Health and Homelessness in Ireland from Economic Book to Bust - Dr Fiona O'Reilly IPH, Open, Conference, Belfast, Northern, Ireland, Dublin, Titanic, October, 2014, Health Public

1. Health & Homelessness in
Ireland:
From economic boom to bust
Fiona O’Reilly PhD,
Ailish Hannigan PhD, Stacey Scriver PhD
Suzanne Barror MSc, Lynn Ruane, Anne MacFarlane PhD
Austin O’Carroll MD

2. Acknowledgements
• Co-funded by the Partnership for Health
Equity, HSE Social Inclusion and Safetynet.
• The Dublin Simon Community (DSC)
• Anna Liffey volunteers collected data in
Limerick.

3. Overview
• Homeless health survey 2013
– Demographics
– Health Status
– Addiction
– Service Usage
• Comparison over time with 2005 &1997
surveys
• Conclusion

4. 1997
• ..best performing economies in the industrialised world..
• 1997 economy grew by 9.5%
• Employment growth 3.8%
• Highest level of job creation in the industrialised world.
http://irelandnow.com/economy.html
2,900 1999, Counted In Homeless Initiative
78% smokers
29% drank alcohol beyond recommended limits
29% illegal drugs
43% perceived themselves to be in only fair or poor health
67% per cent of people had at least one physical or mental health
problem
54% saw a GP
45% had no medical card

5. 2005
• The Economist found Ireland to have the best quality of life in the world
• Employment soared from 1.1 million to 1.9 million (1990-2005)
• Very high economic growth, the highest growth rates in Europe
2,280 2005, Counted In 2005
90% smokers
28% drank alcohol beyond recommended limits
64% had used illegal drugs
54% perceived themselves to be in only fair or poor health
84% per cent of people had at least one physical or mental health problem
74% saw a GP
45% had no medical card

6. 2013
• The economic challenges continues
• Prolonged European sovereign-debt crisis caused a new Irish recession
starting in Q3 2012
• In May 2013 forecast for Ireland predicted its growth rates would return to
a positive 1.1% in 2013 and 2.2% in 2014.
.
3,808 2011 Census
90% smokers
39% drank alcohol beyond recommended limits
78% had used illegal drugs
47% perceived themselves to be in only fair or poor health
89% per cent of people had at least one physical or mental health
problem
82% saw a GP
25% had no medical card

7. Methods
• Cross sectional survey 2013 Dublin & Limerick
(601)
• Health status, service utilization and risk
behaviours
• Interviewer questionnaire (20min)
• Comparison surveys 2005, 1997
• Definition
a)‘roofless’ i.e. people sleeping rough or people in emergency
accommodation and
b) designated accommodation for homeless which is of a temporary nature
ETHOS - European Typology on Homelessness and Housing Exclusion

8. Sample
Accommodation
Type
No.
accommod
ations
North
Dublin/South
Dublin / Limerick
No. residents
previous night
Number
participated in
survey
Response rate (%)
TEA/STA 21 Dublin 485 329 68%
PEA 13 North Dublin 291 186 64%
Limerick STAs 6 Limerick 134 63 47%
Rough
Sleepers
Dublin 23
TOTAL 910 601 66%

9. THE SAMPLE

10. Demographics
• Men: 68%
• Under 45 years: 78%
• Single: 72%
• Parents: 64%
– Few with children: 6%
Homeless > 1 year
In care as a child
• Mainly White Irish: 84%
• Roman Catholic: 82%
• Unemployed:95%
• In Receipt of social welfare: 96%

11. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%
Drug or alcohol and family problems
Family relationship problems /Dom violence
Drugs or alcohol
Drugs
Financial or eviction
Alcohol
Other
Crime
Mental health problems
In care as a child
Limerick
Dublin

12. HEALTH

13. Total
n 650
Self-rated health status Very good or Excellent 19.7%
Good 33.5%
Fair or Poor 46.8%
n 600
Preventing normal daily
activities
Physical health 46.0%
Mental or emotional health 51.5%
Getting older
On methadone Injecting drug use
Diagnosis
Special service attenders High alcohol intake
Hospital inpatient stay A&E Attenders

