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Homelessness and Health in Canada

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Homelessness and Health in Canada HOMELESSNESS AND HEALTH IN CANADA HOMELESSNESS AND HEALTH IN CANADA EDITED BY Manal Guirguis-Younger Ryan McNeil Stephen W. Hwang University of Ottawa Press 2014 The University of Ottawa Press acknowledges with gratitude the support extended to its publishing list by Heritage Canada through the Canada Book Fund, by the Canada Council for the Arts, by the Federation for the Humanities and Social Sciences through the Awards to Scholarly Publications Program and by the University of Ottawa. Copy editing: Trish O’Reilly-Brennan Proofreading: Joanne Muzak Typesetting: Infographie CS Cover illustration and design: Johanna Pedersen eBook development: WildElement.ca Library and Archives Canada Cataloguing in Publication Homelessness & health in Canada / edited by Manal Guirguis-Younger, Ryan McNeil, Stephen W. Hwang. Includes bibliographical references. Issued in print and electronic formats. ISBN 978-0-7766-2143-2 (pbk.).-- ISBN 978-0-7766-2148-7 (pdf).-- ISBN 978-0-7766-2147-0 (epub) 1. Homelessness--Health aspects--Canada. 2. Homeless persons-- Health and hygiene--Canada. 3. Homeless persons--Medical care--Canada. 4. Homeless persons--Government policy--Canada. 5. Homeless persons-- Canada--Social conditions. I. Guirguis-Younger, Manal, 1967- author, editor of compilation II. McNeil, Ryan, 1982- author, editor of compilation III. Hwang, Stephen, editor of compilation IV. Title: Homelessness and health in Canada. RA564.9.H63H64 2014 362.1’0425 C2014-901278-0 C2014-901279-9 © University of Ottawa Press, 2014 Printed in Canada Table of Contents List of Figures ..................................................................................... vii List of Tables ....................................................................................... viii Introduction by Manal Guirguis-Younger, Ryan McNeil and Stephen W. Hwang ........................................................................ 1 Part I—Homelessness & Health in Canadian Populations 1 Being Young and Homeless: Addressing Youth Homelessness from Drop-in to Drafting Policy by Jeff Karabanow and Sean Kidd .............................................. 13 2 Sexual Risk Behaviours and Sexual Health Outcomes among Homeless Youth in Canada by Danielle R. Schwartz, Carolyn A. James, Anne C. Wagner and Trevor A. Hart ..................................................................... 35 3 Helpers, Not Helpless: Honouring the Strength, Wisdom and Vision of Aboriginal Women Experiencing Homelessness or Marginal Housing by Billie Allan and Izumi Sakamoto ........................................... 57 4 Homelessness and Health in the Crowded Canadian Arctic: Inuit Experiences by Nathanael Lauster and Frank Tester ...................................... 87 5 Homeless Immigrants’ and Refugees’ Health over Time by Fran Klodawsky, Tim Aubry and Rebecca Nemiroff .............. 111 Part II—Policy & Programmatic Responses to Homelessness & Health 6 Housing and hiv/aids among People Who Inject Drugs: Public Health Evidence for Effective Policy Response by Brandon D. L. Marshall and Thomas Kerr ............................ 135 7 Supported Housing as a Promising Housing First Approach for People with Severe and Persistent Mental Illness by Tim Aubry, John Ecker and Jonathan Jetté ............................ 155 8 Homelessness and Oral Health by Bruce Wallace, Rafael Figueiredo, Michael MacEntee and Carlos Quiñonez .................................................................. 189 9 Close to the Street: Nursing Practice with People Marginalized by Homelessness and Substance Use by Bernadette Pauly ................................................................... 211 10 Dignity in Design: The Siting and Design of Community and Shelter-Based Health Facilities for Homeless Persons by Ryan McNeil and Manal Guirguis-Younger.......................... 233 Part III—New Approaches: Innovations to Address Homelessness & Health 11 An Examination of the Delivery of Psychiatric Services within a Shelter-Based Management of Alcohol Program for Homeless Adults by Susan Farrell, Beth Wood, Heather King-Andrews, Donna Lougheed, Wendy Muckle, Lynn Burnett and Jeff Turnbull ........................................................................ 255 12 Collaborative Approaches to Community-Based Mental Health Care for Homeless People: Toronto’s Inner City Health Associates by Vicky Stergiopoulos ............................................................... 275 13 The Development and Operational Context of an Emergency Shelter–Based Hospice in Ottawa, Ontario: A Qualitative Study by Manal Guirguis-Younger and Ryan McNeil.......................... 293 Contributors ........................................................................................ 