Issuu on Google+

Health and Homelessness In Halifax:

A report on the Health Status of Halifax’ s Homeless Population

2009 1


WARNING! HOMELESSNESS IS HAZARDOUS TO YOUR MENTAL AND PHYSICAL HEALTH. There are many factors that jeopardize the health of homeless people - crime and violence, prolonged standing, excessive outdoor exposure, unsuitable footwear, overcrowding in shelters, risk of being robbed of medication, sleep deprivation, dehydration and malnutrition, and the stress of being without a home to name a few. These factors are all exacerbated by the barriers in access to health care, such as the lack of primary care and discrimination.

Photo Credit: Roger Lemoyne, Front Line

Community Action on Homelessness has produced a DVD to accompany this report. To access a copy of the DVD please contact info@cahhalifax.org To cite this report: Community Action on Homelessness (2009) Health and Homelessness in Halifax: A report on the health status of Halifax’s homeless population; Halifax, NS 2


Acknowledgements This report was prepared by inquire research, in association with Community Action on Homelessness (CAH) and the “Health and Homelessness in Halifax� committee. Without the following people, this report would not have been possible: Committee Members: Claudia Jahn (CAH), John Hartling (CAH), Jean Hughes (Dalhousie University), Sharon Lawlor (North End Community Health Centre), Jann Ticknor (Community Researcher), Peggy MacCormack (NS Department of Health), Patti Melanson (MOSH), Charlene Croft (inquire research) Advisors: Kate Mason (Street Health Toronto), Fred Wendt & Barb Neely (HRM), Christine Saulnier (Canadian Centre for Policy Alternatives), Ted Naylor (inquire research) Volunteer Data Collectors: Tommy Boutlier, Melissa Campbell, Terra Peers, Lorely Gaunt, Swantje Jahn, Joanne Parker, Jann Ticknor, Amber Graveline, Josh Dunn, Carla Conrod, Walt Vienneau, Denise Boulter, Sandra Hennigar, Peggy MacCormack, Anna Tillett, Patti Melanson, Amber White, Mary Ellen Sullivan, Dorothy R Barnard, John Hartling, Laurie Bryson, Claudia Jahn, Stephanie Hunter, Jean Hughes, Vennesa Cazicchi, Leah Feltham, Joy Woolfery, Haley Grandy, Kristina Fifield Data Entry: Laurie Bryson, Charlene Croft, John Hartling, Haley Grandy, Kristina Fifield Video Interviews: Cindy MacIssac (Direction 180), Pam Chisholm (Department of Health), Sam Campbell (QEII), Kathy Boudreau (Mainline) , Mary Pyche (Mental Health Mobile Crisis Unit), John Hartling, Claudia Jahn, Bryon Anderson, John Fraser (North End Community Health Centre), Patti Melanson, Jean Hughes, Jan Davis Video Production: John Hartling, Charlene Croft, Claudia Jahn, Kevin Moyniham, Russell Wyse Photos: Roger Lemoyne, Front Line Health; canstockphoto.com 3


About the Survey The Health and Homelessness survey was conducted between January 13 and January 23, 2009 with the assistance of many community volunteers. Community Action on Homelessness interviewed 158 homeless people in 6 shelters and 4 other locations throughout downtown Halifax about their lives, their health and their access to health care. For the purposes of this survey, homelessness was defined as: having stayed at a shelter; outdoors or in a public space; or with a friend or relative; for 10 or more days in the 90 days prior to being surveyed. Like many other large scale health studies, including the Canadian Community Health Survey, our study relies exclusively on self-report. We believe that our information is credible. However, we understand that some readers may be concerned about its accuracy, given the evidence that certain factors, such as social desirability, often influence self reporting. However, such factors generally come into play under different conditions - when the nature of the information shared by participants determines follow up action. Our study had a very different design. As with the Canadian Community Health Survey, no action resulted from the information shared by participants in our study. In addition, our findings are consistent with those of other health reviews of homeless people in Canada. Therefore, we have no reason to doubt the messages gained from the findings.

Reader’ s Notes Statistics: In some cases, respondents were only allowed to select one answer (the best) - this means that all of the answers combined = 100%. In other cases, respondents were allowed to select all applicable answers - this means that all of the answers combined = more than 100%. There were a variety of contingent questions - this means that some people weren’t even asked a question if they responded “no” to the previous question. All respondents were free to refuse to answer any given question at any given time in the survey and were also given the option of answering “I don’t know”. For this report, unless otherwise specified, “I don’t know” answers were treated as non-answers, and removed from the total. All raw numbers for the percentages presented in this report can be found at http://www.cahhalifax.org in Appendix 3. Where comparisons are made between the Homeless population and the population of Halifax and Nova Scotia: Source for Halifax and NS data: Canadian Community Health Survey, Statistics Canada, Cycle 2007 (unless otherwise indicated). Quotes: The quotes in speech bubbles have been adapted from the open-ended questions and represent the first voice perspective. The quotes which appear in grey boxes have been taken from the Halifax experts interviewed for the Health Report Video.

4


Contents

EXECUTIVE SUMMARY INTRODUCTION ABOUT THE PEOPLE BEING HOMELESS PHYSICAL HEALTH AND HOMELESSNESS MENTAL HEALTH AND HOMELESSNESS ADDICTION AND HOMELESSNESS BARRIERS TO HEALTH CARE RECOMMENDATIONS APPENDIX 1: STUDY METHODS APPENDIX 2: STUDY LIMITATIONS TERMS REFERENCES

5

6 8 10 16 25 37 45 49 53 58 60 61 62


Demographics Highlights The sample was made up of people who came from a variety of demographic backgrounds •

Executive Summary

• •

54% had less than a high school education and 17% had finished a post-secondary program 14% of the homeless people we interviewed identified as being black or African Nova Scotian and 12% identified as being aboriginal or First Nations 45% were born in Halifax, and 52% have lived here for more than 10 years 42% were living on less than $200 a month 35% did not access any financial government assistance

Being Homeless Daily life was extremely challenging •

• • • •

35% became homeless because of economic reasons and 67% said it was economic reasons preventing them from finding and maintaining housing 35% slept in three or more locations during the month 43% were frequently hungry because they couldn’t get enough to eat 22% slept in a shelter with bedbugs 45% had been physically assaulted in the last year

Physical Health and Care Physical health was poor and access to health care providers difficult •

• • • •

• • • •

40% of homeless people rated their health as fair to poor, compared to 12% of the housed population of Halifax 23% had six or more chronic health conditions 13% of the women were pregnant 45% frequently had pain related to their teeth and gums 29% needed glasses in the last year but were not able to attain them 29% did not have a single source of primary health care 23% accessed health care at a shelter or drop-in clinic 47% accessed health care at the emergency room 59% were supposed to be taking a prescription medication and 35% of them couldn’t afford to get it filled 6


Mental Health, Learning Disabilities and Care Mental health and learning challenges are over-represented •

Executive Summary

• • • •

48% rated their mental health as fair to poor, compared to 6% of the housed population in Halifax 48% of the sample had seriously considered suicide in their lifetime. 52% had a mental heath diagnosis 22% had a learning disability 34% were taking medication for their mental health diagnosis 33% had been hospitalized for an emotional or mental health problem, an average of 4 times in their lifetime

