Research Matters Blog
Over the years, it has become increasingly clear to me that we need to take a different approach to youth homelessness. While many communities struggle with the problem (and it is important to note that homeless youth come from every kind of community), we continue, for the most part, to rely on emergency services, such as shelters and day programs, to meet their needs. In many communities, we also rely on law enforcement, driven by the misguided belief that by virtue of being young and homeless, these youth must also be delinquent.
It is unacceptable for us to continue down this road. We need to think more strategically about the problem, and shift from a narrow emphasis on emergency service provision (which does have an important role to play) to a model that also incorporates effective prevention strategies and housing and support options. In doing this, we need to design strategies and interventions that are tailored to the needs of adolescents and young adults.
Youth homelessness is different from adult homelessness in many important ways. Firstly, homeless youth rarely have independent living experience, as they typically leave situations in which they were dependent upon parents and caregivers. Finding an apartment, dealing with landlords, paying bills, etc., then, are things they will likely have never done before. Independent living therefore becomes a big challenge.
The second distinction – and one that really matters - is that young people who become homeless are in the throes of many important developmental tasks (some physical, cognitive and/or social). In contemporary society, the process of growing into adulthood is something that takes time. Taking on new responsibilities, learning to have adult relationships, developing skills and confidence, taking risks – the tasks of growing into adulthood - are for many part of a slow and arduous process that takes many years and includes trial and error, as well as successes. Changes to our economy also mean that many young people continue to live at home for longer periods in order to obtain more education. In any event, it has become harder and harder to afford housing when the only work one can get is part-time and pays minimum wage.
When young people become homeless, they experience what I like to call ‘adolescence interrupted’. That is, the time granted to move into adulthood is dramatically shortened. The irony being that these young people may need extra time because of potential trauma suffered while growing up. For young people, their experience of homelessness is very different from that experienced by adults. For this reason, we cannot simply take our response to adult homelessness and create a ‘homelessness junior’ system of shelters and day programs. We need to think differently.
So, what role can research play in addressing this important issue? The role of research is essential to identifying the underlying features of the problem, assessing the effectiveness of interventions, and pointing the way towards conceptual shifts that are necessary in the identification of effective solutions. The recently released book, Youth Homelessness in Canada: Implications for Policy and Practice does just this. The book aims to fill a gap in the information available on this important issue by providing an easily accessible collection of the best Canadian research and policy analysis in the field.
If we are going to solve youth homelessness in a meaningful way, we need solutions that are informed by the best research. This book has been written with this in mind. In this volume, leading scholars present key findings from their research on youth homelessness. In an effort to make this research accessible and relevant, contributing authors have been asked to address the ‘so whatness’ of their research; to make clear the policy and practice implications of their research so as to better inform the efforts of those working to address youth homelessness.
One final point: the ePub and PDF versions of this book are available for free from the Homeless Hub! We do this because we are committed to the development of more effective solutions to youth homelessness and getting the best information out to the widest audience. Not only can we do things differently, we must do things differently. And research on youth homelessness can help make a difference.
Twenty years ago, Randy Kuhn and Dennis Culhane published the results of a groundbreaking study in the American Journal of Community Psychology showing that over 80% of people who use emergency shelters in large American cities experienced homelessness for short periods of time and most frequently as a one-time event in their lives. In contrast, a relatively small minority demonstrated a cyclical use of shelters with multiple episodes for short periods of time or a small number of stays but for long periods of time. Although these latter two groups were relatively small making up 10% each of the shelter population, they were shown to occupy over 60% of the shelter beds.
Recently, I collaborated with a group of colleagues (Susan Farrell, Stephen Hwang, and Melissa Calhoun) from the University of Ottawa and St. Michaels Hospital on a study that evaluated four years of shelter data from three Canadian cities of different sizes, namely Toronto, Ottawa, and Guelph (this study replicated the analyses of the influential Kuhn and Culhane study). In line with the results of the American study, our research identified three distinct and similar patterns of shelter stays in the three Ontario cities.
