ArticlePDF Available

Quality of Life and Mental Well-Being: A Gendered Analysis of Persons Experiencing Homelessness in Canada



Homelessness has negative implications for mental well-being and quality of life. This paper identifies the quality of life variables that contribute to positive or negative wellbeing, reporting on a regression analysis from 343 individuals experiencing homelessness in Canada. Results indicate that a lack of sleep duration and quality reduced mental well-being for both genders, not having access to food and/or hygiene facilities decreased men’s well-being, and engaging in illegal subsistence strategies, such as selling drugs, negatively impacted women’s mental well-being. For persons experiencing homelessness, mental well-being and quality-of-life are gendered outcomes of their limited access to social determinants of health.
1 3
Community Mental Health Journal
Quality ofLife andMental Well‑Being: AGendered Analysis ofPersons
Experiencing Homelessness inCanada
KristyBuccieri1 · AbramOudshoorn2· JeannetteWaegemakersSchi3 · BernadettePauly4 · RebeccaSchi5 ·
Received: 10 July 2018 / Accepted: 26 February 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Homelessness has negative implications for mental well-being and quality of life. This paper identifies the quality of life
variables that contribute to positive or negative wellbeing, reporting on a regression analysis from 343 individuals experienc-
ing homelessness in Canada. Results indicate that a lack of sleep duration and quality reduced mental well-being for both
genders, not having access to food and/or hygiene facilities decreased men’s well-being, and engaging in illegal subsistence
strategies, such as selling drugs, negatively impacted women’s mental well-being. For persons experiencing homelessness,
mental well-being and quality-of-life are gendered outcomes of their limited access to social determinants of health.
Keywords Homelessness· Quality of life· Mental well-being· Social determinants of health· Gender· Canada
Mental well-being and quality of life are related concepts.
According to the World Health Organization (WHO), qual-
ity of life is a subjective evaluation of well-being that can
be grouped into the 4 domains of one’s physical health,
psychological state, social relationships, and environment
(WHO Quality of Life [QOL] Group 1995, 1998a, b). It is
well recognized that living in poverty and/or experiencing
homelessness have negative implications for mental well-
being (Kertesz etal. 2005) and for quality of life (Lam and
Rosenheck 2000) but the inter-relation between these factors
is not presently clear. In this paper we conduct a regression
analysis to identify the individual variables that are related
to mental well-being and quality of life for those experi-
encing homelessness. Given that gender has been found to
impact experiences of homelessness (Montgomery etal.
2017; Wachter etal. 2015; Winetrobe etal. 2017) we also
incorporate gender as a grouping variable in each analysis.
Our intent is to identify the specific significant interactions
between mental well-being and quality of life variables,
and to determine the directionality of these relationships
using the WHO Quality of Life domains as a conceptual
* Kristy Buccieri
Abram Oudshoorn
Jeannette Waegemakers Schiff
Bernadette Pauly
Rebecca Schiff
Stephen Gaetz
1 Department ofSociology, Trent University, 1600 West Bank
Dr, Peterborough, ONK9L0G2, Canada
2 Arthur Labatt Family School ofNursing, Western University,
Room 3344 FNB, London, ONN6A5B9, Canada
3 Faculty ofSocial Work, University ofCalgary, Professional
Faculties 4242, 2500 University Drive NW, Calgary,
ABT2N1N4, Canada
4 Canadian Institute forSubstance Use Research, University
ofVictoria, Technology Enterprise Facility Room 273,
Victoria, BCV8P5C2, Canada
5 Health Sciences, Lakehead University, SN 1006B, 955 Oliver
Rd, ThunderBay, ONP7B5E1, Canada
6 Faculty ofEducation, York University, 631 York Research
Tower, Keele Campus, 4700 Keele Street, Toronto,
ONM3J1P3, Canada
Community Mental Health Journal
1 3
Literature Review
Amongst vulnerable populations gender has been found to
be a significant factor in subjective well-being, with males
reporting theirs to be significantly better than females
(Tomyn etal. 2015). The WHO (2004) recognizes gender
as a factor that influences how much control individuals
have over the determinants of their health, which in turn
impacts mental well-being and also a person’s quality of
life. Gender differences have been noted across each of the
4 quality of life domains identified by the WHO (Quality
of Life Group 1995, 1998a, b).
The first domain, physical health, has gendered impli-
cations for those experiencing homelessness. Living in
poverty is a well-documented social determinant that
contributes to poor health (Bryant etal. 2011; Marmot
etal. 2008; Okulicz-Kozaryn 2015). Women who experi-
ence homelessness, in particular, have comparatively more
chronic physical health conditions than their male coun-
terparts (Winetrobe etal. 2017) and additional challenges
accessing sexual health care (Corey etal. 2017; Oliver
and Cheff 2012). Young women experiencing homeless-
ness are also less likely than their male counterparts to
report condom use, but are more likely to be diagnosed
with a sexually transmitted infection and have a sex part-
ner who uses injection drugs (Valente and Auerswald
2013). Additionally, sleep disturbances are a commonly
linked health concern to homelessness (Chang etal. 2015;
Reitzel etal. 2017; Taylor etal. 2019) and studies of the
general population suggest gendered differences exist in
sleep patterns (Röösli etal. 2014) that begin at the onset
of puberty with changes in the hormonal cycle (Krishnan
and Collop 2006).
The second quality of life domain, psychological state,
closely aligns with the concept of mental well-being
and shows gendered differences for persons experienc-
ing homelessness. There is a known association between
social inequity and increased risk of mental health disor-
ders (WHO and Calouste Gulbenkian Foundation 2014).
Compared to the general Canadian population, women
who experience homelessness have substantially higher
prevalence rates of mental disorders (Strehlau etal. 2012)
and women in shelters have reported experiencing ‘dark
thoughts’ that emerge from feelings of resentment, pow-
erlessness, and marginalization (Grabbe etal. 2013). Men
who experience homelessness may struggle with gender
role conflict, such as not expressing emotions, resulting
in higher levels of psychological distress and resistance
to seeking mental health supports (Nguyen etal. 2012).
