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Social factors in frequent callers: a description of isolation, poverty and quality of life in those calling emergency medical services frequently



Frequent users of emergency medical services (EMS) comprise a disproportionate percentage of emergency department (ED) visits. EDs are becoming increasingly overwhelmed and a portion of use by frequent callers of EMS is potentially avoidable. Social factors contribute to frequent use however few studies have examined their prevalence. This study aims to describe social isolation/loneliness, poverty, and quality of life in a sample of frequent callers of EMS in the Hamilton region, a southern Ontario mid-sized Canadian city.

Study design

Cross-sectional quantitative study.


We surveyed people who called EMS five or more times within 12 months. A mailed self-administered survey with validated tools, and focused on four major measures: demographic information, social isolation, poverty, and quality of life.


Sixty-seven frequent EMS callers revealed that 37–49% were lonely, 14% had gone hungry in the preceding month, and 43% had difficulties making ends meet at the end of the month. For quality of life, 78% had mobility problems, 55% had difficulty with self-care, 78% had difficulty with usual activities, 87% experienced pain/discomfort, and 67% had anxiety/depression. Overall quality adjusted life years value was 0.53 on a scale of 0 to 1. The response rate was 41.1%.


Loneliness in our participants was more common than Hamilton and Canadian rates. Frequent EMS callers had higher rates of poverty and food insecurity than average Ontario citizens, which may also act as a barrier to accessing preventative health services. Lower quality of life may indicate chronic illness, and users who cannot access ambulatory care services consistently may call EMS more frequently. Frequent callers of EMS had high rates of social loneliness and poverty, and low quality of life, indicating a need for health service optimization for this vulnerable population.

Peer Review reports


In recent decades, emergency medical service (EMS) use has increased dramatically, straining emergency departments (ED) beyond their capacity and representing a significant cost in the healthcare budget. [1] Between 2012 and 2014 alone, Ontario ambulance use has increased by 8%, representing an increase of 100,000 dispatches and 17% in costs. Out of all calls, 58,000 patients (58%) are transported and 48,000 (48%) are not. [2] Some emergency service use among frequent callers is likely preventable, and may represent a discrepancy between physician and patient perceptions of medical emergencies. [3,4,5,6,7] In previous literature surveying emergency service use, one out of three ambulance dispatches have not been perceived as medical emergencies by health services researchers, [8] and frequent callers account for up to 40% of transports. [9,10,11,12,13,14] In specifically Canadian studies, frequent callers comprise 2.1–3.6% of overall ED users but account for 9.9–13.8% of visits. Frequent callers have been defined as people who call 4 to 5 or more times within 1 year, [15, 16] though definitions range from 3 to 10 times per year. [16,17,18,19,20]

Existing literature from the United States of America (USA) characterizing frequent ED and EMS users (as opposed to callers) reveals that they are often vulnerable populations [15, 21] who tend to be of lower socioeconomic status, [22] have psychiatric and substance use disorders, [23] or have chronic medical conditions (often with multiple comorbidities). [4, 24,25,26,27,28] Common chronic condition exacerbations were found to be in ambulatory care sensitive diseases such as asthma, [29, 30] chronic obstructive pulmonary disease, renal failure, and sickle cell anemia. [23] Consistent with this, frequent EMS users have been found to be high users of ambulatory care services (outpatient medical care that prevents or reduces hospitalizations). [31] Amongst non-specific presenting complaints, nausea and vomiting, chest pain, anxiety, pain, and shortness of breath are most common, which are not necessarily differing from non-frequent callers. [9, 31] Frequent EMS users also have poorer self-rated general health, [32] higher mortality rates post-ED, [33] hospital admissions, [34] and higher rates of ambulance usage. [34]

A growing body of literature studies potential psychosocial factors behind frequent ED usage. Some propose that frequent EMS users lack proper access to primary healthcare services and are forced to rely on emergency health services as their only source of regular medical care, thus presenting for non-urgent health issues. [35,36,37] Ambulatory care-sensitive medical conditions such as asthma, diabetes, chronic obstructive pulmonary disease and congestive heart failure are one example where patients rely heavily on close monitoring in outpatient health services; without this, they are more likely than others to require ED visits and unscheduled hospitalization. [37] Social isolation and loneliness have also been identified as predictors of frequent ED usage (lacking close friends, living alone, unemployment, disability retirement, and subjective feelings of loneliness). [1, 30, 33, 38,39,40] These patients may also have emotional, cognitive, and stress-related neuroendocrine, cardiovascular and immune changes that contribute to difficulty managing their health. [40, 41] The increasing proportion of elderly citizens who live alone is another potential reason for recent increases in ED visits amongst the elderly. [42] Lastly, frequent EMS users have higher rates of poverty, which is associated with a higher prevalence of chronic illnesses, as well as barriers to preventative and primary healthcare services. [43, 44] Additionally, increasing ED use has been associated with homelessness and unstable housing status, further emphasizing the vulnerability of this population. [21] However, the extent to which social factors actually determine ED and EMS usage has not yet been determined.

