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Poor, Sick and Homeless? The Impact of Social Determinants of Health on Women's Mental Health
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Poor, Sick and Homeless? The Impact of Social Determinants of Health on Women's Mental Health



By Susan Farrell, Ph.D., C.Psych. Clinical Director Community Mental Health Program, The Royal

By Susan Farrell, Ph.D., C.Psych. Clinical Director Community Mental Health Program, The Royal



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  • Raphael 2004 <br />
  • Raphael 2004 <br />
  • Difficult to estimate numbers due to transient nature of the population: <br /> Counted homeless re those actually in beds in shelters not those on the streets <br />
  • As reported by hostel staff <br /> Stergiopoulous 2003 CJP <br />
  • My guess is that the sample is older, better educated, and earns more money than the average Canadian. For example, I think the average household income in Canada is about $40,000. <br />
  • Experiences with homelessness were assessed by asking respondents if they had, in the past five years or in their lifetimes, ever slept in a park, abandoned building, in the street, a subway or train station, or spent a night in a homeless shelter. They were also asked if they had ever been precariously housed were also included (“Did you ever sleep at a friend’s or relatives house because you’re homeless? ). <br /> Attitudes toward homelessness were assessed using: <br /> 1} A combination of 4-point scales <br /> “How serious do you think the problem of homelessness is in the city nearest your home?: 1 = very serious, 2 = fairly serious, 3 = not too serious, 4 = not at all serious. <br /> 2) forced-choice questions <br /> e.g., "which of the following do you think should be most responsible for helping the homeless?": 1 = government, 2 = churches and charities, 3 = the homeless themselves. <br /> Items measuring perceptions of the homeless were also included. Respondents were asked to estimate what percentage of the homeless share specific characteristics <br /> (e.g., "out of 100 homeless people how many are male, married, have children, are mentally ill, have criminal records, are schizophrenic, are alcoholics”, etc). <br /> Examples of questions concerning public policy relating to homelessness: <br /> “Do you think Federal spending for helping the homeless should be increased, decreased, or remain the same?” <br /> “Should homeless people be allowed to big or panhandle in public places? (definitely yes, probably yes, probably no, definitely no) <br />
  • If necessary, remind the audience that literal homelessness means the respondents have spent at least one night on the street (on a park bench, in a bus station or subway station, in an abandoned building) or in a homeless shelter. <br /> Precariously housed individuals have spent at least one night at a friends or relatives place because they were homeless. <br />
  • Here respondents were asked to estimate the number of homeless individuals out of 100 are male, married, have children, have a criminal record, are mentally ill, etc. <br />

Poor, Sick and Homeless? The Impact of Social Determinants of Health on Women's Mental Health Poor, Sick and Homeless? The Impact of Social Determinants of Health on Women's Mental Health Presentation Transcript

  • Conversations at The Royal: Poor, Sick and Homeless? The Impact of Social Determinants of Health on Women’s Mental Health December 13, 2012 Susan Farrell, Ph.D., C.Psych. Clinical Director Community Mental Health Program, The Royal
  • My Vantage Point in Studying Homelessness and Mental Health  Clinical Director - Community Mental Health Program  Psychologist on Psychiatric Outreach Team ◦ Provide clinical services for persons who are homeless within all shelters and associated services  Researcher ◦ 15 years – University of Ottawa, ROHCG, Alliance to End Homelessness, CMHA  Female who has received health care services in 3 Canadian provinces, yet always with a bed to sleep in  Belief that housing and access to health care are universal rights
  • Overview Social Determinants of Health ◦ What are they and what is their role? Effects of Social Determinants of Health on Women’s Mental Health Spotlight on Women’s Mental Health and Homelessness Clinical and Community responses to addressing disparities
  • What is a Social Determinant of Health (SDH)? The economic and social conditions that influence the health of individuals and communities The quantity and quality of resources that a society makes available to its members
