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Health of the homeless in Dublin: has anything changed in the context of Ireland's economic boom?

Austin O’Carroll, Fiona O’Reilly
DOI: http://dx.doi.org/10.1093/eurpub/ckn038 448-453 First published online: 25 June 2008

Abstract

Background: In the context of the Irish economic boom we assessed the health, service utilisation and risk behaviour of homeless people in north Dublin city and compared findings with a 1997 study. Methods: A census of homeless adults in north Dublin city was conducted in 2005 using an adapted interviewer-administered questionnaire from the 1997 study. Results: A total of 363 (70%) of the target population participated. Compared to 1997 the population was younger (81% versus 70% under 45 years, P < 0.01) with a higher proportion of women (39% versus 29%, P < 0.05) and long-term homeless (66% versus 44%, P < 0.001). Drug misuse superseded alcohol as the main addiction with a doubling of the proportion reporting past or current drug use (64% versus 32%, P < 0.001). The prevalence of comparable physical chronic conditions was largely unchanged while depression (51% versus 35%, P < 0.01) and anxiety (42% versus 32%, P < 0.05) had increased. There were high rates of blood-borne infections, such as HIV (6%), hepatitis B (5%) and hepatitis C (36%) in 2005 and dental problems (53%) all of which can be associated with drug use. Access to free healthcare had not increased. Similar proportions reported not having medical cards (40% versus 45% NS). Homeless people continued to have higher usage of secondary care services than the general population. Conclusions: This study shows a changing disease profile among the homeless population consistent with a growing drug using population. It confirms that the homeless population in Dublin in terms of health remain excluded from the benefits of an economic boom despite a government policy aimed at redressing social inclusion.

  • health services N02.421
  • homeless persons M01.325
  • illicit drugs D26.87
  • economics 101.261

Introduction

The link between homelessness and poor health is well established. The literature demonstrates higher mortality and morbidity rates and health risk taking behaviour among homeless populations compared to the housed populations. Despite the increased need for health care, studies have consistently demonstrated an under-utilisation of primary care services by homeless people while at the same time revealing high-attendance rates at secondary care services.1 In 1997, the first assessment of the health of the homeless population in Dublin was conducted.2 This study described the health of homeless people within the context of a national policy of equity in health. Since that time the economic boom, commonly referred to as the ‘Celtic Tiger’ has continued. Between 1990 and 2002 Ireland achieved the second highest economic growth rate globally.3 However, during the same period Ireland achieved second place on the relative poverty index. The National Anti Poverty Strategy Unit was established in 1997 as a part of the first National Anti-poverty Plan to ensure the inclusion of marginalized groups in the benefits of the economic boom.4

It is within this context of economic growth and a government policy to redress social exclusion that this study describes the health status, risk behaviour and service utilisation of homeless people in north inner city Dublin. The analysis considers what has changed for the health and care of homeless people since the baseline study in 1997.

Methods

A census of homeless adults living in temporary accommodation within north inner city Dublin was conducted over a two week period in May 2005. Temporary accommodation was defined as hostels (emergency or transitional) and bed and breakfasts (B&Bs). (B&Bs are privately owned and managed houses with separate bedrooms containing 2–4 beds and sharing toilet and washing facilities. Landlords enter into an agreement with the health services or city council to rent these rooms to accommodate homeless people on a night by night basis.) While Holohan (1997) targeted the whole of Dublin city, this study concentrated on the area north of the river Liffey that divides the city. We accessed raw data from the 1997 study and determined the health status and service utilisation for the homeless of north Dublin city at that time. Our target population (521) was defined as the total number of homeless persons present in the hostels and B&Bs in north Dublin city the night before the survey team arrived to conduct the study.

Hostel and B&B managers were approached for permission by phone, letter or person by the research team with a letter of support from health and housing authorities. Ethics approval was received from the Royal College of Surgeons in Ireland. A pilot study was conducted in one of the B&Bs three weeks in advance of the study, which resulted in adjustments made to the questionnaire.

Twenty volunteer medical students were trained in a standardized interview technique. Groups of 3–5 students were supervised by one of the research team. The interviews lasted ∼10 min. Data on demography, length of homelessness, health status, risk behaviour and service utilisation were collected.

Method of analysis

Data were entered to SPSS version 13 and analysed using descriptive statistics. Due to the poor representation of rough sleepers both in our study (2%) and Holohan's (6%) these were excluded from the analysis of both sets of data. Data from the 1997 study were reanalysed for the north side of Dublin using SPSS. Comparison between responses given in 1997 and 2005 surveys was done using chi-square test for categorical variables. Confidence intervals at the 95% level were calculated.

