In 2019 it was estimated that approximately 35 000 Canadians are homeless on any given night, and at least 235 000 in any given year (Rech, 2019). Within Canada homeless people have high levels of morbidity, mortality, and experience significant barriers accessing healthcare. They commonly suffer from a wide range of medical problems, and disease severity can be much higher than those with secure housing. This can be a result of factors such as extreme poverty, delays in seeking medical attention, non-adherence to treatment, cognitive impairment, and effects of homelessness itself. Common health problems seen in homeless often can include COPD, hypertension, diabetes, and anemia, which are often inadequately controlled and may remain undiagnosed for significant periods of time. Homeless individuals also experience higher usage of alcohol and drug use, mental illness and are more at risk for contracting illnesses such as TB, HIV, and Hep C (Hwang, 2001) (Guirguis, McNeil & Hwang, 2014).
Within Canada homeless people are admitted to the hospital up to 5 times more often than the general population, often obtaining primary care from emergency departments (Hwang, 2001). While the homeless have a high level of health service utilization, they frequently have unmet health needs due to the barriers that they face accessing necessary care and adhering to treatment. This is in large due to the daily struggle for survival. Finding immediate needs such as food & shelter, often takes precedence over other health needs. This can lead homeless people to delay seeking medical treatment until it becomes a severe issue (Guirguis, McNeil & Hwang, 2014). Medications to treat conditions such as hypertension, diabetes, etc are often pricey if an individual does not have private insurance, which is a huge financial barrier for controlling conditions in those who are homeless.
Homelessness and Oral Health
I wouldn't be a good hygienist if I didn't tie oral health into every assignment ;)
Overall, homelessness has a direct association with poor oral health. Dental issues such as missing and decayed teeth, oral pain, gum disease and related conditions in need of urgent attention are common in those who are homeless. This results in dentistry is rarely being a priority until an immediate problem surfaces in or around the mouth. Homeless people often have difficulties obtaining food, shelter, safety, and money, which leads to oral hygiene falling to the side.
There are many factors that may contribute to poor oral health of homeless people: • More pressing daily survival needs preventing routine healthy eating and personal hygiene • Acceptance of poor dental health and appearance • Extreme poverty • Limited access to items needed for oral hygiene, as well as facilities • Lack of awareness of diet and oral hygiene issues • Tobacco, alcohol, and illicit drug use can have devastating oral implications • Mental health problems and substance misuse • Dental pain/limited dentition may result in a diet of soft foods which typically contains refined carbohydrates
For the homeless it can be extremely difficult to access primary health care, especially oral health care. Access to dental services is complicated by the private sector that is majority out of pocket expense. Expensive treatment means minor problems are often ignored because of treatment costs and, when untreated, can lead to pain, infection, swelling and more costly care.
As mentioned earlier, hospital emergency departments are often the ‘first line of defence’ for those who are homeless, and often utilized by those who are unable to pay for a visit to a dentist. However, emergency departments are typically not prepared or suitably equipped to care for dental emergencies.
Within Canada, dentistry is generally funded as an employment based benefit or an out of pocket expense rather than the public health care system. This leads socioeconomic status being a heavy influence to access to dental care. Dentists occasionally attempt to meet the needs of homeless persons and other low-income populations through charitable donations of their services. However, there are strong opinions that charity offers little more than a ‘band-aid solution’ to a complicated set of social problems.
Many community dental clinics are expanding dental care for underserved populations, including homeless populations. Inner-city community health centres provide an avenue to address the health care needs of vulnerable and marginalized populations, however few have dental clinics. Oral health care needs to be recognized, and treated as a priority for all, no matter of socio-economic status. As more research is completed we are realizing how much oral diseases can affect the rest of the body. (Guirguis, McNeil & Hwang, 2014).
Homelessness and HIV
A few weeks ago I partnered with Julie and learned A LOT about HIV, so I thought I’d incorporate a bit about HIV within the homeless in this post!
Homelessness is extremely common among people who inject drugs, particularly those who are HIV positive. Substandard housing and homelessness have been identified as key factors that play direct roles in an increased risk of contracting HIV from injection drug use (Rourke, Bacon, Mcgee, Gilbert, 2015).
People with HIV who are unstably housed, and who face food insecurity are more likely to: (Rourke, Bacon, Mcgee, Gilbert, 2015) • Have higher viral loads • Be non-adherent to HIV treatment • Not access medical or social services aimed to treat HIV • Have substance use issues • Experience higher levels of depression and stress. • Have higher mortality and morbidity
An inability to attain safe/stable housing is known to be both a cause and a consequence of drug use. Housing environments can foster, and perpetuate HIV among those who inject drugs at a greater rate than those who are housed. Those who are homeless may also be involved in HIV risk factors such as syringe sharing, shooting gallery attendance, and sex work (Guirguis, McNeil & Hwang, 2014).
Injection drug users experience a multitude of social and structural barriers while attempting to access safe and stable housing. Many are classified as hard to house for reasons including lack of stable employment and income, ‘unclean’ visual appearance, erratic or aggressive behaviour and the presence of co-morbidities associated with chronic substance use. Among homeless people with HIV, treatment compliance is complicated by competing priorities associated with homelessness, such as obtaining shelter and nutrition. Housing programs are becoming more and more valued as a vital component of comprehensive HIV prevention. Rental assistance and other housing support programs can be associated with improved health outcomes and better treatment adherence among those with HIV (Guirguis, McNeil & Hwang, 2014).
HIV infected injection drug users who are homeless are less likely to achieve viral load suppression upon receiving highly active antiviral therapy (Haart) mainly due to compliance and access to care. Therefore, if injection drug using populations are to receive comprehensive programming and preventive benefits of haart, efforts should also be made to address housing instability. Safe and stable housing should be viewed not only as a means effective HIV management and care but also as an intervention to reduce new HIV infections among injection drug users, and of course, housing as a basic human right for everyone (Guirguis, McNeil & Hwang, 2014).
Given the evidence that housing instability significantly reduces one’s ability to maintan HIV treatment and practice risk reduction behaviours, secondary prevention for those at risk for HIV transmission should include housing assistance alongside comprehensive intervention strategies. HIV infected persons with high viral loads are more likely to transmit HIV during high-risk sexual or injection-related behaviours. Higher levels of HIV viral load among injection drug users have also been associated with increased hiv incidence at the community level. Given that antiretroviral therapy induces viral load suppression among adherent patients, the expansion of access to haart is now thought to be an effective means to control the spread of HIV (Guirguis, McNeil & Hwang, 2014).
References
Guirguis-Younger, M., McNeil, R., Hwang, S., (2014) Homelessness & health. University of Ottawa Press. https://ruor.uottawa.ca/bitstream/10393/30952/1/9780776621487.pdf Hwang, S., (January 2001). Homelessness and Health. Canadian Medical Association Journal. https://www.cmaj.ca/content/cmaj/164/2/229.full.pdf
Rech, N., (April 2019). Homelessness in Canada. The Canadian Encyclopedia. https://www.thecanadianencyclopedia.ca/en/article/homelessness-in-canada
Rourke, SB., Bacon, J., Mcgee, F., Gilbert., (December 2015). Tackling the social and structural divers of HIV in Canada. Canada Communicable Disease Report. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5864300/pdf/CCDR-41-322.pdf
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