Research Matters Blog
Reproductive health deals with the reproductive processes, functions and system at all stages of life. Although reproductive health is a universal concern, certain groups face inequalities when accessing healthcare. Socioeconomic status, education level, age, ethnicity and religion can all have an influence on how individuals maintain their reproductive health. As a result, people experiencing homelessness who are economically marginalized often do not have access to the supports, resources and information they need.
According to the World Health Organization, reproductive and sexual ill-health accounts for 20% of the global burden of ill-health for women, and 14% for men. Transgender and non-binary individuals who are disproportionally affected by homelessness also face unique reproductive health issues. They face obstacles to accessing quality healthcare, including gender-based discrimination that may occasionally result in refusal of treatment, and a lack of LGBTQ2S cultural competency. Compounded with the discrimination, erasure and transphobia often normalized in the shelter system, the reproductive health care needs of transgender individuals experiencing homelessness are frequently unaddressed.
Evidently, reproductive health is a universal issue that impacts various populations in different and extensive ways. This blog post will focus on three key areas of reproductive health relating to different populations who experience homelessness: menstruation, pregnancy and contraception.
The difficulties associated with homelessness are extensive, and include a lack of food, shelter, healthcare, mental health supports, and other vital resources. People experiencing homelessness who menstruate have the additional burden of managing their periods — a monthly occurrence that is unavoidable and expensive. Combined with the stigma that surrounds menstruation, women, trans men, and other people experiencing homelessness who menstruate often lack support that would help mitigate many of their problems. The upkeep of menstrual hygiene is a matter of dignity, but it is also crucial in order to avoid damaging reproductive and gynaecological health.
A recent study examined how women experiencing homelessness in the U.K. manage menstruations in a context of financial and social vulnerability. Many of the participants interviewed described the difficulty of prioritizing their limited funds for sanitary products. They were forced to make a decision between cheap self-made solutions and more reliable, but expensive, store-bought products. Those unable to purchase menstrual hygiene products have to manage the problems that arise from using homemade solutions, such as chemical irritation or yeast infections. Homemade solutions can also increase the likelihood of toxic shock syndrome and other life-threatening health risks.
Transgender individuals disproportionately experience homelessness when compared to the cisgender population. Those who were assigned female at birth and are grappling with gender dysphoria (distress because of a mismatch between physical appearance and gender identity) may have preferences over the sanitary products they use to reduce their dysphoria. The experience of homelessness and financial vulnerability removes much of the autonomy people have over how they manage their periods. Therefore, in the interests of both mental and physical health, it is important that menstrual products are widely available to those who are unable to afford them.
In Toronto, there is the Period Project, a street outreach group providing people living unsheltered with free sanitary items. In the U.S., there is Distributing Dignity, a women-led non-profit distributing pads, tampons and bras to people accessing homeless shelters, those who have aged out of the foster care system and families impacted by HIV/AIDS. New York City recently became the first city in the U.S. to require public schools, jails, and homeless shelters to provide free pads and tampons. In the Canadian Observatory on Homelessness’s Point-in-Time Toolkit, we recommend that communities include sanitary products as an honoraria item.
Other activist groups and movements advocate for the “tampon tax” be eliminated from state laws to those who cannot afford menstrual products. They argue the opportunities to enjoy fairly priced, tax-free products are not luxuries; rather, they are necessities. Menstruation is often overlooked and forgotten in reports addressing the health needs of people experiencing homelessness, and therefore fails to come to the attention of policymakers and service managers.
Homelessness and pregnancy
The stress of homelessness can have significant negative impacts for those who are pregnant. Due to compromised health, people who are pregnant and experiencing homelessness face greater health risks. They often have difficulty accessing healthcare and prenatal programs, which can result in potential prenatal complications going unnoticed. No one should be without a safe, stable place to call home, especially during pregnancy since this additional strain on the body can be life-threatening. The emotional and psychological aspects of pregnancy, birth, motherhood and/or the loss of a child can have further negative implications, especially for a vulnerable and marginalized population.
Pregnancy rates are also substantially higher among youth experiencing homelessness than in the general youth population. The adversity of life on the streets means that young people are exposed to increased sexual activity with more partners and increased exposure to STIs. To address this, effective and accessible pregnancy prevention and family planning programs for youth experiencing homelessness are needed.
