Diversity and Alberta Health Services

Diversity Resources

Health and Diverse Populations

Health and Persons Experiencing Homelessness in Canada

Overview
Defining Homelessness
Canadian Homelessness Statistics
Homelessness and Chronic Illness
Homelessness and Mortality
Homelessness and Youth
Homelessness and Diversity
Homelessness, Mental Illness and Substance Abuse
Strategies to Improve the Health of the Homeless
References, Reports and Websites

Overview

Canada is a developed country with an international status for having a relatively high quality of life. However, for a group of vulnerable Canadians, homelessness is a very real daily struggle. Homelessness is a serious health and social issue; individuals are at increased risk of premature death, injury, medical problems, infectious disease, mental illness, substance abuse, chronic health conditions and may encounter significant barriers in accessing health care services. In general, homelessness involves more than just an absence of adequate housing. Homelessness arises as a result of a complex number of issues that places an individual at increased risk of premature death, preventable disease and increased morbidity.

Access to a safe and secure shelter is a major determinant of health and one of the most basic of human needs. The physical environment, in which an individual lives, has a significant impact on their health status and overall wellbeing. The link between homelessness and poverty has been well established. This is of concern when approximately 18% of Canada’s population is living in deep poverty. Individuals living in poverty are at increased risk of homelessness, especially those living on a low and limited income. An illness, layoff, or missed paycheck, can lead to eviction and penalties leaving individuals and families without a home. Individuals living in poverty who are mentally ill, victims of abuse/violence, addiction or those who lack social support are at increased risk for homelessness. In addition to the impacts of poverty and comorbidity, homeless individuals also face a number of internal and external barriers to access medical care services. Homeless individuals may ignore their health problems and concentrate on their basic needs such as food, clothing, shelter, and safety. Further, healthcare providers may become prejudice and frustrated when it comes to caring for homeless individuals leading to a low quality of care. The homeless may be unable to pay for medications prescribed to them and therefore have poor prescription and treatment compliance (Plumb, 2000). The combined impacts from poverty, comorbidity, barriers to healthcare, and the high mortality rates associated with homelessness are understandable. Many homeless individuals are in survival mode, and therefore may overlook health risks to get their basic needs met.

For most individuals experiencing homelessness, the state of homelessness is a one time, short-term and temporary condition. Moreover, the health implications from the short duration of homelessness are typically minimal. However for others, homelessness is a chronic and common condition with enormous health implications.

Homelessness affects individuals of all genders, ages, sexual orientations and racial and ethnic backgrounds (Gaetz, 2004). There is no single cause for homelessness. It occurs as a result of the interaction of a complex number of factors at the individual and societal level. Factors associated with increased risk of homelessness include traumatic childhood, mental illness, substance abuse, low educational attainment, lack of job-related skills, family violence and breakdown, poverty, high living and housing costs, language barriers, racism, unemployment and poor employment conditions (Frankish, Hwang, & Quartz, 2005; Gaetz. 2004).

A strong and complex relationship has been reported between homelessness and adverse health status (Hwang, 2001; Frankish, Hwang, Quantz, 2005; Gaetz, 2004). Firstly, many of the risk factors associated with homelessness come with their own negative health impacts. For example, substance abuse, poverty, mental illness, unemployment, have all been associated with negative health implications and have been reported to be highly prevalent among the homeless (Hwang, 2001). Secondly, homeless individuals are at greater risk of developing a number of specific health conditions compared the general Canadian population as a result of their lifestyle typically. Mortality rates are significantly higher among the homeless compared to the overall general population (Roy, Boivin, Haley, Lemire, 1998; Hwang, 2000). The prevalence of mental illness and substance abuse is significantly higher (Hwang, & Bugeja, 2000). Homeless people are at greater risk of contracting infections and infestations such as scabies and lice, tuberculosis and other respiratory illness. The crowding, lack of ventilation and communal showers and toilets in shelters increases susceptibility to these conditions. Homeless individuals are also more likely to eat a poor nutritional diet (Tarasuk, & Dachner, 2005). Further, homeless individuals are more likely to participate in high risk behaviours such as drug use, multiple sex partners, and inconsistent condom use, that puts them at risk for HIV, AIDS, hepatitis and sexually transmitted diseases (Hwang, 2001). Lack of follow-up and medication compliance is evident among the homeless (Hwang, & Gottlieb, 1999). In addition, poor chronic disease management is common (Lee, Hanlon, Booth, Cantor, Connelly, Hwang, 2005; Hwang, & Bugeja, 2000). Homeless individuals have high incidence of injury and chronic illness (Gaetz, 2004). In addition, homeless individuals may face barriers to health care access.

In 1999, the Government of Canada announced the creation of a National Homelessness Initiative, which was developed to improve access to community programs, services and supports in an attempt to alleviate homelessness across all provinces and territories in Canada. Through extensive organization and consultation, partnerships have been developed and projects have been initiated to help provide coordinated services and supports to homeless individuals.