The largest group of shelter users, characterized as “temporary”, experienced a small number of homeless episodes for relatively short periods of time. This group comprised 88% of shelter users in both Toronto and Ottawa. We also found a smaller group of users that we defined as having “episodic” shelter use, who experienced multiple homeless episodes for short periods of time. This group represented 11% and 9% of shelter users in Toronto and Ottawa respectively. Finally, the smallest group of shelter users, representing 4% of shelter users in Toronto and 2% in Ottawa, had a relatively small number of homeless episodes but for long periods of time.
The two smaller groups of shelter users occupied over one half of the shelter beds in both Toronto and Ottawa. Similar to the American research, our findings suggest that housing and support services targeting the episodic and long stay users are likely to be the most efficient strategy for reducing the shelter population in Canadian cities. A paper on the findings of our research has been published in Housing Studies. The paper is available online here.
Tim Aubry is a Full Professor in the School of Psychology and Director and Senior Researcher at the Centre for Research on Educational and Community Services at the University of Ottawa. He is currently holder of the Faculty of Social Sciences Research Chair in Community Mental Health and Homelessness. Over the course of his career, Dr. Aubry has collaborated on research projects with community organizations and government at all levels, contributing to the development of effective social programs and policies.
Calgary has a 10 Year Plan to End Homelessness. And the Calgary Homeless Foundation has set very aggressive targets and benchmarks to reframe how our city thinks about and responds to homelessness. As a community, we have decided that it is completely inappropriate for a city of opportunity, like Calgary, to ignore the fact that we have 3,500 homeless men, women and children on our streets and in emergency shelters.
We have created 40 new programs in the last five years to move people from homelessness into housing with supports. Finding housing in our city is a key challenge – but just as critical is ensuring people have supports around them whenever they need them to keep that housing. The support piece is called case management. When working with homeless people, case management has to meet the needs of people with very complex lives and difficult histories. Case management should be person-centred, and delivered by a team of people from varying backgrounds. Open, honest communication and a non-judgemental approach are the keys to success as is ensuring people have an equal role in making decisions.
When case management is done well and people are engaged in the process, it changes lives. So far we have housed and supported 4,500 people in our housing and case management programs. Eighty to ninety percent remain in housing. These individuals are using jails and emergency rooms 54-85% less than when they were homeless and most importantly they are safe, secure and supported. We see dramatic results that cost taxpayers significantly less than ignoring the issue. We know that it can cost upwards of $100,000 per person per year to use emergency shelters, and public systems when they are homeless. Our most expensive case management program is $36,000 per person, per year. Most are around $20,000. Each person in a case management program plays an active part in paying rent and accessing supports and many move into volunteer roles, education or employment.
Case management along with safe, affordable housing is a critical part of the success of our 10 Year Plan. We are well on our way to creating a diverse and adaptable system of care that can meet and respond to this complex issue. Our ending homelessness work in Calgary is helping to build a strong community where all Calgarians can take advantage of the great things our city of opportunity has to offer.
Katrina Milaney is the Acting Vice President of Strategy for the Calgary Homeless Foundation. Katrina has been a researcher for several years engaged in numerous collaborative projects that uncover the root causes of social issues including poverty and homelessness. She has a Master’s degree in Community Health Sciences and is currently pursuing a PhD in Interdisciplinary Studies.
A friend of mine, who teaches at York University, recently lamented the fact that “The students in my class, they don’t read newspapers any more”. Well, I still like to read newspapers myself, but that's not the only way I like to get information. I follow twitter, I’m on Facebook, I use Youtube for everything from watching music videos, to seeing web-based comedy, to figuring out how to do a home repair. People consume information and, perhaps more importantly, learn new things in all kinds of ways, many of them mediated through technology.
You see, the world has changed, and as a researcher and an educator focused on the issue of homelessness, I am very interested in figuring out how to help the public – as well as decision-makers in government and the community – understand that in responding to homelessness, we can do things differently, and that we must. Through our work at the Homeless Hub, we recognize that it just isn’t enough to just push out academic papers that nobody wants to read; that if we really want people to engage research, we need to think differently about how people might want to consume information, and do things differently.
