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Housing is a key determinant of child and youth health. A significant number of Canadian children and youth are living in housing need, but information regarding the housing status of children and youth in the Ottawa, Ontario, community is lacking.
To examine the housing status of children and youth accessing emergency health services at the Children’s Hospital of Eastern Ontario (Ottawa, Ontario), and the factors associated with housing status.
Youth and families of children registered at the Children’s Hospital of Eastern Ontario’s emergency department were offered a questionnaire. Affordability, adequacy, suitability and stability of housing were evaluated through self-reporting. Housing need was defined as an inability to meet one or more of these criteria. Associations among housing and household composition, demographics and weight-for-age percentiles were examined.
One thousand three hundred sixty surveys were completed. Fifty-four per cent of respondents (663 of 1224) were living in housing need, including 33% of respondents (381 of 1166) who were living in unaffordable housing. Single-parent families (OR 2.82), families with six or more members (OR 2.51) and families who rented (OR 5.27) were more likely to be living in housing need. Children and youth with a primary care physician were more likely to be living in stable housing (OR 0.41). Unsuitable housing was associated with extreme weight-forage percentiles (OR 1.90).
More than one-half of the children and youth in the present study were living in housing need. Health care providers have a responsibility to identify and understand the determinants of health of their patients, including housing, and to work for the improved health of their patients and their communities.
Le logement est un déterminant clé de la santé des enfants et des adolescents. Une forte proportion d’enfants et d’adolescents canadiens ont des besoins de logement, mais on ne possède pas d’information quant au statut de logement des enfants et des adolescents de la collectivité d’Ottawa, en Ontario.
Examiner le statut de logement des enfants et des adolescents qui reçoivent des services d’urgence au Centre hospitalier pour enfants de l’est de l’Ontario (à Ottawa, en Ontario) et les facteurs reliés à ce statut.
Les jeunes et les familles d’enfants admis au département d’urgence du Centre hospitalier pour enfants de l’est de l’Ontario ont reçu un questionnaire. Les auteurs ont évalué l’abordabilité, la conformité, la pertinence et la stabilité du logement au moyen d’une évaluation volontaire. Les besoins de logement étaient définis comme l’incapacité de respecter au moins l’un de ces critères. Les auteurs ont examiné les associations entre le logement et la composition des familles qui y habitent, la démographie et les percentiles de poids par rapport à l’âge.
Mille trois cent soixante sondages ont été remplies. Cinquante-quatre pour cent des répondants (663 sur 1 224) avaient des besoins de logement, y compris 33 % (381 sur 1 166) qui habitaient dans des logements non abordables. Les familles monoparentales (RR 2,82), les familles composées d’au moins six membres (RR 2,51) et les familles qui louaient leur logement (RR 5,27) risquaient davantage d’avoir des besoins de logement. Les enfants et les adolescents ayant un médecin traitant étaient plus susceptibles de vivre dans un logement stable (RR 0,41). Un logement inadéquat s’associait à des percentiles extrêmes de poids par rapport à l’âge (RR 1,90).
Plus de la moitié des enfants et des adolescents à l’étude avait des besoins de logement. Les dispensateurs de soins ont la responsabilité de repérer et de comprendre les déterminants de la santé de leurs patients, y compris le logement, et de travailler pour améliorer la santé de leurs patients et de leur collectivité.
Housing is a key determinant of health and well-being (1–3). In the 2001 national census, more than 15% of Canadian households were living in housing need (4), and close to 50% of children and youth in single-parent, immigrant and refugee families were living in poverty (5). Physicians and health care professionals have a responsibility to identify, understand and work to improve factors influencing the health and well-being of their patients, communities and populations, as outlined by the Royal College of Physicians and Surgeons of Canada (6) and the College of Family Physicians of Canada (7). Knowledge of local housing concerns and factors associated with housing is essential for an effective and comprehensive local response to housing.
Housing affects the physical and mental health of children, youth and families. Crowded housing – unsuitable housing based on the Canadian National Occupancy Standards for the number of bedrooms appropriate for the size and make-up of the household – may cause or increase respiratory infections, diarrhea and vomiting (8–10), and is associated with increased active tuberculosis in Canadian First Nations communities (11). Damp housing, and sensitization and exposure to cockroaches, are associated with asthma (12–14). Lower quality and crowded housing are associated with increased behavioural disturbances, learned helplessness, and psychological and emotional distress in school-aged children (15–19). Unstable housing is associated with increased youth adjustment problems in low-income families (20). Children and youth living in rented housing have higher proportions of problem behaviour, depression and distress than those living in housing that is owned by caregivers (21,22). Children living in unaffordable housing without the support of housing subsidies have lower weight-for-age scores and are more likely to have a weight-for-age score below the fifth percentile than children receiving public housing subsidies (23,24).
