The Health and Housing in Transition (HHiT) Study

A LONGITUDINAL STUDY OF THE HEALTH OF VULNERABLY HOUSED AND HOMELESS ADULTS IN VANCOUVER, TORONTO, AND OTTAWA

The HHiT study is a large, multi-city study to learn more about the health of vulnerably housed and homeless adults across Canada. The results will help us better understand how changes in housing status can affect health. They will also help us to identify factors that help people achieve stable, healthy housing.

SIGNIFICANCE:

This is the first study to report on longitudinal changes (i.e. changes over time) in the health and housing status of vulnerably housed and homeless people in Canada, and the first to compare their health outcomes.

FOCUS:

This study is tracking the health and housing status of 1,200 vulnerably housed and homeless single adults in Vancouver, Toronto, and Ottawa over a two-year period. We recruited 200 vulnerably housed adults and 200 homeless adults in each city (1,200 total), from shelters, meal programs, single room occupancy hotels, and rooming houses.

WHAT’S NEXT:

In 2009, we completed our first round of interviews with participants. In 2010 and 2011, we’ll conduct follow-up interviews, to see how - and why - participants’ housing and health status have changed. This information will be useful to communities and decision-makers; our goal is to guide the development of effective programs and policies to prevent and end housing vulnerability and homelessness.

WHO’S INVOLVED:

Research partners from the Centre for Research on Inner City Health (St. Michael’s Hospital); Carleton University; Centre for Research on Educational and Community Services (University of Ottawa); Ottawa Inner City Health, Inc; PHS Community Services Society (Vancouver); Royal Ottawa Health Care Group; Street Health (Toronto); and University of British Columbia. HHiT is funded by the Canadian Institutes of Health Research.

DEFINITIONS:

For this study, we defined “homelessness” as living in a shelter, on the street, or in other places not intended for human habitation. We also considered people who were couch surfing (i.e. staying temporarily with family or friends) to be homeless.

A person was “vulnerably housed” if they had their own place, but at some point in the past year had either been homeless or had moved at least twice.

However, the results showed us that in many ways, the division between these two groups is false. The people we identified as “vulnerably housed” were not just at risk of homelessness; in the past 2 years, they had spent almost as much time homeless (just under 5 months per year) as the homeless group did (6.5 months per year). Instead of two distinct groups, this is one large, severely disadvantaged group that transitions between the two housing states.

The HHiT findings in this report are from our first round of in-person, structured interviews with participants, conducted in 2009. We asked questions about demographics, housing history, social support, health status, substance use, and health care utilization. The result is a detailed health and social profile of vulnerably housed and homeless single adults across Canada.

WHAT WE FOUND: PEOPLE WHO ARE VULNERABLY HOUSED FACE THE SAME SEVERE HEALTH PROBLEMS AS PEOPLE WHO ARE HOMELESS.

People who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless - are at high risk of:

Serious physical and mental health problems

Problems accessing the health care they need

Hospitalization

Assault

Going hungry

THE IMPLICATION: A HIDDEN EMERGENCY

The number of people experiencing the devastating health outcomes associated with housing problems could be staggering; far beyond previous estimates based on shelter and street counts. Across Canada, there are about 17,000 shelter beds available on a regular basis.1 But almost 400,000 people are vulnerably housed.2 See page 4 for a breakdown by city and province.

On any given night in Canada, for every one person sleeping in a shelter, there are 23 more people living with housing vulnerability.

They are all at risk of devastating health outcomes.

THE SOLUTION: HEALTHY HOUSING

The real gulf in health outcomes doesn’t lie between people who are homeless and people who aren’t homeless. It’s between those who have continued access to healthy housing, and those who don’t. To support health, housing must be decent, stable, and appropriate to its residents’ needs. See page 6 to learn more about what makes housing “healthy”.

WHAT WE FOUND:

PHYSICAL HEALTH ISSUES

People who are vulnerably housed face the same severe health problems - and danger of assault - as people who are homeless.

Among people who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless:

Chronic health conditions like arthritis (33%), Hepatitis B and C (30%), asthma (23%), high blood pressure (18%), chronic obstructive pulmonary disease (18%), ulcers (9%), diabetes (8%), heart disease (8%), HIV (6%), cirrhosis (6%), cancer (5%), epilepsy (4%), and fetal alcohol syndrome (4%) are common.