Moreover, the relationship between substance use and homelessness is complex, and rates of substance use are disproportionately high among those experiencing homelessness. There are numerous potential harms associated with the use of substances during pregnancy, including Fetal Alcohol Spectrum Disorder (FASD), which can occur as a result of alcohol use during pregnancy, and Neonatal abstinence syndrome (NAS), a condition that a newborn may experience if exposed to addictive opiate drugs while in the womb. Homelessness and parental substance use may reduce neonatal well-being through prematurity and low birth weight.
Pre- and post-natal care programs help to prevent potential health problems throughout the course of the pregnancy. Toronto Public Health’s Homeless At-Risk Prenatal (HARP) team provides intensive prenatal case management to high-risk pregnant women experiencing homelessness in Toronto, focusing on service coordination as a primary intervention.
In spite of this, available services go underutilized often because of parents’ reluctance to self-identify as “homeless” or “underhoused.” According to Ontario’s Ministry of Health and Long-Term Care the number of babies born in the past six years to parents while experiencing homelessness in Ontario each year ranged from fewer than five to eight. However, there is a huge discrepancy between the number of pregnancies that occur and the number that are recorded. Young Parents No Fixed Address (YPNFA), a network of organizations working to address the challenges faced by youth experiencing homelessness or street-involved youth, pregnant and parenting youth and their children, have found this number to be much higher. As reported in July 2017 by Toronto Star, an estimated 300 babies were born into homelessness in Toronto each year between 2012 and 2014. Parents’ fear of losing custody has prevented them from disclosing their housing status, and has resulted in a significant underrepresentation of the scope of the issue.
Much like menstrual hygiene products, methods of contraception can often be costly and difficult to obtain. In Canada, street nurses play a crucial role in contraceptive education and provision for people experiencing homelessness. This can include distributing condoms and other contraceptives, HIV and pregnancy testing as well as educating those experiencing homelessness on safer sex practices.
People experiencing homelessness, particularly young women involved in the sex trade, are at increased risk of sexually transmitted diseases, including hepatitis, chlamydia, gonorrhea and HIV infection. Also, both men and women experiencing homelessness are at increased risk for disease due to injection drug use, multiple sexual partners and unprotected sex.
While access to contraception has increased substantially in recent years, low-income individuals are still twice as likely to use no contraceptives compared to higher income earners. Accessible birth control is one of the easiest ways to reduce costs on the healthcare system, but unlike in the U.S., U.K. and several countries in Europe, there is no universal subsidy for contraception in Canada.
A recent survey conducted by the Society of Obstetricians and Gynaecologists in Canada (SOGC) reported that 61% of Canadian women have had an unintended pregnancy. Following these alarming results, SOGC launched SexandU.ca to raise awareness about contraception and sexually transmitted infections. SexandU.ca provides accurate, credible, and up-to-date information and education on topics related to sexual and reproductive health.
Reproductive health is an extensive topic and this blog post covers only three areas of focus; there are still many other important and complex issues. You can learn more about sex workers and the sex trade in the topics section of our website. You can also help to continue this conversation on the Community Workspace on Homelessness at workspaceonhomelessness.ca.
(Image source: https://www.period.org)
As part of our ongoing commitment to elevating the voices of youth with lived experience of homelessness, A Way Home Canada and the National Learning Community on Youth Homelessness have partnered with Street Child United to send a team of Canadian youth to the 2018 Street Child World Cup in Moscow, Russia. This event will be held prior to the 2018 FIFA World Cup.
There are 22 countries participating in the event and this will be the first year with an equal number of boys and girls teams (12 teams for each). The age range of young people participating is 13-17 years old. This will be Canada’s first time participating.
Here is a powerful video produced by Street Child United called "The Power of Football to Change Lives." Street Child United also created a short video from the 2014 World Cup called “Here Come the Girls!” In this video, there is an amazing moment at the 2:50 mark when Indonesia scores its first goal of the tournament and both teams celebrate.
The Street Child World Cup is more than a football (AKA soccer) tournament. It also incorporates arts programming and an international youth congress. At the 2016 Street Child Games, youth designed their “Rio Resolution,” calling for their countries and communities to act and protect all street children’s rights. There are three main points to the Rio Resolution: protection from violence, right to education and the right to identity. In 2018, youth will design their “Moscow Manifesto.”
The Learning Community will support the selection of the players. A Way Home will support the logistics of getting the team to Moscow (fundraising, training and travel). In our first year participating, Canada will send a girls team, which will consist of nine players and three staff members.
