Survey on the impact of COVID-19 on access to STBBI-related services, including harm reduction services, for people who use drugs or alcohol in Canada

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Organization: Public Health Agency of Canada

Published: 2023-02-16

Cat.: HP40-327/2023E-PDF
ISBN: 978-0-660-46611-8
Pub.: 220629

Acknowledgement

The success of this survey and the development of this report was possible because of the collaboration with the Canadian Association of People who Use Drugs (CAPUD). CAPUD established and led a national Expert Working Group comprised of people with lived and/or living experience of drug use; individuals from the African, Caribbean and Black, Indigenous and 2SLGBTQIA+ communities; representatives from community-based organizations offering sexually transmitted and blood-borne infections (STBBI)-related services, academic institutions and advocacy groups; and community-engaged researchers. The authors gratefully acknowledge the contribution of the participants who completed the survey.

Introduction

Since the start of the COVID-19 pandemic, unprecedented challenges in delivering primary healthcare, including STBBI prevention, testing and treatment services as well as harm reduction services, have been reported across the country. These disruptions may have had a greater impact on populations more at risk for human immunodeficiency virus (HIV), hepatitis C, and other STBBI^{Footnote 1}. In Canada, these key populations include African, Caribbean and Black (ACB) people, First Nations, Inuit and Métis peoples, and people who use drugs or alcohol (PWUD).

The Public Health Agency of Canada (PHAC) identified the need for priority data to measure the impact of COVID-19 on the health and well-being of Canadians and the delivery of healthcare. To address this priority, in collaboration with community partners, PHAC conducted four national online surveys to gain a better understanding of the impact of COVID-19 on the delivery of and access to STBBI-related services.

The first survey, the Survey on the Impact of COVID-19 on the delivery of STBBI prevention, testing and treatment, including harm reduction services, in Canada, was conducted from November to December 2020 to gather information from service providers about the impact of COVID-19 on their ability to provide STBBI-related services^{Footnote 2}. Three separate surveys of key populations were subsequently conducted for ACB people, First Nations, Inuit and Métis peoples, and PWUD. The aim of these population-specific surveys was to explore the impact of COVID-19 on social determinants of health (i.e., mental health and wellness, employment and financial security, food security, domestic violence, and discrimination), substance use, and access to STBBI-related services.

This report presents the descriptive findings of the national Survey on the Impact of COVID-19 on access to STBBI-related services, including harm reduction services, for people who use drugs or alcohol in Canada, conducted from January 5, 2021 to February 5, 2021.

Methods

Survey design

The Survey on the Impact of COVID-19 on access to STBBI-related services, including harm reduction services, for people who use drugs or alcohol in Canada was a cross-sectional, self-administered, online survey. The survey design was based on the rapid assessment trendspotter methodology developed by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)^{Footnote 3}. Conducting the survey online avoided the COVID-19 risk associated with close physical contact that could occur with face-to-face interviews. As well, the online survey method supported data collection from a potentially large number of participants over the planned four-week data collection period.

Community engagement

PHAC collaborated with the Canadian Association of People who Use Drugs (CAPUD) to ensure community engagement in the planning, promotion and recruitment of the survey. CAPUD established and led a national Expert Working Group (EWG) comprised of people with lived and/or living experience of drug use; individuals from the African, Caribbean and Black, Indigenous and 2SLGBTQIA+ communities; representatives from community-based organizations offering STBBI-related services, academic institutions and advocacy groups; and community-engaged researchers.

CAPUD provided input in the development of the questionnaire, developed and implemented a survey as well as a promotional and recruitment strategy, and reviewed survey findings for a PHAC published Data Blog^{Footnote 4}.

Questionnaire

Survey questions were developed from questionnaires used in prior surveys by the National Tracks Surveillance System^{Footnote 5} and existing online surveys measuring the impact of COVID-19^{Footnote 6} ^{Footnote 7} ^{Footnote 8} ^{Footnote 9} ^{Footnote 10} ^{Footnote 11}. Community partners provided input in drafting of the questionnaire to ensure survey questions were relevant, appropriate and population-specific.

In addition to sociodemographic characteristics, the questionnaire collected information on social determinants of health (i.e., mental health and wellness, employment and financial security, food security, domestic violence, and discrimination); substance use; and ability to access STBBI prevention, testing and treatment services, harm reduction services, and substance use and treatment services. With the exception of a few open-ended questions (i.e., participant's age, first three characters of participant's postal code, number of years lived in Canada, and participant comments about their experience during the pandemic), all other questions were closed-ended (i.e., checkboxes).

The questionnaire was available in English and French, and took approximately 10 to 20 minutes to complete. No directly identifying information was captured on the questionnaire.

Eligibility criteria

Participant eligibility criteria included living in Canada at the time of the survey, aged 18 years or older, ability to read English or French, and self-identifying as a person who used drugs including alcohol or cannabis in the 6 months prior to the questionnaire.

Before starting the survey, the participant was provided with information in a question-answer format about the survey, including who can participate, privacy of personal information, how findings will be made available, and an email address if more information about the survey is desired. A web link to mental health support and resources was provided if the participant found any questions upsetting.

After reading through the information, the participant was presented with the following statement: "By clicking the 'Start Survey' button, you have read and understood the information on this page and consent to participation."