Existing literature has largely focused on the characteristics of frequent users of EDs, rather than callers to EMS, who are a different population. [5] Most research regarding frequent users has taken place in large American cities, and has used differing definitions of a frequent user, and tended to focus on psychiatric illness, failing to describe their actual characteristics. There are far fewer primary studies in mid-sized cities and in Canada, which have vastly different health service infrastructure than USA (i.e. universal health insurance). Given that a large proportion of frequent users of ED services arrive by ambulance (59.3% of frequent users vs. 12% of the general population), [5, 15, 17, 45,46,47,48,49] studying this population of frequent callers to EMS will aid in continuing to find a solution to ED overcrowding. Investigating the profile of social factors will assist in planning primary and preventative health services development in these subpopulations of frequent EMS callers.

This study aims to describe social isolation/loneliness, poverty, and quality of life in a sample of frequent users of EMS in the Hamilton region, a southern Ontario mid-sized Canadian city.


Study design and sample

This cross-sectional quantitative study surveyed participants who had called 911 at least five times between April 1st 2015 and March 31, 2016. Participants were residents of the City of Hamilton 18 years or older, and were invited to participate by the Hamilton Paramedic Service, who had extracted their names from their database. The survey was distributed in two occurrences for ease of workload; initially commencing May 2016 and then a second sample commencing September 2017 each time using a modified Dillman’s Total Design. The surveys were mailed with an introductory letter with study objectives and explanation, instructions for return, a pre-stamped envelope, and a $5 gift card. A second mail-out included a reminder letter and was sent 1 week after initial mail-out to non-responding participants. A final mail-out 3–7 weeks later included a replacement introductory letter, instructions for returning the survey, the survey itself, and a pre-stamped envelope. When participants returned the survey, they were given an additional $5 gift card.


The survey questions focused on the following: (1) demographic information, (2) social isolation, (3) poverty, and (4) quality of life.

Demographic information collected included age, sex, body mass index (BMI) and employment status. To measure social isolation and loneliness, two well-validated scales were used since they measured different aspects of loneliness; the UCLA 3 Item Loneliness scale which could quantify loneliness, [50] and a portion of the De Jong Gierveld 6-Item Loneliness Scale which measured social loneliness. [51] To measure poverty, two highly sensitive and specific clinical screening questions were used – whether participants had trouble making ends meet at the end of the month, [52] and whether either they or their family members had gone hungry in the past month. [53] To measure quality of life, we used the EQ5D-3 L, a 5-item preference based instrument for 5 health states at 3 levels (mobility, self care, usual activities, pain/discomfort, anxiety/depression). [54] The scores were converted according to a Canadian preferences valuation to a score for quality adjusted life years (QALY). [54]

Ethical considerations

In order to adhere to high ethical standards, the survey was completely separate from any healthcare provided so that participants would not feel pressured or coerced to participate. Therefore, a group that already had difficulty accessing healthcare would not find this to be an additional barrier. The surveys were kept confidential and anonymous. Additionally compensation was provided for the time taken in filling out the survey. These ethical considerations passed Local Research Ethics Board Standards.

Data analysis

Descriptive statistics were calculated to describe social factors (poverty, loneliness, and quality of life). The mean, median, mode and 25th and 75th quartiles were calculated for QALY. Data was analyzed using SPSS statistical software, version 24. Missing data were excluded from the analyses and the final “valid percent” was taken.


Demographics (Fig. 1)

253 eligible participants were identified. Of those, 81 were excluded as they had given an incomplete address and 5 were excluded as they were from a long-term care facility. 167 people in total were sent a mailed survey, and 67 completed the survey, yielding a response rate of 41.1%. Of the non-responders, 13 were found to be deceased, 21 declined the survey, and 66 did not respond even after reminders (Fig. 1).

