Research Matters Blog
In recent years, "housing first" has emerged as a key response to homelessness in North America. With its growing popularity in Canada comes increasing interest in understanding how the approach works, different program models and its effectiveness for specific populations. One key factor that undoubtedly shapes the success of any housing first program is the nature and supply of affordable housing.
The basic underlying principle of housing first, pioneered by Sam Tsembaris at the Pathways to Housing project in New York in the 1990s, is that people do better moving forward with their lives if they are first housed. This is as true for homeless people and those with mental health and addiction issues as it is for anyone. According to Pathways to Housing, "The Housing First model is simple: provide housing first, and then combine that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment." This approach differs from what has been (and arguably still is) the orthodoxy of our Canadian response to homelessness; in that "treatment first" approach, people who are homeless should be placed in emergency services until they are "ready" for housing (having received access to health care or treatment) or until housing is available.
Research quite convincingly demonstrates the general effectiveness of housing first over treatment first. In a 2000 study, Tsembaris and Eisenberg demonstrated that 90 per cent of people in the Pathways program remained housed five years later. A growing body of research shows that people with mental health and addiction issues do very well with a housing first approach, spend fewer days in hospital and are cheaper to support. (To see the research, visit www.homelesshub.ca/housingfirst.)
Housing first is most effective when, first, people are rehoused rapidly, minimizing time spent on emergency services. Because resources are scarce, priority should be given to high-needs clients, including families and those with mental health and addiction challenges. Second, ongoing and appropriate support must be provided for those who need them (and many don't). Those with addiction issues should have access to harm reduction-based housing, if that is what they prefer. Finally, where possible, clients should have input into the kind and location of their housing. While providing shelter and supports is central to housing first, the approach works best when it helps people nurture supportive relationships and become meaningfully engaged in their communities.
As housing first grows in popularity, it is applied in new ways and in different contexts. One challenge of implementing the approach is the ability to deliver appropriate housing support in the context of a housing shortage. I have often wondered what would have happened if the City of Toronto had attempted to implement its Streets to Homes program in the late 1990s, when rental vacancy rates were routinely below one per cent, compared to the last five years, when vacancy rates have hovered between three and four per cent.
In a tight rental market, one of the first things to go is the notion of consumer choice. One criticism of housing first is that people are often given housing in remote areas of town, far removed from services, poorly served by transit, and where people struggle to connect. Women fleeing violence may be placed in neighbourhoods that are not safe. The outcome is often isolation, continued marginalization and a compromised ability to accesses necessary services and supports. In the long run, this can undermine stability and security of tenure.
Different approaches to housing first take on the challenge of affordable housing supply in distinct ways. In Montreal, all levels of government working with the non-profit sector have sought to address the supply problem with an ongoing investment in social housing, with pathways to that housing for people who are homeless. The Streets to Homes program in Toronto relies almost exclusively on the private market, and rather than use rent subsidies, it has developed a system to fast track people so they can access other government benefits and supports. With a waiting list of more than 75,000 for social housing and with modest targets for expanding its affordable housing supply (up to 1,000 new units annually--though these targets are not being met), Toronto relies on the private rental market, making its housing first program vulnerable if the affordable housing supply shrinks.
In Calgary, the affordable housing supply has shrunk drastically over the past 10 years, while rents have skyrocketed. In rolling out its housing first model, the Calgary Homeless Foundation takes a systems approach, coupling its adaption of housing first with an investment in affordable housing (3,000 units built over the past three years) and with rent supports for people living -- or choosing to live -- in the private rental market.
The best approach to housing first, then, is to treat it not as a program or service tied to an agency, but rather, as part of a broader and more strategic response to homelessness; one that focuses on prevention by ensuring an investment in an affordable housing supply, and by requiring other sectors (mental health and corrections come to mind) to play their part in diverting people from homelessness through more effective discharge planning strategies. It is only by ensuring a sufficient supply of affordable housing that one of the central tenets of housing first -- consumer choice -- is protected.
Reprinted with permission from CAMH.
In an age of self publishing – including blogs, videos, and other Web-based media – why do we still seek to publish in traditional academic peer-reviewed journals? Vanity.
