Women's Health Issues 21-1 (2011) 48e56

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Original article

A Comparison of Individual and Social Vulnerabilities, Health, and Qualityof Life Among Canadian Women With Mental Diagnoses and Young Children

Phyllis Montgomery, RN, PhD a,*, Stephanie Brown, MSW, RSWb, Cheryl Forchuk, RN, PhD c

a School of Nursing, Laurentian University, Sudbury, Ontario, CanadabRegional Mental Health CaredSt. Thomas, Forensic Rehabilitation Readiness Unit, St. Thomas, Ontario, Canadac School of Nursing, Faculty of Health Sciences, Lawson Health Research Institute, University of Western Ontario, London, Ontario, Canada

Article history: Received 24 November 2009; Received in revised form 16 July 2010; Accepted 26 July 2010

a b s t r a c t

Purpose: This study examined whether differences exist among wom

en with mental health issues who had eitheryoung, adult, or no children in relation to their individual and social vulnerabilities, health, and quality of life.Methods: The design of this study was a secondary quantitative analysis of data extracted from a larger Canadian 5-yearstudy focused on mental health and housing. This study’s sample included 234 female psychiatric consumer/survivors:108 (46%) women reported having no children, 68 (29%) had at least one child younger than 18 years of age, and 58(25%) had children 18 years of age or older. The women completed structured interviews between 2004 and 2006.Findings: Seventy-nine percent of mothers were separated from their young children. In comparison with women witholder children and those without children, womenwith young childrenwere more often homeless, had fewer strengths/resources, greater physical but lower cognitive/intellectual functioning, and a low perception of quality of life regardingtheir financial situation. In addition, women with young children reported the greatest problemwith substance use andpoorest quality of life regarding daily activities, health, and overall quality of life. These results, however, were mediatedby the confounding effects of housing. No differences were identified between groups regarding utilization of health andsocial services.Conclusion: These findings support the need for early integrated health and social interventions that assist womenachieve their well-being.

Copyright � 2011 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Introduction

The burden of enduring mental illness can be profound,severely impacting women’s social roles, in particular, their rela-tionshipswith significantothers, including their children.Motherswho become homeless comprise a diverse population. Theseinclude subgroups such as adolescentmothers (Dostaler &Nelson,2003; Meadows-Oliver, 2006); single mothers who are separatedfrom their minor children (Cowal, Shinn, Weitzman, Stojanovic &Labay, 2002; Nicholson et al., 2006; Zlotnick, Robertson, &Wright, 1999), or who parent their children “in public,” or underthe surveillance of shelter staff (Meadows-Oliver, 2003); motherswith children fleeing domestic violence (Neal, 2004; Salomon,Bassuk, & Huntington, 2002; Zlotnick, Tam & Bradley, 2007);

* Correspondence to: Phyllis Montgomery, RN, PhD, Professor, School ofNursing, Laurentian University, Ramsey Lake Road, Sudbury, Ontario, Canada,P3E 2C6. Phone: (705) 675-1151, extension 3818; fax: (705) 675-4861.

E-mail address: pmontgomery@laurentian.ca (P. Montgomery).

1049-3867/$ - see front matter Copyright � 2011 by the Jacobs Institute of Women’sdoi:10.1016/j.whi.2010.07.008

mothers with and without employment (Johnson, 1999; Neal,2004; Smith & North, 1994); and mothers of different sociocul-tural/economic backgrounds (Park, Metraux, Brodbar & Culhane,2004; Paradis, Novac, Sarty, & Hulchanski, 2008; WaegemakersSchiff, 2007).

Despite the rich body of literature on homeless women,Nicholson et al. (2006) argue that the majority of publishedevidence aboutwomenwithmental illness, insecurehousing, andchildren typically has involved small, clinically serviced, conve-nient samples. Paquette and Bassuk (2009) contend that there isa need for additional research to implement evidence informedpractices for this heterogeneous group of vulnerablewomenwhoare seeking secure housing andwanting to parent. The purpose ofthe present study is to describe the differences in select individualand social risk factors, health status, and quality of life amongwomen with mental health issues and who have either youngchildren, older children, or no children.

This focus of inquiry is informed by the theoretical andempirical literature describing the importance of parenting forwomenwithmental illness as they strive to achieve overall health

Health. Published by Elsevier Inc.

IndividualVulnerabilities1

SocialVulnerabilities2

Health Status

Quality of Life

1. Age, Marital Status, Education, Income, Primary Diagnosis, Parenting Status 2. Housing Type, Housing Tenure, Utilization of Services

Figure 1. Adoption of model by Frankish et al. (2003).