(Back To Top)

Defining Homelessness

There are essentially three categories of homelessness (Frankish, Hwang, & Quartz, 2005); 1) Absolutely homeless – refers to individuals who live outdoors, in areas not anticipated for human occupancy and those living in community shelters, 2)couch surfing homeless – includes individuals temporary staying with family and friends, and 3) At risk of homelessness – individuals living in inappropriate or unsafe housing as well as those individuals who spend a significant amount of their total income on housing (more than 50%).

Unless otherwise stated, the term homelessness in this document refers to individuals who are absolutely homeless, therefore living on the street and/or in homeless shelters.

(Back To Top)

Canadian Homelessness Statistics

The 2001 Canadian Census estimated that there are over 14,000 homeless individuals in Canada (Statistics Canada, 2002). Calgary alone has approximately 2600 homeless (Stroik, 2004) and the City of Edmonton estimates about 1900 (Edmonton Homeless Count Committee, 2002). It is difficult to determine the exact number of homeless individuals in Canada. Shelter numbers may underestimate the total number of homeless people because they do not consider the individuals sleeping outdoors.

In many major cities across Canada, the number of homeless people has increased over the past few years. Calgary’s homeless population has increased by 23.3% between 2002 and 2004 (City of Calgary, 2004). The 2004 Count of Homeless Persons identified 2597 homeless individuals; this included the homeless individuals in the shelters as well as those living on the street. The age and sex of the homeless in Calgary in 2004 varied dramatically. 23% were female and 77% were male. 3.8% were under the age of 5 years, 2.2% were between the ages of 6-12 years, 2.8% were youth aged 13-17 years, 8.9% were young adults aged 18-24, 46.7% were between the ages of 25- 44 years, 33.5% were between 45-64 years and 2% were 65 years and older (City of Calgary, 2004). Surprisingly, 104 homeless families were reported in the 2004 count.

Although homelessness impacts a diverse array of individuals, various subgroups are greater represented among the homeless. Single men make up a large proportion of the homeless population in a number of Canadian cities. Studies have reported that between 35-70% of the homeless population in Calgary, Edmonton, Vancouver, Toronto and Ottawa are single men (City of Toronto, 2000; City of Calgary, 2004; Edmonton Homeless Count Committee, 2002). Furthermore, Aboriginal people make up a significant proportion of homeless people in Canada. Aboriginal individuals represent between 11-35% of the homeless population in Calgary, Edmonton, and Vancouver; this can be compared to the general population representation of between 3.8-1.7% (City of Toronto, 2000; City of Calgary, 2004; Edmonton Homeless Count Committee, 2002).

Local Calgary Statistics reported similar findings. The 2002 Biennial Count of Homeless Persons revealed that 85% of the homeless were single, 35% were Aboriginal, 26% had a mental illness, 69% had a substance abuse problem and 10% were women fleeing domestic violence (City of Calgary, 2002).

(Back To Top)

Homelessness and Chronic Disease

Studies and reports have indicated that homeless individuals have a high prevalence for a wide range of medical problems compared to the general population (Hwang, 2001; Hwang, & Bugeja, 2000; Gaetz, 2004). Extreme poverty and inadequate living conditions may exacerbate the onset of chronic disease. In addition, homeless individuals are more likely to delay in seeking medical care and be noncompliant to medical treatment leading to a greater prevalence of highly preventable conditions (Wood, 1992; Hwang, & Gottlieb, 1999). Homeless individuals are also more likely to be exposed to other risk factors such as community bathing and eating, lack of washing facilities, unsanitary shelters, exposure to trauma, violence and crime, poor nutrition, poor medication compliance, smoking and drinking, and lack of social support; thereby increasing the risk of illness and disease (Wright, 1990).

Diabetes

There is limited data outlining the prevalence of diabetes among homeless populations in Canada. Regardless of the lack of data, diabetes is a common illness that homeless people as well as the general population suffer from. However, it has been suggested that homeless individuals are more likely to experience secondary effects due to poor diabetes management. Effective management of diabetes depends on a number of factors including frequent medical care, patient education, dietary modification, pharmacotherapy, and self-monitoring of glucose levels. A study by Hwang & Bugeja (2000) investigated the barriers to diabetes management among homeless individuals in Toronto. A total of 72% of homeless and diabetic individuals involved in the study reported difficulties in managing their diabetes. Further, 64% reported difficulties controlling their diet at the shelters. 12% identified problems with making appointments with their physician. 44% had inadequate glycemic control as measured by hemoglobin A testing. This study concluded in stating that approximately three quarters of the study population reported difficulties managing their diabetes, and close to half of the participants had inadequately controlled diabetes. The poor diabetes management among the homeless is of concern. The longer diabetes goes undetected or poorly managed, the greater the likelihood of secondary disability.

