Sistering

EXECUTIVE SUMMARY

INTRODUCTION

Common Occurrence: The Impact of Homelessness on Women’s Health is a multi-phased project sponsored by two partners: Sistering - A Woman’s Place, and the Toronto Community Care Access Centre – worked together to design and implement a community-based participatory action research project. The goal of this project is:

To increase the knowledge and understanding of key health sector stakeholders about the profile and experiences of homeless women by examining the impact of homelessness on their health and the response of Toronto’s health care system.

Phase I of the project, the design of the research project, was completed in March 2001. The results of Phase II, including the research findings and recommendations for action, are summarized in this report.

To ensure that the project is responsive and grounded in the realities that visible and hidden homeless women are living, an Advisory Committee with agency representatives as well as women with lived experience of homelessness guides the Common Occurrence project. The voices and views of women with lived experience of homelessness have been at the centre of this project and are included here in italics.

A gender-based analytical framework guides all aspects of the project. It points to a unique understanding of homelessness as it pertains to women. For Common Occurrence, homelessness is defined as a continuum that encompasses two broad types of experiences women commonly have:

Visible homelessness, which includes women who stay in emergency hostels and shelters and those who sleep rough in places considered unfit for human habitation, such as parks and ravines, doorways, vehicles, and abandoned buildings.

Hidden homelessness, which includes women who are temporarily staying with friends or family or are staying with a man only in order to obtain shelter, and those living in households where they are subject to family conflict or violence. Hidden homelessness also includes situations where women are paying so much of their income for housing that they cannot afford the other necessities of life such as food; those who are at risk of eviction; and those living in illegal or physically unsafe buildings, or overcrowded households.

From the gender-based perspective, the concept of health that is explored is holistic and includes the physical, mental/emotional and spiritual dimensions. This holistic definition closely links to the Population Health Framework promoted by Health Canada and specifically to Health Canada’s Determinants of Health - factors that heavily influence people’s overall health and well-being. They include:

Income and social status
Social support networks
Education
Employment and working conditions
Social environments
Physical environments
Personal health practices and coping skills.
Gender
Culture
Health Services

Finally, the health care system that is analysed is broad, encompassing not only the traditional heath care system but also social service agencies, settlement and community-based services.

In the fall of 2001, one hundred twenty-six (126) women experiencing both visible and hidden homelessness across the City of Toronto were interviewed in 14 different languages for the research. As well, input was gathered from 38 representatives of agencies in Toronto’s health, settlement, social service and emergency housing sectors. The findings and recommendations reflect their input and analysis.

HIGHLIGHTS OF FINDINGS

There are four major findings from the research project:

The full extent of women’s homelessness is severely underestimated because of a failure to understand the continuum of women’s homelessness.
Homelessness - visible and hidden - is a significant women’s health issue that seriously impacts women’s emotional, mental, spiritual, and physical health.
The Toronto system of supports and services is not fully responsive to visible and hidden homeless women’s health care issues and needs.
The Toronto systems of supports and services fail to tap the strength and leadership skills of women experiencing visible and hidden homelessness to support these survivors build solutions to the issues they face.

The continuum of women’s homelessness is not well understood. Because of this, the full extent of women’s homelessness is severely underestimated.

Women experiencing hidden homelessness face desperate and difficult situations.

I switched around because the house before was not warm, leaking roof, mice and not big. It was very hard because I never knew if I would find something better. Also the rent gets more expensive and it is costly to move around.

The whole house has 7 households renting together. I don’t know most of them. I only use the kitchen and bath when I need to. Even the living room has been divided into 2 rooms.

These women do not label their experience as “homelessness” because they are not living on the street. Even women living in shelters and hostels do not always consider themselves to be homeless. Service providers, when asked to identify women to be interviewed for the research, tended to think mostly of women in shelters, hostels and living on the street as “homeless.” Very few people immediately understood that the word “homeless” could be applied to women who have roofs over their heads. Homelessness was not readily associated with women at risk of losing their housing due to family violence, or women living in substandard, overcrowded living situations. The research validates that:

Very few women end up visibly homeless without first experiencing hidden homelessness.

Lived in basement apartment with husband until assault, then went to shelters, then got an apartment through Metro Housing.

Women move through, back and forth between the various types of homelessness.

I was in hospital, and then jail, then lived at a place by the train track, was at mother’s for 3 days, store and rooming house.

