{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T23:20:32Z","timestamp":1793402432681,"version":"4.5.0"},"reference-count":41,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2025,8,24]],"date-time":"2025-08-24T00:00:00Z","timestamp":1755993600000},"content-version":"unspecified","delay-in-days":54,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2025,8,4]]},"published-print":{"date-parts":[[2025,7]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>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\u2019 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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\u2019 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\u2014particularly abstinence-based policies\u2014created barriers to shelter access, while shifting to encampments worsened participants\u2019 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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Service restriction worsened participants\u2019 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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjph-2025-002639","type":"journal-article","created":{"date-parts":[[2025,8,25]],"date-time":"2025-08-25T01:40:14Z","timestamp":1756086014000},"page":"e002639","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Nowhere to go: a qualitative study examining the health of people who experience emergency shelter service restrictions in Hamilton, Ontario, Canada"],"prefix":"10.1136","volume":"3","author":[{"given":"Suraj","family":"Bansal","sequence":"first","affiliation":[{"name":"Hamilton Social Medicine Response Team, Hamilton, Ontario, Canada"},{"name":"McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stephanie","family":"Di Pelino","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jammy","family":"Pierre","sequence":"additional","affiliation":[{"name":"Hamilton Social Medicine Response Team, Hamilton, Ontario, Canada"},{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathryn","family":"Chan","sequence":"additional","affiliation":[{"name":"Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amanda","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachel","family":"Liu","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Olivia","family":"Mancini","sequence":"additional","affiliation":[{"name":"Department of Social Work, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Avital","family":"Pitkis","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fiona","family":"Kouyoumdjian","sequence":"additional","affiliation":[{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"},{"name":"Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Larkin","family":"Lamarche","sequence":"additional","affiliation":[{"name":"School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robin","family":"Lennox","sequence":"additional","affiliation":[{"name":"Hamilton Social Medicine Response Team, Hamilton, Ontario, Canada"},{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcie","family":"McIlveen","sequence":"additional","affiliation":[{"name":"Hamilton Social Medicine Response Team, Hamilton, Ontario, Canada"},{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timothy","family":"O\u2019Shea","sequence":"additional","affiliation":[{"name":"Hamilton Social Medicine Response Team, Hamilton, Ontario, Canada"},{"name":"Department of Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9560-1818","authenticated-orcid":false,"given":"Claire","family":"Bodkin","sequence":"additional","affiliation":[{"name":"Hamilton Social Medicine Response Team, Hamilton, Ontario, Canada"},{"name":"Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,8,24]]},"reference":[{"key":"2026010703064238000_3.2.e002639.1","doi-asserted-by":"crossref","first-page":"1529","DOI":"10.1016\/S0140-6736(14)61132-6","article-title":"The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations","volume":"384","author":"Fazel","year":"2014","journal-title":"The Lancet"},{"key":"2026010703064238000_3.2.e002639.2","unstructured":"Berenbaum E . Homelessness and Health Outcomes: What are the associations. Public Health 2019."},{"key":"2026010703064238000_3.2.e002639.3","doi-asserted-by":"crossref","DOI":"10.1016\/j.focus.2022.100043","article-title":"Unsheltered Homelessness and Health: A Literature Review","volume":"2","author":"Richards","year":"2023","journal-title":"AJPM Focus"},{"key":"2026010703064238000_3.2.e002639.4","unstructured":"Chiefs of Ontario and Ontario Drug Policy Research Network . Impacts of the covid-19 pandemic on opioid-related poisoning among first nations in Ontario. 2021. Available: https:\/\/odprn.ca\/wp-content\/uploads\/2021\/11\/First-Nations-COVID-Opioid-RelatedPoisoning-Report.pdf"},{"key":"2026010703064238000_3.2.e002639.5","doi-asserted-by":"crossref","unstructured":"City of Hamilton Housing Services Division . Point in time connection results 2021. 