The third quality of life domain, social relationships,
also has clear gender differences for men and women
experiencing homelessness. Feeling socially excluded is
common for individuals experiencing homelessness (Hali-
fax etal. 2008) and is linked to broader mental well-being
themes of not having choice, stability, respect, and the
same rights as others in society (Palepu etal. 2012). Men
who experience homelessness, in particular, may be per-
ceived by the public as dangerous and requiring social
distance (Markowitz and Syverson 2019). Conversely
women who experience homelessness may seek out social
networks for protection, such as from men on the street
(Watson 2016).
The final quality of life domain, one’s environment, is par-
ticularly relevant in terms of gender differences in housing.
Research shows that men are more likely to be unsheltered
than women, but that the risk of being unsheltered increases
for women associated with substance use and for men associ-
ated with mental illness (Montgomery etal. 2017). Lack of
housing is a clear structural barrier to well-being (Rae and
Rees 2015) and Housing First placements have been shown
to improve quality of life (Patterson etal. 2013). However,
housing is not the only environmental consideration in well-
being and quality of life. Engagement in street activity, such
as illegal income generation, has gender differences (Ferguson
etal. 2015), and predictors for multiple arrest also vary by
gender, including exposure to drug culture as significant for
males and drug distribution as significant for females (Wachter
etal. 2015).
While it is clear that the quality of life domains all show
gender differences, it is not presently clear which variables are
most significantly involved and how they inter-relate to one
another within and across domains. In this paper we report
on a gendered analysis guided by the research question: what
quality of life variables significantly impact mental well-
being for women and for men who experience homelessness
in Canada? By a gendered analysis, we mean that gender is
used as a selection variable in all of the analyses, allowing us
to observe potential gender-based differences. We begin by
discussing the World Health Organization Quality of Life scale
[WHOQOL-100], which was not administered directly but
rather used retroactively to organize the categories of analysis;
Sect.3.3 below provides specific details on how our survey
variables were grouped using the WHOQOL-100 as a concep-
tual framework. We then present the results and conclude with
a discussion of how the findings have practical implications for
increasing quality of life and mental well-being for Canadians
who experience homelessness.
Data were collected as part of a multi-site study on human-
acquired influenza (H1N1) in the context of homelessness
Community Mental Health Journal
1 3
in Canada (Buccieri and Schiff 2016). A project total of 343
surveys were administered between 2010 and 2011 in the
4 Canadian cities of Calgary, Regina, Toronto, and Victo-
ria. Participants included individuals who self-identified as
experiencing homelessness at the time of the study, includ-
ing 105 women and 238 men. Female participants ranged in
age from 16 to 64 [35 mean, 11.96 SD], 41.2% were visible
minorities, 51.5% were Indigenous, and 19% identified as
queer. Male participants ranged from 18 to 75 [40.27 mean,
13.38 SD], 27.3% were visible minorities, 26.3% were
Indigenous, and 7.5% were queer. A convenience sampling
method was used in each city and participants were recruited
through social service agencies. A standard survey was used
across all sites. Each participant received $20 remuneration.
Ethics approval was obtained by the authors’ institutions in
all 4 sites.
Mental Well‑Being Variables
According to the WHO (2004), beliefs such as optimism,
personal control, and a sense of meaning are known to be
protective of mental well-being, whereas feelings of insecu-
rity and hopelessness can lead to greater vulnerability and
disadvantaged states. For this analysis, 4 dependent vari-
ables were identified as indicators of positive mental well-
being. Items were based on self-reports from the 30days
preceding the survey and included feeling relaxed, enjoying
life, being hopeful about the future, and feeling happy. Four
dependent variables were identified as indicators of negative
mental well-being. These variables were also based on self-
reports from the 30days preceding the survey and included
feeling very stressed, being lonely, feeling depressed, and
feeling unsafe.
Quality ofLife Variables
Quality of life was assessed through a series of independ-
ent variables that were grouped into categories, within the
4 domains established by WHOQOL Group (1998b); these
included: physical health, psychological state, social rela-
tionships, and environment. These domains are part of the
WHOQOL-100, which is a cross-culturally validated assess-
ment developed by the WHOQOL Group (1998a). Quality
of life assessments, “not only measure mental health but
also usually contain items and domains that directly probe
aspects of mental health” (WHO 2004). While our team did
not administer the WHOQOL-100 or incorporate all items,
the following analysis is informed by its structure and uses
its 4 domains for classification of our independent variables.
All variables were self-reported.
The physical health domain incorporates 4 measures from
our survey that align with the WHOQOL-100, including
sleep and rest, energy and fatigue, mobility, and activities
of daily living. The latter two measures are combined into 1
category, as research has shown that mobility is a large fac-
tor in the daily activities of individuals experiencing home-
lessness in order to meet their subsistence needs (Watson
etal. 2016). Three additional measures are included from
our survey that are not part of the WHOQOL-100 assess-
ment but are important factors in the quality of life of per-
sons experiencing homelessness. These include self-reported
health, age, and meal frequency.
The psychological domain includes the positive feelings
and negative feelings measures from the WHOQOL-100
assessment. The variables in this domain were described
above but are included as independent variables to ascer-
tain the relationship between the psychological domain and
well-being. Positive feelings included 4 positive mental
well-being items. Participants in our survey reported how
often they felt relaxed, happy, hopeful about the future, or
enjoyed life. Negative feelings included 4 negative mental
well-being items. Participants in our survey reported how
often they felt stressed, unsafe, lonely, or depressed.
The social relationships domain includes personal rela-
tionships and social support from the WHOQOL-100. Per-
sonal relationships included 3 items. Participants in our sur-
vey reported the frequency they were by themselves, with
close friends, or with their partner. Social support included 8
items. Participants in our survey also reported the frequency
in the preceding month they slept, spent the day, or ate in
overcrowded places, how often they were able to wash their
hands or clothes, and how often they could eat on a clean
surface, take a shower, or brush their teeth.
The environment domain incorporates 4 measures from
the WHOQOL-100, including physical safety and security,
home environment, financial resources, and health/social
care. Physical safety and security included 8 items from our
survey. Participants reported in the preceding 12months the
frequency they came into contact with police as a victim of
crime, witness to crime, when police stopped to help them,
when making money (such as panhandling or squeegeeing),
being arrested, asked to move on, given a ticket, asked for
identification, or because of being homeless. Home environ-
ment/accommodations included 8 items from our survey.