There is similarity of experiences in both visible and hidden homelessness.
There are common health impacts of all types of homelessness that relate to the determinants of health.

Without a better understanding of the hidden nature of women’s homelessness, the numbers of women who are experiencing homelessness and are at risk of spiraling into visible homelessness is greatly underestimated.

RECOMMENDATION #1: That key stakeholders from the broad health care system organize to undertake and sustain an Advocacy and Policy Agenda that exposes to policy and decision makers, the media and service providers in the formal and informal health care sector in Toronto the full extent of women’s homelessness and advocates for change in the major areas impacting on the health of visible and hidden homeless women.

Homelessness - visible and hidden - is a significant women’s health issue. It seriously impacts on women’s emotional/mental, spiritual, and physical health.

KEY HEALTH IMPACTS OF VISIBLE AND HIDDEN HOMELESSNESS

93% of women report emotional/mental health issues as a result of their living situations.

I am emotionally disturbed. I am physically upset. My body - I can’t eat, have no appetite, have a stomach ulcer and I cry a lot.

I have heart problems because my husband often scolds me. I was once in emergency for heart pain after being told off by my husband. At that time I also could not talk. Now I take medicine and can bear my husband’s verbal abuse without affecting my chest.

Unrelenting, debilitating stress and anxiety top the list of impacts.

I am crying all the time, not hungry. I lost 18 pounds in 13 weeks. Everything is speeding in my mind. I don’t sleep and have migraines. I can’t write, forget spelling.

I am afraid. I have a fear that I can get mad... I am afraid of ending up on the street.

Don’t know what will happen next day, next week, next month. Maybe they’ll ask me to move again. This is on my mind all the time...

Depression, despair and hopelessness are also major impacts as is the exacerbation of existing mental health and addictions issues.

I get really depressed when I think how long I have been here and how little life has improved. I get angry and have to cool off by myself, but it’s hard without privacy.

A lot of suicidal thoughts/slashing/paranoia/hallucinations… I also get violent and rob people. Pick fights.

Not having my own space for the last years had a very bad influence on my health. Lack of energy, fear, anxiety. I cry a lot. I wanted to kill myself.

For many women, their spiritual health is strongest. However, those women who have experience living on the street are less likely to have strong or positive spiritual lives. For them, alienation and hopelessness are more pronounced.

I have to stop and ask God for guidance. I have found myself getting more spiritual…When you get in touch with your spirituality you don’t feel like a number any more.

I don’t believe in the church - the relationship I have with God is between me and him. He knows me and that is good enough for me.

I always prayed a lot... My husband used to say: Such a nothing like you , such a zero. I was getting smaller and smaller. I could not breathe. I was ashamed.

I feel I am like a stone. I am homeless, I am sad even though the staff is good. I am helpless.

KEY CONTRIBUTING FACTORS

Poverty, barriers to economic self sufficiency, lack of affordable, appropriate, safe housing and isolation and family violence are the major underlying issues that influence women’s visible and hidden homelessness.

Poverty

In this sample, 76% of women are receiving some form of social assistance and only 16% say they have an adequate income. This points to inadequacies in income support programs. Poverty prevents women from renting safe housing, causes them and their children to go hungry, presents difficulties in filling medication prescriptions and exacerbates the acute stress and anxiety they experience.

In addition to the poverty they experience, the women also feel that the welfare system does not support them. Many concerns were raised about the rules and regulations of income support programs as well as the way staff treat women.

RECOMMENDATION #2 That Provincial and Municipal governments work together to improve delivery of the Ontario Works (OW) and Ontario Disability Support Program (ODSP) programs so that women experiencing visible and hidden homelessness are financially supported to a level that meets their day to day nutritional, personal care and housing needs.

Barriers to achieving economic self-sufficiency

Only 8% of the women in the sample are employed, while 20% are in a course or training program and 30% are volunteering some of their time in community-based programs and services. Many women desire some form of work or training but face insurmountable systemic barriers to achieving their dreams. Histories of abuse and violence have left many women isolated and unexposed to education and training opportunities necessary to become employable. Some have barriers related to English or French language skills. Others have mental health and/or addiction issues that stand in their way of becoming economically active. Women felt that poverty, the need for stable and secure housing and adequate childcare spaces and subsidies also prevent them from seeking and maintaining work.

