Journal of General Internal Medicine

, Volume 22, Issue 7, pp 1011–1017

Homeless People’s Perceptions of Welcomeness and Unwelcomeness in Healthcare Encounters

  • Chuck K. Wen
  • Pamela L. Hudak
  • Stephen W. Hwang
Populations at Risk



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.


To examine how homeless persons experienced “welcomeness” and “unwelcomeness” in past encounters with health care providers and to characterize their perceptions of these interactions.


Qualitative content analysis of 17 in-depth interviews.


Seventeen homeless men and women, aged 29–62 years, residing at 5 shelters in Toronto, Canada.


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).


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.


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.


homeless persons professional-patient relations trust welcomeness unwelcomeness 


  1. 1.
    Burt MR. Helping America’s Homeless. Washington, DC: Urban Institute Press; 2001.Google Scholar
  2. 2.
    Link BG, Susser E, Stueve A, Phelan J, Moore RE, Struening E. Lifetime and five-year prevalence of homelessness in the United States. Am J Public Health. 1994;84:1907–12.PubMedGoogle Scholar
  3. 3.
    Toronto Report Card on Housing and Homelessness 2003. City of Toronto. Available at: Accessed March 5, 2007.
  4. 4.
    2006 Street Needs Assessment. City of Toronto. Available at: Accessed March 5, 2007.
  5. 5.
    Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. 2000;283:2152–7.PubMedGoogle Scholar
  6. 6.
    Cheung AM, Hwang SW. The risk of death among homeless women: a cohort study and review of the literature. CMAJ Can Med Assoc J. 2004;170:1243–7.Google Scholar
  7. 7.
    Hwang SW. Homelessness and Health. CMAJ Can Med Assoc J. 2001;164:229–32.Google Scholar
  8. 8.
    Hwang SW, Bugeja AL. Barriers to appropriate diabetes management among homeless persons in Toronto. CMAJ Can Med Assoc J. 2000;163:161–5.Google Scholar
  9. 9.
    Hwang SW, Dunn JR. Homeless people. In: Handbook of Urban Health: Populations, methods, and practice. Galea S, Vlahov D, eds. New York: Kluwer/Plenum; 2005:19–41.Google Scholar
  10. 10.
    Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87:217–20.PubMedGoogle Scholar
  11. 11.
    Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285:200–06.PubMedGoogle Scholar
  12. 12.
    Bogart LM. Relationship of stereotypic beliefs about physicians to health care-relevant behaviors and cognitions among African American women. J Behav Med. 2001;24(6):573–86.PubMedGoogle Scholar
  13. 13.
    Atkinson PA, Coffey A. Making Sense of Qualitative Data: Complimentary Research Strategies. Thousand Oaks, CA: Sage Publications; 1996.Google Scholar
  14. 14.
    Buber M. I and Thou. Translated by Walter Kaufmann. New York: Touchstone Books; 1996.Google Scholar
  15. 15.
    Thom DH, Hall MA, Pawlson LG. Measuring patients’ trust in physicians when assessing quality of care. Health Aff. 2004;23(4):124–32.Google Scholar
  16. 16.
    Fiscella K, Meldrum S, Franks P, et al. Patient trust: is it related to patient-centered behavior of primary care physicians? Med Care. 2004;42(11):1049–55.PubMedGoogle Scholar
  17. 17.
    Goffman E. Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice-Hall; 1963.Google Scholar
  18. 18.
    Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92:778–84.PubMedGoogle Scholar
  19. 19.
    North CS, Eyrich KM, Pollio DE, Spitznagel EL. Are rates of psychiatric disorders in the homeless population changing? Am J Public Health. 2004;94:103–8.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2007

Authors and Affiliations

  • Chuck K. Wen
    • 1
  • Pamela L. Hudak
    • 2
  • Stephen W. Hwang
    • 2
    • 3
    • 4
  1. 1.Faculty of MedicineUniversity of TorontoTorontoCanada
  2. 2.Department of MedicineSt. Michael’s HospitalTorontoCanada
  3. 3.Center for Research on Inner City HealthSt. Michael’s HospitalTorontoCanada
  4. 4.Division of General Internal MedicineUniversity of TorontoTorontoCanada

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