Addiction Many had addictions which were creating and exacerbating physical and mental health problems • • •

• •

23% said their addiction was the reason for their homelessness 87% smoked cigarettes 79% had a drink of alcohol in the last month and of those people 20% had not had a drink in the last 30 days 23% used 0 street drugs in the last year, 26% used 6 or more 48% would use a program to quit drugs if it were available, for free, in places where they spend time

Barriers to Access The main barriers for accessing health care were systemic and cultural •

44% said that they had been judged unfairly or treated with disrespect by a doctor or medical staff at least once in the past year for a variety of reasons 26% of those who used the Emergency Room in the last year, left before they were seen by a doctor or nurse because of the negative attitude of reception staff 26% reported having had at least one negative experience with hospital security 27% had been refused health care in the past year because they did not have a health card 7


Introduction

Why are we letting people jump off the cliff, and then starting the extensive and expensive rescue mission?” -Claudia Jahn, CAH

This report examines the daily living conditions of homeless people in Halifax, their physical & mental health status and the barriers they faced as they interacted with the health care system. The results presented here are very specific to the homeless population in Halifax. A health study of this scope and magnitude has never been done before in our community. The purpose of this survey was not to produce another report which describes the negative impacts of homelessness on health outcomes. Rather, its purpose was to create a document that could act as a guide for direct and pragmatic action to improve the quality of life of those who participated, and the many others in similar situations. The existing healthcare system assumes that everyone has a home where people can rest, control their environment, prepare food, securely store medication and other supplies, and can be accessible to health care providers either by phone or in person. While WHY DO WE NEED perhaps this should be a fair assumption given the ANOTHER REPORT wealth of a country such as ours, it is not the reality ON THE HOMELESS? of the situation as highlighted in the 2009 Report Card on Homelessness. The Halifax Street Health Report illuminates responsibilities. It calls on all government departments, non-profit agencies and community volunteers to collaborate with each other to ensure that every Nova Scotian has a home and that everyone’s health care needs are being met. 8

h


Maslow’ s Hierarchy of

Social Determinants

Needs

of Health

Basic needs: shelter, air, water, food, and sleep.

• •

The foundation of the pyramid comprises the most basic need for human existence. When individuals lack access to these basic needs, they are unlikely to fill any of the higher levels of need - safety, love/ belonging, esteem, and selfactualization.1

income & social status social support networks • education & literacy • employment • physical & social environments • biology personal health practices • child development • health services • gender • culture

“The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” 2

Homelessness can no longer be considered as solely a housing issue - it is physical health issue, it is a mental health issue, and it is a community health issue. 9


Sexual Orientation

Gender

About the People Male

75%

Female

25%

Heterosexual

88%

Lesbian/Gay/Bisexual

12%

Adults Age

82%

Youth

18%

Education

No High School

54%

High School

21%

Some Post-Secondary

9%

Racial/Cultural Background

Post-Secondary

17%

White or Caucasian

85%

Black or African Nova Scotian

14%

Aboriginal or First Nations Other

12% 4%

Monthly Income

Place of Birth

Halifax

45%

Elsewhere in Canada International

48% 7%

Less than $200

42%

$201 to $800

40%

$801 or more

18% 0%

10%

20%

30%

10

40%

50%

60%

70%

80%

90%

100%


75% were male 25% were female No one identified as being transgendered (See Appendix 2)

Gender • •

• •

88% identified as being heterosexual 12% identified as being either lesbian, gay or bisexual (LGB)

Age

• •

Sexual Orientation

18% were accessing youth services at the time they were interviewed 82% were accessing adult services (See Appendix 2)

54% did not have a high school education 21% did attain their high school diploma, either through traditional schooling or a GED program. 9% had been enrolled in a post-secondary program, but never finished

Education

17% finished a post-secondary education program

It was critically important that the young people be offered educational programs like upgrading for high school, or beyond. Because some of them were ready for additional education, they needed the education either on site or some link made for them so that they could easily access education. Education was number one.” - Jean Hughes on her research with SHYM 11


Sample*

Halifax3

White or Caucasian

85%

93%

Black or African Nova Scotian

14%

4%

Aboriginal or First Nations

12%

1%

Other

5%

n/a

Racial/ Cultural Background

*In reporting racial/cultural background, survey participants were allowed to identify with more than one cultural group.

In 2006, the Canadian Census indicated just under 4% of Haligonians identified as being African Nova Scotian, and just over 1% identified as being Aboriginal. However 14% of our sample of homeless people were African Nova Scotian and 12% were First Nations. Homeless counts across Canada have found that people in minority groups, particularly Aboriginal people, are vastly over-represented in homeless populations.

Place of Birth GROWING UP IN CANADA, I DID NOT EVEN KNOW THE WORD HOMELESS. BUT HERE I AM.

Q

• • •

45% were born in Halifax 48% were born elsewhere in Canada 7% were born outside of Canada were from a wide range of countries, the most common being the United States.

52%

48%

Have lived in Halifax for more than 10 years

Have lived in Halifax for less than 10 years

12

Length of Time in Halifax


What was your income last month?

42%

were living on less than $6.66 per day (less than $200/month)

16% no income 26% less than $200 40% between $201 and $800 19% over $800

In Halifax, the cost for a 1 bedroom apartment, have a telephone and power connected, eat nutritiously for a month, and have a bus pass is approximately $1009.81 per month

Basic Phone Groceries $22.50/month $179.24/month Eastlink basic phone service

Cost for one man between 25-494

Monthly rent $683/month Average monthly rent for 1 bedroom apartment5

Electricity $55.07/month 2009 Utility Rate Comparisons, Manitoba Hydro average one month bill at 375kWh

Bus Pass $70/month 2009 Metro Transit Adult Pass Rate, HRM

Income indicators from Report Card on Homelessness (2009) Income Assistance (IA for a single person)

$508

IA Disability for a single person

$743

Average monthly # of IA Cases

9,871

13

Photo Credit: Roger Lemoyne, Front Line


Sources of Income Formal employment was a source of income for 18% of the people we talked to: • 12% had casual or piece work • 5% had part-time work • 6% had full-time work

Minimum Wage

$8.60/hr The Living Wage calculated for Halifax in 2009 was PEOPLE PASSING BY US IS THE HARDEST. I SAT FOR EIGHT HOURS ON BARRINGTON STREET AND MADE THREE BUCKS. I EVEN HAD FOOD POISONING, NO ONE STOPPED TO HELP, ALL THEY SAID WAS “ GET A JOB”

s

$12.48/hr ( 40 hour a week, 52 week salary)

The informal economy is driven by informal work. It includes panhandling (7%), sex work (6%) and selling scrap metal or bottles (4%). It also includes illegal activities like drug running (10%) and theft (6%).