RECOMMENDATION #3 That Federal, Provincial, and Municipal governments work with the private sector to remove barriers and increase opportunities so that visible and hidden homeless women can achieve economic self-sufficiency and security for themselves and their children.

Need for affordable, safe and appropriate housing

About 89% of women in the sample report that they pay more than 50% of their income on housing. After they pay rent, many report having very little left over for food and other daily necessities. Other concerns expressed include lack of safety in apartment buildings, unfit housing conditions in spite of high rents, harassment by landlords, and unsafe neighbourhoods. The City’s Report Card on Homelessness and Mayor’s Task Force on Homelessness have acknowledged that there is very limited affordable housing in the GTA as well as limited transitional and supportive housing models that are women-focussed or women-centred. Women also identify that in order for them to maintain newly acquired housing, they need on-going supports because of the numerous serious realities they are facing.

Women and service providers highlighted the need to re-visit the Tenant Protection Act (TPA) and the Ontario Rental Housing Tribunal (ORHT). The TPA is felt to have directly contributed to women’s homelessness and to add to the barriers for people receiving social assistance in their efforts to gain housing. The ORHT also does not work well for women facing eviction or other serious landlord-tenant issues. The Social Housing Reform Act, passed in December 2000, creates additional barriers to women accessing low-income housing.

RECOMMENDATION #4: That Federal and Provincial governments immediately implement a National Housing Strategy that increases the range and types of affordable, safe housing for visible and hidden homeless women and their children.

Housing is not the same as a home

Having a home is about feeling connected, cherished and valued. Women who are experiencing hidden homelessness have roofs over their heads, but many have little support or positive connection with family and friends. Many women in the sample feel extreme isolation and loneliness, even if people surround them.

Family violence and spousal abuse are key issues, facing women experiencing hidden homelessness. However, many do not disclose this to anyone outside the family. This is partly because of the stigma they perceive as associated with the situation, and partly because many programs that women attend are not mandated to address these issues. This is particularly the case in settlement agencies. Service providers in this sector express frustration that their primary funding sources, federal settlement monies, must be directly targeted to specific issues faced by newly arrived individuals and these funds may not be used for violence prevention or support services. Public Health Units are also not specifically funded to provide focussed violence prevention and support services to the many women that they connect with in various contexts.

Violence Against Women (VAW) funding is not equitably distributed among community-based shelters and emergency hostels. Because women entering shelters are fleeing recent violence, funding is made available for counseling and support around these issues. Similar funding is not available to emergency hostels to allow them to address the myriad of issues that homeless women face. While it is well documented that many women who are experiencing visible homelessness (and therefore using emergency hostels) have long and complex histories of abuse, often beginning when they were children, funding for counseling services around violence is not granted to the women’s emergency hostels.

Finally, programs and services expressed concern that they are not able to help build social supports for women because their resources are exhausted dealing with more basic, day-to-day, health or safety issues of women. Clearly, though, building social supports is an area requiring serious attention to prevent women experiencing hidden homelessness from spiraling into visible homelessness.

RECOMMENDATION #5: That Provincial Violence Against Women (VAW) programs and services be expanded and enhanced to provide prevention and support services for all victims of family violence and abuse.

RECOMMENDATION #6: That community-based agencies serving women develop and implement various types of networks of support for women experiencing hidden homelessness to reduce isolation and loneliness, increase connections and feelings of belonging, and prevent the spiral into visible homelessness.

The Toronto system of supports and services is not fully responsive the health care issues and needs of visible and hidden homeless women.

Shelters and Emergency hostels are not appropriate homes for women

Few would dispute that group living environments that accommodate many women, and sometimes their children, dealing with various serious crises of one sort or another are not ideal or desirable living situations. Unfortunately, they are a necessary part of the health care system, as women must be able to flee violence to safety.

The City’s Report Card on Homelessness concurs that there are not enough emergency hostel or shelter beds in Toronto to meet the needs in times of peak demand.
Residential by-laws and zoning restrictions are current issues that the City of Toronto is debating and has not resolved as yet. This makes the location of additional shelters and hostels throughout the city contentious neighbourhood issues.
The funding formula for shelters and hostels is inconsistent. The per diem rate and funding for counseling services vary significantly across the system. Emergency hostels receive fewer funds for counseling and support services, in spite of the fact that they are often serving many women who are experiencing moderate to serious psychiatric, mental health and addictions issues.
Older women and seniors in the sample report having difficulty physically accessing the programs and services offered in emergency hostels because they have physical limitations or health issues that prevent them from climbing stairs or sleeping in bunk beds or on the floor.
Service providers report on the practice of many emergency hostels of discharging women who have not found housing after 3 months. They explain that this is often necessary in order to remain true to the mandate of an emergency hostel. If residents stay for longer periods of time, women in crisis or emergencies would not be able to access them for shelter.
There is a feeling among many women that they are not safe in shelters and emergency hostels. This appears to be related to perceptions of inadequate overnight staffing in houses with women dealing with many serious issues. It is also related to women’s concerns about keeping their children safe.
There are also many concerns about nutrition, cleanliness and safety for belongings in the shelter and emergency hostel system.

