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Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 81, No. 4,
The New York Academy of Medicine 2004; all rights reserved. doi:10.1093/jurban/jth143
596
Homeless People’s Trust and Interactions
With Police and Paramedics
Tanya L. Zakrison, Paul A. Hamel, and Stephen W. Hwang
ABSTRACT Although the health impact of patients’ trust in physicians has been well
documented, less is known about the possible health effects of trust in police or para-
medics. Homeless people frequently interact with police officers and paramedics, and
these experiences may affect their health and future willingness to seek emergency
assistance. We examined homeless people’s self-reported interactions with police and
paramedics in Toronto, Canada, and their level of trust in these emergency service pro-
viders. In a sample of 160 shelter users, 61% had interacted with police in the last 12
months, and 37% had interacted with paramedics (P =.0001). The proportion of sub-
jects who expressed willingness to call police in an emergency was significantly lower
than those willing to call paramedics in an emergency (69% vs. 92%, P =.0001). On a
Likert scale ranging from a minimum of 0 to a maximum of 5, trust levels were lower
in police than in paramedics (median level 3 vs. 5, P =.0001). Among shelter users, 9%
(95% confidence interval [CI], 5% to 14%) reported an assault by a police officer in
the last year, and 0% (95% CI, 0% to 4%) reported an assault by a paramedic. These
findings showed that homeless people have much lower levels of trust in police than
paramedics. Reports of negative interactions with police are not uncommon, and home-
less people’s perceptions of the police may pose a barrier to seeking emergency assis-
tance. Further research is needed for objective characterization of homeless people’s
interactions with police officers and the potential health implications of low levels of
trust in the police.
KEYWORDS Emergency medical technicians, Homeless persons, Police, Trust.
INTRODUCTION
Police officers and paramedics have a highly visible presence in the urban environ-
ment. As the first responders in emergency situations, they play a vital role in safe-
guarding the health and safety of city dwellers. However, the effectiveness of these
services may be compromised by factors such as delayed response times or frankly
negative relationships with certain groups. Low levels of trust in the police are parti-
cularly widespread among urban youths and people living in high-crime urban
neighborhoods.
1,2
Research has consistently shown that individuals evaluate the
police primarily on the basis of how fairly they perceive the police treat the public.
3
Negative personal experiences can therefore lead to a loss of trust in the police and
reluctance to seek emergency aid, even in urgent situations.
Drs. Zakrison and Hamel are with the Faculty of Medicine, University of Toronto; Dr. Hwang is with
the Inner City Health Research Unit, St. Michael’s Hospital and the Department of Medicine, University
of Toronto.
Correspondence: Stephen W. Hwang, MD, MPH, Inner City Health Research Unit, St. Michael’s
Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. (E-mail: hwangs@smh.toronto.on.ca)
POLICE, PARAMEDICS, AND THE HOMELESS 597
A large body of literature has examined the conceptual frameworks and
empiric data related to trust and health. This work has focused almost exclusively
on patients’ trust in physicians, insurers, medical institutions, and the medical pro-
fession.
4–7
In this context and more generally, trust may be defined as “the optimis-
tic acceptance of a vulnerable situation in which the truster believes the trustee will
care for the truster’s interests.”
4
Thus, trust depends on the extent to which a
vulnerable individual has a positive “forward-looking evaluation of an ongoing
relationship” with another entity that is in a position of greater power.
4
These
concepts are clearly relevant to an individual’s relationships with police officers or
paramedics.
In the medical context, trust has significant health implications. Trust in physi-
cians is associated with greater adherence to treatment recommendations and improve-
ment in self-reported health,
4
and trust in the medical profession is correlated with
patients’ desire to seek care.
5
Trust in police or paramedics is also likely to have
health consequences, although this has been less well studied. The most likely adverse
health consequence of lack of trust in police or paramedics would be a tendency to
avoid or delay seeking assistance from these sources, even when urgently needed.
Among injection drug users in San Francisco who had witnessed a heroin overdose,
the most commonly cited reason for not calling 911 for an unconscious overdose
victim was fear of the police.
