Housing Investigations Involving
Marginalized Populations
Report
March 22, 2018
Authors
Suzanne Lemieux, PhD, Public Health Sudbury & Districts
Phyllis Montgomery, RN, MScN, PhD, School of Nursing, Laurentian University
Sherry Price, MSW, Public Health Sudbury & Districts
Acknowledgements
Many people provided invaluable contributions to this study: Public Health Sudbury & Districts
staff, in particular, Burgess Hawkins, Jonathon Groulx, Ryland Yade, and Marissa Perrella as
well as participating Public Health Sudbury & Districts clients, community partners, and
community members as well as Laurentian University nursing students, Emily Crowe, Paul
Lauzon and Mia Pandolf.
Funding
Louise Picard Public Health Research Grant, 2015-2017
Contact for More Information
Suzanne Lemieux
Manager, Knowledge and Strategic Services
Public Health Sudbury & Districts
1300 Paris Street
Sudbury, ON P3E 3A3
Phone: 705.522.9200, ext. 400
lemieuxs@phsd.ca
Citation
Lemieux, S., P. Montgomery, and S. Price (2018). Housing Investigations Involving
Marginalized Populations: Report. Sudbury, ON: Public Health Sudbury & Districts.
Copyright
This resource may be reproduced, for educational purposes, on the condition that full credit is
given to the Public Health Sudbury & Districts and Phyllis Montgomery. This resource may not
be reproduced or used for revenue generation purposes.
© Public Health Sudbury & Districts, 2018
Table of Contents
Executive Summary
1
Background
2
Purpose of study
3
Literature Review
4
Theoretical Review
10
Methods
10
Design
10
Setting
11
Sampling
11
Data collection and analysis
12
Results
Documents
Vignettes based on interviews and field notes
14
14
21
The Visit
21
Hospital
22
Family
23
More
23
Networks
24
Forums
28
■ iii
Conclusion
29
References
30
Appendix A
34
Appendix B
36
Appendix C
38
iv
Executive Summary
Public health inspectors [inspectors] at Public Health Sudbury & Districts are responding to
inspections involving vulnerable individuals living in potentially adverse housing situations and
also have a policy and procedure in place for responding to such calls. However, some cases are
time and resource intensive; some cases often require services that are outside inspectors’ scope
of practice; some inspectors want to improve living conditions of vulnerable persons but are
challenged when the client refuses voluntary resources in the community and responding to
vulnerable clients’ needs is a challenge for other service providers as well.
The purpose of this case study is to investigate Public Health Sudbury & Districts
Environmental Health Division’s response to housing health hazards involving individuals who
are vulnerable. In consultation with the Environmental Health Division and the greater
community, the goal is to propose recommendations for improving such responses.
We sought to understand what a response to adverse housing involving vulnerable individuals
entails. Specifically, its associated challenges, facilitators and ideas for improving such responses
from the perspective of all involved in these situations (Environmental Health Division staff,
clients, citizens, and other service providers).
A case study approach was used to investigate five situations of housing health hazards
involving vulnerable people. Since 2015, the researchers have been conducting a case study to
provide knowledge about inspector’s involvement in referrals about vulnerable individuals living
in hazardous housing situations. This involved the collection of various types of data including
document analysis, field observations, individual and group interviews with clients, citizens,
Environmental Health Division staff and other service providers, and two knowledge translation
activity involving Environmental Health Division staff and their community partners.
Findings highlighted resources that facilitated inspectors’ involvement in addressing housing
environmental hazards. These included public health inspectors and service providers’ expertise,
collaboration between service providers, certain client attributes, solution-focused public health
inspectors and service providers and housing resources for clients. Findings also underscored
circumstances challenging inspectors’ involvement in addressing housing environmental
hazards. These include certain client attributes, poor housing and high cost of housing, some
landlord ways of doing, limits within mandates and systematic issues such as stigma. Proposed
solutions were also identified. Overall, the top ranked proposed solutions are:
1






Improve interagency collaboration and cooperation.
Create and continually update a list of agencies, a contact person, the populations they
serve, and what service they provide.
Be able to provide seamless connections to mental health supports for clients.
Create a specialized group to respond to housing health hazard calls within vulnerable
populations.
Designate a community navigator who will triage and delegate cases to appropriate
agencies.
Advocate for a streamlined procedure for placement of individuals living in hazardous
situations into long term care where appropriate.
Background
There’s a growing body of national and provincial evidence about the relationship between home
environment and health, a public health concern documented in Europe in the 19th century.
According to 2006 census data, one third of Canadians live in substandard living conditions or
are in 'housing need' as defined by the Canadian Mortgage and Housing Corporation. The highest
level of housing need is in the territories and in the provinces of British Columbia, Ontario,
Newfoundland and Labrador (Canadian Mortgage and Housing Corporation, 2009). Rideout and
Oickle (2016) argue that health inequalities contribute to "differences in environmental
exposures, vulnerabilities to and outcomes from those exposures (p. 216)”; a position well
supported by a body of evidence demonstrating the cumulative effects of environmental hazards
on poor health in several at-risk populations (Canadian Population Health Initiative, 2004;
Clarke, 2002; Environmental Health Services BC Centre for Disease Control, n.d.; Toronto
Central Local Health Integration Network, 2015; Wellesley Institute, 2012; White et al., 2014).
The strongest private dwelling evidence for causal relationships exists for a variety of biological,
chemical and physical exposures (Moloughney, 2004). In addition, the address of private
dwellings and neighbourhood-level features influence health outcomes of residents. Researchers
report that Ontarians living in deprived neighbourhoods have higher mortality and suicide rates
(Mikkonen and Raphael, 2010; O'Campo et al, 2015).
The governing legislation of the public health inspector, the Health Protection and Promotion
Act (2016), does not specifically outline a role for the inspector with respect to responding to a
potential health hazard in a private residence. Although the regulations are often subject to
interpretation, there is growing consensus among environmental public health practices that
housing symbolizes a small fraction of an equity problem. During a home environment visit,
inspectors observe: “an open and honest view of that person’s life.”
