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Homelessness & Health in Canada

Manal Guirguis-Younger
Ryan McNeil
Stephen W. Hwang


Manal Guirguis-Younger, Ryan McNeil et Stephen W. Hwang

Texte intégral

Why This Book?

1Stereotypical images of homeless persons, such as those of 'junkies', 'squeegee kids' or 'bag ladies', shape popular understandings of homelessness but obscure the scope and diversity of Canada's homeless population. Over the past thirty years, the retreat of the federal government from social housing, along with reforms to social welfare programs and health care, has contributed to a growing homelessness crisis that affects tens of thousands of people every year (Hulchanski et al. 2009). This steady growth in Canada's homeless population has been accompanied by greater awareness that this population is highly heterogeneous (Gaetz 2010; Laird 2007). Although some groups are overrepresented among the nation's homeless population due to wider social inequities embedded in Canadian society, notably people of Aboriginal ancestry (Hwang 2001), homelessness does not discriminate on the basis of age, gender, sexuality or race. In turn, Canada's homeless population reflects the country's overall diversity.

2Increased recognition of the diversity of Canada's homeless population has led to greater acknowledgement that homelessness encompasses a wide range of living situations (Canadian Homelessness Research Network 2012). Recently, Canadian researchers have advanced a definition of homelessness that recognizes this diversity by situating homelessness along a continuum of living arrangements, including: (1) living outside or in places not fit for human habitation; (2) staying in temporary or emergency accommodations (e.g., emergency and transition shelters); (3) living in accommodations without security of tenure (e.g., 'couch surfing' or staying with friends or acquaintances); and (4) living at risk of homelessness due to lack of financial security or other factors (e.g., intimate partner violence, separation or divorce, etc.) that may compromise housing (Canadian Homelessness Research Network 2012). In many regards, this definition underscores the fact that homelessness is experienced differently by different people, often in accordance with the unique constellation of individual, social and structural factors that shape their lives (see, for example, Karabanow 2004; Menzies 2009; Walsh, Rutherford and Kumak 2009). For example, women and their children escaping intimate partner violence by staying in a transition shelter, street-involved youth sleeping on a friend or acquaintance's sofa and an individual staying in an emergency shelter or sleeping outside may all be characterized as homeless, in that they lack access to secure and stable housing.

3While these diverse categories of homelessness underscore the varied needs and experiences of Canada's homeless population, more than two decades of research indicates that one factor linking this population is poor overall health (Dunn 2000; Frankish, Hwang and Quantz 2005; Hwang 2001). Homelessness is associated with high levels of morbidity and mortality (Hwang 2000; Hwang et al. 2009; Street Health Toronto 2007), with homeless populations in Canada experiencing higher incidences of alcohol and drug use (Grinman, Chiu and Rederlmeier 2010; Kerr et al. 2009; Torchalla, Strehlau and Krausz 2011), mental illness (Stergiopoulos et al. 2010) and infectious diseases, such as hiv/aids and hepatitis C (Corneil et al. 2006; Roy, Haley and LeClerc 2001), than their housed counterparts. In addition, an array of chronic health problems are common among homeless populations, including but not limited to diabetes (Hwang and Bugeja 2000), cardiovascular disease (Lee et al. 2005) and respiratory illnesses (Raoult, Foucault and Brouqi 2001). Unsurprisingly, the cumulative disease burden experienced by homeless persons, when combined with high levels of suicide, fatal injury and homicide, results in some of the highest all-cause mortality rates of any population in Canada (Cheung and Hwang 2004; Hwang, 2000; Hwang et al. 2009).

4Paradoxically, whereas homeless populations have high levels of health services utilization, especially emergency department and in-patient care (Hwang et al. 2011; Palepu et al. 1999), they frequently have unmet health needs due to the barriers that they face to accessing care and adhering to treatment (Hwang et al. 2010; Khandor et al. 2011; McNeil and Guirguis-Younger 2012). The reasons for this are complex and, to a great extent, largely the product of the challenges experienced by homeless persons. For example, the daily struggle for survival, such as addressing immediate needs (e.g., food, shelter etc.), often takes precedence over health needs, leading homeless persons to delay seeking treatment (Gelberg et al. 1997). Furthermore, researchers have found that homeless persons often feel unwelcome in health care settings due to discrimination and subsequent to these experiences are less likely to seek care (Wen, Hudak and Hwang 2007).