Fig. 1

Flow diagram for participants

Most of the respondents were older than 40 years of age (88.1%) (Table 1). With respect to employment status, 85.1% of the sample was unemployed. For BMI, 19.4% of participants had a normal BMI from 18.5–24.9, while 58.3% of the population was underweight, overweight or obese. Most individuals lived with someone (58.2%) but 38.8% of individuals lived alone.

Table 1 Demographic Data

Non-responders had a similar age and sex distribution to responders. In terms of sex, 43.3% were female and 56.7% were male. In terms of age, the most represented categories were ages 41–64 (39.4%) and 74+ (31.7%), which are the same categories that were most represented among responders.

Social factors

On the UCLA 3 Item scale, 49.25% of participants achieved a “lonely” score of 6 to 9, while 47.76% of participants achieved a “not lonely” score of 3 to 5; 20.9% of participants felt that they lacked companionship often, and 40.3% felt that they lacked companionship some of the time. On the De Jong Social Loneliness questions, 37.3% were intensely lonely (Tables 2 and 3).

Table 2 UCLA Social Loneliness Score
Table 3 De Jong Social Loneliness Score

Nearly half of respondents (43.3%) reported not having enough money to make ends meet and 14.9% reported that they or a family member went hungry in the past month (Table 4).

Table 4 Poverty

Quality of life

A large percentage (74.6%) of participants experienced some problems walking; 11.9% were completely unable to wash and dress themselves; most had some problems performing usual activities (56.7%); most experienced pain and discomfort and a high proportion (67.1%) experienced moderate or extreme anxiety and depression (Table 5). When the EQ5D-3 L data were converted to QALYs, the mean was found to be 0.533 (out of a range of 0–1, where 1 described perfect quality of life). The 25th and 75th percentiles were 0.376 and 0.664 respectively.

Table 5 Quality of Life


We conducted a survey of 67 frequent users of EMS in a mid-sized Canadian city and found substantial social isolation, loneliness, income and food insecurity, as well as low quality of life. In the current body of literature, few studies of frequent users measure social isolation/loneliness and quality of life, and most of them survey ED users rather than EMS frequent users. [30, 39, 40] Therefore, our study represents a unique approach to emergency health service usage.

In this study, 37.3 to 49.3% of participants experienced significant degrees of loneliness. Comparatively, Canadian research from 2009 has cited that approximately 19–24% of Canadian seniors lack companionship or wish to participate in more social activities. [55] In Hamilton, in 2006, 15% of senior citizens were estimated to be isolated. [56] The high rates of loneliness found in our study are consistent with existing literature on frequent users of ED. People who live alone, lack friends, are divorced, or lack other social support have been shown to be more likely to be frequent users of ED. [17, 38, 57, 58] Accordingly, 38.8% of our participants live by themselves, a widely used indicator for social isolation, [59] compared to 28.2% Canadians (2016). [60] With respect to potential mechanisms, loneliness and frequent ED use have each been independently linked to increased morbidity, in which chronic illness, poor health behaviours, and poor mental health may result in increased mortality. [25, 39, 41, 61,62,63,64,65] However, studies which show higher rates of loneliness in populations of frequent ED users have not found that rates of chronic illness differ between lonely and non-lonely individuals. [25, 39, 61]

Next, our results indicate that frequent callers to EMS have higher rates of poverty and food insecurity than average Ontario citizen, even those described in our population who are reachable and respond to survey; 14.9% of frequent callers were food insecure, compared to 8.2% of Ontario citizens in 2011. [66] Even more significantly, poverty rates were 43.3% in frequent callers, and 8.8% in Ontarians in 2014. [67] Frequent ED use has previously been associated with poverty in USA studies, where lack of medical insurance was a factor in the delay of seeking other primary and preventative healthcare. [3, 35] The presence of higher rates of poverty in our population is significant, as it is likely to suggest that factors other than lack of medical insurance contribute to frequent ED use behaviours. Besides insurance coverage, poverty can still represent a barrier to primary and preventative health services access in the form of lacking transportation to appointments, not being able to take time off work for appointments, or lack of money to pay for prescription drugs. [68]

Thirdly, participants in our study experienced a lower quality of life than Canadian population averages. In each of the 5 dimensions measured in the EQ5D-3 L, a significantly higher percentage experienced some or extreme problems: mobility (77.6% vs 22%), self care (55.2% vs. 4%), usual activities (77.6% vs. 23%), pain/discomfort (86.5% vs. 51%), and anxiety/depression (67.1% vs. 31%). [54] The most significant differences include difficulties in usual activities (54%), mobility (56%) and self care (51%), which may represent the most significant contributions toward EMS calls in frequent users. Previous studies have found high rates of mobility problems and functional decline in frequent users of ED, and that difficulty in activities of daily living are contributory to the decision to present to ED. [69, 70] Additionally, high rates of ambulatory care conditions have been reported in frequent users, the most common being pain-related conditions. [31, 37] This is consistent with the high prevalence of pain and discomfort found in our study.

