Skip to main content
PMC home page
Canadian Journal of Public Health = Revue Canadienne de Santé Publique logoLink to Canadian Journal of Public Health = Revue Canadienne de Santé Publique
. 2005 Mar 1;96(Suppl 2):S23–S29. doi: 10.1007/BF03403700

Homelessness and Health in Canada: Research Lessons and Priorities

C James Frankish 12,✉, Stephen W Hwang 22, Darryl Quantz 12
PMCID: PMC6976130  PMID: 16078553

Abstract

This article was for prepared for an international think-tank on reducing health disparities and promoting equity for vulnerable populations. Its purposes are to provide an overview of homelessness research and to stimulate discussion on strategic directions for research. We identified studies on homelessness, with an emphasis on Canadian research. Studies were grouped by focus and design under the following topics: the scope of homelessness, the health status of homeless persons, interventions to reduce homelessness and improve health, and strategic directions for future research. Key issues include the definition of homelessness, the scope of homelessness, its heterogeneity, and competing explanations of homelessness. Homeless people suffer from higher levels of disease and the causal pathways linking homelessness and poor health are complex. Efforts to reduce homelessness and improve health have included biomedical, educational, environmental, and policy strategies. Significant research gaps and opportunities exist in these areas. Strategic research will require stakeholder and community engagement, and more rigorous methods. Priorities include achievement of consensus on measuring homelessness, health status of the homeless, development of research infrastructure, and ensuring that future initiatives can be evaluated for effectiveness.

MeSH terms: Homeless persons, vulnerable populations, poverty, health status, health behaviour, health services

Footnotes

Acknowledgements and Sources of Support: This article is based on a paper prepared for the International Think-Tank on Reducing Health Disparities and Promoting Equity for Vulnerable Populations held in Ottawa on September 21–23, 2003. This work was supported by the Canadian Institutes of Health Research, the National Homelessness Initiative, and Human Resources & Skills Development Canada. Production of this article was made possible in part through the support of the National Secretariat on Homelessness. Dr. Frankish holds a Senior Scholar Award from the Michael Smith Foundation for Health Research. Dr. Hwang holds a New Investigator Award from the Canadian Institutes of Health Research. The Centre for Research on Inner City Health is supported in part by a grant from the Ontario Ministry of Health and Long-Term Care. The results and conclusions are those of the authors, and no official endorsement by any organization is intended or should be inferred.