  • How do SDHs affect an Individual? Determine the extent to which a person has personal, social and physical resources to ◦ Satisfy needs ◦ Reach personal ambitions ◦ Cope with the environment Compliments idea of biological or genetic determinants of health
  • Is this a New Way of Thinking about Health? Earliest roots in 19th century with research on poverty and working conditions Increasing research and conceptualizations ◦ Has not translated into increased action to address SDH, particularly for women
  • Current Definition of SDHs  Aboriginal  Early status Life  Education  Employment and Working Conditions  Food Security  Health Care Services  Housing  Income and its Distribution  Social Safety Net  Social Exclusion  Unemployment and Employment Security
  • Social Determinants Defined Aboriginal Early Status Life Experiences Education Employment Food and Working Conditions Security
  • More SDHs Health Care Services – availability and appropriateness Housing Income Social and its distribution safety net
  • More SDHs Social inclusion (exclusion) Unemployment or Employment Security
  • What About Gender?  Not listed as a Social Determinant of Health, yet is related to inequitable distribution of most other determinants  Strong evidence of link between gender and many mental illnesses – course of illness and efficacy of treatment ◦ Consider relationship of gender and depression
  • SDHs and Gender *  Aboriginal  Early status* Life*  Education*  Employment and Working Conditions*  Food Security*  Health Care Services*  Housing*  Income and its Distribution*  Social Safety Net*  Social Exclusion*  Unemployment and Employment Security*
  • Social Determinants of Health and their Effect on Women: Focus on Employment, Income, Food Security, Housing and Health Care Services
  • Employment and Income Disparity for Women Selected Findings
  • Employment and Income Security  Low ◦ ◦ ◦ ◦ wage earners: In Canada it is not enough to have a job to keep you out of poverty. Most poor people do work full- or part-time. Poverty level wages are a particular problem for women. Women and youth account for 83% of Canada's minimum wage workers. 37% of lone mothers with paid employment must raise a family on less than $10 per hour.
  • Women and the Income Gap  72-per-cent gap has held steady since the early 1990s 85% if compare hourly wages Marie Drolet, Senior Research Economist, Statistics Canada (August 2012)  For the most part, it [wage equity] has been treated and continues to be treated as a women’s issue or an equality issue, rather than an economic imperative,” Emanuela Heyninck, commissioner of Ontario’s Pay Equity Commission.
  • Women and Poverty Selected stats from the Canadian Research Institute for the Advancement of Women (2012) A newborn child, just because she happens to be born female, is more likely to grow up to be poor as an adult Women form the majority of the poor in Canada o 1 in 7 (2.4 million) Canadian women living in poverty today o 52% of single parent families headed by women live in poverty o Almost half (41.5%) of single, widowed or divorced ("unattached") women over 65 are poor
  • Women and Poverty (continued)  Women of ethnically diverse backgrounds earn less than Canadian-born women, even with equal educational experiences  Migrant women who are often refugees or foreign domestic workers are also particularly at risk of poverty and exploitation, as they are often forced to work in unregulated or hidden employment. Women make up the majority of migrant workers from Asia and many work here to sustain their families back home.
  • Aboriginal Status and Income  The average annual income of Aboriginal women is $13,300, compared to $18,200 for Aboriginal men, and $19,350 for non-Aboriginal women.  44% of the Aboriginal population living off reserve lives in poverty  On reserved 47% have an income of less than $10,000  Aboriginal women are also more likely than Aboriginal men to be trapped in low-paying jobs- with impacts on insecurities for housing, food and services
  • Food Security & Nutrition and its relationship to Mental Health
  • Key Findings about Nutrition Promoting Mental Health Through Healthy Eating and Nutritional Care (Dieticians of Canada, December 2012) The Role of Nutrition in Mental Health Promotion and Prevention The Role of Nutrition Care for Mental Health Conditions Nutrition and Mental Health: Therapeutic Approaches Access to Affordable Healthy Food Diverse food needs related to gender and developmental stage Nutritional programs’ role in collaborative health care for costeffective positive health outcomes
  • The Absence of Safe and Affordable Housing: Homelessness and Women’s Health and Mental Health
  • Homelessness in Canada • • • Federal estimates in 2005 were 150,000 Homelessness advocates estimate closer to 300,000 Cost of homelessness in 2007 was 4.55-6 billion in emergency services, community organizations and non profits