This is why I was blown away when I saw the NFB’s Here At Home interactive website and video series. This site, and the many videos contained within it, is perhaps one of the richest sources of information on homelessness – and how to address it – that I have seen. Right from the opening sequence, which draws you in to the site, to the important facts and figures relating to the five research sites, to the huge number of short video subjects, this is a site that really allows you to learn about and understand homelessness. The short videos profiling those who were once homeless and who have since been housed through the project, humanizes the subject by helping us understand their lives and the fact that, well, they aren’t really that different from you and me. They want to be safe, to be warm, to have dignity, to be housed. Check out the video of Simon from Montreal, and you will see what I mean.
The videos chronicling the experiences of caseworkers and landlords are equally enlightening. It is fantastic to learn from these videos that there are landlords all over the country who are willing to support Housing First and provide homes for people who are homeless. Many of these landlords like Jim the Housing Agent in Toronto seem to get much from their involvement, besides rent. They get a strong sense of fulfillment and an opportunity to participate in contributing to solutions to a seemingly intractable problem.
The videos here are interesting and well produced. They are also short and easy to consume, which is perfect for social media. So, one can visit the site and browse through them. One can also post them on Facebook (at under five minutes, they are perfect), Tweet them. If you are a teacher or professor, these are a great resource for your students. The videos can be used in community meetings, or to show your friends or family. Content like this is really the future of communication and of learning, and the partnership between the NFB and the At Home / Chez Soi project.
So why does any of this matter? For far too long we have dealt with homelessness by warehousing people in emergency shelters or worse still, throwing them in jail. After years of working with many others to address homelessness in Canada, I just feel that things need to change. And change in a big way. But things won’t change at all if people - and I’m talking about politicians, the news media and most importantly the general public – continue to think that everything is OK, or minimally, that the current system is the best we can offer. You know, “Times are tough, and we do provide people who are homeless with shelter and soup kitchens. And really, don’t most homeless people choose to be homeless after all?”.
We need to educate people on this front. The Here At Home series will play an important role in helping people across the country better understand homelessness, through hearing people who have experienced it talk about it. More importantly, the series helps all of us learn that there are real solutions to this seemingly intractable problem, and that Housing First works! The At Home / Chez Soi project shows that even when you take the most hard core, long term case; when you provide that person with a safe and decent place to live, when you treat them with respect and give them the supports they need, they stay housed. Nobody really wants to be homeless.
So visit the site, watch a video or two, and then share it. There are solutions to homelessness!
This article was originally posted on the National Film Board’s ‘Here at Home: In Search of the Real Cost of Homelessness blog.
We met Sayid after he was hospitalized due to an exacerbation of a pre-existing heart condition and foot pain related to long-standing diabetes and chronic exposure to dampness. His admission, the fourth in a six-month period, was largely related to his inability to take his medications as prescribed, lack of an appropriate diet, and limited access to a primary healthcare provider. Generally, he stayed clear of the healthcare system due to discomfort and fear after experiencing discrimination in numerous Emergency Departments and clinics. Furthermore, when he did seek medical attention, his healthcare providers would often suggest unrealistic treatment plans that did not take his unique set of social and living conditions into account.
In the United States, the National Healthcare for the Homeless Council (NHCHC) has established Clinical Practice Guidelines for care of the homeless to address the fact that chronic homelessness can significantly limit a patient’s ability to adhere to a plan of care. Had Sayid’s healthcare providers had access to evidence-based Canadian guidelines to assist them in the care of homeless patients within a local context, we believe that Sayid’s difficult experiences could have been prevented.
Sayid’s story is not uncommon. In fact, it is one of over 2000 that researchers have heard from homeless individuals across Canada who are enrolled in the At Home/Chez Soi Demonstration Project. This five-site (Toronto, Winnipeg, Moncton, Montreal and Vancouver), five-year, longitudinal study funded by the Mental Health Commission of Canada, is currently investigating ‘Housing First’ as an effective intervention for chronic homelessness. Through the provision of homes to 1000 study participants, we are seeing the way that safe and guaranteed housing is a more efficient and effective way to improve the lives of the homeless. In the Toronto arm of the study, we are conducting an analysis of the medical care that our study participants receive, in order to better understand the quality of healthcare provided to the homeless population.