5Against this backdrop, homelessness has been increasingly characterized as Canada's most significant public health challenge (Frankish, Hwang and Quantz 2005; Hulchanski et al. 2009; Hwang 2001; Layton 2000) and yet no book or edited collection has unpacked the relationship between homelessness and health to identify potential solutions. This book seeks to remedy this by bringing together, for the first time, contributions by leading and emerging Canadian researchers exploring the relationship between homelessness and health. In doing so, it signifies an important step towards advancing our understanding of this relationship and identifying future directions. While fully accounting for the impact of homelessness on health lies beyond the scope of any one project, this book disentangles many important dimensions of this relationship. Accordingly, it has considerable potential to inform the response to one of Canada's enduring social challenges and, to that end, contributors have linked their chapters to policy and practice recommendations. The chapters in this book have been organized into three distinct but complementary sections that address a range of topics, spanning from youth homelessness to hospice and palliative care, and together constitute a blueprint for improving the health of homeless persons in Canada.

The Organization of This Book

6Part 1 of this book highlights the diversity of Canada's homeless population by exploring the health needs and experiences of particular populations. Researchers have increasingly turned their attention toward how individual characteristics intersect with social and structural factors to shape the health of particular homeless populations (i.e., women, persons of Aboriginal ancestry, etc.) and, in many cases, increase their vulnerability to adverse health outcomes (see, for example, Gelberg et al. 2004; Reading and Wien 2010). The chapters in this section of the book expand on this literature, while providing policy and practice recommendations that aim to mitigate these health disparities within the larger homeless population.

7The first two chapters explore the experiences of homeless youth. In Chapter 1, Jeff Karabanow and Sean Kidd review social and structural factors that contribute to youth homelessness, while highlighting the diversity of homeless and street-involved youth. Given that the lived experiences of homeless youth vary in accordance with their age, gender, sexuality and race, Karabanow and Kidd argue that it is critical that interventions to address youth homelessness account for this diversity. Importantly, this chapter seeks to inform the response to youth homelessness by outlining policy and practice recommendations that take into consideration the needs and experiences of homeless youth. In Chapter 2, Danielle Schwartz and her colleagues provide an overview of the individual, social and structural factors that shape sexual health outcomes among homeless and street-involved youth. In light of epidemiological data indicating that homeless youth experience adverse sexual health outcomes (see, for example, Marshall et al. 2009; Shields et al. 2004), this chapter contributes to the literature by outlining how homelessness constrains the ability of youth to adhere to risk reduction strategies.

8Chapters 3 and 4 situate the disproportionate levels of homelessness and unstable housing experienced by people of Aboriginal ancestry within the context of Canada's history of colonialism and racism. In Chapter 3, Billie Allan and Izumi Sakamoto report findings from the Coming Together project, a community-based participatory research project that explored how Aboriginal women and transwomen negotiate and survive the many challenges of homelessness and unstable housing. This chapter highlights the severe marginalization that Aboriginal women and transwomen encounter in Canadian society and presents recommendations for policymakers and service providers that seek to empower these women. In Chapter 4, Nathanael Lauster and Frank Tester report findings from a survey that explored the impact of residential crowding on Inuit people in Nunavut, focusing in particular on the implications for population health. Lauster and Tester link the shortage of safe, affordable housing to high levels of residential crowding and selfreported health problems.

9In Chapter 5, Fran Klodawsky and her colleagues explore how homelessness impacts self-reported health status and health care access among immigrants and refugees. Klodawsky and her colleagues draw upon data from the Ottawa Panel Study on Homelessness, a longitudinal study that examined changes in housing status and health among a cohort of homeless persons in the Greater Ottawa region. This study found that immigrants and refugees experienced better physical and mental health than their Canadian-born counterparts. However, Klodawsky and her colleagues note that, given that health and social service utilization increased among immigrants and refugees over time, greater attention is needed to how well existing services meet the needs of this population.

10Part 2 explores potential policy and programmatic responses to improve health access and outcomes among homeless populations. Over the past two decades, greater attention to the impact that homelessness has on health has been accompanied by calls to implement policy and programmatic reforms to increase access to affordable housing and health care services (Frankish, Hwang and Quantz 2005; Hwang 2001). To date, policy approaches to addressing the intersection of homelessness and health have been lacking, with Canada being notably without a national housing strategy. In many regards, this section of the book adds an important dimension to this ongoing discussion by mapping policies and programs that have the potential to improve our overall response to homelessness at the local, regional and national level.

11Chapters 6 and 7 explore innovative housing policies and interventions with the potential to improve health outcomes among homeless populations. In Chapter 6, Brandon Marshall and Thomas Kerr review the relationship between housing and HIV/AIDS among people who inject drugs. They explore policy and programmatic reforms that have the potential to minimize hiv risks and increase support among this population. Importantly, Marshall and Kerr suggest that integrating housing interventions with addictions treatment, health services and other evidence-based interventions have the potential to achieve the greatest possible benefits. In Chapter 7, Tim Aubry and his colleagues present findings of a review exploring the impact of supported housing initiatives on people with severe and persistent mental illness. They link the history and impact of deinstitutionalization to high levels of homelessness among people with severe and persistent mental illness. Aubry and his colleagues demonstrate that supported housing has been shown to be effective in helping people with severe and persistent mental illness achieve housing stability and should be considered as a central plank of the larger response to homelessness.