P. Montgomery et al. / Women's Health Issues 21-1 (2011) 48e56 49

(Benbow, Forchuk, & Ray, 2009; Nicholson et al., 2006). Althoughnot specifically designed for women living with mental healthchallenges, the conceptual orientation proposed by Frankish,Hwang, and Quantz (2003) includes the common elementsassociated with insecure housing for at-risk populations:vulnerability, housing, health, and quality of life (Figure 1). TheseCanadian authors describe how multiple individual and socialvulnerabilities combine to affect a person’s housing situation andhealth status and, subsequently, a person’s quality of life. For thepurpose of this study, a person’s housing situation, whether theyhad no housing or were precariously housed, was viewed asa social vulnerability. Other Canadian researchers (CanadianInstitute for Health Information, 2007; Forchuk et al., 2007)suggest that mental illness and insecure housing serve to exac-erbate each other as a type of “double jeopardy.” Although themodel illustrates linear linkages between each of the variables,like Frankish et al. (2003), we acknowledge that the relationshipsamong each of themodel’s components aremuchmore complex.Parentalmental health and insecure housing only serve to furthercomplicate the inherent challenges associated with beingresponsible for children.

As a group, homeless women with children frequently live inpovertyandexperience poorhealth. The costs ofmaintaining goodhealth are not feasible for many women when, for example, inCanada in 2003 the national median income of lone-parent fami-lies, most often headed by women, was $28,600, compared with$62,600 for dual parent families (Lessa, 2006). Park et al. (2004)conducted a prospective study of 8,251 homeless American chil-dren. They found that a family’s lack of economic resources (77%),followed by domestic violence (10%), were the most frequentreasons for their first admission to the public shelter system.

Further, before entering shelters, women with children oftenintermittently live with family and friends in overcrowdedaccommodations (Meadows-Oliver, 2003; Trasher & Mowbray,1995). Two American researchers, Lewit and Schuurmann Baker(1996), use the terms “doubled up” or “precariously housed” todefine this type of homeless population. This group consistsprimarily of adult women with children who are without “fixed,regular, and adequate nighttime residence” (p. 146). They live fortime limited durations with acquaintances because they lacka secure place of their own. Lewit and Schuurmann Baker arguethat mothers place their children with relatives or friends to

minimize the family’s risk of absolute homelessness. In the situ-ation of absolute homelessness or no accommodation, womenmay be separated from their children voluntarily or involuntarilythrough involvement of child protection services. For example,a mother maymake the decision to separate from her children inan effort to comply with an adult shelter’s policy. Women unac-companied by their children, however, risk loss of family benefits(Zlotnick, Robertson, & Lahiff, 1998) and longer durations ofhomelessness. Zlotnick, Robertson, and Tam (2004) found thatAmerican women with children exited the shelter system insignificantly less time than unaccompaniedwomen. Themediumlength of a shelter stay for women with children was 1 month,compared with 2 months for other women.

Canadianwomen’s insecure housing circumstances are furtherconfounded by a scarcity of affordable housing within the largercontext of health and social welfare systems lacking in capacity tomeet their diverse needs (Forchuk, Ward-Griffin, Csiernik, &Turner, 2006; Neal, 2004; Rahder, 2006; Rude& Thomas, 2001). Ina Canadian survey of housing conditions, 38% of women-ledfamilies had a core housing need (Canadian Mortgage andHousing Corporation, 2002). That is, their accommodation fellbelow at least one of the adequacy, suitability or affordabilitystandards, and an acceptable alternative dwelling would cost 30%or more of their income. In particular, the rates of core housingneedwere generally higher forwomenwith disabilities. A numberof authors (Paquette & Bassuk, 2009; Woolhouse, Bell, Brown, &Lent, 2004) also suggest that the inability to secure and maintainsafe and affordable accommodation further compounds the chal-lenges of parenting.

Weinreb, Buckner, Williams, and Nicholson (2006) estimatethat three out of four American homeless mothers experiencemental illness and/or substance abuse; health issues often comp-licated by medical problems. In comparison with women withchildren in low-income, stable housing, women with children inshelters were found to have a higher incidence of psychiatric andsubstance abuse disorders in the United Kingdom (Karim, Tischler,Gregory, & Vostanis, 2006). Page and Nooe (2002) compareda number of health factors of homeless women with and withoutminor children in America. They found that both groups ofwomenhad high rates of mental illness and homelessness histories. Incontrastwithaccompaniedwomen, thosewomenunaccompaniedby their children had significantly greater overall health problemsand psychiatric hospitalizations. In addition, Page andNooe reportthat the frequencyofmaternalechild separationswas significantlyhigher formothers livingwith co-occurringmental and substanceabuse disorders. Nicholson et al. (2006) state that stressful lifeevents such as legal involvement, insecure housing, and sexualtrauma (pastor current)aremore frequent for thisgroupofwomencompared with those accompanied by their children.

Despite the adverse relationship between homelessness andhealth, international studies identify personal as well as system-atic barriers confronting homeless mothers’ access to healthservices (Amen & Pacquiao, 2004; Ontario Women’s HealthCouncil, 2002a; Tischler, Rademeyer & Vostanis, 2007; Wenzel,Leake, Andersen & Gelberg, 2001; Woolhouse et al., 2004). Forexample, the inability to access appropriate services, to obtainhealth care coverage, to experience therapeutic respectfulness, aswell as the lack of resources to support continuity of care havebeen identified (Ontario Women’s Health Council, 2002a). Forwomenwith young children, stigma and fear of child removal areadditional barriers resulting in underutilization of services.