14. Self perceived health status: fair/poor
Homeless
Housed

15. Dublin Limerick Total
n 536 63 599
Either mental or physical diagnosis 90% 83% 89%
Physical health condition 83% 67% 81%
At least one mental health diagnosis 58% 59% 58%
Blood borne virus 31% 0% 27%
Liver disease higher in Dublin
Dental problems higher in Dublin
More diagnosis of physical conditions among drug users
Most with diagnosis reported receiving treatment
1 in 4 undiagnosed health problems

16. Dublin
n 531
HIV positive 3.6%
Treated for HIV 3.6%
n 525
Diagnosed with Hepatitis B 4.8%
Treated for Hepatitis B 2.9%
n 530
Hepatitis C positive 28.5%
Hepatitis C positive (n=151)
Treated for Hepatitis C 53.0%
Assessed for treatment or offered treatment 73.5%
Hep C 36% in 2005

17. High mental health morbidity among
homeless people
• 58% at least one mental health
condition.
• 52% reported mental or
emotional health affected
their activities of daily living
• 60% reporting mental health
diagnosis were currently on
prescription medication

18. Total (n=599)
Diagnosed with anxiety 40%
Treated for anxiety 33%
Diagnosed with depression 52%
Treated for depression 44%
Diagnosed with schizophrenia or psychosis 13%
Treated for schizophrenia or psychosis 11%
Mental health diagnosis and
Self-diagnosed addiction problem
47%
Mental health diagnosis and
Currently illicit drug use
35%
Report of a diagnosis of at least one mental health conditions was
more common among current and past drug users and women.

19. Health trend 1997-2013
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
1997 2005 2014
Diagnosed Illness
Taking
Prescription
Medication
Anxiety
Depression
2013

20. 60%
50%
40%
30%
20%
10%
0%
Suicidal ideation and behaviour
self harm suicidal
thoughts
attempted
suicide
prior to last 6 months
in previous 6 months
Drug users <45yrs women
>6months in
homelessness

21. Suicide attempts by mental health problem
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Mental health diagnosis No Mental health diagnosis
Attempted suicide
Did not attempt suicide

22. ADDICTION

23. Excessive drinking
2005 37% 12%
2013 41% 36%
Dublin 39% Limerick 43%
General Population 10% (SLAN 2007)
Above 21 standard drinks for men and 14 for women

24. Drugs
• 78% current or
past
• 55% current users

25. 80
56
46
25
60
49
22
15
Drug Use Ever Current Drug Use IDU Ever IDU (last 12
months)
Dublin % Limerick %

26. 60%
50%
40%
30%
20%
10%
0%
Dublin
Limerick

27. Current drug use by age group

28. Current and Past drug use
Current use Past Use

29. Current & Past heroin
Limerick Dublin
25% in past year - Dublin
15% in past year - Limerick

30. Drug use among people on MMT
70
60
50
40
30
20
10
0
%
n=211
• 42% of current drug users were prescribed sedative / minor tranquillizers
• 49% of those reporting illicit benzo use were also prescribed them

31. Self report main addiction
Dublin Limerick Total
n 377 38 412
Main Problem Drug Alcohol 39.6% 57.9% 41.3%
Opiates 43.6% 15.8% 41.0%
Cannabis 4.0% 13.2% 4.9%
Minor Tranquilizers (tablets) 8.0% 10.5% 8.3%
Cocaine/crack 3.2% 2.6% 3.2%
Other 1.6% 0.0% 1.5%
78% had used a drugs’ service in past 12 months
- counselling 45%,
- needle exchange 28%
- inpatient detox 18%
- rehab or stabilization 18%
- aftercare 12%
…30 waited for inpatient detox

32. Changes in addiction patterns
100
90
80
70
60
50
40
30
20
10
0
1997
(n=502)
2005
(n=363)
2014
(n=601)
%
Ilicit drug use (ever)
Drinking above limits
Smoking
Heroin as main
addiction

