Health & Homelessness in Ireland:

From economic boom to bust

Fiona O’Reilly PhD, Ailish Hannigan PhD, Stacey Scriver PhD

Suzanne Barror MSc, Lynn Ruane, Anne MacFarlane PhD Austin O’Carroll MD

Acknowledgements

• Co-funded by the Partnership for Health Equity, HSE Social Inclusion and Safetynet.

• The Dublin Simon Community (DSC) • Anna Liffey volunteers collected data in

Limerick.

Overview

• Homeless health survey 2013– Demographics– Health Status – Addiction– Service Usage

• Comparison over time with 2005 &1997 surveys

• Conclusion

1997

• ..best performing economies in the industrialised world..• 1997 economy grew by 9.5%• Employment growth 3.8%• Highest level of job creation in the industrialised world.

http://irelandnow.com/economy.html

2,900 1999, Counted In Homeless Initiative

78% smokers29% drank alcohol beyond recommended limits 29% illegal drugs43% perceived themselves to be in only fair or poor health 67% per cent of people had at least one physical or mental health problem54% saw a GP45% had no medical card

2005• The Economist found Ireland to have the best quality of life in the world• Employment soared from 1.1 million to 1.9 million (1990-2005)• Very high economic growth, the highest growth rates in Europe

2,280 2005, Counted In 2005

90% smokers 28% drank alcohol beyond recommended limits 64% had used illegal drugs54% perceived themselves to be in only fair or poor health 84% per cent of people had at least one physical or mental health problem74% saw a GP45% had no medical card

2013• The economic challenges continues • Prolonged European sovereign-debt crisis caused a new Irish recession

starting in Q3 2012• In May 2013 forecast for Ireland predicted its growth rates would return to

a positive 1.1% in 2013 and 2.2% in 2014..

90% smokers 39% drank alcohol beyond recommended limits 78% had used illegal drugs47% perceived themselves to be in only fair or poor health 89% per cent of people had at least one physical or mental health problem82% saw a GP25% had no medical card

3,808 2011 Census

Methods

• Cross sectional survey 2013 Dublin & Limerick (601)

• Health status, service utilization and risk behaviours

• Interviewer questionnaire (20min)• Comparison surveys 2005, 1997• Definition

a)‘roofless’ i.e. people sleeping rough or people in emergency accommodation and b) designated accommodation for homeless which is of a temporary nature

ETHOS - European Typology on Homelessness and Housing Exclusion

SampleAccommodation

Type No.

accommodations

North Dublin/South

Dublin / Limerick

No. residents previous night

Number participated in

survey

Response rate (%)

TEA/STA 21 Dublin 485 329 68%PEA 13 North Dublin 291 186 64%Limerick STAs 6 Limerick 134 63 47%

Rough Sleepers

Dublin 23

TOTAL 910 601 66%

THE SAMPLE

• Men: 68%• Under 45 years: 78%• Single: 72%• Parents: 64% – Few with children: 6%

• Mainly White Irish: 84%• Roman Catholic: 82%• Unemployed:95%• In Receipt of social welfare: 96%

Demographics

Homeless > 1 year

In care as a child

In care as a child

Mental health problems

Crime

Other

Alcohol

Financial or eviction

Drugs

Drugs or alcohol

Family relationship problems /Dom violence

Drug or alcohol and family problems

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

LimerickDublin

HEALTH

Total

n 650

Self-rated health status

Very good or Excellent 19.7%

Good 33.5%

Fair or Poor 46.8%

n 600

Preventing normal daily activities

Physical health 46.0%

Mental or emotional health 51.5%

Getting older

Diagnosis

On methadone Injecting drug use

High alcohol intakeSpecial service attenders

A&E AttendersHospital inpatient stay

Homeless

Housed

Self perceived health status: fair/poor

Dublin Limerick Total

n 536 63 599

Either mental or physical diagnosis 90% 83% 89%

Physical health condition 83% 67% 81%

At least one mental health diagnosis 58% 59% 58%

Blood borne virus 31% 0% 27%

Liver disease higher in Dublin

More diagnosis of physical conditions among drug users

Most with diagnosis reported receiving treatment

Dental problems higher in Dublin

1 in 4 undiagnosed health problems

Dublin

n 531HIV positive 3.6%Treated for HIV 3.6%

n 525Diagnosed with Hepatitis B 4.8%Treated for Hepatitis B 2.9%

n 530Hepatitis C positive 28.5%Hepatitis C positive (n=151)