Results

All hostels (10) and B&Bs (12) for homeless people in north Dublin city were included in the 2005 census. A total of 356 homeless people were interviewed. This represented a 70% response rate. The 1997 census interviewed 192 adults (64%) accommodated in north-side hostels (6) and B&Bs (7).

Demographics and reasons for becoming homeless

Table 1 presents the uni-variate analysis from the 2005 census. In 1997, women made up 5% of the population of those who were homeless longer than a year, while they made up 58% in 2005, an 11-fold increase (CI 5–24%, P < 0.0001). There were 120 children living in homelessness with respondents. There was no significant difference in duration of homelessness for families with children or without children living with them (72%, CI 61–83% versus 65%, CI 59–71%). Being accompanied by children was associated with past rather than current drug use. Three (4%, CI 0–8%) parents with children living in homelessness were current drug users, while 39 (55%, CI 44–66%) said they were past drug users.

View this table:
Table 1

Demographics and characteristics of homelessness

Table 2 presents the bi-variate analysis from the 2005 census. Current or past drug use was associated with report of addiction as the main reason for becoming homeless. Non-drug use was associated with report of financial reasons for becoming homeless. There was a gender difference in report of reasons for homelessness. A higher proportion of women reported eviction and family related reasons as their main reason for homelessness, while a higher proportion of men reported drug abuse. It was not valid to directly compare reasons for becoming homeless with the 1997 study as we asked the question differently offering more categories of ‘main reason’ for respondents to choose from.

View this table:
Table 2

Bi-variate analysis

Health status

In order to assess morbidity, respondents were read a list of physical and mental health problems and asked ‘Have you ever been told by a doctor that you have one of the following?’ The results are presented in table 3.

View this table:
Table 3

Morbidity, risk taking behaviours and service usage

Nineteen people (86%, CI 71–100%), who reported that they were HIV positive had co-existent hepatitis C. Hepatitis C was predominantly found in the 25–34 age group with 51% (CI 41–61%, P < 0.001) affected. Fourteen people (11%, CI 6–16%) with hepatitis C, had co-existent hepatitis B. Eighty respondents (65%, CI 57–73%) with hepatitis C had not been vaccinated against hepatitis B.

Only 14 (18%, CI 10–26%) of those with asthma were on respiratory medication and 14 (50%, CI 32–68%) of those with epilepsy were on anti-epileptic medication. Three (74%, CI 32–100%) of those reporting a diagnosis of diabetes were on diabetic medication.

Women were more likely to have reported worsening health in the previous year and to report a diagnosis of asthma, depression and anxiety. They were also more likely to be hazardous drinkers.

Self-report of fair to poor health was associated with reported diagnosis of chronic disease (P < 0.001).

Risk taking behaviours

Ten (26%, CI 13–39%) current drug users whose main addiction was heroin and who injected, had not attended a needle exchange in the previous 6 months. Ninety-eight drug users (43%, CI 37–49%) and 56 injecting users (33%, CI 26–40%) were not vaccinated against hepatitis B.

While the gender difference in ever use of drugs was not significant the difference in current and past use was. More men reported current use [60 (40%) versus 22 (27%), P < 0.05] while more women reported past drug use [60 (73%) versus 88 (60%) P < 0.05].

Service usage

Over half (57%, CI 48–66%) of the 120 children living in homelessness did not have medical card cover. Seventeen (25%, CI 15–35%) of these families who had no medical card said that this was to do with difficulties getting General Practitioners (GPs) to sign application form. Sixty people (54%, CI 45–63%) attending a methadone dispensing clinic did not have a medical card.

One hundred and nine (32%, CI 27–37%) respondents felt services were good or very good, 101 (30%, CI 25–35%) ‘OK’ and 134 (38%, CI 33–43%) poor or very poor. One hundred and forty-nine (42%, CI 37–47%) respondents commented that improved access to services was required.

Changes since 1997

Table 4 presents the comparison of findings from both the 1997 and the 2005 surveys. In 1997 Holohan found 40% did not have medical card and in 2005 this rose to 45% but was not significant. A lower proportion of those dwelling in B&Bs were represented in our study (35%, CI 30–40% versus 52%, CI 14–20% in 1997, P < 0.001]. The 2005 study population was younger and had more women. A higher proportion was homeless for >1 year than in 1997.