As Patricia Vernon, a PHI with Alberta Health Services put it:
Housing is the glue that holds a person’s world together.” When that house is
falling apart, whether due to a landlord’s neglect, a mental health issue …
hoarding, or a simple lack of resources, most PHIs cannot walk away. (Health
Equity and Environmental Public Health, 2017, p. 14)
2
The Environmental Health Division at Public Health Sudbury & Districts is committed to
effective practices to optimize a healthy living environmental for all. Public Health becomes
involved when the situation reaches the point where a citizen or service provider is concerned
enough to make a referral. Often, the health of the resident(s) and possibility the immediate
neighbours is perceived as threatened as a result of a combination of health and social factors
affecting the living conditions.
Inspectors at Public Health Sudbury & Districts have policies and procedures in place and are
responding to calls for inspections involving individuals who are vulnerable and living in
potentially adverse housing situations. Such referrals for inspector involvement are time and
resource intensive. The multiple challenges that these residences face, make it difficult to remedy
the situations. Inspectors often engage other community partners, such as by-law enforcement,
fire, building, or health authorities to resolve immediate hazards. Further, inspectors are
concerned additional supports may be necessary to support individuals' well-being in their home
environment once the file is closed.
Findings from a 2012 study conducted by Public Health Sudbury & Districts, outlined
inspectors’ uncertainty surrounding their role with vulnerable populations, fearing lack of
legislation would support whatever intervention they recommended (Lefebvre et al., 2012).
Inspectors outlined the importance of partnerships with referral agencies to resolve complaints
and collaborations between community agencies to assist vulnerable clients. However, there
were fewer potential partnerships when it came to housing hazards in unorganized townships and
other rural areas because of fewer services available. Frustrated with all this, they reported going
“above and beyond” their job descriptions to help clients connect with agencies. Nine
recommendations were presented including developing public health guidance documents to
clarify the role of public health inspectors in relation to housing issues.
Purpose of study
The study purpose is to examine Public Health Sudbury & Districts Environmental Health
Division’s response to housing health hazards of adults made vulnerable by an interplay of health
and social determinants. Above all, the purpose is to identify the challenges and facilitators
associated with their involvement as well as recommendations for improvement.
The goal is to provide the Environmental Health Division and the greater community with a
priority list of recommendations for consideration to further the community’s response to
adverse housing situations involving vulnerable people.
3
Literature Review
The following is a systematic review of evidence about public health inspectors or environmental
public health practitioners’ involvement in protecting and promoting the health of residents from
housing hazards. As earlier as 1999, Stewart provides a commentary about the growing role of
environmental health officers in ‘healthful housing’ for disadvantaged populations. For healthy
home environments, this author emphasizes the need for proactive policies, strategies, and
training in response to multiple biological, chemical, physical, economic and social hazards
which limit individual and community health.
The academic databases MEDLINE and Cumulative Index to Nursing and Allied Health
Literature (CINAHL) were searched for current evidence concerning the involvement of
inspectors in response to housing hazards. The search parameters were: peer-reviewed reports;
available electronically; full-text reports; published in English from 2007 to 2017. In
consultation with a health librarian, the list of search terms and combinations shown in Appendix
A were used to locate published reports in MEDLINE. Using the identified search parameters,
and removing duplications, 307 reports were identified. Titles and abstracts were read for topical
relevancy. A total of 31 reports were deemed as potentially relevant for inclusion in the literature
review based on the initial reading of each abstract and in some cases, the full manuscript. The
primary reasons for exclusion of 276 reports were a treatment-specific intervention in
underdeveloped countries or a focus on the association between housing and health.
The full-text of each of the initially accepted 31 reports were retrieved, printed, and read to
ascertain the authors’ stated purposes specific to inspectors' involvement with housing hazards.
An additional 13 reports were excluded from the review where the practical implications of
inspectors were not identified. Of the remaining 18 reports, information was extracted and
tabulated from each report (Table 1). This table is a summary of key features of the selected
studies.
4
Table 1
Selected Inspector literature
Lead author (year),
Location
Dhesi (2016)
United Kingdom
Purpose
Describe inspectors
role given the
relationship between
environmental health
and health
inequalities
Data collection
Case study
Holtzen (2016)
United States
Describe the
Individual interviews
perceptions of tenants
and property
managers in regards
to housing quality
issues that affect
tenants' health.
Rideout, Kosatsky et
al. (2016)
Canada
Illustrate Canadian
and American
inspectors’ efforts to
promote healthy built
environments.
Not applicable
Key findings
These authors found that the role of inspectors is often
unrecognized secondary to:
• narrowing of public health agenda;
• loss of a holistic health orientation during training;
• a general misconception that are statutory 'doers' rather
than critical thinkers tailored to specific contexts; and
• limited budgets in this division of public health.
They recommend the need to further assess their role
given contemporary public health issues and measure their
contribution to public health outcomes.
Health Impact Assessments involve structured, policy
informed processes to determine housing quality and
safety. The majority of property managers followed a
preventive maintenance schedule to minimize the risk of
an accommodation being deemed by inspects as
‘unsatisfactory.’ In contrast, tenants valued input about
housing quality issues even though coordinating a time for
the inspection was challenging.
Inspectors are mandated to protect people from infectious
or toxic agents in food, water and other environmental
sources. Some environmental agencies have adopted built
environment protocols in regards to inspections and or
permitting (oversight of land use planning, health hazards
legislation, and collaboration / advocacy). These practices
shift from safeguarding health by controlling immediate
hazards / infectious agents to protecting vulnerable
persons in at-risk environments.
5
Rideout & Oickle
(2016)
Canada
Cushing (2015)
United States
Knechtges (2015)
United States
Assess how health
equity and the social
determinants of
health (SDH)
intersect with the
scope of inspectors’
practices
Compare the
distribution of
environmental
hazards and
vulnerable
populations
Describe educational
preparation of
environmental health
professionals requires
'knowing how' and
'knowing why' in
view of emerging
health problems
Group interviews
Inspectors identified socioeconomic status, culture,
education and geographic barriers to compliance with
environmental health regulatory practices. To address such
challenges, inspectors rely on unique combinations of
communication, relationship, progressive enforcement and
community collaborative strategies.