Much less is known about how insecure housing affectsmothers’ overall social functioning. Although motherhood is

P. Montgomery et al. / Women's Health Issues 21-1 (2011) 48e5650

central to the identity of most women with mental illness,Nicholson et al. (2006) suggest that their capacity as mothersin disadvantaged circumstances is most likely nonlinear andmultidirectional. Qualitative researchers have describedhomelessmothers’ functioning in terms of their parenting role. For instance,Meadows-Oliver (2003), in a meta-synthesis of 18 qualitativeinterdisciplinary studies about homeless mothers with childrenliving in shelters, found that the shelter’s environment requiredmothers to be consistently on guard to ensure the safety of theirchildren. Lindsey (1998) suggests that, paradoxically, the constantattending to children can both decrease and increase mothers’ability to function. She found that the constant presence of chil-dren contributed to the mothers’ overall sense of vulnerability.Paradis et al. (2008) found that Canadian mothers stayed in shel-ters as a strategy to maintain or regain custody of their children.Further, tenure in shelters was associated with temporary respitefrom the poverty, abuse, and deprivation. Given these compellingand at times conflicting qualitative research findings, furtherunderstanding of barriers and resources for functional recovery inhomeless mothers is necessary to guide interventions.

It is assumed that homelessness in conjunction with mentalillness represents the lowest level of quality of life (Leff, 2006). Leffcautions, however, that much of the homelessness research hasinvolved mixed samples, with an underrepresentation of womenand, inparticular,womenwhoparent. For example, Kyle andDunn(2008) conducted a systematic review of the effects of housing onhealth, service utilization, and quality of life for persons withserious mental illness. They found that of the 29 reviewed studiespublished since 1980, 62% of the samples included more menthanwomen. Inaddition, they identified that services forhomelesswomen with children focused on changing objective circum-stances, provision of health and social services, developing par-enting skills, and employment training. Finally, Scheyett andMcCarthy (2006) conducted a qualitative study involvingAmericanwomenwith seriousmental illness. They identified thatwomen,withorwithout children, continue toperceive themselvesas “invisible”within a complex and fragmented systemof servicesthat lack connectedness for improving their quality of life.

Methods

Design

The data for this study was extracted from a larger, 5-yearCommunityeUniversity Research Alliance (CURA) initiative. Theoverall goal of the primary study’s collaborative partnership wasto identify issues and solutions about the housing needs ofpsychiatric consumers/survivors (Forchuk, Csiernik, & Jensen, inpress; Forchuk et al, 2006). Therefore, mixed methods guidedby participatory action approaches were used. Ethical approvalwas obtained from the sponsor university and the participatingagencies’ respective boards. A variety of sampling methods wereused because the primary study’s population of interest wasadults with mental illness who experienced insecure housing.They constituted a largely invisible group in the community ofLondon, Ontario. To be eligible for the study, adults had to beproficient in English, be 16 years of ageor older, andhave a historyof mental illness lasting a minimum of one year. During 2001 to2006, quantitative data were collected from 887 psychiatricconsumers/survivors who were recruited from a variety ofaccommodations such as shelters, grouphomes, boarding homes,social service agencies, outdoor self-made accommodations,independent dwellingswith orwithout support staff, anddrop-in

centers. With the exception of group homes and supportedapartments, fewer women than men were available to recruit atthe various sites. Homeless women with a history of domesticviolence and day-to-day parenting responsibilities were moredifficult to recruit because they were ranked as “a priority” forhousing. Community workers also suggested that women morecommonly accessed their social support networks, therebyallowing them to “double-up” to avoid shelter stays.

During each year of the primary study, all data were collectedby trained interviewers, including multidisciplinary researchersandundergraduate and graduate students. Participantswerepaidan honorarium of $20.00 Canadian. Depending on the measure,training was mandatory at each 6-month interval to ensure aninter-rater reliability of 90% throughout the duration of the orig-inal project. Trained interviewers conducted face-to-face, struc-tured survey interviews with psychiatric consumers/survivorsthat typically lasted 1 to 2 hours. The interviewers read thequestion items and recorded the participants’ responses. Inaddition, qualitative focus group interviews, lasting fewer than90minutes, were conducted each year with consumers/survivors,family caregivers, and community health and social workers. Theprimary study’s large data set was collected to meet its objectiveof multiple secondary analyses. The purpose of the present studyand intent to compare data collected from different groups ofwomenwith mental health and housing issues was conceived asthe investigators became increasingly aware that a subgroup ofthe adults participating in the focus groups consisted of parents.To distinguish subgroups of women, quantitative data pertainingto childrenwere collected solely in the fourth andfifthyears of theprimary study.

Sample

During the fourth year of the original CURA study, 267 indi-viduals participated in the survey interview. Of these, 113 (42%)were women. In the fifth year, 336 individuals participated and154 (46%) were women. Because 33 of the women who partici-pated in thefifthyearhad also participated in the fourthyear, theywere removed from the sample to control for duplication. For thissecondary analysis, all women interviewed in year 5 plus thosewomen interviewed for the first time in year 5 were included fora total sample of 234 women. The operational definition ofmother in the CURA was a response of “yes” to the question, “Doyouhave children?”Womenwith childrenwere grouped into twosubgroups based on the age of their youngest child: under 18years of age or 18 years of age or older. If awoman had children inboth target groups, she was categorized to the subgroup ofmothers with young children because she had at least one childwas younger than 18 years of age. Children18 years of age or olderare considered adults themselves (Nicholson et al., 2006). For thepurpose of this study, mothers with children 18 years of age orolder were categorized in the subgroup, mothers with adult orolder children. Therefore, in the current sample of mothers (n ¼126), 68 (54%) of them had a least one young child and 58 (46%)mothers had adult children. The total number of womenwith nochildren was 108. Because the living arrangement in the primarystudy was only collected for a woman’s youngest child, there areno data concerning the placement of their additional children.