Recruitment

Several steps were taken to promote the survey and recruit participants. PHAC collaborated with CAPUD to promote and distribute the online survey link. With input from EWG members, CAPUD developed a promotional strategy to recruit participants, especially from different age groups and socioeconomic statuses.

Originally, EWG members were planning to conduct on-foot outreach to recruit participants who used drugs, especially youth (aged < 25 years), older adults (aged > 50 years), and unhoused or precariously housed individuals. To protect the health and safety of EWG members during the COVID-19 pandemic, all on-foot outreach was cancelled. Instead, outreach was done through emails and paid social media advertisements.

The survey was widely promoted through paid social media platforms. CAPUD created text and infographics with the survey link for posting to Facebook, Instagram, Twitter, and LinkedIn. Throughout the data collection period, CAPUD routinely posted (i.e., three times a week) to social media. CAPUD also distributed the survey link via weekly emails to their existing contacts and the networks of EWG members.

PHAC contacted just over 800 stakeholders, including provincial and territorial contacts, local public health, and community-based organizations, to distribute the survey link and participate as appropriate. National and regional STBBI organizations, and other government departments were encouraged to promote the survey link to their networks of service providers. Service providers were also encouraged to share the survey link with other known community-based organizations that provide STBBI services and to share with their clients as deemed appropriate. Combined, over 5,000 different organizations and individuals from the general population were emailed through existing government stakeholder contact lists. The survey link was also distributed via PHAC social media channels (i.e., over 175,000 Facebook followers, 500,000 Twitter followers, and 275,000 LinkedIn followers) throughout the data collection period, and social media posts were re-posted by key national stakeholders.

The survey protocol and questionnaire were approved by the Health Canada/PHAC Research Ethics Board. Due to the anonymous nature of this survey and an anticipated low participant burden, financial compensation was not offered for participation in this survey.

Measures

All indicators were measured from the questions asked in the survey. While most indicators can be interpreted directly from the survey questions, some required additional coding for better interpretation. In some cases, categories were collapsed to account for small cell counts or when similar concepts needed to be grouped. Described below are measures that required additional coding.

Substance use

The list of substances used in the questionnaire was derived from a list used by the National Tracks Surveillance System, specifically the Tracks people who inject drugs Phase 4 (2017-2019) questionnaire^{Footnote 5}.

From a list of substances, including alcohol and cannabis (the Government of Canada legalized its recreational use in October 2018), participants were asked how their consumption for each substance changed since the start of the COVID-19 pandemic. Answer options were "increase", "decrease", "no change", "I do not use this", and "prefer not to answer."

A "drugs used" variable was derived separating participants who reported use of only alcohol and/or cannabis from those who reported use of any illegal substances (with or without alcohol and/or cannabis). This measure was used to compare the two groups across some indicators. Illegal substances used by participants included the following:

Cocaine or crack
Speed, methamphetamine or crystal meth
Hallucinogens
Ecstasy
Heroin, fentanyl or other non-medical opioids
Other substances

Food security

From a list of statements related to food access and food security, participants were asked how true each statement was since the start of the COVID-19 pandemic using a scale of "often true", "sometimes true", and "never true." Participants were classified as experiencing food insecurity if they indicated "often true" or "sometimes true" to any of the following statements:

The food that you or other household members bought just didn't last, and there wasn't any money to get more
You or other household members couldn't afford to eat balanced meals
You personally ever ate less than you felt you should because there wasn't enough money to buy food
Others in your household ate less than you felt they should because there wasn't enough money to buy food
You or other household members accessed food or meals, at no cost to you, from a community organization

Domestic violence

From a list describing specific acts of domestic violence, participants were asked how their experiences with each of these acts, in the place where they lived, changed since the start of the COVID-19 pandemic. Answer options were "less often", "more often", "no change", "did not experience", "does not apply to me", and "prefer not to answer."

For each act of domestic violence, a variable was derived separating participants who reported experiencing the specific act from those who did not. Participants were classified as experiencing domestic violence if they indicated "less often", "more often" or "no change" to any of the following acts:

Someone yelled at you or said things to you that made you feel bad about yourself, embarrassed you in front of others, or frightened you
Someone did things like push, grab, hit, slap, kick, or throw things at you during an argument or because they were angry with you
Someone was more sexually aggressive towards you
Someone yelled at someone you live with
Someone did things like push, grab, hit, slap, kick, or throw things at someone you live with
Someone controlled how money was spent in your household including limiting your access or withholding funds from you

Discrimination

From a list of attributes possibly related to discrimination, participants were asked for their self-perception of change in their experiences of discrimination when accessing healthcare services since the start of the COVID-19 pandemic. Answer options were "increase", "decrease", "no change", and "did not experience."

For each attribute, a variable was derived separating participants who reported experiencing discrimination based on the particular attribute from those who did not. Participants were classified as experiencing discrimination if they indicated "increase", "decrease" or "no change" to any of the following attributes:

Race or ethnicity or skin colour, including anti-Black racism or anti-Indigenous racism
Gender
Sexual orientation
Use of substances
Economic status
Disability
Age

Access to STBBI-related services

Participants were asked about their access to the following three STBBI-related services:

STBBI prevention, testing and treatment services (e.g., STBBI testing and treatment, oral HIV pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP), condom and/or dental dam provision, etc.)
harm reduction services (e.g., needle or syringe distribution, on-site consumption, drug checking, naloxone training and provision, etc.)
substance use and treatment services (e.g., counselling, opioid substitution treatment (OST), inpatient services, community-based programs and services, etc.)