Lastly, demographics of frequent EMS callers in our study are largely consistent with existing literature, which primarily studies frequent ED users. The majority of frequent users are younger than 65 years, [9, 61] and an equal number of males and females are frequent users of ED. [4, 14, 27, 71, 72] Other studies have described that younger users are more likely to be ED “superusers” (those with 15 or more annual ED visits), though unfortunately no studies have been conducted on similar statistics for EMS callers. [4, 9, 61] Our population’s unemployment rate was 85% – however, a limiting factor may be age, as 47.8% of participants were age 65+. After removing those participants, 37.3% of the population were unemployed, much higher than Ontario’s rate of 5.5%, suggesting unemployment to be a potential contributory factor toward frequent ED usage. [73] Unemployment could also contribute to and result from poverty and social isolation.

The combination of these numerous social factors represents a complex and multifactorial problem that may be an issue unable to be addressed by a purely biomedical approach traditionally used by emergency health services. We propose that a salutogenic approach to health service provision may be beneficial. Unlike traditional curative approaches, a salutogenic approach focuses on social factors which have been identified to create wellness. [74] Health is not viewed as being a dichotomous state of the presence or absence of disease, but rather is conceptualised along a health continuum between total health and death. [75] Salutogenic approaches to health are aware that total health may not be achieved in all instances, such as those with chronic illness, however, the overall wellness of the individual can be improved through addressing social factors related to the individual need, by linking the person to the appropriate resources for their situation. [76] Because paramedics have unique access to patients’ living environments, a salutogenic approach may be and has shown to be a promising option for paramedic and health service provision to effectively assess and address such social factors in patient populations. [77, 78]

Limitations of this study include the lack of a comparator group of non-frequent callers of EMS. However, given the difficulties in recruiting our population of frequent callers, it may also be difficult to recruit similar non-frequent callers of EMS. Another limitation is that participant recruitment was limited to the Hamilton region. However, this study is applicable to other mid-sized cities in both Canada and USA, and provides insight into healthcare systems with universal coverage, a gap in existing literature. Lastly, although the response rate was 41.1% which could be viewed as low, this rate is quite good for a mail-in survey, and at least the age and sex profile of non-responders matched our sample. [79] Additionally, 13 of the non-responders were found after to be deceased, and given the high mortality rate in this population, additional non-responders may have passed away without notifying the research team. However, this may mean that participants with the most significant and multiple comorbidities may not be represented in our study, as they are most likely to have been deceased.


Overall, our study describes high rates of social isolation and poverty, and a low quality of life in frequent callers of EMS compared to Canadian and USA averages, and that subpopulations within the frequent users group of EMS callers were largely similar to those in the frequent ED users group already characterized. Our results are consistent with many studies already conducted in USA, UK, Australia, and China, in both urban and suburban EDs. Due to Canada’s unique health service infrastructure, this study proposes a salutogenic approach to health service provision that is directly applicable to Southern Ontario and other mid-sized Canadian and American cities. Future research may be able to further characterize EMS frequent users, and trial preventative programs as well as social support programs by social workers in order to gain additional insight into interventions that may affect social loneliness, poverty and quality of life in frequent users of EMS and ED. [18, 80]



Body mass index


Emergency department


Emergency Medical Services


Quality adjusted life years


United States of America


  1. 1.

    Lowthian JA, Curtis AJ, Cameron PA, Stoelwinder JU, Cooke MW, McNeil JJ. Systematic review of trends in emergency department attendances: an Australian perspective. Emerg Med J. 2011;28:373–7.

    Article  Google Scholar 

  2. 2.

    Office of the Auditor General of Ontario. Annual Report: Land Ambulance Services Section 404.

  3. 3.

    Hunt KA, Weber EJ, Showstack JA, Colby DC, Callaham ML. Characteristics of frequent users of emergency departments. Ann Emerg Med. 2006;48:1–8.