Participants reported in the past month how many times they
had stayed in a homeless shelter, squat, park, on the streets,
their own house or apartment, a friends’ house or apartment,
hostel, transitional housing, motel/hotel, jail, or hospital.
Financial resources included 11 items from our survey. Par-
ticipants reported how many times in the preceding month
they earned money from panhandling, squeegeeing, sex
trade, theft/B&E/jacking, selling drugs, selling stolen goods,
bottle picking, research studies, doing odd jobs, scamming,
or selling their belongings. Health and social care included 8
items from our survey. Participants reported how often in the
preceding month they got meals from a shelter, soup kitchen
Community Mental Health Journal
1 3
or food bank, drop-in centre, mobile van, a friend, a stranger,
buying it themselves, or from bins outside restaurants.
Gender was used as a selection variable in all analyses. A
binary division was used, as only 1.1% of the sample iden-
tified as transgender and all others identified as female or
male. For this analysis, given the small size, transgender
participants were excluded. Linear regression analysis
was conducted for each independent and dependent vari-
able combination. Where a Beta score of 0.300 or greater
was observed, with significance α < 0.05, reciprocal linear
regression analysis was conducted by inverting the depend-
ent and independent variables. This was done to determine
whether there was a one-way or reciprocal significant rela-
tionship between mental well-being and quality of life vari-
ables. Statistical analysis was conducted using SPSS version
The quality of life factors that interacted with women’s nega-
tive mental well-being variables were examined first; num-
bers represent β values that are significant at α < 0.05, with
directionality of the relationship indicated as appropriate.
Within the physical health domain, women reported stress
was reciprocally related to poor sleep (0.451), not enough
sleep (0.402), talking less than usual (0.342), having noth-
ing to do (0.424), and their overall health (0.321). Stress for
women also resulted from being the victim of crime (0.307)
and being in jail (0.422), both within the environmental
domain. For women, feeling lonely was reciprocally related
to poor sleep (0.500), not enough sleep (0.515), talking less
than usual (0.444), not feeling like eating (0.349), and also
resulted from having nothing to do (0.514). Environmental
domain factors such as being in jail (0.434), selling drugs
(0.311), scamming (0.715), and selling possessions (0.559)
contributed to loneliness in women. Feelings of depression
for women reciprocally resulted from poor sleep (0.556),
not enough sleep (0.612), talking less than usual (0.446),
not feeling like eating (0.377), having nothing to do (0.509),
and overall health (0.401). In the psychological domain not
feeling happy was significantly related to feeling depressed
(0.322). Women identified several physical health domain
variables that made them feel unsafe, including poor sleep
(0.478), not enough sleep (0.302), talking less than usual
(0.356), having nothing to do (0.408), spending the day-
time in the park (0.323), and their overall health (0.421).
For women, not being able to shower was associated with
feeling unsafe (0.460) in the social relationships domain.
Feeling unsafe was related to a number of environmental
domain factors for women, including being the victim of
crime (0.410), witness to crime (0.873), being arrested
(0.425), being asked for ID (0.318), stopped by police for
being homeless (0.374), being on the street (0.333), and
being in jail (0.626).
The quality of life variables that improve women’s mental
well-being were examined next, but few were found to be
significant. Women reported that feeling relaxed was related
to environmental domain factors, such as having police stop
to offer help (0.529) and being involved in research studies
(0.594). Enjoying life was related to having good quality
sleep (0.480), having something to do (0.322), eating sup-
per (0.365), not feeling stressed (0.331), and having police
stop to offer help (0.497). Feeling happy was related to hav-
ing good quality sleep (0.350), eating supper (0.335), hav-
ing police stop to offer help (0.488), and being involved in
research studies (0.471). No variables significantly contrib-
uted to women’s sense of hopefulness about the future.
The quality of life variables that decrease men’s mental
well-being were examined next. Within the physical health
domain stress was reciprocally linked to poor sleep (0.603),
not enough sleep (0.531), talking less than usual (0.335),
not feeling like eating (0.428), and uni-directionally with
having gone without food (0.381). Stress was also recipro-
cally related to psychological domain factors of not feeling
relaxed (0.389), not feeling happy (0.369), and not enjoy-
ing life (0.327). Men indicated that in the environmental
domain, scamming to earn money was a source of stress
(0.420). Men reciprocally related loneliness to poor sleep
(0.464), not enough sleep (0.430), talking less than usual
(0.395), not feeling like eating (0.385), and uni-directionally
to having gone without food (0.305). In the environmen-
tal domain, men identified participating in research studies
(0.351) as a factor that decreased their loneliness. Feeling
a sense of depression was reciprocally related to poor sleep
(0.448), not enough sleep (0.404), talking less than usual
(0.380), not feeling like eating (0.341), and uni-direction-
ally to having gone without food (0.323). For men, in the
psychological domain, depression was reciprocally related
to not feeling happy (0.333) and not enjoying life (0.344),
and in the environmental domain depression was related to
scamming for income (0.402). Feeling unsafe for men was
related to poor sleep (0.413), talking less than usual (0.315),
not feeling like eating (0.346), having gone without food
(0.389), not having clean water (0.319), not feeling happy
(0.361), and reciprocally to not enough sleep (0.382).
Finally, the quality of life variables that improved men’s
mental well-being were examined. Relaxation was related to
physical domain factors such as good quality sleep (0.392),
getting enough sleep (0.346), being in good health (0.344),
eating breakfast (0.319), eating lunch (0.383), eating supper
(0.441), and having a snack during the day (0.352). Relaxa-
tion was also related to the psychological domain factors of
Community Mental Health Journal
1 3
feeling safe (0.335), not feeling lonely (0.314), not feeling
depressed (0.408), and reciprocally with not feeling stressed
(0.482). Within the social domain, relaxation for men was
related to washing their hands (0.409), eating on a clean
surface (0.361), taking a shower (0.384), and brushing their
teeth (0.343). Within the environmental domain, relaxation
was related to not being stopped by police and offered help
(0.344), not staying in a squat (0.352) or park (0.511), and
not selling stolen goods for money (0.488). Enjoyment of
life was related to good quality sleep (0.366), good health
(0.330), eating lunch (0.386), and reciprocally to eating
breakfast (0.304) and supper (0.504), and not going with-
out food (0.394). Enjoying life was related to the psycho-
logical domain factors of not feeling depressed (0.415) and
reciprocally to not feeling very stressed (0.347); under the
social relationships domain enjoyment of life was related to
being able to wash one’s hands (0.362). Men’s hopefulness
was related to physical health and environmental domains,
including good quality sleep (0.301), eating lunch (0.316),
eating supper (0.411), not being asked to move on by the
police (0.301), and not sleeping in a park (0.386), on the
street (0.331), or in the hospital (0.427). Men’s sense of hap-
piness was related to good quality sleep (0.321), good health
(0.301), and reciprocally to eating lunch (0.383) and supper
(0.511) under the physical health domain. Men’s happiness
was reciprocally related to not feeling very stressed (0.340)
and not feeling depressed (0.355) under the psychological
domain, washing their hands (0.387) and brushing their teeth
(0.301) under the social relationships domain, and not sleep-
ing in a park (0.312) or on the street (0.308), and not scam-
ming for money (0.372) under the environmental domain.
