Despite experiencing a disproportionate burden of acute and chronic health issues, many homeless people face barriers to primary health care. Most studies on health care access among homeless populations have been conducted in the United States, and relatively few are available from countries such as Canada that have a system of universal health insurance. We investigated access to primary health care among a representative sample of homeless adults in Toronto, Canada.
Homeless adults were recruited from shelter and meal programs in downtown Toronto between November 2006 and February 2007. Cross-sectional data were collected on demographic characteristics, health status, health determinants and access to health care. We used multivariable logistic regression analysis to investigate the association between having a family doctor as the usual source of health care (an indicator of access to primary care) and health status, proof of health insurance, and substance use after adjustment for demographic characteristics.
Of the 366 participants included in our study, 156 (43%) reported having a family doctor. After adjustment for potential confounders and covariates, we found that the odds of having a family doctor significantly decreased with every additional year spent homeless in the participant's lifetime (adjusted odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86-0.97). Having a family doctor was significantly associated with being lesbian, gay, bisexual or transgendered (adjusted OR 2.70, 95% CI 1.04-7.00), having a health card (proof of health insurance coverage in the province of Ontario) (adjusted OR 2.80, 95% CI 1.61-4.89) and having a chronic medical condition (adjusted OR 1.91, 95% CI 1.03-3.53).
Less than half of the homeless people in Toronto who participated in our study reported having a family doctor. Not having a family doctor was associated with key indicators of health care access and health status, including increasing duration of homelessness, lack of proof of health insurance coverage and having a chronic medical condition. Increased efforts are needed to address the barriers to appropriate health care and good health that persist in this population despite the provision of health insurance.
The forces which affect homelessness are complex and often interactive in nature. Social forces such as addictions, family breakdown, and mental illness are compounded by structural forces such as lack of available low-cost housing, poor economic conditions, and insufficient mental health services. Together these factors impact levels of homelessness through their dynamic relations. Historic models, which are static in nature, have only been marginally successful in capturing these relationships.
Fuzzy Logic (FL) and fuzzy cognitive maps (FCMs) are particularly suited to the modeling of complex social problems, such as homelessness, due to their inherent ability to model intricate, interactive systems often described in vague conceptual terms and then organize them into a specific, concrete form (i.e., the FCM) which can be readily understood by social scientists and others. Using FL we converted information, taken from recently published, peer reviewed articles, for a select group of factors related to homelessness and then calculated the strength of influence (weights) for pairs of factors. We then used these weighted relationships in a FCM to test the effects of increasing or decreasing individual or groups of factors. Results of these trials were explainable according to current empirical knowledge related to homelessness.
Prior graphic maps of homelessness have been of limited use due to the dynamic nature of the concepts related to homelessness. The FCM technique captures greater degrees of dynamism and complexity than static models, allowing relevant concepts to be manipulated and interacted. This, in turn, allows for a much more realistic picture of homelessness. Through network analysis of the FCM we determined that Education exerts the greatest force in the model and hence impacts the dynamism and complexity of a social problem such as homelessness.
The FCM built to model the complex social system of homelessness reasonably represented reality for the sample scenarios created. This confirmed that the model worked and that a search of peer reviewed, academic literature is a reasonable foundation upon which to build the model. Further, it was determined that the direction and strengths of relationships between concepts included in this map are a reasonable approximation of their action in reality. However, dynamic models are not without their limitations and must be acknowledged as inherently exploratory.
Cites: Am J Public Health. 2000 Dec;90(12):1939-4111111273
Cites: Am J Public Health. 2002 Feb;92(2):220-711818295
To examine the prevalence of homelessness and its relationship to mental disorder, criminal behaviour, and health care.
Interview and file data were collected for 790 male admissions to a large, pretrial jail facility over a 12-month period.
A significant relationship was found between homelessness and severe mental disorder as well as between homelessness and prior psychiatric history. There were no significant differences found between the homeless and the nonhomeless on the types of crimes for which they were incarcerated or on contact with health care services within the past year.
