Research Matters Blog
Young people who are homeless have few of the securities that those with shelter take for granted. Youth who are homeless face an increased risk of being victims of violence, especially sexual violence. The relationship between sexual violence and homelessness is complicated: sexual violence is both a contributor to homelessness and a factor resulting from homelessness. The below infographic, published by the National Sexual Violence Resource Center in the United States, looks into the link that exists between youth homelessness and sexual violence.
One way of understanding the scope of the problem at hand is by comparing the rates of sexual violence among youth in the general population to the rates of sexual violence among youth living in homelessness. The infographic states that 21-41% of homeless youth in the US report sexual abuse compared to just 1%-3% of youth in the general population. This is a startlingly high discrepancy. Clearly, living on the streets dramatically increases the risk of being a victim of sexual violence.
Among homeless youth, certain groups are at increased risk of being victims of sexual violence. Findings from a 2009 survey among homeless youth in Toronto found that among female youth, black females were more likely to be victims of sexual assaults (47%) than white females (33%). The same survey found that 33.4% of homeless LGBTTQ youth (who represented a quarter of youth surveyed) had been victims of sexual assaults, compared to 13.5% of homeless heterosexual youth. Despite this knowledge, there are zero specialized housing initiatives for LGBTQ2 youth in Canada. We need to ensure that services and supports available to youth adequately addressed heightened risks and dangers that exist among the lines of gender, race and sexual identity.
When interpreting the above figures, it’s important to keep in mind that many assaults go unreported. This means the incidence rate of violent crime against homeless youth is likely far higher than these numbers suggest. The presence of stigma, as well as victim-blaming stereotypes, play a large role in keeping youth from speaking up about the problems they are facing. Research shows that widespread acceptance of victim-blaming stereotypes can lead to the internalization of these beliefs. This means that a youth who is a regular victim of sexual violence may come to believe that he or she is somehow responsible for crimes that have been committed against them. If we want victims of sexual violence to feel secure about reporting assaults, it’s essential that the stigma associated with being homeless and being a victim of sexual violence are removed. The removal of stigma needs to be coupled with robust responses by law enforcement authorities that demonstrate our commitment to the wellbeing of youth living in homelessness.
The incidence of sexual violence among youth has strong implications for the healthy physical, psychological, and emotional development of youth. Municipalities and provincial governments need to work directly with service providers to ensure measures are in place to protect homeless youth. We have a responsibility to these youth to bridge the existing gaps in supports and service provision.
Substance use prevention refers to interventions that seek to delay the onset of substance use, or to avoid substance use problems before they occur. Effective prevention strategies begin early in life and continue through adolescence and into adulthood; they reinforce consistent messages across the life span. Prevention is more than education though. It also includes a broad range of health promotion strategies such as building skills, engaging youth in the development of appropriate messages, and ensuring that environmental supports are in place such as employment, positive school culture and strong family supports. It also includes strengthening the health, social and economic factors that can reduce the risk of substance use. This includes access to health care, stable housing, education and employment.
Adolescence is an important developmental stage in life. Young people are learning to be independent and take on roles and patterns that will carry them into adulthood. This includes decisions about what substances they use and how they use them. While some trends in substance use among youth are of concern, the majority of youth try alcohol and other drugs without becoming frequent or problem users. Research has found that experimentation with drugs and alcohol is in many ways part of normal adolescent development and levels of use and experimentation decline, as youth get older and take on adult roles and responsibilities. It is unrealistic to think that all youth won’t try alcohol or other drugs like cannabis. But prevention strategies can encourage youth to delay their use until they’re older and help them learn safer, more sensible ways to use substances, if they are already using them.
Providing young people with good information is important. However, the research is clear that simply educating youth about avoiding substance use is not effective. Scare tactics or hard-line approaches like zero-tolerance have little or no effect. When kids are told that substances, including marijuana, are extremely dangerous and addictive, and then they learn through experimentation that this is false, the rest of the message is discredited. Honest drug education is one key to ensuring that individuals know how to make informed decisions. Effective programs start with the very young and extend through all stages of life. They use a range of health promotion strategies and target policy and legislative change.
Do you have any estimate of immunization rates among people living on the street or in shelters? That's such a good place to communicate disease among already weakened people.
In short, there is no one single estimate. The literature on this subject finds those who are homeless are less likely to be immunized against a variety of diseases, including influenza. One Toronto influenza study found that out of 75 participants, only 6.7% had documentation indicating they had received vaccination the year before the study. In Buchner et. al’s study in New York, only 25% of people experiencing homelessness had received an influenza vaccine. (The authors also highlight the fact that influenza or influenza-like illness was the suspected cause of death for 3.4% of deaths among the homeless in the city.)
