Welcome to the Homelessness and Health learning module! You are here because you are passionate about working with populations experiencing marginalization, are dissatisfied with the inequities that exist in our healthcare system, and/or as future physicians you need to learn more about people who experience homelessness and their health. Whatever the case, you have come to the right place. To help you get started, we have outlined below the module learning objectives, the layout of the module, and the instructions on how to complete the module.
Objectives – those who complete this module will be able to:
1. Describe the various types of homelessness and risk factors associated with becoming homeless.
2. Discuss the relationship between homelessness and health status, including mental and physical health considerations particularly relevant for this population.
3. Identify challenges that can be experienced by people experiencing homelessness including barriers to accessing healthcare, adhering to treatment plans, and challenges specific to the Winnipeg context.
4.Summarize challenges that physicians may encounter when providing care to people experiencing homelessness, and actions physicians can take to provide appropriate and effective healthcare to this group (e.g., modified treatment plans, harm reduction, advocacy).
The learning module contains three chapters:
- Chapter 1 – Homelessness in Winnipeg
- Chapter 2 – Health and Homelessness
- Chapter 3 – Caring for the Homeless
Each chapter is presented in the following format:
- Preface – What you can expect from the chapter.
- Learning objectives – The priority content you should take away from the chapter.
- Introductory video (Note: most videos are optional!) – Our narrator will take us through her journey as a person experiencing homelessness. The content of the introductory video will be related to topics and issues covered in the chapter content. Most of the videos are designated as optional viewing. However, several videos are required viewing and may be tested on your exam; this will be indicated in the description located near the video.
- Content – The bulk of the content will be presented as text, graphs, tables, and pictures. References can be found in the final section (Epilogue & References), and are organized by chapter.
- Conclusion video (Note: most videos are optional!) – Our narrator will continue her story of her time spent on the streets. The content of the conclusion video will be related to topics and issues covered in the chapter content and will help transition to the next chapter. Again, some issues in the video may not be covered in the chapter content, and vice versa.
Lastly, although this module profiles homelessness in Winnipeg, Canada, the statistics presented can be replaced with those of any city, and the ideas and lessons can be adapted to your local setting. This module was adapted from a medical student project and we want to thank the original authors, Golden Gao, Alyssa Kim and Alisha Zacharias, for their excellent work. We hope you enjoy your learning experience and, more importantly, become inspired to take action in improving the healthcare of marginalized populations!
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
CHAPTER 1 | HOMELESSNESS IN WINNIPEG
Trends, Statistics and Demographics
Statistics and demographic information on the homeless population are explored in Chapter 1. To complement this, data pertaining to risk factors that may contribute towards a person becoming (and remaining) homeless are included. Shelter and service use patterns of people experiencing homelessness are also investigated to provide a better picture of the homeless population residing in Winnipeg. This chapter intends to give readers a more comprehensive understanding of who makes up the homeless population in Winnipeg. After all, as future healthcare professionals, it is important to possess knowledge of the different types of populations with whom we will work. Individuals who are marginalized often face complex health problems which can be better understood and treated by healthcare workers who understand their personal, social, and economic contexts. However, each individual is unique, and the facts that we have gathered here may not always apply in every situation or with every individual experiencing homelessness.
Required video: Meet Pam Young. She spent 19 and a half years living in the Downtown East side of Vancouver and is currently working for Unlocking the Gates Peer Mentor Program. Here is what Pam has to say about her initial struggles after she left home and before becoming homeless.
Required viewing: please watch this video to introduce Pam’s story.
Trends in Homelessness
“Homeless” is an umbrella term used to describe several different types of living situations. The 2013 State of Homelessness in Canada report includes a typology to describe four different housing circumstances that could fall under the term “homeless” (#1-3) or are associated with homelessness (#4) (Gaetz, Donaldson, Richter, & Gulliver, 2013).
1. UNSHELTERED, living on the streets and/or in places not intended for human habitation (such as public/private spaces without permission, in cars, abandoned buildings).
2. EMERGENCY SHELTERED, including those staying in overnight shelters for people who are homeless, and shelters for people impacted by family violence or natural disaster (such as flood, fire).
3. PROVISIONALLY ACCOMMODATED, those whose accommodation is temporary and/or lacks security of tenure. This includes people in interim or transitional housing, living temporarily with others (couch surfing), accessing short term, temporary accommodation (motels), and people living in institutional contexts (hospital, prison) without permanent housing arrangements.
4. AT RISK OF HOMELESSNESS, people who are not homeless, but whose current economic and/or housing situation is precarious or does not meet public health and safety standards. Often, individuals at risk of homelessness are not included in homeless counts – however, due to fluid and often quickly shifting housing circumstances, it should be noted that someone may oscillate between “at risk of homelessness” and a form of homelessness outlined in #1-3 above.
According to the Winnipeg Street Census (Brandon et al., 2018), there are 1,519 persons experiencing some level of homelessness in Winnipeg (13.4% unsheltered, 25.8% emergency sheltered, 58.9% provisionally accommodated). This can be compared to a City of Vancouver report that found there were 1,600 homeless persons residing in Vancouver (Eberle Planning and Research, 2013). It is important to highlight that these numbers are merely snapshots of homelessness in the cities of Winnipeg and Vancouver and therefore may underestimate the true number of homeless persons. Estimates are based on data that is collected within a 24-hour period by volunteers who perform counts at emergency shelters, transitional housing, bottle depots, community agencies, and safe houses in the region. As a result, it is easy to miss homeless individuals who were not occupying the pre-determined areas within the specified 24-hour period (particularly individuals who are not accessing services). The following graph depicts the distribution of the homeless population in Vancouver between 2005 and 2013. These multi-year data are not currently available for Winnipeg.