    Article  Google Scholar 

  4. 4.

    Hall MK, Raven MC, Hall J, Yeh C, Allen E, Rodriguez RM, et al. EMS-STARS: Emergency Medical Services “Superuser” Transport Associations: An Adult Retrospective Study. Prehosp Emerg Care. 2015;19:61–7.

    Article  Google Scholar 

  5. 5.

    Scott J, Strickland AP, Warner K, Dawson P. Frequent callers to and users of emergency medical systems: a systematic review. Emerg Med J. 2014;31:684–91.

    Article  Google Scholar 

  6. 6.

    Knowlton A, Weir BW, Hughes BS, Southerland RH, Schultz CW, Sarpatwari R, et al. Patient demographic and health factors associated with frequent use of emergency medical Services in a Midsized City. Acad Emerg Med. 2013;20:1101–11.

    Article  Google Scholar 

  7. 7.

    Oktay C, Cete Y, Eray O, Pekdemir M, Gunerli A. Appropriateness of emergency department visits in a Turkish university hospital. Croat Med J. 2003;44:585–91.

    PubMed  Google Scholar 

  8. 8.

    Hjalte L, Suserud B-O, Herlitz J, Karlberg I. Initial emergency medical dispatching and prehospital needs assessment: a prospective study of the Swedish ambulance service. Eur J Emerg Med. 2007;14:134–41.

    Article  Google Scholar 

  9. 9.

    Moe J, Bailey AL, Oland R, Levesque L, Murray H. Defining, quantifying, and characterizing adult frequent users of a suburban Canadian emergency department. CJEM. 2013;15:214–26.

    Article  Google Scholar 

  10. 10.

    Chan BTB, Ovens HJ. Frequent users of emergency departments. Do they also use family physicians’ services? Can Fam Physician Med Fam Can. 2002;48:1654–60.

    Google Scholar 

  11. 11.

    Doupe MB, Palatnick W, Day S, Chateau D, Soodeen R-A, Burchill C, et al. Frequent users of emergency departments: developing standard definitions and defining prominent risk factors. Ann Emerg Med. 2012;60:24–32.

    Article  Google Scholar 

  12. 12.

    CIHI. Emergency department visits in 2014–2015. Canada: Canadian Institute for Health Information; 2015.

  13. 13.

    South Carolina Public Health Institute. A report on frequent users of hospital emergency departments in South Carolina. South Carolina. USA: SCPHI; 2011.

    Google Scholar 

  14. 14.

    Weiss SJ, Ernst AA, Miller P, Russell S. Repeat EMS transports among elderly emergency department patients. Prehosp Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir. 2002;6:6–10.

    Google Scholar 

  15. 15.

    Jelinek GA, Jiwa M, Gibson NP, Lynch A-M. Frequent attenders at emergency departments: a linked-data population study of adult patients. Med J Aust. 2008;189:552–6.

    PubMed  Google Scholar 

  16. 16.

    LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data, and the policy implications. Ann Emerg Med. 2010;56:42–8.

    Article  Google Scholar 

  17. 17.

    Markham D, Graudins A. Characteristics of frequent emergency department presenters to an Australian emergency medicine network. BMC Emerg Med. 2011;11:11–12.

  18. 18.

    Skinner J, Carter L, Haxton C. Case management of patients who frequently present to a Scottish emergency department. Emerg Med J. 2009;26:103–5.

    CAS  Article  Google Scholar 

  19. 19.

    Cook LJ, Knight S, Junkins EP, Mann NC, Dean JM, Olson LM. Repeat patients to the emergency Department in a Statewide Database. Acad Emerg Med. 2004;11:256–63.

    Article  Google Scholar 

  20. 20.

    Matsumoto CL, O’Driscoll T, Madden S, Blakelock B, Lawrance J, Kelly L. Defining “high-frequency” emergency department use: Does one size fit all for urban and rural areas? Can Fam Physician Med Fam Can. 2017;63:e395–9.

    Google Scholar 

  21. 21.

    Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National Data from the Veterans Health Administration. Ann Emerg Med. 2013;62:151–9.

    Article  Google Scholar 

  22. 22.

    Ku BS, Scott KC, Kertesz SG, Pitts SR. Factors Associated with Use of Urban Emergency Departments by the U.S. Homeless Population. Public Health Rep. 2010;125:398–405.

