This model examines the factors that play a role in health outcomes, not specific to just mental health although, it can be applied to the context of mental health in a rural region of Ontario, Canada. Those suffering with mental illness already have difficulty accessing healthcare services and advocating for supports. This framework is used to identify all the contributing factors, outside of physiology, that impact health.

The center of this model is based around personal traits including sex, age, and heredity. In relation to mental health, these are also factors which would impact how treatment starts or what treatment options are considered. Age plays a role in treatment options for both pharmacological interventions as well as non-pharmacological therapies. Age is a factor to take into consideration in terms of comprehension, language, and even attitude towards mental illness.

The next surrounding area is individual lifestyle factors. This will include personal, behavioural and lifestyle choices. Examples of this are alcohol or substance use, smoking, addictive behaviours, food choices, physical exercise and quality of sleep. This factor plays a large role in those suffering with mental illness. In my role as a mental health clinician, I work with patients who are on Ontario Disability Support Program (ODSP) as a means of income. Through this program, single clients have an average income of approximately $1,169.00 a month to live on (Government of Ontario, 2018). This is the amount of money they have to budget for all their living expenses including rent, groceries, and bills. One could deduct that on this limited budget there is not a lot of leftover money at the end of the month to pay for a gym membership, buy the freshest produce or even to cover the cost of living for all their monthly bills. It was brought to my attention that this is not far off from the disability allowance that a single individual in British Columbia would receive at $1,183.00 a month (Government of British Columbia, 2019). This seems to be a significant contributing factor to the ongoing crisis of homelessness in British Columbia as well. Similar to Ontario, approximately 7500 British Columbia residents are homeless according to a local online media source (Surrey Now-Leader, 2018).

Moving on through the model we can next examine social and community networks. This area focuses on the importance of a support system whether it’s family, friends or a neighbour. This network of individuals makes up the social involvement someone has with others. This is a barrier for clients with mental illness, especially those dealing with homelessness. I have witnessed clients lose relationships with family and friends directly related to their illness and negative symptoms. Caregivers may feel burdened or fatigued and pull supports away from their loved one and friends have diminished over the years of ongoing psychiatric hospitalizations. It’s not uncommon for clients to lose their tenancy due to their psychotic symptoms. This framework acknowledges the importance of a support system outside of health supports and clinicians to evoke the best health outcomes.

Next is living and working conditions. This is a vast category that encompasses many facets of one’s life. This is directly related to the day to day activities that someone engages in; going to work; their environment; school, housing etc. Mental illness comes with a difficult symptomology to manage in the best circumstances. When we consider the fact that there are many reasons why mental illness may result in homelessness, it becomes more clear that symptom reduction may be the last priority for clients who are suffering and are now homeless. Once a client becomes homeless there is even less access to healthcare resources and with the compounding increase in symptoms, it can be assumed that these clients will not be thriving and will likely end up in the emergency department or with legal involvement.

Finally, general socio-economic, cultural and environment conditions can be understood as any factors that would impact health decisions and availability such as competing financial burdens (ie. child support payments), availability and access to jobs, and transportation services. In my experience, not only does homelessness create difficulty in a client maintaining any routines around preparing for work but clients who indicate ‘no fixed address’ on an employment application are rarely considered for a job. According to a recent survey done by the City of Toronto (2019) the current annual income required to afford a one bedroom apartment is $38,000 while the annual income of a single individual relying on Ontario Works is $7,104. It’s not hard to see the disparity between the two factors.

By applying Dahlgren and Whitehead’s (1991) model to the homeless population we can identify the compounding concern that lack of access to healthcare will have on this demographic. According to a survey conducted in Toronto, Ontario by the HomelessHub (2016) 67% of homeless individuals surveyed met the diagnostic criteria for two or more mental illnesses. Of that 67%, many are tasked with managing comorbidities associated with their mental illness such as diabetes mellitus type 2. Suvisaari et al. (2016) explains that people with schizophrenia are at a much higher risk of developing type 2 diabetes than the general population, possibly due to the effects of antipsychotic medications. These medications run the risk of type 2 diabetes both by directly affecting insulin sensitivity and indirectly by causing weight gain (Suvisaari et al., 2016). It is likely that the management to treat diabetes will succumb to the overwhelming constraints of not being adequately housed. This will create a snowball effect and result in more emergency department visits and higher acuity patients. Furthermore, Saklayen (2018) published an informative article that explains the prevalence of metabolic syndrome in those affected by mental illness, and the cost that uncontrolled metabolic syndrome can have on the economy and makes suggestions towards mitigating the issue. According to Saklayen (2018) the cost of health care when managing metabolic syndrome and loss of potential economic activity is in trillions of dollars. The present trend is not sustainable unless concerted global/governmental/societal efforts are made to change the lifestyle that is promoting wellness (Saklayen, 2018). In addition, Saklayen (2018) suggests making changes to affordable healthy food options, higher taxes for processed food, and overall making food more affordable and accessible. This is in line with a harm reduction approach to healthy living and the same theory can be applied to housing. In order to mitigate the issue, there needs to be long standing systemic change to create housing that is affordable.