Over 1/4 (28%) have trouble walking, lost a limb, or other problems with mobility.

38% had been beaten up or attacked in the past year.

MENTAL HEALTH ISSUES

People who don’t have a healthy place to live are at high risk of serious mental health problems.

Among people who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless:

More than half (52%) reported a past diagnosis of a mental health problem.

61% have had a traumatic brain injury at some point in their lives.

The top-reported mental health issues were depression (31%), anxiety (14%), bipolar disorder (13%), schizophrenia (6%), and post-traumatic stress disorder (5%).

BARRIERS TO SELF CARE

1 in 3 people who don’t have a healthy place to live have trouble getting enough to eat.

Among people who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless:

1 in 3 (33%) reported having trouble getting enough to eat.

1 in 4 (27%) reported not being able to get good quality food.

1 in 5 (22%) reported that their diet is not nutritious.

Of the 36% who have been advised to follow special diets, only 38% actually follow them.

BARRIERS TO HEALTH CARE

Almost 40% of people who don’t have a healthy place to live can’t access the health care they need.

Among people who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless:

38% reported having unmet health care needs (i.e. needing health care, but being unable to get it) at some point in the past year.

23% reported having had unmet mental health care needs.

The top barriers to accessing health care were: being too depressed/not up for going (11%); being refused service (10%); not having a health card (9%); and the wait for an appointment was too long (8%).

1 in 5 (19%) reported that they didn’t know where to go to get the mental health care they needed.

HOSPITAL VISITS

Many people who don’t have a healthy place to live end up hospitalized or in the emergency department.

Among people who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless:

55% had visited the emergency department at least once in the past year.

1 in 4 (25%) had been hospitalized overnight at least once in the past year (not counting nights spent in the emergency department).

Other National Research: VULNERABLY HOUSED AND HOMELESS PEOPLE NATIONWIDE DIE MUCH EARLIER THAN PEOPLE WHO LIVE IN STABLE HOUSING.

In 2009, Hwang et al.3 analyzed the mortality rates and causes of death for 15,000 people living in shelters, rooming houses, and hotels across Canada. The study found that among people in Canada who don’t have a healthy place to live:

The average lifespan is 7-10 years shorter than the lifespan of the general Canadian population.

Men have about the same chance (32%) of surviving to age 75 as an average man in 1921 - before the advent of antibiotics.

Women have about the same chance (60%) of surviving to age 75 as an average woman in Guatemala, where a significant proportion of the population lacks access to basic health care services.

Many excess deaths are related to mental disorders and suicides. Homeless and vulnerably housed men are twice as likely as the general Canadian population to commit suicide. Homeless and vulnerably housed women are almost 6 times more likely to commit suicide.

THE IMPLICATION: CANADA’S HIDDEN CRISIS

On any given night in Canada, for every one person sleeping in a shelter, there are 23 more people living with housing vulnerability.

They are all at risk of devastating health outcomes.

ABOUT THESE TABLES: HOMELESSNESS AND HOUSING VULNERABILITY ACROSS CANADA

We used Homeless Individuals and Families Information System (HIFIS) data on Canada’s shelter bed capacity to estimate how many people may be homeless on any given night in Canada. However, it’s important to note that shelter counts don’t include people who are sleeping on the street or couch surfing. The total number of homeless people in Canada is unknown.

We used Canada Mortgage and Housing Corporation (CMHC) data on low and moderate income renters who spent more than 50% of their income on rent to estimate how many people are vulnerably housed across Canada. When housing costs more than 50% of a low household income, tenants don’t have enough money left over to meet basic needs, like paying for food, clothing, and medication.2, 4

This is a different definition of “housing vulnerability” than the one we used for the HHiT study (see page 1). There’s no national data for our specific criteria. We’re using the CMHC data for this purpose because the “vulnerably housed” individuals we looked at for the HHiT study are likely to share many important characteristics with the individuals in the CMHC “vulnerably housed” group, since (a) the vulnerably housed group we looked at in the HHiT study had a low income (about $900/month), and spent an average of 52% of their income on rent, and (b) this extreme level of housing affordability stress is likely to put tenants at risk of homelessness. It’s also important to note that the shelter bed data in this table indicates individuals, but the housing vulnerability data indicates households (i.e. groups of people who live together).