    Article  Google Scholar 

  23. 23.

    Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency Department’s frequent users. Acad Emerg Med. 2000;7:637–46.

    CAS  Article  Google Scholar 

  24. 24.

    Langer S, Chew-Graham C, Hunter C, Guthrie EA, Salmon P. Why do patients with long-term conditions use unscheduled care? A qualitative literature review: long-term conditions and unscheduled care: a review. Health Soc Care Community. 2013;21:339–51.

    Article  Google Scholar 

  25. 25.

    Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, Bury G. Frequent attenders to an emergency department: a study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med. 2003;41:309–18.

    Article  Google Scholar 

  26. 26.

    Chambers C, Chiu S, Katic M, Kiss A, Redelmeier DA, Levinson W, et al. High utilizers of emergency health Services in a Population-Based Cohort of homeless adults. Am J Public Health. 2013;103:S302–10.

    Article  Google Scholar 

  27. 27.

    Tangherlini N, Villar J, Brown J, Rodriguez RM, Yeh C, Friedman BT, et al. The HOME Team: Evaluating the Effect of an EMS-based Outreach Team to Decrease the Frequency of 911 Use Among High Utilizers of EMS. Prehosp Disaster Med. 2016;31:603–7.

    Article  Google Scholar 

  28. 28.

    Ford JG, Meyer IH, Sternfels P, Findley SE, McLean DE, Fagan JK, et al. Patterns and predictors of asthma-related emergency department use in Harlem. Chest. 2001;120:1129–35.

    CAS  Article  Google Scholar 

  29. 29.

    Griswold SK, Nordstrom CR, Clark S, Gaeta TJ, Price ML, Camargo CA. Asthma exacerbations in North American adults. Chest. 2005;127:1579–86.

    Article  Google Scholar 

  30. 30.

    Andrén KG, Rosenqvist U. Heavy users of an emergency department: psycho-social and medical characteristics, other health care contacts and the effect of a hospital social worker intervention. Soc Sci Med 1982. 1985;21:761–70.

    Google Scholar 

  31. 31.

    Blank FSJ, Li H, Henneman PL, Smithline HA, Santoro JS, Provost D, et al. A descriptive study of heavy emergency department users at an academic emergency department reveals heavy ED users have better access to care than average users. J Emerg Nurs. 2005;31:139–44.

    Article  Google Scholar 

  32. 32.

    Zuckerman S, Shen Y-C. Characteristics of occasional and frequent emergency department users: do Insurance coverage and access to care matter? Med Care. 2004;42:176–82.

    Article  Google Scholar 

  33. 33.

    Genell Andrén K, Rosenqvist U. Heavy users of an emergency department--a two year follow-up study. Soc Sci Med 1982. 1987;25:825–31.

    Google Scholar 

  34. 34.

    Lucas RH, Sanford SM. An analysis of frequent users of emergency Care at an Urban University Hospital. Ann Emerg Med. 1998;32:563–8.

    CAS  Article  Google Scholar 

  35. 35.

    Pane GA, Farner MC, Salness KA. Health care access problems of medically indigent emergency department walk-in patients. Ann Emerg Med. 1991;20:730–3.

    CAS  Article  Google Scholar 

  36. 36.

    Richardson LD, Hwang U. Access to care a review of the emergency medicine literature. Acad Emerg Med. 2001;8:1030–6.

    CAS  Article  Google Scholar 

  37. 37.

    Oster A, Bindman AB. Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations. Med Care. 2003;41:198–207.

    PubMed  Google Scholar 

  38. 38.

    Andrén KG. A study of the relationship between social network, perceived ill health and utilization of emergency care: A case-control study. Scand J Soc Med. 1988;16:87–93.

    Article  Google Scholar 

  39. 39.

    Geller J, Janson P, McGovern E, Valdini A. Loneliness as a predictor of hospital emergency department use. J Fam Pract. 1999;48:801–4.

    CAS  PubMed  Google Scholar 

  40. 40.

    Molloy GJ, McGee HM, O’Neill D, Conroy RM. Loneliness and emergency and planned hospitalizations in a community sample of older adults: LONELINESS AND HEALTHCARE USE. J Am Geriatr Soc. 2010;58:1538–41.

    Article  Google Scholar 

  41. 41.

    Steptoe A, Owen N, Kunz-Ebrecht SR, Brydon L. Loneliness and neuroendocrine, cardiovascular, and inflammatory stress responses in middle-aged men and women. Psychoneuroendocrinology. 2004;29:593–611.