ResearchImpact-York published two academic papers in 2009. In 2010 we had one in press, two submitted, and one just rejected for a second time, from the same journal. Since our first post on May 30, 2008, ResearchImpact has published 206 blogs on Mobilize This!, an average of 6 or 7 each month.
Here’s a comparison of blogging and peer-reviewed publishing:
TIME: I started drafting our paper on ResearchSnapshot clear language summaries in July 2009. I submitted with revisions in September. It just got rejected. I can write a blog in about one hour and get it posted in 20 minutes.
ACCESS: We published our first paper on York’s KMb Unit in Evidence & Policy [Phipps, D.J. and Shapson, S. 2009. Knowledge mobilisation builds local research collaboration for social innovation. Evidence & Policy. 5(3): 211-227]. I have no idea who, apart from my mother, has read this paper. Mobilize This! has received 55,171 page views as of December 28, 2010 and has a subscriber list of over 1200. Blogs are accessible to anyone with an internet connection. Except for Open Access journals, most journals limit access to those who can afford a subscription.
RESPONSIVENESS: Blogging also has the added feature of allowing readers to respond by leaving comments. Try the comment feature below to leave your thoughts and let everyone know what you’re thinking. Now, try to do the same with a peer-reviewed paper you’ve printed out.
PAYBACK: I am not an academic. Unlike scholars seeing tenure and promotion based on their publications, my publications do not have an impact on how my performance is measured.
If it takes less time to reach more people in a two-way fashion, why do I take the trouble to publish in peer-reviewed journals if it doesn’t benefit me in any way?
Peer review provides a level of quality control; however, so does blogging. If you don’t find our writing valuable you won’t return to this blog or you’ll tell us so. And even though I believe peer-reviewed publishing and blogging are complementary, both take time. So why do we continue to take the time to pursue both forms of dissemination when blogging seems to meet our needs?
In practical terms, publishing in peer-reviewed journals gives us credibility in the eyes of one of our key constituents: faculty. Faculty’s currency is peer review. We gain credibility when faculty peers approve our work and find it worthy of publication. But the real truth is, publishing in peer-reviewed journals provides a sense of personal satisfaction that boarders on vanity. I enjoy the sense of satisfaction when faculty peers (finally) approve our publications. At the end of the day my ego is stroked when our work is accepted for peer-reviewed publication as well as when I receive comments on Mobilize This! Together, these two forms allow you, the KMb stakeholder, to know that our work is not only immediate, accessible and engaging (thank you, blogging!) but it also has the peer reviewed seal of approval (even if the seal is delayed by 12-18 months).
As Web 2.0 and open access move into the academy I predict we will increasingly see a blend of peer-reviewed and online media. To get to there from here all we need to do is change tenure and promotion, peer review, and the academic publishing industry. I’ll get right on that….after my next blog…
ResearchImpact is a service-oriented program designed to connect university research with research users across Canada to ensure that research helps to inform decision-making. This article was originally published in ResearchImpact's blog, Mobilize This!.
Housing first is a crucially important model for addressing homelessness. As mentioned recently by Stephen Gaetz, we need to shift the resources from managing homelessness to focusing on prevention and rapid rehousing. It has been said before, and I say it again, homelessness is a housing problem.
However, although I have previously argued for the importance of focusing on politics and policy, that should not be the full extent of our work on addressing homelessness. So, although the model is ‘housing first’ we also need to think about what is second, and third. In this vein, I have found a 3-level model to be helpful: Policy, Public Perceptions, and Personal Engagement.
I will say little about policy, as there are many amazing resources already available (for example this and this), other than to suggest that each service provider or researcher has many opportunities to become involved in policy development, if only at the municipal committee level to start with. For example, myself and other members of the London Homelessness Outreach Network sit on local committees around homelessness and housing, and community advisory boards for service agencies.
As for public perceptions, this is of key importance as political will follows public will. If there is no will in our communities, provinces, and nations to proactively address homelessness, then politicians will have no incentive to move resources towards this issue. A large part of this in Canada is confronting perceptions that homelessness is a personal problem based on bad choices. We need to find ways to creatively engage with the general population to outline the challenges in our society that make homelessness an inevitability. I had an opportunity to do this at a TED talks style event in London, addressing some of the popular misconceptions (see the video below). For me this highlights the value of arts-informed research as a means of interacting with those who would not be reached by traditional methods of knowledge translation.
