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Impact of welfare cheque issue days on a service for those intoxicated in public Li, Xin; Sun, Huiying; Marsh, David C; Anis, Aslam H Apr 26, 2007

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ralssBioMed CentHarm Reduction JournalOpen AcceBrief reportImpact of welfare cheque issue days on a service for those intoxicated in publicXin Li1,2, Huiying Sun2, David C Marsh1,2,3,4 and Aslam H Anis*1,2Address: 1Department of Healthcare and Epidemiology, University of British Columbia, Vancouver, Canada, 2Centre for Health Evaluation and Outcome Sciences, Vancouver, Canada, 3Vancouver Coastal Health, Vancouver, Canada and 4Providence Health Care, Vancouver, CanadaEmail: Xin Li - xin@hivnet.ubc.ca; Huiying Sun - hsun@sm.hivnet.ubc.ca; David C Marsh - David.Marsh@vch.ca; Aslam H Anis* - aslam.anis@ubc.ca* Corresponding author    AbstractIn British Columbia (BC), the Ministry of Human Resources issues welfare cheques to eligiblerecipients monthly on the last Wednesday of each month. Previous studies have indicated thatthere are significant increases in hospital admission, ED admission, 911 calls and deaths shortly afterthe distribution of the monthly welfare cheques. The objective of this analysis was to rigorouslyexamine the impact of welfare cheque issue dates on admission to the Sobering Unit (SU), a servicefor the publicly intoxicated, in Vancouver, Canada. Data on 1234 consecutive admissions to the SUover a 7-month period were assessed, and the average number of daily admissions on each of the7 days of the welfare cheque issue week and similar weekdays in other weeks were compared. AWilcoxon rank-sum test was performed for the comparisons. Our results showed that there weresignificant increases in the number of admissions on the 3 days starting with "Welfare Wednesday"compared to the similar weekdays in other weeks (Welfare Wednesday vs. other Wednesdays: 8.7vs. 5.1, p = 0.02; Welfare Thursdays vs. other Thursdays: 9.6 vs. 5.3, p = 0.02; Welfare Fridays vs.other Fridays: 8.6 vs. 5.7, p = 0.04). The demonstrated impact of welfare cheque issue dates is animportant consideration for the re-design, staffing and resource allocation of services forwithdrawal management and potentially for other services offered to this population.FindingsIn British Columbia (BC), the Ministry of HumanResources issues welfare cheques to eligible recipientsmonthly on the last Wednesday of each month. Previousstudies in the public health literature, primarily from theUnited States, have shown that there are significantincreases in hospital admission, ED admission, 911 callsand deaths shortly after the distribution of monthly wel-fare cheques [1-4]. Similar results have also been found inCanadian studies, in which the authors show that welfareand mortality [6], an increase in hospital inpatients leav-ing a specialized HIV inpatient ward AMA [7] and adecrease in occupancy rate to a medical withdrawal man-agement [8].This study is designed to rigorously examine the impact ofwelfare cheque issue dates on admission to the SoberingUnit (SU) in Vancouver, BC. In particular this study willexamine how the level of substance use in the community,reflected by the number of public intoxicants brought byPublished: 26 April 2007Harm Reduction Journal 2007, 4:12 doi:10.1186/1477-7517-4-12Received: 12 May 2006Accepted: 26 April 2007This article is available from: http://www.harmreductionjournal.com/content/4/1/12© 2007 Li et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4(page number not for citation purposes)cheque issue dates are associated with an increase in thelikelihood of an overdose [5], an increase in morbiditythe police to the SU, is related to the welfare cheque issuedates. As well the impact of these dates on the utilizationHarm Reduction Journal 2007, 4:12 http://www.harmreductionjournal.com/content/4/1/12patterns of services designed to serve those with sub-stance-related problems will be examined.The SU is a 15-bed facility operated by Vancouver CoastalHealth (VCH) that offers a supportive environment forintoxicated individuals who do not have a safe place inwhich to recover from the effects of substances. The serv-ice includes nursing staff on a 24-hour, 7-day-per-weekbasis and is designed for those who come to the attentionof the police because of substance intoxication in public.It is located in Vancouver's Downtown Eastside (DTES),the most impoverished urban neighborhood in Canadawith a high proportion of welfare recipients, and home topeople with substance use disorders and injection druguse [9,10]. As a result, the SU service is aimed at the mostvulnerable and marginalized individuals who use sub-stances. Because of the target population of the SU, it isanticipated that the majority of those served in this settingwill be eligible for social support payments and therefore,this is an ideal setting in which to evaluate the associationbetween welfare cheque issue dates and substance use.Individuals admitted to the SU are brought by the policeafter being found intoxicated, and often disruptive in thecommunity. It is an alternative to incarceration and cli-ents can be held involuntarily until they are competent todecide on further care. Medications may be administeredin the SU