health and homelessness in ireland from economic book to bust - dr fiona o'reilly
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Health and Homelessness in Ireland from Economic Book to Bust - Dr Fiona O'Reilly IPH, Open, Conference, Belfast, Northern, Ireland, Dublin, Titanic, October, 2014, Health PublicTRANSCRIPT
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