December 21, 2012

Women and homelessness

Health is more than biology and genetics, important as those are. At a recent lecture at the Royal Ottawa Hospital, the hospital's Clinical Director of the Community Mental Health Program, psychologist Susan Farrell, discussed the other factors, the social determinants of health, especially as they affect women.

She explained that social determinants—the economic and social conditions—influence the health of individuals.  The questions to be addressed are: do these conditions satisfy needs, do they enable the person to realize personal ambitions, and do they enable the person to cope with social involvement.

Farrell listed the determinants as follows: Aboriginal status, early life experiences (trauma or neglect versus early childhood with love and appropriate nurturing), education, employment and working conditions, food security, health care, income and its distribution, social safety net, social inclusion (or exclusion), and employment security or unemployment. 

Let’s look at employment and income security.  83% of minimum wage workers are women and youth, and most poor people do work either full- or part-time.  Poverty is a mental health issue, and clearly, as she said, “poverty is expensive.”  Women make up a majority of Canada’s poor, with one out of every seven women in that category. 

Women from ethnic minorities are more likely to be poor than other women.  44% of all Aboriginals off reserve live in poverty, with 47% having an income below $10,000 a year.  Aboriginal women fare less well than their male counterparts.

Food security and good nutrition are important for physical and mental health.  In fact, appropriate diet can be prescribed as one element in a mental health treatment plan.  The diet is not just for physical health. 

Now let us turn to housing.  In Canada, on any given night somewhere between 150,000 and 300,000 people are homeless.  Like poverty generally, homeless is expensive.  Looking at the issue from a gender perspective, factors leading to homelessness vary by age, for those above and below 65.

For women in the younger group, the most important factors include family violence, eviction, mental health, substance abuse, and hospital referral (often to a shelter).  For seniors the most significant factors are elder abuse, family breakdown, eviction, and substance abuse.

Homelessness is not all of the same cloth.  For some, homelessness is just a single episode.  For others it is episodic, from time to time.  And finally for some it is chronic.  The differences are important in planning appropriate responses to the problem. 

Beyond homelessness, we deal with the fact that not all housing is equal.  People in rooming houses are still at risk for poor health, as they may be lacking other resources.

A study of Montreal street youth found that males had a death rate nine times as high as that for their housed counterparts.  The figure for females was 31 times higher.

Mental illness and substance abuse can be contributing factors for homelessness.  As well, homelessness can be a factor leading to mental illness and substance abuse.  Homeless women fare more poorly than their housed sisters on various conditions: physical health, mental health, and abuse of alcohol and drugs.  Homeless persons have more visits to general practitioners than do those who have accommodations, women more than men.  These tend to be episodic visits, not ongoing care, often to hospital emergency departments, with no follow-up care and inadequate discharge planning. 

One barrier to health care for the homeless is the health card, which may be lost or stolen.  A person without a card may face the prospect of having to pay for service.  Waiting room etiquette and culture can also act as a barrier.  While the most common reason for housed persons to visit an emergency is an injury, for the homeless it is a mental health issue.  Typically, “homeless persons in a medical setting are treated and sent back to the conditions that made them sick,” said Farrell. 

She put forward a model for assisting the homeless mentally ill: include them in the service plan, in delivery of the service, and in governance and evaluation.  “Promote peer support in women’s services.”