Our study is one of the first to assess a wide range of sociodemographic characteristics of a homeless population in the city of Montreal, and to examine their relation to the prevalence of visual health problems. More than 60% of our sample were men, which is comparable to the situation in Canada; reports indicate that 50–70% of the homeless population in Canada is male (Employment and Social Development Canada, 2019; Hwang, 2001). The sociodemographic characteristics of the participants of this study are similar to those obtained by Noel et al. (2015) in Toronto, Canada, including the average age (48 years), ethnicity (over 70% Caucasian) and high level of education (high school and above). In our sample, 13% of participants identified as Indigenous, compared to less than 1% of the general Montreal population (Montreal: Service du développement économique, 2018). This over-representation of Indigenous among the homeless is consistent with findings across Canada, where Indigenous persons account for approximately 30% of all individuals experiencing homelessness, compared to just 5% of the general Canadian population (Gaetz et al., 2016). While the prevalence of 13% in our sample is less than 30%, this could be because Indigenous persons may be less likely to frequent shelters (Hwang, 2001). This could also explain the predominantly Caucasian nature of our sample; immigrants and refugees may be more likely to live in “hidden homelessness”, such as couch surfing or sharing accommodations with other families, instead of in homeless shelters (Keung, 2012).
Over three quarters (77%) of our sample had a valid health insurance card, a higher percentage than was found in a similar study conducted across three homeless shelters and drop-in centres in Toronto, Canada, where it was less than 50% (Hwang et al., 2000). This high rate of coverage could be related to the high levels of social support we also found among our sample; despite experiencing homelessness, many reported having people in their lives they could rely on for help. Such help could include navigating the administrative processes of renewing one’s health insurance or applying for a replacement card if it was lost or stolen. A reverse association is also plausible: services for individuals experiencing homelessness may help them to increase their social network. Another possibility is that, compared to Toronto, many homeless services in the city of Montreal are more geared towards longer-term objectives of social reinsertion rather than short-term or emergency shelter interventions (Derworiz, 2021).
Our sample also had a high level of education (68% had completed high school or more), which is comparable to what has been observed in Toronto, Canada (Noel et al., 2015). However, this proportion is lower than in the general population in Quebec (84%), a province with one of the lowest tuition fees for post-secondary education in all of Canada (Macdonald & Shaker, 2012; Statistics Canada, 2017). In addition, this may be an over-estimation of the education level of the homeless population in Montreal, as homeless persons who visit shelters may have a higher education than those who remain in the streets (Slomovic et al., 2021).
The prevalence rates of chronic health conditions in our sample, including diabetes (14%), hypertension (25%), cardiovascular disease (15%) and HIV/AIDS (3%), are similar to what has been found in other homeless populations in Canada (Employment and Social Development Canada, 2019; Noel et al., 2015) and in the United States (Morelli et al., 2018). When compared with Quebec’s general adult population, the prevalence of hypertension was similar (24%) (Blais et al., 2014), but the prevalence of other chronic conditions was higher. Only 7% and 11% of the Quebec population are affected by diabetes and cardiovascular diseases, respectively, while less than 1% of the Canadian population is affected by HIV/AIDS (HIV/AIDS prevalence in Quebec unavailable) (Blais & Rochette, 2018; Challacombe, 2021; Statistics Canada, 2018). The higher likelihood of these chronic conditions in our sample reflects a high prevalence of smoking, inadequate nutrition despite regular meal intake, and substance abuse (including injectables like heroin), as well as other contributing factors such as the daily stress of being without a home. It is noteworthy that the majority of those who reported being affected by these conditions were receiving treatment: 100% for diabetes and HIV/AIDS and 70% for hypertension. This could be partly due to Montreal’s high rate of health coverage and high levels of social support, and the fact that our participants were visitors of homeless shelters, which provide a certain level of stability, support, and referrals to needed services, including healthcare. The untreated burden is arguably larger among the homeless population, given that a high proportion of these conditions remain undiagnosed.
Consistent with what has previously been found in the literature, substance use was higher among male than among female participants (Grinman et al., 2010; Hwang, 2001). While drug consumption combined with excessive alcohol use and cigarette smoking is a well-known risk factor for visual health, there was no strong or significant association between substance use and ocular health in this study. However, it is interesting to note that male participants had a higher prevalence of visual impairment, refractive errors and ocular pathologies than female participants. The high use of cigarettes, drugs and alcohol in the homeless population remains concerning, given these are important risk factors for numerous physical and mental health issues (Sayal et al., 2021).
