Conversations at The Royal:

Poor, Sick and Homeless?
The Impact of Social Determinants of Health
on Women’s Mental Health...
My Vantage Point in Studying
Homelessness and Mental Health


Clinical Director - Community Mental Health
Program



Psy...
Overview
Social

Determinants of Health

◦ What are they and what is their role?
Effects

of Social Determinants of Heal...
What is a Social Determinant of
Health (SDH)?
The

economic and social conditions that
influence the health of individual...
How do SDHs affect an Individual?
Determine

the extent to which a person
has personal, social and physical
resources to
...
Is this a New Way of Thinking
about Health?
Earliest

roots in 19th century with
research on poverty and working
conditio...
Current Definition of SDHs
 Aboriginal
 Early

status

Life
 Education
 Employment and
Working Conditions
 Food Secur...
Social Determinants Defined
Aboriginal
Early

Status

Life Experiences

Education
Employment
Food

and Working Condit...
More SDHs
Health

Care Services – availability and
appropriateness

Housing
Income
Social

and its distribution

safet...
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 ot...
SDHs and Gender *
 Aboriginal
 Early

status*

Life*
 Education*
 Employment and
Working Conditions*
 Food Security*
...
Social Determinants of Health
and their Effect on Women:
Focus on Employment, Income, Food Security, Housing
and
Health Ca...
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 ...
Women and the Income Gap
 72-per-cent

gap has held steady since the early 1990s 85% if compare hourly wages Marie Drolet...
Women and Poverty
Selected stats from the Canadian Research Institute for the
Advancement of Women (2012)
A newborn child,...
Women and Poverty (continued)
 Women

of ethnically diverse backgrounds earn less than
Canadian-born women, even with equ...
Aboriginal Status and Income
 The

average annual income of Aboriginal women is $13,300,
compared to $18,200 for Aborigin...
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, De...
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
Cos...
Homelessness in Ottawa
7,045

people stated in emergency shelters in
Ottawa in 2008
◦ 1,179 of them were children – 473 m...
# of People Using Emergency Shelters in
Ottawa (2004-2008)
Family Members
Single Women
8000
7000
6000
5000
4000
3000
2000
...
Average Length of Stay in Emergency
Shelters in Ottawa (Days) 2004-2008
Overall
Youth

Single men
Families

Single women

...
# 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...
Most Common Reason for
Hostel use
Male > 65

Male < 65

Female >65

Female < 65

Family
breakdown

Unemployment

Elder abu...
Important Things to Remember
Homelessness

is not homogeneous

◦ Adult men, women, youth, families & children
Experience...
SDH in Homeless Women
•
•
•
•
•
•

Aboriginal status*
Early Life *
Education *
Employment and Working
Conditions *
Food Se...
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 ...
Issues in Assuming a Causal
Relationship
 Homelessness

is clearly associated with poor health

◦ The HOW and WHY are mor...
Relationship between Housing Conditions and
Health Status – Rooming Houses in Toronto
( Hwang et al., 2003)
 Rooming

hou...
Housing Vulnerability and Health: Canada’s
Hidden Emergency (REACH3)
 Review

of persons who are homeless and vulnerably
...
“Forty is too young to die”
Report

from Toronto’s Early-Onset Illness and
Mortality Working Group

Once

adjusted for o...
Homelessness and Mental Health
Estimates

vary from 10-60% across North
American research
Significant role of substance ...
What Comes First?
Mental Health Problems

Homelessness

 Mental

 Homelessness

health problems,
mental illness or
subst...
Impact of Homelessness
on Mental Health
Sleep here for a night and come to the hospital at 9 am for
treatment of:
•PTSD, s...
Mental Health and Housing Status in BC
women (Strehlau et al, 2012)
 Prevalence

of mental health problems substantially
...
Physical and Psychosocial Outcomes
in housed & homeless youth (Votta & Farrell)
Homeless:

n = 172

◦ Males (n = 100); Fe...
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-Ris...
Report of Depressive Symptoms
25
20

22

Males (%)
Females (%)

20

16

15

15
11

10

10

5
0
Homeless

At-Risk

Housed
G...
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
◦ Adu...
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
...
Profile Related to Substance Use
(Homeless Sample)

60
50
40

Adult Males
Adult Females
Youth Males
Youth Females

30
20
1...
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
Mal...
Using Heath Care...Without Health?
 Homeless

women with symptoms of mental illness had
higher rates of service use in be...
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...
Homeless Persons Perceptions of
“Welcomeness” in Health Care Settings
Many

perceive homelessness as barrier to
getting t...
Additional Perceptions
Most

frequent source of health care was
the Emergency Department

Follow-Up

care from hospitali...
Hospital Use (CIHI, 2008)
Mental

health is #1 reason for ER visits
and hospital stays for persons who are
homeless

In
...
Issues with Discharge
“What

good does it do to treat people’s
illness, to send them back to the
conditions that made the...
Improving Access…Improving Health
Consider

widening access within existing
models of service

Understand

and expand av...
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...
Service Considerations
Past

Experiences
Trust
Role of Trauma
Social Determinants of Health
Cultural Awareness and co...
“We’re Not Asking, We’re Telling”
(Paradis et al, 2012)
Good Practices in Organizations:
Inclusion in service planning
I...
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)