Poor sleep quality and duration are significantly related to
homelessness (Chang etal. 2015; Taylor etal. 2019) and
among the general population women report higher sleep
disturbances (Krishnan and Collop 2006). In this study we
examined sleep quality and whether individuals experi-
enced difficulty getting enough sleep as separate variables.
Both variables were central to negative mental well-being
experienced by women and men; this is a finding that sup-
ports other recent conclusions about the link between lack
of sleep and poor physical and mental health for persons
experiencing homelessness (Reitzel etal. 2017). Poor sleep
quality led women to enjoy life less and feel less happy; it
also decreased men’s sense of relaxation, hopefulness, hap-
piness, and enjoyment of life. For women and men, poor
sleep had a reciprocal relationship with stress, loneliness,
and depression, and also led both to feel unsafe. The places
where women and men sleep are also important factors in
their mental well-being. For women, spending the night in
jail led to stress, loneliness, and feeling unsafe. For men,
sleeping in a park reduced relaxation, hopefulness, and hap-
piness. Poor sleep quality and trouble getting sleep were sig-
nificant variables to negative mental well-being for women
and men. Implementing approaches that improve sleep
duration and quality could be the most important recom-
mendation in promoting the well-being of women and men
experiencing homelessness. Development of permanent and
affordable housing options are needed (Patterson etal. 2013)
to ensure individuals have a safe, secure, and private place
in which to sleep.
The link between poverty and poor health is clearly estab-
lished in the literature (Bryant etal. 2011; Marmot etal.
2008; Okulicz-Kozaryn 2015). In this study, having poor
health led women to feel stressed and unsafe, and had a
reciprocal relationship with depression. Men who reported
being in poor health also reported higher levels of depres-
sion. For men, improved health contributed to enjoying life,
feeling relaxed, and being happy. These links suggest that
physical health may be an underlying factor in negative
mental well-being for women and men. When working with
patients, health care practitioners must recognize the inter-
play between emotions and health, such that negative emo-
tions can be detrimental to one’s mental and physical health.
For those who experience homelessness, the struggle
to find food can lead to a lack of dignity associated with
mealtimes (Watson etal. 2016). Women and men both
reported that not feeling like eating was reciprocally related
to depression; men also reported not feeling like eating was
reciprocally related to stress and loneliness. Not eating may
be indicative that a person is feeling poorly but given the
reciprocal nature, encouraging a person who is depressed,
stressed, or lonely to eat when food is available may help to
alleviate their symptoms. Having regular access to food was
particularly important to the emotional well-being of men,
for whom going without food was linked to stress, lone-
liness, decreased life enjoyment, and feeling unsafe. Con-
versely, drinking clean water and eating breakfast, lunch,
supper, and a daytime snack were all related to positive men-
tal outcomes for men. For women, eating supper was the
only significant factor leading to greater enjoyment of life.
Ensuring food and clean water is readily accessible through-
out the day is key to improving the mental well-being of
individuals experiencing homelessness.
Women and men both reported that when they felt
stressed, lonely, or depressed they talked less and that talk-
ing less in turn increased their feelings of stress, loneliness,
or depression. This lack of self-expression may be indicative
of social exclusion (Markowitz and Syverson 2019; Palepu
etal. 2012). Talking less than usual may be an indicator that
a person is experiencing these negative feelings and, given
their reciprocal nature, actively engaging that person in con-
versation may help improve feelings of stress, loneliness,
Community Mental Health Journal
1 3
or depression. This lends support for relationship-based
practices in health and social care with people experiencing
homelessness (Kahan etal. 2019). Additionally, for women,
not feeling like doing anything increased stress and depres-
sion, which in turn reinforced not wanting to do anything.
Doing nothing further led women to feel lonely, unsafe, and
less joyful. These findings challenge the common neoliberal
discourse that portrays individuals who experience home-
lessness as lazy or not wanting to work. These findings sup-
port a contrary view, that not being active is part of a cycle
that creates and reinforces negative emotional experiences.
Women identified very few psychological quality of life
variables that improved their mental well-being, which is
perhaps not surprising given women report higher rates of
mental disorders (Strehlau etal. 2012) and ‘dark thoughts’
(Grabbe etal. 2013). Men, however, showed a dichoto-
mous relationship between the positive feelings and nega-
tive feelings variables, such that a decrease in one led to an
increase in the other. This effect was observed in the recip-
rocal relationships men reported between several variables,
such as increased happiness resulting from less stress, and
depression leading to less happiness. Men’s positive emo-
tional states were more closely tied to an absence of nega-
tive emotional states (and vice versa) than was reported
by women. This suggests that one approach to improving
men’s emotional well-being may be to address the factors
that contribute to their negative experiences, which could
have particular benefits for men who struggle with gender
role conflict and avoid seeking out mental health supports
(Nguyen etal. 2012). Opportunities to engage in hygienic
maintenance were also particularly important for men’s
emotional well-being. Specifically, showering or eating on a
clean surface contributed to men’s relaxation; brushing their
teeth promoted relaxation and happiness; and washing their
hands led to relaxation, happiness, and greater enjoyment
of life. Having access to private and secure bathing facili-
ties could contribute to enhanced emotional well-being of
individuals experiencing homeless, with particular benefits
for men.
