspective of staff at a Swedish support home for homeless people	Qualitative - Longitudinal	Staff at a Swedish Care Home n = 12 consented but only (n = 10); 55 years	Support Home (for those experiencing homelessness in Sweden)	SW
Webb	2015	To explore the perceptions and lived experiences of people working in hostels where the homeless residents may be approaching end-of-life and have a wide range of life-limiting palliative conditions	Qualitative	Hostel staff (n = 7) discussed 37 cases with each staff member	Homeless Hostels	UK
MacWilliams et al.	2014	To identify best practice for managing the palliative care needs of clients experiencing homelessness in a community setting and to guide the development of policies for a community-based palliative care service working with these clients.	Qualitative - QI/Case Study	(1) Homeless palliative client (n = 1) − 54 years; (2) key informants (n = 6)	Homeless Case study	AUS
Chan et al.	2023	How might inequitable material options for dying well at home be shaped by structural forces that simultaneously shape people’s preferences for dying well at home	Qualitative	Key Informants / Stakeholders (participants who could provide insights into locations of dying and preferences, either for themselves personally or for a population group with which they were familiar), n = 24	“Home” setting	CA
Stajduhar et al.	2020	The purpose is to report on ICWs experiential knowledge and contribute findings that can help inform decision makers on the most effective ways to enhance equitable access to palliative care	Qualitative - Longitudinal	Involving ICWs (n = 31), a subset of the larger service provider participant group (e.g., people working in inner-city housing/shelter, health, and social services) (n = 16) and inner-city key informants (e.g., executive directors and managers in health and social services) (n = 15) were examined		CA
Funk et al.	2023	The purpose of this article is to explore the nuanced complexity of meanings of dying at home among diverse community members, including health and social care stakeholders, as these meanings manifest in their talk about preferences and logistics of dying at home	Qualitative - Longitudinal	Community and practitioner representatives and advocates n = 24 (p.3)	‘Home’	CA
Ontario Health: Palliative Care Network*	2019	The goal of the Delivery Framework is to recommend a model of care that delivers high-quality, culturally safe palliative care in Ontario	Framework	General Population		CA
Ontario Health: Palliative Care Network*	2024	This quality standard addresses palliative care for adults with a serious illness, and for their family and care partners. It focuses on palliative care in all health settings, for all health disciplines, and in all health sectors. It includes information about general palliative care that applies to all health conditions	Quality Standards	General Population		CA
Stajduhar & Mollison*	2018	1. Provide a detailed contextual description of the experiences of homeless and barely housed individuals in accessing health care services at the end-of-life in Victoria, BC; 2. Identify barriers and facilitators to promoting quality palliative care for this population; 3. Review promising programs and practices; and 4. Develop recommendations for improving access to end-of-life care for structurally vulnerable people.”	Report	Structurally vulnerable populations (n = 25), 57 years; Support people (n = 25), 50 years; Service Providers (n = 69); Key Informants (n = 20)	“Unsheltered; emergency sheltered; provisionally accommodated; or at risk of homelessness”	CA
Centre for Urban Health Solutions Survey Research Unit*	2017	Recognizing the complex social and health care circumstances of people experiencing homelessness in Toronto, this report aims to identify the state of the palliative care services available to this population	Report	Populations experiencing homelessness	Living rough (living on the streets) and shelters	CA
Reimer-Kirkham et al.	2016	To articulate the philosophical, theoretical, and empirical scaffolding required for equity-informed palliative care and draw on a current study to illustrate such an approach to the care of people who experience structural vulnerabilities	Qualitative - Case study	Structurally vulnerable populations; n = 3; 63 years	Supportive housing facility, Boat, Motel room, Transitional shelter	CA
Quinn et al.	2023	To present data which reveal how some health and social care professionals view home dying for people experiencing financial hardship and deprivation	Qualitative	Health and social care professionals who support people at the end-of-life (n = 12)	Home and hospice	UK
Quinn et al.	2024	Case report from Scotland, UK illustrates how unresolved traumatic experiences across the life course can affect a patient’s engagement with palliative care and offers insights into the flexibility and adaptations necessary for taking a trauma informed approach to care for an individual experiencing multiple disadvantage	Qualitative - Case study	n = 1; older adult male, disadvantaged and experiencing homelessness; 65 years	Hospice; couch surfing, low income apartment	UK
Richards et al.	2024	To deploy visual methods to address this gap in knowledge, focusing on barriers to, and experiences of, home dying for people experiencing poverty and deprivation in the UK	Qualitative, Visual arts	Phase 1 participants People who: (1) were considered by relevant health care providers to be living with serious advanced illness and nearing the end-of-life and (2) living in areas of relatively high deprivation and self-reported as experiencing financial hardship. n = 8; 53 years old Phase 2 participants People who: (1) were between 2 months and 2 years bereaved and (2) whose friend or relative had experienced financial hardship at the end of their life - and participated in Phase 1 of the study. n = 4	Low-income housing, hospice	UK
Jensen & Thorpe	2023	The purpose of this article is to share a historical report of the development process of 1 SMH, TIB in Salt Lake City, in order to assist other community leaders interested in replicating or adapting this model.	Qualitative	Population served by their SMH = unstably housed people who have been diagnosed with a life-limiting illness. 104 clients in last fiscal year	Social Model Hospice	US
Johnson et al.	2024	identifies provider experiences and perceptions of supportive housing’s capacity to support serious illness and end-of-life across systems and outlines possible changes that can promote better quality care	Mixed Methods	Housing and shelter workers n = 7, hospital workers n = 10, community-based workers n = 7, criminal/legal workers n = 2, nurses n = 2, medicate respite n = 1	Permanent Supportive Housing	US
Dilico Anishinabek Family Care*	2018	The purpose of this report is to explore current practices and best approaches for delivering palliative and end-of-life care services to people who are vulnerable and live homeless in Northwestern Ontario	Report	1) Service providers n = 74 2) Service users n = 86	Multiple	CA
Fruch et al.	2016	The purpose of the article is to enhance understanding of how other communities can incorporate dying within a First Nations wellness tradition that focuses on providing quality of life to the end-of-life	Qualitative - Case Study	Indigenous individuals living in the community of Six Nations (Ontario)	Community-based palliative care program	CA