Environmental
Justice Screening
Tool
(CalEnviroScreen
1.1) yields a
cumulative score
based on 11
indicators of
pollution burden and
6 indicators of
population
vulnerability
Not applicable
The purpose of the tool is to measure the impact of
environmental exposures and population vulnerabilities;
useful information for addressing health disabilities in
communities disproportionately influenced by multiple
environmental health hazards. Results showed higher
cumulative scores in non-Caucasian compare to Caucasian
communities. In communities with higher levels of
poverty, the pollution scores were significant higher as a
result of pesticide use and toxic release from cleanup sites,
hazardous waste and diesel.
Several academic environmental health educators identify
the need to promote ‘environmental public health’
knowledge in the credentialing of inspectors. As compared
to the US, there is an agency referred to the Institute of
inspectors in Canada. It is responsible for professional
certification, program accreditation, and standardization of
competencies and policies. Evolving academic and
increasingly complex public health issues demand novel
innovation in the educational preparation of the future
workforce.
6
Rideout, Oickle,
Scarpino et al.
(2015)
Canada
Explore how
inspectors can
respond to health
inequities and take
action on the social
determinants of
health (SDH)
Pilkington (2013)
United Kingdom
Describe a project of Not applicable
involving a public
health officer in an
architecture
educational program
Describe the
Not applicable
contemporary role of
housing
environmental health
practitioners since the
introduction of the
2004 Housing Act
Stewart & Bourn
(2013)
United Kingdom
Lefebvre (2012)
Canada
Explore inspectors'
experiences in
response to requests
for investigating
private housing
hazards
Summary of
inspectors response to
findings about SDH
influencing the
implementation of
their role
Interviews
No single agency has sufficient capacity to identify all
vulnerable situations or address all health hazards.
Effective collaborations and inter-sector partnerships are
essential to addressing complex situations in private
individual and residential dwellings. At a system level, a
referral process or centralized 'health equity lead' may
assist inspectors to identify and facilitate a team response
in health inequity situations. Respectful working
partnerships with First Nations communities are possible
when inspectors are viewed as educators rather than
government employees.
The officer delivered workshops, tutorials and one-to-one
guidance on individual students' design projects to
promote environmental health features. This 'in residence
model' was positively evaluated by students.
Based on a growing body of literature, there is a
recognized need to mitigate housing risks for optimal
health. Private-sector housing services are becoming
focused on the public health aspect of housing and
involved in advocating for vulnerable residents living in
health, economic and fuel poverty. These authors
anticipate an increasing number of public concerns about
poor housing conditions and the need for inspectors’
involvement.
Inspectors described being confronted with a dilemma
about the imposition of sanitation standards and an
individual’s right for privacy in response to referrals
involving persons residing in private dwellings.
7
Campbell (2011)
Canada
Explore inspectors
experiences in health
promotion practices
Interviews and field
notes
Jacobs (2011)
United States
Review of
effectiveness of
control biological,
chemical, structural
and communitybased housing
interventions
Review
DiGuiseppi
(2010)
United States
Review of evidence
on the effectiveness
of housing
interventions that
affect safety
outcomes associated
with structural
housing deficiencies
Review of housing
interventions for
health
Review
Jacobs (2010)
United States
Systematic review
Inspectors viewed health promotion as an aspect of
enforcement. Interventions aimed at building healthy
public policy, developing personal skills, and creating
healthy environments support promotion. To this end,
resources such as practical training, clear expectations,
accountability, resources, and relationships with various
community partners facilitated implementation.
Eleven interventions had sufficient evidence to support
effectiveness to improve particular health outcomes. Many
of these interventions were related to biological and
chemical risk management. Green Community Standards
project and the Health Impact Assessment show promise.
Yet, there is a need for more housing disparity health
research in order to focus remediation and prevention
practices.
Studies found that falls, fire-related, scalding-related,
drowning, carbon monoxide poisoning, heat-related
mortality and poor self-rated health are associated with
structural problems in homes. A total of 17 interventions
by professionals were examined; three of them were
linked to positive health outcomes. These included
installation of smoke alarms, fencing around pools and
pre-set temperature on hot water heaters.
Four panel members reviewed literature about interior
biological agents, interior chemical agents, structural
deficiencies and community-level housing risks. The two
broad sources of evidence were labeled clinical
interventions and environmental measurement. Overall,
interventions in the areas of biological and chemical
agents have sufficient evidence. Structural interventions
(smoke alarms, fencing and safe temperature hot water
heaters) also yield positive health outcomes.
8
Kangsen Scammell
(2010)
United States
Review of the
qualitative evidence
published between
1991-2008
concerning the
relationship between
environmental
exposures and human
health
Review
Kuholski (2010)
United States
Describe a 'onetouch' approach to
support vulnerable
citizens facing
disproportionate
impacts of housing
hazards
Examine the
effectiveness of
housing interventions
that affect health
outcomes.
Not applicable
Describe housing and
health trends over 30
years
Re-analysis of
national surveys
Sandel (2010)
United States
Jacobs (2009)
United States
Review
This included 91 studies involved diverse samples'
exposure to risk by detailing their experiences and
perceptions influenced by various social, economic,
cultural and political contexts. Nearly half of the reviewed
evidence described negative health outcomes (respiratory,
infestations, hygiene, injuries, increased stress). A few
studies appraised interventions aimed at mitigating
environmental risks. A shared recommendation across this
body of evidence was the need to address wider macrostructural factors for environmental health.
'One-touch' integrates public health and energy efficiency
strategies to yield improved health and service outcomes
in vulnerable families and older persons. This approach
supports a person’s capacity to overcome barriers for
change.
Four of the 14 interventions with sufficient evidence were
use of active soil depressurization systems, integrated pest
management, smoke-free home policies and residential
lead hazard control. The authors concluded that housing
improvements have the potential to decrease certain
illnesses and injury.