Personal engagement has proven to be the most difficult, and yet the simplest, component of addressing homelessness. Social disaffiliation and strong class systems are major barriers to altering homelessness and poverty in general. Ask yourself, do I have any friends who live in absolute poverty? People experiencing homelessness have long pointed out that a move out of homelessness is often just a move to being a second-class citizen, one living in poverty. Our social systems, such as our neighbourhoods, are structured to divide people by socio-economic status, so it takes will and intention to break this down. And yet, it is so very simple. Personal engagement with homelessness can be as simple as volunteering at a local soup kitchen, spending time at a drop-in centre, or hanging out regularly at a downtown library. I have found the homeless community to be incredibly friendly, the barriers are all ours to break.
Abe Oudshoorn is a Registered Nurse and faculty member at the School of Nursing, The University of Western Ontario. Abe’s clinical experience and academic research focus on health and homelessness, and Abe has recently founded the London Homelessness Outreach Network (www.londonhon.ca). Abe blogs at www.abeoudshoorn.com/blog, would be happy to hear from you at email@example.com, or can be followed on twitter @abeoudshoorn.
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Stephanie Szakall is the Homeless Hub Coordinator. She's been working in the social justice field for over 5 years as a multimedia/web and graphic designer. She has an HonBA from McMaster University. Upon graduation, she spent 2 years working in the Communications department for a human rights NGO in Geneva, Switzerland.
By Stephen Hwang & Emily Holton
For the first time in Canada, we have the numbers to show that people who are vulnerably housed face the same severe health problems - and danger of assault - as people who are homeless. This means that the number of people experiencing the devastating health outcomes associated with inadequate housing could be staggering. There are about 17,000 shelter beds available across Canada every night, but almost 400,000 Canadians are vulnerably housed. This means that for each person who is homeless in Canada, there are more than 20 other low-income individuals who are vulnerably housed - paying more than half of their monthly income for rent, and living with substantial risk of becoming homeless. We’ve shed light on a hidden emergency.
For the Health and Housing in Transition (HHiT) study, we interviewed 1200 vulnerably housed and homeless single adults in Vancouver, Toronto, and Ottawa. The results were disturbing. People who don’t have a healthy place to live - regardless of whether they’re vulnerably housed or homeless - are at high risk of serious physical and mental health problems and major problems accessing the health care they need. Many end up hospitalized or in the emergency department. Almost half (40%) of people who don’t have a healthy place to live have been assaulted at least once in the past year, and 1 in 3 (33%) have trouble getting enough to eat.
Check out the report on our early findings here: Housing Vulnerability and Health: Canada’s Hidden Emergency. We’re presenting it today at National Housing Day in Ottawa. Over the next two years, the HHiT study will continue to track the health and housing status of our participants. The results will help us better understand how changes in housing status can affect health. They will also help us to identify factors that help people achieve stable, healthy housing.
Having a roof over one’s head is not enough. The HHiT results showed us that the real gulf in health outcomes doesn’t lie between people who are homeless and people who aren’t homeless. It’s between those who have continued access to healthy housing, and those who don’t. To support health, housing must be decent (i.e. good quality), stable (i.e. affordable), and appropriate to its residents’ needs. We’re calling for the federal government to respond by setting national housing standards that ensure universal, timely access to healthyhousing. The need is overwhelming.
Stephen Hwang's primary appointment is in the Department of Medicine at the University of Toronto, with cross-appointments in the Departments of Public Health Sciences and Health Policy, Management and Evaluation. His research focuses on deepening our understanding of the relationship between homelessness, housing, and health through epidemiologic studies, health services research, and longitudinal cohort studies. His current research projects include a study of predictors of health care utilization in a representative sample of 1,200 homeless men, women, and families in Toronto, a study of the barriers to the management of chronic pain among homeless people, and an evaluation of the effects of a supportive housing program on health and health care utilization among homeless and hard-to-house individuals.
Emily Holton is a research writer and knowledge transfer specialist at the Centre for Research on Inner City Health, St. Michael's Hospital.
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