Similar to Sayid, many homeless Canadians experience perpetual worsening of their physical and mental health for reasons that are, for the most part, preventable. Those who stay on the streets often lack access to clean water to take their medication or a safe place to store them. Further, most homeless individuals are unable to access nutritious meals to keep them healthy. When the homeless do receive care, the more frequent users of healthcare institutions report experiencing stigma and discrimination from healthcare providers and authorities. For others, accessing healthcare can be challenging for simple reasons, like having their health card stolen. Finally, up to 67% of the homeless have at some point been diagnosed with a mental illness, which itself is an obstacle to utilizing our universal healthcare system.
The NHCHC guidelines used in the United States are accessed by healthcare providers in a variety of settings and have become the nation’s go-to resource for homeless health provision and education. “The development of evidence-based, homeless-specific Adapted Clinical Guidelines has helped us to firmly establish that people experiencing homelessness have distinctive health care needs that require tailored interventions,” says NHCHC Executive Director, John Lozier. We feel that the homeless in Canada and the United States, and the healthcare systems in which they seek care, are sufficiently different in nature, such that a distinctly Canadian set of evidence-based guidelines will serve to improve the physical and mental health outcomes of our most vulnerable and marginalized. Differences in demographics (e.g. Aboriginal and immigrant populations), causes of mortality and morbidity and access to medical care, underscore a few of the reasons for the development of Canadian guidelines for the homeless.
Clinical Practice Guidelines specific for Canada’s homeless could lead to increased consistency, application and dissemination of best practices in care, thereby empowering healthcare providers to address the lives of these patients holistically, within a locally relevant context. “Increasingly, the social determinants of health are recognized as central to health status, but they are too often understood as phenomena well beyond the reach of healthcare practitioners,” adds John Lozier. Canadian-specific guidelines have the potential to lead to more effective implementation of preventative health measures, early identification of medical issues more commonly seen in homeless patients and more sensitive and less stigmatizing care by healthcare providers. For example, Canadian guidelines could assist healthcare providers in the management of less commonly seen presentations, such as the effects of Canada’s extreme weather patterns (e.g. heat, frostnip, frostbite, trench foot) on a population that is more exposed to the elements. Further, these guidelines could help practitioners by listing locally-relevant opportunities and resources that can potentially increase income and thereby reduce the effects of poverty on health (e.g. navigating provincial disability paperwork, special diet forms, local assistance programs for the homeless). These benefits are especially important given chronic homelessness’ heavy cost to Canadian society and the growing body of literature that supports the stigmatization of homeless populations in healthcare institutions.
As for Sayid, housing, supportive case management and attentive medical care provided through the study have contributed to improved physical and mental health, which has led to increased confidence and hope for the future. With approximately 300,000 homeless Canadians and 10,000 living on the streets without shelter on any given night, we hope that Sayid’s experience can become the norm, through ‘Housing First’.
Excellent Clinical Practice Guidelines have already been established for other vulnerable populations in Canada, such as for the care of immigrants and refugees. Initiatives like the At Home/Chez Soi Demonstration Project contribute to a larger body of knowledge aimed at addressing the challenges and obstacles that Canada’s homeless face on a day-to-day basis. We continue to seek solutions to end chronic homelessness. In the meantime, the development of evidence-based guidelines that address the unique needs of homeless people in Canada is a necessary step forward to improving the health of this marginalized population.
Naheed Dosani is a Family Medicine Resident Physician with the Department of Family and Community Medicine at the University of Toronto and is training at St. Michael’s Hospital. Follow Naheed on Twitter @NaheedD. Adam Whisler is a Research Coordinator for the At Home/Chez Soi Demonstration Project at the Centre for Research on Inner City Health at St. Michael’s Hospital. Follow Adam on Twitter @WhislerA.
This article was originally posted on the National Film Board’s ‘Here at Home: In Search of the Real Cost of Homelessness’ and Health Debate blogs.
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The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.