The review supports the relationship between health status
and housing quality. With time, research supports a direct
relationship between childhood lead poisoning and
exposure to lead-based paints.
9
Theoretical Review
Rideout and the National Collaborating Centre for Determinants of Health (2014) emphasize that
inspectors play a key role in the promotion of health equity, regardless if there are inspecting
facilities, conducting an environmental health risk assessment, enforcing public health
regulations, promoting actions to reduce risk exposure, or advocating for healthy build
environment policies. To this end, Linder and Sexton (2011) proposed a model, entitled
Cumulative Risk Assessment, to achieve health equity. It combines the distinguishing features of
social determinants, health disparities and multiple stressors models. The dynamic among these
three components, although complex and contextualized, offers a more comprehensive
understanding of implemented practices by environmental agencies and health outcomes. The
creators of the model wanted it to be used as a pragmatic guide for the assessment “health risks
from human exposure to a combination of chemical and nonchemical stressors” (Linder &
Sexton, p. S80) and ultimately, assist in the identification, analysis and interpretation of risk to
protect the vulnerably housed. Appendix B offers a summary of the model prepared by the
United States Environmental Protection Agency (2003).
Methods
The study methods were ethically approved by two separate ethic boards in 2015. During the
same year, the researchers created a Study Advisory Committee. This forum offered
opportunities for researchers and staff from the Environmental Health Division to discuss ideas,
information and possibilities and to acquire an understanding of the study context: Public Health
Sudbury & Districts’ Environmental Health Division.
Design
The study design was a qualitative case study design (Figure 1). It allows for a concentrated
examination of a specific, complex, dynamic phenomenon or integrated system over time
through the collection of multiple sources of information (Creswell, 2009; Sandelowski, 2011;
Stake, 1995). Combining sources of data yields a contextually rich, interpretive description of
‘the case.’ The case in this study was Environmental Health Division of Public Health Sudbury
& Districts. Its distinct activities, processes and people (inclusive of inspectors, clients, and
community partners) characterize the department. Case study has been used in numerous other
public health studies. For example, Brand and associates (2016) argued that it allows for the
identification and understanding of environmental, social, and behavioural dynamics
contributing to health disparities of subgroups of persons living in hazardous housing.
10
Setting
This agency services a population 196,448 people residing in 18 municipalities located within a
geography of approximately 46,550 square kilometers (Public Health Sudbury & Districts, 2017).
Sampling
The sampling method was information-orientated sampling (Flyvbjerg, 2006; Stake, 1995). This
approach is defined as the involvement of key sources of context-dependent knowledge and
experience in relation to the Environmental Health Division.
Figure 1. Stages of the research study in consultation with Advisory Committee
11
Data collection and analysis
The two sources of data were, documents and interviews with accompanying field notes for the
purpose of keeping a narrative account of observations and reflections following discussions
with participants. Knowledge translation forums concluded this stage of the study.
Documents: Anonymized inspectors’ records specific to involvement with a vulnerably housed
citizen were provided to one researcher. She reviewed and further redacted any identifying
information. The 94 records were dated between 2013 and 2015. The standardized record
includes details about the referral source and presented concern, and the inspectors’ response.
The response is typically structured by the assessment, implementation and evaluation process.
Data was extracted, coded and underwent content analysis.
Field Observations: Field observations were conducted where a researcher accompanied an
Inspector as he responded to housing cases involving vulnerable people. These observations
were documented by the researcher. Notes were taken to describe the interactions between
inspector and clients and other service providers. Notes were also taken to describe the nature of
the complaint and the housing condition. This information was coded and underwent content
analysis.
Interviews: Audio-recorded conversational interviews with identified stakeholders within and
outside of the environmental department were conducted. These interviews were in person. Some
clients were interviewed on more than one occasion for the purpose of exploring emerging
variables and being respectful of their communication style. The use of conversational interviews
allowed the interviewer to get to know the other in relation to his/her concerns and actions
(Liamputtong, 2007), an approach particularly suitable as there is no ‘one size fits all’
concerning data collection with vulnerable adults. At the beginning of an interview, the
participant received a verbal explanation and a written consent form outlining the study purpose
and his/her rights. Examples of questions, depending on the type of participant (service user or
service provider), were:





What is the nature of inspector’s service request involving persons living in potential
adverse housing?
What types of factors influence inspector's response?
What are the outcomes of the exchange between service seekers, inspector and
community partners?
How do community partners describe their involvement with inspectors?
How do service seekers perceive their home environment?
12
Following the conversations, the interviewer wrote descriptive field notes as a record of their
observations (Swanborn, 2010; Amba & Stake, 2014) and discussions during client visits with
inspectors. This accounting facilitated the researcher's understanding of the inspector's
assessment of health risks and resultant plan of action. With time in the project, the nature of the
notes became increasingly detailed rendering vignettes that explained the what, where, why as
seen by involved persons.
The interviewers were transcribed and coded. The interview transcripts and the field notes were
thematically analysis guided by Guest and associates (2012). According to these authors, data is
segmented, coded and categorized to reveal themes - labels or phrases representative of
described or interpreted data sets. Two core questions continually posed by the researchers
during data analysis were,


What is this data an expression of?
What is the interviewee’s experiences and perceptions in view of study purpose? (Guest,
MacQueen & Namey)
Forums: The results of the document and interview data were presented in two forums for the
purpose of knowledge translation. The first forum involved inspectors and the participants of the
second forum were various community partners of the Environmental Health Division. These
forums provided an opportunity for researchers to dialogue with key stakeholders about their
interpretations of the “happenings” in the field. Mutual, purposeful interactions fosters a richer
understanding of 'the case' as well as contributes to the credibility and utility of the research
generated knowledge (Flyvjerg, 2013). Each forum was less than two hours. One activity of the
forum involved inviting participants to prioritize practices to address the vulnerably housed. The
list of practices were extracted from the document and verbal data.
This was strategic as it moves the case study focus from description to action.