*Specified grey literature articles. While some of these reports focused on general population studies, they were included because they contained sections specifically addressing populations experiencing structural vulnerability

Five themes (see Table 4) were identified through narrative synthesis methods that addressed the research question on factors that facilitate or prevent the provision of palliative care at ‘home’ among people who experience structural vulnerability. These themes included: (1) systemic complexity; (2) financial resources; (3) value systems; (4) social supports; and (5) education and training.

Table 4.

Summary of interpreted themes and sub-themes

Overarching themes	Sub-themes
Systemic complexity	a) System navigation, administration, and bureaucratic challenges b) Housing needs c) Restrictive policies d) Creative workarounds
Financial resources
Value systems
Social supports
Education and training

Systemic complexity

Systemic complexity refers to structures, processes, and policies that limit options for individuals experiencing structural vulnerability to receive care and die at home, often forcing people into unsuitable environments or abandoning them to inadequate end-of-life support. However, innovative and unconventional strategies, often implemented without formal health and social care system support, were found to be effective in helping people who were structurally vulnerable to navigate challenges and access the care needed to die at home. Four sub-themes were identified: (1) system navigation, administration, and bureaucratic challenges, (2) housing needs, (3) restrictive and misaligned policies, and (4) creative workarounds.

System navigation, administration, and bureaucratic challenges

Administrative barriers, bureaucratic complexities, and challenges in system navigation were identified that hinder access to appropriate end-of-life care and housing. Hansford et al. [31] found that when “social housing was considered unsuitable for palliative care, professionals noted it was very difficult to sort out alternative housing due to the lack of housing stock and lengthy bureaucratic processes” (p.5). Moreover, one report suggested that “many clients do not have primary care providers, some do not have Health Cards, and some are unaware of what services are available due to the complexity of our healthcare system” [34 p.36]. Additionally, “[s]ervice providers reported being unaware themselves of the resources that are available and that they are often unsure of where they can send clients for help” [34 p.36].