...
Focus of The Royal’s teams
 Specialized

Clinical
Service Delivery to
persons who are
homeless or at-risk of
homelessness...
ROHCG Community Mental Health Program – Advocacy,
Research & Education
Advocacy
 For clients
 In collaboration with
part...
Collective Voices and Advocacy
What can ALL Citizens do to address the inequities
in Social Determinants of Health and the...
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 resp...
Thank You
For more information:
Susan Farrell, Ph.D., C.Psych.
Community Mental Health Program
Royal Ottawa Health Care Gr...
Extra Information
Selected ATEH Advocacy Recommendations
(see- http://www.endhomelessnessottawa.ca/)
 Federal

action to put in place a new...
Attitudes of Canadians towards
Homelessness
 Research

suggests that public opinion, to some extent,
drives social policy...
Sample Characteristics
The

mean age was 42 years.
55% had some form of postsecondary education.
66% voted in the previ...
The Measure
The

◦
◦
◦
◦

151 item survey assessed:
Experiences with homelessness.
Attitudes toward and perceptions of th...
Results - Prevalence
7.5%

of respondents had experienced literal
homelessness in our lifetimes, which is similar
to prev...
Experiences with the Homeless
71%

had been asked for money by homeless
panhandlers in the previous year.
65% had given ...
Attitudes
Who

is primarily at fault for homelessness?

◦ 47% felt society and the government.
◦ 46% felt the homeless th...
Perceptions of the Homeless
Respondents

estimated that the majority of
homeless individuals were male (67%),
alcoholics ...
Upcoming Local REACH3
Research
 Longitudinal

analysis of predictors of housing
stability and health status for persons w...
The Challenge of Promoting
Awareness
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

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

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  • Raphael 2004
  • Raphael 2004
  • Difficult to estimate numbers due to transient nature of the population:
    Counted homeless re those actually in beds in shelters not those on the streets
  • As reported by hostel staff
    Stergiopoulous 2003 CJP
  • 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.
  • 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? ).
    Attitudes toward homelessness were assessed using:
    1} A combination of 4-point scales
    “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.
    2) forced-choice questions
    e.g., &quot;which of the following do you think should be most responsible for helping the homeless?&quot;: 1 = government, 2 = churches and charities, 3 = the homeless themselves.
    Items measuring perceptions of the homeless were also included. Respondents were asked to estimate what percentage of the homeless share specific characteristics
    (e.g., &quot;out of 100 homeless people how many are male, married, have children, are mentally ill, have criminal records, are schizophrenic, are alcoholics”, etc).
    Examples of questions concerning public policy relating to homelessness:
    “Do you think Federal spending for helping the homeless should be increased, decreased, or remain the same?”
    “Should homeless people be allowed to big or panhandle in public places? (definitely yes, probably yes, probably no, definitely no)
  • 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.
    Precariously housed individuals have spent at least one night at a friends or relatives place because they were homeless.
  • 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.
  • Poor, Sick and Homeless? The Impact of Social Determinants of Health on Women's Mental Health

    1. 1. 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
    2. 2. 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
    3. 3. 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
    4. 4. 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
    5. 5. 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
    6. 6. 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
    7. 7. 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
    8. 8. Social Determinants Defined Aboriginal Early Status Life Experiences Education Employment Food and Working Conditions Security
    9. 9. More SDHs Health Care Services – availability and appropriateness Housing Income Social and its distribution safety net
    10. 10. More SDHs Social inclusion (exclusion) Unemployment or Employment Security
    11. 11. 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
    12. 12. 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*
    13. 13. Social Determinants of Health and their Effect on Women: Focus on Employment, Income, Food Security, Housing and Health Care Services
    14. 14. Employment and Income Disparity for Women Selected Findings
    15. 15. 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.
    16. 16. 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.
    17. 17. 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
    18. 18. 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.
    19. 19. 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
    20. 20. Food Security & Nutrition and its relationship to Mental Health
    21. 21. 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
    22. 22. The Absence of Safe and Affordable Housing: Homelessness and Women’s Health and Mental Health
    23. 23. 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
    24. 24. 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
    25. 25. # 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
    26. 26. 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
    27. 27. # 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
    28. 28. 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
    29. 29. 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
    30. 30. 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 *
    31. 31. Relationship between Homelessness, Housing and Health What American and Canadian Research has told us
    32. 32. 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
    33. 33. 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
    34. 34. 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
    35. 35. 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)
    36. 36. “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
    37. 37. 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
    38. 38. 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
    39. 39. 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?
    40. 40. 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
    41. 41. 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)
    42. 42. 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
    43. 43. 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
    44. 44. Health and Health Care Utilization If we build it they will come… or will they?
    45. 45. 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
    46. 46. 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
    47. 47. 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)
    48. 48. 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
    49. 49. 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)
    50. 50. 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
    51. 51. 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
    52. 52. 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
    53. 53. 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
    54. 54. 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
    55. 55. 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!
    56. 56. Lessons to be Learned from our Service Users Listening to Women The Story of Goldilocks and the Three Bears
    57. 57. Service Design Location of services ◦ Considerations of setting ◦ Outreach models Hours of services Cooperation with other providers Cognitive tasks required to attend an appointment
    58. 58. 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
    59. 59. “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
    60. 60. Service Delivery at The Royal Focus on Community Mental Health Program
    61. 61. 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
    62. 62. 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
    63. 63. 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
    64. 64. Collective Voices and Advocacy What can ALL Citizens do to address the inequities in Social Determinants of Health and their Impact on Women?
    65. 65. Levels of Advocacy Ecological Systems Theory (Bronfenbrenner)
    66. 66. 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”
    67. 67. 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
    68. 68. Extra Information
    69. 69. 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
    70. 70. 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)
    71. 71. 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.
    72. 72. 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.
    73. 73. 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.
    74. 74. 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.
    75. 75. 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.
    76. 76. 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%).
    77. 77. 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
    78. 78. The Challenge of Promoting Awareness

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