1. Introduction
Homelessness is a major public health concern in Canada, with at least 235,000 individuals estimated to experience homelessness annually [
1]. Moreover, an even larger number of individuals are vulnerably housed, living in precarious or sub-standard housing [
2,
3]. In Canadian cities, homeless and vulnerably housed individuals are concentrated in low-income, urban areas, where the majority of shelters, marginal housing, and associated health and social services are located [
4,
5]. Research with homeless and vulnerably housed individuals living in these areas has found that experiences of being either homeless or housed tend to be transitory, rather than stable life contexts [
6]. Moreover, prior work has found that distinctions between being homeless as opposed to housed are less salient among populations accessing low-quality, socially marginal housing [
7]. Research has found that both homeless individuals and vulnerably housed individuals living in marginal housing (e.g., single room occupancy hotels and rooming houses) experience worse physical and mental health and increased mortality rates [
4,
8,
9,
10]. For example, Hwang et al. [
9] found that life expectancy was reduced by 13 and eight years for men and women living in shelters, 11 and nine years for men and women living in rooming houses, and eight and five years for men and women living in single room occupancy hotels, respectively, compared to the general population.
An important component of health among homeless and vulnerably housed individuals is health-related quality of life (HRQoL). HRQoL measures individuals’ perception of how they are impacted by their mental and physical health [
11]. This reflects the World Health Organization’s definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” [
12]. In addition, studies have shown that HRQoL is predictive of morbidity and mortality [
13,
14]. Similar to other measures of health, both mental and physical HRQoL have been shown to be reduced among homeless and vulnerably housed individuals, compared to the general population [
4,
15]. In addition, the baseline results from the health and housing in transition (HHIT) cohort study in three Canadian cities found that homeless and vulnerably housed individuals did not differ greatly on both mental and physical HRQoL [
4].
Given the negative health consequences associated with being both homeless and vulnerably housed, and the importance of HRQoL, it is critical to understand the predictors of both mental and physical HRQoL in this population. Prior research has identified demographic, health, and social support variables that are predictive of either or both physical and mental HRQoL among homeless and vulnerably housed individuals [
16,
17,
18]. For instance, Cherner et al. [
16] found that among homeless and vulnerably housed adults in Vancouver, Toronto and Ottawa, having fewer chronic health conditions and greater social support was associated with higher mental HRQoL among both men and women. In the current study, we investigated the extent to which homeless and vulnerably housed individuals’ perceptions of the quality of their living spaces is associated with their physical and mental HRQoL.
The quality of living spaces may impact HRQoL through a number of pathways. Lower quality physical conditions of living spaces increase the likelihood of exposure to environmental hazards (e.g., poor ventilation, mold, and low heat) that are associated with ill health [
7,
19], which in turn is associated with lower HRQoL [
13]. In addition, the social climate of a living space may positively benefit HRQoL through facilitating the development of supportive relationships and connections to health and social services [
7,
19]. Furthermore, individuals’ experience of their living spaces as having positive qualities (e.g., privacy, safety, and friendliness) may benefit HRQoL by contributing to psychological well-being and reducing stress [
7,
19].
Past research has demonstrated that the physical conditions of housing are associated with health status and HRQoL [
3,
19,
20,
21,
22,
23]. For instance, Hwang et al. [
22] had observers rate the physical conditions of rooming houses (e.g., building structure, noise levels) and found that individuals living in the lowest quality rooming houses reported the lowest levels of both mental and physical HRQoL (measured with the short form health survey; SF-36). In addition, a select number of studies have examined associations between perceived social and physical qualities of living spaces and HRQoL or general quality of life [
24,
25,
26]. For example, Rourke et al. [
24] found that satisfaction with both material (e.g., light, heating and air quality of dwelling) and meaning (e.g., feelings of identity, control and belonging associated with dwelling) dimensions of housing were associated with both mental and physical HRQoL among 519 individuals living with HIV (human immunodeficiency virus) in Ontario. It is important to examine individuals’ perception of the quality of their living spaces, as this reflects their psychological experience of these spaces.
Much of the existing research examining associations between the perceived quality of living spaces and HRQoL has relied on cross-sectional designs or longitudinal designs with follow-up periods of one year or less [
24,
26]. In addition, the majority of research examining associations between the quality of living spaces and HRQoL has focused on housed individuals. However, there is substantial variation in the types of spaces that homeless individuals occupy (e.g., sheltered spaces, outdoor spaces, and couch surfing) and this variation may have important consequences for HRQoL [
27]. For instance, one study [
28] conducted with a sample of 209 caregivers living in homeless shelters in New York City found that negative perceptions of the social environment of shelters were associated with worse mental health. Very little research has examined the perceived quality of living spaces and HRQoL among homeless individuals.