  • Homelessness in Ottawa 7,045 people stated in emergency shelters in Ottawa in 2008 ◦ 1,179 of them were children – 473 more children than in 2007 By mid-2008 shelters ran out of beds every night Average length of stay = 51 days
  • # of People Using Emergency Shelters in Ottawa (2004-2008) Family Members Single Women 8000 7000 6000 5000 4000 3000 2000 1000 0 2004 2005 Youth Single Men 2006 Source: City of Ottawa. Note. 2004-2006 data adjusted to 2007 results. 2007 2008
  • Average Length of Stay in Emergency Shelters in Ottawa (Days) 2004-2008 Overall Youth Single men Families Single women 60 50 40 30 20 10 0 2004 2005 2006 Source: City of Ottawa. Note. 2004-2006 data adjusted to 2007 results. 2007 2008
  • # of Shelter Beds Used in Ottawa (2004-2008) Bed Nights 386,506 400,000 322,626 309,353 322,639 341,212 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 2004 2005 2006 Source: City of Ottawa Note. 2004-2006 data adjusted to 2007 results. 2007 2008
  • Most Common Reason for Hostel use Male > 65 Male < 65 Female >65 Female < 65 Family breakdown Unemployment Elder abuse Family violence Eviction Eviction Family breakdown Eviction Cognitive impairment Mental Illness Eviction Mental Illness Alcohol abuse Substance Use Hospital Referrals Substance use
  • Important Things to Remember Homelessness is not homogeneous ◦ Adult men, women, youth, families & children Experiences of homelessness are not the same ◦ One-time crisis, episodic, chronic condition ◦ Characteristics associated with each experience Individual risk factors and societal risk factors impact on both health and housing status
  • SDH in Homeless Women • • • • • • Aboriginal status* Early Life * Education * Employment and Working Conditions * Food Security * Health Care Services *  Housing *  Income and its Distribution  Social Safety Net  Social Exclusion *  Unemployment and Employment Security *
  • Relationship between Homelessness, Housing and Health What American and Canadian Research has told us
  • Some Unfortunate Universal Findings…  Homeless people are at increased risk of death ◦ Montreal Street Youth: 9x higher for males, 31 x higher for females ◦ Males in Toronto using shelters: 2-8x more likely than general population  Rates of chronic conditions higher  Prevalence of mental illness and substance abuse higher than in housed populations
  • Issues in Assuming a Causal Relationship  Homelessness is clearly associated with poor health ◦ The HOW and WHY are more individual stories  Many health related conditions contribute to homelessness – they existed before homelessness  Being homeless can make it more difficult to take care of your health  Homelessness can increase experiences of some mental health problems
  • Relationship between Housing Conditions and Health Status – Rooming Houses in Toronto ( Hwang et al., 2003)  Rooming houses provide low cost shelter – yet living in a rooming house to be consider a marker for risk of poor health, similar to homelessness, above effects of poverty alone  Rooming house residents have high prevalence of ill health (physical health conditions) than in more stable housing arrangements  Worst health concentrated in rooming houses of poorest physical condition
  • Housing Vulnerability and Health: Canada’s Hidden Emergency (REACH3)  Review of persons who are homeless and vulnerably housed in Vancouver, Ottawa, Toronto: ◦ Same high rates of physical health problems for homeless and vulnerably housed ◦ Over 50% of both groups report a diagnosis of a mental health problem ◦ Almost 40% cannot access the health care they need (physical and mental health)
  • “Forty is too young to die” Report from Toronto’s Early-Onset Illness and Mortality Working Group Once adjusted for other factors, there is still a 29% excess mortality rate for persons with mental illness Those who are also homeless – and do not disappear if marginally housed
  • Homelessness and Mental Health Estimates vary from 10-60% across North American research Significant role of substance abuse Significant role of trauma Seeing trends towards onset of symptoms at younger age and differences in presentation across gender
  • What Comes First? Mental Health Problems Homelessness  Mental  Homelessness health problems, mental illness or substance use can be a contributing factor to homelessness has been found to be both an etiological factor and exacerbating factor mental health problems
  • Impact of Homelessness on Mental Health Sleep here for a night and come to the hospital at 9 am for treatment of: •PTSD, social anxiety, depression, schizophrenia… How could housing not affect mental health?
