By Susan Farrell, Ph.D., C.Psych.Clinical DirectorCommunity Mental Health Program, The Royal

1. Conversations at The Royal:
Poor, Sick and Homeless?
The Impact of Social Determinants of Health
on Women’s Mental Health
December 13, 2012
Susan Farrell, Ph.D., C.Psych.
Clinical Director
Community Mental Health Program, The Royal

2. My Vantage Point in Studying
Homelessness and Mental Health

Clinical Director - Community Mental Health
Program

Psychologist on Psychiatric Outreach Team
◦ Provide clinical services for persons who are
homeless within all shelters and associated
services

Researcher
◦ 15 years – University of Ottawa, ROHCG,
Alliance to End Homelessness, CMHA

Female who has received health care services in 3
Canadian provinces, yet always with a bed to
sleep in

Belief that housing and access to health care are
universal rights

3. Overview
Social
Determinants of Health
◦ What are they and what is their role?
Effects
of Social Determinants of Health
on Women’s Mental Health
Spotlight on Women’s Mental Health and
Homelessness
Clinical and Community responses to
addressing disparities

4. What is a Social Determinant of
Health (SDH)?
The
economic and social conditions that
influence the health of individuals and
communities
The
quantity and quality of resources
that a society makes available to its
members

5. How do SDHs affect an Individual?
Determine
the extent to which a person
has personal, social and physical
resources to
◦ Satisfy needs
◦ Reach personal ambitions
◦ Cope with the environment
Compliments
idea of biological or genetic
determinants of health

6. Is this a New Way of Thinking
about Health?
Earliest
roots in 19th century with
research on poverty and working
conditions
Increasing
research and
conceptualizations
◦ Has not translated into increased action to
address SDH, particularly for women

7. Current Definition of SDHs
 Aboriginal
 Early
status
Life
 Education
 Employment and
Working Conditions
 Food Security
 Health Care Services
 Housing
 Income
and its
Distribution
 Social Safety Net
 Social Exclusion
 Unemployment and
Employment Security

8. Social Determinants Defined
Aboriginal
Early
Status
Life Experiences
Education
Employment
Food
and Working Conditions
Security

9. More SDHs
Health
Care Services – availability and
appropriateness
Housing
Income
Social
and its distribution
safety net

10. More SDHs
Social
inclusion (exclusion)
Unemployment
or Employment Security

11. What About Gender?
 Not
listed as a Social Determinant of Health, yet is related
to inequitable distribution of most other determinants
 Strong
evidence of link between gender and many mental
illnesses – course of illness and efficacy of treatment
◦ Consider relationship of gender and depression

12. SDHs and Gender *
 Aboriginal
 Early
status*
Life*
 Education*
 Employment and
Working Conditions*
 Food Security*
 Health Care Services*
 Housing*
 Income
and its
Distribution*
 Social Safety Net*
 Social Exclusion*
 Unemployment and
Employment Security*

13. Social Determinants of Health
and their Effect on Women:
Focus on Employment, Income, Food Security, Housing
and
Health Care Services

14. Employment
and Income Disparity
for Women
Selected Findings

15. Employment and Income Security
 Low
◦
◦
◦
◦
wage earners:
In Canada it is not enough to have a job to keep you
out of poverty.
Most poor people do work full- or part-time.
Poverty level wages are a particular problem for
women. Women and youth account for 83% of
Canada's minimum wage workers.
37% of lone mothers with paid employment must
raise a family on less than $10 per hour.

16. Women and the Income Gap
 72-per-cent
gap has held steady since the early 1990s 85% if compare hourly wages Marie Drolet, Senior Research
Economist, Statistics Canada (August 2012)
 For
the most part, it [wage equity] has been treated
and continues to be treated as a women’s issue or an
equality issue, rather than an economic imperative,”
Emanuela Heyninck, commissioner of Ontario’s Pay Equity Commission.