to prevent harm to the client or others. If with-drawal care is needed and requested following resolutionof intoxication, they are matched to the most appropriatelevel of care based on client needs.Our hypothesis is that the level of substance use in thecommunity is driven by the date of welfare payments.Specifically, we hypothesize that the number of admis-sions to the SU will fall towards the end of the paymentperiod as substance use falls in the community and riseabruptly on the days commencing with "Welfare Wednes-day". All these trends would support the concept that thelevel of substance use in this marginalized populationrises and falls in concert with the payment of social bene-fits.Therefore, to test the hypothesis, we compared mean dailynumber of admissions on each of day in welfare weekswith those on similar weekdays in other weeks. Becausethe data was not normally distributed, a Wilcoxon rank-sum test was performed for the comparisons.In addition, our analysis will also inform the overall utili-zation of these services. Any demonstrable impact of wel-fare cheque issue dates will be important for the design,staffing and resource allocation for these services andpotentially for other services offered to this population.The present study extracted seven-month data (August 1,2003 to Feb. 29, 2004) from VCHs Primary AccessRegional Information System (PARIS) database. EthicalApproval for the study was obtained from the BehaviouralResearch Ethics Board of the University of British Colum-bia.Overall, 1234 admissions were made to the SU during thestudy period, the median age was 40 (Q1–Q3: 30–49),and the majority was male (80%). Most of clients, 854(69%), were discharged from the SU at the same day ofadmission, 366 (30%), stayed overnight, and 14 (1%)stayed more than one night. Figure 1 illustrated the meannumber of SU admissions on specific weekdays in the wel-fare weeks and the mean daily admission number in allother weeks. The average daily admission peaked on Sat-urdays in other weeks. This might be due to an increase insubstance use over the weekends. We did not find signifi-cant changes in the number of admissions on Mondaysand Tuesdays in welfare weeks compared to those onother Mondays and Tuesdays, although the numbers inwelfare weeks were lower (Mondays: 3.0 (95% CI = 1.07–4.93) vs. 4.1 (95% CI = 3.37–4.89), P = 0.20; Tuesdays:2.9 (95% CI = 0.83–4.89) vs. 4.7 95% CI = 3.54–5.94), P= 0.14). On the other hand, we found a significantincrease in the number of admissions on each of the 3days commencing with "Welfare Wednesday" comparedto the similar weekdays in other weeks. Specifically, thenumber of admissions on "Welfare Wednesday" was 71%higher than that on other Wednesdays (8.7 (95% CI =5.71–11.72) vs. 5.1(95% CI = 4.24–5.93), P = 0.02), and81% and 51% higher on Thursdays and Fridays following"Welfare Wednesday" compared to other Thursdays andFridays, respectively (Thursdays: 9.6 (95% CI = 6.33–12.81) vs. 5.3 (95% CI = 3.87–6.65), P = 0.02; Fridays: 8.6(95% CI = 6.13–11.01) vs. 5.7 (95% CI = 4.45–6.96), P =0.04). In terms of weekend comparisons, although wefound the number of admissions during welfare week-ends were higher than those in other weekends, the differ-ences were not statistically significant (Saturdays: 9.0(95% CI = 6.03–11.97) vs. 7.8 (95% CI = 6.1–9.48), P =0.37; Sundays: 6.9 (95% CI = 4.83–8.89) vs. 5.3 (95% CI= 4.26–6.41), P = 0.14).Our study demonstrates a clear temporal relationship ofincreased medical events to "Welfare Wednesday" byshowing that there are significant increases in the numberof admissions to the SU following "Welfare Wednesday".The findings indicate that in addition to buying food, orpaying rent, some welfare recipients may use the moneyto buy substances. Simply discontinuing the welfare pay-ments to substance users is unlikely to be an attractive pol-icy option since it will not eliminate substance use andPage 2 of 4(page number not for citation purposes)might exacerbate hunger and homelessness [11]. Onepossible solution is to appoint a payee who receives andHarm Reduction Journal 2007, 4:12 http://www.harmreductionjournal.com/content/4/1/12manages welfare income on behalf of the substance users.Specifically, the payee could dispense the money throughthe course of the month or arrange for its use for food andshelter. However, the effectiveness of payees approach isstill under debate [11-13]. Another controversial proposalis to require addiction treatment as a condition of receiv-ing welfare. Specifically, those with positive tests could berequired to receive treatment and abstain from substanceuse or risk losing their benefits. However, this proposal isnot supported by evidence and may produce increases incrime, health problems and other social costs [14].Our results also highlight the importance of interventionsin preventing the potential variability in demand for theSU due to the dates of welfare payments. The decreasedadmissions right before "Welfare Wednesday" and thesmooth out over a month but is peaked in the "WelfareWednesday" weeks. This sudden increased demand forthe SU service could present pressures on the systemincluding the police and health care resources. Two possi-ble interventions might be used to solve the unevendemand problem. The first intervention