Subsistence strategies on the street, including illegal
income generation, have been shown to be gendered (Fer-
guson etal. 2015). For women in this study, money-making
activities that involved negative encounters, such as selling
drugs, their own possessions, or scamming, increased their
sense of loneliness. Selling drugs has also been found to
increase chances of multiple arrests for women (Wachter
etal. 2015). Men who scammed felt more stressed and
depressed. Earning money in these ways was detrimental to
women’s and men’s emotional well-being, but both benefited
from involvement in research studies (women were more
relaxed and happy; men were less lonely). Engaging indi-
viduals with lived experience of homelessness in research
studies, and potentially as peer researchers, could be one
form among others of creating opportunities to earn money
in a way that promotes mental well-being while decreasing
the need for other money-making pursuits. An additional
benefit of providing alternative income sources is that it may
reduce police encounters. Women could particularly benefit
from having less negative police encounters, such as being
arrested or asked for identification, which led them to feel
unsafe. However, police should be encouraged to stop and
offer help to women who might be experiencing homeless-
ness, as these positive encounters reportedly led women to
enjoy life more, feel more relaxed, and be happier.
The data were collected through self-reports and not exter-
nally verified for accuracy. This research was conducted in
the 4 diverse Canadian cities. Further analysis would be
needed to determine whether the locations, or other demo-
graphic factors, affected participant responses. It is noted
that the demographic characteristics show women were
younger, and comprised of more visible minority, Indige-
nous, and LGBTQ respondents. It is unknown whether these
demographics impacted women’s reporting of quality of life
and mental well-being. Additionally, as previously noted,
we used a gender binary of ‘man’ or ‘woman;’ although
‘transgender’ was provided, few respondents selected this
option and the binary may not accurately reflect all partici-
pants’ gender-identities.
There were also limitations in the methodology and anal-
ysis used. While the literature indicates that substance use
is linked to decreased quality of life and mental well-being
(Kertesz etal. 2005; Lam and Rosenheck 2000), our data on
substance use was not thorough enough to include it as a var-
iable in this study. Additionally, because we relied on self-
reporting, the use of ‘depression’ as a variable reflected each
participant’s feelings and not a clinical diagnosis. Finally,
the WHOQOL-100 was not administered to participants but
rather used retroactively as a typology for organizing data. It
is unknown how the results may have differed had the instru-
ment been administered.
We have reported on a gendered analysis of women and men
experiencing homelessness in Canada, using the 4 quality of
life domains of physical health, psychological state, social
relationships, and environment as a conceptual typology.
Health inequity is evident in this research, through the emer-
gence of poor sleep, lack of regular access to food, and lim-
ited economic opportunities as sources of decreased mental
well-being and quality of life. Although homelessness is
related to negative mental well-being, the significant quality
Community Mental Health Journal
1 3
of life variables were different for women and men. Our
analysis strongly supports treating gender as an additional
layer of health inequity that must be considered in concert
with other social determinants of health and well-being.
Funding This study was funded by the Canadian Institutes of Health
Research Planning and Dissemination Grant (Grant 201408PDI)
“Pandemic Preparedness: Knowledge Translation in the Ontario
Homelessness Sector” to Kristy Buccieri. This study was funded by
the Canadian Institutes of Health Research (Grant 200904PAP-203559-
PAM-CEPA-119142), “Understanding Pandemic Preparedness in the
Context of the Canadian Homelessness Crisis” to Stephen Gaetz. This
study was funded by the Canadian Institutes of Health Research (Grant
20100H1N-218568-H1N-CEPA-119142) “Responding to H1N1 in the
Context of Homelessness in Canada” to Stephen Gaetz.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
Bryant, T., Raphael, D., Schrecker, T., & Labonte, R. (2011). Canada:
A land of missed opportunity for addressing the social determi-
nants of health. Health Policy, 101(1), 44–58.
Buccieri, K. & Schiff, R. (Eds.) (2016). Pandemic preparedness and
homelessness: Lessons from H1N1 in Canada. Toronto, ON:
Canadian Observatory on Homelessness Press.
Chang, H. L., Fisher, F. D., Reitzel, L. R., Kendzor, D. E., Nguyen, M.
A. H., & Businelle, M. S. (2015). Subjective sleep inadequacy
and self-rated health among homeless adults. American Journal
of Health Behavior, 39(1), 14–21.
Corey, E. K., Frazin, S., Heywood, S., & Haider, S. (2017). Homeless
women’s desire for and barriers to obtaining effective contracep-
tion. Contraception, 96(4), 287.
Ferguson, K. M., Bender, K., & Thompson, S. J. (2015). Gender, cop-
ing strategies, homelessness stressors, and income generation
among homeless young adults in three cities. Social Science &
Medicine, 135, 47–55.
Grabbe, L., Ball, J., & Goldstein, A. (2013). Gardening for the men-
tal well-being of homeless women. Journal of Holistic Nursing,
31(4), 258–266.
Halifax, N. V. D., Yurichuk, F., Meeks, J., etal. (2008). Photovoice
in a Toronto community partnership: Exploring the social deter-
minants of health with homeless people. Progress in Commu-
nity Health Partnerships: Research, Education, and Action, 2(2),
Kahan, D., Lamanna, D., Rajakulendran, T., Noble, A., & Stergio-
poulos, V. (2019). Implementing a trauma-informed intervention
for homeless female survivors of gender-based violence: Lessons
learned in a large Canadian urban centre. Health and Social Care
in the Community. https :// .
Kertesz, S. G., Larson, M. J., Horton, N. J., Winter, M., Saitz, R.,
& Samet, J. H. (2005). Homeless chronicity and health-related
quality of life trajectories among adults with addictions. Medical
Care, 43(6), 574–585.
Krishnan, V., & Collop, N. A. (2006). Gender differences in sleep dis-
orders. Current Opinion in Pulmonary Medicine, 12(6), 383–389.
Lam, J. A., & Rosenheck, R. A. (2000). Correlates of improvement
in quality of life among homeless persons with serious mental
illness. Psychiatric Services, 51(1), 116–118.
Markowitz, F. E., & Syverson, J. (2019). Race, gender, and home-
lessness stigma: Effects of perceived blameworthiness and dan-
gerousness. Deviant Behavior. https ://
625.2019.17061 40.