As a department, what are next steps? (Abma & Stake, 2014)
At the beginning of each forum, participants received a verbal explanation and a written consent
form about its purpose and their rights. They were not required to submit their list of priorities
for further descriptive analysis. Rankings were tallied to determine the most favoured proposed
solutions in each of the two groups of participants.
13
Results
Documents
In the area served by the Environmental Division between January 2013 and December 2015, a
total of 94 documents involving persons who were vulnerable living in potentially adverse
housing conditions were opened by inspectors. The records addressed the needs of 87 separate
individuals; nine individuals had a previous environmental health record. All of these records
were identified as “housing health hazards” in “marginalized populations.” All of the inspections
except for one were completed within the City of Greater Sudbury. The postal code indicated on
the records was in the district of Wanup (Figure 2).
Figure 2. Identified geographic area of potential housing health hazard.
14
The most common source of referral for inspector involvement was a health care provider
associated either with hospital or community health services (Table 2). Over three quarters of the
referrals were categorized as "house disrepair /sanitation" (Table 3). The lapse of time between
date of referral and onset of action was often under 50 minutes (Table 4). Most records (Table 5)
contained less than five separate entries detailing activities. The lifecycle of a record was
typically one month (Table 6).
Table 2
The source of the referral for inspector involvement
Not identified
Health provider
Police
Fire
Sudbury Housing
Building Manager
Property Manager
Landlord
Neigbhour
Family
Client
0
5
10
15
20
25
30
35
40
% (N = 94)
15
Table 3
Types of reported problems at initial contact with environmental services
Rodents
Infestation
Flooding
Garbage
Mould
Odors/Animal Excrement
House disrepair/Sanitation
0
10
20
30
40
50
60
70
80
90
Frequency
16
Table 4
Minutes from time of referral to action initiated by inspector
60
50
40
30
20
10
0
< 10
11 to 20
21 to 30
31 to 40
41 to 50
51 to 60
61 to 70
71 to 80
81 to 90 91 to 100 101 to 110111 to 120
> 121
Minutes
Table 5
Number of entries per record (N = 94)
> 26
21 to 25
16 to 20
11 to 15
6 to 10
<5
0
10
20
30
40
50
60
70
80
%
17
Table 6
Duration of clients' record in days (n = 93)
40
35
30
25
20
15
10
5
0
<5
6 to 20
21 to 35
36 to 50
51 to 65
66 to 80
81 to 100 101 to 115 116 to 130 131 to 145
> 146
The reviewed records involved 16 individual inspectors who averaged 7.4 contacts per record.
Many of the entries (82%) indicated inspectors' engaging other community partners in the
delivery of environmental practices. The average number of agencies involved with inspectors
was 1.7 per file. These included property managers; building inspectors; by-law officers; fire,
police and pest control officers; social and health care workers; family members; neighbours;
and workers from private companies for cleanup and plumbing.
When age of resident was recorded, most of them were over 60 years of age (Table 7). The range
of age was 16 to 91 years. The majority of residents lived alone (72%) and self-reported several
health problems (66%). In nearly 70 % of the records, the residents' described their support
network as limited or non-existent.
18
Table 7
Age of clients at time of referral (n = 54)
90 to 99
80 to 89
70 to 79
60 to 69
50 to 59
40 to 49
30 to 39
20 to 29
10 to 19
0
5
10
15
20
25
30
%
All the records were closed with the exception of one in the two year period. Satisfactory
resolution was documented in nearly one third of the cases. In 27% of the files, the notation
indicated lack of resolution.
Table 8 presents a summary of the assessment and resultant actions documented in the 94
records. The cumulative effects of multiple health disparities were reflected in the majority of the
records.
19
Table 8
The assessment and resultant actions of inspectors
Who involved in
assessment
Content of
assessment
• Hazardous agents
• Property owner
• Property manager • Environmental (availability of
water, quality of air, physical
• Fire services
safety, plumbing, waste / garbage
• Family and nonmanagement, functional fridge /
family members
stove, mould]
• Other inspectors
• Infestation [insects or rodents]
• Police
• Effects on
• Building
a) health [morbidity, potential of
inspectors
injuries / accidents, confounding
• Landlords
factors]
• By-law officers
b) future generations [adult
• Power-ofattorney
parents and their children]
• Exterminators
• Hospital and
c) health care services [denied
community
access by tenant or service
health care
provide refuse to access or unable
providers
to access with stretcher]
• Social services
• Structural issues [leaking pipes]
• Temperature [room]
• Sanitation
• Egress
• Pets
Context of assessment
Actions taken
Determinants of health
• Gaining access
• Observing
• Physical environment
[passageway, clutter in- and out- • Screening of potential hazards
• Prioritizing risks
side of dwelling, use of space]
• Monitoring of actual impacts
• Physical and mental health
• Facilitating communication
status [appearance, mobility,
among relevant stakeholders
functionality]
• Coordinating services
• Personal health practices
• Identifying solutions to manage /
[medication]
resolve issues
• Lifestyle practices [diet]
•
Inquiring about subsidies
• Social supports and networks
• Providing literature
[isolated, family, neighbours]
• Networking, consulting and
• Economic status
referring
• Employment status
• Use of health services [known to • Evaluating
inspector]
• Geography [rural]
• Access / available food
• Developmental [child, seniors]
20
Vignettes based on interviews and field notes
The following vignettes showcase the key patterns of the qualitative data set. To protect all
participants, the voices of service users, inspectors and community partners are integrated to
provide a rich description of five dynamic situations to detail the what, where and why of
involved individuals. This section concludes with two tables that summarize the factors
influencing inspectors' efforts to assess and mitigate housing environmental hazards.
The Visit
The stairs wobble and creak under the weight of William’s footsteps. Snow covers the three steps
leading up to the back porch of the one-story home. The door is slightly ajar and he pushes it
open, half expecting to find the elderly homeowner inside, like he has so many times before.