In terms of eye health, our findings are consistent with those of previous studies of homeless populations that have found an elevated prevalence of VI compared to in the general population (Noel et al., 2015; Sayal et al., 2021; Yelle et al., 2022). In our sample, 20% of participants had some form of VI, compared to 6% of the general Canadian population (Aljied et al., 2018). We also found a high percentage of unmet needs in terms of uncorrected refractive error (66%), which is treatable by the prescription of spectacles. While approximately 40% of the participants reported already owning spectacles, 70% of those who reported not having spectacles were found to need them. This finding is perhaps unsurprising given that one third of participants had not had an eye examination in at least 2 years (or ever). While eye examinations are fully covered for those who have healthcare coverage and welfare benefits, there is an important distinction between having availability and accessibility of healthcare services. Barriers such as fear of stigmatization from healthcare professionals, transportation difficulties, bureaucracy within the public healthcare system, lack of understanding of their rights, and eye health being a low priority for homeless individuals can contribute to this gap (Cernadas & Fernández, 2021; Ramsay et al., 2019). Individuals experiencing homelessness may not seek treatment until an issue incapacitates them, as other survival needs, including food and shelter, take precedence (Cernadas & Fernández, 2021; Hwang, 2001). As such, in order to reduce health inequities among individuals experiencing homelessness, healthcare delivery, including optometry services, may have to be adapted for and targeted towards such individuals. Potential ideas include mobile health clinics, such as the mobile eye clinic initiated by co-author BI (Tousignant, 2018); shelter-based clinics; or more multidisciplinary approaches involving greater case management, such as the involvement of social workers to facilitate coordination between different health and social issues (Institute of Medicine (US) Committee on Health Care for Homeless People, 1988).
Age was strongly associated with VI, ocular pathologies, and uncorrected refractive errors, which was not surprising since age is one of the most important risk factors in both the general and homeless populations (Ackland et al., 2017; Nia et al., 2003). Surprisingly, no other factor was associated with the study outcomes, including health and sociodemographic characteristics that have been shown to be contributory factors in previous studies (Cumberland & Rahi, 2016; Silverberg et al., 2021). There are several hypotheses that can explain this. First, the effect size of the associations with health and sociodemographic characteristics are modest, and our sample size may not have been large enough to detect them with statistical significance. This was compounded by the characteristics of our sample, too heterogeneous regarding some of these determinants (e.g. education level, food consumption, alcohol and cigarette usage) and too homogeneous regarding others. For example, the predominantly Caucasian nature of our participants made it difficult to detect whether an association exists between ethnicity and visual impairment. Some proxy variables may not have accurately measured what we had intended to measure, especially given the cross-sectional nature of the study. For instance, it is imprecise to assess nutritional deficiencies in a questionnaire, although an accurate assessment would be of high relevance since they can contribute to VI (Lawrenson & Downie, 2019). One variable we did not assess that could be associated with VI is the length of time participants have experienced homelessness, as those who have been homeless or marginally housed for longer may be at higher risk of poor health. Prior to designing our questionnaire, we conducted a literature review to determine what health and sociodemographic factors have been linked with ocular health in homeless populations. Length of homelessness did not emerge as an important factor. However, this could be due to the inherent difficulties in assessing length of homelessness. Homelessness is often not linear or chronic but episodic, with individuals transitioning in and out of homelessness, and it is those experiencing episodic homelessness who are over-represented in shelters (Gaetz et al., 2014).
There are some limitations pertaining to the recruitment of participants. Because participants were specifically recruited from homeless shelters, certain segments of the Montreal homeless population may have been excluded, such as those who choose to not frequent shelters. This selection bias might have influenced our results; for example, it has previously been found that Indigenous individuals experiencing homelessness are less likely to visit shelters (Hwang, 2001). Furthermore, while every effort was made to adhere to our random sampling approach within each shelter (i.e. every third person in line), some arrangements had to be made at times to work with shelters’ own internal logistics and procedures. Finally, as previously mentioned, our recruitment of female participants was hampered by the pre-vaccination phase of the COVID-19 pandemic and our sample of women was smaller than expected.
Nevertheless, our findings are important; not only do they provide a sociodemographic portrait of the homeless population in Montreal, they also highlight the often overlooked issue of VI. Vision plays a key role in many everyday activities of the homeless population, including mobility, reading, facial recognition, getting food, and using the telephone (Welp et al., 2016; West et al., 2002). VI has been associated with depression, anxiety, and lower levels of life satisfaction (Brown & Barrett, 2011). Individuals experiencing VI are also less likely to be employed and, when employed, earn significantly less than their non-visually impaired counterparts (Lennie & Van Hemel, 2002). The unmet need for spectacles we observed is important to highlight, since high VI may increase the risk of trauma and sexual assault and make it increasingly difficult to negotiate food, employment and shelter (Morelli et al., 2018). Having uncorrected eye problems may therefore exacerbate the situation that individuals experiencing homelessness find themselves in, making it increasingly difficult to break through the cycle of poverty and instability. Because eye problems can also serve as red flags for other underlying conditions (e.g. thyroid disease, diabetes, multiple sclerosis), ensuring routine eye examinations among homeless populations could also help promote their overall health and thus quality of life.
Additional studies are required to build upon our findings and provide additional insights. Similar research with larger sample sizes is needed, particularly regarding women experiencing homelessness, as homelessness has long been regarded as a predominantly male issue and research on homelessness has favoured male participants while overlooking gender as an important consideration (Bretherton, 2017; Clarke, 2019). Although logistically challenging, it would be ideal to conduct similar research with individuals experiencing homelessness who do not frequent shelters and to compare their eye health with individuals experiencing homelessness within shelter environments, to determine whether they are at greater risk for eye problems. Finally, based on our finding that the majority of our sample had not visited an eye care professional recently despite having health insurance coverage, research exploring the barriers to accessing eye care and how to promote eye health as a priority among homeless populations is important.