Marmot, M., Friel, S., Bell, R., Houweling, T. A., & Taylor, S.
(2008). Closing the gap in a generation: Health equity through
action on the social determinants of health. The Lancet,
372(9650), 1661–1669.
Montgomery, A. E., Szymkowiak, D., & Culhane, D. (2017). Gen-
der differences in factors associated with unsheltered status and
increased risk of premature mortality among individuals experi-
encing homelessness. Women’s Health Issues, 27(3), 256–263.
Nguyen, C. M., Liu, W. M., Hernandez, J. O., & Stinson, R. (2012).
Problem-solving appraisal, gender role conflict, help-seeking
behavior, and psychological distress among men who are home-
less. Psychology of Men & Masculinity, 13(3), 270–282.
Okulicz-Kozaryn, A. (2015). Income inequality and wellbeing.
Applied Research in Quality of Life, 10(3), 405–418.
Oliver, V., & Cheff, R. (2012). Sexual health: The role of sexual
health services among homeless young women living in
Toronto, Canada. Health Promotion Practice, 13(3), 370–377.
Palepu, A., Hubley, A. M., Russell, L. B., Gadermann, A. M., &
Chinni, M. (2012). Quality of life themes in Canadian adults
and street youth who are homeless or hard-to-house: A multi-
site focus group study. Health Qual Life Outcomes, 10, 93.
Patterson, M., Moniruzzaman, A., Palepu, A., Zabkiewicz, D.,
Frankish, C. J., Krausz, M., etal. (2013). Housing first improves
subjective quality of life among homeless adults with mental
illness: 12-month findings from a randomized controlled trial in
Vancouver, British Columbia. Social Psychiatry and Psychiatric
Epidemiology, 48(8), 1245–1259.
Rae, B. E., & Rees, S. (2015). The perceptions of homeless people
regarding their healthcare needs and experiences of receiving
health care. Journal of Advanced Nursing, 71(9), 2096–2107.
Reitzel, L., Short, N., Schmidt, N., Garey, L., Zvolensky, M. J., Moi-
siuc, A., etal. (2017). Distress tolerance links sleep problems
with stress and health in homeless. American Journal of Health
Behavior, 41(6), 760–774.
Röösli, M., Mohler, E., Frei, P., & Vienneau, D. (2014). Noise-
related sleep disturbances: Does gender matter? Noise Health,
16, 197–204.
Strehlau, V., Torchalla, I., Kathy, L., Schuetz, C., & Krausz, M.
(2012). Mental health, concurrent disorders, and health care
utilization in homeless women. Journal of Psychiatric Practice,
18(5), 349–360.
Taylor, A., Murillo, R., Businelle, M. S., Chen, T. A., Kendzor, D.
E., & McNeill, L. H. (2019). Physical activity and sleep prob-
lems in homeless adults. PLoS ONE. https ://
journ al.pone.02188 70.
Tomyn, A. J., Cummins, R. A., & Norrish, J. M. (2015). The sub-
jective wellbeing of ‘at-risk’ Indigenous and Non-Indigenous
Australian adolescents. Journal of Happiness Studies, 16(4),
Valente, A. M., & Auerswald, C. L. (2013). Gender differences in sex-
ual risk and sexually transmitted infections correlate with gender
differences in social networks among San Francisco homeless
youth. Journal of Adolescent Health, 53, 486–491.
Wachter, K., Thompson, S. J., Bender, K., & Ferguson, K. (2015). Pre-
dictors of multiple arrests among homeless young adults: Gender
differences. Children and Youth Services Review, 49, 32–38.
Watson, J. (2016). Gender-based violence and young homeless women:
Femininity, embodiment and vicarious physical capital. The Soci-
ological Review, 64, 256–273.
Community Mental Health Journal
1 3
Watson, J., Crawley, J., & Kane, D. (2016). Social exclusion, health and
hidden homelessness. Public Health, 139, 96–102.
Winetrobe, H., Wenzel, S., Rhoades, H., Henwood, B., Rice, E., & Har-
ris, T. (2017). Differences in health and social support between
homeless men and women entering permanent supportive hous-
ing. Womens Health Issues, 27(3), 286–293.
World Health Organization. (2004). Promoting mental health: Con-
cepts, emerging evidence, practice. Summary report. Geneva:
World Health Organization.
World Health Organization and Calouste Gulbenkian Foundation.
(2014). Social determinants of mental health. Geneva: World
Health Organization.
World Health Organization Quality of Life Group. (1995). The World
Health Organization Quality of Life assessment (WHOQOL):
Position paper from the World Health Organization. Social Sci-
ence and Medicine, 41, 1403–1409.
World Health Organization Quality of Life Group. (1998a). Develop-
ment of the World Health Organization WHOQOL-BRIEF quality
of life instrument. Psychological Medicine, 28(3), 551–558.
World Health Organization Quality of Life Group. (1998b). The World
Health Organization Quality of Life assessment (WHOQOL):
Development and general psychometric properties. Social Sci-
ence and Medicine, 46(12), 1569–1585.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
... The concept of hybrid Sufism also include achieving quality of life. They include four indicators: (1) physical health, (2) mental state, (3) good social relations and (4) harmony with nature (environment) (Buccieri et al. 2020). There are three important things in reassessing the quality of life, namely honesty, fairness and grateful (Smedema 2020). ...
Full-text available
Sufism has two main dimensions: vertical (God’s pleasure) and horizontal (harmony with nature, society and local wisdom). In reality, many Sufis are considered less concerned about the balancing between vertical and horizontal dimensions. The research explores the concepts and practices of hybrid Sufism undertaken by Kyais (religious leaders) and their followers in improving quality of life. Ethnography was used for exploring the mindset and activities of Kyai and his followers. This study involved four Kyais in Java and Kalimantan, Indonesia. Research data were obtained through participant observations, in-depth interviews and documentation. The data were analysed by Spadley’s ethnographic steps as follows: (1) domain analysis, (2) taxonomy analysis, (3) componential analysis and (4) cultural-thematic analysis. The results showed that hybrid Sufism could improve quality of life. Hybrid Sufism can better appreciate and interpret local wisdom with an attitude of preserving nature and a positive understanding of worldly wealth, increasing the hard work ethos to achieve material–spiritual qualities. Contribution: This article shows that hybrid Sufism encourages the life of Sufis in harmony between vertical and horizontal aspects. This understanding and lifestyle give rise to respect for others, being friendly to the environment and interpreting life and local wisdom.