Immunization rates can also be lower for certain groups, such as youth, whose early departure from school and non-participation in public health programs makes them more vulnerable to vaccine-preventable diseases.
But immunization is complicated, and even housed people sometimes have difficulty keeping track of their vaccinations. Even healthcare providers have been found to be lacking knowledge about immunization schedules.
With cases of measles popping up in Canada, immunization has become quite a hot topic. The immunization rate for measles, tuberculosis and DPT3 has been declining over the past decade—so much so that a 2013 UNICEF report card ranked Canada 28 of 29 developed countries in that category. According to an article in The Globe and Mail, Canada has an approximate measles vaccination rate of 95%, but there are areas where it’s as low as 50%. Religious and philosophical beliefs often play roles in parents deciding whether or not to vaccinate their children.
While early vaccination is important, according to Immunize Canada, even adults need booster shots to maintain immunity. Due to inconsistent record keeping, many people are not aware of vaccination schedules or what they’ve been immunized for.
These issues are even more complicated for people experiencing homelessness. As we’ve covered before, health, poverty and homelessness are interrelated and introduce some key challenges. People experiencing homelessness often have poorer health and are susceptible to a number of communicable diseases. Many have difficulty accessing healthcare, even from public programs, due to a number of barriers, including: missing identification, lack of permanent address, fear of stigma or discrimination, and limited or no funds for prescription medication.
Solutions: Education, incentives and tracking
The unpredictability of homeless people’s lives makes it difficult to adhere to vaccination schedules, as explored in Stein and Nyamathi’s research on hepatitis B vaccination. With case management, incentives and tracking, however, researchers found that 68% of the participants completed their schedules.
One Vancouver study found that immunization in non-traditional settings is very successful in reducing reported diseases. Vaccines were offered in blitz formats and combined, achieving vaccination rates among participants between 58% and 79%. In a Halifax study with homeless youth, participants recommended better advertising of free vaccination programs, and generally more youth- and homeless-friendly approaches to care.
When it comes to avoiding pandemics, communities can greatly reduce transmission and impact through comprehensive planning. For people working in the social services, the Influenza Planning Guide for Alberta’s Vulnerable Populations and Shelter Serving Agencies is a great resource.
As some experts have argued, it’s important to go beyond calculating medical risks to keep the social determinants of health in mind when discussing pandemics, disease and immunization. Social factors—like poverty and other sites of oppression—are key to helping us understand how risk and vulnerability vary from person to person.
This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at email@example.com and we will provide a research-based answer.
Photo: PATH Global Health
On January 29, hundreds of volunteers canvassed the streets of Houston for the annual Homeless Count. This is an opportunity for homeless service providers to learn more about the homeless population by physically reaching out to them. The Homeless Count is an example of ways Houstonians are working together as a team to end homelessness. As I stated in the USA Today article, Mental Disorders Keep Thousands of Homeless on Streets, the collaborative efforts of Houston’s homeless service providers is successfully tackling homelessness in our City. As portrayed in the USA Today infographic, the way that our system works is through outreach, assessment, matching and referral/waitlist.
The outreach team for the count is made up of 3-4 individuals and typically includes a Licensed Chemical Dependency Counselor, a social worker, a mental health provider, and a Coordinated Access Assessor. The Houston Police Department Mental Health Division also operates Homeless Outreach Teams, and a police officer is included in those teams. Outreach teams are equipped with iPads and Wi-Fi “hotspots” to be able to assess clients in the field. These tools can be helpful as it allows outreach teams to immediately and effectively interact with clients who are fairly disengaged and hesitant or unable to access services. The teams ask each homeless individual a series of short questions known as Vulnerability Index Assessment to determine the severity of their situation and what housing option best fits the person. The questions on the Vulnerability Index Assessment focus on markers with a scale from 0-8, with eight being the most vulnerable. Those markers focus on items such as the number and frequency of emergency room/hospital visits, age, if the individual has one or more serious and/or chronic illnesses, and the presence of “tri-morbidity,” which is co-occurring psychiatric, substance abuse, and chronic medical conditions. The Vulnerability Index also asks other questions, including but not limited to: 1) the length of time of homelessness, 2) where the individual sleeps most frequently, 3) where they access services most frequently, 4) veteran status, and 5) source of income.
