Housing need in Canada: Healthy lives start at home

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Housing directly affects the health of children and youth, including their ability to develop optimally and achieve life goals. Approximately 30% of Canadian households live in substandard housing or core housing need, ^[1] as defined by the Canada Mortgage and Housing Corporation (Table 1).

Paediatricians and other physicians caring for children can help their patients mitigate the health impacts of housing need in daily practice. Addressing the issue of housing need more broadly requires coordinated and collaborative effort among key sectors, including health professionals, social services, educators and all levels of government. Legislation in the form of housing-supportive policies and full implementation of the national housing strategy would be the start of establishing safe, adequate, accessible, suitable and affordable housing for all families in Canada. Physicians caring for children have a responsibility to ensure that representatives at all levels of government understand the multiple impacts of housing need on child and youth health.

The present statement reviews the literature regarding the health impacts of housing, and how housing problems influence a family’s ability to access and engage with the health care system. The importance of understanding the housing status of patients is emphasized. How physicians can better assess a family’s housing situation in the clinical setting, and their role in addressing housing need when it is identified – at the patient, family and community levels – are examined. Finally, recommendations for advocacy initiatives, policies and legislation are made.

Definitions of housing need in Canada

The term ‘housing need’ is used to describe substandard living conditions. Table 1 summarizes definitions and standards developed by the Canada Mortgage and Housing Corporation to describe some forms of housing need in the Canadian context.^[2] The Canada Mortgage and Housing Corporation is a national housing agency that provides and facilitates housing policy and programs, housing research and mortgage loan insurance.

Not included in these terms are additional factors that also lead to housing need. These include:

• Infestations (e.g., cockroaches, bed bugs, mice and other pests);
• Poor water and air quality;
• Unsafe neighbourhoods;
• Unstable housing, leading to frequent moves (>3 in a child’s lifetime) or the use of temporary housing; and
• Inaccessibility for family members with a disability.

Government-subsidized housing is provided by municipal governments to families and individuals who cannot afford local rents. Wait times for subsidized housing vary widely depending on the municipality, but can be several years. Accurate national data regarding wait times, wait lists and the number of households in need of subsidized housing are not available. However, the Federation of Canadian Municipalities’ estimates suggest several tens of thousands of families are waiting for subsidized housing in Canada.^[3]

TABLE 1
Types of housing need
Term	Definition
Inadequate housing	In need of major repairs
Unsuitable housing (crowded)	Fails to meet the National Occupancy Standard requirements for number of bedrooms for the size and make-up of the household
Unaffordable housing	30% or more of gross household income spent on shelter costs
Unacceptable housing	Does not meet at least one of the standards of adequacy, suitability and affordability
Core housing need	Unacceptable housing and household would have to spend 30% or more of their gross household income to access acceptable housing in their community
Adapted from reference 2

Health impacts from various types of housing need

Living in housing need can negatively impact all aspects of child and youth physical, mental, developmental and social health.^[4]

Inadequate, crowded and unaffordable housing

The National Longitudinal Survey of Children and Youth is a long-term study that follows the health, development and well-being of a cohort of Canadian children and youth, pairing these parameters with national census data. Compared with peers living in adequate housing conditions, children and youth living in inadequate and crowded housing exhibit a number of negative outcomes, including aggressive behaviours, property offences, diminished school performance, asthma symptoms and diminished overall health status.^[5] Other studies link inadequate housing with poor air quality and lead exposure,^[6] an increased risk for asthma,^[7] and exposure to health hazards and injury risks.^[8]

Crowded housing is associated with a wider and faster spread of communicable diseases, such as lower respiratory tract infections and gastroenteritis.^[9][10] Children and youth living in crowded housing conditions were also found to experience more psychological distress and helplessness, and to not perform as well in school.^[11]

High housing cost is one of the most frequently cited causes of hunger.^[12] Unaffordable housing is linked to food insecurity and inadequate childhood nutrition.^[13] One American study involving children from low-income families who rent in six urban centres revealed that receiving housing subsidies was associated with improved nutritional status, demonstrated by healthier weight-for-age percentiles.^[14]