33. Changes in illicit drug use
60
50
40
30
20
10
0
2005 (n=363) 2013 (n=531)
%
Heroin use (ever)
Cocaine (ever)
Benzos (ever)
Street Methadone
(ever)
Injected drugs (ever)

34. HEALTH SERVICE USE

35. Medical card and GP Registration
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Dublin Limerick
Has medical card
Registered with GP

36. Health professionals seen
in last 6 months
Dublin Limerick Total
Own GP 57.1% 81.0% 59.6%
Nurse 38.4% 40.3% 38.6%
Any GP or Nurse including special
81.5% 90.5% 82.7%
homeless services
Social Worker 27.2% 19.7% 26.5%
Counsellor 30.1% 35.0% 30.6%
Chiropodist 5.1% 8.2% 5.4%
Dentist 27.9% 23.0% 27.4%
Psychiatrist 17.9% 23.0% 18.4%
Psychiatric Nurse 10.4% 26.2% 12.0%
Any Special Service* 52% 38% 50%
* Safetynet in Dublin , Multi disciplinary outreach team in Limerick

37. On site support and key working
• Almost 60% had key workers and over 40%
had care plans.
• Support within accommodation more
common in Limerick & STAs in Dublin.
• People with a key worker were more likely to
have a medical card and access services.

38. Changes in service use and access
90
80
70
60
50
40
30
20
10
0
1997 2005 2013
%
Own GP
Social Worker
Any GP or Nurse
Medical Card

39. Attended psychiatrist or psychiatric nurse
80
70
60
50
40
30
20
10
0
1997 2005 2013
%
Psychiatrist
(Depression/Anxiet )
Psychiatric Nurse
(Depression/Anxiety)
Psychiatrist(All)
Psychiatric Nurse (All)
Psychiatrist
(Schizophrenia)
Psychiatric Nurse
(Schizophrenia)

40. Use of secondary services
50
45
40
35
30
25
20
15
10
5
0
1997 2005 2013
%
A&E
Hospital
Outpatients
Inpatient
Psychiatric
inpatient

41. Barriers to health service use
• Previous Negative Experiences 79
• Service(s) not open when needed 42
• No Medical Card 41
• Too Expensive/Cost 36
• Long waiting 23
• Can’t get required treatment 13
• Other Things more Important 12
• Difficulty getting a GP 10
• Experienced HRC/not legally resident 4
• Other 27

42. Satisfaction with services
40%
35%
30%
25%
20%
15%
10%
5%
0%
Very Good Good Ok Bad Very Bad
Dublin
Limerick

43. Improvements needed
Services were people are at!
• More outreach on site services and information
• Non discriminating services
Ultimately HOUSING
“Get homeless people off the streets so they can get better health
services”
“If the housing facilities were better and so many not boarded up
then less people would be homeless and their health would be better”

44. CONCLUSIONS

45. Context of boom and bust
http://www.irisheconomy.ie/index.php/2012/09/21/trends-in-living-standards/

46. • In context of increasing numbers of homeless & reconfiguration of
services … increasing access to health care, more diagnosed &
treated illness however increased A&E use
• Homelessness is an unhealthy state with homeless people suffering
disproportionate levels of illness and addiction
• High level of mental health problems and suicidality
• High poly drug use with concurrent legal illegal and prescribed
drugs
• Key working improving access
• Better access in limerick with small manageable population

47. Recommendation
• A&E liaison for homeless
• Suicide prevention and crisis centre
• Coherent mental health strategy that targets dual
diagnosis
• Target individual needs with service rather than fitting
person to services
• All health services for homeless should incorporate
stable accommodation as a treatment goal
“I’m 13 years on a housing list. Being housed will improve
health. Instead I’m given the run around and pawned off”

48. Life on the streets
Backed into a corner,
wishing away pain.
Satanic whispers in your ear,
driving you insane.
Frustrations get the best of you,
all you’ll do is scream.
You’ll realize you’ll never win,
because demons never dream.
—17-year-old homeless girl, Toronto, March 2004
Kidd S, Factors Precipitating Suicidality among Homeless Youth : A Quantitative Follow-
Up. Youth Society 2006 37: 393

49. Homeless people
have attempted
suicide