Data Collection

The measures used in this study are a subset of those used inthe CURA survey. Responses from five questionnaires were

P. Montgomery et al. / Women's Health Issues 21-1 (2011) 48e56 51

analyzed to determine differences among the three subgroups ofwomen in terms of individual and social vulnerabilities, healthstatus, and quality of life.

Individual and social vulnerabilitiesA Demographic Form, created for the purposes of the CURA,

was used to collect data regarding gender, age, marital status,highest level of education, psychiatric diagnosis, and age at firstcontact with the mental health system. Primary psychiatric diag-nosis was collected by self-report and classified as schizophrenia,mood disorder, anxiety disorder, personality disorder, other, orunknown. Asmentioned, in year 4 of the primary study, questionsabout the number of children and description of the youngestchild’s current living arrangementwas added to the DemographicForm. Income data were collected using the Lehman Quality ofLifedBrief Version (QOLI-Brief; Lehman, Postrado, Roth, McNary,& Goldman, 1994) that required participants to provide theirmonthly income in Canadian dollars.

To operationalize social vulnerabilities, weused twomeasures.First, datawere collectedwith amodified version of theUtilizationof Hospital and Community Service Form (Browne, Arpin, Corey,Fitch, & Gafni, 1990). This self-report measure of 30-itemsassesses the type and frequency of service use 1 month beforethe interview. Of interest for the current analysis were contactswith peer supports, psychiatrists, family doctors, emergency roomvisits, physiotherapists, occupational therapists, social workers,nutritionists/dieticians, registered nurses, registered psychiatricnurses, chiropractors, and psychologists.

Second, housing status was examined on two levels: type ofhousing andnumberof residences in thepast 2years.Data forbothvariables were collected using the Housing History Form, createdfor the purposes of the original CURA. Participants were classifiedashoused if they reported living independently or in a group livingenvironment at the time of the structured survey interview. Incontrast, participants were classified as homeless if they reportedresiding on the streets or in a homeless shelter. The number ofresidences during the 2-year period before the survey interviewwascollectedbycompilingadetailedhistoryof consecutivemovesand determining the total number of residences in that timeperiod.

Health statusThe standardized clinical assessment form, theColoradoClient

Assessment Record (Ellis, Wackwitz, & Foster, 1991) was used asa measure of health status. It measures three dimensions: prob-lems in relation to symptomatology, strengths/resources, andlevel of functioning. The problem domains included emotionalwithdrawal, depression, anxiety, hyperaffect, attention, suicide,thought processes, cognitive, self-care, resistiveness, socializa-tion, legal, aggressiveness, family, interpersonal, role, substanceuse, medical, and security. Each domain is rated on a nine-pointseverity scale ranging from 1 (no problem) to 9 (extremeproblem). Of particular interest in this current secondary analysisare the substance abuse domain and the overall level of problemseverity.

Quantity and quality of strengths/resources were assessed infive domains: economic, education, support (friends and family),personal (judgment and insight), and current overall strengths.Each domain was rated on a 9-point scale anchored from 1 (veryhigh) to9 (very low). Level of functioning consists of six subscales:societal/role, interpersonal, daily living, physical, cognitive/intel-lectual, and overall level of functioning. Again, the responseformat was a 9-point scale ranging from 1 (very high function) to

9 (very low function). The Cronbach’s alpha value of the ColoradoClient Assessment Record was 0.74.

Quality of lifeTheQOLI-Briefmeasures subjectiveandobjectivequalityof life.

The 78-item questionnaire includes eight subscales: living situa-tion, family relations, social relations, daily activities, finances,safety/legal, work/school, and health. It also includes a subjectiveglobal scale of life satisfaction. The questionnaire uses a 7-pointsatisfaction scale (1 ¼ terrible to 7 ¼ delighted). The internalconsistency of the QOLI- Brief for people with chronic mentalillness ranges from 0.56 to 0.87 (Lehman, 1988). In the currentanalysis, Cronbach’s alpha was computed to be 0.86.

Data Analysis

Descriptive statistics were computed on all variables. Pearsonchi-square tests were calculated to compare housing type acrossthe three groups of women. One-way analysis of variance wasused to compare age and age at first contact with the mentalhealth system across groups. Age and housing were thought topossibly act as intervening variables. Thus, analysis of covariancewas used to determine differences between groups regardingutilization of services, problem severity, level of functioning, andquality of life, while controlling for age and housing. The level ofstatistical significancewas set at .05 and testswereunidirectional.All statistical analyseswere executed using the Statistical Packagefor the Social Sciences Version 13.0 (SPSS, Inc., Chicago, IL).