17. Women and Poverty
Selected stats from the Canadian Research Institute for the
Advancement of Women (2012)
A newborn child, just because she happens to be born female, is
more likely to grow up to be poor as an adult
Women
form the majority of the poor in Canada
o 1 in 7 (2.4 million) Canadian women living in poverty today
o 52% of single parent families headed by women live in poverty
o Almost half (41.5%) of single, widowed or divorced
("unattached") women over 65 are poor

18. Women and Poverty (continued)
 Women
of ethnically diverse backgrounds earn less than
Canadian-born women, even with equal educational
experiences
 Migrant
women who are often refugees or foreign domestic
workers are also particularly at risk of poverty and
exploitation, as they are often forced to work in unregulated
or hidden employment. Women make up the majority of
migrant workers from Asia and many work here to sustain
their families back home.

19. Aboriginal Status and Income
 The
average annual income of Aboriginal women is $13,300,
compared to $18,200 for Aboriginal men, and $19,350 for
non-Aboriginal women.
 44%
of the Aboriginal population living off reserve lives in
poverty
 On
reserved 47% have an income of less than $10,000
 Aboriginal
women are also more likely than Aboriginal men
to be trapped in low-paying jobs- with impacts on
insecurities for housing, food and services

20. Food Security & Nutrition
and its relationship to Mental Health

21. Key Findings about Nutrition
Promoting Mental Health Through Healthy Eating and Nutritional Care
(Dieticians of Canada, December 2012)
The
Role of Nutrition in Mental Health Promotion and Prevention
The Role of Nutrition Care for Mental Health Conditions
Nutrition and Mental Health: Therapeutic Approaches
Access to Affordable Healthy Food
Diverse food needs related to gender and developmental stage
Nutritional programs’ role in collaborative health care for costeffective positive health outcomes

22. The Absence of Safe and
Affordable Housing:
Homelessness
and Women’s Health and Mental Health

23. Homelessness in Canada
•
•
•
Federal estimates in 2005 were 150,000
Homelessness advocates estimate closer to
300,000
Cost of homelessness in 2007 was 4.55-6 billion
in emergency services, community organizations
and non profits

25. Homelessness in Ottawa
7,045
people stated in emergency shelters in
Ottawa in 2008
◦ 1,179 of them were children – 473 more
children than in 2007
By
mid-2008 shelters ran out of beds every
night
Average
length of stay = 51 days

26. # of People Using Emergency Shelters in
Ottawa (2004-2008)
Family Members
Single Women
8000
7000
6000
5000
4000
3000
2000
1000
0
2004
2005
Youth
Single Men
2006
Source: City of Ottawa.
Note. 2004-2006 data adjusted to 2007 results.
2007
2008

27. Average Length of Stay in Emergency
Shelters in Ottawa (Days) 2004-2008
Overall
Youth
Single men
Families
Single women
60
50
40
30
20
10
0
2004
2005
2006
Source: City of Ottawa.
Note. 2004-2006 data adjusted to 2007 results.
2007
2008

28. # of Shelter Beds Used in Ottawa (2004-2008)
Bed Nights
386,506
400,000
322,626 309,353 322,639 341,212
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
2004
2005
2006
Source: City of Ottawa
Note. 2004-2006 data adjusted to 2007 results.
2007
2008

29. Most Common Reason for
Hostel use
Male > 65
Male < 65
Female >65
Female < 65
Family
breakdown
Unemployment
Elder abuse
Family violence
Eviction
Eviction
Family
breakdown
Eviction
Cognitive
impairment
Mental Illness
Eviction
Mental Illness
Alcohol abuse
Substance Use
Hospital
Referrals
Substance use

30. Important Things to Remember
Homelessness
is not homogeneous
◦ Adult men, women, youth, families & children
Experiences
of homelessness are not the same
◦ One-time crisis, episodic, chronic condition
◦ Characteristics associated with each experience
Individual
risk factors and societal risk factors
impact on both health and housing status