22% cited income from at least one source of informal employment as part of their income 14


35% Monthly Government Assistance

did not access any type of Government assistance in the previous month

“

Our research has proven that it is very difficult for a homeless person to access any type of government benefits. Often it requires the support of a social worker to go through the process. Given the new fiscal reality many Canadians are facing we must act and renew commitments to programs & services for the homeless and ensure our social safety net working for everyone in our society.� - John Hartling, CAH

15


Being Homeless

y the time we put our heads on our pillow at night we probably haven’t drank our 8 glasses of water, we didn’t exercise for the amount of time we should have. There’s a lot of things we haven’t done to maintain wellness. So, can you imagine trying to do all that while homeless? - Patti Melanson

16


Reasons for homelessness

How Did You Become Homeless ?

As respondents were allowed to choose their top two reasons, therefore percentages do not add up to 100%

35% had economic reasons

26% left unsafe living conditions

25%

Safe, supervised housing was a central recommendation of most previous Halifax studies on Public Safety including the recent Mayor’s Roundtable.

Throughout Canada, that has been the central recommendation of virtually all studies of the homeless and the threat to public safety. The “housing first” approach has become almost a mantra. Getting people into supportive housing would yield big savings in public outlays for diverse social services.” - Don Clairmont

were evicted by their landlords 17


What is Preventing You From Finding and Maintaining Housing? 67%

36%

economic reasons

mental and physical health conditions

(cost of rent, low income, unemployment)

Length of Time Homeless

(& addictions)

24%

21%

17%

lack of suitable housing options

discrimination (against welfare recipients, people with criminal records)

lack of adequate support

20%

(resources to find housing)

27%

homeless more than 3years

Homeless less 1 year

54% homeless 1 –3 years

LAST YEAR WAS THE FIRST YEAR I HAD BEEN HOMELESS IN MY ENTIRE LIFE AND I DON'T FEEL I HAVE BEEN HELPED OUT PROPERLY BY SOCIAL SERVICES DISABILITY, OR THE SHELTERS SYSTEM. 18

R


Where Do You Sleep?

35% stayed in 3 or more locations in a one month period

Without having a home to call their own, homeless people constantly have to think about where they sleep on a daily basis. The people we interviewed were asked to tell us about the places they found shelter in the past month.

1. Shelter

2. Couch surfing

3. Sleeping Rough

87%

43%

25%

slept in a homeless shelter

stayed with a friend or family member

slept outside, in abandon structure, or public place

4. Room

5. Hospital or treatment

6. Jail

18%

14%

6%

stayed in a hotel/motel or boarding house room

stayed in the hospital or treatment overnight

had been in jail

19


How Well Do You Sleep?

33% Top 5 reasons for lack of sleep

got less than 5 hours of sleep per night

The homeless people in our survey got anywhere between 2 hours to 13 hours of sleep per night 54% indicated that in the past month they had been so tired that they did not have the energy to walk one block or do light physical work

IT IS HARD TO EAT WELL BECAUSE OF ALL THE RUNNING AROUND YOU HAVE TO DO TO GET YOUR BASIC NEEDS MET. SHELTER HAS TO COME FIRST BUT YOU SPEND ALL DAY ON THE STREET JUST TRYING TO SCRAPE UP A FEW DOLLARS TO SURVIVE. 20

Z


How Well Do You Eat? THE FOOD WE EAT IS JUST FULL OF CRAP… WE GET THE STUFF THAT NO ONE ELSE WANTS. IMAGINE EATING YOUR SUPPER AND THE CHOICES YOU GET ARE FROM THINGS THAT NO ONE ELSE WOULD EAT.

52% ate at a meal program, like a soup kitchen 26% ate at a drop-in centre

43%

When asked “How often are you still hungry after meal program/drop-in for food?” 38% were often still hungry

were frequently hungry because they could not find enough food to eat.

Food Security means that all people, at all times, have access to nutritious, safe, personally acceptable and culturally appropriate foods. Food security is recognized as a key social determinant of health. Food insecurity is a reality for homeless people who do not have adequate resources to access enough healthy and safe food to meet their dietary needs and food preferences for an active and healthy life.3 21

R


What About Hygiene Practices? IT IS REALLY HARD TO KEEP YOUR HYGIENE GOOD. ALWAYS WEARING THE SAME CLOTHES CAN CAUSE YOUR SKIN TO GET INFECTED.

q

25% 28% 51% experienced some level of difficulty finding a place to use the washroom

experienced some level of difficulty finding a place to bathe

experienced some level of difficulty finding a place to do laundry

In the last year, 18% suffered from bed bug bites and 13% suffered from skin infections, sores and ulcers. 22% slept in a shelter with bed bugs

Quite often they’ve been living on the streets, they haven’t bathed for a long time, or they’ve been sick or incontinent on themselves. So, there’s this physical unpleasantness that turns staff against them, that puts them in a less nice light. If you have a homeless man who is 65, and sick and a neat 65 year old in a shirt and tie sitting next to them, generally the caregiver is going to take the patient they perceive as less of a discomfort to them. So often the homeless people end up waiting and other people going ahead of them time and time again. - Dr. Sam Campbell, on hygiene as a barrier to emergency health care 22


Injury Without their own private or safe spaces to go and stay, many homeless people are forced to live much of their lives in public, putting them at greater risk for injuries and accidents.

i

10%

had been hit by a car, truck, public transit vehicle, or bicycle in the past year.

Violence - Physical Assault

45%

100% = 71 people

Who assaulted you?

were physically assaulted in the last year

By comparison, in the 2008 Halifax Roundtable on Violence and Public Safety, 6% of those surveyed from the general population indicated that they had been the victim of a violent crime in a 12 month period.6

23


“

The correlates of violent crime in HRM were the usual factors identified in the literature, namely single parent family (female), unaffordable housing (persons spending more than 30% of income on housing), low household income, low educational achievement and so forth.� - Don Clairmont on crime in HRM

Police Violence

33% reported being assaulted by police officers or corrections officers in the year before they were surveyed

44% said it happened more than once

IT IS HIS WORD AGAINST MINE, WHO ARE THEY GOING TO BELIEVE? A COP? OR A PUNK KID?

13% reported the assault

Sexual Harassment and Assault

19% experienced sexual harassment in the past year

10% had been victims of sexual assault, or rape in the past year 24

R


Physical Health and homelessness

he physical health problems faced by the homeless are the same as the ones everyone in the population faces. However, the exacerbation of things that can go wrong are much more severe for individuals who are living in situations where their nutrition is poor and they are living under a lot of stress and anxiety because of their housing situation. - Patti Melason 25


Self Rated Physical Health

40% of homeless people rated their health as fair or poor compared to

12% of the general population of Halifax

Self Rated Pain 48% indicated that they usually experienced some level of pain or discomfort... compared to only 16% of the general population of Halifax Of those in pain, 19% said that this pain was severe 26


Chronic and Ongoing Health Conditions

80%

23%

reported at least one of the chronic health conditions listed below.

had 6 or more chronic health conditions

Homeless people in our survey compared with the general population of NS/Canada

Arthritis or Rheumatism Migraines Allergies other than food allergies Asthma High blood pressure Physical handicap Chronic obstructive pulmonary disease Hearing Problems Vision and Eye Problems Hepatitis C Stomach or Intestinal Ulcers Skin disease (e.g. eczema, psoriasis) Angina Anemia Heart disease Heart attack in lifetime Diabetes Fetal Alcohol Spectrum Disorder (FASD) Stroke in lifetime Hepatitis B Epilepsy HIV positive Cancer Congestive Heart Failure Inactive or latent tuberculosis 27

Homeless 43% 37% 28% 25% 22% 22% 22% 21% 21% 17% 17% 13% 12% 11% 8% 7% 6% 5% 5% 5% 3% 3% 3% 3% 1%

NS/Canada 23% 12% 28% (2005) 11% 19% n/a 3% n/a n/a n/a 5% n/a n/a n/a 6% n/a 7% n/a 1%2 n/a .6% (2005) n/a 2% 1% (2003) n/a


Acute and Episodic Health Conditions

q 13%

Episodic Health Issues

THE SHELTER IS OVERCROWDED, AND IT IS UNSANITARY, PEOPLE ARE GETTING SICK AND STAFF NOT LOOKING AFTER THIS ISSUE. THERE IS NO HAND WASHING AND THE FACILITIES, IN GENERAL, ARE NOT CLEAN.