Sources:

2009 Shelter Capacity Report, Homeless Individuals and Families Information System (HIFIS) (Homelessness Partnering Secretariat). Ottawa: Human Resources and Skills Development Canada; 2010.

CMHC (census-based housing indicators and data, 2006), quoted in 2006 Census Housing Series: Issue 8 - Households in Core Housing Need and Spending at Least 50% of Their Income on Shelter. Socio-economic Series 10-017. Canada Mortgage and Housing Corporation; 2010.

CMHC (census-based housing indicators and data, 2006), quoted in 2006 Census Housing Series: Issue 2 - The Geography of Core Housing Need, 2001-2006. Socio-economic Series 09-005. Canada Mortgage and Housing Corporation; 2009.

NUMBER OF HOUSEHOLDS EXPERIENCING HOUSING VULNERABILITY

THE SOLUTION:

A healthy place to live is more than just a roof over one’s head. To support health, housing must be decent, stable, and appropriate to its residents’ needs.

“Decent” housing is good quality.

Decent housing is safe, clean, in reasonable repair, and offers basic privacy, security, personal space, and protection from dangerously hot or cold weather. In decent housing, residents can rest and recover when they’re ill, and stay healthy when they’re well.

“Stable” housing is affordable.

Affordable housing costs 30% or less of residents’ income, including utilities. At this level, rent is financially sustainable and unlikely to eclipse other basic needs (like buying food, clothing, or medication). Subsidized rent on private market rentals, or on housing that’s owned and managed by government agencies and/or non-profit organizations (i.e. “social housing”), is an affordable housing solution for people with low incomes.

“Appropriate” housing offers needed supports.

The vast majority of vulnerably housed and homeless people - even those with severe mental health and/or substance use issues - can successfully stay housed and off the street when the right supports are in place.

For example, many “supportive” and “supported” housing programs have been very successful in helping people with high needs for support stay housed.5, 6, 7 “Supportive housing” is social housing that provides tenants with on-site or closely linked medical, mental health, and substance abuse services. “Supported housing” allows people to live independently, in regular housing in the community, and service providers visit clients as needed. Research shows that supportive and supported housing can lead to fewer hospitalizations and less time spent in jail among homeless people with severe mental health issues. The resulting cost savings in these areas significantly offset the cost of the programs.8, 9, 10

Everyone needs a healthy place to live.

Our minimum standards for health care - the Canada Health Act - were introduced “to protect, promote, and restore the physical and mental well-being of residents of Canada”.11 Without healthy housing, the chances of all Canadians benefiting from these standards are very slim.

Our federal government must respond, and set national housing standards that ensure universal, timely access to decent, stable, and appropriate housing. Everyone should be able to access – and keep - housing that supports their health.

References

1. 2009 Shelter Capacity Report, Homeless Individuals and Families Information System (HIFIS) (Homelessness Partnering Secretariat). Ottawa: Human Resources and Skills Development Canada; 2010.

2. CMHC (census-based housing indicators and data, 2006), quoted in 2006 Census Housing Series: Issue 8 - Households in Core Housing Need and Spending at Least 50% of Their Income on Shelter. Socio-economic Series 10-017. Canada Mortgage and Housing Corporation; 2010.

3. Hwang SW, Wilkins R, Tjepkema M, O’Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses and hotels in Canada: An 11-year follow-up study. BMJ. 2009 Oct 26;339:b4036.

4. Statistics Canada (Spending Patterns in Canada 2001, Catalogue no. 62-202-XPE) 2001.

5. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004; 94(4):651-656.

6. Pearson C, Locke G, Montgomery A, Buron L. The Applicability of Housing First Models to Homeless Persons With Serious Mental Illness. Washington, DC: US Dept of Housing and Urban Development, Office of Policy Development and Research; 2007.

7. What Housing First Means For People: Results of Streets to Homes 2007 Post-Occupancy Research. Toronto: City of Toronto Shelter, Support and Housing Administration; 2007.

8. Gilmer TP, Stefancic A, Ettner SL, Manning WG, Tsemberis S. Effect of full-service partnerships on homelessness, use and costs of mental health services, and quality of life among adults with serious mental illness. Arch Gen Psychiatry. 2010 Jun;67(6):645-52.