31. SDH in Homeless Women
•
•
•
•
•
•
Aboriginal status*
Early Life *
Education *
Employment and Working
Conditions *
Food Security *
Health Care Services *
 Housing *
 Income and its Distribution
 Social Safety Net
 Social Exclusion *
 Unemployment and
Employment Security *

32. Relationship between Homelessness,
Housing and Health
What American and Canadian Research
has told us

33. Some Unfortunate Universal Findings…
 Homeless
people are at increased risk of death
◦ Montreal Street Youth: 9x higher for males, 31 x
higher for females
◦ Males in Toronto using shelters: 2-8x more likely than
general population
 Rates
of chronic conditions higher
 Prevalence
of mental illness and substance abuse higher
than in housed populations

34. Issues in Assuming a Causal
Relationship
 Homelessness
is clearly associated with poor health
◦ The HOW and WHY are more individual stories
 Many
health related conditions contribute to
homelessness – they existed before homelessness
 Being
homeless can make it more difficult to take care
of your health
 Homelessness
can increase experiences of some mental
health problems

35. Relationship between Housing Conditions and
Health Status – Rooming Houses in Toronto
( Hwang et al., 2003)
 Rooming
houses provide low cost shelter – yet living in
a rooming house to be consider a marker for risk of
poor health, similar to homelessness, above effects of
poverty alone
 Rooming
house residents have high prevalence of ill
health (physical health conditions) than in more stable
housing arrangements
 Worst
health concentrated in rooming houses of
poorest physical condition

36. Housing Vulnerability and Health: Canada’s
Hidden Emergency (REACH3)
 Review
of persons who are homeless and vulnerably
housed in Vancouver, Ottawa, Toronto:
◦ Same high rates of physical health problems for
homeless and vulnerably housed
◦ Over 50% of both groups report a diagnosis of a
mental health problem
◦ Almost 40% cannot access the health care they need
(physical and mental health)

37. “Forty is too young to die”
Report
from Toronto’s Early-Onset Illness and
Mortality Working Group
Once
adjusted for other factors, there is still a
29% excess mortality rate for persons with
mental illness
Those
who are also homeless – and do not
disappear if marginally housed

38. Homelessness and Mental Health
Estimates
vary from 10-60% across North
American research
Significant role of substance abuse
Significant role of trauma
Seeing trends towards onset of symptoms at
younger age and differences in presentation
across gender

39. What Comes First?
Mental Health Problems
Homelessness
 Mental
 Homelessness
health problems,
mental illness or
substance use can be a
contributing factor to
homelessness
has been
found to be both an
etiological factor and
exacerbating factor
mental health problems

40. Impact of Homelessness
on Mental Health
Sleep here for a night and come to the hospital at 9 am for
treatment of:
•PTSD, social anxiety, depression, schizophrenia…
How could housing not affect mental health?

41. Mental Health and Housing Status in BC
women (Strehlau et al, 2012)
 Prevalence
of mental health problems substantially
higher in homeless women
 Moderate
to high suicide risk in1/4 homeless women
 Concurrent
disorder in 58% of sample – higher lifetime
prevalence
 Rates
of anxiety disorders and PTSD highest

42. Physical and Psychosocial Outcomes
in housed & homeless youth (Votta & Farrell)
Homeless:
n = 172
◦ Males (n = 100); Females (n = 72)
At-Risk:
n = 166
◦ Males (70); Females (n = 96)
High-School:
n = 156
◦ Males (n = 56); Females (n = 100)

43. Report of Physical Health Issues
50
45
40
35
30
25
20
15
10
5
0
45
Males (%)
Females (%)
43
34
26
7
Homeless
At-Risk
10
Housed
Group, p < .001
Gender, p < .001

44. Report of Depressive Symptoms
25
20
22
Males (%)
Females (%)
20
16
15
15
11
10
10
5
0
Homeless
At-Risk
Housed
Group, p < .001
Gender, p < .001