View this table:
Table 4

Comparison between this study (2005) and Holohan T. (1997)

The proportion of those with at least one comparable chronic physical disease was similar in both studies at 41% (CI 37–45%) and 43% (CI 38–48%), however this rose to 70% (CI 65–75%) in 2005 when HIV, hepatitis and asthma were included. There has been a change in the psychiatric morbidity profile with higher proportions reporting depression and anxiety in our study. No comparison could be made with the proportion reporting a diagnosis of schizophrenia, as this was not assessed in 1997. A higher proportion of respondents were on prescription medication in 2005.

Discussion

This study demonstrates that while Irish society was experiencing growth in the economy and reducing absolute poverty, the situation for homeless people as measured by duration of homelessness, morbidity pattern, self-assessed health and risk behaviours worsened. The demographic shift towards a younger population and more women has resulted in large numbers of children living in homelessness.

The definition of homelessness and the sample selection was the same in both the 1997 and 2005 studies. The growth in the target population was 74%. This could only be partially explained by the rise in population of the north Dublin inner city which rose by 17% between 1996 and 2006.5 Other studies have shown an increase in the number of homeless in this time period; however, unlike this study different definitions are used.6 We did not include rough sleepers, as they were not well represented in either study. Estimates of rough sleepers in Dublin have decreased from 275 in 1999 to 185 in 2006.6

Particularly worrying is the growing numbers of women and children in homelessness. The gender difference analysis sees women with a worse mental health profile than men. Poor health may affect ability to get out of homelessness and requires specific interventions targeted at women.

Changes in health status and risk behaviour

The most significant difference between 1997 and 2005 was the changing nature of addiction in the homeless population. Drug addiction has more than doubled since 1997 and supersedes alcohol as the main addiction amongst the homeless population. Findings from other studies in Dublin though not directly comparable, also suggest a rise in the proportion of homeless people reporting lifetime drug use.7

The changes in health status are consistent with the change in profile to a drug using population. Except for dental health the comparable physical disease profile shows little change since 1997, however there is a significant rise in depression and anxiety. Holohan did not include blood-borne infections in the list of conditions explored. Studies conducted in Dublin since 2000 demonstrate similar prevalence rates for blood-borne infectious diseases.8 The prevalence of blood-borne infections can be directly related to the rise in illicit drug use and in particular the high prevalence of injecting noted in this study. Previous studies found injecting rates of 24% (2001)9 and 35% (2005).7 Self-report of fair to poor health status had increased since 1997 and was twice that of the general population.9

Changes in service access and utilisation

The Irish Health system is unique in that entitlement to free primary health care is means tested for all people under 70 years old. Eligible applicants are given a medical card which gives them access to free health, dental care and medications. Medical card coverage for homeless people remains as poor as it was in 1997. It is worrying to note the poor medical card cover for homeless children who are more likely to have learning difficulties,10 delayed development,11 and mental health problems.12

Homeless populations, use secondary care services more than housed populations.13 We found a much higher rate of secondary care service usage among the study population when compared to the general population. This has occurred in a national context where the health strategy has emphasised primary care services as the appropriate place to treat 95% of all ill health and political interest in decreasing inappropriate pressure on secondary care services has been intense.

Services gaps in a changing homeless population

In Dublin there are few health services that have specifically targeted the homeless population. Services have not adapted to the changing pattern of morbidity by the increased prevalence of drug use. Indeed policy on hepatitis C treatment would appear to make it difficult for homeless individuals to receive anti-viral treatment for their hepatitis C.14

There are a number of specific measures that have been proven to reduce harm when targeted at homeless populations including needle exchanges, fast tracking to methadone treatment,15 safe injecting rooms16 and hepatitis B immunization.17

Internationally, it is recognized that while catering for the health needs of homeless persons in mainstream health services is desirable, there is a need for safety net services.18

Reasons for becoming homeless

Family related reasons, addiction and financial reasons were the top three main reasons given for becoming homeless. These too were the top three groups of reasons found in the 1997 study.2 However, it was clear that reasons were diverse and multi-factorial. Forcing choice to one of 13 categories was over simplistic when these categories are not mutually exclusive.

A number of Irish studies have suggested that the Miscellaneous Provisions Act (1997), which allows for the eviction of tenants for ‘anti-social behaviour’ including the possession of illegal drugs, is a causative factor in drug users becoming homeless.7,19 While our study did not find an association between drug use and ‘eviction’, it is possible that drug users leave home or are asked to leave to prevent eviction of the family. The increased durations of homelessness for those on drugs suggest that this group may find it more difficult to get out of homelessness than other groups. This is consistent with local policy, which ensures strict vetting by local housing authorities which acts as a barrier to drug users moving out of homelessness.