313 List of Figures Figure 3-1 Members of the advisory board and research team ................................................................................ 68 Figure 3-2 Example of Coming Together project dissemination posters ...................................................74 Figure 3-3 Illustrating the themes of ‘inclusion and accountability’ to address homelessness ................... 78 Figure 6-1 Cumulative incidence of hiv infection among Vancouver injection drug users from 1996 to 2007, stratified by housing status at baseline .................... 139 vii List of Tables Table 2-1 Overview of major e-sys findings in 1999, 2001 and 2003 ......................................................................... 36 Table 4-1 Homelessness dimensions as measured by equivalent survey item responses ............................... 95 Table 4-2 Estimates of homelessness prevalence by dimension amongst those over age 15 ........................ 98 Table 4-3 Coincidence of homelessness dimensions (homelessness index alpha = 0.396) ............................. 99 Table 4-4 Other measures of housing need and crowding from survey (weighted to Nunavut age/sex distribution) ................................................................. 100 Table 4-5 Items measuring health conditions and related problems .......................................................................101 Table 4-6 Links between homelessness measures and health conditions or related problems .......................102 Table 4-7 Links between health conditions and housing situation, as perceived by respondents (weighted to Nunavut age/sex distribution) ............ 103 Table 4-8 Links between related problems and the number of people in the house, as perceived by respondents (weighted to Nunavut age/sex distribution) ................................................................. 103 Table 5-1 Overview of panel study subgroups, sampling criteria, number of recruitment sites and baseline and follow-up sample size ..........................................114 Table 5-2 Country of origin of foreign-born respondents .......116 Table 5-3 Health-related quantitative results for panel study matched Canadian-born and foreign-born respondents, and immigrant and refugee respondents ................................................................. 120 Table 5-4 Health-related quantitative results for immigrant and refugee respondents ............................................ 121 viii Table 7-1 Description of different housing approaches implemented after deinstitutionalization ................ 158 Table 7-2 Criteria of supported housing as defined in different reviews focusing on implementation issues .............................................................................163 Table 7-3 Characteristics of selected supported housing studies ...........................................................................168 Table 7-4 Summary of outcomes in effectiveness studies on supported housing ................................................ 173 Table 8-1 Select published studies of the oral health status of homeless people .......................................................193 Table 11-1 Demographic characteristics of study sample ......... 265 Table 11-2 Changes in clinical outcomes .................................... 267 ix Introduction Manal Guirguis-Younger, PhD Faculty of Human Sciences, Saint Paul University Ryan McNeil, PhD British Columbia Centre for Excellence in hiv/aids Faculty of Health Sciences, Simon Fraser University Stephen W. Hwang, MD Centre for Research on Inner City Health, St. Michael’s Hospital Why This Book? tereotypical images of homeless persons, such as those of ‘junkies’, S‘squeegee kids’ or ‘bag ladies’, shape popular understandings of homelessness but obscure the scope and diversity of Canada’s home- less population. Over the past thirty years, the retreat of the federal government from social housing, along with reforms to social welfare programs and health care, has contributed to a growing homelessness crisis that affects tens of thousands of people every year (Hulchanski et al. 2009). This steady growth in Canada’s homeless population has been accompanied by greater awareness that this population is highly heterogeneous (Gaetz 2010; Laird 2007). Although some groups are overrepresented among the nation’s homeless population due to wider social inequities embedded in Canadian society, notably people of Aboriginal ancestry (Hwang 2001), homelessness does not discriminate on the basis of age, gender, sexuality or race. In turn, Canada’s homeless population reflects the country’s overall diversity. Increased recognition of the diversity of Canada’s homeless population has led to greater acknowledgement that homeless- ness encompasses a wide range
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