Nowhere to Go: A parallel convergent mixed methods study examining the health of people who experience emergency shelter service restrictions

Abstract

Background

Emergency shelters offer temporary sleeping accommodation to people deprived of housing and connect them to services. Service restriction is the practice of limiting or denying someone access to emergency shelters. This parallel convergent mixed methods study describes the characteristics, healthcare utilization, and morbidity of people experiencing service restrictions in Hamilton, Ontario, and explores the relationship between health and service restriction.

Methods
We recruited 20 people who had experienced service restriction and accessed healthcare from the Shelter Health Network clinic. We conducted semi-structured interviews and performed reflexive thematic analysis. We reviewed participants’ medical records from January 1, 2018 to December 31, 2021 to calculate simple descriptive statistics. Mixing our qualitative and quantitative results, we generated narrative meta inferences. We employed community-based research principles, including a research team with lived and living experiences of being service restricted, implementing service restrictions, or providing care to people experiencing service restrictions.

Results
We generated six themes: 1) Losing your home shouldn’t mean losing your humanity, 2) Where am I supposed to go?, 3) The snakes and ladders of service restrictions, 4) Abandoned to survive, 5) Constantly criminalized, 6) Harnessing the wisdom of community. Participants averaged 17.4 primary care visits, 11 emergency department visits, and 4 hospital admissions over 4 years. The most common reasons for visit were infections, traumatic injuries, and substance use-related concerns. Narrative meta inferences highlighted how people experience dehumanization when accessing shelters or healthcare; how service restrictions and encampment living contribute to infections; the lack of practical supports for people using substances in shelters; the ubiquitous criminalization of people experiencing homelessness; and the care people practice for one another to reduce substance-related harms.

Conclusions
Participants’ high healthcare need and utilization was shaped by criminalization, stigma, societal abandonment, and abstinence-based substance use policies. Participants practiced care for themselves and others to navigate these barriers. Shelters should have a transparent service restriction process and employ harm reduction practices. Healthcare should provide affirming and accessible treatment for common conditions. Social and health services must contend with broader social forces while building on the strengths of people with lived experience to improve the health of people who are service restricted.