Results

Individual and Social Vulnerabilities

This sample of women ranged in age from 18 to 75 years witha mean age of 43 (Table 1). There was a statistically significantdifference in age among the three groups of women (F[2] ¼40.51; p < .001). As expected, mothers with children 18 years orolder had the highest mean age (51.48 � 6.15), compared withwomen with no children (42.95 � 12.92) and mothers with atleast one child under the age of 18 years (34.91 � 8.23).

The majority of women were either single/never married orseparated/divorcedanddifferences inmarital statuswereobservedbetween groups. Womenwithout children were more likely to beuncoupled. Grade school was reported as the highest level ofeducation for all the women. The primary diagnosis for the totalsample was mood disorder followed by schizophrenia. Motherswere significantly more likely to report their primary diagnosis asa mood disorder than women without children. The mean age offirst contact with the mental health system was 21 years of age(range, 1.5e70; n ¼ 216). No significant differences were foundamong the three groups of women with regard to age of initialcontact with the mental health care system. The range of incomefor the entire sample was $0.00 to $3,344.80 per month. Specifi-cally,motherswith a child under the age of 18 years had the lowestincome ($796.07 � $500.93), followed by mothers with adultchildren ($834.86 � $321.87) and women without children($871.29 � $427.26). No difference was observed between themonthly incomes of the three groups.

For the entire sample, the number of children per womanranged from zero to eight. Mothers had an average of two chil-dren. Of the mothers with at least one young child, 79% (n ¼ 54)reported not being the primary parent or current caregiver. Forthis group, the youngest child was either paternally parented

Table 1Individual Vulnerabilities of Women with Mental Illness

Individual Vulnerabilities Women With YoungChildren (n ¼ 68)

Women With AdultChildren (n ¼ 58)

Women With NoChildren (n ¼ 108)

Statistics

df F c2

Age (yrs)Mean � SD 34.91 � 8.23 51.48 � 6.15 42.95 � 12.92 2 40.51Range 18e49 39e70 18e75

Marital statusSingle/never married 42 10 80 8 67.2*

Separated/divorced 14 40 19Widowed 2 5 4Married/common law 9 3 5Other 1 0 0

EducationGrade school 39 25 42 4 5.7High school 20 20 41College/university 9 13 22Missing 0 0 3

Psychiatric diagnosisSchizophrenia 10 14 43 10 0.48 19.4*

Mood disorder 34 24 29 2Anxiety disorder 10 8 18Personality disorder 1 2 3Unknown 12 8 11Other 1 2 4

Age of first contact with mentalhealth system, mean � SD (yrs)

19.57 � 8.74 23.13 � 10.63 21.40 � 10.12

Income (CAN $)Mean � SD 796.07 � 500.93 834.86 � 321.87 871.29 � 427.26 2 0.64Range 0e2,150.00 84e1,520.15 0e3,344.00

* p < .05.

P. Montgomery et al. / Women's Health Issues 21-1 (2011) 48e5652

(n ¼ 21), living with relatives (n ¼ 15), in the custody of Chil-dren’s Services (n¼ 14), or in unknown accommodations (n¼ 4).Fourteen mothers were primary parents to their youngest child;nine lived in shelters and five were housed.

The total number of health and social services contacts forthe sample of women was 469 in 1 month (Table 2). On average,a woman accessed approximately two services 1 month beforedata collection.Asagroup, theymostoftenaccessed the servicesoffamilydoctors, socialworkers, psychiatrist, nurses, andemergencyrooms 1 month before the interview. No significant differenceswere found in the frequency of services accessed among the threegroups ofwomenwhen statistically controlling for the variables ofage and housing type. With regard to the other types of healthproviders, the number of contacts per provider for the threegroups was not large enough for statistical comparison.

There were significant differences found among the groupsregarding housing type (c2[2] ¼ 61.37; p < .001; Table 2).Women with at least one young child predominantly experi-enced homelessness, whereas the women in the other twogroups were more often housed. After statistically controlling forage, a significant difference was found in the number of resi-dences during the past 2 years among the groups of women(F[2]¼ 12.54; p< .001). Mothers with a minor child had a highermean number of relocations than mothers with adult children orwomen with no children.

Health statusNo significant differences in the overall level of problem

severity were found among the three groups of women whencontrolling for age and housing type (Table 3). There were,however, significant differences among the three groups con-cerning problems with substance use after controlling for age(F[2]¼ 3.37; p< .05). Mothers with at least one young child were

more likely to report substance use (2.57 � 1.43) compared withmothers with older children (2.12 � 0.88) and women withoutchildren (1.96 � 1.14). Further, no significant differences wereobserved across groups in the substance use domain whencontrolling for both age and housing type.

A significant difference among the three groups ofwomenwasfound regarding strengths/resources when controlling for age (F[2] ¼ 9.58; p < .001). Mothers with at least one young child hadsignificantly fewer strengths/resources (5.51 � 1.26) comparedwith mothers with adult children (4.72 � 1.45) and women withno children (4.68� 1.50). Similarly, when controlling for both ageand housing, a significant difference between the three groupswas observed with regard to the strengths/resources dimension(F[2] ¼ 4.02; p < .05).