  • Mental Health and Housing Status in BC women (Strehlau et al, 2012)  Prevalence of mental health problems substantially higher in homeless women  Moderate to high suicide risk in1/4 homeless women  Concurrent disorder in 58% of sample – higher lifetime prevalence  Rates of anxiety disorders and PTSD highest
  • Physical and Psychosocial Outcomes in housed & homeless youth (Votta & Farrell) Homeless: n = 172 ◦ Males (n = 100); Females (n = 72) At-Risk: n = 166 ◦ Males (70); Females (n = 96) High-School: n = 156 ◦ Males (n = 56); Females (n = 100)
  • Report of Physical Health Issues 50 45 40 35 30 25 20 15 10 5 0 45 Males (%) Females (%) 43 34 26 7 Homeless At-Risk 10 Housed Group, p < .001 Gender, p < .001
  • Report of Depressive Symptoms 25 20 22 Males (%) Females (%) 20 16 15 15 11 10 10 5 0 Homeless At-Risk Housed Group, p < .001 Gender, p < .001
  • Health and Health Care Utilization If we build it they will come… or will they?
  • Health Profile and Service Utilization Review (Farrell) Participants:  230 homeless persons in Ottawa ◦ Adult women ◦ Adult men ◦ Youth females and males  Use of National Population Health Survey (10,000+ households) for housed Canadian data
  • Profile Related to Mental Illness & Service Use (Homeless sample) 80 74 70 60 50 61 52 44 40 39 28 30 26 17 20 10 0 Self Report Screen Dx Dx Given Admission Adult Males Adult Females Youth Males Youth Females
  • Profile Related to Substance Use (Homeless Sample) 60 50 40 Adult Males Adult Females Youth Males Youth Females 30 20 10 0 Alcohol (CAGE) Drugs (DAST)
  • Use of family physician services in past 12 months 80 80 70 74 62 60 48 50 40 30 20 20 24 15 19 10 0 Adult Males Adult Females Youth Males Youth Females Homeless Housed
  • Using Heath Care...Without Health?  Homeless women with symptoms of mental illness had higher rates of service use in behavioural and physical medicine services – but not for homeless mothers (US national data; Tam et al, 2008)  Highest rates of use of ER, walk in clinic models in women’s health (Strehlau et al)
  • Needed health care but unable to obtain services (%) (Farrell) 45 40 35 30 25 20 15 10 5 0 45 35 28 21 Homeless Housed 3 Adult Males 5 Adult Females 3 4 Youth Males Youth Females
  • Homeless Persons Perceptions of “Welcomeness” in Health Care Settings Many perceive homelessness as barrier to getting treatment The “politics” of the waiting room Perceptions of “diagnostic overshadowing” based on homelessness Health cards and payment
  • Additional Perceptions Most frequent source of health care was the Emergency Department Follow-Up care from hospitalization was poor – unfilled prescriptions, no followup, inadequate discharge planning
  • Hospital Use (CIHI, 2008) Mental health is #1 reason for ER visits and hospital stays for persons who are homeless In the entire population, injury most common reason for ER visit and childbirth most common reason for hospital stays
  • Issues with Discharge “What good does it do to treat people’s illness, to send them back to the conditions that made them sick?” The Honourable Monique Begin, Member of WHO Commission on the Social Determinants of Health
  • Improving Access…Improving Health Consider widening access within existing models of service Understand and expand availability of evidencebased community models of intervention or service delivery Reduce the Other Language Transit Map Phenomenon to Accessing Care!