The Children’s Hospital of Eastern Ontario (CHEO) Housing Checkup survey examined the housing status of children and youth accessing emergency health services at the regional children’s hospital – CHEO in Ottawa, Ontario. It was hypothesized that there was an increased likelihood of housing need among children of immigrant, refugee and single-parent families, and significant associations among housing status and access to a regular primary care physician, as well as weight-for-age percentiles.
The 25-question survey was developed de novo. Survey items were generated following a literature review and consultation with housing experts and paediatric health care professionals. The survey domains were demographics, household composition and housing status. Youth, and immigrant and refugee families, piloted the survey using focus groups and read-through methodology. Housing, health and cultural competency experts advised throughout the survey development to help ensure content validity and to assist with item reduction through a judgemental approach. Purposeful piloting with individuals with limited literacy competencies established face validity. The final survey was translated into the five most common languages of the population served by the CHEO – English, French, Arabic, Somali and Chinese.
The study was conducted in the CHEO emergency department (ED) following approval by the CHEO Research Institute Ethics Board. CHEO is a paediatric tertiary care hospital that serves children and youth up to 18 years of age from eastern Ontario and western Quebec. It has a catchment population of 1.5 million people, and is the only hospital in Ottawa that admits children and youth. The ED has approximately 55,000 patient visits each year, and was chosen as the study setting because of its accessibility to all children and youth in the community, including those without regular primary care physicians.
All eligible youth and families of children who registered in the ED during the one-month study period received a survey. Patients 16 to 18 years of age, or parents and guardians of children younger than 16 years of age, were eligible for the study if there was an anticipated stay in the ED of more than 0.5 h and if they were able to complete the survey in one of the provided languages. People were excluded from the study if the child or youth was admitted to the resuscitation room or if the parent or guardian, or youth, was deemed too distressed by the ED staff. An explanation of consent issues and a list of local available housing resources were provided to participants with the survey.
The definitions of housing standards used in the present study, as presented in Table 1, were based on those of the Canadian Mortgage and Housing Corporation (CMHC), and were assessed through self-reporting. Housing affordability was determined through self-report of the proportion of household income spent on housing costs rather than through derivation from reported total gross income and total shelter costs.
Weight-for-age data were translated into one of three nominal categories – lower than or equal to the fifth percentile or greater than or equal to the 95th percentile, using the 2000 US Centers for Disease Control and Prevention growth data. Because responses to the sex of the child or youth were insufficient to allow sex-specific determination of weight-for-age percentiles, categorical weight-for-age placement was determined by identifying children and youth at either end of the extremes (lower than or equal to the fifth percentile and greater than or equal to the 95th percentile) based on both female and male data.
A random sample of 670 children and youth was adequate to generalize rates of housing need to the greater population of 55,000 children and youth who use CHEO’s ED annually, and allowed for an estimation of the proportion of families living in substandard housing within 3.5%, 19 times out of 20.
Following a descriptive analysis, a comparative analysis was performed using χ2 tests. Logistic regression models were used to explore the relationship between housing status and household characteristics as independent variables, using single-parent families, immigrant and refugee families, families who rent and families with six or more members. Estimates of frequency and ORs are presented along with their 95% CIs (25). Missing data due to nonresponse were excluded from the analyses.
One thousand three hundred sixty surveys were returned, representing 25% (1360 of 5446) of the children and youth who registered in the ED during the study period. Ninety-six per cent of surveys (1299 of 1350) were completed by parents, with 3% (35 of 1350) completed by youth. Other respondents included siblings, step-parents, and other relatives or friends.
The demographics of the respondent families are presented in Table 2. Eleven per cent (147 of 1304; 95% CI 10% to 13%) of respondent households had an income of less than $20,000, which is below the low-income cut-off set for a family of two in an urban setting in 2003 (26), while 43% (556 of 1304; 95% CI 40% to 45%) of respondent households had an income of greater than $75,000. Of the families living on less than $20,000 a year, 55% (79 of 143; 95% CI 47% to 63%) were living in unaffordable housing, spending more than one-half of their income on housing.
Ninety-four per cent (1267 of 1354; 95% CI 92% to 95%) of children and youth had access to a regular primary care physician.
Overall, 54% of respondents were living in housing need. The data presented in Table 1 demonstrate that housing need was predominantly due to issues of affordability and stability.
Regression models were used to identify significant risk factors for housing standards. Results are shown in Table 3. An OR of greater than one indicates a significant risk factor for the corresponding housing standard. The likelihood of these same risk factors being associated with other markers of housing need are presented in Table 4.
Children and youth living in unsuitable or crowded housing were approximately twice as likely to have an extreme weight-for-age percentile, either under- or overweight, which are both recognized health risks (OR 1.9; 95% CI 1.1 to 3.3). No other housing standards were statistically associated with extreme weight-for-age percentiles.