8
A similar study of heroin users in Sydney, Australia,
found that 24% of subjects had been present at an overdose, but had stopped or
delayed seeking help specifically because of fear of police involvement; 5% of all
overdoses in this study resulted in death.
9
Homeless people, like injection drug users, are a vulnerable and marginal-
ized urban population at high risk of morbidity and mortality.
10
Homelessness is
a growing problem in Canada: In Toronto, Canada’s largest city, the nightly
count of people sleeping in homeless shelters doubled over the last decade.
11
Currently, more than 30,000 individuals use shelters in Toronto each year.
11
Homeless people suffer from high rates of physical and mental illness
12,13
and
are therefore likely to use paramedic services at higher-than-average rates.
Homeless people also interact frequently with police. In both Canada and the
United States, homeless people have high arrest rates, and although some arrests
involve serious charges, homeless people are often charged with minor offenses
such as petty theft or entry into vacant buildings.
14–19
Some interactions with
police may also be related to prohibitions against loitering, camping, and pan-
handling.
20
The manner in which police and paramedics treat homeless people is therefore
an important issue. In addition to affecting homeless people’s trust and willingness
to seek assistance, these interactions can also have a direct impact on their physical
well-being. News accounts have described incidents in which police officers in vari-
ous Canadian
21–24
and US cities
25–29
reportedly used unjustified and excessive force
against homeless people. In some of these cases, the fact that the individual was
homeless appeared to be a factor contributing to their victimization. However, it is
unknown if these reports reflect rare and extreme cases, or if they are symptomatic
of a larger underlying problem.
We therefore conducted this study to assess homeless people’s trust and inter-
actions with emergency service providers in Toronto, which has a single police force
and a unified emergency paramedic service. We studied experiences with both
police and paramedics to provide comparative data on homeless people’s relation-
ships with these service providers.
598 ZAKRISON ET AL.
METHODS
Study Population and Recruitment Strategy
We interviewed a systematic sample of 160 persons at 18 of the largest shelters and
drop-in centers for homeless single adults and youths in Toronto, Canada, in 2001.
Interviewers approached every 10th person in sleeping quarters or common areas. If
an individual declined to participate, the next consecutive individual was
approached. Individuals were excluded if they were sleeping, frankly psychotic, or
severely intoxicated. Individuals were also excluded if they could not communicate
fluently in English. A convenience sample of 40 street dwellers was obtained by
approaching individuals at outdoor sites where homeless people congregate. Sub-
jects were told the study examined “homeless people’s perceptions of emergency
services.” Participants gave informed consent and received two public transport-
ation tokens. To ensure confidentiality, participants were not required to give their
full name. The Research Ethics Board of St. Michael’s Hospital approved this study.
Survey Interviews
In a face-to-face interview, we obtained information on demographic characteristics
and duration of homelessness. Subjects were asked whether they had interacted with
paramedics in Toronto during the past 12 months and, if so, the number of inter-
actions during that time. Subjects were asked to state how many of the interactions
were “good overall” and to describe what happened during the best interaction. They
were then asked to state how many of the interactions were “bad overall” and to
describe what happened during the worst interaction. Descriptions of these interactions
were recorded. What constituted a “good” or “bad” interaction was intentionally left
undefined to avoid prompting subjects to describe specific types of events. Subjects
could report both good and bad interactions in the last 12 months. Subjects were
asked to rate their trust in paramedics in Toronto on a Likert scale of 0 to 5, where 0
was defined as “no trust at all” and 5 was defined as “absolute trust.” They were then
asked: “In an emergency, would you call the paramedics?” An identically worded
series of questions was then asked about interactions with police in Toronto.
In an effort to avoid biasing subjects or prompting them to report assaults, the
issue of assaults was not mentioned until the final section of the interview. Subjects
were asked if they had been assaulted during the past 12 months, with assault
defined as a “sudden, violent physical attack.” If an assault was reported, the iden-
tity of the alleged assailant was determined. Finally, subjects were asked if they had
ever been assaulted by paramedics in Toronto, and if they had ever been assaulted
by the police in Toronto. The dates of reported assaults were obtained.