could be done byhealth care providers, in which staffing and resource allo-cation for the services could be based on the demand forthe service. Specifically, as demand goes up, more staffand more health care resources should be allocated. Thereverse could happen when demand goes down. The sec-ond possible intervention could be done by policy makersof the provincial government, in which distribution ofwelfare cheques could be spread out over a month. Forinstance, cheques could be distributed on the individual'sbirthday. Doing so could spread out the demand for theComparison of the mean number of SU admissions on a given day of the welfare week and the mean daily admission number in all othe  weeksFigur  1Comparison of the mean number of SU admissions on a given day of the welfare week and the mean daily admission number in all other weeks. P = P value.5.35.77.84.14.75.15.36.92.99.698.7 8.63024681012Mon Tues Wed Thurs Fri Sat SunDay of weekNumber of admissionsother weekWelfare weekP=0.20 P=0.1P=0.02P=0.02P=0.04P=0.37P=0.14Page 3 of 4(page number not for citation purposes)increased admissions starting from "Welfare Wednesday"indicate that the demand for the SU service does notSU service, therefore eliminating the variability indemand. This could also decrease the negative impact onPublish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2007, 4:12 http://www.harmreductionjournal.com/content/4/1/12other health care resources resulting from the peak incommunity substance use due to the current pattern ofwelfare payment.Our study has several limitations. First, our study cannotisolate other forms of payment from welfare paymentssince we could not isolate clients on assistance. However,it is likely that the effect will be more dramatically shownif only the clients receiving welfare were tracked ratherthan using the whole sample. Second, our study was con-ducted at a single sobering unit. Thus, our results may notbe generalizable to patterns in other settings. However,previous studies have shown that the timing of welfarecheque issue is associated with an impact on utilization ofother health care services.In summary, fewer admissions are made to the SU rightbefore "Welfare Wednesday", and more admissions aremade on each of the 3 days commencing with "WelfareWednesday". The demonstrable impact of welfare chequeissue dates will be important for the design, staffing andresource allocation for these services and potentially forother services offered to this population.Competing interestsThe author(s) declare that they have no competing inter-ests.Authors' contributionsAll coauthors made significant contributions to the con-ception and design of the analyses, interpretation of thedata and drafting of the manuscript, and they all approvedthe version to be published.AcknowledgementsLi holds a postdoctoral fellowship from the Michael Smith Foundation for Health Research.References1. Brunette D, Kominsky J, Ruiz E: Correlation of emergency healthcare use, 911 volume and jail activity with welfare check dis-tribution.  Ann Emerg Med 1991, 20:739-742.2. Phillips DP, Christenfeld N, Ryan NM: An increase in the numberof death in the United States in the first week of the month.NMAJ 1999, 341(2):93-98.3. Halpern SD, Mechem CC: Declining rate of substance abusethroughout the month.  Am J Med 2001, 110:347-351.4. Shaner AE, Eckman TA, Roberts LJ, Wilkins JN, Tucker DE, TsuangJW, Mintz J: Disability income, cocaine use, and repeated hos-pitalization among  schizophrenic cocaine abuser -- a gov-ernment-sponsored revolving door?  NMAJ 1995,333(12):777-783.5. Riddell C, Riddell R: Welfare Checks, Drug Consumption, andHealth: Evidence from Vancouver Injection Drug Users.  JHuman Resources 2006, 41(1):138-161.6. Verheul G, Singer SM, Christenson JM: Mortality and morbidityassociated with the distribution of monthly welfare pay-ments.  Acad Emerg Med 1997, 4(2):118-23.7. Anis AH, Sun H, Guh DP, Palepu A, Schechter MT, O'Shaughnessy8. Li X, Sun H, Puri A, Marsh DC, Anis AH: The Vancouver Detoxi-fication Service: Description and Evaluation.  Addictive Behaviors2007, 32(5):1043-53.9. Schechter MT, O'Shaughnessy MV: Distribution of injection drugusers in the Lower Mainland.  BC Medical Journal 2000,42(2):80-88.10. Wood E, Kerr T: What do you do when you hit rock bottom?Responding to drugs in the city of Vancouver.  Intl J Drug Policy2006, 17(2):55-60.11. Gresenz CR, Watkins K, Podus D: Supplemental security,income (SSI), disability insurance (DI), and substance abus-ers.  Comm Mental Health J 1998, 34(4):337-350.12. Examining entitlements for the mentally ill.  Wall Street Journal:A18. January 28, 199313. Rosenheck R, Lam J, Randolph F: Impact of representative pay-ees on substance use by homeless persons with serious men-tal illness.  Psychiatr  Serv 1997, 48(6):800-6.14. Macdonald S, Bois C, Brands B, Dempsey D, Erickson P, Marsh DC,Meredith S, Shain M, Skinner W, Chiu A: Drug testing and manda-tory treatment for welfare recipients.  International Journal ofDrug Policy 2001, 12:249-257.yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 4 of 4(page number not for citation purposes)MV: Leaving hospital against medical advice among HIV-pos-itive patients.  CMAJ 2002, 167(6):633-637.

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