  • Lessons to be Learned from our Service Users Listening to Women The Story of Goldilocks and the Three Bears
  • Service Design Location of services ◦ Considerations of setting ◦ Outreach models Hours of services Cooperation with other providers Cognitive tasks required to attend an appointment
  • Service Considerations Past Experiences Trust Role of Trauma Social Determinants of Health Cultural Awareness and competency ◦ Culture defined by geography, religion, social group, street, other ◦ Language and use of language
  • “We’re Not Asking, We’re Telling” (Paradis et al, 2012) Good Practices in Organizations: Inclusion in service planning Inclusion in service delivery Inclusion in governance and evaluation Promoting peer support and women’s leadership
  • Service Delivery at The Royal Focus on Community Mental Health Program
  • The Royal’s Community Mental Health Program – Specialized Mental Health Services  Psychiatric Outreach Team (Outreach)  Assertive Community Treatment Teams (ACT)  Step-Down Diagnosis Consultation and ACT Teams  Homes for Special Care (Housing – first!) from ACT(model of Intensive Case Management)  Dual  Community Treatment Orders
  • Focus of The Royal’s teams  Specialized Clinical Service Delivery to persons who are homeless or at-risk of homelessness with mental illness  Advocacy  Research  Education ROHCG Mandate: Delivering specialized mental health Care Advocacy Research and Education within integrated systems
  • ROHCG Community Mental Health Program – Advocacy, Research & Education Advocacy  For clients  In collaboration with partner agencies Education  To community agencies  In public forums and conferences Research  Tracking client outcomes to improve service delivery  Part of local and national research networks to examine health and housing issues  REACH3
  • Collective Voices and Advocacy What can ALL Citizens do to address the inequities in Social Determinants of Health and their Impact on Women?
  • Levels of Advocacy Ecological Systems Theory (Bronfenbrenner)
  • Continued Challenge for us All  The continued challenge of pairing good science with social advocacy … “There is a responsibility in each of us to fight for change…it doesn’t matter where you stand – in some lab, some school, some office, some hospital or on the street”
  • Thank You For more information: Susan Farrell, Ph.D., C.Psych. Community Mental Health Program Royal Ottawa Health Care Group (613) 722-6521 ext 6922 susan.farrell@theroyal.ca
  • Extra Information
  • Selected ATEH Advocacy Recommendations (see- http://www.endhomelessnessottawa.ca/)  Federal action to put in place a new National Housing Strategy to enshrine housing as a human right for everyone  Federal funding to ensure increased available affordable housing  Increased and ongoing funding to homelessness programs
  • Attitudes of Canadians towards Homelessness  Research suggests that public opinion, to some extent, drives social policy.  For example, attitudes towards homelessness have been found to predict intentions to support program initiatives to help the homeless.  Part of a larger study, called random numbers The final sample consisted of 479 respondents (242 females, 216 males; 364 landlines and 101 cell phones)- all adults (English and French)
  • Sample Characteristics The mean age was 42 years. 55% had some form of postsecondary education. 66% voted in the previous Federal election. 49% of the sample reported an annual family incom of $57,000 or more.
  • The Measure The ◦ ◦ ◦ ◦ 151 item survey assessed: Experiences with homelessness. Attitudes toward and perceptions of the homeles Opinions concerning public policy relating to homelessness. Demographic characteristics.
  • Results - Prevalence 7.5% of respondents had experienced literal homelessness in our lifetimes, which is similar to prevalence rates in United States. 8 respondents (1.7%) had been literally homeless in the previous five years. 9.8% had been precariously housed at some point in their lives.
  • Experiences with the Homeless 71% had been asked for money by homeless panhandlers in the previous year. 65% had given money to panhandlers. 58% reported seeing at least one homeless person per week. 20% indicated they had had a close friend who had been homeless.
  • Attitudes Who is primarily at fault for homelessness? ◦ 47% felt society and the government. ◦ 46% felt the homeless themselves. Who should be most responsible for helping homeless? ◦ 63% said the federal government. ◦ 32% the homeless themselves. ◦ Only 4% said churches and charities.
  • Perceptions of the Homeless Respondents estimated that the majority of homeless individuals were male (67%), alcoholics (53%), drug addicts (51%), depressed (51%), and on public assistance (51%). Many were assumed to have children (43%), a criminal record (39%) or a mental illness (34%).
  • Upcoming Local REACH3 Research  Longitudinal analysis of predictors of housing stability and health status for persons who are homeless/vulnerably housed in Ottawa, Toronto and Vancouver  Determining patterns of homelessness shelter use in Ottawa, Toronto and Guelph  Costs of homelessness
  • The Challenge of Promoting Awareness