Reproductive Health & Pregnancy •

• •

75% reported being sexually active and of those 33% always used condoms/dental dams for protection from STDs and 34% always used condoms/dental dams for protection from STDs 53% had been tested for an STI in the last year 72% have been tested for HIV/AIDS in their lifetime

of the women we interviewed were pregnant

28


Self-Rated Oral Health

Oral Health

36% had not been seen by a dentist in the past three years and of those, 63% said the main reason was that they couldn’t afford it

45% frequently had discomfort or pain related to dental problems

Vision

21%

29%

had vision problems that were unrelated to needing glasses

needed glasses in the last year but were unable to obtain them 29


Physical Check-ups

53% didn’t think it was necessary

40%

25% didn’t make it a priority

have not had a physical check-up in more than three years

20% had a fear or negative feelings about doctors

Accessing Primary Health Care 29% did not have a single source of primary health care and of those 56% said that a primary care location was not needed or that they treated themselves, and 24% said that some aspect of their lifestyle made it hard to access and maintain primary care. Of those who did have a usual source of primary health care: •

29% used a doctor’s office

15% used the North End Community Health Centre

14% used the hospital emergency room

12% used a walk-in clinic

5% were receiving outpatient care

4% received primary care at a shelter or drop-in clinic 30


Accessing Health Care

Where did you access healthcare last year?

Regardless of whether they had a regular source of health care, people accessed services in the past year in a variety of places.

FAMILY DOCTORS Although 59% reported receiving health care from a doctor’s office at least once in the last year, only 29% indicated that they had a regular family doctor. Of those 113 people who did not go to a doctor’s office for primary care: •

56% used the North End Community Health Centre & 52% used the emergency room 63% had one or more serious health conditions 31


COMMUNITY HEALTH CENTRE & PUBLIC HEALTH THE NORTH END HEALTH CENTRE WAS SUPPORTIVE WHEN I MOVED BACK FROM ONTARIO WITH A HEALTH CARD. NO WAITING, AWESOME. I ALMOST CRIED BECAUSE THEY OFFERED SUPPORT RIGHT AWAY

39% 23% reported using the North End Community Health Centre in the past year

Q

reported accessing health care at shelters and drop-in clinics in the past year.

Photo Credit: Roger Lemoyne, Front Line

MOBILE OUTREACH STREET HEALTH (MOSH) MOSH is a community developed program operating out of the north end community health centre. MOSH has a team of health and social work professionals who visit shelters, soup kitchens, and local drop-in centres. It also has a street presence, and accompanies already existing outreach organizations like Stepping Stone and Mainline. The realization of MOSH was a truly collaborative effort. The support of the department of health, capital district health authority, and a charitable donation from frontline health made this initiative possible. 32


EMERGENCY DEPARTMENTS

47%

51% who had used an ER in the past year reported leaving before being seen by a doctor at least once.

(100%= 74 people)

Why did you go to the emergency room last year?

used the emergency room in the past year

The two most common reasons for leaving before treatment were: • •

92% wait time was too long 26% negative attitude of reception staff

33


HOSPITALS 22% said that they had stayed in the hospital overnight (not in the ER) at least one night in the past year. When these 35 people were asked about their experience in their most recent hospitalization: •

• •

47% said no arrangements were made so that there was a place to stay upon discharge 46% said there was no assistance in getting prescriptions filled 58% said that a follow-up appointment was not set up

In a 2006 study on the cost of homelessness in Halifax, it was estimated that it cost

$662.00 per person per day to use a hospital in metro Halifax. A person who was homeless spent an

8.25 days in the hospital, compared to an average of 1.65 days per average of

person in a supportive housing unit $662.00 X 8.25 days = $5461.50 vs. $662.00 X 1.65 days = $1092.307

WE CAN'T BE HEALTHY IF WE DON'T HAVE GOOD HOUSING. WE NEED NURSES AND DOCTORS WITH GOOD UNDERSTANDING OF ADDICTIONS AND TREAT PEOPLE WELL WHEN THEY COME TO SEE THEM.

h

Supportive Housing = Health Care Savings 34


Following Treatment Plans MEDICATION

59% had a prescription they were supposed to be taking

35% were not able to get their prescription filled

43% could not afford it

Even if you are covered by social assistance there is a five dollar copay. Five dollars doesn't sound like much unless you don’t have any money at all, then five dollars is a big deal. And so often even though an individual gets a prescription, that prescription is not filled. If the prescription is filled chances are it will not be taken properly. The medication may get stolen, it may get shared or whatever but it probably isn’t going to be taken as prescribed.” -Bryon Anderson on barriers following treatment plans 35

36% were not always able to take prescriptions as directed

MY LIFE IS CRAZY, AND I FIND IT HARD TO REMEMBER TO TAKE MY ANTIBIOTICS.

W


HEALTH ADVICE

35% said their living situation interfered with it

33%

29%

said that although they were given it, they did not follow doctor’s advice

said the advice was too difficult

22% said it cost too much money

SUPPLIES & ASSISTIVE DEVICES •

• •

12% indicated that they required medical supplies that they were not able to attain in the past year 10% said that they required an assistive device to function 4% reported requiring daily personal care 36


Mental Health and homelessness

he overall health status of the clients in the shelter system, both physical and mental, is very poor. Some of our larger shelters like our men's shelter with 80 clients is a good example of people who are at the bottom of the totem pole in some ways. They do come with a huge amount of health issues, but people who don`t have mental health issues when they enter our shelters certainly do by the time they leave our shelters or often do have a high percentage of problems with depression or anxiety. - Pam Chisholm 37


“

Mental Health is the capacity of each and all of us to think and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections and personal dignity.�8

Self-Rated Mental Health

Mental Health and Stress

said their life was very stressful, compared to

21% of general population in Halifax

48% rated their mental health as either fair or poor, compared to

6% of the general population in Halifax

Self-Rated Stress

55%

Youth and Adult Survey Locations

38


Social Isolation

40%

29%

often felt very lonely or remote from other people

“ “

never or rarely had someone they could count on to listen when they needed to talk

Homeless people need to be respected, they want to feel connected, they want to feel they can trust somebody.” - Jean Hughes