From a list of specific services for each of the above three STBBI-related services, participants were asked to describe their access to these services since the start of the COVID-19 pandemic. Answer options were "always able to access", "sometimes able to access", "wanted or tried to, but was not able to access", and "did not try to access." Participants were classified as having difficulty accessing a particular service if they reported "sometimes able to access" or "wanted or tried to, but was not able to access."

Analysis

The purpose of this report and the analyses undertaken were exploratory and descriptive in nature. Small cell counts were assessed to determine the risk of identifying individual participants, and were left in when it was determined that there was no risk of re-identification, as per PHAC's Directive for the Collection, Use and Dissemination of Information Relating to Public Health (PHAC, 2013, unpublished document). Where data in the table contain small cell counts, the results should be interpreted with caution. All descriptive statistics were computed with SAS Enterprise Guide 7.1.

For each survey question, participants who responded with answer options "prefer not to answer", "don't know", "refused" (i.e., did not answer a question and proceeded to next question), or "not stated" (i.e., question not answered because session timed out or exited survey before completion) were excluded from analyses of the question except where otherwise indicated.

Results

Sociodemographic characteristics

A total of 1,034 eligible individuals participated in the survey from January 5 to February 5, 2021. More than one-third (39.7%) of participants were living in Ontario with smaller proportions living in British Columbia (14.2%), Quebec (12.2%), Nova Scotia (9.4%), Alberta (7.3%), Manitoba (4.5%), New Brunswick (4.0%), Saskatchewan (3.8%), Newfoundland and Labrador (3.0%), Prince Edward Island (0.7%), and the Territories (1.4%) (Table 1).

Among all participants, the average age was 40.5 years, ranging from 18 to 84 years. The largest proportion were between the ages of 25 to 39 years (43.4%), followed by those aged 40 to 54 years (28.8%) then those aged 55 years or older (17.6%) and younger than 25 years (10.2%).

Nearly two-thirds (61.2%) identified their gender as cisgender female, 32.6% as cisgender male, 4.2% as transmasculine (i.e., those assigned female at birth who identified with either male or a non-binary gender), and 2.0% as transfeminine (i.e., those assigned male at birth who identified with either female or a non-binary gender). Almost three-quarters (70.2%) reported their sexual orientation as heterosexual or straight and smaller proportions identified as bisexual (13.7%), gay or lesbian (7.8%), Two-spirit (1.1%), other (5.0%), or don't know (2.1%).

A large proportion identified as White (85.0%) and smaller proportions identified as Indigenous (8.5%), Black (2.9%) or South Asian (2.3%). Among participants who self-identified as Indigenous, 59.8% identified as First Nations, 32.2% as Métis, and 11.5% as another unspecified Indigenous subgroup.

Most (89.4%) were Canadian citizens born in Canada with a small proportion (8.2%) born outside of Canada. Of those born outside of Canada, the median (with interquartile ranges or IQR) number of years lived in Canada was 26 (30 to 50) years.

Among all participants, most (86.2%) had more than a high school education, 7.9% completed high school, and 6.0% had less than a high school education.

Since the start of the pandemic, most (91.5%) were living in stable housing (i.e., living in their own apartment or house, or in a family or friend's place). A small proportion (8.5%) reported living in precarious or inadequate housing (i.e., living in multiple residences or couch surfing, a hotel or motel room, rooming or boarding house, shelter or hostel, transition or halfway house, psychiatric institution or drug treatment facility, public place, or correctional facility).

As noted, participants were separated into one of two groups based on the substances they used: those who used only alcohol and/or cannabis (i.e., "legal" drugs) and those who used illegal drugs (with or without alcohol and/or cannabis). Some sociodemographic characteristics varied between these two groups. Compared to participants who used only alcohol and/or cannabis, there appears to be higher proportions of participants who used illegal drugs who: were between the ages of 25 to 39 years (51.0% vs. 34.6%); were cisgender male (36.3% vs. 29.4%); identified as bisexual (18.5% vs. 10.2%); and reported living in precarious or inadequate housing (14.2% vs. 4.2%).