No differences among groups were observed when control-ling for age with regard to the following levels of function,societal/role, interpersonal, daily living, or overall level of func-tioning. A significant difference among the groups was found inphysical scores (F[2] ¼ 3.38; p < .05). Women with youngerchildren were assessed to have the highest physical functioning.Significant differences were observed among the three groups onthe cognitive/intellectual subscale (F[2] ¼ 4.05; p < .05).Specifically, mothers of adult children had the highest func-tioning in this domain and mothers of younger children scoredaverage tomoderately low. Although analyses of covariancewerecomputed controlling for age and housing type, the functioningresults did not differ from those obtained when controllingsolely for age.

Quality of lifeTable 4 presents the results of the women’s quality-of-life

scores. Scores were not computed for the work/school domainbecause fewer than 10 women were currently working or

Table 2Social Vulnerabilities of Women with Mental Illness

Social Vulnerabilities Women With YoungChildren (n ¼ 68)

Women With AdultChildren (n ¼ 58)

Women With NoChildren (n ¼ 108)

Statistics

c2 F (df ¼ 2)

Utilization of servicesPeer supporter 5 6 15 N/APsychiatrist 17 22 40 .07Family doctor 23 40 56 .17Emergency room 20 9 18 N/APhysiotherapist 0 4 1 N/AOccupational therapist 1 4 6 N/ASocial worker 33 26 36 .30Nutritionist/dietitian 0 3 5 N/ARegistered nurse 13 14 30 2.13Registered psychiatric nurse 0 6 2 N/AChiropractor 0 2 6 N/APsychologist 1 5 0Total 113 141 215 N/A

Housing typeHoused 18 (26.5) 44 (75.9) 89 (82.4) 61.3* 12.5*

Homeless 50 (73.5) 14 (24.1) 19 (17.6)Number of residences 4.16 � 2.45 2.43 � 1.76 2.11 � 1.94

* p < .05.

P. Montgomery et al. / Women's Health Issues 21-1 (2011) 48e56 53

undertaking educational pursuits. When controlling for both ageand housing type, no differences were found among the groupsin relation to the quality-of-life domains of living situation,family relations, social relations, or legal/safety. Mothers withyounger children reported significantly lower subjective qualityof life scores in daily activities compared with the other twogroups when controlling for age (F[2] ¼ 5.55; p < .01). Whencontrolling for both age and housing type, a significant differenceamong the groups was no longer observed. Comparison of thefinances domain among the groups revealed a significantdifferencewhen controlling for age (F[2]¼ 7.81; p< .01).Womenwith younger children reported the most dissatisfaction. Simi-larly, when controlling for age and housing, significant differ-ences were observed among groups regarding their financescores (F[2] ¼ 3.70; p < .05).

A significant difference among the groups existed whencontrolling for age on the health domain (F[2] ¼ 5.49; p < .01).Womenwith no children reported the highest health satisfactionin comparison with the other two groups of women. No differ-ences among the groups were observed regarding health aftercontrolling for age and housing type. Finally, controlling for age,women with no children reported a significantly higher overallquality of life compared with women with children (F[2] ¼ 3.51;p < .05). No significant overall quality-of-life score differences

Table 3Health Status of Women with Mental Illness

Domains At Least 1Young Child

AdultChildren

NoChildren

F(df ¼ 2)y

Problem severity 4.41 � 1.10 1.28 � 0.95 4.31 �1.21 0.57Strengths/resources 5.51 � 1.26 4.72 � 1.45 4.68 � 1.50 9.58**

Level of functioningSocietal 5.57 � 0.97 5.14 � 0.95 5.31 � 1.07 2.305Interpersonal 5.63 � 0.91 5.48 � 1.13 5.45 � 1.17 2.777Daily living 5.90 � 0.79 5.53 � 0.88 5.63 � 1.19 2.671Physical 3.47 � 2.30 5.31 � 1.98 4.27 � 2.27 3.380*

Cognitive/intellectual 5.50 � 0.99 5.19 � 1.15 5.41 � 1.29 4.054*

Overall 5.90 � 0.90 5.67 � 0.74 5.77 � 0.80 2.965

y Controlling for age.* p < .05.

** p < .001.

between groups was found when controlling for both age andhousing type.

Discussion

We found differences among individual and social vulnerabil-ities, health, and quality of life in a sample of Canadianwomenwhohaveeitheryoung, adult, ornochildren.Likeother studies involvingwomen with mental illness, this study included a heterogeneousgroup of women in terms of vulnerabilities, health status, andquality of life. This study’s sample shared a number of individualvulnerabilities with previous published international work(Canadian Institute forHealth Information, 2007;OntarioWomen’sHealthCouncil, 2002a; Smith&North,1994).Overall, theywere lesslikely to have married, have achieved post-secondary education,have adequatematerial resources, and be employed, all risk factorscontributing to insecure housing and poor health (Smith & North,1994).

In general, other researchers have found that homeless fami-lies headed by single women are between their mid 20s and 30s(Lewit & Schuurmann Baker,1996). Smith andNorth (1994) foundthat American mothers with children under the age of 16 weresignificantly younger compared with other subgroups of home-less women. In their study, the mean age of mothers not accom-panied by their young children was 31. This is comparable to themean age of 35 for this study’s subgroup of mothers with at leastone child younger than 18 years of age. Similarly, this group ofwomen was significantly younger than the other two groups ofwomen.