Demographic Information on the Homeless
According to the Winnipeg Street Census (Brandon et al., 2018), it is estimated that the majority of people experiencing homelessness in Winnipeg are male (65.4%). However, the number of homeless women may be underestimated since they tend to stay with others as a means of preventing homelessness (Eberle Planning and Research, 2013). In the 2018 Winnipeg Street Census, 1.6% of participants identified as other gender identities and the median age of people experiencing homelessness was 39; Three years earlier (Maes Nino et al., 2015), it was found that women experiencing homelessness in Winnipeg were younger on average than their male counterparts. In that same census data, just over one quarter of homeless persons were under the age of 30.
Indigenous people make up 11% of Winnipeg’s overall population. However, 61.2% of respondents in the 2018 Winnipeg Street Census identified as Indigenous, making this group significantly over-represented among people experiencing homelessness (Brandon et al., 2018). The 2013 State of Homelessness in Canada report describes that the historical and ongoing experiences of colonialism (resulting in intergenerational trauma, poverty, and racism) contributes towards limited housing opportunities and greater risk of homelessness for Indigenous people (Gaetz et al., 2013). In the 2015 Winnipeg Street Census report, half of the First Nations respondents in the Winnipeg Street Census indicated that they grew up in a First Nations community (Maes Nino et al., 2015).
Obtaining government assistance can be very challenging for homeless individuals due to their lack of physical address, difficulty obtaining legal identification (leading to challenges opening bank accounts, cashing cheques, accessing food banks, accessing healthcare) and inability to receive mail. In 2015, 35% of people experiencing homelessness in Winnipeg relied on income assistance as their main source of income (Maes Nino et al., 2015). Other sources of income might include informal employment (such as collecting scrap metal, panhandling, sex work), disability assistance, formal employment, and financial support from family/friends.
Respondents who participated in the 2011 Winnipeg Street Health Report (n=300) described challenges in navigating income assistance systems. Thirty percent of respondents receiving income assistance had experienced their income being cut off without notice. One third of respondents believed they should be eligible for disability financial assistance but were not receiving it. The most common reason participants cited for being turned down for disability assistance was not providing sufficient, or properly documented, medical information for their application (Gessler & Maes, 2011).
Homelessness Risk Factors
“[She] found out she was adopted at age 13 and likely had FASD. She started using alcohol to cope and her adopted parentscouldn’t cope with her struggles and evicted her. She’s had lifelong addictions challenges and periods of homelessnesssince she was 13.”
“I spoke with a man in his late 50s who first became homeless at age 12 when his parents abandoned him. He has been homeless about 30 years in total… He stays outdoors because he does not trust shelters, but has been badly hurt and beat up on the streets.”
Quotes from data collectors from the Winnipeg Street Census 2015 (Maes Nino et al., 2015, p.8 & 15).
The 2013 State of Homelessness Canada report describes that “many Canadians are at risk of homelessness. Risk factors include poverty, personal crises, discrimination, a lack of affordable housing, insecurity of tenure and/or the inappropriateness of their current housing” (Gaetz et al., 2013, p.16).
According to the British Columbia Health of the Homeless Survey Report (Krausz & Schutz, 2011), 85% of participants experiencing homelessness reported previous childhood experiences of emotional, physical, or sexual abuse (n=484). Other studies with similar findings have cited that homeless individuals have often experienced households characterized by significant abuse and neglect (Whitbeck & Simmons, 1993). As well, the National Homeless Initiative reported an increase in the number of homeless individuals who have a history of involvement in the child welfare system (Serge, Eberle, Goldberg, Sullivan & Dudding, 2002). This was primarily due to significant gaps in our current system where youth involved in child welfare face many obstacles, such as the inability to access protection services beyond the age of 16. Evidence from the 2015 Winnipeg Street Census demonstrates that Winnipeg also reflects these trends; almost half of all survey respondents reported having been in foster care or group homes. The large discrepancy in the experiences of Indigenous and non-Indigenous respondents in Winnipeg is particularly notable (see table below).
“We met a group of youth who had been homeless since beingdisplaced from their homes and in group homes. They said thesystem has failed them.”
“He told his story simply even though it was filled with tragedy. From the 60’s scoop, residential school, foster homes until CFS said ‘good-bye’ at age 18, when he first became homeless.”
Quotes from data collectors from the 2015 Winnipeg Street Census (Maes Nino et al., 2015, p.11 & 15).
Homophobia from others was also found to increase the likelihood of an individual becoming homeless, with lesbian, gay, bisexual, transgender and queer (LGBTQ) individuals representing 11% of all homeless participants, and 23% of homeless youth in the 2015 Winnipeg Street Census. Many members of the LGBTQ community face discrimination and hostility from family members and/or peers, and some are forced to leave home. Without adequate support systems or resources, these individuals may eventually end up living on the street (de Castell & Jenson, 2002).
Although poverty is typically reported as the primary reason for homelessness, the 2015 Winnipeg Street Census found that family conflict/violence was cited by 40% of respondents as the reason for their first experience of homelessness. Addiction was also cited as a major cause at 15% while other medical or mental health issues contributed an additional 10% (Maes Nino et al., 2015, p.16).
“A common struggle was the inability to find a home because of lack of income, and people were unable to work because of a physical disability or a health condition. One gentleman worked as a labourer for over 30 years when he injured his shoulder and was unable to work. He found himself homeless.”
Quote from data collector from the 2015 Winnipeg Street Census (Maes Nino et al., p.14).
While not the #1 cause, the 2015 Winnipeg Street Census indicated that poverty (“economic/ financial problems”) is a major cause of homelessness and one of the top 3 causes of first instance of homelessness in Winnipeg. Similarly, 39% of participants in the Winnipeg Street Health Report indicated that “economic reasons” were one of the top two reasons they first became homeless (followed by eviction 30% and drug/alcohol use 25%). In both of these reports, when survey participants were asked about barriers to attaining housing after an initial experience of homelessness, lack of income was reported as the number one barrier (Maes Nino et al., 2015; Gessler & Maes, 2011).
For many individuals, circumstances contributing to homelessness are complex and due to a combination of risk factors. Therefore in order to reduce homelessness, it is necessary to address multiple potential underlying factors and provide adequate resources to support both individuals at risk of homelessness and individuals already experiencing homelessness. It is also essential that individuals affected by homelessness provide leadership in developing sustainable and effective solutions to homelessness.