12The remaining chapters in Part 2 explore policy and programmatic strategies with the potential to improve health services delivery to homeless populations. In Chapter 8, Bruce Wallace and his colleagues explore the oral health care needs of homeless populations, which have been largely overlooked by researchers. This chapter reviews barriers that homeless populations encounter to accessing oral health care services, linking unmet oral health needs to poor overall health outcomes. Wallace and his colleagues examine how community dental clinics, and in particular those integrated into existing community health clinics, have the potential to minimize barriers that homeless populations encounter to accessing oral health care services and thus improve oral health outcomes. In Chapter 9, Bernadette Pauly explores how nurse–patient interactions shape health care access among homeless and street-involved populations. Drawing on ethnographic fieldwork, including participant observation in community health clinics and an urban emergency department, Pauly reports that by adopting non-judgmental, harm reduction approaches, nurses are able to establish trust with homeless and street-involved populations and thereby facilitate access to health care services. This chapter argues that the widespread adoption of these approaches is critical to increasing health equity. In Chapter 10, Ryan McNeil and Manal Guirguis-Younger draw on qualitative interviews conducted with health and social services professionals to examine factors that influence the siting and design of community and shelter-based health facilities for homeless populations. Given that community and shelter-based health facilities occupy an increasingly prominent role in health services delivery to homeless populations, this chapter outlines important recommendations to inform the continued development of these services across Canada and internationally.

13The final section of this book highlights innovative programs that have emerged to address the unmet health needs of homeless populations. Across Canada, communities have developed programs responsive to the needs of local homeless populations that, in many cases, represent innovative service delivery models. While, in many respects, these programs are tailored to the unique social, structural and environmental factors that shape health access and outcomes among homeless persons in these communities, they may be adapted and implemented elsewhere to respond to similar challenges. In Chapter 11, Susan Farrell and her colleagues present findings from research conducted at Ottawa's managed alcohol program, an innovative shelter-based harm reduction program for homeless persons with alcohol dependency. This chapter reviews this innovative service delivery model, which has since been replicated in several Canadian cities, and evaluates the integration of psychiatric services into this program. Farrell and her colleagues found that program participants experienced improvements in mental health outcomes, thereby underscoring the significant potential of integrating housing, harm reduction and mental health services.

14In Chapter 12, Vicky Stergiopoulos discusses Toronto's Inner City Health Associates, a program funded by the Ontario Ministry of Health and Long Term Care that aims to improve access to health care services for homeless persons by placing physicians in homeless health care settings (e.g., emergency shelters and drop-in shelters). This program has been critical in the development of innovative health care programs, such as shelter-based collaborative mental health care teams and interdisciplinary mental health outreach teams. Accordingly, this chapter provides many insights that could inform the development of similar approach in other provinces. Finally, in Chapter 13, Guirguis-Younger and McNeil discuss the dynamics that shaped the development of the Ottawa Mission Hospice, a shelter-based hospice that provides end-of-life care to homeless persons. Drawing on qualitative fieldwork, they discuss the complexities of delivering compassionate palliative care in the context of homelessness. Guirguis-Younger and McNeil contend that the development of shelter-based palliative services required a higher level of integration across the health and social care system and map the relationships between the Ottawa Mission Hospice and its partnering organizations, notably Ottawa Inner City Health. By focusing on the planning and implementation of this program, this chapter presents a framework for those who wish to adapt this model to their community.



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Postdoctoral Fellow at the British Columbia Centre for Excellence in hiv/aids and Faculty of Health Sciences at Simon Fraser University. His current research focuses on the socialstructural production of harm among drug-using populations. His previous work explored the intersection of homelessness and health, and in particular interventions to improve health outcomes among homeless populations

Research Chair in Homelessness, Housing and Health at the Centre for Research on Inner City Health in the Keenan Research Centre for the Li Ka Shing Knowledge Institute of St. Michael's Hospital and Associate Professor in the Department of Medicine and Director of the Division of General Internal Medicine at the University of Toronto. Dr. Hwang is widely considered to be one of North America's leading experts on homelessness and health. His current research projects include a longitudinal observational study of homeless populations in Toronto, Ottawa and Vancouver and a randomized controlled trial of a Housing First program for homeless persons with mental health challenges. In addition, Dr. Hwang is a staff physician at St. Michael's Hospital with more than twenty years of experience providing frontline care to homeless persons

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