Over 50% of the families who participated in the CHEO Housing Checkup were living in housing need. Single-parent families, immigrant and refugee families, families with six members or more, and families who rented were found to be at increased risk for living in substandard housing. To optimize efforts to address housing and child and youth health, interventions could target these populations.
Although the risk factors found for living in housing need were similar to those identified by the CMHC (27,28), the overall rate of housing need was higher than that reported regionally and provincially (4,29). The present study was unique in its aim to assess the housing need of families accessing health services at a tertiary care hospital in Canada.
Unaffordable housing was the primary cause of housing need, with one-third of respondents spending 50% or more of their household income on housing. Given that a conservative cut-off was used, the results are thought to demonstrate the households with severe affordability issues. This is reflected in the CMHC findings that 90% of households in the Ottawa-Gatineau area who were spending 50% or more of their household income on housing in 2001, were unable to afford acceptable local housing (27). These results are likely generalizable to the actual rates of unaffordable housing in Ottawa, because the distribution of incomes in the study population was similar to the results of the 2001 census for Ottawa. The percentages of households with incomes less than $20,000 and greater than $75,000 were 11% and 43%, respectively, in the study, compared with 13% and 36%, respectively, in the 2001 census results for Ottawa (30).
The present study identified that families who rented had the highest risk for living in housing need (OR 5.27; 95% CI 3.84 to 7.23), with a significantly higher proportion living in unsuitable or crowded housing than any other population identified (OR 9.03; 95% CI 3.72 to 11.32). It is likely that factors associated with renting or having to rent housing, rather than renting itself, are what contribute to people living in housing need, as well as any associated resulting health factors, such as depression and behavioural issues (21,22). Health care professionals may use renting status to help identify populations living in housing need.
The relatively good housing status of participant immigrant and refugee families may reflect longer lengths of time since their entry into Canada. The increased housing need experienced by recent immigrant and refugee families in Canada (ie, those who arrived less than five years ago) has been found to decrease over time such that immigrant and refugee families who have been in the country for 20 years or more experience housing need at a similar rate to non-immigrant families (28). The extent of housing need in the recent immigrant population may not be accurately reflected in the study results because they constituted a small portion of respondents. Literacy and language levels may have precluded some recent immigrant and refugee families from completing the survey, although, the survey was written below a grade eight literacy level and was offered in five languages.
Having a primary care physician was associated with living in stable housing. This association could reflect an increased ability to maintain a relationship with a primary care physician with less residential change. It may also represent a protective effect of having a primary care physician. Further investigation is required to elucidate causation.
Unsuitable housing was the only housing variable that was significantly associated with extreme weight-for-age of children and youth. Associations have previously been reported between low weight-for-age scores and unaffordable housing, especially in the three months after the coldest month of the year (23,24,31). There was a lack of significant association between low weight-for-age scores and unaffordable housing in the present study, despite being performed in the period following the coldest month of the year. Parents may have ensured adequate nutrition of their children in the face of limited resources by decreasing their own intake. Parents have been shown to decrease their absolute caloric intake more than their children in response to increased heating costs during winter months (32).
Limitations of the study include a low response rate of 25%, with the potential for response and volunteer bias given the sensitive nature of the questions and that those concerned about their housing status may have been more or less likely to complete the questionnaire. Despite the low response rate, however, the proportion of individuals in the present study in housing need was comparable with that reported in the 2001 census results for Ottawa. In addition, families without access to a primary care physician and potentially with housing need may be over-represented in the population using emergency health services. Unaccompanied youth may have been under-represented in the study because participation required the completion of the questionnaire, despite their illness. The present study did not aim to examine the reasons for the emergency visits, medical diagnoses or rates of admissions to the hospital.
The CHEO Housing Checkup was performed to better understand the housing needs of children, youth and families in the Ottawa region, and to raise awareness of these issues within the health care sector. Our findings confirm that a significant number of children and youth in the Ottawa region are living in housing need.
The study results have informed the activities of the Ottawa Child/Youth Housing Advocacy Initiative (OCHAI). The OCHAI aims to improve the housing and, hence, the health of children, youth and families in Ottawa by facilitating a collaborative, comprehensive advocacy initiative by the housing and health sectors. The information from the present study will be used in the development of a toolbox specifically developed for health care providers to facilitate the integration of housing as a determinant of health into daily clinical practice. Specifically, health care providers should incorporate questions about housing when obtaining patient social histories, be able to identify when a family has housing need and be aware of local resources available to assist with these issues. The OCHAI toolbox will have educational materials for the public and health care providers, a housing screening tool, as well as a referral tool for local resources.
Physicians and other health care providers have a responsibility to better understand the issues affecting the health of their patients and communities, and should work toward improved health for all.
FINANCIAL SUPPORT: The present study was funded in part by the Canadian Paediatric Society, Resident Advocacy Grant.