Negative selection or increasing barriers

O’Toole et al. in a comparison of two similar studies of a US homeless population in 1995 and 1997 found that the morbidity of homeless people had worsened over an economic boom period.20 The authors hypothesized that this may have been related to a ‘negative selection’ bias whereby those homeless people who are most able/healthy were more likely to obtain jobs and escape homelessness during periods of high employment. This would imply that those remaining in homelessness may have a higher concentration of need in periods of high employment where entry level jobs are more readily available.20 However, the observed rising rents and house prices suggested that economic barriers to leaving homelessness may be higher in a robust economy.

We agree with O’Toole's finding that the benefits of an economic boom do not ‘trickle down’ to the homeless population. However, the negative selection hypothesis only stands if the total number of homeless decreases which is not the case in Dublin. While estimates of numbers of homeless vary, none show a decrease. Our estimates indicate an increase in numbers using temporary accommodation within the Dublin area. State estimates show little change in numbers of households using homeless services (1290 in 1999,21 1470 in 200222 and 1317 in 20055). The rising barriers to getting out of homelessness noted by O’Toole are also found in the Irish context. Between 1997 and 2005 house prices grew by 192%23 and between 1998–2001 rents rose by 53%.24

Saris et al. noted that over the span of the Celtic Tiger Ireland has been shifting from the European concept of social inclusion as a response to poverty towards the American concept of an ‘under-class’ of ‘feckless’ individuals unable and/or unwilling to avail of the benefits of a full employment economy.25 O’Toole et al. similarly noted that during an economic boom period where public policies are encouraging all individuals to enter the workforce the public loses sympathy for the plight of those unable to enter employment.20 Thus homeless people not only unable to take advantage of the benefits accruing from the robust Irish economy, may also be blamed for not partaking. In policy terms Drudy and Punch maintain that this attitude emphasizes individualism and downplays ‘the role of the State and the legitimacy of intervention’.24

If health is the pre-eminent measure of the success of development policies then the results of this study call into question Ireland's position as fourth on the Human Development Index and questions the neo-liberal presumption that a healthy economy is a good arbiter of social progress.26

Conclusions

In the context of economic growth and a reduction of absolute poverty, the health needs of homeless people have increased, while access to free health care remains poor. Secondary services continue to carry the burden created by the worsening morbidity of homeless people. The health profile of the homeless population has been affected by the rising prevalence of drug users becoming homeless. This change requires specifically targeted responses. There is an urgent need for the health system to implement its mandate by providing needs-based services for homeless people. These services should have a two pronged approach to target homeless people where they are, while at the same time working to integrate as many as possible into mainstream services and society.

This study suggests that the State aim of combating social exclusion is not succeeding for homeless people and the benefits enjoyed by the Irish population of increased wealth and prosperity did not trickle down to the bottom of the economic ladder. More worryingly the combination of the boom's effect on raising barriers to affordable accommodation, the barriers to local authority housing for current or past drug users and the move towards a more individualistic society is set to increase rather than decrease exclusion of society's most vulnerable.

Acknowledgements

The authors acknowledge the seminal work of Dr Tony Holohan in conducting the baseline study in Dublin in 1997 without which no trend analysis would be possible. We gratefully acknowledge the support of the medical students from MedAction for volunteering time to administer the questionnaires. We also acknowledge Mary Corbett for overseeing data collection and entry. We acknowledge Prof. David Whitford, Prof. Tom Fahey (RCSI) and Dr Igor von Laere for commenting on drafts. Thanks to Dr Ciara McMeel and the Staff at the Mountjoy Street Family Practice, the Directorate of Social Inclusion and the Health Service Executive for help in data collection. Thanks to the 363 people living in homelessness who took part in the study.

A poster presentation of this work was presented at the scientific meeting of the Association of University Departments of General Practice (Ireland) in March 2006 in Belfast, Northern Ireland.

The Survey was funded by the Fiona Bradley Foundation. We acknowledge the Dept of General Practice and Family Medicine RCSI, in supporting the Mountjoy Street Practice as a Research Practice.

Conflicts of interest: none declared.

Key points

  • Despite a national economic boom period the health status of the homeless population and access to services had not improved.

  • In 2005 the homeless population were younger, comprised a higher proportion of females and were more likely to be homeless for >1 year than in 1997.

  • Drug abuse had superseded alcohol as the main addiction with a doubling in the proportion reporting current or past drug use.

  • The morbidity profile of homeless people in Dublin is consistent with a drug using population.

  • A comprehensive homeless health policy and strategy which takes account of the changing morbidity profile requires development.

References

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