Respiratory Tract Infections

Given the poor living conditions, poor diet and the high level of substance abuse and violence, recuperation from common respiratory illness is likely more difficult for homeless individuals compared to the general population. Because ailments for common respiratory illness are not always readily available for homeless people, they tend to suffer from longer and more serious colds and flu’s (Brickner, 1990).

In addition, a large percentage of homeless individuals smoke. Thereby, increasing their risk of respiratory illness such as chronic obstructive pulmonary disease, emphysema, and asthma (Thomas, Semogas, & Gordon, 2004).

Oral disease

Oral health plays a significant role in overall health status. Homeless individuals have limited access to materials and space to disregard good oral hygiene practices and it is therefore understandable that their oral health may be poor. Dental care is not covered under Canada’s universal health care. Therefore, homeless individuals as well as those with low income have limited access to preventative and acute oral health care services. Homeless children and adults are among those individuals in Canada who suffer most from the impacts of poor oral health. Late research has reported that tooth decay and periodontal disease is significantly worse for street youth, compared to the general youth population (Lee, Gaetz, & Goetler, 1994).

Skin and foot problems

Skin and foot problems are highly prevalent among the homeless population. People living on the street and in shelters are more likely to develop skin conditions such as impetigo, cellulitis, lice, and scabies. These skin conditions can be easily treated, however, conditions such as over crowding and communal bathing, often evident in shelters, make these infestations more difficult to eliminate. If left untreated, scabies and lice can result in infection (Dennis, Levine, Osher, 1991). Any type of infection has the tendency to lead to systemic infection and associated complications.

Foot problems are also prevalent, as transportation by foot is typically the major mode of transportation for homeless people. Cellulitis, frost bite, immersion foot, athlete’s foot and warts are all common foot disorders experienced by the homeless (Maser, 2003). Adequate environments for healing may be out of reach for some homeless (such as clean and supportive footwear and a restful environment), leading to progression and worsening of foot conditions.

Often foot and skin problems are neglected until the state of the problem becomes disabling. This is of concern as a preventable and/or easily treatable condition can become unmanageable resulting in morbidity, disability and increased health care costs.

Peripheral vascular disease

Extended periods of standing or sitting are common behaviours of the homeless. This can cause poor circulation in the legs and in turn swelling of the legs, placing the individual at risk for cellulitis, ulceration and skin breakdown (Dennis, Levine, Osher, 1991; Hwang, 2001; Wrenn, 1990).

Tuberculosis

Homeless individuals are at greater risk of contracting tuberculosis (TB), due to the crowding, inadequate ventilation and large transitory populations often evident in homeless shelters (Barnes, El-Hajj, Preston-Martin, Cave, Jones, & Otaya, 1996). TB transmission can be potentially increased due to the presence of certain underlying condition such as AIDS, poor nutrition, substance abuse, and lack of access to care, which are common conditions prevalent among the homeless. Treatment from active Tuberculosis for homeless people comes with some barriers. Noncompliance with TB medication and treatment is a concern. Homeless people may go long periods of time before the disease is detected, thereby worsening the symptomology and spreading the bacteria to others. In addition, homeless individual may become resistant to the drugs after numerous administrations and prolonged infestations (Pablos-Mendez, Knirsch, Barr, Lerner, Frieden, 1997).

Studies investigating the prevalence of Tuberculosis among Canada’s homeless populations are scarce. TB prevalence data for the Toronto area has been reported in media releases and past studies. A 1997 study by Yuan, Simor, Louie, Pollock, Gould, & Jamieson (1997), reported the incidence of active tuberculosis among homeless Torontonians to be 71 per 100,000; a value approximately 10 times that of the Ontario Provincial average. Moreover, in 2001, a Tuberculosis outbreak was reported among Toronto’s homeless where counts rose to 14 active cases. (link no longer available).

Individuals with HIV and AIDS are at greater risk of developing active TB, due to their decreased host defense (Mehta, Roy, Hughes, Byrd, & Harvill, 1999).

Slide show on Tuberculosis in the Homeless/Underhoused population. Presented by Dr. Tamara Wallington, Toronto Public Health 2004. http://microbiology.mtsinai.on.ca/presentations/wallington/wallington.html

HIV/AIDS

Homeless individuals are at increased risk of contracting HIV and AIDS due to their increased exposure to risk factors. As well, the onset of a severe disability such as HIV and AIDS can result in homelessness for those individuals with limited income and lack of social support. Homeless individuals are at increased risk for exposure to HIV/AIDS risk factors such as prostitution, injection drug use, multiple sex partners and variable condom use (Roy, Haley, Lemire, Boivin, Leclerc, & Vincelette, 1999). Canadian studies investigating the prevalence of HIV and AIDS among homeless people are limited. However, studies examining HIV and AIDS high-risk behaviours have been conducted and show a definite correlation (Roy, Haley, Boivin, Vincelette, Lemire, 2000; Hwang, 2001).