Shelter and Service Use Patterns
As previously described, not all individuals experiencing homelessness live “unsheltered” on the streets. Shelters, community health centres, rooming houses, and single-room occupancy hotels exist across Canada as housing options. People experiencing homelessness can be differentiated as unsheltered, emergency sheltered, or provisionally accommodated. Individuals who are “unsheltered” and “emergency sheltered” can also be described as experiencing “absolute homelessness” as reflected in the data from the 2018 Winnipeg Street Census below.
Surveys from Vancouver found that many homeless individuals did not stay in shelters because they had a friend or family they could stay with, or they simply disliked shelters. The following were cited as reasons for disliking shelters: a “preference to be alone, having a better location to sleep, and finding shelters unsafe or unhygienic”. Other reasons, such as “bed bugs, lack of trust, and concern for pets or inability to take them into shelters, wanting to stay with a partner or child, and being banned from a shelter for a variety of reasons” were also cited in the survey (Sundberg & Papadionissiou, 2012, p.33).
Furthermore, for individuals who are residential school survivors, institutionalized settings such as shelters may have traumatic associations. A data collector from the Winnipeg Street Census described that one of the respondents had tried to access a shelter in the city, “…but it reminded him of residential school. The set-up of the beds looked the same as the beds in the schools” (Maes Nino et al., 2015, p.11).
However, contrary to what may be a common belief, an individual who spends most of their time in a shelter may not be better off than people living unsheltered on the streets (Palepu, Hubley, Russell, Gadermann & Chinni, 2012). For instance, an ambitious multi-site prospective cohort study of homeless and marginally housed individuals in Vancouver, Toronto, and Ottawa found that the proportion of individuals with zero, one, or two chronic health conditions was higher amongst the homeless, but the proportion of individuals with two or ≥ three chronic health conditions was higher amongst the marginally housed. Similarly, the proportion of individuals diagnosed with mental health problems was greater in the marginally housed population.In the end, it seems that individuals experiencing homelessness often have poor overall health, regardless of their specific housing status (Hwang et al., 2011).
In a focus group study involving participants from Toronto, Ottawa, Montreal, and Vancouver, it was found that while individuals in shelters were thankful to be off the streets, they did not necessarily feel that their quality of life improved. The participants found the shelters to be too restrictive, often barring visitors and contact with people outside of the shelter systems thus contributing to social isolation. Though those in shelters were fed more consistently, obtaining proper nutrition still proved to be difficult. Many sheltered homeless individuals complained about lack of protein, vegetables, and general variety in their diet (Palepu et al., 2012).
Challenges Faced by Women and Families
Statistics on homelessness consistently show that women experiencing homelessness are more likely to find provisional accommodation rather than residing outdoors or in emergency shelters. Safety concerns for women are a common reason that women will avoid a shelter setting (Gessler & Maes, 2011). Furthermore, the inability of most homeless shelters to accommodate pets can also prove to be a disincentive to access services. It is not uncommon for women to remain in situations of domestic violence due to a fear of leaving their animal behind due to no-pet shelter policies (Schnurr, 2016).
Families with children also face major barriers when seeking services. Parents experiencing homelessness will rarely report that they have children with them and are often too scared to ask for support or to access services out of fear of losing their children to Child and Family Services (Maes Nino et al., 2015). In the 2015 Winnipeg Street Census, 121 dependent children were identified as staying with a parent/guardian experiencing homelessness; no dependent children were identified as staying with a parent/guardian who is currently unsheltered (Maes Nino et al., 2015). However, it is likely this is underreported.
Challenges Faced by Homeless Youth
A number of studies and articles have been published on youth living on the streets – a population often characterized as emotionally and physically vulnerable. Homeless youth are an important subset of the population to consider in the context of homelessness. From a health perspective, the likelihood of health deterioration among homeless youth increases with time spent on the streets, translating into worse health outcomes and more health resources that need to be spent on preventable illnesses or diseases.
Local non-profit agency Resource Assistance for Youth (RaY) extracted the youth-related data from the 2015 Winnipeg Street Census (n=371); “youth” is defined as individuals under 30 years old. Contrary to the gender distribution of the overall homeless population in Winnipeg, 48% of youth respondents experiencing homelessness in the Winnipeg Street Census identified as female (Godoy, 2016). Half of the youth respondents to the 2015 Winnipeg Street Census indicated experiencing homelessness at least 3 times in the past 3 years (Godoy, 2016). The following excerpt from the Youth Homelessness in Winnipeg Infographic (Godoy, 2016) indicates where youth respondents to the 2015 Winnipeg Street Census described staying, and also the possible limitations to this information:
Various reports and studies demonstrate that youth experiencing homelessness face a number of challenges that can impact their physical and emotional well-being. For example, homeless teenagers must deal with stresses related to their survival. According to Krammer and Schmidt as cited in Kufeldt & Burrows (1994), youth experiencing homelessness have to scavenge for food, determine a means of supporting themselves financially, and face ongoing worry about where they will next sleep or eat. Youth experiencing homelessness may also struggle with substance use disorders, such as those related to drugs and alcohol, and their associated consequences. As well, youth experiencing homelessness can also face problems related to health and trouble with the law, including issues related to substance use, theft, or violence. Youth are at a particularly high risk of becoming victims of crime and abuse (Kufeldt & Burrows, 1994).
In some cases, youth experiencing homelessness may lack the education skills and/or credentials that would assist them in finding jobs (Dachner & Tarasuk, 2002). In addition, many of the jobs youth are able to obtain are characterized by poor wages and menial labour (Kelly & Caputo, 2007).
Winnipeg’s Homelessness & Housing Challenge
There are a number of factors which contribute towards homelessness in Winnipeg, including the rising cost of housing, problems related to addiction and mental health, decreases in housing stocks, and few inflation increases for people on fixed incomes.