Suicide

According to the World Health Organization, internationally mental disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide: however, suicide results from many complex socio-cultural factors and is more likely to occur particularly during periods of socioeconomic, family and individual crisis situations (e.g. Loss of a loved one, employment).”9 48% of the sample had seriously considered suicide in their lifetime. Of those 75 people: • 61% had considered suicide within the past year (29% of the whole sample) • 75% have actually tried to commit suicide sometime in their lifetime (35% of the whole sample) 39


Mental Health Symptoms “The World Health Organization estimates that, internationally, one in four patients visiting a health service has at least one mental, neurological, or behavioural disorder, but most of these disorders are undiagnosed and untreated.�10

72% had experienced serious depression in their lifetime

60% in the past year 72% had experienced serious anxiety or tension in their lifetime

64% in the past year 61% had experienced trouble understanding, concentrating or remembering in their lifetime

53% in the past year 26% had experienced hallucinations

10% in the past year 40


Mental Health Diagnoses (from Doctor or Psychiatrist)

Mental Health Diagnoses

A scale was created which counted the number of mental health diagnoses any one individual had. Out of thirteen possible diagnoses, the maximum number of mental health diagnoses reported was 9.

52% had a diagnosed mental health issue

s

WHEN EVERYTHING BUILDS UP IT'S OVERWHELMING. HAVING NO HOME AND NO MONEY FEEDS MY DEPRESSION. 41


Mood disorders are those characterized by a disturbance in mood and emotion and include depression, bipolar and manic disorders.

Mood Disorders

• • •

31% were diagnosed with depression 13% were diagnosed with bipolar affective disorder 3% were diagnosed with a manic disorder

15% of those diagnosed with a mood disorder said this was their only mental health diagnosis; 85% had at least one other mental health issue to deal with.

I once had a mental health consumer say to me, If you think about my depression in the same way you think about having a disability, a physical disability and being paralyzed and can’t move, when I have my depression I can’t move, I can’t get out of bed in the morning. That means I don’t get up to clean the apartment, I probably don’t eat very well because I eat whatever’s in the house and maybe there isn’t very much.” - Jean Hughes on depression Anxiety Disorders categorize a large number of disorders which are characterized by abnormal or inappropriate anxiety. • • •

20% were diagnosed with anxiety 8% were diagnosed with panic disorder 7% were diagnosed with post-traumatic stress disorder (PTSD) 4% were diagnosed with phobia

Only 10% of those diagnosed with Anxiety Disorder indicated that this was their only mental health diagnosis; 90% had at least one other mental health issue to deal with. 42

Anxiety Disorders


Schizophrenia and psychosis are characterized by delusions, hallucinations, disturbance in thinking and withdrawal from social activity. 6% of the sample was diagnosed with schizophrenia.

Schizophrenia

For 40% of those diagnosed, schizophrenia was the only mental health diagnosis. Personality disorders are characterized by severe disturbance in character and behaviour usually involving several areas of the personality and nearly always associated with considerable personal and social disruption.

Personality Disorders

6% were diagnosed with antisocial/sociopath personality disorder 6% were diagnosed with obsessive compulsive disorder (OCD) 4% were diagnosed with borderline personality disorder 2% were diagnosed with multiple personality disorder

18% were diagnosed with an addiction related mental disorder. An in-depth analysis of addictions will be explored in the next section.

Addiction

The mental health people say we can’t deal with this individual because they have a substance abuse problem… so you send them to the substance abuse people and the substance abuse people say we can’t look at this person because they have mental health problems and so the person ends up on the street.” -Bryon Anderson on coordinating services for clients with addictions 43


Learning Disabilities

61%

53%

experienced trouble understanding, concentrating and remembering in their lifetime

experienced trouble understanding, concentrating and remembering in the last year

22% had a learning disability • • • •

9% ADD 12% ADHD 5% Dyslexia 6% Other Learning Disabilities

Learning disabilities refer to a number of disorders which may affect the acquisition, organization, retention, understanding or use of verbal and nonverbal information. These disorders affect learning in individuals who otherwise demonstrate at least average abilities essential for thinking and/or reasoning. As such, learning disabilities are distinct from global intellectual deficiency. Learning disabilities result from impairments in one or more processes related to perceiving , thinking, remembering or learning.11 44


Mental Health Treatment MEDICATION

34%

26%

had been prescribed medication for mental health reasons in the past year

said the side effects were not explained to them

HOPITALIZATION 33% had been hospitalized for an emotional or mental health problem, an average of 4 times in their lifetime Of those 52 people who had been hospitalized: • •

60% said their most recent hospitalization was voluntary 40% said it was involuntary

I HAVE BEEN TRYING TO FIND SOMEONE TO TALK TO BUT I DON'T KNOW WHERE TO GO

EMOTIONAL CRISIS INTERVENTION

26% felt they had no where to turn in an emotional crisis

W

I encounter the gamut of mental health issues right from somebody who’s distraught because they’ve broken up with their girlfriend to someone who’s fairly psychotic and everything in between.”

- Pam Chisholm on delivering mental health care in the shelter 45


Addiction

try almost daily to find detox spaces for some of our clients. But all I hear is, “No I can’t take you, you’ll have to go on the waiting list.” That is terrible. There should be beds available for people when they are ready to make that change. In the end it would save so much money. - Cathy Boudreau

46


Smoking

87%

51% of smokers indicated that if there was a free program to help them quit smoking, they would use it

smoked cigarettes Of those 137 people

94% said that they smoked daily

79% had a drink of alcohol in the past 12 months

20% had not had a drink in the last month

Alcohol consumption in last 30 days

Alcohol

47


Types of drugs used in last year

Drugs

DRUG PROGRAMS

23% Used 0 street drugs over a one year period 26% used 1 type of street drug 35% used 2-5 types of street drugs 26% Used 6 or more different types of street drugs

16% had tried to get into some kind of drug treatment program in the past year, but were unable to

48%

29%

would use a program to quit drugs if it were available, for free, in places where they spend time

said they would use a supervised consumption site in their neighborhood

48


Barriers to Access

’ve gone to the emergency room sick and in excruciating pain. They would say to me, “You’re just here for a quick fix.” And I would say, “No, I am not here for a quick fix. I am here because I am in pain. If I was looking for a quick fix, I wouldn’t spend 12 hours in the emergency room. I could get a fix in 5 minutes.” - Jan Davis

49


Attitudes

The perception of some staff is often based on experience. And there is a kind of vicious cycle where the homeless people are used to being treated badly. So they arrive prepared to being treated badly, so they’re rude to staff. Staff feel, ‘Well I’m going to be rude back to them’ and there’s this kind of vicious cycle. There’s also a lot of homeless people who are substance abusers, so that they arrive either with the police or they are brought in under the influence of some kind of substance which makes them very difficult to work with. - Dr. Sam Campbell on the cycle of discrimination in the ER

44% said that they had been judged unfairly or treated with disrespect by a doctor or medical staff at least once the past year

s

A COUPLE TIMES I WOULD HEAR THE NURSES TALKING CALLING ME A JUNKIE. I HEARD THE NURSE SAYING THAT THERE WAS NO POINT IN KEEPING ME BECAUSE I WAS A JUNKIE. THEY SAID I WOULD BE PROBABLY GOING TO USE AGAIN ANYWAY. 50


Reasons for discrimination by health care providers 7% of the sample reported “other reasons” for feeling disrespected by health care professionals. One respondent noted that they felt they had “too many health issues” and the “doctor didn't want to deal with me.” Other reasons given in these responses were related to disrespect due to age and dressing in the “gangster” style.