According to the United States Interagency Council on Homelessness (USICH), the Vulnerability Index was created through collaboration between Common Ground, Dr. Jim O’Connell, and the Center for Urban Community Services. Common Ground created a new nonprofit organization, Community Solutions, in 2011 and launched the 100,000 Homes Campaign. Houston’s homeless service providers adopted the Vulnerability Index to help prioritize our most vulnerable homeless citizens for placement into permanent housing.
From Homeless to Housed
The waiting period to be placed in housing is typically 14 days. Some clients are living in shelters during the time of their assessment, and choose to remain in the shelter while they wait for housing. Clients who are living on the street when assessed typically choose to remain living on the street, but Coordinated Access staff make the option of shelter available to them. Homeless service providers can also help assist the client in getting into shelter if they choose.
Clients are sometimes able to provide a phone number or Community Voice Mail number to Coordinated Access staff, who can then contact the client once housing becomes available. For clients with no means of contact, once housing is available, Coordinated Access staff will flag the client in the HMIS database. Then, when a client accesses services at an agency using HMIS, agency staff will get a notification to direct the client back to Coordinated Access to continue the process to housing. Also, there is one day each week when clients who have been assessed can go to the primary Coordinated Access assessment hub (this primary hub is located at a day shelter in downtown Houston) to check in with a Coordinated Access staff member on the status of their case.
The successful implementation of a county-wide placement system has reduced the rate of chronic homelessness in the area by 57 percent. Since 2012 we have housed 3,300 homeless veterans and are on target to eliminate veteran homelessness in 2015. The newest collaborative effort among Houston’s homeless service providers is The Way Home. Launched on July 2nd, the goal of The Way Home is to end chronic and veteran homelessness by 2015, to end family and youth homelessness by 2020, and to build a system in which no one has to be without housing for more than 30 days. We are confident that we can reach these goals working as a community. The results from the Homeless Count completed in January is expected to be released this summer. The data will let us know the current status of homelessness in Houston. We will take this information and as a team, work together to provide supportive housing for Houston’s homeless.
The Ontario Human Rights Code has a rather long definition of disability, but it can be loosely summarized as any physical or mental condition that affects mobility, understanding, learning or day-to-day functioning. The Rick Hansen Foundation estimates that 4.4 million Canadians have a disability and that within 20 years, this number will grow to one in five Canadians. The organization also refers to people with disabilities as "the world's biggest minority that anyone can become a part of at any time," yet many are unable to fully participate in society.
People living with disabilities are often marginalized. The links between poverty, risk of homelessness and living with disabilities has been well documented. According to one IRIS report, people living with disabilities are twice as likely to live below the poverty line. (Additionally, living in poverty is likely to increase instances of disability.)
So while we don’t have concrete numbers on how many people experiencing homelessness in Canada live with disabilities, we know that there are many. The Center for Justice and Social Compassion estimates that 45% of all people experiencing homelessness are disabled or diagnosed with a mental illness. Given that the Canadian Survey on Disability showed that 13.2% of Canadians self-identified as disabled in 2012, this shows just how over-represented people living with disabilities are in the homeless population.
In Toronto, we’ve seen comparable numbers. Street Health Toronto found that 55% of people experiencing homelessness had a serious health condition, and of those, 63% had more than one. In a different study the organization conducted, 16% of their sample of people experiencing homelessness had been diagnosed with learning disabilities, compared to 2% of the city’s general population. In a report by the Daily Bread, it was reported that 49% of people frequenting Toronto food banks have disabilities.
While poverty plays a large part of why people living with disabilities are more likely to be homeless, there are a few more interrelated causes: employment issues, difficulty securing benefits, and a lack of supportive housing.
Long-term employment issues
Employment is a major issue for people living with disabilities. According to A Report on the Equality Rights of People with Disabilities (2012) by the Canadian Human Rights Commission (CHRC), the unemployment rate for people with disabilities was 8.6% versus an overall average of 6.3% in 2006. In that same year, just over half of all people living with disabilities were employed.
As the Canadian Labour Congress pointed out in 2008: “While it is certainly true that many people with disabilities are unable to participate in the paid workforce, it is also true that many others could work, and would like to work, but are prevented from doing so because of discrimination and barriers.”
A survey by BMO Financial Group found that few businesses hire people with disabilities: 3 in 10 in 2013; and 69% had never hired someone living with a disability. This remains an issue even though more than 75% of the respondents said their disabled hires met expectations (62%) or exceeded them (15%).