Treated for Hepatitis C 53.0%

Assessed for treatment or offered treatment 73.5%

Hep C 36% in 2005

High mental health morbidity among homeless people

• 58% at least one mental health condition.

• 52% reported mental or emotional health affected their activities of daily living

• 60% reporting mental health diagnosis were currently on prescription medication

Total (n=599)

Diagnosed with anxiety 40%

Treated for anxiety 33%

Diagnosed with depression 52%

Treated for depression 44%

Diagnosed with schizophrenia or psychosis 13%

Treated for schizophrenia or psychosis 11%

Mental health diagnosis and Self-diagnosed addiction problem

47%

Mental health diagnosis and Currently illicit drug use

35%

Report of a diagnosis of at least one mental health conditions was more common among current and past drug users and women.

Health trend 1997-2013

1997 2005 20140%

10%20%30%40%50%60%70%80%90%

100%

Diagnosed IllnessTaking Prescrip-tion MedicationAnxietyDepression

2013

self harm suicidal thoughts

attempted suicide

0%

10%

20%

30%

40%

50%

60%

prior to last 6 monthsin previous 6 months

Suicidal ideation and behaviour

Drug users women<45yrs>6months in homelessness

Suicide attempts by mental health problem

Mental health diagnosis No Mental health diagnosis0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Attempted suicideDid not attempt suicide

ADDICTION

2005 37% 12%2013 41% 36%

Dublin 39% Limerick 43%General Population 10% (SLAN 2007)

Above 21 standard drinks for men and 14 for women

Excessive drinking

Drugs

• 78% current or past

• 55% current users

Drug Use Ever Current Drug Use IDU Ever IDU (last 12 months)

80

56

46

25

60

49

2215

Dublin % Limerick %

Cannab

is Use

Benzo

s (Str

eet) U

se

Heroin Use

Stree

t Meth

adone U

se

Cocaine U

se

Crack U

se

Other Drug U

se

Ecsta

sy Use

Head Sh

op Powders Use

Amphetamines

Use0%

10%

20%

30%

40%

50%

60%

DublinLimerick

Current drug use by age group

Current and Past drug use

Current use Past Use

Current & Past heroin

Limerick Dublin

25% in past year - Dublin

15% in past year - Limerick

Drug use among people on MMT

• 42% of current drug users were prescribed sedative / minor tranquillizers• 49% of those reporting illicit benzo use were also prescribed them

Street b

enzodiaza

pines

Prescribed benzo

diazapines

Heroin

Prescribed anti-psych

otics

Street m

ethadoneCrack

Cocaine

0

10

20

30

40

50

60

70

n=211%

Self report main addiction Dublin Limerick Total

n 377 38 412Main Problem Drug

Alcohol 39.6% 57.9% 41.3%Opiates 43.6% 15.8% 41.0%Cannabis 4.0% 13.2% 4.9%Minor Tranquilizers (tablets) 8.0% 10.5% 8.3%Cocaine/crack 3.2% 2.6% 3.2%Other 1.6% 0.0% 1.5%

78% had used a drugs’ service in past 12 months- counselling 45%, - needle exchange 28% - inpatient detox 18% - rehab or stabilization 18% - aftercare 12%

…30 waited for inpatient detox

Changes in addiction patterns

1997 (n=502)

2005 (n=363)

2014 (n=601)