Although Winnipeg has lower housing costs than some other Canadian cities, it unfortunately has one of the lowest rental vacancy rates at ~1% (Distasio, Sareen & Isaak, 2014). A balanced rental market, on the other hand, has a vacancy rate between 3-4% (Goering et al., 2014). Indeed, 37% of the participants in the 2015 Winnipeg Street Census indicated that Winnipeg’s lack of affordable housing was their main barrier to finding a home.
Measures of affordability often compare the ratio of housing costs to an individual’s income (Thomson, 2012). According to the Canada Mortgage and Housing Corporation (CMHC), “a household should not spend more than 30 percent of its gross income on rental shelter costs” (CMHC, 2002, p.4). Unfortunately, approximately 67% “of recent low-income immigrants and newcomers live in unaffordable housing, using more than 30% of their gross household income” on housing alone (Fenton, 2010). Furthermore, approximately 40% of Winnipeg’s rental properties are located within the inner city; often these properties are older and in need of significant repair (Distasio, Sareen & Isaak, 2014). Lastly, long wait lists resulting from very low vacancy rates have allowed landlords to be increasingly selective when reviewing applications for tenancy. Individuals who are experiencing homelessness may experience discrimination and/or negative stereotypes as a result of their housing status (Goering et al., 2014).
Optional Video: Let’s hear a little bit more about Pam’s experiences living on the streets, as well as challenges she may have faced in the context of housing.
This video is optional to view.
CHAPTER 2 | HEALTH & HOMELESSNESS
It is not surprising to find that homelessness is linked to poor health. Not only is the physical environment, including housing, one of the social determinants of health, but homeless individuals are almost always affected by other social determinants of health, such as income insecurity, unemployment, food insecurity, social exclusion, and many more (Mikkonen & Raphael, 2010). As discussed in Chapter 1, individual risk factors directly contribute towards poor health and homelessness (arrows A and D, please refer to the picture below); similarly, societal factors can also directly impact homelessness (arrow B) (Frankish, Hwang & Quantz, 2005). Furthermore, health and homelessness are invariably linked as health may cause or perpetuate homelessness (arrow C), and homelessness also leads to poor health (arrow E) (Frankish, Hwang & Quantz, 2005). In this chapter, we will attempt to paint a clear picture of the intricacies of the connections formed by arrows C and E.
1. Describe the physical and mental health considerations that may be particularly relevant to people experiencing homelessness.
2. Discuss the relationship between homelessness and health status.
Optional video: In this clip, Pam describes some of the health issues she faced while living in the Downtown Eastside of Vancouver.
This video is optional to view.
Health of the Homeless
As part of the 2015 Winnipeg Street Census, participants were asked about their service needs. Note that the question did not ask which conditions/diagnoses the individual has, but rather what types of services/supports participants required. One-third of participants surveyed indicated they need services for an addiction. One-quarter stated they required services for a mental health condition, approximately 20% for chronic medical conditions, and another 20% for a physical disability (Maes Nino et al., 2015).
In Vancouver, a more comprehensive survey was completed (Sundberg & Papadionissiou, 2012). Participants were asked whether they had one or more addiction, medical condition, physical condition, and mental illness. The majority of participants (62%) had multiple illnesses, while about 38% reported only one illness; only 3 participants (0.3%) responded with no illness. Interestingly, a higher proportion of sheltered individuals reported multiple illnesses, while the majority of unsheltered individuals reported only one illness. Overall, results indicated that the prevalence of addiction was the highest amongst all types of homelessness surveyed, especially among the unsheltered population in comparison to the sheltered population. The two tables below summarize the results.
When comparing findings from the Vancouver homeless count to previous reports, some very disconcerting trends can be observed: 1) The proportion of participants reporting one illness increased significantly from 2008 to 2011 (27% to 38%); 2) The proportion of participants reporting more than one illness increased dramatically between 2005 and 2011 (35% to 62%); and 3) The proportion of participants in good health with no illness decreased dramatically from 2008 to 2011 (28% to 0.3%) (Sundberg & Papadionissiou, 2012).
Additional questions pertaining to social isolation and access to food were included in the health section of the survey. Overall, the homeless population was found to be very isolated, with 75% of the respondents found to be alone on the day of the count. Notably, sheltered individuals were more likely to be alone than unsheltered individuals. As for food, it was found that the sheltered homeless were more likely to have had a good meal recently than the unsheltered homeless. It should be noted that despite these findings, food and nutrition were of great concern to all homeless individuals surveyed (Sundberg & Papadionissiou, 2012).
For some individuals experiencing homelessness, the experience of staying in a shelter, or accessing community resources, may provide very important opportunities for social interaction. One data collector from the Winnipeg Street Census described a respondent sharing that”…having his own place means he would live alone – he talked a while about how lonely that would be.” (Maes Nino et al., 2015, p.11)
A smaller study in Winnipeg echoes the findings from Vancouver. The Winnipeg Street Health Report personnel (Gessler & Maes, 2011) interviewed 300 people experiencing homelessness. Twenty eight percent of respondents described rarely or never having someone to listen to them when they need it, and 39% identified as feeling very lonely. Further exacerbating feelings of social isolation and social marginalization, 71% of respondents described that they do not participate in any social or recreational activities.
According to the results, individuals experiencing homelessness in both Winnipeg and Vancouver may encounter multiple health challenges and, according to the Vancouver data, health outcomes for people experiencing homelessness have been declining within the past decade. We will now explore the social causal agents behind many of these observations in more detail.
Acute & Chronic Illnesses
To begin, the living conditions of the unsheltered homeless are ripe for disease and infection. People experiencing homelessness are disproportionately affected by respiratory disorders, such as tuberculosis, due to living conditions that increase chances of transmission, including crowding, large transient populations, and inadequate ventilation (Hwang, 2001). People experiencing homelessness have an increased susceptibility to skin and foot disorders, such as cellulitis, impetigo, venous stasis disease, scabies, and body lice. Inadequate footwear, long periods of walking and standing, as well as minor traumas repetitive in nature correlate to foot disorders such as onychomycosis, tinea pedis, corns, and callouses (Hwang, 2001). Prolonged exposure to moisture, and exposure to extreme cold such as Winnipeg winters, can also contribute to foot and skin disorders/injury. Diabetes can also play a significant role in foot disorders, particularly if the individual experiences food insecurity which impacts diabetes management. The following table summarizes some of the results of the Winnipeg Street Health Report (Gessler & Maes, 2011) in comparison to the general population (n=300).