Unstable housing

Youth and families in housing need are more likely to move frequently,^[15] and may be forced to rely on temporary shelters or to stay with friends or family members (“couch surfing”). Children and youth who have moved ≥3 times in their lives are at a higher risk for experiencing emotional problems, repeating a grade, or being suspended or expelled from school.^[16] A 2013 position statement from the Canadian Paediatric Society, Meeting the health care needs of street-involved youth, addressed the problem of accessing health care for this vulnerable group.^[17]

Inaccessible housing

Children and youth living with a disability in inaccessible housing often feel stranded in one part of the home and must rely on an adult to move them around.^[18] Inaccessible housing impacts a child’s or youth’s independence and mobility, and can negatively impact self-esteem. Inaccessible housing has also been associated with higher rates of unintentional injuries for individuals with mobility issues and their caregivers (i.e., from falls, unsupported lifting and transfers).^[19]

Exposure to environmental hazards

Children and youth spend most of their time at home. Living in housing need can lead to prolonged exposure to environmental hazards. Exploratory behaviours and being physiologically more vulnerable to toxic effects on immature and developing organs, tissues and metabolic systems, means that children and youth are more susceptible to harmful environmental toxins than adults. Pests in the home, such as bedbugs, cockroaches and mice, have effects on physical and mental health. Bedbug bites can cause allergic reactions and secondary infections,^[19] and cockroach and rodent allergens are associated with worsening asthma.^[20] The presence of pests also increases exposure to the pesticides used to control infestations.^[21] Mental health effects of pests include anxiety and insomnia.^[19]

Housing need has been associated with lack of access to a safe water supply. In 2011, >1,800 First Nations homes in Canada did not have running water.^[22] In 2006, two-thirds of the First Nations reserves in Canada had drinking water systems that posed potential health risks, and in 2016 151 drinking water advisories were in effect among First Nations across Canada.^[23]

Unsafe neighbourhoods

Children and youth who perceive their neighbourhood as unsafe or untrustworthy have been found to experience higher rates of anxiety disorders.^[24] Concerns about neighbourhood safety can also play a role in limiting their outdoor physical activity levels.^[25] Neighbourhoods with quality sidewalks and parks have been associated with less screen time and more physical activity among local children and youth.^[26]

Impacts on the health care system

Housing instability has been associated with lack of access to a primary health care provider.^[27][28] Crowded and inadequate housing have been associated with increased paediatric hospital admissions for respiratory tract illnesses.^[29]

Housing need costs the health care system and society at large, both directly and indirectly. One economic model estimated the direct cost of housing need on England’s public health care system, based on 2006 injury and illness data, to be UK£600 million per annum (approximately CAD$900 million).^[30] There has not been a comparable study performed in the Canadian context, but we know from associations described above, that significant health impacts result from living in housing need, which in turn increase demands on the health care system. Furthermore, unaffordable housing leaves limited resources for prescription medications and other frequently uninsured or underinsured health services, such as dental and vision care. In the United States, unaffordable and unstable housing have been associated with delayed use of prescribed medications and increased use of emergency departments.^[27]

Housing need in Canada

According to the 2016 census, rates of core housing need in Canada are highest in the territories, with Nunavut at 36.5%.^[31] Of the provinces, Ontario and British Columbia have the highest levels of core housing need at 15.3% and 14.9% respectively.^[31] Among census metropolitan areas in 2016, Toronto (34%) and Vancouver (32%) had the highest proportion of households that paid 30% or more of their total income for shelter.^[32]

A study conducted at the Children’s Hospital of Eastern Ontario (Ottawa, Ontario) in 2005, revealed that 54% of children and youth accessing the emergency department lived in housing need.^[28] A study involving children and youth presenting to seven other Canadian paediatric emergency departments in 2011 found that slightly more than one-half, at 53%, were living in housing need (preliminary data, verbal communication). In both studies, unaffordable and unstable housing were the most-cited causes for housing need. Single-parent (lone-parent)-led families, families new to Canada, Aboriginal families and families of individuals with a physical, developmental or mental health disability were at greatest risk for experiencing housing need.