45. Health and Health Care
Utilization
If we build it they will come… or will they?

46. Health Profile and Service Utilization
Review (Farrell)
Participants:
 230 homeless persons in Ottawa
◦ Adult women
◦ Adult men
◦ Youth females and males
 Use
of National Population Health Survey (10,000+
households) for housed Canadian data

47. Profile Related to Mental Illness
& Service Use (Homeless sample)
80
74
70
60
50
61
52
44
40
39
28
30
26
17
20
10
0
Self Report Screen Dx
Dx Given Admission
Adult Males
Adult Females
Youth Males
Youth Females

48. Profile Related to Substance Use
(Homeless Sample)
60
50
40
Adult Males
Adult Females
Youth Males
Youth Females
30
20
10
0
Alcohol (CAGE)
Drugs (DAST)

49. Use of family physician services
in past 12 months
80
80
70
74
62
60
48
50
40
30
20
20
24
15
19
10
0
Adult
Males
Adult
Females
Youth
Males
Youth
Females
Homeless
Housed

50. Using Heath Care...Without Health?
 Homeless
women with symptoms of mental illness had
higher rates of service use in behavioural and physical
medicine services – but not for homeless mothers (US
national data; Tam et al, 2008)
 Highest
rates of use of ER, walk in clinic models in
women’s health (Strehlau et al)

51. Needed health care but unable to
obtain services (%) (Farrell)
45
40
35
30
25
20
15
10
5
0
45
35
28
21
Homeless
Housed
3
Adult
Males
5
Adult
Females
3
4
Youth
Males
Youth
Females

52. Homeless Persons Perceptions of
“Welcomeness” in Health Care Settings
Many
perceive homelessness as barrier to
getting treatment
The
“politics” of the waiting room
Perceptions
of “diagnostic overshadowing”
based on homelessness
Health
cards and payment

53. Additional Perceptions
Most
frequent source of health care was
the Emergency Department
Follow-Up
care from hospitalization was
poor – unfilled prescriptions, no followup, inadequate discharge planning

54. Hospital Use (CIHI, 2008)
Mental
health is #1 reason for ER visits
and hospital stays for persons who are
homeless
In
the entire population, injury most
common reason for ER visit and
childbirth most common reason for
hospital stays

55. Issues with Discharge
“What
good does it do to treat people’s
illness, to send them back to the
conditions that made them sick?”
The Honourable Monique Begin,
Member of WHO Commission on the
Social Determinants of Health

56. Improving Access…Improving Health
Consider
widening access within existing
models of service
Understand
and expand availability of evidencebased community models of intervention or
service delivery
Reduce
the Other Language Transit Map
Phenomenon to Accessing Care!

57. Lessons to be Learned from our Service Users
Listening to Women
The Story of Goldilocks and the Three Bears

58. Service Design
Location
of services
◦ Considerations of setting
◦ Outreach models
Hours
of services
Cooperation with other providers
Cognitive tasks required to attend an
appointment

59. Service Considerations
Past
Experiences
Trust
Role of Trauma
Social Determinants of Health
Cultural Awareness and competency
◦ Culture defined by geography, religion, social
group, street, other
◦ Language and use of language

60. “We’re Not Asking, We’re Telling”
(Paradis et al, 2012)
Good Practices in Organizations:
Inclusion in service planning
Inclusion in service delivery
Inclusion in governance and evaluation
Promoting peer support and women’s
leadership

61. Service Delivery at The Royal
Focus on Community Mental Health Program

62. The Royal’s Community Mental Health Program –
Specialized Mental Health Services
 Psychiatric
Outreach
Team (Outreach)
 Assertive
Community
Treatment Teams (ACT)
 Step-Down
Diagnosis
Consultation and ACT
Teams
 Homes
for Special
Care (Housing – first!)
from
ACT(model of Intensive Case
Management)
 Dual
 Community
Treatment Orders

