Urban homelessness and emergency department usage: Predictors and user narratives of emergency care

Emergency Department (ED) usage among people who are homeless is higher than in the general population; however, myths regarding people who are homeless inappropriately using the ED are present in public and scholarly discourse. Further, minimal research has investigated ED use among those who are homeless in a Canadian context, or regarding how those who are homeless understand the role of the ED in their healthcare. Study 1 explores the question of which factors predict ED use among people who are homeless in a Canadian sample. Participants (n = 483) from a local, longitudinal Housing First demonstration project consented to the linkage of their survey responses regarding housing, health and social service use to the provincial administrative health data repository. Predictor relationships were analyzed using negative binomial longitudinal mixed modelling. In the full model ED visits were positively and reliably predicted by Indigenous ancestry, high needs mental illness, pre-baseline ED use, and concurrent increased social assistance, primary care visits, ratings of physical health, substance use problems and case management visits. Study 2 addresses the question of how participants understand the role of the ED in their healthcare and day-to-day lives. A subset of participants from Study 1 were recruited (n = 16) to participate in semi-structured interviews regarding their ED stories and experiences. Interviews were analyzed using narrative analysis. Set within the context of narratives of disempowerment, participants storied the ED in differing ways. The findings indicate that participants understand the ED to be a public, accessible space where they could exert agency in obtaining necessary healthcare. ED narratives were also paradoxical, storying it as a fixed place of transient care in their transient lives; as a result, they were isolated, and yet belonged. Each study is accompanied by a discussion of the implications of their respective findings. The thesi