A 2013 Ipsos Reid poll suggested that as many as 1.3 million Canadians had experienced homelessness or extremely insecure housing at some point within the previous five years.^[33] There are approximately 15,467 permanent shelter beds in Canada, and in 2009 alone, an average of 14,400 were occupied each night.^[34] The number of children staying in shelters increased >50% between 2005 (6,205) and 2009 (9,459). The average length of a shelter stay for families was 50.2 days, more than triple the average stay for the total population of people who experienced homelessness in that same period.^[34]

Populations at higher risk for housing need

Some populations are disproportionally affected by housing need. According to 2016 census data, one-quarter (26.2%) of Inuit, 24.2% of First Nations people and 11.3% of Métis lived in a dwelling in need of major repairs.^[35] Inuit households are over five times more likely to live in crowded housing compared with the general population.^[36] Recent immigrant households, lone-parent-led households, and visible minority households are also at significantly higher risk for living in housing need.^[37]-[39] More accurate and consistent monitoring and evaluation mechanisms are essential to addressing long-standing housing inequities, particularly on First Nations reserves.

There is a strong association between housing need and living in poverty. In 2018, approximately 1 in 5 children in Canada were living in poverty and 1 in 4 were living in unaffordable housing.^[40] Children and youth from a visible minority or living with a disability are also at higher risk for living in poverty. More than one-third of lone parent families are in unaffordable housing, with women-led, Indigenous, racialized and immigrant families disproportionately affected.^[40]

In 2001, more than one-half of parents of children with a disability reported that their child’s condition had an impact on the family’s employment situation.^[41] On average, the households of children with a disability have 88% of the family income of the general population,^[41] while the costs associated with raising a child with a disability can be much higher.^[18]

 

Assessing the housing needs of children, youth and families

Housing affects child and youth health. To fully comprehend the health care needs of patients, physicians must know whether they are living in housing need. They can then assess for associated health effects, adjust their risk assessment and ensure that older patients and parents are aware of the potential health effects of their housing situation. Knowledge of the impacts of their housing on their children’s health enables families to make more informed choices.

The way to determine whether patients are living with housing need is to ask. Paediatricians and other physicians caring for children should include an assessment of housing status as part of every patient history. There are many ways to screen for housing need. No particular screening or assessment tool has been validated at this time. One way to screen for housing need is by asking a single question, such as: “Do you have any concerns about where you live?” Another way is to use a screening tool. One example is the mnemonic HOME (Table 2), which was developed by the Ottawa Child/Youth Housing Advocacy Initiative and piloted in different clinical settings.^[42] This tool can help practitioners identify whether a more in-depth assessment of housing need is warranted.

Some organizations have recommended a broader screening approach by asking the question, “Do you have difficulty making ends meet at the end of the month?”^[43]-[46] Physicians may consider asking this question and when they get a positive response, proceed to specific questions regarding housing concerns.

TABLE 2
Ottawa Child/Youth Housing Advocacy Initiative screening questionnaire for assessment of housing need
Introductory questions:
On a scale of 1 to 10 (1 being a difficult living situation and 10 being an ideal living situation), how would you rate where you are living now? What would you like to make better about where you are living?
Screening questions by topic (HOME):
Harm	Is your home in need of major repairs?
Occupancy	How many people live in your home, in how many rooms?
Moves	How many times has your child or youth moved? Have you used a shelter or informal, temporary housing such as staying with friends or family?
Enough/Income	Do you have enough money for housing, food and utilities?
Adapted from reference 42

Addressing housing need

Paediatricians and other physicians caring for children are uniquely qualified to advocate for enhanced action from all levels of government for housing-supportive policies, including fully implementing Canada’s new national housing strategy. However, they also need to collaborate within the health care system, work with other sectors caring for children and youth, and engage with organizations involved in building community and housing support.

Addressing housing need is a complex process. Physicians can help policy makers recognize and act on the link between housing and health. By fully implementing Canada’s new national housing strategy, the federal government can lead and facilitate the development of policies and programs to create and maintain enough affordable housing for all. Canada was the last G7 country to implement a national housing strategy. Canada’s commitment to the Universal Declaration of Human Rights of 1948 included an obligation to ensure that everyone in Canada has access to housing that is adequate for health and well-being. Canada also ratified the United Nations’ Convention on the Rights of the Child in 1991, which recognized the right of all children and youth to housing of a standard that enables full development. The Convention states that “governments shall assist parents (…) to implement this right and shall in case of need provide material assistance and support programmes, particularly with regard to (…) housing”.^[47] Housing-supportive policies at all levels of government will help ensure that Canada meets these longstanding obligations.