Several researchers identified stringent service eligibility criteria that created barriers to gaining access to housing and care provision, such as restrictions around age, substance use, or serious mental illness, and requirements around employment or specific health diagnoses [32–34]. Jensen et al. [33] described guidelines that added additional challenges for people to maintain housing, noting that “residents would agree to a code of conduct and house rules to remain in residence, which included maintaining a drug-free, sober living environment” (p. 94). Such requirements can create a disconnect, as substance use can be common among populations experiencing structural vulnerability, effectively excluding those who may most need stable housing during end-of-life. Recognizing that stable housing is not always accessible for peoples experiencing structural vulnerabilities, many remain in emergency shelters or temporary accommodations, which are often inadequate to support end-of-life care needs. Many authors described shelters and hostels as overcrowded, lacking privacy for end-of-life conversations, and unsuitable for safely storing medications and medical equipment [32, 35–37]. Other researchers report that the physical layout of some supportive housing units did not align with people’s preferences to die at home due to accessibility barriers, inadequate space for hospital beds, overcrowding, insufficient electrical outlets, hoarding behaviours, mold and biohazards, excessive noise, and the lack of elevators for staff use, all of which further complicated or prevented care delivery [38–41]. Despite advocacy to address some of these physical space challenges, Richards et al. [40] found that the healthcare and social housing system were “unresponsive to individuals’ urgent needs…[and] representatives of those organizations also sometimes failed to show compassion in their interactions or to recognize the distress which unresponsive systems were causing them” (p. 6).

Housing needs

Several authors described the need to shift care from hospitals and hospices into the community through innovative models that prioritize compassionate, accessible care in peoples’ preferred environments. Mobile models of palliative outreach were reported as a promising, bringing healthcare directly to people in shelters, on the streets, and in non-traditional spaces using harm reduction strategies and collaborative care models [38]. A social model hospice reported programs that offer companionship and ways to honor peoples’ final wishes [33]. Dilico Anishinabek Family Care [38] noted that shelter-based hospices facilitated end-of-life care amongst friends in familiar surroundings. These community-based models were shown to provide low-barrier, culturally sensitive services that address not only medical needs but also social, spiritual, and emotional support, to improve treatment outcomes, increase quality of life, and reduce hospitalizations [38].

In addition, four articles highlighted the need for early and expanded access to stable, subsidized housing, with the use of programs such as the Housing First model [38] or specifically targeted spaces such as the COVID-avoidance hotels [42] to improve end-of-life care. The authors emphasized the importance of inclusive at-home care, with on-site healthcare programs that provide healthcare provider access [14, 42], and “safety netting” (contingency planning) to ensure safe care in non-traditional settings [47 p.5]. Several researchers reported that the design of supportive housing must be intentional, with accessibility in mind, reliable infrastructure, private bathrooms, on-site laundry, dedicated spaces for health and mental health services to ensure privacy and dignity, and common areas for social interaction with other residents and visitors [39, 43, 44].

Restrictive and misaligned policies

Restrictive policies and the ways in which they prevented precariously housed people from dying at home were explored in many of the included studies [20, 39, 45]. Five studies noted that strict visitor rules can limit informal care from friends and family, while cohabitation restrictions separate people from their partners or caregivers who provide critical support [12, 20, 35, 39, 45]. Stajduhar et al. [20] discussed how caregivers are put at risk of losing their own housing if they want to ‘house’ their friend or loved one due to restrictive single occupancy residences, citing that “many caregivers, some of whom were also very sick, wished to cohabitate with care recipients to provide ongoing care. Yet housing policies (e.g., single occupancy) prevented them from living with care recipients” (p.950). Stajduhar et al. [45]. further noted that, “‘no guest’ policies were found to leave participants with no choice but to move, as they were unable to access needed informal care” (p.7). Some supportive housing policies required staff to evict residents “once care needs became too great” [45], either forcing people into institutionalized settings [32] or more precarious housing situations [45]. Johnson et al. [34] found that restrictive policies often led to eviction “four of six of these patients were evicted from supportive housing for behavioral reasons (e.g., assault, hoarding or related behaviors, persecutory beliefs implicating rent and rental arrears)” (p. 218).

