Abstract
BackgroundPeople experiencing homelessness have poor health indices and poor access to health care. Their health service utilisation (HSU) is typified by: late illness presentations; poor attendance rates at appointments; low usage of primary care services and outpatient departments; and high utilisation of emergency departments and inpatient services. Why people experiencing homelessness have these particular HSU patterns is poorly understood.AimThis research sought to explore barriers to health service usage for people experiencing homelessness.Design & settingThe authors conducted critical realist ethnography over 13 months in Dublin with people experiencing homelessness at four purposively chosen sites (a food hall, a drop-in centre, an emergency department, and an outreach service for rough sleepers).MethodEthnographic research was supplemented with focus groups of hospital doctors and people experiencing homelessness, and with 50 semi-structured interviews with people experiencing homelessness. The epistemological framework was critical realism.ResultsOne of the factors identified in the research as contributing to the HSU pattern of people experiencing homelessness was recurrent interactions between health professionals and patients, whereby patients were either excluded or discouraged from attending health services, or self-excluded themselves from services. These interactions were described as ’conversations of exclusion’. Four such conversations were described: ‘the benzodiazepine conversation‘; ‘the mistrustful conversation‘; ‘the blaming conversation‘; and ‘the assertive conversation’.ConclusionThere are certain recurrent interactions between people experiencing homelessness and doctors that result in the exclusion of people experiencing homelessness from health services.
Highlights
One of the factors identified in the research as contributing to the health service utilisation (HSU) pattern of people experiencing homelessness was recurrent interactions between health professionals and patients, whereby patients were either excluded or discouraged from attending health services, or self-e xcluded themselves from services
There are certain recurrent interactions between people experiencing homelessness and doctors that result in the exclusion of people experiencing homelessness from health services
The literature outlines numerous reasons why people experiencing homelessness have this particular HSU pattern. These include primary and secondary care barriers they face.[8,12,14,24,25,26,27,28,29]. Such barriers include physical barriers; administrative barriers; communicative barriers; attitudinal barriers; and internalised barriers, which are internal thoughts and/or feelings influenced by the sociocultural environment that result in reduced health service attendance.[14]
Summary
People experiencing homelessness have poor health and mortality indices.[1,2,3,4,5,6,7,8,9,10,11,12,13] Despite this, they make poor use of health services.[14,15,16] For example, they tend to: present late in the course of illness;[14,17,18,19] default from services before treatment is completed or miss appointments;[14,16,18,20,21,22] and be high utilisers of secondary care services and low utilisers of general practice.[14,17,23] The literature outlines numerous reasons why people experiencing homelessness have this particular HSU pattern. Why people experiencing homelessness have these particular HSU patterns is poorly understood
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