Prior to arriving in Moscow in 2018, Team Canada participants will not only show off their soccer skills, but also participate in workshops on public speaking, community organizing, anti-oppression and team building. Our focus is ensuring that Team Canada is prepared for the congress component of the Street Child World Cup. We also want to make sure our players are prepared for returning home after the World Cup is over.
To prepare for the 2018 event, Street Child United hosted a summit in Moscow from June 19 to 23 for the team leaders of the countries participating in the 2018 World Cup. The primary focus of the summit was keeping the young people who will represent their countries at the centre of the World Cup and ensuring they are prepared to participate and for going home post event.
Street Child United shared a great summary of the Summit. “... Delegates shared insights into their work with the world’s most marginalised children, and took part in sessions on topics such as safeguarding and how to organise visas for more than 200 children who have never had a birth certificate or identity card who will travel to Russia next year.” (The Summit has given our movement real momentum.)
For us, it was a great experience to meet the team leaders from the other participating countries and learn from those who are returning for another event. Returning team leaders shared their experiences with the new leaders.
Jessica Hutting, who works at Kampus Diakoneia Modern Foundation (KDM) in Jakarta, Indonesia, shared that the girls on her team were surprised to learn that there were youth experiencing homelessness in countries like England and the U.S. Florence Soyekwo from RETRAK in Uganda highlighted that there was a need to address the economic disparity that exists between countries.
We are excited to be involved with this project and support the convening of Team Canada for the first Street Child World Cup. Stay tuned for updates as this initiative unfolds!
Team leaders from Mexico, Brazil, the U.S. and Canada
Team leaders working in small groups
On May 18, 2017, the Second Annual Canadian Homelessness Data Sharing Initiative took place in Calgary (all slide presentations, as well as photos from the event, are available here). The event was organized by the Calgary Homeless Foundation and the University of Calgary’s School of Public Policy, and the participants included: people who build datasets (about persons experiencing homelessness); researchers who use that data; persons with lived experience; and public servants.
Here are 10 things to know about this year’s event:
- For the second year in a row, there was strong representation from Canada’s federal government. Five officials from Employment and Social Development Canada (ESDC) participated, three of whom had formal speaking roles at the event. Aaron Segaert (from ESDC) presented data from more than 200 homeless shelters between 2005 and 2014, showing that:
- the occupancy rate (i.e. % of beds filled each night) across these shelters rose from 83% in 2010 to 92% in 2014;
- the average ‘duration of stay’ by households using these shelters is increasing, especially for families and seniors;
- the number of seniors using homeless shelters annually nearly doubled across Canada between 2005 and 2014.
- This year’s event had strong Quebec representation. Research presented by Annie Duchesne, for example, finds that certain subgroups of persons in Montreal’s largest homeless shelter are more likely to experience chronic homelessness (i.e. long-term homelessness) than others—those subgroups include persons over the age of 50, persons with mental health problems and persons with disabilities.
- Indigenous perspectives were presented. Bonnie Healy’s presentation focused on the work of the Alberta First Nations Information Governance Centre. Topics raised in her presentation included First Nations OCAP principles, a publication titled First Nations – Health Trends Alberta, the First Nations health status report for the Alberta region, the work of the Alberta First Nations Governance Centre, and Indigenous logic models.
- Several data-sharing advocates actively participated in this year’s event. Michael Lenczner, a data-sharing champion in Canada’s social sector, attended and spoke at this year’s event. He stated that, in terms of data sharing, he’s not aware of any other subsector of Canada’s non-profit sector that has an annual forum to discuss the importance of data. He also cited Alberta as a leader in data sharing, making reference mostly to PolicyWise, who’ve worked with government to link client administrative data from multiple ministries. They’re the leaders of this kind of data-linking in Canada, and possibly the world.
- Difficulties with researchers accessing federal homelessness data were raised. Tracey Lauriault is a Carleton University professor who described her past difficulties in trying to access HIFIS data for research. When she did, she was told that her data requests must be sent to community coordinators; yet, federal officials were never able to provide her with a list of community coordinators.