The included studies frequently reported abstinence requirements in current housing models, which prohibit substance use, making sustained housing difficult for people who use drugs [12, 35, 46]. Additionally, some shelters and housing units required residents to leave during daytime hours, preventing them from resting in bed when needed and leading some to forgo medications that cause drowsiness [35, 45]. Purkey and Mackenzie [47] further illustrated these challenges, describing “the experience of receiving chemotherapy while living on the street, being kicked out of shelters because he was vomiting too much and being too sick to walk to find food” (p. 862). In addition, strict medication storage rules created impractical barriers to adherence such as requiring people to store medications at the front desk rather than in their rooms [32, 48]. Safety and risk mitigation policies can further restrict care, as some buildings are labeled unsafe or “no-go zones” due to hygiene concerns, substance use, smoking, criminalized drugs or drug-use equipment, overcrowding, or past violence, all of which can prevent home health care providers from entering [2, 14, 35, 41, 49]. MacWilliams et al. [48] highlighted that ensuring safe entry into a facility or shelter required the presence of two service providers, a standard that many organizations struggle to meet due to limited staffing, further complicating access to end-of-life care. While it was reported that some providers chose not to follow organizational risk mitigation protocols, they often do so at their own risk and against organizational policies, placing themselves in precarious ethical and professional situations [14, 50]. Service-level protocols related to provider-client engagement (e.g., preventing boundary violations, burnout) can further constrain care, increasing the likelihood of individuals dying in settings that do not align with their preferences [51].

Creative workarounds

A common theme in the included studies was the tension between existing rules, protocols, and policies in health institutions and housing organizations and the flexible, creative workarounds used by healthcare providers and housing staff to support people experiencing structural vulnerability to die at home [14, 34, 45, 50]. To navigate restrictive risk-mitigation policies and rules, service providers developed innovative strategies to provide care for people. For instance, they frequently went beyond their formal roles to offer support, with some describing how “in some cases, care was completely restricted except where healthcare providers went against institutional policies to provide care ‘under the grid’” [14 p.29]. Additionally, when a building was flagged as a safety risk, service providers leveraged their professional networks to facilitate access, coached people on how to communicate effectively over the phone to reduce perceived risks or accompanied home care nurses on visits [14, 42, 50].

Many of the studies highlighted strategies for making policies more flexible for both people who experience structural vulnerability and staff. Key recommendations include broadening the definition of family, easing visitor restrictions to improve guest access, and reconsidering blanket risk and safety policies that often fail to align with the needs of people experiencing structural vulnerability at end-of-life [19, 34, 47]. Stajduhar et al. [45] suggested “integrating a system that would allow individual workers the autonomy to define their own risk thresholds and the population groups they feel comfortable working with, [which] would enhance safety for all, not only workers, but clients as well” (p. 9). Similarly, Johnson et al. [39] emphasized that “[s]upportive housing policies, such as overnight caregiving, must be examined to ensure that health-related evictions are prevented and resident choice in relocation and care is supported” (p. 10). Other researchers advocated for policies to adopt a harm reduction approach, allowing substance use until end-of-life and improving access to home supports [52].