Our definition of a reported assault by police in the last 12 months was a speci-
fied set of internally consistent responses to six survey questions. The responses
were (in order of their occurrence in the survey) as follows: (1) a report of inter-
action with police in the past 12 months, (2) a report of at least one bad interaction,
(3) a description of the “worst” interaction that was consistent with our definition
of an assault, (4) a report of having been assaulted in the past 12 months, (5) a
report of having ever been assaulted by police, and (6) a report that such an assault
had occurred within the past 12 months. The definition of a reported assault by
paramedics in the last 12 months used the same criteria. In subjects meeting these
criteria for a reported assault by police in the last 12 months, descriptions of the
interactions were examined for meaningful patterns. This exploratory effort did not
employ formal qualitative analysis.
POLICE, PARAMEDICS, AND THE HOMELESS 599
Statistical Analyses
Separate analyses were conducted for shelter users and street dwellers because of
differences in sampling methods. The sample size of 160 homeless shelter users was
selected to provide a 95% confidence interval (CI) of 5% for key events occurring
at a rate of 10%–20%. Confidence intervals were not calculated for responses by
street dwellers because this group was selected by convenience sampling. Compara-
tive data on the demographic characteristics of the general population of Toronto
were obtained from Statistics Canada.
The binomial test was used to compare dichotomous response items regarding
police and paramedics. The difference in trust in police compared to paramedics
was examined using the Wilcoxon signed ranks test. Differences in level of trust in
police among various subgroups of homeless subjects were examined using the
Mann-Whitney or Kruskal-Wallis test, as appropriate. Logistic regression analyses
were used to identify predictors of self-reported assault by the police or by anyone
in the last 12 months. Significant predictors were selected using backward selection.
RESULTS
Characteristics of subjects and their reported interactions with paramedics and police
are shown in the Table. Results are shown separately for the shelter-using and street-
dwelling samples. Shelter users had a mean age of 35.5 years, 73% were male, and
45% were non-white. By comparison, the general population of Toronto has a
median age of 36.9 years and is 48% male and 43% non-white. Among homeless
shelter users, interaction within the last 12 months was more common with police
than paramedics (61% vs. 37%, P=.0001). The proportion of homeless shelter users
who expressed willingness to call police in an emergency was significantly lower than
those willing to call paramedics in an emergency (69% vs. 92%, P=.0001).
Among 160 homeless shelter users, 15 (9%; 95% CI, 5% to 14%) reported
experiencing an assault by a police officer in Toronto in the last 12 months. The fre-
quency of such reports by street dwellers was 8%. No shelter user (0%; 95% CI,
0% to 4%) or street dweller reported an assault by a paramedic in the last 12
months. A remarkably large proportion of homeless shelter users (36%) and street
dwellers (50%) reported having been assaulted by police at some point in the past.
In the shelter sample, age was a significant predictor of self-reported assault by
police in the last 12 months (P =.01). Such reports were made by 26% of the shelter
users younger than 20 years, 11% of those 20 to 39 years of age, and 2% of those
40 years of age and older. Sex, race, and duration of the current episode of home-
lessness were not significantly associated with report of assault by police. Among
shelter users, age, sex, race, and duration of homelessness were not associated with
the likelihood of report of any assault in the last 12 months.
Homeless shelter users had lower levels of trust in police than in paramedics
(median level of trust =3 vs. 5, respectively, P =.0001) (Fig. 1). Not surprisingly,
individuals who reported ever having been assaulted by police tended to have much
lower levels of trust in police than individuals who did not report any such past
experience (median level of trust =1 vs. 3, respectively, P =.0001) (Fig. 2). To exam-
ine attitudes in a subset of subjects with limited personal experience with the police,
we focused on the 59 shelter users who stated they had never been assaulted by
police and who reported no interaction with police in the last year. Even in this
subgroup, trust levels in police were significantly lower than trust in paramedics
600 ZAKRISON ET AL.
TABLE. Characteristics of subjects and their reported interactions with paramedics
and police in Toronto
*Among subjects reporting any interaction in the last 12 months. Subjects could report both good and bad
interactions in the last 12 months.
†See text for definitions.