2021. Available: https:\/\/www.hamilton.ca\/sites\/default\/files\/2022-10\/PIT-2021-Cityof_hamilton-Results.pdf","DOI":"10.1093\/hropen\/hoab033"},{"key":"2026010703064238000_3.2.e002639.6","doi-asserted-by":"crossref","first-page":"241","DOI":"10.1016\/S0140-6736(17)31869-X","article-title":"Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis","volume":"391","author":"Aldridge","year":"2018","journal-title":"The Lancet"},{"key":"2026010703064238000_3.2.e002639.7","unstructured":"City of Hamilton . Emergency and violence against women shelter & drop-in programs. 2025. Available: https:\/\/www.hamilton.ca\/people-programs\/housing-shelter\/preventing-ending-homelessness\/emergency-and-violence-against-women#emergency-violence-against-women-shelters"},{"key":"2026010703064238000_3.2.e002639.8","unstructured":"City of Hamilton . Open data: shelter beds. 2025. Available: https:\/\/open.hamilton.ca\/datasets\/4bb655e968a246fd95332f447609120e_23\/explore"},{"key":"2026010703064238000_3.2.e002639.9","unstructured":"Mitchell D . Spike in Hamilton homeless encampments a \u2018difficult challenge,\u2019 says city. Global News; 2020. Available: https:\/\/globalnews.ca\/news\/7204646\/hamilton-homeless-encampments"},{"key":"2026010703064238000_3.2.e002639.10","unstructured":"Quayum S , Love C , Hunter P . Everyone counts 2020-2022: results from the third nationally coordinated point-in-time counts of homelessness in Canada. Government of Canada; 2023."},{"key":"2026010703064238000_3.2.e002639.11","unstructured":"Infrastructure Canada . Homelessness data snapshot: findings from the 2022 national survey on homeless encampments. 2025. Available: https:\/\/housing-infrastructure.canada.ca\/homelessness-sans-abri\/reports-rapports\/encampments-survey-2022-enquete-campements-eng.html"},{"key":"2026010703064238000_3.2.e002639.12","unstructured":"City of Hamilton . Service restriction policy for emergency shelters. 2024. Available: https:\/\/www.hamilton.ca\/sites\/default\/files\/2024-07\/PreventingHomelessness-Service-Restriction-Policy-Final.pdf"},{"key":"2026010703064238000_3.2.e002639.13","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1080\/09638237.2021.2022629","article-title":"Workplace trauma and chronic stressor exposure among direct service providers working with people experiencing homelessness","volume":"32","author":"Kerman","year":"2023","journal-title":"J Ment Health"},{"key":"2026010703064238000_3.2.e002639.14","unstructured":"Schwan K , Vaccaro M , Reid L , et al . The pan-canadian women\u2019s housing & homelessness survey. 2021. Available: https:\/\/womenshomelessness.ca\/wp-content\/uploads\/EN-Pan-Canadian-Womens-Housing-Homelessness-Survey-FINAL-28-Sept-2021.pdf"},{"key":"2026010703064238000_3.2.e002639.15","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1016\/j.drugpo.2017.12.011","article-title":"Sheltering risks: Implementation of harm reduction in homeless shelters during an overdose emergency","volume":"53","author":"Wallace","year":"2018","journal-title":"Int J Drug Policy"},{"key":"2026010703064238000_3.2.e002639.16","doi-asserted-by":"crossref","first-page":"86","DOI":"10.1016\/j.healthplace.2018.07.011","article-title":"Negotiating space & drug use in emergency shelters with peer witness injection programs within the context of an overdose crisis: A qualitative study","volume":"53","author":"Bardwell","year":"2018","journal-title":"Health & Place"},{"key":"2026010703064238000_3.2.e002639.17","doi-asserted-by":"publisher","DOI":"10.1080\/2159676x.2019.1628806"},{"key":"2026010703064238000_3.2.e002639.18","unstructured":"Creswell JW . A Concise Introduction to Mixed Methods Research. SAGE Publications, 2021."},{"key":"2026010703064238000_3.2.e002639.19","unstructured":"Greer AM , Buxton JA . Paying Peers in Community Based Work: An Overview of Considerations for Equitable Compensation. 2018."},{"key":"2026010703064238000_3.2.e002639.20","doi-asserted-by":"crossref","unstructured":"Braun V , Clarke V , Hayfield N , et al . Thematis analysis. In: Liamputtong P , ed. Handbook of Research Methods in Health and Social Sciences. Singapore: Springer, 2018: 843\u201360.","DOI":"10.1007\/978-981-10-5251-4_103"},{"key":"2026010703064238000_3.2.e002639.21","unstructured":"UN News . What is social justice and how is the un helping make it a reality. United Nations; 2025. Available: https:\/\/news.un.org\/en\/story\/2025\/02\/1160301"},{"key":"2026010703064238000_3.2.e002639.22","unstructured":"Harm Reduction International . What is harm reduction. Harm Reduction International; 2025. Available: https:\/\/hri.global\/what-is-harm-reduction\/"},{"key":"2026010703064238000_3.2.e002639.23","first-page":"1189","article-title":"Enhancing the quality and credibility of qualitative analysis","volume":"34","author":"Patton","year":"1999","journal-title":"Health Serv Res"},{"key":"2026010703064238000_3.2.e002639.24","doi-asserted-by":"crossref","first-page":"409","DOI":"10.17763\/haer.79.3.n0016675661t3n15","article-title":"Suspending Damage: A Letter to Communities","volume":"79","author":"Tuck","year":"2009","journal-title":"Harv Educ Rev"},{"key":"2026010703064238000_3.2.e002639.25","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1177\/00207314221122657","article-title":"Thinking with and Against the Social Determinants of Health: The Latin American Social Medicine (Collective Health) Critique from Jaime