Financial resources

Financial resources were reported to be a major barrier in facilitating people to die at home [2, 14, 31, 40–54]. Shelters and temporary housing facilities were described as often lacking funding for end-of-life care, with low incentives for agencies to provide in-home support [39]. Several authors identified that essential supports such as food, phones, computers, and transportation were often unavailable or inaccessible for people experiencing structural vulnerabilities, making it difficult to attend appointments, manage medications, or communicate with healthcare providers [2, 31, 40]. Dying at home often incurs considerable expenses, including costs for “primarily electricity, heating, equipment, taxis, and care” [41 p.4]. Without stable financial resources, care can be disrupted. For example, Johnson et al. [42] described a case in which a person lost access to hospice services due to inconsistent phone access. Many people also lack informal caregivers and are unable to afford private care [2, 41, 54]. The latter “was consistently described as the primary means by which socioeconomic status impacts home death” [42 p.6]. Researchers also identified that these financial challenges are amplified in rural and remote communities, where transportation costs and geographic barriers add further financial strain [2, 43, 49, 50, 55]. For instance, Fruch et al. [53] noted that “in most First Nations communities, the limited funding allows for services only during the day, Monday to Friday” (p.6).

To address these financial barriers to dying at home, Quinn et al. [50] recommended “[m]ore straightforward applications for financial support” (p. 7) and “simplify[ing] access to welfare and benefits support [such as] by including financial considerations as part of a needs assessment or care plan” (p. 9). They also proposed establishing “emergency grants” to cover the cost of medical equipment and urgent needs (p. 7). Other researchers suggested adapting provincial guidelines to ensure populations experiencing structural vulnerability receive equitable access to funded equipment and services [43].

Building on these recommendations, researchers also emphasized the critical role of community contributions in end-of-life care. For example, Jenson et al. [56] highlighted the invaluable financial and in-kind contributions from community members to support a nonprofit social model hospice, including volunteer-provided hospice care and donations of bedding and clothing. Additionally, staff frequently used their own resources, with one study noting that “[c]ertified nurses’ assistants purchased electrolyte drinks and picked up food at a resident’s favorite restaurant and would not accept reimbursement” (p. E78).

Value systems

All the studies included in this review described how values, beliefs, and perceptions within communities and healthcare systems shaped peoples’ ability to die and be cared for at home. Social stigmas, along with biases among healthcare providers and housing staff, limited peoples’ choices when those choices fell outside dominant cultural norms at end-of-life [12, 20, 34, 41, 45, 55]. Several researchers found that people experiencing structural vulnerability wanted care and services that were flexible and adaptable to their needs at end-of-life [20, 46]. For example, some people expressed a desire to avoid institutional rules they perceived as unreasonable, such as restrictions on mealtimes and visitor access. In the absence of autonomy, they sometimes chose to leave care settings, even if it meant dying on the street [47].

Additionally, healthcare provider biases restricted peoples’ access to and requests for care. Stajduhar et al. [45] noted that “barriers to pain management in the community often involved health care professionals’ assumptions of, and fear regarding, the risks associated with drug-seeking and diversion” (p. 6). Armstrong et al. [36] further reported that some general practitioners “are now refusing to go into the hostels at all and are refusing to see any homeless patient” (p. 1212).

Other studies identified pervasive beliefs among shelter and hostel staff that such environments were unsuitable for end-of-life care, which further limited peoples’ ability to die at home [32, 36]. Stajduhar et al., [14] for instance, highlighted the “misconception by managers and workers that palliative care happens in a separate domain from housing, shelter, and other social services” (p. 26), leading to frequent transfers of people out of their communities when their care needs became too complex. Quinn et al. [50] also observed that “elements of a ‘blame’ culture…exist, with a focus on individual responsibility as a means of overcoming inequities in care rather than on structural change” (p. 9).

Several authors recommended broader societal shifts that prioritize empathy, flexibility, collaboration, and inclusivity to better support dying at home in the context of structural vulnerability [47, 57]. Hansford et al. [31] and Stajduhar et al. [45] argued for reframing discourses of individual “choice” to acknowledge both the goals of palliative care and the larger social structures that contribute to inequities. Public awareness campaigns, partnerships with local organizations, and community-based palliative care models were identified as strategies to strengthen support networks and challenge societal biases, such as NIMBYism, which can limit end-of-life care options [33, 49, 53, 56]. Stajduhar et al. [45] emphasized the need for “a re-evaluation of the definitions of ‘home’ within palliative care, but also the need to acknowledge the contexts in which many people live that do not ‘fit’ within the more traditional, normative structures upon which our health care systems are based” (p. 9).

