Research paper
The impact of unregulated single room occupancy hotels on the health status of illicit drug users in Vancouver

https://doi.org/10.1016/j.drugpo.2005.09.002Get rights and content

Abstract

Introduction

Single room occupancy (SRO) hotel units represent the most basic shelter provided for low-income individuals living in Vancouver's Downtown Eastside (DTES). While homelessness and marginalized housing in general, have been identified as environments that facilitate HIV risk behaviours, less attention has been paid to the specific context of living in SRO hotels. This analysis was therefore undertaken to describe the characteristics of individuals living in SRO hotels and to explore the association between living in SRO hotels and health status.

Methods

From January 2003 to November 2004, we enrolled participants into a large community-based cohort study (CHASE Project) involving a baseline questionnaire and data linkages to existing health service registries. Recruitment followed census track data in order to select a representative sample of the community residents. Logistic regression was used to identify socio-demographic, drug use, and health status characteristics independently associated with living in SRO hotels.

Results

Of the 2574 participants included in this analysis, 1813 (70%) reported living in SROs and 761 (30%) reported living in stable housing. The median age was 42 years (IQ range: 36–49 years). Among residents of SROs, 1108 (61%) had lived in the current SRO for less than 1 year, with the median number of moves in the past year being 5. Variables found to be independently associated with SROs included HIV infection (Adjusted Odds Ratio [aOR], 1.6 = 95% CI: 1.2–2.0), emergency room use (aOR = 1.7, 95% CI; 1.3–2.2), cocaine injection (aOR = 1.9, 95% CI; 1.5–2.5), heroin injection (aOR = 2.0, 95% CI: 1.6–2.3), recent incarceration (aOR = 2.1, 95% CI: 1.7–2.4), having been physically assaulted (aOR = 2.3, 95% CI: 1.7–2.8), crack cocaine smoking (aOR = 2.3, 95% CI: 1.7–2.7), and crystal methamphetamine injection (aOR = 2.9, 95% CI: 1.7–5.8).

Conclusions

Living in SRO hotels was associated with intensive illicit drug use, and poor health status, including HIV infection. These findings highlight the urgent need to address housing conditions in the DTES that threaten to undermine the harm reduction strategies and drug policy reforms in the City of Vancouver.

Introduction

The single room occupancy (SRO) hotel exists in most North American cities as the housing of last resort for those with the most limited incomes and resources. Despite the links between marginalised housing, illicit drug use and poor health outcomes (Desai, Lui-Mares, Dausey, & Rosenheck, 2003; Galea & Vlahov, 2002; Galea, Ahern, & Vlahov, 2003; Kushel, Vittinghoff, & Haas, 2001), unregulated SROs have remained largely at the periphery of harm reduction policy and practice (Fuentes & Heller, 1999).

Impoverished living conditions increases the likelihood of sexual and drug-related harms due to social isolation, depression, limited access to adequate health care and social services, disrupted social networks, and inadequate sanitation facilities (Coumans & Spreen, 2003; Kushel, Evans, Perry, Robertson, & Moss, 2003; Metraux, Metzger, & Culhane, 2004; Riley, Wu, Perry, Robertson, & Moss, 2003). Unstable living conditions have also been associated with increased likelihood of injecting in less secure locations (Friedman, Jose, Deren, Des Jarlais, & Neaigus, 1995), and injection drug users (IDUs) living in unstable housing are twice as likely to contract HIV as those in more stable housing (Patrick et al., 1997). In addition, the predominance of SROs in a condensed neighbourhood serve to replace shooting galleries as locations that promote syringe sharing (Harvey et al., 1998; Strathdee, Patrick, Currie et al., 1997) and have recently been associated with an increased risk of accidental drug overdose mortality (Hembree et al., 2005).

While the historical background and public response to SRO proliferation differs from city to city, the documented living environment and social context of SRO living is similar. SRO residents represent societies’ most marginalised from new immigrant populations to those struggling with multiple comorbidities (mental illness, drug addiction, HIV/HCV/TB) (Foley, 1998a). A standard SRO unit contains a small single room (∼100 sq. feet) with a mattress, occasional cooking facilities, and toilet facilities that are usually shared by all residents on a floor of a hotel. Living conditions have been described as deplorable, unsanitary, and dangerous (BC Ministry, 1994; Foley, 1998a). The majority of unregulated SRO buildings are privately run and offer no services or building maintenance (Foley, 1998b). Many are found in century-old buildings that require frequent repair and structural maintenance (Smith, 2003). Neglect and poor management by absentee landowners is not uncommon resulting in dilapidated structures that do not meet even the most basic of housing standards (BC Ministry, 1994; SFTU, 2005). In several cases, managers require tenants to leave their rooms for a day or two after renting for 21–28 days to circumvent the law that states residents acquire permanent tenancy after 30 days of continuous occupation (Fuentes & Heller, 1999; SFTU, 2005). As such, many SRO residents find themselves sleeping on the streets at some point throughout the month. By United Nations’ definitions, people living in SROs are the “relative homeless”, lacking adequate protection from the elements, access to safe water and sanitation, affordability, and security of tenure and personal safety (Gurstein & Small, 2005). Despite the substandard living conditions of these SROs, in many cities they represent the only safety net between a resident and the street, or absolute homelessness (Foley, 1998a; Vancouver Courier, 2002).