    CAS  Article  Google Scholar 

  42. 42.

    Lowthian JA, Jolley DJ, Curtis AJ, Currell A, Cameron PA, Stoelwinder JU, et al. The challenges of population ageing: accelerating demand for emergency ambulance services by older patients, 1995-2015. Med J Aust. 2011;194:574–8.

    PubMed  Google Scholar 

  43. 43.

    Rust G. Practical barriers to timely primary care access: impact on adult use of emergency department services. Arch Intern Med. 2008;168:1705.

    Article  Google Scholar 

  44. 44.

    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.

    Article  Google Scholar 

  45. 45.

    Locker TE, Baston S, Mason SM, Nicholl J. Defining frequent use of an urban emergency department. Emerg Med J. 2007;24:398–401.

    Article  Google Scholar 

  46. 46.

    Gibson NP, Jelinek GA, Jiwa M, Lynch A-M. Paediatric frequent attenders at emergency departments: a linked-data population study: Paediatric frequent attenders at emergency departments. J Paediatr Child Health. 2010;46:723–8.

    Article  Google Scholar 

  47. 47.

    Fuda KK, Immekus R. Frequent users of Massachusetts emergency departments: a statewide analysis. Ann Emerg Med. 2006;48:16.e1–8.

    Article  Google Scholar 

  48. 48.

    Geurts J, Palatnick W, Strome T, Sutherland KA, Weldon E. Frequent users of an inner-city emergency department. CJEM. 2012;14:306–13.

    Article  Google Scholar 

  49. 49.

    CIHI. Health Care in Canada, 2012: A focus on wait times. Canadian institute for health information.

    Google Scholar 

  50. 50.

    Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. A Short Scale for Measuring Loneliness in Large Surveys: Results From Two Population-Based Studies. Res Aging. 2004;26:655–72.

    Article  Google Scholar 

  51. 51.

    Gierveld JDJ, Tilburg TV. A 6-item scale for overall, emotional, and social loneliness: confirmatory tests on survey data. Res Aging. 2006;28:582–98.

    Article  Google Scholar 

  52. 52.

    Brcic V, Eberdt C, Kaczorowski J. Development of a Tool to Identify Poverty in a Family Practice Setting: A Pilot Study. Int J Fam Med. 2011;2011:1–7.

    Article  Google Scholar 

  53. 53.

    Kleinman RE, Murphy JM, Wieneke KM, Desmond MS, Schiff A, Gapinski JA. Use of a single-question screening tool to detect hunger in families attending a neighborhood health center. Ambul Pediatr. 2007;7:278–84.

    Article  Google Scholar 

  54. 54.

    Bansback N, Tsuchiya A, Brazier J, Anis A. Canadian valuation of EQ-5D health states: preliminary value set and considerations for future valuation studies. PLoS One. 2012;7:e31115.

    CAS  Article  Google Scholar 

  55. 55.

    Statistics Canada. Canadian community health survey - healthy aging (CCHS). 2009.

  56. 56.

    Hamilton seniors isolation impact plan (HSIIP). Project Overview.

  57. 57.

    Purdie FR, Honigman B, Rosen P. The chronic emergency department patient. Ann Emerg Med. 1981;10:298–301.

    CAS  Article  Google Scholar 

  58. 58.

    Padgett DK, Brodsky B. Psychosocial factors influencing non-urgent use of the emergency room: a review of the literature and recommendations for research and improved service delivery. Soc Sci Med 1982. 1992;35:1189–97.

    CAS  Google Scholar 

  59. 59.

    Cornwell EY, Waite LJ. Measuring social isolation among older adults using multiple indicators from the NSHAP study. J Gerontol B Psychol Sci Soc Sci. 2009;64B(Supplement 1):i38–46.

    Article  Google Scholar 

  60. 60.

    Statistics Canada. Families, households and marital status: key results from the 2016 census. 2016.

    Google Scholar 

  61. 61.

    Carret ML, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res. 2007;7.

  62. 62.

    Seguin J, Osmanlliu E, Zhang X, Clavel V, Eisman H, Rodrigues R, et al. Frequent users of the pediatric emergency department. CJEM. 2017;20(3):1–8.

    Article  Google Scholar 

  63. 63.

    Keefe J, Andrew M, Fancey P, Hall M. A profile of social isolation in Canada: final report. Mount saint Vincent University; 2006.