Physicians caring for children need to advocate for and work with children, youth and families experiencing housing need. To improve the health of children and youth long term, they must help ensure better access to safe, adequate, accessible, suitable and affordable housing for all. Evidence of success using collaborative approaches has been seen in Toronto, where the involvement of pro-bono lawyers with a multidisciplinary health team enabled direct housing support for patients, joint advocacy efforts and new social policy recommendations.^[48]

Health care providers can help families be more aware of how their housing situation impacts their health. When housing need is identified, physicians should support families in mitigating associated negative health impacts. They may need to modify management advice to optimize adherence (e.g., not prescribing medications that require refrigeration for a family with no refrigerator, or tailoring advice about “tummy time” to include out-of-home locations, such as a community centre, for households living with a cockroach infestation). Physicians should be ready to connect a family in need with a local housing service, agency or professional who can facilitate their interactions with a difficult landlord or an application for subsidized housing. They need to be familiar – and interact if needed – with housing and related supportive services in their community.

Physicians should receive training and be prepared to evaluate and address housing need, both with patients and the broader community. Education on the health impacts of housing must to be incorporated into undergraduate and postgraduate medical curriculums in the future.

Recommendations

All levels of government need to develop and implement housing-supportive policies informed by the national housing strategy. Collaborative action should involve the following:

• Local governments, provincial/territorial ministries of housing and health, the federal departments involved with housing, health, social services and education, as well as community groups, local health and housing authorities, and health and housing professionals.
• Policies that recognize housing as a public health issue and strategies at each governmental level and across sectors to ensure safe, adequate, accessible, suitable and affordable housing for all children, youth and families in Canada.
• Housing-supportive policies based on accurate information about the state of housing and housing need, and specifically informed by the health impacts of housing on children and youth. To achieve this, the federal government must continue the mandatory long-form census and fulfil commitments made in the National Housing Strategy to invest in enhanced housing research and data, recognizing that Canada is currently lagging behind other countries in the development and collection of housing data. Accurate data, including the number and demographics of households waiting for subsidized housing in Canada is needed to implement and assess the national housing strategy.

Paediatricians and other physicians caring for children are uniquely qualified to support and promote enhanced action by governments to develop and implement housing-supportive policies, including the national housing strategy. They should also:

• Advocate for improved housing as a key determinant of child and youth health, both nationally and within their own communities.
• Ask about the housing status of families in their care, to better understand their health issues and ability to access and engage in health care.
• Make sure that families they see are aware of the potential health effects of housing need and help them make informed housing choices.
• Be aware of local resources to which they can refer youth and families experiencing housing need.
• Consider writing letters for youth and families experiencing housing need and related health effects, to help them gain access to safe, adequate, accessible, suitable and affordable housing.

Undergraduate and postgraduate medical training programs must ensure competencies in assessing and addressing housing need. Related research priorities include:

• Building knowledge around the causes of housing need in Canada and specific impacts on child and youth health.
• Identifying housing needs for specific geographical regions and populations, and evaluating the efficacy of targeted housing intervention strategies on health outcomes and health costs.
• Validating housing need screening and assessment tools.
• Developing comprehensive lists of local resources for use by health care providers and the families they see.

Acknowledgements

This position statement was reviewed by the First Nations, Inuit and Métis Health and Mental Health and Developmental Disabilities Committees of the Canadian Paediatric Society, as well as by Dr Elizabeth (Lee) Ford-Jones and representatives from the Canadian Child and Youth Health and Housing Network. 

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CPS COMMUNITY PAEDIATRICS COMMITTEE



Members: Carl Cummings MD (Chair); Umberto Cellupica MD (Board Representative); Sarah Gander MD; Barbara Grueger MD (past member); Julia Orkin MD; Larry Pancer MD; Anne Rowan-Legg (past member)
Liaisons: Krista Baerg MD; CPS Community Paediatrics Section
Principal authors: Sarah Waterston MD; Barbara Grueger MD; Lindy Samson MD

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References

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Disclaimer: The recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. Internet addresses are current at time of publication.