Injury

Injury as a result of violence and abuse is a common concern among the homeless population in Canada. Lacerations, wounds, sprains, bruises and fractures are common traumatic injuries. Homeless individuals are at increased risk for such injuries because they are often victims of violence and abuse, and/or live in areas where crime rates are high.

Unintentional injuries are also common among the homeless population. Essentially, any human being will have an unintentional injury during their lifetime. However, for homeless individuals, access to treatment and prevention strategies may not be as widely available. Unintentional injuries may arise as a consequence from a fall or being hit by a car; these are leading causes of morbidity among homeless males. In addition, unintentional drug overdoses are common (Hwang, 2000).

Injury as a result of extreme weather conditions is common among the homeless. Living on the street in the middle of a Canadian winter puts an individual at risk for frostbite and hypothermia. Moreover, extremely hot weather conditions place an individual at risk of heat stroke, sun burn and dehydration (Maser, 2003).

The Physical and Mental Health Status of Homeless Adults. http://www.knowledgeplex.org/kp/text_document_summary/
scholarly_article/relfiles/hpd_0203_dennis2.pdf

For information on current homelessness projects going on in Calgary visit
http://www.calgaryhomeless.com/images/products/documents/1157/409C7DD8-4439-49D6-8124-754806F1739E.pdf

(Back To Top)

Homelessness and Mortality

Mortality rates among the homeless have been reported to be significantly higher than the general population (Hwang, 2001; Hwang, 2000; Roy, Boivin Haley, & Lemire, 1999).

An investigation into the mortality rates of street youth in Montreal indicated that the mortality rates for male street youth are 9 times higher and mortality rates for female street youth are 31 times higher than the general Canadian youth population (Roy, Boivin, Haley, Lemire, 1999).

Mortality rates have also been investigated among men using homeless shelters in Toronto, Ontario. Mortality rates among this population of men were 8.3 times higher that the general population for men aged 18-24 years, 3.7 times higher for men between the ages of 25 and 44 years, and 2.3 times higher for men 45 – 64 years (Hwang, 2000). The mortality rates identified in this study indicate a higher mortality for men living in homeless shelters in Toronto; however, mortality rates were much lower compared to that observed in the United States. One explanation for this difference may be the universal health care system established in Canada.

(Back To Top)

Homelessness and Youth

Homeless youth are at increased risk for a number of health problems, including communicable diseases, infections, mental illness, and sexually transmitted diseases as a result of increased exposure to factors that negatively affect their health Boivin, Roy, Haley, Galbaud du Fort, 2005). Homeless youth, also known as street youth, typically refers to youth under the age of 20 years. On average, street youth typically leave the home at age 15 years and many are leaving a family where they have directly or indirectly experienced some form of abuse (Janus, Archambault, Brown, Welsh, 1995). Because homeless youth typically do not use shelters, an accurate count of street youth is difficult.

Recent studies have reported that the prevalence of Hepatitis B and Hepatitis C are significantly higher among homeless youth compared to the general Canadian youth population (Roy, Haley, Leclerc, Boivin, Cedras & Vincelette, 2001; Roy, Haley, Lemire, Boivin, Leclerc, & Vincette, 1999). Hepatitis B is a major cause of chronic liver disease. It is typically transmitted from person to person through unprotected sex and needle drug use, high risk behaviours that are common among street youth (Mast, Alter, Margolis, 1999). Further, the prevalence of HIV among Montreal street youth was also investigated. Findings indicated that Montreal Street youth had a high prevalence of HIV compared to the general youth population (Boivin, Roy, Haley, & Galbaud du Fort, 2005).

Street youth have been reported to participate in high-risk behaviours such as needle sharing, prostitution, multiple sex partners and inconsistent condom use (Roy, Haley, Boivin, Vincelette, Lemire, 1996; Roy, Haley, Lemire, Boivin, Leclerc, Vincelette, 1999). One particular study revealed that 58% of street youth in Montreal participated in needle sharing at least once, 28% had participated in prostitution, and 58% had multiple sexual partners and did not demonstrate high compliance for condom use (Roy, Haley, Boivin, Vincelette, Lemire, 1996). Furthermore, 27% of a male street youth population in a 2004 study reported participation in survival sex, in which unprotected sex was a common activity (Haley, Roay, Leclerc, Boudreau, Boivin, 2004).

A 2002 study by Haley, Roy, Leclerc, Lambert, Boivin, & Cedras investigated the prevalence of Chlamydia and Gonorrhea among homeless youth in Montreal. Their findings indicated a higher prevalence of Chlamydia among young Montreal street youth compared to the general population. However, the prevalence of gonorrhea among Montreal street youth was not significantly different from the general population.