26%

26%

of those who used the emergency room in the last year left before they were seen by a doctor or nurse because of the negative attitude of reception staff

reported having had at least one negative experience with hospital security

Homeless people reported the following negative experiences with hospital security:

11% had been denied access or told to go away 5% had been threatened or verbally assaulted 6% had been physically removed 51


A 2007 study of homeless people’s perceptions of welcomeness and unwelcomeness in healthcare encounters found that perceptions of welcomeness and unwelcomeness were critical dimensions for their participants. Respondents often reported that unwelcoming experiences elicited strong emotional responses and decreased the likelihood they would seek health care in the future. In this study “most participants perceived their experiences of unwelcomeness as acts of discrimination. Homelessness and low social class were most commonly cited as the perceived basis for discriminatory treatment. Many participants reported intense emotional responses to unwelcoming experiences, which negatively influenced their desire to seek health care in the future.�12

MSI Cards

27% had been refused health care in the past year because they did not have a health card

Where were you denied healthcare?

41% did not have an MSI card

52


Recommendations The following section highlights our recommendations to immediately respond to the issues plaguing the homeless population in Halifax. These recommendations were developed by the Street Health Committee in direct response to our findings.

Address the Poverty that Underlies Homelessness People become homeless and stay homeless largely because of poverty.14 Thirty-five percent of the homeless people in our survey named their economic circumstances as one of the most important reasons they were homeless. Almost one half of homeless people in our survey had monthly incomes of $200 or less. People need adequate incomes in order to be healthy. Currently, social assistance benefits and even full-time minimum wage work do not provide enough income for people to meet their basic needs. In addition, homeless people face many barriers to accessing social assistance. Ensuring adequate incomes for everyone will reduce homelessness and improve the health of people who are currently homeless.

Recommendation

Action Items •

Increase social assistance rates

Improve access to Income Assistance & Disability Support

• • •

Increase minimum wage

Increase social assistance rates to reflect a minimum standard of living Establish an independent committee (made up of labour, business, academic and community sectors) to set rates and to monitor their adequacy in meeting a minimum standard of living, as well as their impact on employment and the economy Increase availability of Income Assistance to youth who have a case-worker with any recognized programs in HRM Remove access restrictions related to requiring a permanent address Streamline the decision making process for eligibility to further reduce wait times and improve quality of service Increase the availability of up-front supports to assist applicants in navigating the application process. Raise the minimum wage rate to $12.48 an hour (the calculated living wage for Halifax) Establish an independent committee (made up of labour, business, academic and community sectors) to set rates and to monitor their adequacy in meeting a minimum standard of living, as well as their impact on employment and the economy 53


Providing Affordable and Appropriate Housing People need adequate, affordable housing in order to stabilize their lives and be healthy. In addition to poverty, people become homeless and stay homeless because there is a serious lack of affordable, adequate and supportive housing in Halifax. Homelessness was not a short term crisis for 73% of the people in our survey, who had been homeless for over a year. Additionally, 36% said their physical or mental health conditions were preventing them from securing and maintaining housing, indicating a strong need for supportive housing to help address their specific needs. This report identified a strong need for eviction prevention, trusteeship and housing maintenance services, as 25% of respondents indicated that the reason they were homeless was because they were evicted. Ensuring that Halifax has enough affordable, adequate and supportive housing will both move homeless people into housing and prevent people from becoming homeless.

Recommendation Develop an affordable housing strategy for Nova Scotia

Action Items • Conduct roundtables on affordable housing involving all public, private and community stakeholders • Engage private sector landlords to provide adequate housing for people who require housing • Set targets and monitor outcomes • Construct sufficient affordable units according to the Nova Scotia housing strategy Increase availability • Provide rent supplements where needed of affordable and • Renovate sub-standard existing homes, targeting social housing and adequate housing in low-income homes needing repairs Halifax • Implement inclusive planning that requires at least 20% of all new housing developments to be designated as truly affordable and accessible housing for low income people •

Increase availability of supportive housing units

Provide long-term program funding for programs that effectively deliver housing support in HRM

• •

Create new supportive homes that meet specific health and social needs Create support services to help people transition to and maintain housing. This includes housing designed to accommodate individuals with physical and mental health needs, as well as harm reduction housing which supports people with alcohol and other drug use issues Allow for non-profit ownership of buildings and community capital investments

Provide program funding that allows for long-term planning Provide long-term funding for eviction prevention, trusteeship services and housing maintenance 54


Improve Quality of Life Access to adequate incomes and affordable housing is ultimately what is needed to end homelessness and improve the health of homeless people. In the meantime, there is an immediate need to improve the difficult daily living conditions of people who are homeless. It can be hard for homeless people to access shelters. Not all shelters provide enough support for people with physical and mental health conditions or substance use issues. The conditions of some shelters increase homeless people’s risk for acquiring physical and mental illnesses and many homeless people cannot meet their nutritional needs through the shelter and meal program system; 43% of the homeless people we interviewed reported being frequently hungry. Due to gaps in the provision of meal programs and drop-in services, some homeless people need to resort to emergency departments, a costly alternative, to get food, to warm up or to rest. Even as homelessness is growing, critical services for homeless people are not getting the funding they need to meet homeless people’s basic needs. While many shelters, meal programs and drop-ins are doing their best with limited resources, more needs to be done to improve access and quality in these services. Homeless people’s lives are isolated and filled with violence., 45% had been physically assaulted in the past year and some of that violence has come at the hands of the police. Until income and housing security are adequately addressed, improvements to services for homeless people are needed immediately to improve their health and well-being.

Recommendation

Improve quality in emergency homeless services in Halifax

Provide an ombudsman/field officer for the homeless

Action Items • Improve and enforce shelter standards to address issues such as over-crowding, safety, and nutrition • Provide flexible, less institutional shelter alternatives designed to better accommodate homeless people’s health needs, including an increase in the number of shelter beds that operate from a harm reduction philosophy • Ensure shelters receive adequate funding appropriate to services being offered • Provide in-house recreation & life skills programming • Create buddy program and partner homeless people with community mentors • Increase the wage standard for front line workers • Expand hours in existing meal programs, and increase the quantity and quality of food served so that homeless people have access to three nutritious meals a day, seven days a week • Expand hours of existing drop-ins, so that homeless people always have a safe, indoor space to spend time and connect with other people • Establish a permanent cold-weather shelter in Halifax for people who can’t be served by the existing shelter system • •

Add an investigator responsible for the homeless to the Ombudsman's office Add an homelessness advocacy position to the Public Safety Office 55


Reducing Barriers to Health Care Access Despite their poor health status, homeless people cannot access the healthcare they urgently need. They often receive inadequate care and frequently face discrimination from healthcare providers. Homeless people’s access to comprehensive primary healthcare is poor. Seventy-one percent of the homeless people in our survey do not have a family doctor, and many have used hospital emergency departments instead, at far greater cost to the healthcare system. More than a quarter had been refused health care services in the past year because they did not have Nova Scotia Health Card. Further, 44% felt they had been judged unfairly or treated with disrespect by a healthcare provider in the past year. Until access to primary health care improves, hospitals will continue to be a frequently used source of health care for homeless people. Hospital emergency departments were the most frequently used source of health care, used by almost half of the homeless people in our survey in the last year. Many homeless people receive inadequate care and encounter discrimination in hospitals, and their unique needs are often not addressed. Hospitals are not equipped to ensure that homeless people will be able to get the prescriptions and follow-up care they need, the food they should eat, and an adequate place to rest when they leave the hospital. Homeless people in our survey also have very poor access to dental and vision care, as well as to prescription drugs. This not only affects their health, but also their ability to gain employment.