... Comparatively less is known about the subjective quality of life (SQoL) of homeless and vulnerably housed individuals . The limited research on SQoL in individuals who are homeless has found that they tend to report lower SQoL compared to the general population or housed individuals (Buccieri et al., 2020;Hubley et al., 2014;van der Laan et al., 2017). Previous studies on homelessness have typically focused more narrowly on a specific dimension of SQoL, namely health-related quality of life or subjective functional health status (Gadermann et al., 2014;Hubley et al., 2014;Sarajlija et al., 2014;Sun et al., 2012). ...
Full-text available
Purpose Much of the extant research on quality-of-life (QoL) in homelessness has focused narrowly on health-related QoL. Far less is known about broader subjective quality-of-life (SQoL). The purpose of this study was to examine levels and predictors of SQoL among homeless and vulnerably housed individuals in a 4-year longitudinal study. Methods Data were from the Health and Housing in Transition (HHiT) study, a prospective cohort study of 1190 individuals from three Canadian cities who were homeless or vulnerably housed. SQoL was measured using a scale designed specifically for this population. Predictor variables were time-varying indicators of housing status, substance use, and social support as well as baseline measures of physical and mental health problems. Generalized estimating equation (GEE) analysis examined these predictors of SQoL, adjusting for baseline age, gender, ethnicity, employment, income, and city of residence.
... People who are homeless or threatened with homelessness often have multiple and complex needs (Fitzpatrick et al., 2015); with their previous life experiences frequently associated with trauma, abuse, neglect, violence, addiction, physical ill-health or mental distress (e.g. Buccieri et al., 2020;Kidd et al., 2007;Whitbeck et al., 2015). ...
Full-text available
While psychologically informed environments (PIEs) are gaining in prominence in efforts to improve well‐being and practice in the homeless sector, their empirical foundations remain tenuous. We present a unique scoping needs analysis of staff and client well‐being, staff attitudes and the social–therapeutic climate in a UK‐based homeless prevention organisation (prior to PIE implementation). Our aims were: (a) to apply a robust framework to pinpoint need and target forthcoming PIE initiatives and (b) to establish a validated needs baseline that informs and measures efficacy of PIE for its future development. Four established personal and practice well‐being measures were administered to 134 (predominantly ‘frontline’) staff and 50 clients. Staff completed the: Warwick‐Edinburgh Mental Wellbeing Scale (WEMWBS), Professional Quality of Life Scale (measuring compassion satisfaction [CS], burnout [BO] and secondary traumatic stress [STS]), Attitudes related to Trauma‐informed Care Scale (ARTIC‐10; measuring practice attitudes towards trauma‐informed values) and the Essen Climate Evaluation Schema (EssenCES; measuring perceptions of client cohesion, safety and practitioner relationships in housing projects). Clients completed the WEMWBS and EssenCES. Vulnerability to STS was evident in nearly two‐thirds of frontline staff and it was a statistically significant predictor of BO. It was not, however, associated with lesser levels of CS. We discuss this complex dynamic in relation to highlighted strategic recommendations for the PIE framework, and the identified potential challenges in implementing trauma‐informed and reflective practice in the organisation. We conclude with a critique of the value and the lessons learnt from our efforts to integrate stronger empirical substance into the PIE approach.
Full-text available
Males and black persons are overrepresented among the homeless population and experience differential trajectories in homelessness and access to services. However, research has not fully examined the extent to which the race and sex of homeless persons affect stigmatizing responses toward them. Drawing on stigma and attribution theories and using data from experimental vignettes administered to a sample of public university students (n = 195), we examine the effects of the race and gender of homeless persons on perceptions of blameworthiness, dangerousness, and social distance. We find that black and male homeless persons are perceived as more dangerous, but not more blameworthy. Both perceived dangerousness and blameworthiness are associated with increased desired social distance. Also, we find that subjects who are more politically conservative desire greater social distance from homeless persons because they consider them more blameworthy and more dangerous.
Full-text available
Background: For the estimated 554,000 homeless individuals on any given night in the United States, obtaining quality sleep is often challenging. This group is known to have multiple health disparities, potentially affected by sleep problems; therefore, identifying lifestyle factors-such as physical activity-that are associated with improving both quality and quantity of sleep has important implications for public health. Here, we examine associations of physical activity with subjective sleep problems within a large sample of homeless adults. Methods: Participants were homeless adults recruited from Dallas and Oklahoma (N = 747; 66.1% men, Mage = 43.7±12.1). Participants self-reported insufficient sleep (number of days without sufficient rest/sleep in the last month; categorized as 0, 1-13, 14-29, or ≥30 days), sleep duration (over average 24 hours; categorized as ≤6 [short sleeper], 7-9 [optimal sleeper], or ≥10 hours [long sleeper]), and unintentional daytime sleep (number of days with unintentional sleep in the last month; categorized as 0 vs ≥30 days). Physical activity was assessed subjectively using the BRFSS Physical Activity Questionnaire. Regression analyses were performed to examine the associations between physical activity and sleep problems, controlling for age, sex, race, education, body mass, months homeless, at-risk drinking, self-rated health, serious mental illness, smoking status, and recruitment city. Results: Failure to meet/exceed physical activity guidelines was associated with higher likelihood of being a long sleeper (OR = 2.64, 95% CI: 1.46, 4.78) but a lower likelihood of having ≥30 days of insufficient rest/sleep (OR = 0.52, 95% CI: 0.29, 0.93). Conclusions: Findings suggest that physical activity promotion may hold promise for addressing the problem of too much sleep, but not other manifestations of sleep problems among this vulnerable group.