Table 1. Sociodemographic characteristics of participants in the survey
Characteristic	All participants			Used only alcohol and/or cannabis			Used illegal drugs
Characteristic	n	Total^{Footnote a}	%	n	Total	%	n	Total	%
Province or territory where participant lives
British Columbia	146	1,032	14.2	56	451	12.4	66	393	16.8
Alberta	75	1,032	7.3	39	451	8.7	27	393	6.9
Saskatchewan	39	1,032	3.8	20	451	4.4	12	393	3.1
Manitoba	46	1,032	4.5	14	451	3.1	19	393	4.8
Ontario	410	1,032	39.7	184	451	40.8	159	393	40.5
Quebec	126	1,032	12.2	54	451	12.0	45	393	11.5
New Brunswick	41	1,032	4.0	18	451	4.0	15	393	3.8
Nova Scotia	97	1,032	9.4	44	451	9.8	34	393	8.7
Prince Edward Island	7	1,032	0.7	3	451	0.7	3	393	0.8
Newfoundland and Labrador	31	1,032	3.0	16	451	3.6	9	393	2.3
Territories^{Footnote b}	14	1,032	1.4	3	451	0.7	4	393	1.0
Age group
Younger than 25 years	105	1,034	10.2	35	451	7.8	40	394	10.2
25 to 39 years	449	1,034	43.4	156	451	34.6	201	394	51.0
40 to 54 years	298	1,034	28.8	151	451	33.5	105	394	26.7
55 years or older	182	1,034	17.6	109	451	24.2	48	394	12.2
Gender identity^{Footnote c} ^{Footnote d}
Cisgender female	622	1,016	61.2	305	449	67.9	201	383	52.5
Cisgender male	331	1,016	32.6	132	449	29.4	139	383	36.3
Transfeminine^{Footnote e}	20	1,016	2.0	3	449	0.7	16	383	4.2
Transmasculine^{Footnote f}	43	1,016	4.2	9	449	2.0	27	383	7.1
Sexual orientation^{Footnote g}
Heterosexual or straight	726	1,034	70.2	367	451	81.4	222	394	56.4
Bisexual	142	1,034	13.7	46	451	10.2	73	394	18.5
Gay or lesbian	81	1,034	7.8	23	451	5.1	43	394	10.9
Two-spirit	11	1,034	1.1	0	451	0.0	11	394	2.8
Other	52	1,034	5.0	10	451	2.2	35	394	8.9
Don't know	22	1,034	2.1	5	451	1.1	10	394	2.5
Race or racial background^{Footnote h}
White	879	1,034	85.0	395	451	87.6	327	394	83.0
Indigenous	88	1,034	8.5	28	451	6.2	44	394	11.2
Black	30	1,034	2.9	8	451	1.8	14	394	3.6
South Asian	24	1,034	2.3	16	451	3.6	<5	394	-
Middle Eastern	15	1,034	1.5	7	451	1.6	5	394	1.3
Latino	13	1,034	1.3	6	451	1.3	5	394	1.3
East Asian	10	1,034	1.0	<5	451	-	<5	394	-
Southeast Asian	9	1,034	0.9	<5	451	-	<5	394	-
Other race unspecified	31	1,034	3.0	8	451	1.8	18	394	4.6
Indigenous subgroup^{Footnote i}
First Nations	52	87	59.8	20	28	71.4	23	43	53.5
Métis	28	87	32.2	8	28	28.6	15	43	34.9
Inuit	<5	87	-	0	28	0.0	0	43	0.0
Other Indigenous subgroup^{Footnote j}	10	87	11.5	0	28	0.0	8	43	18.6
Citizenship status
Canadian citizen, born in Canada	923	1,032	89.4	396	451	87.8	359	393	91.4
Canadian citizen, not born in Canada	85	1,032	8.2	43	451	9.5	26	393	6.6
Landed immigrant or permanent resident	17	1,032	1.7	8	451	1.8	6	393	1.5
Convention refugee or temporary resident^{Footnote k} ^{Footnote l}	7	1,032	0.7	4	451	0.9	2	393	0.5
Education, highest level
Less than high school	61	1,019	6.0	17	445	3.8	34	389	8.7
Completed high school	80	1,019	7.9	28	445	6.3	36	389	9.3
More than high school	878	1,019	86.2	400	445	89.9	319	389	82.0
Housing status^{Footnote m}
Stable housing^{Footnote n}	946	1,034	91.5	432	451	95.8	338	394	85.8
Precarious or inadequate housing^{Footnote o}	88	1,034	8.5	19	451	4.2	56	394	14.2
Abbreviations: STBBI: sexually transmitted and blood-borne infection; -: indicates data was suppressed due to small cell counts. Note: The sum of the percentages may not equal 100% due to rounding, unless stated otherwise. Footnote a Total represents total counts for the corresponding indicator excluding "Don't know", "Prefer not to answer", "Refused", and "Not stated" values, unless stated otherwise. Return to footnote a Footnote b Includes Nunavut, Yukon and Northwest Territories. Return to footnote b Footnote c The Multidimensional Sex/Gender Measure was used to measure gender identity. Return to footnote c Footnote d Bauer GR, Braimoh J, Scheim AI, Dharma C. Transgender-inclusive measures of sex/gender for population surveys: mixed-methods evaluation and recommendations. PLoS One [Internet]. 2017 May; 12(5). Available from: https://doi.org/10.1371/journal.pone.0178043 Return to footnote d Footnote e Transfeminine included those assigned male at birth who identified with either female or a non-binary gender. Return to footnote e Footnote f Transmasculine included those assigned female a birth who identified with either male or a non-binary gender. Return to footnote f Footnote g Total represents total counts for this indicator excluding "Prefer not to answer", "Refused" and "Not stated" values. Return to footnote g Footnote h The proportions for race or racial background do not add up to 100% as they were not mutually exclusive; participants could report more than one type of race or racial background. Race or racial background included: Black (e.g., African, Caribbean, Black descent); East Asian (e.g., Chinese, Korean, Japanese, Taiwanese descent); Indigenous (e.g., First Nations, Inuit, Métis); Latino (e.g., Latin American, Hispanic descent); Middle Eastern (e.g., Arab, Persian, Afghan, Egyptian, Iranian, Lebanese, Turkish, Kurdish); South Asian (e.g., East Indian, Pakistani, Bangladeshi, Sri Lankan, Indo-Caribbean); Southeast Asian (e.g., Cambodian, Indonesian, Laotian, Vietnamese descent); or White (e.g., European descent). Return to footnote h Footnote i This indicator was measured among participants who self-identified as First Nations, Inuit or Métis. The proportions for Indigenous subgroup do not add up to 100% as they were not mutually exclusive; participants could report more than one type of Indigenous subgroup. Return to footnote i Footnote j This included other unspecified Indigenous subgroups. Return to footnote j Footnote k For the answer option "convention refugee or protected person", participants were provided with the following additional information: "i.e., you have been formally approved as a refugee." Return to footnote k Footnote l For the answer option "temporary resident", participants were provided with the following additional information: "e.g., student, temporary worker, visitor, super visa (parent and grandparent)." Return to footnote l Footnote m This indicator measured the participant's living situation since the start of the COVID-19 pandemic. Participants could report more than one type of living situation. Return to footnote m Footnote n Participants were classified as living in stable housing if they were only living in their own apartment or house, or in a relative's or friend's place. Return to footnote n Footnote o Participants were classified as living in precarious or inadequate housing if they indicated living in any of the following situations: living in multiple residences or couch surfing; a hotel or motel room; rooming or boarding house; shelter or hostel; transition or halfway house; psychiatric institution or drug treatment facility; public place; or correctional facility. Return to footnote o