9. Rosenheck R, Kasprow W, Frisman L, Liu-Mares W. Cost-effectiveness of supported housing for homeless persons with mental illness. Arch Gen Psychiatry. 2003;60(9):940-951.

10. Culhane D, Metraux S, Hadley T. Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing. Housing Policy Debate. 2002;13(1):107-163.

11. Canada Health Act 1984, c. 6, s. 9. (Act current to October 6th, 2010).

About this Report

About this Report

Published by: Research Alliance for Canadian Homelessness, Housing, and Health (REACH3)

Prepared by: Emily Holton, Evie Gogosis, and Stephen Hwang

Health and Housing in Transition (HHiT) study research team:

TORONTO:

Stephen Hwang, St. Michael’s Hospital

Laura Cowan, Street Health

James Dunn, St. Michael’s Hospital

Stephanie Gee, Street Health

Evie Gogosis, St. Michael’s Hospital

Jeffrey Hoch, St. Michael’s Hospital

David Hulchanski, University of Toronto

Rosane Nisenbaum, St. Michael’s Hospital

Ying Di, St. Michael’s Hospital

OTTAWA:

Tim Aubry, University of Ottawa

Susan Farrell, Royal Ottawa Health Care Group

Josh Greenberg, Carleton University

Elizabeth Hay, University of Ottawa

Fran Klodawsky, Carleton University

Wendy Muckle, Ottawa Inner City Health, Inc

VANCOUVER:

Anita Palepu, University of British Columbia

Liz Evans, PHS Community Services Society

Sarah Evans, PHS Community Services Society

Clare Hacksel, PHS Community Services Society

Anita Hubley, University of British Columbia

Shannon Pidlubny, University of British Columbia

Funding and coordination:

The Health and Housing in Transition (HHiT) study is funded by the Canadian Institutes of Health Research (CIHR).

The preparation of this report was funded by the Canadian Homelessness Research Network and BMO Financial Group.

The Research Alliance for Canadian Homelessness, Housing, and Health (REACH3) is coordinated by the Centre for Research on Inner City Health (CRICH), part of the Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital. CRICH receives annual core funding from the Ministry of Health and Long-Term Care, Ontario. Learn more about CRICH and REACH3 at www.crich.ca.

How to cite this document: Housing Vulnerability and Health: Canada’s Hidden Emergency. Toronto: Research Alliance for Canadian Homelessness, Housing, and Health; November 2010.

An electronic version of this report is available at www.homelesshub.ca.

Cette publication st également disponible en français aux adresses www.homelesshub.ca et www.crich.ca avec le titre: La vulnérabilité en matière de logement et la santé : l’urgence cachée du Canada.

For more information about this report or the Health and Housing in Transition (HHiT) study, contact Evie Gogosis at GogosisE@smh.ca.

©2010 Research Alliance for Canadian Homelessness, Housing, and Health (REACH3).

The views expressed herein are those of the authors and do not necessarily represent the views of the above organizations.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the proper written permission of the publisher.

How to cite this document: Housing Vulnerability and Health: Canada’s Hidden Emergency. Toronto: Research Alliance for Canadian Homelessness, Housing, and Health; November 2010.

An electronic version of this report is available at www.homelesshub.ca.

This publication is also available in English at www.homelesshub.ca and www.crich.ca under the title: Housing Vulnerability and Health: Canada’s Hidden Crisis.

For more information about this report or the Health and Housing in Transition (HHiT) study, contact Evie Gogosis at GogosisE@smh.ca.

©2010 Research Alliance for Canadian Homelessness, Housing, and Health (REACH3).

The views expressed herein are those of the authors and do not necessarily represent the views of the above organizations.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the proper written permission of the publisher.

Founded in 2003, REACH3 is a national, transdisciplinary alliance of academic investigators and community-based organizations. Its members share a long-term commitment to research that improves the health of Canadians experiencing housing vulnerability.

Principal Investigator: Stephen Hwang, MD, MPH, Centre for Research on Inner City Health, St. Michael’s Hospital.

Funder: The Canadian Institutes of Health Research.

For more information visit www.crich.ca.