Are Canadians who are experiencing homelessness getting the health care that they need? The average person might assume that the answer to this question must be “yes,” because Canada has a system of universal health insurance. In fact, almost all previous studies of unmet needs for health care among homeless people have been done in the US, where more than half of people who are homeless do not have any health insurance. These studies have (not surprisingly) found that lack of health insurance greatly increases the risk of unmet needs for care. Amazingly, almost no studies have looked at this issue in countries that ensure that its citizens and residents have universal health insurance.
We recently published a study in the American Journal of Public Health that looked at unmet needs for health care among homeless people in Toronto, Canada. We surveyed a representative sample of 1169 homeless individuals at shelters and meal programs and asked them if within the last year they had needed health care but been unable to get it. Fully 17% of homeless individuals -- about one in six – reported unmet needs for care. Mothers with children who were living in family shelters were more than twice as likely to have unmet needs for care than the average mother with children living in Toronto. Among the homeless people that we interviewed, those who were younger and those who had been a victim of physical assault in the past year were more likely to have unmet needs.
These findings show us that homeless people still have substantial unmet health care needs within Canada’s system of universal health insurance. However, it’s important to realize two things. First, this finding should not be misinterpreted to mean that our system of universal health insurance is “broken” or “doesn’t work.” In fact, another recent study asked almost the same question that we did of homeless people across the US and found that 32% had been unable to obtain needed medical or surgical care in the past year. So, the rate of unmet needs among homeless people in the Canadian system is about half that of homeless people in the US. Universal health insurance works!
Second, our study underscores the importance of understanding the difference between a health insurance system and a health care delivery system. When people are disadvantaged and marginalized, it’s not enough to say that that their health care will be paid for, so there’s nothing to worry about. We need to realize that there can be many other barriers to obtaining needed care, such as not having a family physician, not having transportation to the clinic or doctor’s office, not understanding when it’s important to seek health care, or being reluctant to seek care because of previous bad experiences with health care providers. All of these factors, and more, come into play when a person is homeless.
We need to continue to design health care delivery systems that meet the needs of people who are homeless. Some of the most promising strategies include having teams of health care providers work in outreach settings such as shelters, drop-in centres, and mobile health units; enhancing the capacity of our many outstanding community health centres to provide comprehensive care for homeless patients; integrating the delivery of care for physical health, mental health, and addictions; and educating and empowering individuals who are homeless to help improve their own health.
Stephen Hwang's primary appointment is in the Department of Medicine at the University of Toronto, with cross-appointments in the Departments of Public Health Sciences and Health Policy, Management and Evaluation. His research focuses on deepening our understanding of the relationship between homelessness, housing, and health through epidemiologic studies, health services research, and longitudinal cohort studies. His current research projects include a study of predictors of health care utilization in a representative sample of 1,200 homeless men, women, and families in Toronto, a study of the barriers to the management of chronic pain among homeless people, and an evaluation of the effects of a supportive housing program on health and health care utilization among homeless and hard-to-house individuals.
The Government of Alberta has announced its intention to put forward a plan that encourages people to refrain from giving money to panhandlers, and instead to give those resources to agencies serving people who are homeless. While many people may be annoyed at the sight of panhandlers, we need to dig a little deeper to understand what is driving this initiative. At the root of many people’s negative responses to panhandling are prejudices about homeless people, and why they panhandle in the first place. Is this same prejudice driving government policy? The Alberta Minister of Housing and Urban Affairs Jonathan Denis says: “Most people think if they are giving to panhandlers they are helping the problem, but they are hurting the problem. Almost 80% of money going to panhandlers goes to negative habits — drugs, alcohol, gambling — anything that can be destructive.”
I would argue that this kind of thinking represents policy making at its worst – driven by ideology rather than evidence. People panhandle for many reasons, most notably to put cash in their hands on a day to day basis, so they can purchase what they want and need (not all needs are supplied by shelters and drop ins, such as hygiene products, adequate food, etc.). Just like you and me, people who are homeless want to be independent and make their own choices. The notion that they should not have money because they are irresponsible speaks to a paternalistic viewpoint that we wouldn’t apply to anyone else.
A key piece of research on this topic is Making Money, by Bill O’Grady and me (1999, 2002). This research shows that most people who panhandle would much rather make money through regular jobs, but because of their poverty, they face incredible barriers in obtaining – and maintaining – employment. People panhandle so that they can earn money to meet their immediate needs, and to pay for food, clothing and yes, sometimes cigarettes or alcohol. They make choices about what they spend their money on. We might not always agree with these choices, but then, you might not agree with how I spend my money.