Breilh","volume":"52","author":"Harvey","year":"2022","journal-title":"Int J Health Serv"},{"key":"2026010703064238000_3.2.e002639.26","doi-asserted-by":"crossref","unstructured":"Breilh J , Krieger N. J . Critical Epidemiology and the People\u2019s Health. Oxford University Press, 2021.","DOI":"10.1093\/med\/9780190492786.001.0001"},{"key":"2026010703064238000_3.2.e002639.27","doi-asserted-by":"crossref","first-page":"85","DOI":"10.1016\/j.socscimed.2017.01.027","article-title":"Community-based participatory research in a heavily researched inner city neighbourhood: Perspectives of people who use drugs on their experiences as peer researchers","volume":"176","author":"Damon","year":"2017","journal-title":"Social Science & Medicine"},{"key":"2026010703064238000_3.2.e002639.28","doi-asserted-by":"crossref","first-page":"842","DOI":"10.1007\/s11524-022-00680-0","article-title":"Shelter Bans Among People Experiencing Homelessness: an Exploratory Study of Predictors in Two Large Canadian Datasets","volume":"99","author":"Kerman","year":"2022","journal-title":"J Urban Health"},{"key":"2026010703064238000_3.2.e002639.29","doi-asserted-by":"crossref","first-page":"101673","DOI":"10.1016\/j.evalprogplan.2019.101673","article-title":"\u201cIf you\u2019re gonna help me, help me\u201d: Barriers to housing among unsheltered homeless adults","volume":"76","author":"Wusinich","year":"2019","journal-title":"Eval Program Plann"},{"key":"2026010703064238000_3.2.e002639.30","doi-asserted-by":"crossref","first-page":"288","DOI":"10.1080\/15228932.2012.695645","article-title":"Safer Outside: A Qualitative Exploration of Homeless People\u2019s Resistance to Homeless Shelters","volume":"12","author":"Donley","year":"2012","journal-title":"J Forensic Psychol Pract"},{"key":"2026010703064238000_3.2.e002639.31","doi-asserted-by":"crossref","first-page":"1824","DOI":"10.1177\/08862605241265419","article-title":"Antecedents and Consequences of Violence in Homeless Shelters: Perspectives and Experiences of Service Users and Shelter Staff","volume":"40","author":"Kerman","year":"2025","journal-title":"J Interpers Violence"},{"key":"2026010703064238000_3.2.e002639.32","doi-asserted-by":"crossref","first-page":"116831","DOI":"10.1016\/j.socscimed.2024.116831","article-title":"Service restrictions from emergency shelters among people experiencing homelessness: Uncovering pathways into unsheltered homelessness and institutional circuitry","volume":"348","author":"Kerman","year":"2024","journal-title":"Social Science & Medicine"},{"key":"2026010703064238000_3.2.e002639.33","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-12-1"},{"key":"2026010703064238000_3.2.e002639.34","doi-asserted-by":"publisher","DOI":"10.1016\/j.soscij.2008.03.001"},{"key":"2026010703064238000_3.2.e002639.35","doi-asserted-by":"crossref","DOI":"10.1186\/s12954-022-00614-8","article-title":"The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: a case study","volume":"19","author":"Lew","year":"2022","journal-title":"Harm Reduct J"},{"key":"2026010703064238000_3.2.e002639.36","doi-asserted-by":"crossref","DOI":"10.1186\/s12954-024-00930-1","article-title":"\u201cI don\u2019t think of it as a shelter. I say I\u2019m going home\u201d: a qualitative evaluation of a low-threshold shelter for women who use drugs","volume":"21","author":"Beaugard","year":"2024","journal-title":"Harm Reduct J"},{"key":"2026010703064238000_3.2.e002639.37","doi-asserted-by":"publisher","DOI":"10.1016\/j.healthplace.2010.05.001"},{"key":"2026010703064238000_3.2.e002639.38","unstructured":"Milliken S . \u201cHere, I Feel Completely Whole\u201d: Exploring How YWCA Hamilton\u2019s Safer Drug787 Use Space Supports Women and Non-Binary People Experiencing Gender-Based788 Homelessness. Hamilton (CA): McMaster University, 2023."},{"key":"2026010703064238000_3.2.e002639.39","doi-asserted-by":"publisher","DOI":"10.1007\/s11606-021-07312-4"},{"key":"2026010703064238000_3.2.e002639.40","doi-asserted-by":"crossref","first-page":"870","DOI":"10.1007\/s40615-022-01275-w","article-title":"Health Effects of Policing in Hospitals: a Narrative Review","volume":"10","author":"Gallen","year":"2023","journal-title":"J Racial Ethn Health Disparities"},{"key":"2026010703064238000_3.2.e002639.41","unstructured":"City of Hamilton Housing Services Division . Open data: scale of homelessness. 2025. Available: https:\/\/open.hamilton.ca\/datasets\/0869417f4ab04937a9fa3acc770b3d12_22\/explore"}],"container-title":["BMJ Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjph-2025-002639","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,7]],"date-time":"2026-01-07T11:08:24Z","timestamp":1767784104000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjpublichealth.bmj.com\/lookup\/doi\/10.1136\/bmjph-2025-002639"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,7]]},"references-count":41,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,8,24]]},"published-print":{"date-parts":[[2025,7]]}},"alternative-id":["10.1136\/bmjph-2025-002639"],"URL":"https:\/\/doi.org\/10.1136\/bmjph-2025-002639","relation":{},"ISSN":["2753-4294"],"issn-type":[{"value":"2753-4294","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,7]]}}}