Social supports

Many included studies identified the absence of stable and supportive relationships as significant barriers to dying at home [2, 14, 39–41, 49–51, 54]. Hansford et al. [31] highlighted that social isolation and strained relationships left many people without support, advocates, or surrogate decision-makers, supports considered to be crucial for enabling people to die at home [41, 49]. Similarly, Funk et al. [2] noted that “the choice to die at home was dependent on the availability of family caregivers; those without family networks or who had experienced past family conflict and trauma would face challenges in dying at home” (p. 8).

The challenges of dying at home extended beyond personal relationships to the support available from healthcare providers and housing staff, who often faced time constraints, competing responsibilities, and the complex task of integrating end-of-life care with other essential services. Several studies indicated that healthcare providers, including supportive housing nurses, struggled to build rapport with people who experience structural vulnerability due to time limitations and multiple site responsibilities [42, 51, 54]. Similarly, shelter staff described the added strain of balancing mental health support, harm reduction services, and end-of-life care with their daily responsibilities [35]. de Veer et al. [54] stated that “professionals in shelters said that they usually did not have enough time to go to the person’s room to talk with that person, other than bringing them meals and offering physical care” (p.7), while other researchers noted that high burnout rates and frequent staff turnover further disrupted continuity of care [51]. Many of the included studies discussed the mistrust that people who experience structural vulnerability had in healthcare providers and the larger system, often noting they did not feel safe expressing their needs and wishes. This mistrust was perpetuated by gaps in services (such as insufficient time and staffing), which further challenged rapport-building between people and their healthcare providers [14, 31, 38, 43, 45, 50, 52].

Supportive relationships, whether formal or informal, played a crucial role in facilitating dignity, trust, and respect at end-of-life. The included studies commonly identified healthcare providers, housing staff, case managers, chosen family, friends, community members, and animals as key relationships involved in peoples’ care [38, 53]. For some people who experience structural vulnerability, housing and shelter staff, and case managers were the closest and most trusted individuals, offering emotional, social, and practical support at end-of-life. For example, McCune et al. [51] noted that some participants identified permanent supportive housing staff as the people they trusted most to be there and to make decisions for them (p.12). Expanding collaboration among health, housing, and social services to address barriers like unstable contact information, fragmented services, and communication breakdowns emerged as a common theme in the included studies. Partnerships between shelters, community organizations, and palliative care teams, along with multidisciplinary case reviews and the integration of more psychological supports into care, were seen as ways to bridge care gaps [32, 58]. Many studies identified strategies such as integrating palliative approaches to care, enhancing healthcare provider communication, and creating spaces for people experiencing structural vulnerability to share their stories, as ways to foster trust and improve end-of-life encounters [32, 37, 48, 58, 59].

Education and training

Proactive discussions about death, goals of care, setting preferences, and people’ wishes at end-of-life were found to support positive death experiences. [51] However, several studies identified a shortage of trained staff capable of engaging in these critical conversations or recognizing individuals on a palliative trajectory [54, 59]. In particular, those employed in social housing, often felt emotionally and logistically unprepared to support people who were dying [32, 37, 48]. In addition, a lack of awareness about available resources and services, a common issue among service providers, further complicated the delivery of end-of-life support [19]. Several studies found that familiarizing housing staff with supportive resources, trauma-informed practices, cultural safety, de-escalation strategies, and harm reduction techniques was crucial for effective end-of-life care [36, 39, 50]. Additionally, McCune et al. [51] found that permanent supportive housing programs needed to build staff capacity for end-of-life decision-making in order to prevent burnout and ensure that residents’ needs were met. These findings highlighted that housing staff, when properly trained and supported, played a key role as part of the death system, contributing to the creation of larger ‘compassionate communities’ [31].