Further, in this current study the women’s mean income wasapproximately $850.00 (Canadian) per month. This amount isreflective of the average social assistance in Ontario, Canada. Asingle person receiving income support from the OntarioDisability Support Program (ODSP) collects less than $12,000 peryear and subsists at “a mere 63% of the poverty line”(Schizophrenia Society of Ontario, 2006). Although there was nosignificant difference in the average monthly income among thethree groups of women in this study, women with younger chil-dren received slightly less per month and reported significantlygreater dissatisfaction with their financial situation. As previous

Table 4Analysis of Covariance for Quality of Life

Domains Mean � Standard Deviation (I) Controlling for Age(df ¼ 2)

Controlling for Age andHousing (df ¼ 2)

At Least 1Young Child

AdultChildren

No Children F p F p

Living situation 3.72 � 1.78(n ¼ 68)

4.54 � 1.55(n ¼ 58)

4.41 � 1.55(n ¼ 108)

1.303 .274 0.407 .666

Daily activities 4.04 � 1.35(n ¼ 68)

4.56 � 1.43(n ¼ 58)

4.80 � 1.24(n ¼ 108)

5.545** .004 0.803 .449

Family relations 3.60 � 2.02(n ¼ 67)

4.64 � 1.66(n ¼ 57)

4.40 � 1.64(n ¼ 94)

1.610 .202 0.419 .658

Social relations 4.58 � 1.13(n ¼ 68)

4.89 � 1.26(n ¼ 57)

5.02 � 1.19(n ¼ 106)

2.412 .092 0.367 .693

Finances 2.65 � 1.57(n ¼ 68)

2.80 � 1.37(n ¼ 58)

3.52 � 1.62(n ¼ 105)

7.806** .001 3.697* .026

Work/school 4.72 � 0.71(n ¼ 6)

5.33 � 0.69(n ¼ 7)

4.95 � 1.52(n ¼ 19)

0.313 .733 0.350 .708

Legal/safety 4.71 � 1.36(n ¼ 68)

4.74 � 1.26(n ¼ 58)

4.96 � 1.33(n ¼ 108)

1.123 .327 0.866 .422

Health 3.72 � 1.38(n ¼ 68)

3.89 � 1.49(n ¼ 58)

4.42 � 1.42(n ¼ 108)

5.492** .005 2.260 .107

Global 3.76 � 1.66(n ¼ 68)

4.32 � 1.66(n ¼ 58)

4.56 � 1.61(n ¼ 108)

3.514* .031 0.130 .897

** p < .01.* p < .05.

P. Montgomery et al. / Women's Health Issues 21-1 (2011) 48e5654

American and Canadian research suggests, exclusive reliance onsocial assistance benefits leaves single mothers unable to meettheir basic subsistence needs (Connolly, 2000; Lenon, 2000;Lessa, 2006). Thus, it is not surprising that mothers of depen-dent children in the current analysis were most dissatisfied withtheir income. As Connolly (2000) argues, adequate material helpand security is morally and practically imperative to supportvulnerable womenwhowant to parent. In Canada, if a maximumprovincial social assistance program, such as ODSP, is notadequately addressing the cost of women living with children,a long-standing recommendation for intersector collaboration toincrease rent supplement programs and to adjust ODSP benefitsto support women as parents seems even more critical to lessentheir individual and social vulnerabilities (Ontario Women’sHealth Council, 2002b; Waegemakers Schiff, 2007).

Mothers with at least one young child were significantly morelikely to live inanumberof residenceswithina specific timeperiodaswell as to be homeless in comparisonwithwomenwith older orno children. Rahder (2006) suggests that such findings may bea broader social indicator of poverty-related factors amongvulnerable groups of Canadian women. In the context of limitedmaterial possessions, women’s efforts to secure and maintainhousing are jeopardized. The discrepancy between needs andincome remains because current social policy provisions do notsufficiently address the complex health and personal securitydilemmas faced by poor Canadian womenwith children, many ofwhom resort to shelters to lessen their vulnerability to unsafecircumstances (Ontario Human Rights Commission, 2008; Paradiset al., 2008). Dependence on the public shelter system for housingbecomes a significant risk factor for motherechild separations(Park et al., 2004; Varney & Van Vliet, 2008).

In Canada, there is no national housing program despite thegovernment’s acknowledgement of the problem severity ofwomen’s “core housing need.” In Ontario, social housing stock ismaintained at the municipal level in accordance with provincialbuilding codes. There is not, however, sufficient public admin-istrated housing stock to provide accommodations for all peoplewho qualify. Currently, Ontario is in the process of implementing

the mandate of the Accessibility for Ontarians with Disability Act(Canadian Mental Health Association, 2005). This legislation setsambitious, hard targets for eliminating barriers for people withmental disabilities to all public spaces and services. This evolvingmindset for the gatekeepers of health and social services willrequire guaranteed access by policies, standards, and modes ofpractices that truly address the vulnerabilities of women withillness and young children as found in this study.