Victimization, violence and abuse are common before a youth leaves home as well as when the youth are living on the street (Kirpe, Simon, Montgomery, Unger, Iverson, 1997; Janus, Archambault, Brown & Welsh, 1995; Cameron, Racine, Offord, Cairney, 2004). One common reason for leaving the home among street youth was exposure to abuse and violence in the home either directly or indirectly. Moreover, when on the street, youth are at an increased risk of living in a dangerous environment and being exposed to illegal and violent activity. In a 1995 study conducted in Toronto, a significant proportion of street youth reported being physically abused and/or assaulted during the time they lived on the street (Janus, Archambault, Brown & Welsh, 1995).

A recent study conducted in Toronto, investigated the nutritional vulnerability and dietary intake among homeless youth (Tarasuk, & Dachner, 2005). Findings indicated that 7% of the youth were underweight and 22% were overweight or obese. Further, over 50% of youth had insufficient daily intakes of vitamin A, vitamin C, magnesium, zinc and folate. In addition, the majority of females involved in the study had inadequate intakes of iron and vitamin B-12. Inadequate consumption of essential vitamins and nutrients raises concern about the risk for illness and malnutrition.

Studies have reported high levels of depression and ideas of suicide among street youth compared to mainstream youth (Cameron, Racine, Offord, Cairney, 2004; Ayerst, 1999). Moreover, a large number of street youth had contact with the police, either for questioning or for an arrest. Attendance at school is poor among street youth. A Cameron, Racine, Offord, & Cairney study (2004) revealed that 55.1% of street youth interviewed indicated they were not attending school. Moreover, a large percentage (82.6%) reported being suspended from school at some point in their life.

Current research suggests that Canadian street youth are affected by many health-related problems such as infectious disease, high mortality and mental illness; however, Canadian research is limited surrounding the health status of street youth. Up-to-date Canadian data is required in the areas of mental health status, addiction, pregnancy, violence and abuse, sexually transmitted diseases, infectious diseases and mortality.

The mental health needs of homeless young people. http://www.mentalhealth.org.uk/

Pathways to Homelessness among Caribbean youth 15-25 in Toronto. Springer, & Roswell, http://www.wellesleycentral.com/ITGUpload/doc/83/ryerson_carribean%20youth_springer-EN.pdf

(Back To Top)

Homelessness and Diversity

The common stereotype of a homeless person places one distinct face on a person that is homeless. In fact, the Canadian homeless population is extremely diverse, representing individuals from all genders, ages, sexual orientations and racial and ethnic backgrounds (Gaetz, 2004). However, some sub populations are over represented compared to their population proportions.

According to the 2004 Biennial Count of Homeless persons in Calgary, 75.8% of the homeless counted were Caucasian, 14.7% were Aboriginal and 8.4% were of another visible minority (City of Calgary, 2004).

Immigrants and Refugees

Immigrants and refugees are at increased risk of becoming homeless, particularly due to poverty, unrecognized work and education credentials, delays in attaining work permits, language barriers, racism and mental health issues (Access Alliance Multicultural Community Health Centre, 2003; Gaetz, 2004). Shelter and drop in centre staff in Toronto, Ontario estimate that between 20-60 percent of the clientele are immigrants and/or refugees (Access Alliance Multicultural Community Health Centre, 2003).

Best Practices for working with homeless immigrants and refugees. Access Alliance Multicultural Community Health Centre. (2003).http://atwork.settlement.org/downloads/Best_Practice_Report.pdf

Aboriginal Homelessness

Homelessness is a very real issue for Aboriginal people of Canada. Aboriginal people are a population that is overrepresented among Canada’s homeless population (Hwang, 2001). Statistics and reports have indicated that many Aboriginal Canadians live in inadequate housing conditions (Report on the Royal Commission of Aboriginal People, 1996). Studies have reported a high level of unemployment, low education attainment and childhood poverty among this population, all of which place Aboriginals at greater risk of homelessness (Statistics Canada, 2003).

Recent studies have shown that between 5-35% of the homeless populations in Toronto, Calgary, Vancouver and Edmonton are of Aboriginal origin. In addition, a significant number of Aboriginal people sleep on the streets as opposed to shelters (Golden, Currie, Grieves, Latimer, 1999).