References

  • 1.Begin P, Casavant L, Miller Chenier N, Dupuis J. Homelessness. Ottawa, ON: Parliamentary Research Branch; 1999. [Google Scholar]
  • 2.Quantz D, Frankish J. Homelessness Research in the Greater Vancouver Regional District: An Agenda for Moving Forward. Vancouver, BC: University of British Columbia; 2002. [Google Scholar]
  • 3.Statistics Canada. Census: Analysis Series. Collective Dwellings. 2001. [Google Scholar]
  • 4.Canada MortgageHousing Corporation. Documentation of Best Practices Addressing Homelessness. 1999. [Google Scholar]
  • 5.Woodward J, Eberle M, Kraus D, Graves J. Research Project on Homelessness in Greater Vancouver. 2002. [Google Scholar]
  • 6.City of Toronto. The Toronto Report Card on Homelessness 2000. 2000. [Google Scholar]
  • 7.Stroik SM. Biennial Count of Homeless Persons in Calgary: Enumerated in Emergency and Transitional Facilities, by Service Agencies, and On the Streets - 2004. Calgary, AB: City of Calgary; 2004. [Google Scholar]
  • 8.Bentley D. Measuring Homelessness: A Review of Recent Research. 1995. Winnipeg, MB: Institute of Urban Studies, University of Winnipeg; 1995. [Google Scholar]
  • 9.Hwang SW. Homelessness and health [comment] CMAJ. 2001;164:229–33. [PMC free article] [PubMed] [Google Scholar]
  • 10.Kuhn R, Culhane DP. Applying cluster analysis to test a typology of homelessness by pattern of shelter utilization: Results from the analysis of administrative data. Am J Community Psychol. 1998;26:207–32. doi: 10.1023/A:1022176402357. [DOI] [PubMed] [Google Scholar]
  • 11.Herman DB, Susser ES, Struening EL, Link BL. Adverse childhood experiences: Are they risk factors for adult homelessness. Am J Public Health. 1997;87:249–55. doi: 10.2105/AJPH.87.2.249. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Koegel P, Melamid E, Burnam A. Childhood risk factors for homelessness among homeless adults [comment] Am J Public Health. 1995;85:1642. doi: 10.2105/AJPH.85.12.1642. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Susser E, Moore R, Link B. Risk factors for homelessness [review] Epidemiol Rev. 1993;15:546–56. doi: 10.1093/oxfordjournals.epirev.a036133. [DOI] [PubMed] [Google Scholar]
  • 14.Jencks C. The Homeless. 1994. [Google Scholar]
  • 15.O’Flaherty B. Making Room: The Economics of Homelessness. Cambridge, MA: Harvard University Press; 1996. [Google Scholar]
  • 16.Schwartz S, Carpenter KM. The right answer for the wrong question: Consequences of type III error for public health research [comment] Am J Public Health. 1999;89:1175–80. doi: 10.2105/AJPH.89.8.1175. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Stratigos AJ, Katsambas AD. Medical and cutaneous disorders associated with homelessness. Skinmed. 2003;2:168–72. doi: 10.1111/j.1540-9740.2003.01881.x. [DOI] [PubMed] [Google Scholar]
  • 18.Hwang SW. Is homelessness hazardous to your health? Obstacles to the demonstration of a causal relationship. Can J Public Health. 2002;93:407–10. doi: 10.1007/BF03405026. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Gelberg L, Leake BD. Substance use among impoverished medical patients: The effect of housing status and other factors. Med Care. 1993;31:757–66. doi: 10.1097/00005650-199309000-00001. [DOI] [PubMed] [Google Scholar]
  • 20.Lehman AF, Kernan E, DeForge BR, Dixon L. Effects of homelessness on the quality of life of persons with severe mental illness. Psychiatr Serv. 1995;469:922–26. doi: 10.1176/ps.46.9.922. [DOI] [PubMed] [Google Scholar]
  • 21.Roy E, Boivin JF, Haley N, Lemire N. Mortality among street youth. Lancet. 1998;352:32. doi: 10.1016/S0140-6736(05)79510-6. [DOI] [PubMed] [Google Scholar]
  • 22.Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario. JAMA. 2000;283:2152–57. doi: 10.1001/jama.283.16.2152. [DOI] [PubMed] [Google Scholar]
  • 23.Canadian Mental Health Association. Mental Illness and Pathways into Homelessness: Proceedings and Recommendations. 1998. [Google Scholar]
  • 24.Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychol. 1991;46(11):1115–28. doi: 10.1037/0003-066X.46.11.1115. [DOI] [PubMed] [Google Scholar]
  • 25.Smart RG, Adlaf EM. Substance use and problems among Toronto street youth. Br J Addict. 1991;86:999–1010. doi: 10.1111/j.1360-0443.1991.tb01861.x. [DOI] [PubMed] [Google Scholar]