To the left of him stands a monstrous four-foot tower of rubbish. The plywood beneath his feet is
damp and littered with torn flyers and paper. Tracing the cracks along the ceiling, William walks
toward the living room, lowering his head slightly to avoid cobwebs. The cool January air
follows him indoors, lingering indefinitely.
Beyond the entrance, sun fills the living room with light, illuminating a small path toward an
office chair in the middle of the room. A small space heater sits beside the chair. Stacks of
tattered phone books, empty food containers, plastic shopping bags surround the room, reaching
a height of four and five-feet in some areas. Paper layered within the stacks of rubbish are
shredded, perhaps by mice looking to nest, Williams imagines.
William walks up to one of the towers and peers into a half empty box of cereal. He jumps when
a mouse scurries across the floor in front of him. He lifts his foot to avoid pellet droppings but
his boot snags on something – a series of extension cords buried beneath paper blanketing the
floor.
Inside the kitchen, Williams notes dirty dishes pilled in the sink and across the counter. Empty
food containers are stacked at one of the counters. He writes it all in his notebook. But a noise
lures William away from the kitchen and toward a doorway leading to the basement. He
descends cautiously, mold and mildew framing the door and walls leading downstairs. In the
basement, water is gushing from a broken pipe, flowing into a drain. A small heater located
beneath the waterfall is turned on. William figures the pipe has burst because of the lack of heat
in the home. The basement appears less cluttered than the main floor but is much cooler. He
21
finds a toilet filled with feces and buckets of dark coloured ice. Williams thinks to himself, this
must be sewage. But since it is frozen, he can’t be certain.
Walking up the stairs and then outdoors, William reaches for his cellphone and calls building
control to arrange a site visit.
Hospital
John lays in bed, his eyes half closed, as Peter with his notepad, papers and plastic bag walks in
the hospital room.
Two days ago, John had asked Peter to check on the pipes in his home because the temperature
had dropped to -20C. He also wanted him to pick up a computer, radio and headphone for him.
John had signed a consent form to permit Peter to enter his house.
Now, looking at the hardware in the plastic bag, John remembers. He opens his mouth but
struggles to articulate his thoughts. Instead he jots down something on paper but to Peter, most of
it is illegible.
He takes a sip of water and clears his throat.
John left his home on a scooter a few weeks earlier, headed for the hospital. He complained to
the nurse in the emergency department he had a swollen arm. He doesn’t have a family doctor
but visits a nurse at a downtown community clinic for his primary health care needs. But John is
diabetic and has a heart disease, too. And while in hospital this time round, he suffered a stroke.
Peter places the shopping bag with computer hardware on the side table and asks John how’s
he’s doing. John says it looks like he will be relying more on his motorized scooter to get him
around. But, he realizes his home isn’t accessible. He needs to build some shelves and a ramp.
“I got all that wood to put shelving up around so make space as I keep a lot of
stuff and I will be able to move my scooter in and out with a subsidy so I will
be much better off,” he says.
John says he has managed quite fine up until his recent hospital visit. “I try to stay healthy and
do things for myself…” he says, adding he takes his scooter to the grocery store and laundromat.
As for cleaning, he doesn’t need help. He believes the last cleaning crew that came into his home
stole his metal.
“Once I get the scooter in and cabinets in, there will be big improvements.”
Peter nods and scribbles something in his notepad.
22
Family
A knock at the door interrupts the conversation between William and Liam. The door slowly
opens and a woman appears, holding what seems to be a box of chocolates. William wrinkles his
brow and looks to Liam who invites the woman in. She introduces herself as Tammy, Liam’s
sister.
More than 20 years have passed since the siblings last saw each other. During that period
Tammy received calls from the city housing department, asking if she could help convince her
brother to clean up his yard. But she didn’t even know where he was living anymore and she
didn’t have his phone number either She tried sending a birthday card one year but found it in
her mailbox a few weeks later. Last she heard, his neighbour was helping him with some yard
work and would even take him to the occasional medical appointment.
Tammy walks over to Liam and awkwardly touches his hand. She thanks William for calling her
– she received his voice message that Liam was in the hospital – and decided to purchase a bus
ticket and make the four-hour trip to visit him. She was surprised to learn how much her
brother’s health had deteriorated in the last few years. The last time she sat in the same room as
him, he was employed as an electrician, managing his diabetes well, eating healthy and living an
active lifestyle. She wonders whatever happened to his canine companion.
More
Sitting in the passenger seat, Deborah flings her wrist in an upward motion to direct the driver to
continue along the gravel road. The vehicle slows when three cats emerge from a clearing up
ahead. Deborah’s eyes brighten and she calls out the animals by their names.
The vehicle pulls up to a weathered trailer decorated with solar panels and a web of extension
cords. About six more cats appear, others crawl up from beneath the trailer. The vehicle stops
and the driver walks around to the passenger side, stopping to take something out of the trunk,
then opens Deborah’s door and hands her a cane.
A slip on the kitchen floor landed Deborah in hospital for three days. She had called an
ambulance – she didn’t have anyone else to call. The closest neighbour was about one kilometre
away. And besides, she couldn’t imagine he would respond to her plea for help. The last time he
called the cops on her, and it didn’t end well.
Deborah had told the nurses how anxious she was to return to her cats. Now, back at home, she
thanks the volunteer for the ride home. He offers his arm for support but Deborah shrugs off the
gesture. Limping, she manages to get ahead. The cats purring at her arrival, follow her indoors.
And so does the driver to ensure her safety.
The driver’s eyes widen once he steps inside the trailer. He raises his hand to his nose, to hide
the expression on his face and block the odour. He noticed barrels outside and wondered if that
was the source of the odour. Or, it could be the cat urine and feces.
23
Deborah notices his reaction and begins to explain how she is able to live off of solar energy as
funds are limited. She used the last of her savings after her husband passed away to purchase the
piece of property. She was done with city living. There was a generator. It only lasted a year.
“…and so here I am sitting with no generator and no power and then
somebody told me about solar,” she says. “So, I did a little bit of research and
I was really lucky, the guy who sold me solar panel was very well informed
and he was willing to teach me.”