Recommendation

Action Items • •

Increase alternative care & outreach programs to improve primary health care delivery to the homeless population

• • • • •

Improve services to homeless patients who are in need of primary and follow up care

• • •

Allocate appropriate long term funding for those programs which have proven to be effective Monitor effectiveness of new and existing models of alternative care and outreach on an annual basis, to determine community need Hire an advocate who is connected to system and can develop a multi-program plan with clients & ensure no overlap and gaps in services with clients Offer more health services at clinics and shelters Offer primary care health services on weekends and in the evening Conduct regular evaluation of outreach programs and cost benefit analysis Involve homelessness patients in finding solutions to their health care needs Create opportunities to partner with existing health service providers; to expand and develop creative approaches to delivery of primary health, mental health and addiction treatment services Remove $5 co-pay for people living on income assistance Ensure that homeless patients being released from hospital have a place to stay the day of their release Create crisis stabilization beds in the community for people going through mental health crises or who have been victims of violence 56


Recommendation Action Items Increase data and information sharing • Allow for case conferences with all service providers working in collaboration regardless of departments or jurisdiction within government • Integrate all medical records throughout the Capital Health District agencies and Authority, allowing community case workers to input relevant contact between the information updates when available government and the non-profit sector • •

Improve access and quality in hospital care

• • •

Improve access to MSI Cards and other identification documents Provide more options to people with addictions who are seeking help

• •

• • •

Make homeless people a health priority

Conduct mandatory education and training for all hospital staff to increase awareness and understanding about homelessness Create a Community Support Worker position within emergency departments, available 24 hours a day, and 7 days a week, who provides support to homeless people when they are accessing the emergency department and being released from hospital Ensure that all hospital security guards receive mandatory education and training to increase awareness and understanding about homelessness, and have strong skills in non-violent de-escalation Establish and maintain an accessible 3rd party complaints process through a patient relations or similar office. Ensure that the process for making a complaint is clearly posted in all hospital departments Include poverty as an aspect of cultural competency training for doctors and nurses Train on harm reduction models & benefits Regular reflection activities with health care teams about homeless populations in the city Create programs that help homeless people to replace health cards and other identification Create programs that help homeless people to store their identification safely Open enough detox and crisis stabilization beds so that immediate access is available when required Streamline referral process for long-term stabilization programs Offer more free programs to homeless people in the shelters and the places where they gather to eat and sleep Establish a task force to develop an action plan to address health equity for homeless people. Reporting to Community Action on Homelessness, this task force should ensure the input and representation of homeless people, and identify and promote appropriate and innovative strategies for health care access and addressing health disparities for homeless people, including mental health and addictions services for homeless people 57


Appendices Appendix 1: Study Methods Surveys on health status and access to services were completed, data-entered and analyzed for a representative sample of 158 homeless men and women in Halifax who were “absolutely homeless”. Sample Size The exact number of homeless people living in Halifax is unknown. We assumed a population of 266 homeless people in Halifax based on the estimated population given in “Homelessness in HRM: Portrait of Streets and Shelters” conducted by the HRM in June 2004. Our calculated sample size with a 95% confidence level for 1-sided testing was 134. In total, 160 people were interviewed; only 158 surveys could be used after excluding duplicates and incomplete surveys. Stratification by Gender Fewer women use homeless services than men, and there are fewer services targeted towards homeless women. To ensure that women’s experiences were appropriately represented we over-sampled women at a variety of women’s shelters and services. Stratification by Shelter Use Many homeless people do not regularly use shelters, but instead stay in public spaces, outdoors, or with friends. In order to capture a substantial portion of homeless people who are not regular shelter users, we stratified our sample by “shelter users” and “non-shelter users”. In our total sample, shelter users made up 78%, while non-shelter users accounted for 22%. Interview Sites Community Action on Homelessness used established connections with community-based organizations serving homeless people across the city to set up interview sites where participants were recruited. Participants were recruited at a wide range of homeless shelters and resource centres across downtown Halifax. 10 different sites were used for recruitment altogether. We chose to recruit only at shelters and drop-in and resource centres excluded outdoor gathering places. Our interview sites were located within the Halifax Peninsula. We focused on downtown Halifax, as this is the area where the majority of services for the homeless exist. 58


Eligibility In order to be eligible for the study, participants had to be what is often referred to as “absolutely” homeless. This was defined as: having stayed in a shelter, public place, or other site not intended for human habitation for at least 10 of the last 90 nights. As discussed, enrolment in the study was stratified by shelter use. “Shelter users” were defined as people who had stayed in a homeless shelter in the last 10 days, including the night before the interview. “Non-shelter users” were defined as people who had not stayed in a shelter in the last 10 days, but were still considered to be “absolutely homeless” – that is, they had stayed in a public place or at a friend or relative’s place (and not in a shelter) in the last 10 days. Accordingly, a screening tool was used before conducting every survey. Recruitment With the help of shelter staff, we conducted outreach in the shelters and resource centres, attempted to find those people who were selected, approached them and asked if they wanted to participate, and if interested, screened them to see if they were eligible. Prior to interview time, the shelters posted posters with screening information and a sign up sheets. Participants scheduled an interview time and date with shelter organizers. The Survey Instrument This survey was adapted from a study designed and implemented by the Street Health organization in Toronto. Our committee reviewed and refined the survey instrument for a Halifax context. The survey was approved by the Research Ethics Board at St. Michael’s Hospital for Street Health. Community Action on Homelessness did not conduct additional ethics consultations. Data Collection We conducted our interviews in January 2009, when more homeless people were likely to be accessing the services where our recruitment took place. The survey took approximately 45 minutes to one hour to complete. Study participants were given a $15 honorarium for their time. We recruited volunteers from our existing community network and a variety of health and social services associations to conduct the interviews. Each interviewer was given a 3-hour workshop on research methods and best practices for interview-style face-to-face data collection. Data Analysis Data was entered manually, stored and analyzed using SPSS Statistics 15 software. A series of five variables collected through the survey (i.e. gender, ethno-racial background, height, weight and date of birth) were identified and correlated for the purpose of identifying duplicate interviews. Duplicate surveys were deleted from the dataset. Quantitative analyses focused on descriptive statistics and comparisons with general population data retrieved and compiled by Annie Xu at the Department of Health. Participants’ answers to open-ended questions were reviewed, and some illustrating key ideas were selected. All data was analyzed to identify key study findings, issues, themes and policy. 59