For indicators measuring social determinants of health, a comparison between the groups of participants who reported use of only alcohol and/or cannabis and those who reported use of illegal drugs yielded similar results, thus only the overall results (i.e., among all participants) are presented.

Mental health and wellness

At the time of the survey, nearly one-quarter (23.7%) of participants reported their mental health was excellent or very good, 29.8% reported good, 30.3% reported fair, and 16.3% reported poor mental health (Table 2). When asked how their mental health had changed since the start of the pandemic, 59.8% reported their mental health was worse.

Since the start of the pandemic, among participants who accessed, considered accessing or wanted to access mental health and wellness services, 65.6% indicated they were "not always able" (i.e., not able or sometimes not able) to access such services.

Table 2. Mental health of participants in the survey
Indicator	n	Total^{Footnote a}	%
Mental health at the time of the survey
Excellent or very good	245	1,034	23.7
Good	308	1,034	29.8
Fair	313	1,034	30.3
Poor	168	1,034	16.3
Change in mental health since the start of the COVID-19 pandemic
Better	94	1,033	9.1
About the same	321	1,033	31.1
Worse	618	1,033	59.8
Accessed, considered accessing or wanted to access mental health and wellness services^{Footnote b} since the start of the COVID-19 pandemic
Yes	600	1,029	58.3
No	429	1,029	41.7
Not always able to access mental health and wellness services^{Footnote c}	392	598	65.6
Abbreviations: STBBI: sexually transmitted and blood-borne infection. Note: The sum of the percentages may not equal 100% due to rounding, unless stated otherwise. Footnote a Total represents total counts for the corresponding indicator excluding "Don't know", "Prefer not to answer", "Refused", and "Not stated" values, unless stated otherwise. Return to footnote a referrer Footnote b This included mental health care providers, community supports, faith-based and spiritual care supports, etc. Return to footnote b referrer Footnote c This indicator was measured among participants who accessed, considered accessing or wanted to access mental health and wellness services. Return to footnote c referrer

A pattern of worsening mental health was observed among participants who reported poor mental health at the time of the survey (Figure 1). Among participants who reported their mental health was excellent or very good at the time of the survey, 32.2% felt their mental health was worse since the start of the pandemic and more notably, among those who reported poor mental health at the time of the survey, 84.5% felt their mental health had worsened since the start of the pandemic.

**Figure 1. Changes in mental health since the start of the COVID-19 pandemic among participants in the survey**

Changes in mental health since the start of the COVID-19 pandemic among participants in the survey
Change category for mental health	Excellent or very good	Good	Fair	Poor
Better	11.4%	10.1%	9.3%	3.6%
About the same	56.3%	32.3%	20.5%	11.9%
Worse	32.2%	57.7%	70.3%	84.5%

Employment and financial security

Before the COVID-19 pandemic, over one-half (58.9%) of participants were working full time, 17.4% were working part time, and 11.4% were either a full or part time student (Table 3). Smaller proportions were not working due to a disability (7.0%), volunteering (6.4%), unemployed (6.2%), retired (6.0%), looking after children or other family members (3.5%), or had other unspecified work (3.7%). Participants could report more than one work situation.

Since the start of the pandemic, while 51.7% of participants indicated there was little to no change to their work situation, 18.2% had stopped working and 14.1% had their hours and/or pay reduced. Main reasons for these changes were related to the COVID-19 pandemic and included business closures or layoffs (46.9%) and personal circumstances (25.8%) (e.g., personal safety, own or household member's exposure, self-isolation after recent travel, or taking care of children due to school and/or daycare closures).

Regarding the impact of the pandemic on the ability to pay bills for essential needs (e.g., rent, mortgage payments, utilities, or groceries), 44.3% of participants reported there was no impact or it was too soon to tell, 20.7% indicated a moderate impact, and 15.1% reported a major impact.

Since the start of the pandemic, nearly one-third (31.8%) of participants applied to and received employment or emergency response benefits. The Canada Emergency Response Benefit (64.9%) and regular employment insurance benefits (30.4%) were the most commonly received benefits. Participants could report more than one benefit received.