Deborah pulls out a cell phone from her pocket. “I use my cell phone for everything. However, I
still have WiFi and I get Netflix, that’s my entertainment.”
She walks to a recliner in the corner of the room and sits down. Three cats jump into her lap and
she gently rubs the belly of one of them. “I just need people to stop judging me,” she says. “Yeah
my house looks like a disaster but so what? It’s my disaster but I can manage it. I am not sitting
in a food bank and I am not sitting in those little apartments freezing to death. I am not on the
street.”
The driver forces a smile and tells Deborah to have a good day. As he walks toward his car, he
takes one last look around before he reaches for his phone to call for assistance for Deborah.
Networks
Representatives from many community agencies and services typically respond to inspectors
requests for conversations about plans to service persons living in vulnerable housing. Not all
representatives have met with John, Liam, and Deborah, but they have come in contact with
similar clients. And many are repeat visits. Attendees are from the city’s bylaw department,
building services, mental health supports, police, fire and emergency services, and community
home care supports.
Inspectors share that they are not provided with training when it comes to responses to
vulnerable populations. Individual inspectors have developed relationships with clients beyond
the scope of their practise, connecting them with other agencies. Inspectors express their
willingness to mentor other inspectors and share what they have learned along the way, but there
needs to be a better coordinated response.
“…I really don’t think it’s going to get any better…” one inspector says.
Inspectors referred some clients to community and home care support but when it comes to
mental health support, they haven't had much success in clients adopting their recommendations.
Paramedics often are the first person of contact when it comes to vulnerable people.
“Because paramedics are invited into people’s homes, often when they are in a
state of an emergency, we see people as they truly live,” says one paramedic.
To help identity high risk older adults, EMS uses the clinical tool, Paramedics
assessing Elders at Risk for Independence Loss, or PERIL." But paramedics
can only do so much, he says.
24
One firefighter says he has encountered some homeowners and tenants who have accumulated so
much rubbish in their home that it becomes a fire hazard, putting everyone at risk, including the
first responders who may have to overcome physical barriers in the event of a fire.
“I really think this is a community concern,” interjected the paramedic. “I
think it should be led by the public health and perhaps the fire department and
the city and I really think we need to address it. You do not need to watch
Discovery Channel to see hoarding.”
These situations cannot be resolved by just clearing away the “stuff, says the coordinator of the
drop-in centre. She had some cases where clients had more than a dozen animals in their
possession. Simply removing the animals does little to resolve the problem because it will start
all over again, she says.
The coordinator for the drop-in centre meets with clients like John and Deborah on a daily basis,
providing housing and health care support and referrals.
“In these extreme situations, I would think the best thing for them would be to
put them in long term facility where they would have access to help for
showering, to help them with their medical needs…,” says the coordinator of
the drop-in centre.
She says someone needs to take the lead and find housing solutions for vulnerable population
and suggests the city should appoint a liaison person like it has for the elderly. Typically, what
happens, she says, is an agency will take the initiative and lead on their own. That person will
“care from the bottom of their heart and will go out of the way to help that individual….and they
do it on (their) own time.”
Everyone in the conversation focuses on the inspectors.
The following two tables provide a summary of key information shared by participants with
regards to inspectors' involvement in addressing housing environmental hazards. Resources
supportive of inspectors' practices are organized according to expertise, client attributes,
collaboration, solution-focused and additional housing resources (Table 9). Table 10 presents
multi-level challenges for inspectors to achieve positive environmental outcomes for vulnerable
cohorts.
25
Table 9
Resources facilitating inspectors' involvement in addressing housing environmental hazards
Resource
Expertise
Collaboration
Client Attributes
Solution-focused
Housing resources
Features
• Awareness of guiding mandate, legislation and policies
• Opportunities for continuing professional development
• Sharing of experience among providers
•
•
•
•
Intra-agency sharing of resources
Inter-sector sharing of information and resources
Forum such as Community Mobilization Sudbury
Liaise with multiple stakeholders
•
•
•
•
•
•
•
Access to family, friends, neighbour
Accept support for care for self and pets
Owner of property
Basic needs meet
Transportation available
Co-partner to address housing hazards
Allow entry into dwellings
•
•
•
•
•
•
Commitment/dedication of service networks
Supportive vs enforcement orientation
Strength-based to uphold clients' preferences
Advocate for and navigation of persons
Timely response to requests
Comprehensive assessments
•
•
•
•
•
Supportive landlords
Availability of shelter services
Affordable housing
Home with functional appliances and services
Housing subsidies
26
Table 10
Circumstances challenging inspectors' involvement in addressing housing environmental
hazards
Topic
Client
Housing
environment
Landlords
Service providers
Systematic
Features
•
•
•
•
•
•
Requires crisis interventions
History of chronic and multiple illnesses
Self-neglect / isolated
Lack of informal supports
History of insecure housing, hoarding
Declines services
• Unsanitary, poor air quality, lighting
• Access / egress challenges
• Unaffordable, poorly maintained
•
•
•
•
•
Offers limited information about ownership and tenants
Eviction process
Declines involvement to support tenant
Timeliness of repairs
Additional costs (e.g. financial, demanding tenants,
frequent expenses)
Clear protocols, most responsible agency
Safety and legal implications
Credibility of caller (exaggerated); repeat callers
Comprehensive follow-up
Challenging communication and coordination among
agencies
• Available resources (manpower, funds, supports for
temporary removal, training)
•
•
•
•
•
•
•
•
•
•
Stigma
Social responsibility / Human Rights
Health disparities
Equitable access to achieve health for all
Legislation
27
Forums
Inspectors, other service providers, and clients proposed numerous solutions to optimize the
environment health of private residents. These solutions were translated into 25 priorities for
potential action (Appendix C). Each priority was typed on an individual card. Attendees were
invited to rank each priority from 1 to 25, from highly possible / feasible to least possible
/feasible. At the first forum, inspects top three priorities for action were:



Improve interagency collaboration and cooperation.
Create and continually update a list of agencies, a contact person, the populations they
serve, and what service they provide.