- One of the event highlights was a panel discussion on moving towards increased national integration of Homelessness Management Information Systems (HMIS). As I’ve written before, there are multiple software systems across Canada that keep data on persons experiencing homelessness; many people would like to see increased integration of these systems (possibly into one very large system, or at least the sharing of data among these systems so that researchers can have larger samples for their work). Henry Dagher (ESDC) discussed the evolution of the Homeless Individuals and Families Information System (HIFIS) software system (which is one type of HMIS system). This federally-administered HIFIS system is now operating in more than 100 communities. HIFIS 4 is now web-based and gaining strong momentum; BC Housing is now implementing HIFIS province-wide (spanning approximately 200 service providers). Several panel members suggest that community members need to gain more control of HIFIS (via a stakeholder advisory body with some clout that includes persons with lived experience). As Michael Lenczner puts it: “The tail shouldn’t wag the dog.” Jenn Legate (Calgary Homeless Foundation) raised several operational concerns that need to be kept in mind as we move forward on increased national integration of HIMIS systems—namely, the ongoing costs a server, the cost of migrating data from an old database system to a new system, challenges pertaining to customer service provided by software vendors, and legal barriers to data sharing.
- Important findings were presented from Canada’s recent nationally-coordinated Point in Time Count of homeless persons. Patrick Hunter’s presentation noted that more than 25% of homeless persons enumerated during the 2016 count did not use an emergency shelter during the previous year—I think this speaks in part to conditions in emergency shelters, about which there’s virtually no research. Hunter also reported that Indigenous peoples are nine times more likely to experience homelessness than the rest of Canada’s population; what’s more, more likely to experience longer homeless spells than non-Indigenous people.
- One of the event highlights was a “review of the day” by Stephen Metraux. Metraux, the Director of the Health Policy Program at the University of the Sciences in Philadelphia, gave a ‘wrap up’ presentation that included a short slide presentation. He subsequently wrote a blog post in which he reflected on his experience at the event.
- Several suggestions were made about a ‘way forward.’ Topics that need to be tackled in the future include:
- important work being done by Statistics Canada pertaining to data linking;
- work being done by the Canadian Institute for Health Information, where medical data is being consolidated across provinces (i.e., provinces are sharing health care data);
- better national coordination of HMIS systems;
- more data sharing and standards;
- the possibility of developing a repository of data pertaining to homelessness (see point #7 of this previous blog post); and
- the development of a National Data Strategy for Homelessness.
- This will continue to be an annual event that we expect to be held each year in (or near) Calgary. It may also evolve into a two-day format, with one day focusing on the operational aspects associated with building, maintaining and improving HMIS systems. All of these operational matters are the focus of this biannual event in the United States; yet, no Canadian equivalent currently exists.
In Sum. We hope this annual event will help communities across Canada get closer to ending homelessness. The event web page—with slide presentations and minutes from the event—can be found here.
A blog post written about the First Annual Canadian Homelessness Data Sharing Initiative can be found here.
The author wishes to thank the following individuals for invaluable assistance with this blog post: Vicki Ballance, Ron Kneebone, Eric Latimer, Tracey Lauriault, Kara Layher, Michael Lenczner, Lindsay Lenny, Stephen Metraux and one anonymous source. Any errors lie with the author.
 This 2016 report on conditions inside Out of the Cold facilities and Warming Centres is worth reading. However, it should be noted that the facilities that are the focus of this report are not “homeless shelters” as defined by City of Toronto officials; rather, they operate separately from the formal shelter system.
This blog post has been republished with permission from the Calgary Homeless Foundation website.
Calgary Homeless Foundation (CHF) recently unveiled new key performance indicators (KPIs) for programs they fund. These new indicators were developed after nine months of community consultation and have been piloted over the course of the past year. A May 2017 slide presentation on the development of some of these KPIs can be found here, while a seven-page guide for staff in the sector who do data entry can be found here.
Here are 10 things to know.
- Once a client is referred to a housing program, staff who work for that program are expected to locate the client and move them into housing ASAP. Calgary’s Homeless-Serving System of Care uses a triage system called Coordinated Access and Assessment (CAA). On a weekly basis, staff from the sector meet to discuss persons who are experiencing homelessness and who need to be housed, available housing units and ‘who fits where.’ Program referrals are based on conversations that take place at that table. Once a referral is made, CHF makes sure program entry occurs in the shortest possible time. CHF’s KPIs also monitor the percentage of referrals that never materialize (possible reasons for a referral not materializing include: the referral was declined by the funded program or by the client, or the referral didn’t happen because the client couldn’t be located).
- Funded programs are encouraged to provide staff only as required (i.e. to not ‘over support’). CHF takes the position that while some tenants will always need case management support (i.e., ongoing professional staff support) many tenants won’t require such support (and some never require it). CHF therefore encourages funded programs to remove unnecessary professional support and promote independence. In that way, CHF creates a smoother ‘flow’ through the system.