RECOMMENDATION #7: That Provincial and Municipal governments, along with their funded agencies, improve the overall quality and extent of shelter and emergency hostel services for women and children in Toronto to increase safety, security and access to needed temporary shelter supports

Women report that traditional health care services are not adequately meeting their needs

Many women reported that they do not seek any assistance at all for their mental or emotional and spiritual health needs. Those that do often turn to workers and supports outside the “traditional” health care sector such as settlement workers, drop-in staff, etc. Women experiencing visible and hidden homelessness give high marks to newer more accessible and holistic health services such as those provided by Community Health Centres and Street Health. Other key issues are:

Discharge planning for women with limited housing is lacking in coordination and inter-agency communication between the traditional health care system and community-based agencies. Hostel and shelter staff who participated in the research expressed concerns about how they are often not included in the discussions and planning even though they will be the primary “home” or “family” that women will have on discharge. This can result in difficulties with follow-up treatments and adequate attention to women’s physical or emotional health care.
Even with good discharge planning, service providers agreed that hostels and shelters are not appropriate destinations for women released from hospital and still requiring rest and recuperation. Examples were cited about visibly homeless women in the end stage of life, who are often unable to access Palliative Care beds for the length of time they need. Other alternatives such as an “infirmary” or short-term transitional beds are not readily available for women at present and are the focus of Toronto Public Health’s Homeless Health Reference Group.
While Community Health Centres (CHCs) are seen as responsive to the needs of homeless women, these organisations face a number of constraints in service delivery. Many are at capacity and have closed their clinics to new admissions CHCs often the first place where women without a health card obtain primary health care. However, CHCs often exhaust their budget line for non-insured clients. The Ministry of Health and Long Term Care has not funded any new CHCs in Toronto in the last 10 years, and 80% of CHCs in Ontario report that they are at capacity and are closed to new clients.
CCACs are not funded to provide care to people without health cards. However, a few CCACs have developed some services to support care for the homeless in the community.
Women with concurrent issues or dual diagnoses such as addictions and mental health issues are reported to have difficulty in locating and accessing appropriate supports and services.
Women without legal status in Canada are ineligible for health care cards. This makes accessing any form of health care difficult and expensive unless it is accessed through Community Health Centres or CCAC services for the homeless.

RECOMMENDATION #8: That Ministry of Health-Long Term Care and their funded institutions and organisations remove barriers and strengthen the response of the traditional health care system to improve the physical, emotional and mental health of visible and hidden homeless women.

Community-based agencies face numerous challenges serving women experiencing visible and hidden homelessness.

PROGRAM APPROACHES

The limited understanding of the nature of hidden homelessness makes it is easy for women experiencing hidden homelessness to spiral into visible homelessness. The act of naming women’s situations as “hidden homelessness” adds the necessary sense of urgency to more readily command attention and action.
The current level of outreach to women experiencing hidden homelessness is insufficient.
Service providers and women reported that the “system” places a strong emphasis on women’s problems and deficits. Programs are funded based on gaps or needs, not on building women’s skills and capacities. This makes it more difficult for workers in community-based programs to keep women’s strengths in focus as they provide their programs and services.
Individualized, client-centred approaches to service delivery are slowly coming into focus and being effective. However, this individualized approach is often more challenging for programs to integrate since it requires staff to use discretion, judgment and to have the ability to be more flexible with rules and guidelines.
Spirituality plays a big part in the lives of many women. While this is true for many women, especially those experiencing hidden homelessness, it is not a focus that service providers tend to emphasise. It is not surprising that this disconnect exists. Most health and social services, are firmly secular, and understand the value of tapping into women’s spiritual lives and health. What is notable is the strength, for many women, of their spiritual health, at least before they are living on the street. For women on the street, those who are able to find their way back to their roots often find renewed hope for a brighter future.
Most funding available to combat homelessness is targeted to women experiencing visible homelessness. The majority of programs focussed on women’s homelessness deal with crises women face in their lives such as fleeing family violence and eviction. There is less funding available to focus the same level of attention on preventing hidden homelessness. Clearly, if hidden homelessness could be reduced or eradicated, visible homelessness would also be dramatically decreased. Funding is needed to allow agencies to raise awareness and implement prevention interventions to address needs of hidden homeless women.