Appendix 2: Study Limitations While we are confident that our findings are representative of the experiences and health status of homeless people in Halifax, this study has some limitations that should be acknowledged. Our survey only captures the experiences of a segment of the homeless population, often referred to as “absolutely” homeless. In addition to people who have no place of their own to live, the term “homelessness” includes people living in poor housing or overcrowded conditions, people at risk of becoming absolutely homeless, and people living on low incomes who spend a large part of their income on rent. People in these circumstances face many of the same health issues and barriers to health care as absolutely homeless people. However, we chose to narrow our focus to “absolutely” homeless people because of the logistical challenges to including a much less visible group of people who could be broadly defined as homeless. In addition, it is important to acknowledge that the small percentage of absolutely homeless people who do not use any services for homeless people were excluded from the study because we only recruited survey participants at shelters and meal programs. Due to an oversight in survey adaptation, age was not collected from survey respondents. We identified “youth” as being individuals who were accessing youth services at the time they were interviewed. We do know that youth also access services from organizations that are not aimed specifically at youth. However, the proportion of youth in this survey is similar to the proportion of youth surveyed for the 2008 Street Count. Survey respondents were not asked about their gender identification either. The male/female variable was created by identifying the survey respondents who were asked questions specifically related to women’s health issues. Only survey respondents who replied to all questions pertaining to women’s health (and pregnancy in particular) were coded as female. Being transgendered was inappropriately asked in the section on sexual orientation, however no one identified as being transgendered in our sample. Women are often less visibly homeless than men, because they are more likely to double up with friends or relatives, and “couch surf”, or move between temporary situations. Fewer women use homeless services than men, and there are fewer services targeted towards homeless women. We deliberately recruited so that at least a quarter of our sample was women. If we had randomly recruited survey participants without regard to gender, it is likely that even fewer women would have been interviewed. By intentionally recruiting women to make up 25% of our sample, we ensured that we interviewed enough women to make our findings meaningful. However, because we used this strategy, the gender breakdown of our sample may not be representative of the proportion of women who are homeless. Our survey deliberately focused on downtown Halifax as a result, homeless people outside of the downtown core were excluded from the study. Further, when asked about place of birth, we did not include a category for being born elsewhere in Nova Scotia. Identifying these issues will assist us in the development of next year’s Health and Homelessness Survey 60


Terms Absolute homelessness – the absolute homeless are those who live on the street, in temporary shelters, or in locations not intended for human habitation. This group may also include those who must move continuously among temporary housing arrangements provided by strangers, friends or family. The absolute homeless have no home to return to. • Affordable housing – A. Dwellings costing less than 30% of before-tax household income. Costs include [for renters]: rent and any payments for electricity, fuel, water, and other municipal services; [for owners] mortgage payments (principal and interest), property taxes and/or any condominium fees, along with payments for electricity, fuel, water, and other municipal services. B. public housing intended for low-income people and/or people with disabilities, or specific groups who cannot afford to rent a place to live at market prices. • Community Action on Homelessness (CAH) is an umbrella group that promotes partnerships to build community's capacity to address issues associated with homelessness and affordable housing. CAH is guided by its mission: “to work in partnerships within our community, to advance community solutions that address homelessness, and the right to a home as a key to the ‘quality of life’ for everyone in our community.” CAH is funded by Supporting Communities Partnership Initiative (SCPI), a program of the Government of Canada, and supported by other government and community partners. The CAH initiatives that advance the mission and achieve its objectives would not be possible without this support. • Emergency shelter – facility providing temporary and shortterm accommodation (from a few days up to six months) to homeless individuals or families who would otherwise sleep on the street. Typically, these facilities provide single or shared bedrooms or dormitory-type sleeping arrangements. • First Voice - the name given to persons who are homeless or live at risk of homelessness. This includes persons who live in inadequate or over-crowded conditions and persons living in poverty. Community Action on Homelessness recognizes the invaluable contribution that First Voice makes to community solutions that work. There is First Voice representation on the Steering Committee and on sub-committees. An honorarium model – perhaps the first of its kind in Canada - recognizes the First Voice expertise and participation! • Harm Reduction - a non judgemental approach to providing persons with supports and services that recognizes some individuals may never cease harmful behaviours. The goal of harm reduction is to minimize negative impacts drinking or drug use. • Supportive housing – A. long-term or permanent accommodation for people who cannot achieve or maintain housing stability independently and who require long-term or permanent services to help them maintain an appropriate level of safety and stability, while moving toward greater independence and quality of life. B. Safe, affordable housing for individuals and families that includes supports and services integrated into the housing and no length-of-stay duration. •

61


References 1 “A theory of human motivation” (1943) A. Maslow, Psychological Review, Vol.50 2 - Commission on Social Determinants of Health 3 - Cost and Affordability of a Nutritious Diet in Nova Scotia (2008) Nova Scotia Food Security Network (Adapted quote) http://www.gov.ns.ca/hpp/publications/food_costing_study.pdf 4 - Statistics Canada Summary tables (2006 Census) Visible Minority Population; Population reporting an Aboriginal Identity 5 - Cost and Affordability of a Nutritious Diet in Nova Scotia (2008) Nova Scotia Food Security Network http://www.gov.ns.ca/hpp/publications/food_costing_study.pdf 6 - Halifax Report Card on Homelessness (2009) Community Action on Homelessness www.cahhalifax.ca http://www.cahhalifax.org/ReportCard/Halifax_Report_Card.pdf 7 - Mayor’s Roundtable on Violence and Public Safety (2008) Don Clairmont http:// www.halifax.ca/council/mayor/documents/ViolenceandPublicSafetyinHRMMainReport.pdf 8 - The costs of homelessness and the value of investment in housing support services in Halifax Regional Municipality (2006) Frank Palermo http://www.cahhalifax.org/DOCS/ costofhomelessnessjune06report.pdf 9 - Improving the Health of Canadians: Exploring Positive Mental Health (2009) Canadian Institute of Health Information (Direct quote) http://secure.cihi.ca/cihiweb/products/ summary_mh_mar0309_e.pdf 10 - Mental Health—Suicide Prevention (SUPRE) (2008) World Health Organization http:// www.who.int/mental_health/prevention/suicide/suicideprevent/en/ (Direct quote) 11 - Mental Health (2008) World Health Organization http://www.who.int/mental_health/en/ (Quoted in Suicide and Attempted Suicide in Nova Scotia 1995–2004, Province of NS, PHRU) 12 - About Learning Disabilities (2008) Learning Disabilities Association of Nova Scotia http://www.ldans.ca/ldinfo.php (Direct Quote) 13 - Homeless People’s Perceptions of Welcomeness and Unwelcomeness in Healthcare Encounters (2007) Chuck K. Wen, Pamela L. Hudak, and Stephen W. Hwang, Journal of General Intern Medicine, Vol. 22(7) 14 - Some recommendations adapted from 2008 Street Health Report, Street Health Toronto 62


Notes

63


64


HealthReport2009