In addition to acute illnesses, chronic conditions – often multiple – affect a significant proportion of people experiencing homelessness. Medical problems that are prevalent among the homeless population include seizures, chronic obstructive pulmonary disease, arthritis, and other musculoskeletal disorders (Frankish, Hwang & Quantz, 2005). Additional chronic conditions such as hypertension, diabetes, and anemia are generally poorly managed and can be exacerbated by late diagnoses (Frankish, Hwang & Quantz, 2005). Oral hygiene and dental health is also often poor. Of the participants in the Winnipeg Street Heath Report (Gessler & Maes, 2011), 51% rated their dental health as “poor” or “fair”; 43% had not seen a dentist in over 2 years, and 26% had not seen a dentist in more than 5 years. Overall, the experience of homelessness can reduce a person’s life from between 7-10 years (Hwang et al., 2009)
The health of homeless individuals is further endangered by heightened risk of violence and/or exploitation. Individuals involved in sex work may experience adverse outcomes as a result of power imbalances, such as violence, sexual assault, and theft. Individuals experiencing homelessness may not have sufficient access to safe sex or safe drug use supplies; this may result in increased rates of sexually transmitted infections (STIs), unplanned pregnancies, and blood borne infections (Frankish, Hwang & Quantz, 2005).
The Winnipeg Regional Health Authority operates Street Connections, a mobile public health service that aims to reduce the spread of sexually-transmitted and blood-borne infections (STBBIs), including hepatitis C and HIV, and reduce other drug-related harms. Service provision from a mobile vehicle allows resources and health services (including harm reduction supplies) to be provided to individuals in Winnipeg that, for a variety of reasons, may not be accessing health care services.
In general, people experiencing homelessness are more affected by violence than people who are housed. According to a survey conducted in Toronto, when compared to the general population, homeless individuals were at a greater risk of being assaulted, and homeless women had an increased risk of being raped. As well, homeless men were nine times more likely to be murdered in comparison to the general population (Hwang, 2001).
Mental Illness & Substance Use Disorder
The relationship between mental health and substance use disorder has been demonstrated in a number of studies. For instance, in a longitudinal study involving a cohort of homeless individuals who experience addiction and substance use disorder, it was found that drug use, older age, younger age of first onset of homelessness, and the presence of dependents/co-dependents were all independently associated with higher levels of mental health symptoms (Palepu et al., 2013). In the same study, the top-five most used drugs – marijuana, crack cocaine, alcohol, heroin, and amphetamines – were shown to impact health negatively, thereby exacerbating mental illnesses that may already exist amongst the people experiencing homelessness.
Of the participants in the Winnipeg Street Census (Maes Nino et al., 2015) who expressed a need for either addiction and/or mental health services, the following tables outline the distribution of types of services respondents desire to access:
Not only can substance use disorder be associated with mental illness, but experiencing homelessness can be a direct risk factor for substance use disorder. According to a prospective cohort study of street-involved youth in Vancouver, homelessness was independently associated with injection drug use initiation, even after adjusting for sociodemographic factors and other drug use behaviours (Feng, DeBeck, Kerr, Mathias, Montaner & Wood, 2013). Given the interconnectedness of these issues, to begin to address homelessness, it is highly important to address the underlying root causes and risk factors associated with mental health and substance use within the homeless population.
Some individuals who experience homelessness and have a substance use disorder spend the majority of their time with symptoms of craving and compulsion in order to get their drug of choice and experience the elusive ‘fix.’ One individual experiencing homelessness sums it up plainly:‘Sometimes living in chaos is easier… better the devil you know…’(Palepu et al., 2012).
It is important to consider that many individuals who experience homelessness may have experienced traumatic events. For example, almost half of the participants in Winnipeg’s At Home/Chez Soi Housing First project had 10 or more exposures to traumatic events over their lifetime (Distasio, Sareen & Isaak, 2014). Approximately 42% of Winnipeg At Home/Chez Soi participants had a parent/grandparent who attended Residential School; 11% attended residential school themselves (Goering et al., 2014, p.16). Experiences of trauma combined with lack of mental health resources, and paired with long periods of unoccupied time and/or social isolation, may contribute to use of substances in order to deal with/distract from unresolved trauma. Twenty-one percent of the respondents to the Winnipeg Street Health Report reported spending 3 or more hours each day walking to different places and waiting in line for food. Thirty-two percent of these same respondents said “they would have no one to talk to or help them if they were to have an emotional crisis that they could not handle on their own” (Gessler & Maes, 2011, p. 17).
Now that we have looked at some of the health needs of people who experience homelessness, you must wonder: can anything help? Can shelters alleviate some of these health conditions? What about healthcare services?
So what does all this mean? In the end, all that we have talked about leads us back to the diagram discussed at the beginning of this chapter. While a complex and multi-faceted relationship between homelessness and health exists, both factors impact an individual’s quality of life. Consequently, it is not surprising that people experiencing homelessness have significantly higher mortality rates, even when compared with individuals who have homes, but are in the lowest fifth of the income bracket (Hwang et al., 2009). In a decade-long, nation-wide study, it was found that the probability of survival to age 75 for the homeless was only 32% for men and 60% for women. Compared to similarly poor but housed individuals, people experiencing homelessness were much more likely to die of drug-related incidents, alcohol-related incidents, mental health problems, and suicide (Hwang et al., 2009). In the next chapter, we will explore in more detail the delivery of healthcare services to the homeless and how we can potentially change some of these statistics for the better.
Optional video: We will end by listening to Pam’s view on health and homelessness.
Optional to view this video.