Table 3. Employment and financial security of participants in the survey
Indicator	n	Total^{Footnote a}	%
Work situation before the COVID-19 pandemic^{Footnote b}
Employed or self-employed full time	594	1,009	58.9
Employed or self-employed part time	176	1,009	17.4
Full or part time student	115	1,009	11.4
Not working due to a disability	71	1,009	7.0
Volunteering	65	1,009	6.4
Unemployed	63	1,009	6.2
Retired	60	1,009	6.0
Looking after children or other family members	35	1,009	3.5
Other	37	1,009	3.7
Change in work situation since the start of the COVID-19 pandemic
Little to no change	518	1,002	51.7
Had to stop working	182	1,002	18.2
Increased hours and/or pay	161	1,002	16.1
Reduced hours and/or pay	141	1,002	14.1
Main reason for limited or stopped work^{Footnote c} during the COVID-19 pandemic
Business closure or layoff related to the COVID-19 pandemic	151	322	46.9
Personal circumstances related to the COVID-19 pandemic^{Footnote d}	83	322	25.8
Unplanned absence not related to the COVID-19 pandemic^{Footnote e}	41	322	12.7
Planned absence not related to the COVID-19 pandemic^{Footnote f}	7	322	2.2
Other unspecified reason	40	322	12.4
Impact of the COVID-19 pandemic on ability to pay bills^{Footnote g}
Major impact	150	997	15.1
Moderate impact	206	997	20.7
Minor impact	199	997	20.0
No impact or too soon to tell	442	997	44.3
Employment or emergency response benefits received since the start of the COVID-19 pandemic
Applied and received benefits	313	985	31.8
Did not apply for any benefits	365	985	37.1
Did not qualify for any benefits	307	985	31.2
Type of employment or emergency response benefits received since the start of the COVID-19 pandemic^{Footnote h}
Canada Emergency Response Benefit (CERB)^{Footnote i}	203	313	64.9
Regular Employment Insurance benefits	95	313	30.4
Canada Emergency Student Benefit (CESB)^{Footnote j}	40	313	12.8
Sickness	31	313	9.9
Other Employment Insurance benefit	14	313	4.5
Other^{Footnote k}	12	313	3.8
Abbreviations: STBBI: sexually transmitted and blood-borne infection. Note: The sum of the percentages may not equal 100% due to rounding, unless stated otherwise. Footnote a Total represents total counts for the corresponding indicator excluding "Don't know", "Prefer not to answer", "Refused", and "Not stated" values, unless stated otherwise. Return to footnote a Footnote b The proportions for work situation do not add up to 100% as they were not mutually exclusive; participants could report more than one type of work situation. Return to footnote b Footnote c This indicator was measured among participants who indicated they had reduced their hours and/or pay or had to stop working. Return to footnote c Footnote d Personal circumstances related to COVID-19 included: personal safety; own or household member's exposure; self-isolation after recent travel; or taking care of children due to school and/or daycare closures. Return to footnote d Footnote e An unplanned absence not related to COVID-19 included: illness or disability other than COVID-19; caring for children or elder relative for non-COVID-19 reasons; or labour dispute (strike or lockout). Return to footnote e Footnote f A planned absence not related to COVID-19 included: vacation; work schedule; maternity or parental leave; or seasonal job or business. Return to footnote f Footnote g Bills referred to those for essential needs, such as rent or mortgage payments, utilities, and groceries. Return to footnote g Footnote h This indicator was measured among participants who applied for employment or emergency response benefits. The proportions for benefits do not add up to 100% as they were not mutually exclusive; participants could report more than one type of benefit. Return to footnote h Footnote i The Canada Emergency Response Benefit (CERB) provided financial support to employed and self-employed Canadians who were directly affected by COVID-19 between March 15 and September 26, 2020. Return to footnote i Footnote j The Canada Emergency Student Benefit (CESB) provided financial support to post-secondary students, and recent post-secondary and high school graduates who were unable to find work due to COVID-19 between May 10 and August 29, 2020. Return to footnote j Footnote k Other included caregiving or compassionate care and work-sharing. Return to footnote k

Food security

Since the start of the COVID-19 pandemic, under one-half (42.1%) of participants reported they experienced food insecurity (Table 4). Participants' experiences of food insecurity included: couldn't afford balanced meals (34.4%), food didn't last in the household and participants didn't have money to get more (31.4%), participants (28.2%) or other household members (20.7%) ate less because there was not enough money to buy food, and participants accessed food from a community organization (17.6%).

Table 4. Food security among participants in the survey
Indicator	n	Total^{Footnote a}	%
Experienced food insecurity^{Footnote b}
Yes	399	947	42.1
No	548	947	57.9
Experiences of food insecurity^{Footnote b}
Couldn't afford balanced meals	326	948	34.4
Food didn't last and no money to get more	297	948	31.4
Personally ate less because not enough money to buy food	267	946	28.2
Other household members ate less because not enough money to buy food	196	948	20.7
Accessed food (at no cost) from a community organization	167	948	17.6
Abbreviations: STBBI: sexually transmitted and blood-borne infection. Note: The sum of the percentages may not equal 100% due to rounding, unless stated otherwise. Footnote a Total represents total counts for the corresponding indicator excluding "Don't know", "Prefer not to answer", "Refused", and "Not stated" values, unless stated otherwise. Return to footnote a Footnote b Derived variable, for further details see section Measures-food security. Return to footnote b

Food insecurity was highest among participants not working due to a disability (78.3%), those looking after children or other family members (71.0%), and those who were unemployed (67.9%) (Figure 2).