The National Homelessness Initiative has an Urban Aboriginal Homelessness component that concentrates on addressing the unique needs of Homeless Aboriginals in cities across Canada. For more information visit
http://www.homelessness.gc.ca/initiative/uah_e.asp

For more information about the Aboriginal Homeless Strategies currently in place in Calgary visit http://www.calgaryhomeless.com/images/products/documents/1226/5E53D6BB-9C6E-41A2-897F-D92D840AACB0.pdf

(Back To Top)

Homelessness, Mental Illness and Substance Abuse

It is estimated that approximately one in five Canadians will suffer from a mental health disorder at some point in their lives (Canadian Mental Health Association, 2002). In addition, there is a general acceptance that individuals with mental illness are at greater risk of developing a substance abuse disorder (Mueser, 1997). It is estimated that between 40-60% of people with serious mental illness develop a drug abuse problem at some point in their lives (Ananth, 1989). Substantial evidence exists to support that the high rate of comorbid substance abuse in people with mental illness is greater than that of the general population (Regier, 1990).

Interestingly, individuals with mental illness and substance abuse are disproportionately affected by homelessness (Wasylenki, & Tolomiczenko, 1999). Published reports indicate the prevalence of mental illness and substance abuse to be between 20-86% of the homeless population (Hwang, & Bugeja, 2000) The relationship between homelessness and mental illness has been well established and documented in a series of studies.

A document released by the City of Toronto (1999) reported that between 30-35% of the homeless population in Canada suffer from a mental illness (City of Toronto, 1999). Further, the mental illness prevalence estimates are greater for some specific populations. An estimated 75% of homeless women suffer from mental illness (Springer, Mars, Denison, 1998). Concurrent disorders are also prominent among the homeless; estimates of between 20-25% of homeless individuals suffer from concurrent mental health and substance abuse disorders (Golden, 2000).

A study by Stuart, & Arboleda-Florez (2000) investigated the psychiatric symptomatology and mental health needs of homeless shelter users in Calgary, Alberta. Findings from the study reported that approximately 33% of shelter users had a significant mental health problem. Moreover, 33.6% reported suffering from alcohol abuse. Those with identified psychiatric symptomatology were more likely to be poorly educated, unemployed, unmarried, and a member of a visible minority. Individuals with mental health problems were more likely to participate in unhealthy behaviours such as going without food for a day or more, sleeping outdoors, abuse and violence, and participating in sexual acts for food, money or shelter. Individuals with mental illness reported significant difficulties in finding access to mental health professionals and shelter support. Findings from this study concluded that homeless individuals with mental illness may be more disadvantaged compared to homeless individuals without an underlying mental illness (Stuart, & Arboleda-Florez, 2000).

A study by Wasylenki and Tolomiczenko (1999) investigated the prevalence of mental illness and substance abuse among a sample of homeless individual in metro Toronto. The finding indicated that approximately 66% of the homeless population in the study had a mental illness; a proportion that is significantly higher than the mean for the general Canadian population. The most common mental illnesses reported were depression, anti-social personality disorder and post traumatic stress disorder. Surprisingly, only 25% of the sample population had utilized psychiatric outpatient services in the year prior to the interview. Schizophrenia and its associated hallucinations and delusions are often the stereotype for homeless individuals. However, in this particular study, only 5.7%, had symptoms consistent with schizophrenia criteria; although higher than the general Canadian population, a relatively low prevalence among this population. The prevalence of substance abuse was very similar to the prevalence of mental illness. Almost two-thirds of the individuals in this study reported substance abuse problems, a proportion approximately 4-5 times the prevalence rate in the overall general population. The combined prevalence of substance abuse and mental illness for this population was 86%, meaning that only 14% of the population in the study had no diagnosis of either substance abuse or mental illness (Wasylenki, & Tolomiczenko, 1999). In no way can it be concluded that mental illness and substance abuse is a cause for homelessness. However, it can be suggested that mental illness and substance abuse are highly prevalent among the homeless and are possibly considerable risk factors.

A locally conducted study by Gardner & Cairns (2002) investigated the prevalence of addictions among 238 homeless individuals in Calgary, Alberta. Findings indicated that 73% of this sample was identified as having an addiction. To review the full study, refer to the following web link http://www.calgaryhomeless.com/images/products/documents/1223/3496151F-5379-4040-9976-FABBA7690F23.pdf

Homelessness and Addictions in Calgary. http://www.calgaryhomeless.com/images/products/documents/1223/06CAC4EF-CF8E-41CA-8617-667FE38B72FA.pdf

(Back To Top)

Strategies to Improve the Health of the Homeless

A number of interventions and strategies have been put in place across Canada in an attempt to decrease the prevalence of homelessness and improve the overall health status of homeless individuals. Strategies have essentially been implemented in four specific areas 1) educational and behavioural strategies, 2) environmental strategies, 3) policy and legislative strategies and 4) health care strategies.

There is considerable agreement as to the effectiveness of the Assertive Community Treatment model for homeless individuals with mental illness and other health and social related needs (Frankish, Hwang, Quartz, 2005). Harm reduction strategies have also been effective in decreasing the health impacts among homeless substance abusers.

Educational programs directed at homeless individuals and those at risk for homelessness are common. Behaviour strategies such as harm reduction, counselling and referral services are common and show to be effective in addressing the unique needs of each homeless individual.