CHAPTER 3 | CARING FOR THE HOMELESS
This chapter will explore the barriers many homeless individuals face when trying to access healthcare. It will also investigate challenges experienced by physicians and will conclude with actions healthcare providers and future healthcare providers can take in order to improve the health and well-being of Canada’s homeless population.
1. Identify barriers individuals who are experiencing homelessness may face when trying to access the healthcare services.
2. List challenges that physicians might encounter when providing care to people experiencing homelessness.
3. Describe actions that physicians could take in order to provide appropriate and effective healthcare to people experiencing homelessness.
Required video (may be tested on exam):
Here, Pam continues her story by describing a negative and a positive experience with the healthcare system.
This video is required viewing.
Barriers in Accessing Healthcare Services
As discussed in the previous chapter, people experiencing homelessness often experience a disproportionate burden of disease compared to the general population, including a high prevalence of chronic physical and mental illness, mortality, substance use harms and violence (Palepu et al., 2013). To further compound this high disease prevalence, due to a variety of barriers, individuals experiencing homelessness may be unable to access and maintain a continuum of healthcare within our current system, which has subsequently led to unmet healthcare needs. Barriers to accessing healthcare include: lack of a family doctor, not having a health card, lack of knowledge of where to seek proper care, inability to pay for prescription medications and/or required documentation (such as requesting a form to be filled out by a doctor regarding disability benefits, forms for a special diet, etc.), transportation challenges, shortage in appropriate programs and treatment options (or, programs existing but in a far geographic location), lack of access to calendars/clocks, and competing priorities (e.g. finding shelter and food) (Khandor & Mason, 2007; Khandor et al., 2011). Furthermore, systemic barriers – racism, in particular – have proven themselves tremendous barriers to accessing healthcare services.
One example of systemic racism resulting in a tragic outcome is the case of Brian Sinclair, an Indigenous man who died in a Winnipeg emergency room in 2008 after waiting to be seen for 34 hours. Mr. Sinclair was seeking health care to change his catheter. In an inquest into Mr. Sinclair’s death, “health-care workers from the hospital said they’d assumed Sinclair was drunk and ‘sleeping it off,’ had been discharged previously and had nowhere to go, or was homeless and had come to avoid the cold” (Geary, 2017). While Mr. Sinclair had experienced eviction in the past, the inquest determined that he was neither intoxicated nor homeless at the time of seeking health services (Dehaas, 2014). The final report of the inquest concluded that Mr. Sinclair’s death was indeed preventable (Geary, 2017). The Brian Sinclair Working Group, a collaboration of Canadian academics and doctors, continue to highlight and interrogate the role of systemic racism in this specific case, and within the larger context of the healthcare system.
Many people who have experienced homelessness have cited negative experiences in healthcare settings as a significant barrier to seeking care. Several studies have found that being labeled and stigmatized due to housing status, being treated with disrespect, and feeling invisible and unwelcomed by healthcare providers are significant barriers which impede seeking care (Wen, Hudak & Hwang, 2007). The following are some of the answers from Toronto survey respondents who were asked about their experiences with healthcare and healthcare providers:
“Once they see that you’re homeless, their attitude goes from caring to ‘get out of here.’” (Khandor & Mason, 2007, p. 42)
“Just the way they talk to you…they look down on you and most of the time they are rude. I’ve stopped going to places because I know they’re how they’re going to react.” (Khandor & Mason, 2007, p. 42)
Challenges Physicians May Face in Providing Adequate Healthcare
There are a number of challenges physicians may face when treating the people experiencing homelessness. People experiencing homelessness may have competing priorities that may come before their health needs, such as maintaining employment so that they can afford housing and food (Gelberg, Gallagher, Andersen & Koegel, 1997). Healthier foods are often inaccessible and unaffordable for people experiencing homelessness; as well, the food served at shelters is often rich in starch, sugar, and fat, making it difficult to sustain a healthy diet. This could impede a physician’s ability to manage illnesses related to diet such as diabetes or hypertension (Hwang & Bugeja, 2000). The large amounts of time spent waiting in line and finding food/shelter mean these individuals also have much less time available to manage their health concerns.
As discussed in Chapter 2, individuals experiencing homelessness may have skin and foot problems related to “inadequate footwear, prolonged exposure to moisture (or cold), long periods of walking and standing, lack of glycemic control and repetitive minor trauma” (Hwang, 2001, p. 230). However, it may be difficult for healthcare professionals to help prevent such disorders when people experiencing homelessness may not have access to shelter (to dry out their feet, maintain foot hygiene) and may not be able to afford adequate socks and shoes/boots. Depending on their individual circumstances, people experiencing homelessness who are dealing with addictions and/or mental health diagnoses may experience challenges with keeping appointments and/or accessing the healthcare system (Hay & Krausz, 2009).
For a variety of reasons, some people experiencing homelessness may experience challenges with lack of adherence to treatment and management plans. In addition to feeling stigmatized by healthcare workers, people experiencing homelessness are often prescribed treatment plans which do not take into account their living situations. Whitney and Glazier (2004) found that medication adherence was influenced at three different stages of the medication-taking process: access to medication, retrieving or retaining medications, and compliance to the treatment regimen.
Access: Barriers that negatively impacted people experiencing homelessness in accessing medication were related to finances and the healthcare system, as well as social isolation (Whitney & Glazier, 2004)
Retrieving/retaining: People experiencing homelessness may experience challenges in retaining medication due to frequently changing locations (and perhaps leaving medication behind at the shelter, the community resource centre, etc.) and/or may be susceptible to having their medication stolen. In some cases, individuals experiencing homelessness may sell their medications to acquire funds to meet other needs (Whitney & Glazier, 2004). Other complications can include lack of access to refrigeration and storage for medications, lack of food security in the event that medications need to be taken with food, and lack of facilities to clean skin prior to injections.
Adherence: Finally, many people experiencing homelessness in the Whitney & Glazier (2004) study did not follow their medication regimen as a result of alcohol and drug dependency, competing priorities to find food/shelter, inability to follow directions (e.g. having to find food to take with the medication, literacy), as well as mental illnesses. In addition, the simple lack of access to a clock can make medication timing very challenging.