In this study, nearly 80% of the women experienced separa-tions from their minor children. Of the remaining 20%, 13% wereparenting in the shelter setting and a mere 7% were parenting ina home environment. Other evidence suggests that such a highrate of motherechild separation may be indicative of accumula-tion of stressful life events including maintaining stable housing(Jones et al., 2008; Nicholson et al., 2006; Smith & North, 1994;Zlotnick et al., 2007). Zlotnick (2009) discusses the “doublejeopardy” experienced by women with children, mental illness,and homelessness. Loss of housing is often associatedwith loss ofchildren in women’s struggles with mental illness includingsubstance abuse problems. She emphasizes that “[f]ractured andsevered relationships are a common legacyof transiency” (p. 322),an inherent feature of homelessness and children removed fromtheir families of origin. Gerwirtz, DeGarmo, Plowman, August,and Realmuto (2009) argue that there is clear evidence thatsupportive housing has a positive impact on parental health,positive parenting practices, and ultimately child adjustmentdespite being a very high-risk population.

With respect to health status, few differences were observed.Women with younger children were observed to have greatersubstance abuse problem severity. Thisfinding, however,must beinterpreted cautiously. The group’s average score remained low,suggestive of a minimal substance problem that may partially beexplainedby their smokingbehaviors. Further, this differencewasno longer evidentwhen controlling for housing. Although there isevidence that substance use is associated with maternalechildseparation even after controlling for a range of individual andsocial vulnerabilities (Jones et al., 2008; Zlotnick et al., 2003), thisstudy’s finding highlights the importance of gender-sensitive

P. Montgomery et al. / Women's Health Issues 21-1 (2011) 48e56 55

measures that operationally distinguish among types ofsubstances abuse in relation to vulnerable women’s abilities.

Women with young children were found to have the highestphysical functioning and the poorest cognitive/intellectual func-tioning. These differences remainedwhen controlling for age andhousing. Moreover, womenwith young childrenwere also foundto have significantly fewer strengths/resources, placing them ina vulnerable position with limited supports to compensate forfunctional deficits. This is consistent with previous research thatfound a relationship between low levels of social support andinconsistent parenting practices in a sample of Americanmotherswho were homeless or at risk for homelessness (Marra et al.,2009). These researchers advocate for a strengths-based casemanagement approach to promotemothers’well-being and theirabilities to parent. The need for more emphasis on early, inte-grated preventive mental health strategies that recognize genderand housing as a determinant of health has been internationallyrecognized (Connolly, 2000; Monds-Watson, Manktelow, &McColgan, 2010; Neal, 2004; Nicholson et al., 2006; OntarioWomen’s Health Council, 2002b; Rahder, 2006).

In this study, differences in perceived quality of life wereobserved between groups for the daily activity, health, overall,and financial domains; however, with the exception of finances,differences were eliminated when controlling for housing. Thesefindings corroborate previous research that indicates that qualityof life andhousing and intricately related (Kyle&Dunn, 2008) andsupport the findings of Paradis et al. (2008), who recommenda guaranteed minimum income sufficient to ensure housingsecurity. No significant differences were observed in service use.This may be reflective of the fact that few women of minor chil-dren were in active parenting roles; however, it is more likelyreflective of the inherent and significant barriers that womenwithmental illness and insecure housing face (Canadian Institutefor Health Information, 2007; Connolly, 2000; Cowal et al. 2002;Paquette & Bassuk, 2009).

Because of the inherent limitations of a secondaryanalysis andthe small subsample size of women not separated from theiryoung children, the current findings warrant further explorationof the impact of parenting status on determinants of health.Womenwith child care,mental health, andhousing issues provedto be a challenge to classify into distinct categories. Often,womenhad several children in various living situations. Specification ofthe living situation of multiple children was not possible in thiscurrent analysis. Further studies, however, that delineate thesecomplexities may provide greater insight into the differences inprovision of care and theneeds ofmothers. In future research, thisis important to delineate, especially in view of Metraux andCulhane’s (1999) finding that women were at an increased riskfor repeated shelter stays when their children live elsewhere, orthatwomen utilized shelter services as a condition tomaintain orregain custody of their children (Paradis et al., 2008).

In conclusion,womenwithmental illnessandyoungerchildrenreported significant individual and social risk factors, includinginsecure housing. Their efforts to overcome such obstaclesmay beimpededby theirdissatisfactionwith theirfinancial situation,poorcognitive functioning, and limited supportsandresources. Further,housing mediated differences in quality of life and substance useamong the groups ofwomen, lending support to greater provisionof early support and housing services. Moreover, the currentfindings revealed that few mothers of young children strugglingwith mental illness are providing direct care to their offspring,which has significant effects onboth themother anddevelopmentof the child, thus warranting further research in this area.

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Author Descriptions

Phyllis Montgomery is a professor and researcher in the area of mental health.Many of her research activities focus on women’s efforts to craft a life in thepresence of challenging situations.

Stephanie Brown is a social worker and researcher interested in promoting socialcare for persons with enduring mental illness.

Cheryl Forchuk is a professor and researcher. She has published on many topicsincluding homelessness, transitional discharge, therapeutic relationships, denialand sexuality.