The views expressed by the minister above, reflect longstanding prejudices that portray people who are homeless as addicts. While there is no doubt that some people who are homeless have addictions issues (and some of them panhandle) the vast majority do not. If one is concerned about the behaviours of homeless addicts, one should really ask oneself, if you take away panhandling as a source of income, exactly where will people with addictions get their money to feed their addictions? Take away panhandling, and will people do worse and more destructive things to meet needs they can’t control – things like the sex trade, drug dealing, crime and theft?
The good news in Alberta is that there is an emerging public debate on this issue that will hopefully inform the decisions that get made by politicians and average citizens. An excellent discussion took place on the news affairs program “Alberta Prime Time”.
Both University of Calgary professor Dave Este (Social Work) and Calgary Chief Bylaw Officer Bill Bruce (Calgary Police Service) presented reasoned views supported by research. Both oppose the proposed move by the Alberta government.
The other good news is that the Calgary Homeless Foundation is conducting a new study on the money making practices of people who are homeless – this will shed light on why people who live in extreme poverty panhandle.
Good policy is supported by good evidence. Research can contribute to solutions to homelessness.
Last week the CHRN launched our Leadership Academy in Program Evaluation. We brought together service providers and administrators from more than 15 homeless-serving agencies from across Canada. The idea was to begin a year long process of building capacity within the homelessness sector to conduct program evaluation that is meaningful to agencies and their clients, rather than an activity that simply responds to the demands from funders.
This Leadership Academy began with a two and a half day conference / workshop held at York University in Toronto. We had a great panel of presenters, including Michaela Hynie of York University, Stephanie Baker-Collins of McMaster, Jennie Vengris from Hamilton SPRC, Marylin Dyck from the Doorway in Calgary, Diane Dyson from Woodgreen in Toronto, and Audrey Cole and Ashley Lacome-Duncan from the Paloma Foundation. I also presented a few sessions.
Our goals for the event included:
Providing people with an understanding of basic concepts in program evaluation, tailored to concerns and issues found in the homelessness sector. We introduced participants to some key examples, including the Outcomes Star from the UK, and the Paloma -Wellesley Guide to Participatory Program Evaluation;
Having each agency leave with an action plan to help them move forward with program evaluation;
Finally, we wanted to establish a learning community to carry this work forward in the coming year. Establish is probably not the right word. We are building on the amazing work of Eva's Initiatives, which has already nurtured the development of a vibrant learning community amongst agencies working with street youth across Canada. The majority of attendees at our Leadership Academy were from Eva's Learning Community, with a few other additions.
We’re calling this a Learning Academy, because the 2.5 day event was only the beginning. Over the coming year, the agencies, will continue their work supported by the learning community, the Canadian Homelessness Research Network (CHRN), and York University. We feel this is a much better way to support learning and the application of this new knowledge.
Through the CHRN, and in partnership with York University, the Faculty of Education and the York Institute for Health Research, we are beginning to develop a fully fledged certificate course in program evaluation, that will have a strong web-based component, so stay tuned for developments on this.
My final comments have to do with the success of the event: It was incredible to have in one room such amazing talent, knowledge and experience. The conversations that took place were the major highlight for me. This is an amazing group of people who through their work demonstrate their commitment to ending homelessness in Canada. We hope that the Leadership Academy in Program Evaluation will help people working in this field to not only improve upon their work, but to make their work visible to others, and to really contribute to good solutions to the problem of homelessness. More to come on this one…
Until then, here are some photos from the event...
I am very excited to be writing the inaugural Homeless Research Matters blog post! And while I hope the title I chose, Research Cannot End Homelessness, caught your attention, I also hope you don’t buy it.
Mobilizing research to help end homelessness is kinda our shtick. We can be heard touting our slogan “Making Research Matter” from the rooftops. We actually have a lot riding on this belief...and we’re not the only ones.
What the numbers say
Between 157,000 and 300,000 Canadians experience absolute homelessness and 3.5 million Canadians live in poverty.
But where does the research come into play?
Simple - we believe that the impact of research is threefold:
· Research can help educate the general public about people who are homeless and homelessness issues;
· Research can inform policy makers and help them make evidence-based decisions;
· Research can provide evidence-based solutions to service providers in the social, health care and housing sectors.
We hope to reach more people and get evidence-based information about homelessness out to a larger audience. So, please, share this with colleagues and friends, add us to your blogroll and check back regularly for our latest posts.
How can I learn more?
Visit the homelesshub.ca for:
· Education materials for teachers and students to raise awareness of homelessness
· Arts-based research, including films, theatre, music, photography and visual art
· First-hand experiences written by homeless people, formerly homeless and service providers
· Homelessness-related events across Canada
Allyson Marsolais, Project Coordinator for the Canadian Homelessness Research Network, has a Masters Degree in Critical Disability Studies from York University and has been working in the social justice field for over 5 years.
Content on this site is licensed under a Creative Commons Attribution Non-Commercial No Derivatives License
The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.