**Figure 2. Food insecurity since the start of the COVID-19 pandemic by employment status among participants in the survey**

Food insecurity since the start of the COVID-19 pandemic by employment status among participants in the survey
Experience of food insecurity	Not working due to disabilities	Unemployed	Volunteering	Employed or self-employed part time	Full or part time student	Looking after children or other family members	Retired	Employed or self-employed full time	Other
Did not experience food insecurity	21.7%	29.0%	32.1%	40.6%	48.5%	54.1%	64.3%	83.3%	38.9%
Experienced food insecurity	78.3%	71.0%	67.9%	59.4%	51.5%	46.0%	35.7%	16.7%	61.1%

A pattern of greater food insecurity was observed among participants who reported changes to their work situation since the start of the pandemic. Food insecurity was highest among those who reported reduced hours and/or pay (66.4%) and those who had to stop working (63.4%) (Figure 3).

**Figure 3. Food insecurity by changes in work situation since the start of the COVID-19 pandemic among participants in the survey**

Food insecurity by changes in work situation since the start of the COVID-19 pandemic among participants in the survey
Experience of food insecurity by changes in work situation	Reduced hours and/or pay	Had to stop working	Little to no change	Increased hours and/or pay
Did not experience food insecurity	33.6%	36.6%	67.8%	70.9%
Experienced food insecurity	66.4%	63.4%	32.2%	29.1%

Domestic violence

More than two-thirds (69.9%) of participants were living with family since the start of the pandemic (Table 5). One-fifth (19.8%) were living alone while 9.2% were living with a roommate(s) or friend(s), and 1.1% were living in a shelter or were homeless.

In the year before the pandemic, most (67.8%) participants reported feeling very safe where they lived, 26.8% reported feeling somewhat safe, and 5.4% reported feeling not safe.

Table 5. Living arrangement and feelings of safety in the home among participants in the survey
Indicator	n	Total^{Footnote a}	%
Living arrangement since the start of the COVID-19 pandemic
Living with family	653	934	69.9
Living alone	185	934	19.8
Living with roommate(s) or friend(s)	86	934	9.2
Living in a shelter or homeless	10	934	1.1
Feelings of safety where participant lived in the year before the COVID-19 pandemic
Felt very safe	632	932	67.8
Felt somewhat safe	250	932	26.8
Did not feel safe	50	932	5.4
Abbreviations: STBBI: sexually transmitted and blood-borne infection. Note: The sum of the percentages may not equal 100% due to rounding, unless stated otherwise. Footnote a Total represents total counts for the corresponding indicator excluding "Don't know", "Prefer not to answer", "Refused", and "Not stated" values, unless stated otherwise. Return to footnote a

Feeling safe where they lived since the start of the pandemic varied depending on the level of safety participants felt before the pandemic (Figure 4). Among participants who felt very safe in their home before the pandemic, 19.3% felt less safe since the start of the pandemic while 76.4% felt no change in their safety. Among participants who felt somewhat safe before the pandemic, over one-third (35.6%) felt less safe and 55.2% felt the same since the start of the pandemic. Among participants who did not feel safe before the pandemic, one-half (50.0%) felt less safe, 22.0% felt the same, and 28.0% felt safer since the start of the pandemic.

**Figure 4. Changes in feelings of safety in the home since the start of the COVID-19 pandemic among participants in the survey**

Changes in feelings of safety in the home since the start of the COVID-19 pandemic among participants in the survey
Changes in feelings of safety	Felt very safe	Felt somewhat safe	Did not feel safe
Felt more safe	4.3%	9.2%	28.0%
The same	76.4%	55.2%	22.0%
Felt less safe	19.3%	35.6%	50.0%

Among those who experienced any act of domestic violence (Table 6), participants were asked how their experiences had changed since the start of the pandemic (Figure 5). Since the start of the pandemic, participants reported the largest increase in verbal abuse directed towards them (62.7%), followed by verbal abuse directed at someone else in the household (56.5%), physical abuse directed at them (39.3%), physical abuse directed at someone else in the household (35.0%), financial abuse (34.3%), and sexual aggression (32.5%).

Table 6. Experiences of domestic violence among participants in the survey
Indicator: Since the start of the COVID-19 pandemic	n	Total ^{Footnote a}	%
Experienced verbal abuse^{Footnote b} ^{Footnote c}
Yes	475	804	59.1
No	329	804	40.9
Experienced verbal abuse directed at someone else in household^{Footnote b} ^{Footnote d}
Yes	455	753	60.4
No	298	753	39.6
Experienced physical abuse^{Footnote b} ^{Footnote e}
Yes	219	751	29.2
No	532	751	70.8
Experienced physical abuse directed at someone else in household^{Footnote b} ^{Footnote f}
Yes	177	695	25.5
No	518	695	74.5
Experienced financial abuse^{Footnote b} ^{Footnote g}
Yes	242	709	34.1
No	467	709	65.9
Experienced sexual aggression^{Footnote b} ^{Footnote h}
Yes	228	721	31.6
No	493	721	68.4
Abbreviations: STBBI: sexually transmitted and blood-borne infection. Note: The sum of the percentages may not equal 100% due to rounding, unless stated otherwise. Footnote a Total represents total counts for the corresponding indicator excluding "Don't know", "Prefer not to answer", "Refused", and "Not stated" values, unless stated otherwise. Return to footnote a Footnote b Derived variable, for further details, see section Measures-domestic violence. Return to footnote b Footnote c Included participants who provided a valid answer to "Since the start of the COVID-19 pandemic, how often did someone yell at you or said things to you that made you feel bad about yourself, embarrassed you in front of others, or frightened you?" Return to footnote c Footnote d Included participants who provided a valid answer to "Since the start of the COVID-19 pandemic, how often did someone yell at someone you live with?" Return to footnote d Footnote e Included participants who provided a valid answer to "Since the start of the COVID-19 pandemic, how often did someone do things like push, grab, hit, slap, kick, or throw things at you during an argument or because they were angry with you?" Return to footnote e Footnote f Included participants who provided a valid answer to "Since the start of the COVID-19 pandemic, how often did someone do things like push, grab, hit, slap, kick, or throw things at someone you live with?" Return to footnote f Footnote g Included participants who provided a valid answer to "Since the start of the COVID-19 pandemic, how often did someone control how money was spent in your household including limiting your access or withholding funds from you?" Return to footnote g Footnote h Included participants who provided a valid answer to "Since the start of the COVID-19 pandemic, how often did someone be more sexually aggressive towards you?" Return to footnote h

