Nowhere to go: a qualitative study examining the health of people who experience emergency shelter service restrictions in Hamilton, Ontario, Canada

Introduction: Emergency shelters offer temporary accommodation to people deprived of housing. Service restriction is the practice of limiting or denying access to emergency shelters in response to behaviours deemed harmful to staff, community members or other clients. This community-based qualitative study describes the characteristics, healthcare utilisation and morbidity of people experiencing service restrictions. Methods: We recruited 20 people who had experienced service restrictions in Hamilton, Ontario, Canada. Semistructured interviews were conducted and analysed using reflexive thematic analysis. To contextualise participants' experiences, we reviewed their medical records from 1 January 2018 to 31 December 2021 and calculated simple descriptive statistics. We employed community-based research principles, including a research team with lived experiences of being service restricted, implementing service restrictions or providing front-line care to people who are service restricted. Results: Participants averaged 17.4 primary care visits, 11 emergency department visits and 4 hospital admissions over 4 years. Common visit reasons included infections, traumatic injuries and substance use-related concerns. Service restriction exacerbated participants' health by increasing exposure to violence, infectious disease and psychological distress. Participants were dehumanised by being labelled, stigmatised and treated without compassion in healthcare and shelter settings. Institutional rules-particularly abstinence-based policies-created barriers to shelter access, while shifting to encampments worsened participants' physical and mental health. Despite these challenges, participants highlighted the strength of peer networks and community-led care. These findings illustrate how exclusionary policies and practices in shelters and healthcare settings shape the health and well-being of people who are service restricted. Conclusions: Service restriction worsened participants' health by pushing people into unsheltered homelessness, separating them from their belongings, networks and access to their usual health and social services, and increasing their likelihood of criminalisation. Abstinence-based shelter policies were important contextual factors that increased the use and harm of service restrictions. Participants practised care for themselves and others to navigate these barriers. Health and social services should champion an inclusion health approach by building on the wisdom of people with lived experience to reduce the use and impact of service restrictions.