Health and homelessness

La version française de ce billet se trouve ici.

I’m writing an open access e-book on homelessness and have just released Chapter 5 titled “Health and health conditions.” The PDF version of the full chapter is available here.

Here are 10 things to know:

1. Persons experiencing homelessness face more health challenges than do members of the general population. Physically, this includes high rates of hepatitis C, epilepsy, heart disease, cancer, asthma, arthritis/rheumatism, and diabetes. Mentally, it includes high rates of anxiety, depression, bipolar disorder, schizophrenia and substance use disorders.

2. Many people experiencing homelessness do not have a primary care provider. This may stem from numerous factors, including: service payment mechanisms that do not make providing care to complex patients lucrative, ‘cherry picking’ by some physicians to avoid caring for people who are experiencing homelessness, not having a telephone, a lack of health insurance, a lack of low-barrier clinic options (e.g., drop in hours) and frequent moves.

3. Persons experiencing homelessness often seek health care in Emergency Departments. It is also well-established that, largely due to health vulnerabilities, persons experiencing homelessness die much sooner than the rest of the population.

4. Trauma contributes to poor health outcomes. This includes trauma experienced early in life, as well as ongoing physical and sexual assault during homelessness. A Canadian study has confirmed that persons experiencing long-term homelessness suffered child trauma at a rate five times higher than the general population. Such trauma includes neglect, parents with substance use challenges, domestic violence and abuse.

5. Living without adequate shelter exposes people to both extreme weather and precipitation. Exposure to cold weather can cause frostbite and hypothermia. Exposure to hot weather can lead to heat exhaustion, heat stroke, dehydration and skin cancer. Precipitation can lead to fungal infections and other skin problems. Further, exposure to both extreme heat and extreme cold can be fatal.

6. Congregate living is also a factor. Most emergency facilities are overcrowded. In some cases, there is just one foot (i.e., 30 cm) separating persons. In other cases, vulnerable persons (including children) are in close proximity to strangers. Such overcrowding both increases infectious disease transmission and contributes to conflict among residents, all of which can negatively impact mental health. There is also often a lack of food, especially healthy food, at emergency facilities.

7. Persons experiencing homelessness are often discharged quickly from hospital with inadequate planning. Reasons for this include: pressure on hospital staff to promptly discharge patients; insufficient communication between hospital staff and community; and a lack of information sharing between hospital and community. Further, most communities lack the necessary infrastructure to support post-discharge recovery.

8. There is potential for improved hospital discharge. A Canadian study assessed the impact of on-site, predischarge housing-related assistance for psychiatric clients. With the treatment group, a manager with the local income assistance program fast-tracked social assistance funds for first and last month’s rent, while a housing worker was assigned almost immediately to the soon-to-be-discharged patient. The housing worker helped members of the treatment group call prospective landlords, and sometimes visit the housing unit with the prospective tenant. Income assistance staff were able to then provide the fast-tracked funds directly to landlords. “The housing [worker] would also assist in setting up payments to landlords if the client wished this, reviewing lease arrangements, and helping to arrange utility payments if needed.” The intervention significantly reduced the number of persons discharged into homelessness.

9. There are important harm reduction initiatives in the homeless-serving sector. Harm reduction often refers to reducing harm caused by the use of illicit substances without requiring total abstinence. Such approaches often target persons experiencing homelessness. Harm reduction approaches include the distribution of clean syringes, safe inhalation kits and supervised consumption services. This book chapter shines the light on several promising practices in this respect.

10. Some emergency facilities provide good health care. Nurses can provide wound care, medication administration, overdose responses and other health-related assessments. Physicians make regular visits to some emergency facilities in order to build trust and rapport with residents, provide episodic care for acute health conditions as well as longitudinal care for chronic conditions, and to facilitate the connection of patients to primary care or specialist care at traditional health care settings.

In sum. This is a summary of Chapter 5 of a sole-authored, open access interdisciplinary textbook intended to provide an introduction to homelessness for students, service providers, researchers, policy-makers and advocates. All material for this book is available free of charge here. Newly-completed chapters will be uploaded throughout the year.

I wish to thank Sylvia Regnier and Alex Tétreault for assistance with this blog post.