Healthcare providers may need to explore alternative treatment (i.e. medications that don’t require high rates of adherence, treatments with fewer daily doses, non-refrigerated options, less expensive options, non-injectable options) for the presenting illness in order to provide more appropriate and effective healthcare.
One study conducted by Mitchell and Selmes (2007) compiled a list of key predictors of non-attendance to psychiatric appointments. Predictors fell into six categories: environmental and demographic factors, patient factors, memory/cognitive problems, information and health beliefs, illness factors, and clinician and referrer factors. Many of these factors are fairly general and therefore may also be relevant to the failure to attend non-psychiatric related appointments. A more comprehensive list of these predictors can be seen below.
There a number of contextual factors that may impact the ability to access healthcare and maintain treatment plans for people experiencing homelessness. However, there are also a number of considerations related to a physician’s practices that can be modified to enhance care for the people experiencing homelessness. These considerations will be expanded upon later in this chapter.
The Cost of Providing Inadequate Healthcare
Due to circumstances such as lack of a family doctor, challenges in accessing the healthcare system, and delayed presentation for medical care (which may result in more serious medical issues), the hospital, notably the emergency room, may be the point of access to health services for people experiencing homelessness. Individuals experiencing homelessness are admitted to the hospital five times more frequently than the general population and typically stay longer in the hospital. Additionally, people experiencing homelessness are much more likely to receive their healthcare from the emergency department, with some cities witnessing up to 54% of their homeless population using the emergency department within the last year (Khandor & Mason, 2007; Trypuc & Robinson, 2009).
The Winnipeg Street Health Report (Gessler & Maes, 2011) specifically asked respondents about their experiences accessing health care (n=300). When asked about the sources of health care used within the past year, 61% of respondents reported seeking care in an emergency room (average 4 visits over the past year), followed by 54.7% reporting seeking care in a walk in clinic (average 8 visits over the past year). The following table outlines the reasons respondents cited for visiting the emergency room in the past year:
Despite the need for medical care, 36% of respondents interviewed for the 2011 Winnipeg Street Health Report left an emergency room before being seen by a healthcare professional. Reasons for leaving without receiving care included waiting too long (48%), negative reception by hospital staff (15%), needing to leave to get to the shelter (which often has a curfew; 7%), and needing to leave to get a meal (7%).
Currently, it is estimated that, as a nation, Canada spends approximately $1.1 billion total or $35,000 per homeless person each year in order to pay for emergency healthcare, emergency shelters, and criminal justice and social services (Trypuc & Robinson, 2009).
Overcoming Challenges & Barriers to Provide Adequate Healthcare
The ability to access to healthcare services is an important social determinant of health. However, even in a universal healthcare system, access to, and continuing to use, these health services are deeply rooted in societal values and constructs (McNeil, Guirguis-Younger, Dilley, Turbull & Hwang, 2013). A recent study explored clinicians’ preparedness to address the complexities of the healthcare needs with their patients experiencing homelessness and found that undergraduate medical training often did not address the social determinants of health within this context. Another study discovered that empathy levels for the homeless decreased significantly as medical school training progressed, which was in part attributed to students’ clinical teachers (Fine, Zhang & Hwang, 2013).
Dr. Gary Bloch is a Canadian physician who has engaged in advocacy regarding poverty as a social determinant of health, and explored how doctors might provide responsive and appropriate care for individuals experiencing poverty. Bloch et al. (2011) conducted a small study with Ontario physicians, and patients experiencing poverty, and identified structural, attitudinal and, among healthcare providers, knowledge barriers that can impact patient care. Regarding healthcare providers, “inflexible practice rules that are difficult for low-income patients to comply with, billing structures that discourage longer appointments, unwelcoming practice environments and a lack of familiarity with the social security system and relevant community-based resources were frequently named as contributing to sub-optimal care for this patient group” (Bloch, Rozmovits & Giambrone, 2011, p.3).
In order for clinicians to better prepare to provide care for people experiencing homelessness, a concerted effort to gain the appropriate skill and knowledge is required. A study conducted by McNeil et al. (2013) identified key steps in this process: (1) knowledge acquisition through engagement with homeless clients in a multitude of settings and contexts; (2) ongoing evaluation and reflection on the effectiveness of healthcare strategies; and (3) adjustment of clinical practice to further enhance their ability to respond to social determinants of health. In addition to physicians actively working to improve their skills, it has been recommended that medical schools strengthen curricula and training around homelessness and health through the incorporation of health screening on issues such as mental health, addictions, and infectious disease (Fine, Zhang & Hwang, 2013).
As health is multi-faceted and not confined to biological processes alone, it is important to find solutions that involve relevant stakeholders in addressing the health needs of the homeless. Not only must physicians alter their practices, they must also collaborate with other professionals to address the unique complex needs of the homeless. One proposed model is that of assertive community treatment (ACT), whereby a multi-disciplinary team works with smaller groups of homeless individuals with mental health concerns in providing the care, management, and support they require. Community-based studies have shown that the ACT model is effective as patient outcomes are improved (Hay & Krausz, 2009). Other studies have emphasized the importance of having mental health specialists, such as psychiatrists, within a team of healthcare providers, as this has been effective in addressing the complex physical and mental needs of the homeless (Stergiopoulos, Dewa, Rouleau, Yoder & Chau, 2008). Programs and approaches such as the one mentioned above, in which the care is tailored towards the needs of the homeless while diminishing potential barriers (e.g. travel), can be effective in delivering comprehensive care to individuals who are homeless.
The following video briefly describes the ACT program in Winnipeg. This video is required viewing.
In addition to having comprehensive, appropriate care delivered and tailored to the homeless population, it is also important to consider harm reduction measures. Initiatives such as needle distribution programs have been shown to reduce infections commonly associated with injection use. For example, research indicates a 38% decline in syringe sharing over the past 15 years in Vancouver’s Downtown Eastside (BC DOAP Report, Chapter 6, 2014). Much of this progress has been made through sterile needle programs such as Insite. Although these programs may not offer a solution to overcoming addiction disorders, they help minimize health risks for those injecting drugs while serving as a contact point for healthcare providers to reach out.