63. Focus of The Royal’s teams
 Specialized
Clinical
Service Delivery to
persons who are
homeless or at-risk of
homelessness with
mental illness
 Advocacy
 Research
 Education
ROHCG Mandate:
Delivering specialized
mental health
Care
Advocacy
Research and
Education
within integrated systems

64. ROHCG Community Mental Health Program – Advocacy,
Research & Education
Advocacy
 For clients
 In collaboration with
partner agencies
Education
 To community agencies
 In public forums and
conferences
Research
 Tracking client outcomes
to improve service delivery
 Part of local and national
research networks to
examine health and
housing issues
 REACH3

65. Collective Voices and Advocacy
What can ALL Citizens do to address the inequities
in Social Determinants of Health and their Impact on
Women?

66. Levels of Advocacy
Ecological Systems Theory (Bronfenbrenner)

67. Continued Challenge for us All
 The
continued challenge of pairing good science
with social advocacy …
“There is a responsibility in each of us to fight for
change…it doesn’t matter where you stand – in
some lab, some school, some office, some hospital
or on the street”

68. Thank You
For more information:
Susan Farrell, Ph.D., C.Psych.
Community Mental Health Program
Royal Ottawa Health Care Group
(613) 722-6521 ext 6922
susan.farrell@theroyal.ca

69. Extra Information

70. Selected ATEH Advocacy Recommendations
(see- http://www.endhomelessnessottawa.ca/)
 Federal
action to put in place a new National Housing
Strategy to enshrine housing as a human right for everyone
 Federal
funding to ensure increased available affordable
housing
 Increased
and ongoing funding to homelessness programs

71. Attitudes of Canadians towards
Homelessness
 Research
suggests that public opinion, to some extent,
drives social policy.
 For example, attitudes towards homelessness have
been found to predict intentions to support program
initiatives to help the homeless.
 Part of a larger study, called random numbers The final
sample consisted of 479 respondents (242 females, 216
males; 364 landlines and 101 cell phones)- all adults
(English and French)

72. Sample Characteristics
The
mean age was 42 years.
55% had some form of postsecondary education.
66% voted in the previous Federal election.
49% of the sample reported an annual family incom
of $57,000 or more.

73. The Measure
The
◦
◦
◦
◦
151 item survey assessed:
Experiences with homelessness.
Attitudes toward and perceptions of the homeles
Opinions concerning public policy relating to
homelessness.
Demographic characteristics.

74. Results - Prevalence
7.5%
of respondents had experienced literal
homelessness in our lifetimes, which is similar
to prevalence rates in United States.
8 respondents (1.7%) had been literally
homeless in the previous five years.
9.8% had been precariously housed at some
point in their lives.

75. Experiences with the Homeless
71%
had been asked for money by homeless
panhandlers in the previous year.
65% had given money to panhandlers.
58% reported seeing at least one homeless
person per week.
20% indicated they had had a close friend
who had been homeless.

76. Attitudes
Who
is primarily at fault for homelessness?
◦ 47% felt society and the government.
◦ 46% felt the homeless themselves.
Who
should be most responsible for helping
homeless?
◦ 63% said the federal government.
◦ 32% the homeless themselves.
◦ Only 4% said churches and charities.

77. Perceptions of the Homeless
Respondents
estimated that the majority of
homeless individuals were male (67%),
alcoholics (53%), drug addicts (51%),
depressed (51%), and on public assistance
(51%).
Many were assumed to have children (43%),
a criminal record (39%) or a mental illness
(34%).

78. Upcoming Local REACH3
Research
 Longitudinal
analysis of predictors of housing
stability and health status for persons who are
homeless/vulnerably housed in Ottawa, Toronto
and Vancouver
 Determining
patterns of homelessness shelter use in
Ottawa, Toronto and Guelph
 Costs
of homelessness

79. The Challenge of Promoting
Awareness