    Google Scholar 

  64. 64.

    Nicholson NR. A review of social isolation: an important but Underassessed condition in older adults. J Prim Prev. 2012;33:137–52.

    Article  Google Scholar 

  65. 65.

    Stewart M, Reutter L, Makwarimba E, Veenstra G, Love R, Raphael D. Left out: perspectives on social exclusion and inclusion across income groups. Health Sociol Rev. 2008;17:78–94.

    Article  Google Scholar 

  66. 66.

    Statistics Canada. Household food insecurity in Canada statistics and graphics (2011 to 2012). 2012.

    Google Scholar 

  67. 67.

    Statistics Canada. Towards a poverty reduction strategy - a backgrounder on poverty in Canada. 2016.

    Google Scholar 

  68. 68.

    Loignon C, Hudon C, Goulet É, Boyer S, De Laat M, Fournier N, et al. Perceived barriers to healthcare for persons living in poverty in Quebec, Canada: the EQUIhealThY project. Int J Equity Health. 2015;14:4.

    Article  Google Scholar 

  69. 69.

    McCusker J, Healey E, Bellavance F, Connolly B. Predictors of repeat emergency department visits by elders. Acad Emerg Med. 1997;4:581–8.

    CAS  Article  Google Scholar 

  70. 70.

    Salvi F, Morichi V, Grilli A, Giorgi R, De Tommaso G, Dessì-Fulgheri P. The elderly in the emergency department: a critical review of problems and solutions. Intern Emerg Med. 2007;2:292–301.

    CAS  Article  Google Scholar 

  71. 71.

    Brokaw J, Olson L, Fullerton L, Tandberg D, Sklar D. Repeated ambulance use by patients with acute alcohol intoxication, seizure disorder, and respiratory illness. Am J Emerg Med. 1998;16:141–4.

    CAS  Article  Google Scholar 

  72. 72.

    Chi CH, Lee HL, Wang SM, Tsai LM. Characteristics of repeated ambulance use in an urban emergency medical service system. J Formos Med Assoc Taiwan Yi Zhi. 2001;100:14–9.

    CAS  PubMed  Google Scholar 

  73. 73.

    Statistics Canada. Labour force survey: labour market report, November 2017. 2017.

    Google Scholar 

  74. 74.

    Lindstrom B. Salutogenesis. J Epidemiol Community Health. 2005;59:440–2.

  75. 75.

    Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int. 1996;11:11–8.

    Article  Google Scholar 

  76. 76.

    Antonovsky A. Unraveling the mystery of health: how people manage stress and stay well. 1st ed. San Francisco: Jossey-Bass; 1987.

    Google Scholar 

  77. 77.

    Cockrell KR. Exploring rural paramedics’ capacity for utilising a salutogenic approach to healthcare delivery; 2018.

    Google Scholar 

  78. 78.

    Cockrell KR. Exploration of rural paramedics’ capacity for utilising a salutogenic approach to health care delivery: a mixed methods study; 2017.

    Google Scholar 

  79. 79.

    Shih T-H, Fan X. Comparing response rates in e-mail and paper surveys: a meta-analysis. Educ Res Rev. 2009;4:26–40.

    Article  Google Scholar 

  80. 80.

    Brydges M, Denton M, Agarwal G. The CHAP-EMS health promotion program: a qualitative study on participants’ views of the role of paramedics. BMC Health Serv Res. 2016;16.

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We acknowledge Hamilton Paramedic Services for their cooperation and assistance.



Availability of data and materials

The datasets used and/or analysed during the current study are not publicly available to protect participants’ identifying information, but are available from the corresponding author on reasonable request.

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All authors have approved the final article. GA: Coordinated and led all aspects of the study including conception and design, data collection, data analysis and manuscript writing. JL: Conducted data analysis and drafting and revising the manuscript. BM: Data collection. SM: Data collection. MH: Data collection. KC: Data collection. RA: Conception and design of study and data collection.

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Correspondence to Gina Agarwal.

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The authors declare that they have no competing interests.

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Agarwal, G., Lee, J., McLeod, B. et al. Social factors in frequent callers: a description of isolation, poverty and quality of life in those calling emergency medical services frequently. BMC Public Health 19, 684 (2019).

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  • Health services
  • Emergency medical services
  • Frequent callers
  • Social factors
  • Poverty
  • Quality of life
  • Social isolation