Making Sense of Street Chaos: An Ethnographic Exploration of Homeless Peoples Health Service Usage in Dublin
Homeless people have some of the worst morbidity and mortality statistics of the Western World yet make poor usage of health services. They present late when illness are fulminating. They are low users of primary care, outpatients and psychiatric services yet have high rates of Emergency Department and inpatient admission. This research sought to identify and understand the factors that influenced the Health Service Usage (HSU) of Homeless People in Dublin.
A critical realist ethnographic approach was adopted and conducted in four sites frequented by homeless people over one year. This was supplemented by 47 semi-stctutured interviews and 2 focus groups.
How the HSU of homeless people in Dublin differed from that of the domiciled population was identified. They tended to present late in their illness; default early from treatment; have low usage of primary-care, preventative and outpatient services; have high usage of Emergency and Inpatient services; and poor compliance with medication. The research introduced a new classification of barriers as being external barriers (that prevented access) or deterrents (that discouraged but did not prevent access) to health service usage. These barriers and deterrents were classified as physical (distance) administrative (application process for medical care; appointments; queues; management of addiction in hospital; rules of service; and information providing processes); and attitudinal (stigma; differing attitudes as to appropriate use of services). The study also identified a new concept termed Conversations of Exclusions which were interactions between health professionals and homeless people which resulted in the homeless person being excluded or self-excluding. Three such conversations are described including the Benzo conversation, the Deceitful Conversation and the Assertive Conversation. External promoters included specialised services and keyworkers. The study introduced the concept of internalised inhibitors which were cognitive or emotional process that inhibited health service usage. A number of such inhibitors were identified which were either cognitive (fatalistic, denial, deferral to future, presumption of poor treatment or discrimination, self blame and survival cogntions) or emotional (fear; embarrassment, hopelessness and poor self-esteem). Hope and positive self-esteem were promoters of HSU. Critical realist generative mechanisms for these factors were identified which either affected participants prior to homelessness (poverty causing hopelessness, familial dysfunction, substance misuse, fear of authority, illiteracy; mental health; and poor English) or after becoming homeless (homelessness; ubiquity of premature death; substance misuse; prioritization of survival over health; threat of violence; chaotic nature of homelessness; negative experiences of authority; stigma; and design of health services.
This research described a new understanding of the factors that affect the Health Service Usage of homeless people. This is presented in the format of a new critical realist explanatory model for why homeless people use health services differently to that of the general population is described.