In sum, it is important to examine predictors of HRQoL in homeless and vulnerably housed individuals as this is a key component of health [
11,
12,
13,
14] that has been shown to be reduced in this population [
4,
15]. Moreover, it is vital to examine individuals’ perception of the social and physical qualities of their living spaces as this reflects their personal experience of these spaces, which has the potential to uniquely affect HRQoL [
7,
19]. While past research has demonstrated that housing quality is associated with health [
19,
20,
21,
22,
23], and that perceived housing quality is associated HRQoL in specific populations [
24], few studies have examined associations between perceived quality of living spaces and both mental and physical HRQoL in diverse samples of homeless and vulnerably housed individuals. To address these gaps, we examined the association between perceived quality of living spaces (based on rated comfort, safety, spaciousness, privacy, friendliness and overall quality) and both mental and physical HRQoL among individuals in Vancouver, Toronto and Ottawa who were either homeless or vulnerably housed at baseline. Moreover, we examined these associations between perceived quality of living spaces and both mental and physical HRQoL over a four-year follow-up period and controlled for time-varying housing status and several time-varying and fixed clinical and demographic variables. Given past research demonstrating connections between perceived housing quality and HRQoL among individuals with HIV [
24] and between perceived homeless shelter social environment and mental health [
28], we expected that perceived quality of living spaces would be positively associated with both mental and physical HRQoL among individuals who were homeless and vulnerably housed at baseline in our study.
4. Discussion
Understanding the predictors of HRQoL among homeless and vulnerably housed individuals is important, as HRQoL is a key component of health predictive of morbidity and mortality [
11,
12,
13,
14] and because there are over 200,000 homeless and over 600,000 vulnerably housed individuals living in Canada [
1,
2]. In the current study, our key finding was that, over time, both higher mental and physical HRQoL were associated with more positive perceptions of one’s living spaces, as reported by a sample of individuals who were homeless and vulnerably housed at baseline. Notably, these associations were observed over a four-year follow-up period and while controlling for covariates such as time-varying housing status (homeless or housed at each time point) as well as several fixed and time-varying clinical health and socio-demographic variables associated with HRQoL. Moreover, we found that the perceived quality of living spaces did not differ between homeless and vulnerably housed individuals at baseline, and that the longitudinal association between perceived quality of living spaces and HRQoL was not moderated by time-varying housing status (homeless versus housed at each time point).
Findings from this study align with previous research demonstrating a connection between housing quality and health [
19,
20,
21,
22,
23], perceived housing quality and general HRQoL among specific populations [
24], and perceived social environment of a homeless shelter and mental health [
28]. In addition, the current study extends prior work by demonstrating that perceived quality of living spaces is positively associated with both mental and physical HRQoL in a diverse sample of homeless and vulnerably housed individuals in three cities in Canada. Moreover, by examining associations over a four-year follow up period, this study provided more reliable estimates of population average associations between perceived quality of living spaces and both mental and physical HRQoL, compared to previous studies that were either cross-sectional or based on shorter and fewer follow up periods.
The findings from this study that individuals who were homeless and vulnerably housed at baseline did not differ in their report of the quality of their living spaces, and that the longitudinal associations between perceived quality of living spaces and physical and mental HRQoL did not differ by time-varying housing status, aligns with prior research findings that distinctions between being housed and homeless are less salient among homeless individuals and vulnerably housed individuals living in highly marginalized, low-quality housing [
4,
7]. Particularly in this population, housing status does not fully capture individuals experience of their living spaces. Perceived social and physical qualities of living spaces vary for both homeless and housed individuals in these socially marginal areas, and someone who is homeless may have more positive perceptions of their living spaces compared to someone who is housed. For instance, a homeless person living in a tent city may feel safer and more socially connected compared to someone living in a single room occupancy hotel or rooming house [
7,
43].
These findings indicate that housing policy should prioritize access to high-quality housing that takes into consideration individuals’ subjective experience of their living spaces, in addition to their health care needs and the physical conditions of their living spaces. A focus on housing individuals without thoughtful consideration of quality and subjective experience, such as forcibly removing people from tents on city property and offering limited spaces in single room occupancy hotels and shelters [
44], is likely to miss opportunities to improve HRQoL. Moreover, findings from this study indicate that improving the experienced social and physical quality of shelters may be associated with improved HRQoL among currently homeless individuals.
This study has a number of limitations. First, the use of observational data restricts our ability to determine causality. While the higher perceived quality of living spaces may improve HRQoL, it may also be the case that higher HRQoL leads to more favorable perceptions of the quality of living spaces, or that more optimistic individuals perceive both higher quality living spaces and higher HRQoL. Future research may better assess the causality of these associations by experimentally improving living conditions and measuring the effects on the perceived quality of living spaces and HRQoL and controlling for personal characteristics such as optimism. Second, this study did not include objective measures of the physical conditions of living spaces. As such, it was not possible to tease apart the individual effects of the subjective experience of quality and the objective physical conditions of living spaces. Future research should address this by obtaining both objective and subjective measures of the quality of living spaces and specific physical characteristics of living spaces. This would also allow for an examination of the ways in which specific physical characteristics of living spaces may be associated with an improved subjective experience of quality. Finally, because this research focused on vulnerably housed individuals living in specific forms of marginal housing (i.e., single room occupancy hotels and rooming houses) and homeless individuals who accessed shelters and meal programs, the results may not generalize to other homeless and vulnerably housed populations who live in different forms of housing or do not access the service sites sampled.