Discussion

This scoping review examined the factors that facilitate or hinder the provision of palliative care at home for people experiencing structural vulnerability. Using narrative synthesis and thematic analysis of the included literature, we identified five overarching themes that influenced the ability to remain at home at end-of-life: (1) systemic complexity, (2) financial resources, (3) value systems, (4) social supports and (5) education and training. The findings suggest that current health and social care systems are often misaligned with the needs of populations experiencing structural vulnerability, creating significant barriers to accessing timely, safe, and equity-oriented end-of-life care at home. These systemic gaps are shaped by broader structural inequities, including poverty, housing precarity, stigmatization, and other intersecting forms of marginalization, which directly influence access to home-based care and the ability to remain at home at end-of-life [45, 55, 60]. In line with prior research, the results demonstrate that health and social care structures continue to be largely designed around normative assumptions about who accesses care and where, thereby reinforcing barriers that exclude people facing intersecting inequities [20, 40, 45].

Central to these findings is a re-examination of what constitutes home. As Stajduhar and colleagues [45] have emphasized, broader definitions of home are essential for delivering equitable end-of-life care and acknowledging that care at the end-of-life can occur in non-traditional settings. However, developing a more nuanced understanding of home requires addressing deeply held values and perceptions about appropriate places to die. While values and perceptions emerged as a major theme in our scoping review, few studies identified specific facilitators for changing these beliefs at micro, meso, and macro levels. Addressing these belief systems requires interventions at multiple levels to counter “not in my backyard” (NIMBY) attitudes [49], alongside larger public awareness campaigns that reframe societal assumptions about dying at home for people experiencing structural vulnerability.

Further, our review revealed that these belief systems are embedded within and reinforced by structural and policy frameworks. Current housing and risk mitigation policies continue to reinforce private housing as the default (or only) desirable place to die. Without a broader recognition of nontraditional or community-based settings as legitimate homes, many people living in shelters, transitional housing, or other precarious environments will remain excluded from the supports necessary to die in the places they consider meaningful and safe. For example, several studies described residents of supportive housing programs who were prevented from receiving end-of-life care because of institutional policies restricting visiting, privacy, or access to palliative resources [20, 39, 45]. In some cases, these policies resulted in medical evictions, with residents deemed “beyond our level of care,” illustrating how institutional rules can actively displace people at the end-of-life [45]. Recognizing diverse understandings of home underscores the need for care models that are flexible, relational, and responsive to people’s circumstances, emphasizing approaches that move beyond inflexible policies and institutional definitions of who can receive care and where.

Importantly, this review suggests that the solution does not lie solely in generating further research but rather in fostering a cultural shift and a re-centring of community values within healthcare and social systems. Current service models, structured around task-oriented roles and fixed professional responsibilities, cannot always adequately support the level of care that people experiencing structural vulnerability need in order to die in places of their choosing. Although many healthcare and social systems were conceived with community care in mind, decades of professionalization have narrowed care toward more formal services [61, 62]. Moving toward community-centered care requires looking beyond rigid role definitions to the ways in which community members actively provide support and care. When communities are resourced as partners, collaborative, community-embedded approaches are associated with better access, continuity, and experiences than strictly individual-focused models. Advancing this shift requires intentional investment in community capacity and recognition of chosen family and community networks, alongside biological family, as legitimate sources of support. Such recognition is critical to creating the conditions in which people may be supported to die at home.

Building on this perspective, the themes of social supports, value systems, and education and training highlight the potential of collaborative models that integrate multiple services and can be delivered in people’s homes. Many of the included studies suggest that combining chronic disease management, palliative care, case management, and mental health supports within community-based models represents an important shift toward more equitable healthcare [32, 37, 48, 58, 59]. Yet the effectiveness of these models depends on robust, trusting relationships and adequate investment in staff time, training, and resources. Without these supports, the burden of equity-oriented care falls disproportionately on social care providers and housing staff, potentially exacerbating burnout and staffing shortages identified in our scoping review. Examples from mobile palliative programs and Housing First adaptations illustrate how relational and flexible approaches can improve access and outcomes while mitigating provider and staff strain [35, 38]. These models demonstrate how adaptability, flexible service delivery, and creative funding arrangements can reorganize care around people and their home environments, rather than expecting people to navigate mainstream healthcare structures.