Barriers to accessing the existing spectrum of health care services

Women in this sample are not well informed about what is available and/or what supports they are eligible to receive.
Many critical services need more supports to be able to communicate with women in their preferred language or provide cultural interpretation.
Service providers highlighted the lack of coordination and location of services throughout the city, which compels women to go to many different services in various locations to get what they need.
Service providers also discussed the general lack of harm reduction approaches to service delivery, which creates many insurmountable barriers for the most vulnerable women.

Service Delivery Quality

Women reported encountering judgmental attitudes and discrimination from workers at social assistance offices, hostels and shelters and hospital emergency rooms.
Service providers expressed concern over role conflicts that can interfere with the delivery of services to women experiencing visible and hidden homelessness. These can arise when, for example, supportive housing workers move from being advocates for women to becoming landlords and possibly having to take disciplinary actions or issue eviction notices.
There is a need to increase innovative training opportunities to expand and improve the skills and expertise of emergency health care providers, hostel and shelter staff to improve overall quality of service delivery, increase staff satisfaction and reduce staff burnout.

RECOMMENDATION #9: That community-based agencies serving women increase the range and type of services available, remove barriers to access and enhance the quality and accessibility of programs and services available to visible and hidden homeless women.

Women experiencing visible and hidden homelessness are strong and have a great deal to contribute. They have many untapped leadership skills to contribute to building solutions to the issues they face.

Their aspirations for their children and hopes and dreams for the future are some of the key manifestations of this strength.

Their children’s futures keep many women going. Women with children sacrifice everything for their children, thinking that if their futures are secure, they have fulfilled their purpose or role. This belief makes it hard for women to look after themselves, especially given the limited resources, time and energy they have.

Women have aspirations and desires to pursue self and career development. Putting aside their many hardships, most of the women in the sample have hopes and dreams for the future. Their abilities to reflect on, analyse and articulate their life stories are impressive. Not surprisingly, a significant number of women want to stop relying on the system and find ways of putting their lives back together through self-development, education, training and employment.

RECOMMENDATION #10: That MCSS and MOH-LTC increase supports for children of visible and hidden homeless women to decrease child poverty and improve the safety and quality of life they experience.

RECOMMENDATION #11: That organisations within the health care system increase the leadership and involvement of visible and hidden homeless women on boards, committees, public education initiatives and outreach efforts so that their lived experiences can influence positive organisational decision making.

CONCLUSIONS

The research phase of Common Occurrence has been ambitious, complex and rewarding. The data that were collected has been synthesized and highlighted in order to point to actions necessary to improve the reach and responsiveness of Toronto’s health care system. When looking back at the goals for the research, the following can be said:

Much more is known about who visible and hidden homeless women are.
Hidden homelessness is a significant problem in Toronto.
Homelessness is a women’s health issue.
Many opportunities exist for the health care system to improve its responsiveness and effectiveness in supporting women.

Eleven (11) broad recommendations for change are made with 62 specific actions for implementation. These were based on input from the Common Occurrence Advisory Committee to ensure their relevance and appropriateness. However, Common Occurrence cannot do all of the work alone, despite the strong and committed core groups of agency and non-agency representatives involved. It will take leadership and commitment from others as well. To drive the agenda that is recommended, dedicated, targeted funding must be granted to facilitate forward movement.

RECOMMENDATION #12: That Common Occurrence be funded to represent and advocate on behalf of homeless women on an ongoing basis and steer the agenda and recommendations being put forward in this report.

The recommendations need urgent and immediate attention. The partnerships created through the research process can be built on to effect change. Women’s visible and hidden homelessness and the impact it has on their health will not improve without dedicated and concentrated commitment and effort. While there are many changes that government ministries and individual organisations can make, an effective mechanism to mobilize, coordinate and track activity would greatly improve the lives and futures of women experiencing homelessness.

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