Choksi, Twinkle
(2025)
Understanding decision making by people experiencing homelessness about accessing Accident and Emergency (A&E) Departments.
DClinPsy thesis, University of Nottingham.
Abstract
People experiencing homelessness face significant health inequalities. Statistically, people experiencing homelessness are disproportionately high users of Accident and Emergency departments (A&E), although some individuals are known to entirely avoid A&E. However, little is known about what informs these decisions. Existing research around people experiencing homelessness and their use of A&E primarily focuses on presenting conditions or frequency of attendance, with limited exploration of when or how they decide to access A&E. Without this understanding, services risk failing to truly understand and address this population’s needs around A&E use.
The study aimed to explore internal (psychological) and external (physical) factors influencing decision-making about accessing or not accessing A&E for people experiencing homelessness. The study adopted a qualitative methodology and a critical realist perspective. Twelve participants were recruited from third sector homelessness services and charities across an East Midlands organisation, using purposive and volunteer sampling. Each participant took part in a semi-structured interview, which was audio-recorded and transcribed verbatim. The data was analysed using reflexive thematic analysis and a hybrid inductive-deductive approach was used to identify and interpret recurring patterns of meaning (themes) across the data.
Reflexive thematic analysis resulted in three themes: Seeking compassion beyond healthcare (Subthemes: The need for human connection, Emotional safety in accessing healthcare); Prioritising safety over physical health (Subthemes: Desperate but underserving, The cost of accessing A&E); and Navigating the breaking point (Subthemes: Seeking immediate reassurance, Attending at point of crisis).
The findings were interpreted using the COM-B (capability, opportunity, and motivation) model and Maslow’s hierarchy of needs, providing a psychologically informed evidence-based understanding of the internal and external factors influencing decision-making behaviours. The results evidence that the decision to access A&E was rarely shaped solely by physical health concerns but rather by a complex link between unmet emotional needs, interpersonal relationships, psychological coping strategies, and systemic factors. These factors were understood within the broader context of homelessness and contribute to the limited qualitative literature on homelessness and healthcare. People experiencing homelessness often encounter services, such as hostels and outreach services, before accessing A&E. To better recognise and respond to their unique physical and psychological needs, early, preventative support, such as embedding trauma-informed and person-centred approaches, are recommended within these services. A more collaborative approach between services, staff, and people experiencing homelessness is needed to support timely and appropriate A&E access, reducing the risk of excessively accessing A&E or avoiding A&E until escalated acuity and severity of need. Further research is needed to develop interventions that staff working in homelessness settings can use to ultimately improve service accessibility and equity for people experiencing homelessness.
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