Efforts have been made to create a supportive environment for homeless individuals. Supportive housing programs and outreach programs are common. Many communities have implemented an integrated approach to shelter care, thereby addressing the comprehensive array of issues that the homeless individual has and providing support and guidance on how to get off the street.

Policy and legislative strategies include housing and support services, local capacity building strategies and coordination between governmental agencies. These strategies attempt to deal with homelessness at a policy level by regulating and developing health public policy and community involvement strategies.

Moving Forward: Homeless Policy Framework Implementation Strategy. Alberta. 2000. http://www.seniors.gov.ab.ca/housing/homeless/homelessnessreport.pdf

How can you help the homeless?

http://www.calgaryhomeless.com/images/products/documents/1157/72768D59-E647-4B25-BBB2-E592220A7481.pdf

(Back To Top)

References, Reports and Websites:

1. Frankish, J., Hwang, S., & Quantz, D. (2005). Homelessness and Health in Canada. Canadian Journal of Public Health, 96, p.S23-S29.
Statistics Canada. (2002).

2. Stroik, S. (2004). Biennial Count of Homelessness Persons in Calgary. The City of Calgary.

3. Hwang, S. (2001). Homelessness and Health. Canadian Medical Association Journal, 164, 229-233.

4. Roy, E., Boivin, J., Haley, N., Lemire, N. (1998). Mortality among street youth. Lancet, 352:32

5. Hwang, S. (2000). Mortality among men using homeless shelters in Toronto. JAMA, 283, 2152-2157.

6. Casavant, L., Chenier, N., Dupuis, J. (1999). Homelessness. Website link no longer available.

7. Edmonton Homeless Count Committee, 2002 http://www.ehtf.ca/homeless_oct02.pdf

8. Springer, J., Mars, J., & Dennison, M. (1998). A Profile of the Homeless Population in Toronto. Report prepared for the Homelessness Action Task Force, June 1998.

9.Golden, A. (2000). Mental Health and Homelessness. The future of health in Canada.

10. Stuart, H., Arboleda-Florez, J. (2000). Homeless Shelter users in the post deinstitutionaloization Era. Canadian Journal of Psychiatry, 45, 55-62.

11. Mast, E., Alter, M., Margolis, H. (1999). Strategies to prevent and control hepatitis B and C virus infections: a global perspective, Vaccine, 17(13), 1730-1733.

12. Roy, E., Haley, N., Boivin, J., Vincelette, J., Lemire, N. (2000). HIV infection among street youth: prevalence study. International Journal of STD and AIDS, 11, 241-247.

13. Roy, E., Haley, N., Lemire, N., BOivin, J., Leclerc, P., Vincelette, J. (1999). Hepatitis B virus infection among street youth in Montreal. Canadian Medical Association Journal, 161(6), 689-693.

14. Roy, E., Haley, N., Leclerc, P., Boivin, J., Cedras, Vincelette, J. (2001). Risk factors for hepatitis C virus infection among street youth, Canadian Medical Association Journal, 165, 557-560.

15. Haley, N., Roy, E., Leclerc, P., Lambert, G., Boivin, J. Cedras, L. (2002). Risk behaviours and prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae genital infection among Montreal street youth, International Journal of STD and AIDS, 13, 238-245.

16. Roy, E., Haley, N., Leclerc, P, Cedras, I, Weber, A (2003). HIV incidence among street youth in Montreal, Canada. AIDS, 17, 1071-1075.

17. Smart, R., Adlaf, E., Walsh, Zdanowicz, Y. (1994). Similarities in drug use and depression among runaway students and street youth. Canadian Journal of Public Health, 85, 17-18.

18. Kipke, M., Simon, T., Montgomery, S. Unger, J., Iverson, E. Homeless youth and their exposure to and involvement in violence while living on the streets, Journal of Adolescent Health, 20, 360-367.

19. Janus, M., Archambault, F., Brown, S., Welsh, L. (1995). Physical abuse in Canadian runaway adolescents, Journal of Child Abuse and Neglect. 19, 433-447.

20. Boivin, J., Roy, E., Haley, N., Galbaud, G. (2005). The health of street youth. Canadian Journal of Public Health, 96(6), 432-437.

21. Tarasuk, V., Dachner, N., Li, J. (2005). Homeless youth in Toronto are nutritionally vulnerable, Journal of Nutrition, 135(8), 1926-1933.

22. Ayerst, S. (1999). Depression and stress in street youth. Adolescence, 34, 567-575.

23. Cameron, K., Racine, Y., Offord, D., Cairney, J. (2004). Youth at risk of homelessness in an Affluent Toronto Suburb. Canadian Journal of Public Health, 95(5), 352-356.