Lastly, there is a clear need for greater understanding of how equity-deserving groups experience dying at home, including Indigenous peoples (in both urban and rural or reserve contexts), immigrants and refugees, and people with disabilities. For example, while a few included studies mentioned dying at home on-reserve for Indigenous peoples, there remains a significant gap in understanding what culturally aligned, community-embedded care looks like for Indigenous people living in urban areas or other community settings. Across Global North settings, mainstream health systems that facilitate dying at home often overlook or insufficiently address the needs, cultural practices, and priorities of structurally vulnerable groups, resulting in care approaches that are mismatched to community values and supports. Addressing this gap is not only a research priority but essential in advancing equity in end-of-life care. Frameworks such as cultural safety, trauma-informed care, and community-led palliative approaches point to ways forward, emphasizing that equity requires embedding care in the values, practices, and leadership of communities themselves.

Implications for policy

This scoping review identifies several critical areas where policy reform is needed to support people experiencing structural vulnerability to die at home. Key policy priorities include broadening the definition of home in government guidance and policy documents, minimizing or adapting abstinence requirements and restrictive guest and occupancy policies in supportive housing, allocating dedicated public funding for mobile palliative care teams that can provide care in non-traditional settings, and establishing emergency grants for end-of-life equipment and housing needs. In addition, policy action to streamline administrative processes for accessing income supports, benefits, and alternative housing is essential to improving opportunities to die at home. While these policy changes require significant investment and cross-sector collaboration, the evidence suggests that without addressing structural inequities produced through restrictive policies, inadequate funding, and policy frameworks that exclude non-traditional care settings, people experiencing structural vulnerability are likely to face continued barriers to dying in places of their choosing.

Limitations

This scoping review provides important insights into the factors that support or prevent people experiencing structural vulnerability from dying at home, though we acknowledge several limitations. While we followed the methodological approach guided by JBI scoping review methodology, and searched eight scholarly and many grey literature sources, it is possible that some relevant studies were missed. We excluded conference abstracts, dissertations and publications not available in English language which may contribute to studies being missed. However, we have reported our methods transparently, and our team included members with content, methodological, and information retrieval expertise and experience. Additionally, this scoping review did not include a formal quality appraisal of included studies, in line with methodological guidance. As a result, while the review identifies patterns and gaps in the literature, it does not evaluate the reliability of the findings. Despite these limitations, this review is, to our knowledge, among the first to examine in detail the factors that facilitate or hinder palliative care at home for people experiencing structural vulnerability.

Conclusion

People experiencing structural vulnerability are too often denied the choice of where they die. Achieving greater equity at the end-of-life will require both structural and policy reforms to meet diverse social, medical, and community needs. Evidence from our scoping review highlights the need for policy frameworks that support social connection, involve communities in care, and recognize chosen and informal networks alongside formal services. While there is no single approach that will work universally, policies that empower communities to shape care around their own needs and values is essential for supporting those experiencing structural vulnerability to be cared for and die at home.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

AS: conceptualization, data extraction, analysis, writing – original draft, revising draft. AB: conceptualization, data extraction, analysis, writing – original draft, review and editing. KKM: conceptualization, data extraction, writing – review & editing, supervision. KSM: data extraction, analysis, writing – original draft, review & editing. ZP: conceptualization, development of the search strategy, review, and editing. AG: conceptualization & data extraction. KS: conceptualization, analysis, writing, funding acquisition, supervision, and editing. All authors critically revised the manuscript and read and approved the final manuscript.

Funding

This work is supported by a Canadian Institutes of Health Research (CIHR) Project Grant (PJT – 186033) and by Dr. Kelli Stajduhar’s CRC in Palliative Approaches to Care in Aging and Community Health (CRC-00182-2021).

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.