The findings indicate the need for a link between the jail and community services for homeless individuals.
A level-of-care needs assessment was undertaken at Ontario's largest shelter to establish homeless clients' mental health service needs and identify service gaps.
A level-of-care planning model was applied to data on 356 men. Assessments included the Colorado Client Assessment Record and a Service Needs and Use Questionnaire.
Among the clients, 32% (N=105) were recommended for weekly support, 38% (N=125) for Intensive Case Management or Assertive Community Treatment, and 9% (N=29) for 24-hour supervision in a residential care facility. Despite on-site health services, half the men did not have their level of service need met.
The wide range of unmet specialized mental health needs suggests that interventions of different structure and service intensity may be required for this population. A level-of-care planning model may be a helpful tool for ensuring homeless clients are matched to appropriate services and supports.
This study explored self-reports of five childhood maltreatment (CM) subtypes and their associations with current suicide risk in a sample of 500 homeless persons. Participants completed the Childhood Trauma Questionnaire and the Mini-International Neuropsychiatric Interview. Individual, unique, and cumulative associations of CM subtypes and subtype combinations with suicide risk (no vs. low vs. moderate/high) were examined. In multivariate analyses, four of the five CM subtypes were associated with suicide risk in individual models, but not in a model that included all CM subtypes. The strongest associations were found for reports of multitype CM involving all five subtypes. Mental disorders and female sex were independently associated with suicide risk. Clinicians working with CM victims should be aware that homeless clients are likely to report multitype maltreatment and should assess a variety of CM experiences. Future studies need to further examine multitype maltreatment and suicidal behaviors in homeless populations with complex conditions.
This study was carried out with three goals: (1) to determine the prevalence of suicidal ideation and suicide attempts among the homeless; (2) to determine what aspects of homelessness predict suicidality, and (3) to determine which aspects remain predictive after controlling for key covariates, such as mental illness. A sample of 330 homeless adults were interviewed. Sixty-one percent of the study sample reported suicidal ideation and 34% had attempted suicide. Fifty-six percent of the men and 78% of the women reported prior suicidal ideation, while 28 percent of the men and 57% of the women had attempted suicide. Childhood homelessness of at least 1 week without family members and periods of homelessness longer than 6 months were found to be associated with suicidal ideation. Psychiatric diagnoses were also associated with suicidality in this sample.
This article reports the qualitative findings of a multimethod study of the homeless population in Toronto, Canada. The qualitative component sought to identify how people become homeless and why some individuals remain homeless for an extended period of time or cycle in and out of homelessness (the chronically homeless). In-depth, semistructured interviews were conducted with 29 homeless adults. The findings suggest that people both become and remain homeless due to a combination of macro level factors (poverty, lack of employment, low welfare wages, lack of affordable housing) and personal vulnerability (childhood abuse or neglect, mental health symptoms, impoverished support networks, substance abuse). Chronically homeless individuals often reported experiences of severe childhood trauma and tended to attribute their continued homelessness to a substance abuse problem. It is concluded that both macro and individual level factors must be considered in planning programs and services to address the issue of homelessness in Canada.
While there exists an extensive body of knowledge regarding the risks associated with youth homelessness, very little work has addressed the process of exiting street contexts. This paper reports baseline findings from an ongoing longitudinal study assessing factors associated with a successful transition out of homelessness. Fifty-one formerly homeless youth who obtained stable housing in the past 2 months to 2 years participated in this study which took place in two Canadian urban centres. Findings include poorer functioning across all domains for youth residing in housing contexts without supports, a lack of relationship between psychological and behavioural aspects of community integration, and the central role of self-concept in mental health and quality of life. These findings suggest the need for ongoing support for youth exiting street spaces and social contexts, with attention to the importance of self-concept and psychological aspects of community integration.