0

10

20

30

40

50

60

70

80

90

100

Ilicit drug use (ever)Drinking above limitsSmokingHeroin as main addic-tion

%

Changes in illicit drug use

2005 (n=363) 2013 (n=531)0

10

20

30

40

50

60

Heroin use (ever)Cocaine (ever)Benzos (ever)Street Methadone (ever)Injected drugs (ever)

%

HEALTH SERVICE USE

Medical card and GP Registration

Dublin Limerick0%

10%20%30%40%50%60%70%80%90%

100%

Has medical cardRegistered with GP

Health professionals seen in last 6 months

Dublin Limerick Total Own GP 57.1% 81.0% 59.6%

Nurse 38.4% 40.3% 38.6%

Any GP or Nurse including special homeless services

81.5% 90.5% 82.7%

Social Worker 27.2% 19.7% 26.5%

Counsellor 30.1% 35.0% 30.6%

Chiropodist 5.1% 8.2% 5.4%

Dentist 27.9% 23.0% 27.4%

Psychiatrist 17.9% 23.0% 18.4%

Psychiatric Nurse 10.4% 26.2% 12.0%

Any Special Service* 52% 38% 50%* Safetynet in Dublin , Multi disciplinary outreach team in Limerick

On site support and key working

• Almost 60% had key workers and over 40% had care plans.

• Support within accommodation more common in Limerick & STAs in Dublin.

• People with a key worker were more likely to have a medical card and access services.

Changes in service use and access

1997 2005 20130

10

20

30

40

50

60

70

80

90

Own GPSocial WorkerAny GP or NurseMedical Card

%

Attended psychiatrist or psychiatric nurse

1997 2005 20130

10

20

30

40

50

60

70

80

Psychiatrist (De-pression/Anxiet ) Psychiatric Nurse (Depression/Anxiety)Psychiatrist(All)Psychiatric Nurse (All) Psychiatrist (Schizophrenia)Psychiatric Nurse (Schizophrenia)

%

Use of secondary services

1997 2005 20130

5

10

15

20

25

30

35

40

45

50

A&EHospital Outpa-tientsInpatientPsychiatric inpa-tient

%

Barriers to health service use

• Previous Negative Experiences 79• Service(s) not open when needed 42• No Medical Card 41• Too Expensive/Cost 36• Long waiting 23• Can’t get required treatment 13• Other Things more Important 12• Difficulty getting a GP 10• Experienced HRC/not legally resident 4• Other 27

Satisfaction with services

Very Good

Good Ok Bad Very Bad0%

5%

10%

15%

20%

25%

30%

35%

40%

DublinLimerick

Improvements neededServices were people are at!• More outreach on site services and information• Non discriminating services

Ultimately HOUSING

“Get homeless people off the streets so they can get better health services”

“If the housing facilities were better and so many not boarded up then less people would be homeless and their health would be better”

CONCLUSIONS

Context of boom and bust

http://www.irisheconomy.ie/index.php/2012/09/21/trends-in-living-standards/

• In context of increasing numbers of homeless & reconfiguration of services … increasing access to health care, more diagnosed & treated illness however increased A&E use

• Homelessness is an unhealthy state with homeless people suffering disproportionate levels of illness and addiction

• High level of mental health problems and suicidality

• High poly drug use with concurrent legal illegal and prescribed drugs

• Key working improving access

• Better access in limerick with small manageable population

Recommendation

• A&E liaison for homeless• Suicide prevention and crisis centre• Coherent mental health strategy that targets dual diagnosis• Target individual needs with service rather than fitting

person to services• All health services for homeless should incorporate stable

accommodation as a treatment goal

“I’m 13 years on a housing list. Being housed will improve health. Instead I’m given the run around and pawned off”

Life on the streetsBacked into a corner,wishing away pain.

Satanic whispers in your ear,driving you insane.

Frustrations get the best of you,all you’ll do is scream.

You’ll realize you’ll never win,because demons never dream.

—17-year-old homeless girl, Toronto, March 2004

Kidd S, Factors Precipitating Suicidality among Homeless Youth : A Quantitative Follow-Up. Youth Society 2006 37: 393

Homeless people have attempted

suicide