Homeless people's perceptions of welcomeness and unwelcomeness in healthcare encounters

Background: Homeless people face many barriers to obtaining health care, and their attitudes toward seeking health care services may be shaped in part by previous encounters with health care providers. Objective: To examine how homeless persons experienced welcomeness and unwelcomeness in past encounters with health care providers and to characterize their perceptions of these interactions. Design: Qualitative content analysis of 17 in-depth interviews. Participants: Seventeen homeless men and women, aged 29-62 years, residing at 5 shelters in Toronto, Canada. Approach: Interpretive content analysis was performed using iterative stages of inductive coding. Interview transcripts were analyzed using Buber's philosophical conceptualization of ways of relating as I-It (the way persons relate to objects) and I-You (the way persons relate to dynamic beings). Results: Most participants perceived their experiences of unwelcomeness as acts of discrimination. Homelessness and low social class were most commonly cited as the perceived basis for discriminatory treatment. Many participants reported intense emotional responses to unwelcoming experiences, which negatively influenced their desire to seek health care in the future. Participants' descriptions of unwelcoming health care encounters were consistent with I-It ways of relating in that they felt dehumanized, not listened to, or disempowered. Welcoming experiences were consistent with I-You ways of relating, in that patients felt valued as a person, truly listened to, or empowered. Conclusions: Homeless people's perceptions of welcomeness and unwelcomeness are an important aspect of their encounters with health care providers. Buber's I-It and I-You concepts are potentially useful aids to health care providers who wish to understand how welcoming and unwelcoming interactions are fostered.