Vancouver's Downtown Eastside (DTES), an area consisting of ten city blocks and over 16,000 residents, including an estimated 5000 IDUs, has an extremely high concentration of unregulated SRO hotels (Buxton, 2003). The absence of a comprehensive governmental response to housing shortages and homelessness, the high price of rental accommodation in the city, as well as the de-institutionalization of psychiatric patients (BC Ministry, 1994), have served to perpetuate SROs in the neighbourhood (COV, 2005a, COV, 2005b). In 2001, the City of Vancouver adopted the Four Pillars strategy – an approach that integrates prevention, harm reduction, drug treatment and enforcement – to address the serious problem of illicit drug use in the DTES and surrounding communities. While this strategy has helped to facilitate innovative harm reduction approaches (including expanded syringe exchange programs, increased access to methadone maintenance therapy, a new supervised injection facility, and the launch of a heroin maintenance trial) (City of Vancouver, 2005b), inadequate housing and deplorable living conditions of the residents threaten to undermine the positive impact of these policy efforts. As in other cities, a process of gentrification, “urban renewal”, and loss of SRO units through fires and demolitions have directly contributed to increased homelessness in the city (BC Ministry, 1994; SFTU, 2005; Vancouver Courier, 2002). Given the known links between unstable living conditions, risky drug use practices, infectious disease transmission, and concerns of public order (Andia et al., 2001; City of Vancouver, 2005b; Malakmadze et al., 2005) a comprehensive action plan targeting unregulated SROs needs to be adopted as part of the city's drug policy response.

Of the 6435 SRO units in Vancouver, 5150 (80%) are located in the Downtown Eastside core (City of Vancouver, 2001; Statistics Canada, 2001). These SRO units represent the most basic shelter provided for individuals on income assistance, and, in most cases, the monthly fee of Can$325 is paid directly to the hotel owners from government offices. As of March 2003, 27% of SRO units rented for Can$325 or less (the maximum BC Employment and Assistance shelter allowance), a decline from 49% in 2001 (City of Vancouver, 2001; Statistics Canada, 2001). Even at this level, SRO tenants typically pay over 60% of their income for their room. Although the high costs of providing alternative housing for people living in SROs is cited as the major obstacle to change, the ultimate cost to health, along with the adverse social consequences of living in these environments are not considered.

While the extent and risk of homelessness in particular, and unstable housing in general, has been well established, there has been far less attention paid to the specific context of unregulated SRO hotels. This analysis was therefore undertaken to describe the characteristics of individuals living in unregulated SRO hotels and to explore the association between living in SRO hotels, health status and current drug use policies.

Section snippets

The Community Health and Safety Evaluation (CHASE) Project

The Community Health and Safety Evaluation (CHASE) Project is a prospective open cohort that was established to evaluate the impact of recently implemented health initiatives on residents of the DTES; to identify priority health issues; shortfalls; and populations at greatest risk. All community residents are eligible to participate, and are enrolled through various recruitment strategies including community-based organizations, several storefront locations and door-to-door initiatives in SRO

Results

A total of 2985 participants were recruited between January 2003 and November 2004, and were successfully linked with external data sources and thus initially eligible for this analysis. Of these, 217 (10%) were excluded from this analysis as they reported living outside the DTES core at the time of recruitment. Given that this analysis was focused on the specific risk factors of living in SRO hotels as compared to stable housing, individuals who reported living in other unstable living

Interpretation

In this large community study we compared 1813 residents of SROs with 761 residents living in more stable living arrangements. Variables independently associated with living in SRO hotels included higher rates of HIV infection, emergency department use, cocaine injection, heroin injection, recent incarceration, having been physically assaulted, crack cocaine smoking and crystal methampethamine injection.

As would be expected residents of SRO hotels were more likely to report a move within the

Acknowledgements

This work was supported by grants from Vancouver Coastal Health and we would like to thank all participants, peer researchers, and community organisations for their ongoing contribution.

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