Characteristic
Homeless shelter user
group (N =160), n (%)
Street dweller
group (N =40), n (%)
Age, mean ± SD 35.5 ± 12.8 37.1 ± 10.5
Sex
Male 117 (73) 29 (73)
Female 43 (27) 11 (28)
Race
White 88 (55) 25 (63)
Black 36 (23) 6 (15)
Aboriginal 11 (7) 7 (18)
Other 25 (15) 2 (5)
Duration of current episode of homelessness
Less than 6 months 72 (45) 12 (30)
6 to 12 months 45 (28) 10 (25)
More than 12 months 40 (25) 16 (40)
No response 3 (2) 2 (5)
Interaction with paramedics in last 12 months
Any interaction 59 (37) 17 (43)
Number of interactions (median and
interquartile range)* 2 (1–5) 2 (1–4.5)
At least one interaction rated good* 53 (90) 15 (88)
At least one interaction rated bad* 14 (24) 4 (24)
Would call paramedics in an emergency
Yes 147 (92) 34 (85)
No 8 (5) 4 (10)
Undecided 5 (3) 2 (5)
Interaction with police in last 12 months
Any interaction 97 (61) 32 (80)
Number of interactions (median and
interquartile range)* 3 (1–8) 5 (2–19)
At least one interaction rated good* 58 (60) 19 (59)
At least one interaction rated bad* 63 (65) 23 (72)
Would call police in an emergency
Yes 111 (69) 20 (50)
No 34 (21) 17 (43)
Undecided 15 (9) 3 (8)
Reported assault by anyone in last 12 months† 58 (36) 20 (50)
Reported assault by paramedics in last 12 months† 0 (0) 0 (0)
Reported assault by paramedics ever in the past† 1 (1) 0 (0)
Reported assault by police in last 12 months† 15 (9) 3 (8)
Reported assault by police ever in the past† 57 (36) 20 (50)
POLICE, PARAMEDICS, AND THE HOMELESS 601
0
5
10
15
20
25
30
35
40
45
50
0 1 2 3 4 5 don't
know
Level of Trust
%
FIGURE 1. Homeless service-users’ (N =160) level of trust in paramedics (white bars, median level
of trust =5) and police (black bars, median level of trust =3). Highest possible level of trust is 5.
P =0.0001 for the difference in trust.
0
5
10
15
20
25
30
35
40
45
50
012345don't
know
Level of Trust in Police
%
FIGURE 2. Homeless service-users’ level of trust in police. Black bars represent individuals who
reported any experience of assault by police in the past (N =57, median level of trust =1) and white
bars, those who reported no such history (N =103, median level of trust =3). P =0.0001 for the dif-
ference in trust.
602 ZAKRISON ET AL.
(median level of trust = 3 vs. 4, respectively, P =.01). Among all shelter users, age,
sex, race, and duration of the current episode of homelessness were not significantly
associated with level of trust in police in bivariate analyses.
Overall findings in street dwellers were similar to those in shelter users. Street-
dwelling subjects were more likely than shelter users to have interacted with police
at least once in the last 12 months (80% vs. 61%, respectively). The difference in
street dwellers’ trust in police compared to paramedics was large (median level of
trust = 1 vs. 4, respectively).
Of the 18 subjects in the entire study who reported an assault by police in the
last 12 months, 56% were male, and their age ranged from 15 to 44 years (mean 27
years). Review of these individuals’ comments showed that 4 assaults reportedly
occurred during the process of an arrest, and 8 reportedly occurred after an arrest.
Two individuals stated that after being arrested by police they were taken to
“Cherry Beach” (an isolated area of industrial land near downtown Toronto) and
assaulted. A third individual claimed that after he was arrested, officers threatened
to take him to Cherry Beach, but subsequently assaulted him at a different location.
DISCUSSION
In this study, homeless people in Toronto expressed significantly less trust in police
than in paramedics. A low level of trust in police was seen among homeless people
of all ages and races and was particularly common among homeless people with a
history of contact with the police. These findings were not entirely unexpected:
Paramedics have a clearly defined helping role, whereas the police serve a more
complex function in society that can result in significant conflict.