The same report also acknowledged that discrimination could hinder employment, with nearly half of all respondents believing that people are more likely to advance in the workforce if their disability is unknown or hidden.
This discrimination also shows in the ongoing lack of true accommodations for people with disabilities in most workplaces. Some install ramps and elevators to make physical mobility easier, but many conventional offices continue to use processes, technology, and systems that do not consider differences in ability (ie. paper filing, visual computer systems). This is a particular challenge for people with visual disabilities. The Canadian National Institute for the Blind estimates that over three million Canadians cannot read in the traditional way (or it is very difficult), which increases their difficulty in securing work.
Difficulty accessing benefits
For people with disabilities who cannot work, there is a whole other site of struggle in receiving disability benefits. The 2007 Street Health report noted that cuts to social programs have had a catastrophic effect on low-income Canadians. At that time, Ontario welfare benefits were half of what they were in 1995 and disability benefits were 22% less.
Furthermore, it is rarely easy to apply and be granted such benefits. Complicated processes and confusing paperwork is often a challenge for people to complete properly. In the Globe and Mail, Michael Prince wrote about how people with severe and prolonged disabilities face many challenges when trying to get their benefits, and appealing decisions when their applications are rejected. About 60% of applications are rejected. Prince claims that the system is “…structurally flawed” and asks: “Who suffers? The clients and their families, who confront new obstacles to access to an income security program vital to their well being and financial security.”
In Ontario, there are similar challenges obtaining ODSP—so much so that Street Health conducted a study on the barriers to receiving ODSP among homeless people with disabilities. 70% of participants were unable to get an application form without staff help. The greatest irony of ODSP is that it is a system for people with disabilities, yet its application process does not accommodate them. As the authors wrote:
“Several project participants found that their hearing, language, literacy, and communication challenges were not accommodated by the ODSP system. Mental health, cognitive, and hearing disabilities made it impossible for many participants to clearly express themselves and to follow through with the tasks needed to complete the application. Some participants were too afraid to ask for an application or to find a doctor and attend a medical appointment. Others could not clearly explain how they were disabled to their health care provider. Many had memory challenges and became disoriented, and were unable to make sure all of the steps needed to apply were completed. Inability to follow through on tasks is a common problem for people with cognitive and mental health disabilities, yet the ODSP considers incomplete applications to be “abandoned.” Rather than follow up with applicants to fill in missing pieces, the ODSP instead dismisses incomplete applications…”
Once people have managed to apply, they often face extraordinarily long wait times for rejection or approval—sometimes up to two years. As most applicants are in dire need of their benefits as soon as possible, one might wonder what the point of applying is if it takes that long to be approved.
Even when applicants are approved for ODSP, the amount of money they receive is dismally low and not in keeping with costs of living. As Olivia Carville pointed out in The Toronto Star (September 2014):
“ODSP monthly allowance has increased by only $156 in the past 19 years. Disability beneficiaries receive $1086 a month under ODSP and this is set to increase to $1098 on Oct. 1, under the latest provincial government budget.
The ODSP allowance has not kept up with inflation since former premier Mike Harris’ social-welfare reforms froze the amount at $930 in 1995.”
While there are many benefits available for people with disabilities in Canada, these systems are not accessible, nor do they provide a living income for the vast majority of people who need them. As a result, some researchers have called for a basic income plan for people living with disabilities.
Limited availability of affordable, supportive housing
According to the CHRC report, the number of adults in core housing need is 6.2% higher for those with disabilities. The report also found that a significantly higher proportion of adults with disabilities spend more than 50% of their before-tax income on housing than adults without disabilities. (10.3% compared to 7.7% in 2006.) This means many people living with disabilities are vulnerably housed and at risk of homelessness.
As we’ve mentioned before, a lack of affordable housing combined with poverty and poor employment opportunities all contribute to homelessness. These causes are intensified for people with disabilities, some of whom need caregivers and other supports—making the search for independent, long-term housing very difficult. In 2013, 12,000 adults in Ontario were waiting for supportive housing in a system that is backlogged and engineered to solve crises, but not prevent them.
If people with disabilities do become homeless, they often find themselves struggling to find shelters that can accommodate them.
People living with disabilities comprise a significant number of people experiencing homelessness due to marginalization and the intersections of health and poverty; as well as a serious lack of employment opportunities, proper benefits, and housing/social supports.
This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at firstname.lastname@example.org and we will provide a research-based answer.
Photo credit: Help Change Disability Statistics, Rick Hansen Foundation.
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The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.