Programs and approaches such as the ones mentioned above, in which care is tailored towards the needs/circumstances of people experiencing homelessness while also working to diminish potential barriers and harms, can be effective in promoting health amongst individuals experiencing homelessness.
So what can you do to overcome these barriers?
1. Start at the Individual Level.
“You might live in a mould-infested basement that’s really the cause of your respiratory illness and the physician might never think to say, “Where are you staying and what’s it like there?…maybe he spends a year giving you medicines that don’t work because the cause of your problem is your crappy housing” (Participant quote from Bloch, Rozmovits & Giambrone, 2011, p. 4)
“I had…an old guy that needed diabetes medicine who lived in a shelter in Toronto…he was elderly and he had mobility issues and he didn’t take any of his diabetic medication because the side-effect that it caused for him was diarrhoea and he was living in a shelter with 60 younger men and two toilets…he had no chance of getting to the toilet if he needed to quickly so he wasn’t going to take his pills.” (Physician quote from Bloch, Rozmovits & Giambrone, 2011, p. 4)
One of the main barriers to adequate healthcare for people experiencing homelessness is healthcare providers. As mentioned previously and discussed in the video, physicians don’t always listen to their patients adequately; this can result in preconceived ideas and/or stereotypes to influence treatment plans. The most important thing to remember is that every patient has their own unique circumstances. Hence, in order to provide adequate healthcare to someone experiencing homelessness, you must take a thorough history while putting biases and stereotypes aside, and work on treatment plans together with the patient. Ask questions about the patient’s social situation and whether they think it is possible to follow drug regimens or make follow up appointments, whether specific drug side effects may be uniquely problematic, etc. If you find yourself working with a person experiencing homelessness, look for opportunities to learn more about your patients.
Check out local organizations, such as harm reduction centres and community resource centres, to understand some of the unique circumstances faced by people experiencing homelessness. This includes: reading up on methadone and suboxone treatment and taking steps toward becoming educated on how to practice anti-racist healthcare (particularly in light of the overrepresentation of Indigenous individuals among Winnipeg’s homeless population).
And lastly, get creative and adjust your typical treatment approaches. Ask colleagues who work with similar populations for advice. Consider working in an interdisciplinary team. Look for alternatives to typical treatment (fewer daily doses, non-refrigerated options etc). Order same-day tests so travel is reduced. Include walk-in options for your patients who face structural barriers. Ensure your clinic provides harm reduction services. Work at a clinic with an onsite lab. Offer food to homeless patients who are seeking emergency care. Look for opportunities to challenge and dismantle systemic racism and discrimination in healthcare against people who experience homelessness.
Ultimately, it is imperative to keep an open-mind and continually fill knowledge gaps you may have in this area. As concluded by Bloch and colleagues, “while poverty as a social determinant of health has traditionally been tackled by public health practitioners and public policy developers…[there exists] the potential ability of individual primary care providers to directly mitigate the effect of poverty as a risk to health by means of enhanced education and alteration of routine practices. This may allow for significant action on poverty as a health risk, while simultaneously working toward higher level systemic changes” (Bloch, Rozmovits & Giambrone, 2011, p. 5).
2. Get Involved with Organizations Tackling this Issue.
Perhaps you’re still at the beginning stages of your healthcare education and are not yet working with marginalized patients on a regular basis. Don’t let that stop you from gaining experience now. Winnipeg has many opportunities for healthcare students to get involved with organizations that work with people experiencing homelessness. This is a fantastic way to get engaged with your community and understand some of the challenges and intricacies of life for people experiencing homelessness. Here are a few of examples of organizations around the province that are working with improving the health and wellness of people experiencing homeless:
Doorways is a community collaboration designed to meet the needs of individuals, families and youth in Winnipeg who are experiencing chronic or episodic homelessness. Doorways provides intake and referral services for youth who are close to aging out of Child & Family Services (CFS) care and have no place to live. Doorways also provides centralized intake and referral to decentralized supports and services, including Winnipeg’s Housing First programs, in support of The Plan to End Homelessness in Winnipeg. For more information check out http://ahwc.ca/doorways-program/.
Siloam Mission is a connecting point between the compassionate and Winnipeg’s less fortunate. Siloam Mission is a Christian humanitarian organization that alleviates hardships and provides opportunities for change for those affected by homelessness including meals, clothing, emergency shelter, training/employment and supportive housing. For more information check out their website at http://www.siloam.com.
Resource Assistance for Youth (RaY) provides prevention, intervention, outreach and support services to youth in Winnipeg who are street-involved and/or homeless. RaY’s mission statement is “to provide youth with what they need, on their terms, to better their lives.” Their programs include meals, clothing, showers, and support with eviction prevention and seeking both transitional and permanent housing. For a complete list of services and programs, please visit: http://rayinc.ca/programsservices/
These are just a few examples; there are many, many more organizations working across Manitoba and Canada to improve the living conditions of people experiencing homelessness. Do a quick Google search to see what organizations are working in your community, or chat with friends who are already involved with this type of volunteering to learn more about how you can get involved.
3. Be an Advocate.
As touched upon previously, the health of people experiencing homelessness is intrinsically tied to the social determinants of health. Many of these determinants can be improved upon. Consider writing to your local mayor, your Member of the Legislative Assembly (MLA), or your Member of Parliament (MP) about what is currently happening on our streets and in our communities. Partner with local organizations trying to tackle this issue and ask them what kind of advocacy work they need, and how you can support the work they are already doing. Advocate for improved medical education on homelessness and health. And lastly, don’t be afraid to educate your family, friends, classmates, and colleagues on this topic.
Optional video: Pam concludes by telling us how she cleaned up, got off the streets, found work, and eventually ended up where she is now.
EPILOGUE & REFERENCES
Optional Video: In the epilogue, Pam describes how she has been able to mend her relationships with her family members.
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