Previous studies have shown that minority group members and urban youths
tend to have low levels of trust in the police.
1–3
Further research is needed to assess
the possible health consequences of lack of trust in police, paramedics, or other
emergency service providers among disadvantaged urban populations. Such effects
could plausibly occur at the individual level, through chronic mental stress or delay
in seeking needed assistance, or at the neighborhood level, through a decline in
social capital.
30
A disturbing finding in our study was that almost 1 in 10 homeless individuals
reported experiencing an assault by a police officer in the last 12 months. Obvi-
ously, the accuracy of homeless people’s self-reports of assaults is a pivotal concern.
It is conceivable that some of these reports were fabricated, or that the actual events
involved police officers’ use of justified and proportionate force in the course of an
arrest. However, anecdotal evidence from cities in Canada
21–24
and the United
States
25–29
demonstrated that homeless people’s allegations of assault by police are
not inherently implausible. Our finding is also consistent with the results of a 1992
health survey in which 10% of 458 homeless people in Toronto reported having
been assaulted by a police officer in the last year.
31
It is interesting to note that three subjects in our study reported that assaults
after police arrest were associated with a specific site in Toronto known as Cherry
Beach. In 1996, a homeless man accused police of taking him to this location after
his arrest and beating him there.
22
The alleged victim filed a civil suit against
police officers that was settled out of court in 2003 for an undisclosed sum.
23,24
It
is unlikely that the publicity surrounding this case prompted our subjects to men-
tion this specific site because our interviews were conducted 5 years after the
attack allegedly occurred and 1 year before the civil suit came to trial and was
POLICE, PARAMEDICS, AND THE HOMELESS 603
ultimately settled. This raises the question of why three different study subjects
would mention the same location as a place where assaults took place after police
arrests.
Certain considerations have an impact on the generalizability of this study. The
race of our study population was about 55% white and 45% black, Aboriginal, or
other, which accurately reflected the racial composition of the adult homeless popu-
lation of Toronto.
13
In many US cities, however, a much larger proportion of home-
less persons belong to racial minorities.
32
Because non-white race is correlated with
lower trust in police,
2,3
a similar study of homeless people in a US city might find
substantially lower levels of trust in police. In addition, the relationship between
police and racial and ethnic minorities may vary substantially between countries
and from city to city within a single country.
This study had certain limitations. The exclusion of persons who did not speak
English may affect estimates of level of trust because non-English speakers (parti-
cularly those belonging to racial minorities) may have less trust in the police. How-
ever, 98% of homeless people in Toronto are able to communicate in English.
18
Our
study did not include efforts to objectively confirm subject’s reports of assaults or
the health consequences of alleged assaults. We did not formally assess subjects’
substance use or mental health. When subjects were asked whether they would call
police or paramedics in an emergency, we did not describe the type of circumstances
that might prompt such a call; in future studies, this question may be better posed
by providing specific scenarios. Finally, we did not use formal qualitative analysis in
this exploratory study. Future investigations should consider employing these meth-
ods in addition to attempting to characterize interactions between homeless people
and police officers objectively.
In conclusion, our study documents that homeless people in Toronto have a
much lower level of trust in police than in paramedics, and about 9% reported hav-
ing been assaulted by police in the last 12 months. Homeless people’s perceptions of
the police may pose a barrier that prevents them from seeking needed care in an
emergency. Our findings also highlight the need for independent investigation of
homeless people’s reports of victimization by police. Further research in this area of
urban health is clearly needed.
ACKNOWLEDGEMENT
Dr. Hwang is the recipient of a New Investigator Award from the Canadian Insti-
tutes of Health Research. The Inner City Health Research Unit is supported in part
by a grant from the Ontario Ministry of Health and Long-Term Care. The results
and conclusions are those of the authors, and no official endorsement by these orga-
nizations is intended or should be inferred. Preliminary results of this study were
presented at the Second International Conference of the International Society for
Equity in Health, Toronto, Ontario, June 2002, and at the 26th Annual Meeting of
the Society of General Internal Medicine, Vancouver, British Columbia, May 2003.
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