Be able to provide seamless connections to mental health supports for clients.
Agency representatives who attended the second forum, identified their three priorities for action
as:



Create a specialized group to respond to housing health hazard calls within vulnerable
populations.
Designate a community navigator who will triage and delegate cases to appropriate
agencies.
Advocate for a streamlined procedure for placement of individuals living in hazardous
situations into long term care where appropriate.
Although the priorities are not the same between the two groups, collectively they suggest the
need for inter-sector, coordinated, partnerships among inter-professionals to structure seamless
health and social services to optimize the health of persons living in private, hazardous housing
circumstances.
28
Conclusion
Public health inspectors respond to housing complaints involving vulnerable individuals. Such
calls may be complex and require resources outside of Public Health. The purpose of this study
was to investigate response to housing health hazards involving individuals who are vulnerable.
Through this study the goal was to propose recommendations for improving such responses.
Findings from this study pointed to certain things that are working well. A consideration could
be to continue to build off of the things that are current working well, such as leveraging internal
and external expertise, furthering inter-agency collaboration, as well as focusing on findings
solutions and resources for clients. Participants shared specific recommendations which pointed
to greater collaboration between agencies. Specifically, gaining a better understanding of what
agencies have to offer and who to contact when needed and having a process to be able to
navigate clients through the system, particularly linking clients to mental health supports and\or
appropriate long term care.
29
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33
Appendix A
MEDLINE Search Protocol
Search
Search term(s)
#
1
("environmental health" adj2 practitioner).mp. [mp=title, abstract,
original title, name of substance word, subject heading word, keyword
heading word, protocol supplementary concept word, rare disease
supplementary concept word, unique identifier]
2
("environmental health" adj2 practitioners).mp. [mp=title, abstract,
original title, name of substance word, subject heading word, keyword
heading word, protocol supplementary concept word, rare disease
supplementary concept word, unique identifier]
3
("environmental health" adj2 officer).mp. [mp=title, abstract, original
title, name of substance word, subject heading word, keyword heading
word, protocol supplementary concept word, rare disease supplementary
concept word, unique identifier]
4
("environmental health" adj2 officers).mp. [mp=title, abstract, original
title, name of substance word, subject heading word, keyword heading
word, protocol supplementary concept word, rare disease supplementary
concept word, unique identifier]
5
("public health" adj2 inspector).mp. [mp=title, abstract, original title,
name of substance word, subject heading word, keyword heading word,
protocol supplementary concept word, rare disease supplementary
concept word, unique identifier]
6
("public health" adj2 inspectors).mp. [mp=title, abstract, original title,
name of substance word, subject heading word, keyword heading word,
protocol supplementary concept word, rare disease supplementary
concept word, unique identifier]
7
("public health" adj2 inspection).mp. [mp=title, abstract, original title,
name of substance word, subject heading word, keyword heading word,
protocol supplementary concept word, rare disease supplementary
concept word, unique identifier]
8
"community health practitioner".mp. [mp=title, abstract, original title,
name of substance word, subject heading word, keyword heading word,
protocol supplementary concept word, rare disease supplementary
concept word, unique identifier]
9
"community health practitioners".mp. [mp=title, abstract, original title,
name of substance word, subject heading word, keyword heading word,
protocol supplementary concept word, rare disease supplementary
concept word, unique identifier]
10
1 OR 2 OR 3 OR 4 OR 6 OR 7 OR 8 OR 9
Results
6
36
15
76
19
36
75
8
48
300
34
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
Exp administrative personnel/
Professional role/
10 OR 11 OR 12
Exp housing/
"built environment".tw
"apartment*".tw
Home*.tw
House.tw
houses.tw
tenant.tw
tentants.tw
14 OR 15 OR 15 OR 16 OR 18 OR OR 19 OR 20 OR 21
13 AND 22
exp public health/
exp "social determinants of health"/
exp environmental health/
exp health equity/
24 OR 25 OR 26 OR 27
23 AND 28
37624
10009
47031
27884
1305
1698
30820
42014
7863
137
289
102539
581
6428865
786
22552
100
6433580
307
35
Appendix B
36
37
Appendix C
Proposed solutions
Order from most [1]
feasible to least [25] feasible
Improve interagency collaboration and cooperation
Encourage decision makers of involved community services to attend
meetings where housing health hazards in vulnerable populations are
discussed so that solutions to recurring problems can be created
Locate an agency or group who can support infrastructure
improvements required to keep an individual in their own home
Be able to provide seamless connections to mental health supports for
clients
Have mental health training for public health inspectors delivering
services to vulnerable populations
Designate an internal or external navigator who will triage and
delegate cases to appropriate agencies
Educate tenants on the services provided in Sudbury to assist with
housing health concerns
Provide training about hoarding to all front line workers
Respect the wishes of clients, without judgement, who are living a
lifestyle of their own choosing and who are posing no risk to others
Create and continually update a list of agencies, a contact person, the
populations they serve, and what service they provide
Design a standardized recording form to use when investigating
housing health hazards that provides sufficient detail for follow-up
Be provided clarity on how an individual’s health (as in a vulnerable
housing situation) fits into a public health model
38
Proposed solutions
Order from most [1]
feasible to least [25] feasible
Advocate for a streamlined procedure for placement of individuals
living in hazardous situations into long term care where appropriate
Keep all cases open until an assessment can be completed and
preferably until a solution can be delivered
Have the support of by-law officers to enforce early clean-up of
hoarding situations
Create a specialized group within the health unit to respond to
housing health hazard calls within vulnerable populations
Be able to provide mental health assessments to clients in their own
homes
Have more boarding houses
Encourage landlords to periodically check on high risk clients
Advocate for finances to assist with hoarding clean-up
Establish a process for sharing basic information about clients with
the necessary community supports
Raise community awareness about what a healthy housing situation is
Advocate for subsidies for landlords to bring their units up to current
fire code (installing sprinklers)
Advocate for standards for boarding houses
Adopt a scale that measures hoarding
39