24. Plumb, J. (2000). Homelessness: reducing health disparities. Canadian Medical Association Journal, 163(2), 172-173.

25. Hwang, S., Gottlieb, J. (1999). Drug access among homeless men in Toronto. Canadian Medical Association Journal, 160(7), 1021.

26. Ananth, J. (1989). Missed diagnosis of substance abuse in psychiatric patients. Hospital and Community Psychiatry, 40, 297-299.

27. Mueser, K., Drake, R., & Miles, K. (1997). The course and treatment of
substance use disorder in patients with severe mental illness. National Institute on Drug Abuse Research Monograph. Rockland, MD: U.S. Department of Health and Human Services.

28. Regier, D., Farmer, M., Rae, D., Locke, B., Keith, S., Judd, L., & Goodwin, F. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. JAMA, 264, 2511-2518.

29. Wasylenki, D., & Tolomiczenko, G. (1999). Mental Illness and Pathways into Homelessness: Findings and Implications. Website link no longer available.

30. Hwang, S., & Bugeja, A. (2000). Barriers to appropriate diabetes management among homeless people in Toronto. Canadian Medical Association Journal, 163(2), 161-165.

31. Hwang, S. (2000). Mortality among men using homeless shelters in Toronto, Ontario. JAMA, 283(16), 2152-2157.

32. Haley, N., Roy, E., Leclerc, P., Boudreau, J., & Boivin, J. (2004). HIV risk profile of male street youth involved in survival sex. Journal of Sexually Transmitted Infection, 80(6), 526-530.

33. City of Calgary. (2004). Biennial Count of Homeless Persons 2004.

34. Dennis, D., Levine, I., & Osher, F. (1991). The Physical and Mental Health Status of Homeless Adults. Housing Policy Debate. 2.3 : 815-835.

35. Mehta, J., Roy, T., Hughes, S., Byrd, R., & Harvill, L. (1999). Demographic changes in tuberculosis: high risk groups. South.Med.J. 92 (3):280-284

36. Maser, E. (2003). Delivering health care to the Homeless. (link no longer available)

37. Access Alliance Multicultural Community Health Centre. (2003). Best Practices for working with homeless immigrants and refugees. Available at
http://atwork.settlement.org/downloads/Best_Practice_Report.pdf

38. Gaetz, S. (2004). Understanding research on homelessness in Toronto: A literature Review. Available at http://www.wellesleycentral.com/ITGUpload/doc/83/HomelessLitReview%20final%20gaetz-%20EN.pdf

39. Thomas, H., Semogas, D., Gordon, J. (2004). Health and Homelessness: Heath needs assessment and recommendations for improving the health of those experiencing homelessness in Hamilton.

40. Golden, A., Currie, W., Greaves, E., Latimer, E. (1999). Taking responsibility for homelessness: an action plan for Toronto.

41. City of Toronto. 2000. The Toronto report card on homelessness 2000.

42. Roy, E., Boivin, J., Haley, N., Lemire, N. (1998). Mortality among street youth, Lancet, 352, 32.

43. Lee, J., Gaetz, S., Goettler, F. (1994). The oral health of Toronto’s street youth. Journal of the Canadian Dental Association, 60, 545-548.

44. Yuan, L., Simor, A., Louie, L., Pollock, S., Gould, R., Jamieson, F. (1997). Tuberculosis clusters among homeless in Toronto, Canada.

45. Lee, T., Hanlon, J., Booth, G., Cantor, W., Connelly, & Hwang, S. (2005). Risk factors for Cardiovascular disease in homeless adults. Circulation, 111, 2629-2635.

46. Lee, J., Gaetz, S., & Goettler, F. (1994). The oral health of Toronto’s Street youth. Journal of the Canadian Dental Association, 60(6), 545-548.

47. Addressing the Needs of Calgary’s Homeless
http://www.calgaryhomeless.com

48. The Calgary Community Plan 2003-2008: Building Paths out of Homelessness.
http://www.calgaryhomeless.com/images/products/
documents/1222/1611B97F-6373-438E-B0F9-8DF43D408604.pdf

49. more extensive Literature review of Homelessness in Canada is available at http://www.wellesleycentral.com/ITGUpload/doc/83/HomelessLitReview%20final%20gaetz-%20EN.pdf

50. The National Homelessness Initiative. http://www.homelessness.gc.ca/home/index_e.asp

51. Taking Responsibility for Homelessness. http://www.toronto.ca/pdf/homeless_action.pdf

52. Calgary Homeless Foundation 2002 report
http://www.calgaryhomeless.com/images/products/
documents/1223/0CFD996D-5968-4625-A5B1-09A1E75D4295.pdf

53. Aboriginal Housing Association. http://www.aboriginalhousing.org/

(Back To Top)

Health and Ethnicity

Diversity and Alberta Health Services

Diversity Resources

Health and Diverse Populations

Health and Persons Experiencing Homelessness in Canada

Overview