**Figure 5. Changes in the frequency of experienced domestic violence since the start of the COVID-19 pandemic among participants who experienced domestic violence in the survey**

Changes in the frequency of experienced domestic violence since the start of the COVID-19 pandemic among participants who experienced domestic violence in the survey
Changes in frequency of experienced domestic violence	Verbal abuse	Verbal abuse towards others	Financial abuse	Physical abuse	Physical abuse towards others	Sexual aggression
Less often	4.0%	3.7%	2.3%	2.3%	3.3%	5.3%
No change	33.3%	39.8%	58.5%	62.7%	62.4%	62.3%
More often	62.7%	56.5%	39.3%	35.0%	34.3%	32.5%

Discrimination

In the year before the pandemic, one-third (33.3%) of participants reported experiencing discrimination when accessing healthcare services while two-thirds (66.7%) reported "never" experiencing such discrimination (Table 7).

Table 7. Experiences of discrimination when accessing healthcare among participants in the survey
Indicator: In the year before the start of the COVID-19 pandemic	n	Total^{Footnote a}	%
Experienced discrimination^{Footnote b} ^{Footnote c}
None	520	780	66.7
Any	260	780	33.3
Frequency of experienced discrimination^{Footnote b} ^{Footnote c}
Often	61	780	7.8
Sometimes	127	780	16.3
Rarely	72	780	9.2
Never	520	780	66.7
Abbreviations: STBBI: sexually transmitted and blood-borne infection. Note: The sum of the percentages may not equal 100% due to rounding, unless stated otherwise. Footnote a Total represents total counts for the corresponding indicator excluding "Don't know", "Prefer not to answer", "Refused", and "Not stated" values, unless stated otherwise. Return to footnote a Footnote b Experienced discrimination included discrimination based on participant's race, ethnicity or skin colour (including anti-Black racism, anti-Indigenous racism), gender, sexual orientation, use of substances, economic status, disability, age, or other identity. Return to footnote b Footnote c This indicator was measured among participants who accessed healthcare services in the year before the start of the COVID-19 pandemic. Return to footnote c

Experiences of discrimination when accessing healthcare services during the pandemic varied depending on these experiences before the pandemic (Figure 6). Participants who often experienced discrimination before the pandemic reported the largest increase (59.7%) in these experiences since the start of pandemic. Increased experiences of discrimination during the pandemic was reported by 36.0% of participants who sometimes experienced discrimination, 18.8% of those who rarely experienced discrimination, and 4.4% of those who never experienced discrimination in the year before the pandemic.

Figure 6. Changes in the frequency of experienced discrimination when accessing healthcare services since the start of the COVID-19 pandemic among participants who experienced discrimination in the survey

Changes in the frequency of experienced discrimination when accessing healthcare services since the start of the COVID-19 pandemic among participants who experienced discrimination in the survey
Changes in frequency of experienced discrimination	Often	Sometimes	Rarely	Never
Decrease	14.0%	12.6%	7.8%	1.6%
No change	26.3%	51.4%	73.4%	94.0%
Increase	59.7%	36.0%	18.8%	4.4%

Among participants who experienced discrimination since the start of the pandemic, most reported no change in their experiences of discrimination based on substance use, disability, age, economic status, race, gender, or sexual orientation (Figure 7). Many reported experiencing an increase in discrimination related to their substance use (40.7%), disability (31.5%), age (26.2%), economic status (22.6%), race/ethnicity/skin colour (15.5%), gender (13.9%), and sexual orientation (8.8%) when accessing healthcare services since the start of the pandemic. Participants could report more than one attribute related to their experienced discrimination.

**Figure 7. Changes in the frequency of experienced discrimination when accessing healthcare services by attributes among participants who experienced discrimination in the survey**

Changes in the frequency of experienced discrimination when accessing healthcare services by attributes among participants who experienced discrimination in the survey
Changes in experienced discrimination by attribute	Use of substances	Disability	Age	Economic status	Race or ethnicity or skin colour	Gender	Sexual orientation
Decrease	7.9%	3.8%	2.2%	11.9%	3.2%	1.6%	2.4%
No change	51.4%	64.7%	71.6%	65.5%	81.3%	84.5%	88.8%
Increase	40.7%	31.5%	26.2%	22.6%	15.5%	13.9%	8.8%