Gender‐based violence is associated with an elevated risk of physical and psychological harm for girls and women. This study examines service user and provider experiences of a trauma‐informed, peer‐facilitated group psychosocial intervention (Peer Education and Connection through Empowerment [PEACE]) targeting female‐identified youth experiencing homelessness and gender‐based violence. Participants were recruited among service users and providers of the intervention, delivered in Toronto, Canada. We conducted 19 semi‐structured interviews between May and October 2017, engaging 12 service users and 7 additional stakeholders (including social service providers, peers and program administrators). We elicited participant perspectives on the acceptability of the intervention and key enablers of successful implementation and engagement of the target population. Qualitative transcripts were analysed using thematic analysis. Service users, including survivors of sexual exploitation, forced marriage and honour crimes, described satisfaction with and acceptability of the intervention. A number of factors were perceived by service users and providers as contributing to the intervention's successful implementation, including a focus on service user needs, program quality, flexibility and accessibility and strong inter‐and intra‐agency networks. Introducing peers as mentors led to challenges that could be mitigated through peer mentor education and training to maintain healthy boundaries and enhance peer mentor retention. The need for clear guidelines on the management of trauma disclosures in community settings and a systems‐wide approach to service provider and administrator training in the effective integration of peer support services also emerged as important areas for future development. A group‐based, trauma‐informed and peer‐supported psychosocial intervention was acceptable to service users and providers and successfully engaged female‐identified survivors of gender‐based violence who were also experiencing homelessness. Findings add to the scant knowledge base on interventions to support this population and identify important areas for future research.
Objective: We examined associations between sleep problems, distress intolerance, and perceived stress and health in a convenience sample of homeless adults. Methods: Participants (N = 513, 36% women, Mage = 44.5 ±11.9) self-reported sleep adequacy, sleep duration, unintentional sleep during the daytime, distress tolerance, urban stress, and days of poor mental health and days of poor physical health over the last month. The indirect effects of sleep problems on stress and health through distress tolerance were examined using a non-parametric, bias-corrected bootstrapping procedure. Results: Sleep problems were prevalent (eg, 13.0 ±11.4 days of inadequate sleep and 4.7 ±7.9 days of unintentionally falling asleep during the preceding month). Distress intolerance partially accounted for the associations of inadequate sleep and unintentionally falling asleep, but not sleep duration, with urban stress and more days of poor mental and physical health. Conclusions: Many homeless individuals endure sleep problems. Given the connections between sleep and morbidity and mortality, results further support the need for more attention directed toward facilitating improvements in sleep quality to improve the quality of life of homeless adults, potentially including attention to improving distress tolerance skills.
Background: Among individuals experiencing homelessness, unsheltered status is associated with poor health and access to care and an increased risk for premature death. Insufficient research has explored gender differences in these outcomes; the objective of this study was to address this gap in the research. Methods: This study used survey data collected during the 100,000 Homes Campaign. Chi-square tests identified differences in the characteristics of women, men, and transgender individuals. Generalized linear mixed models fit with demographic, homelessness, mental/behavioral health, institutional, and income characteristics were run separately for women and men to assess correlates of unsheltered status and increased risk of premature mortality. Results: Men reported more frequently experiencing unsheltered homelessness while women and transgender participants more frequently met the criteria for risk of premature mortality. Women reported less frequently than men a history of or current substance use, but it significantly increased their likelihood of unsheltered homelessness; reports of mental health issues were rarer among men but significantly increased their odds of unsheltered homelessness. The experience of a violent attack while homeless was most strongly related to increased risk of premature mortality for both women and men. Conclusions: Interventions to reduce unsheltered homelessness among men should be particularly sensitive to mental health issues while for women there may need to be increased attention to substance use. A focus on experience of trauma and the provision of trauma-informed care is essential to address the increased risk of premature mortality among both men and women experiencing homelessness.
Background: Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH. Methods: This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area participated. Results: Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict. Conclusions: There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.
Objectives: Homelessness and poverty are extreme forms of social exclusion which extend beyond the lack of physical or material needs. The purpose of this study was to explore and expand the concept of social exclusion within the social determinants of health perspective - to understand how the social environment, health behaviours and health status are associated with material and social deprivation. Study design: Fundamental qualitative description with tones of focused ethnography. Methods: Participants who identified as hidden homeless described their everyday living conditions and how these everyday conditions were impacted and influenced by their social environments, coping/health behaviours and current health status. Research Ethics Board approval was granted and informed consents were obtained from 21 participants prior to the completion of individual interviews. Results: Qualitative content analysis examined the descriptions of men and women experiencing hidden homelessness. Participants described the 'lack of quality social interactions and supports' and their 'daily struggles of street life'. They also shared the 'pain of addiction' and how coping strategies influenced health. Participants were hopeful that their insights would 'better the health of homeless people' by helping shape public policy and funding of community resources that would reduce barriers and improve overall health. Conclusions: Health professionals who understand health behaviours as coping mechanisms for poor quality social environments can provide more comprehensive and holistic care. The findings of this study can be used to support the importance of housing as a key factor in the health and well-being of people experiencing poverty, homelessness and social exclusion; and consequently, reinforces the need for a national housing strategy.
This article discusses how the gender-based violence of homelessness contributes to young women engaging in bodily alliances with men as a strategy for physical protection. The embedding of individualized and postfeminist discourses through the conditions of neoliberalism and the structural disadvantage of homelessness have meant that young women are required to adopt self-regulatory practices and take personal responsibility for their physical safety. Drawing on Bourdieu's social capital theory and its development by Skeggs and Shilling, and based on qualitative research undertaken with fifteen young women who had experienced homelessness in Australia, I suggest that feminine capital is mobilized through necessity by young homeless women through the formation and maintenance of intimate relationships with men to access a sense of safety in an environment that is hostile to the female body. However, as the narratives presented here demonstrate, the value and privilege ascribed to (certain) male bodies is only accessible vicariously to young women, it is inherently precarious, it can undermine access to other types of capital and these intimate relationships can also be a source of gender-based violence.
This study investigates the effect of income inequality (gini) on health outcomes across U.S. counties using recent data. Health outcomes are both subjective and objective: mentally and physically unhealthy days, years of potential life lost and low birth weight. Regression models control for many county-level characteristics: county size, per capita income, persistent poverty, percent uninsured, percent unemployed, percent college, and percent Black. In addition, state dummies are included to account for state-level differences. This is a more extensive set of controls than that used in any study so far. Results show that inequality is associated with worse health in terms of all the above measures. The magnitude of the effect is comparable to, or even higher than that of the per capita income. The reason may be that, as suggested in the literature, the level of contextual income does not matter for health in the rich countries, such as the United States. What matters is the distribution of income. This is an ecological study, and hence, it does not claim causal relationship.