  • 26.Shinn M, Weitzman BC, Stojanovic D, Knickman JR, Jimenez L, Duchon L, et al. Predictors of homelessness among families in New York City: From shelter request to housing stability. Am J Public Health. 1998;88:1651. doi: 10.2105/AJPH.88.11.1651. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Advisory Council for the Elimination of Tuberculosis. Prevention and control of tuberculosis among homeless persons. Recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR. 1992;41:13–23. [PubMed] [Google Scholar]
  • 28.Nolan CM, Elarth AM, Barr H, Saeed AM, Risser DR. An outbreak of tuberculosis in a shelter for homeless men. A description of its evolution and control. Am Rev Respir Dis. 1991;143:257–61. doi: 10.1164/ajrccm/143.2.257. [DOI] [PubMed] [Google Scholar]
  • 29.Barnes PF, el Hajj H, Preston-Martin S, Cave MD, Jones BE, Otaya M, et al. Transmission of tuberculosis among the urban homeless. JAMA. 1996;275:305–307. doi: 10.1001/jama.1996.03530280057037. [DOI] [PubMed] [Google Scholar]
  • 30.Pablos-Mendez A, Knirsch CA, Barr RG, Lerner BH, Frieden TR. Nonadherence in tuberculosis treatment: Predictors and consequences in New York City. Am J Med. 1997;102:164–70. doi: 10.1016/S0002-9343(96)00402-0. [DOI] [PubMed] [Google Scholar]
  • 31.Nazar-Stewart V, Nolan CM. Results of a directly observed intermittent isoniazid preventive therapy program in a shelter for homeless men. Am Rev Respir Dis. 1992;146:57–60. doi: 10.1164/ajrccm/146.1.57. [DOI] [PubMed] [Google Scholar]
  • 32.Roy E, Haley N, Lemire N, Boivin JF, Leclerc P, Vincelette J. Hepatitis B virus infection among street youths in Montreal. CMAJ. 1999;161:689–93. [PMC free article] [PubMed] [Google Scholar]
  • 33.Manzon L, Rosario M, Rekart ML. HIV sero-prevalence among street involved Canadians in Vancouver. AIDS Educ Prev. 1992;Suppl:86–89. [PubMed] [Google Scholar]
  • 34.Wang EE, King S, Goldberg E, Bock B, Milner R, Read S. Hepatitis B and human immunodeficiency virus infection in street youths in Toronto, Canada. Pediatr Infect Dis J. 1991;10:130–33. doi: 10.1097/00006454-199102000-00011. [DOI] [PubMed] [Google Scholar]
  • 35.Goering P, Tolomiczenko G, Sheldon T, Boydell K, Wasylenki D. Characteristics of persons who are homeless for the first time. Psychiatr Serv. 2002;53:1472. doi: 10.1176/appi.ps.53.11.1472. [DOI] [PubMed] [Google Scholar]
  • 36.Allen DM, Lehman JS, Green TA, Lindegren ML, Onorato IM, Forrester W. HIV infection among homeless adults and runaway youth, United States, 1989–1992. AIDS. 1994;8:1593–98. doi: 10.1097/00002030-199411000-00011. [DOI] [PubMed] [Google Scholar]
  • 37.Roy E, Lemire N, Haley N, Boivin JF, Frappier JY, Claessens C. Injection drug use among street youth: A dynamic process. Can J Public Health. 1998;89:239–40. doi: 10.1007/BF03403926. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Roy E, Haley N, Leclerc P, Cedras L, Blais L, Boivin JF. Drug injection among street youths in Montreal: Predictors of initiation. J Urban Health. 2003;80:92–105. doi: 10.1093/jurban/jtg092. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Greene JM, Ringwalt CL. Pregnancy among three national samples of runaway and homeless youth. J Adolesc Health. 1998;23:370–77. doi: 10.1016/S1054-139X(98)00071-8. [DOI] [PubMed] [Google Scholar]
  • 40.Crowe C, Hardill K. Nursing research and political change: The street health report. Can Nurse. 1993;89:21–24. [PubMed] [Google Scholar]
  • 41.Hwang SW, Bugeja AL. Barriers to appropriate diabetes management among homeless people in Toronto. CMAJ. 2000;163:161–65. [PMC free article] [PubMed] [Google Scholar]
  • 42.Kinchen K, Wright JD. Hypertension management in health care for the homeless clinics: Results from a survey. Am J Public Health. 1991;81:1163. doi: 10.2105/AJPH.81.9.1163. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Gelberg L, Linn LS, Mayer-Oakes SA. Differences in health status between older and younger homeless adults. J Am Geriatr Soc. 1990;38:1220. doi: 10.1111/j.1532-5415.1990.tb01503.x. [DOI] [PubMed] [Google Scholar]
  • 44.Pizem P, Massicotte P, Vincent JR, Barolet RY. The state of oral and dental health of the homeless and vagrant population of Montreal. J Can Dental Assoc. 1994;60:1061. [PubMed] [Google Scholar]
  • 45.Lee J, Gaetz S, Goettler F. The oral health of Toronto’s street youth. J Can Dental Assoc. 1994;60:545–48. [PubMed] [Google Scholar]
  • 46.Gibson G, Rosenheck R, Tullner JB, Grimes RM, Seibyl CL, Rivera-Torres A, et al. A national survey of the oral health status of homeless veterans. J Public Health Dentistry. 2003;63:30–37. doi: 10.1111/j.1752-7325.2003.tb03471.x. [DOI] [PubMed] [Google Scholar]
  • 47.Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87:217–20. doi: 10.2105/AJPH.87.2.217. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Wasylenki DA, Goering PN, Lemire D, Lindsey S. The hostel outreach program: Assertive case management for homeless mentally ill persons. Hospital & Community Psychiatry. 1993;449:848–53. doi: 10.1176/ps.44.9.848. [DOI] [PubMed] [Google Scholar]
  • 49.Hwang SW, Gottlieb JL. Drug access among homeless men in Toronto. CMAJ. 1999;160:1021. [PMC free article] [PubMed] [Google Scholar]
  • 50.Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons. JAMA. 2001;285:200–206. doi: 10.1001/jama.285.2.200. [DOI] [PubMed] [Google Scholar]
  • 51.Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: Results from a community-based study. Am J Public Health. 2002;92:778–84. doi: 10.2105/AJPH.92.5.778. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Martell JV, Seitz RS, Harada JK, Kobayashi J, Sasaki VK, Wong C. Hospitalization in an urban homeless population: The Honolulu Urban Homeless Project. Ann Intern Med. 1992;116:299–303. doi: 10.7326/0003-4819-116-4-299. [DOI] [PubMed] [Google Scholar]
  • 53.Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with home-lessness in New York City [comment] N Engl J M. 1998;338:1734. doi: 10.1056/NEJM199806113382406. [DOI] [PubMed] [Google Scholar]
  • 54.Lehman AF, Dixon LB, Kernan E, DeForge BR, Postrado LT. A randomized trial of assertive community treatment for homeless persons with severe mental illness. Arch Gen Psychiatry. 1997;54:1038. doi: 10.1001/archpsyc.1997.01830230076011. [DOI] [PubMed] [Google Scholar]
  • 55.Metraux S, Marcus SC, Culhane DP. The New York-New York housing initiative and use of public shelters by persons with severe mental illness. Psychiatr Serv. 2003;54:67–71. doi: 10.1176/appi.ps.54.1.67. [DOI] [PubMed] [Google Scholar]
  • 56.Zerger S. Substance Abuse Treatment: What Works for Homeless People? A Review of the Literature. Nashville, Tennessee: National Health Care for the Homeless Council; 2002. [Google Scholar]
  • 57.Canada MortgageHousing Corporation. Inventory of Projects and Programs Addressing Homelessness. 1995. [Google Scholar]
  • 58.Provincial Task Force on Homelessness. Report of the Provincial Task Force on Homelessness. 1998. [Google Scholar]
  • 59.May KM, Evans GG. Health education for homeless populations. J Community Health Nurs. 1994;11:229–37. doi: 10.1207/s15327655jchn1104_5. [DOI] [PubMed] [Google Scholar]
  • 60.Green L, Kreuter M. Health Promotion Planning: An Educational and Ecological Approach. Mountain View, CA: Mayfield; 1999. [Google Scholar]
  • 61.Boydell KM, Goering P, Morell-Bellai TL. Narratives of identity: Re-presentation of self in people who are homeless. Qualitative Health Research. 2000;10(1):26–38. doi: 10.1177/104973200129118228. [DOI] [PubMed] [Google Scholar]
  • 62.Boyce WF. Disadvantaged persons’ participation in health promotion projects: Some structural dimensions. Soc Sci Med. 2001;52:1551–64. doi: 10.1016/S0277-9536(00)00268-9. [DOI] [PubMed] [Google Scholar]
  • 63.Alberta Community Development. Moving Forward … Homelessness Policy Framework: Implementation Strategy. 2000. [Google Scholar]
  • 64.Glasser I, Fournier L, Costopoulos A. Homelessness in Quebec City, Quebec and Hartford, Connecticutt: A cross-national and cross-cultural analysis. Urban Anthropology. 1999;28:141–59. [Google Scholar]
  • 65.Novac S, Serge L, Eberle M, Brown J. On Her Own: Young Women and Homelessness in Canada. Ottawa, ON: Status of Women Canada; 2002. [Google Scholar]
  • 66.Kufeldt K. Social policy and runaways [review] J Health Soc Pol. 1991;2:37–49. doi: 10.1300/J045v02n04_04. [DOI] [PubMed] [Google Scholar]
  • 67.Appathurai C. Developing policies for runaways: Insights from the literature [review] J Health Soc Pol. 1991;2:51–64. doi: 10.1300/J045v02n04_05. [DOI] [PubMed] [Google Scholar]
  • 68.Eberle M, Kraus D, Serge L. Homelessness: Causes & Effects — Background Report: A Profile and Policy Review of Homelessness in the Provinces of Ontario, Quebec and Alberta. Vancouver, BC: Ministry of Social Development and Economic Security; 2001. [Google Scholar]

Articles from Canadian Journal of Public Health = Revue Canadienne de Santé Publique are provided here courtesy of Springer

RESOURCES