- Programs funded by CHF are encouraged to persevere in keeping challenging tenants housed. Programs in the single adults and families sector are encouraged to keep people housed for at least nine months (i.e., three consecutive quarters); whereas those in the youth sector are expected to keep a person housed for at least six months (i.e., two consecutive quarters). In all sectors, maintaining housing can include moving people to a new unit in cases where a specific tenancy hasn’t worked well. In effect, programs are encouraged to take on challenging clients and to not give up on them.
- Once a person is successfully housed, CHF encourages program staff to be mindful of ‘missing tenants.’ This incentivizes funded programs to track down clients who are missing and to go back to the ‘CAA table’ to offer the vacated spaces to a future tenant within a short time frame.
- CHF-funded programs are encouraged (and generally want) to beat the average score for their cohort. On most of the above measures, a cohort average figure (based on the previous year) is calculated for all programs in a specific category (for more on the different categories of programs funded by CHF, see this recent blog post on CHF’s System Planning Framework). CHF sets a benchmark score 10% above the average. Funded programs in that category are then encouraged to score at or better than that benchmark (i.e. at or better than 10% above the cohort average of the previous year).
- All of this data is tracked through Calgary’s HMIS system. Each quarter, CHF staff use HMIS data to calculate KPI results for all CHF-funded programs. KPI results are then emailed to funded programs each quarter. No follow-up is required for programs that perform well in their KPIs. However, if CHF staff finds a program’s KPIs to be problematic, they may contact the program for clarification. CHF recognizes that a problem may be simply technical in nature (e.g., a new staff person isn’t entering data into HMIS properly). Other times, it may be a performance issue.
- An accreditation process helps ensure accurate data entry. Programs funded by CHF go through an accreditation process with an external accrediting body called the Canadian Accreditation Council (CAC). This service is paid for by CHF. CHF has its own standards that it has developed with help from CAC, and CHF-funded programs are expected to meet these standards. This process involves client file review, staff interviews and client interviews. Detailed reports are then provided to both CHF and the funded program. Among other things, this process helps ensure accurate data entry. Client case notes and files are reviewed during each accreditation by the CAC team.
- HMIS training also helps ensure accurate data entry. This training, provided free of charge, is provided to programs by CHF staff on a regular basis. Follow-up HMIS technical support is offered throughout the year.
- The Government of Alberta (GoA) is a strong supporter of the CHF’s KPIs. The GoA continues to show very strong interest in CHF’s KPIs. GoA plans to report on similar KPIs for the 2018/19 Ministry of Community and Social Services Business Plan which will include results from across the homeless serving system. According to one GoA source: “We have drawn heavily on CHF work to inform this thinking.”
- CHF will soon unveil new KPIs for programs that specifically serve Indigenous peoples. These KPIs have been developed in collaboration with key members of Calgary’s Indigenous community. This will be the subject of a future blog post.
The author wishes to thank Brian Bechtel, Jennifer Eyford, Geoff Gillard, Chantal Hansen, Sarah Knopp, Friney Labranche, Kara Layher, Sara Mikhail, Angela Pye, Jaime Rogers, Ken Swift, Alina Turner and two anonymous reviewers for invaluable assistance with this blog post. Any errors lie with the author.
This blog post has been republished with permission from the Calgary Homeless Foundation website.
We’re in the heart of the month of Ramadan, a time of prayer, fasting, reflection, and community for many Muslims. Within youth-serving environments, there’s a lot we can do to take a proactive approach and better support young people who are observing Ramadan. It is critical that youth are not always required to do the asking for accommodations and supports; we should plan to offer it first.
Tip 1: We can avoid assumptions.
We’re in a context where Christian traditions are considered a norm and other spiritual and faith traditions don’t get the same attention and support. That in and of itself can make it difficult for youth accessing community services to disclose that they’re observing or want to observe Ramadan.
At the same time, making an assumption that a young person is observing Ramadan is also a problem. Youth in precarious situations are not usually required to fast. And some youth may find this to be a triggering time of year in general, as many people struggle during holiday, celebration, or holy seasons. There may be many reasons behind this struggle. For example, young people may be feeling mixed emotions during Ramadan because their homelessness may make them feel far from family and community practices that are important to them.
This is why it’s so important to be conscious of and put aside our assumptions.
Tip 2: We can open space for observance.
It takes intentional effort to create a welcoming environment where youth can disclose their observance of Ramadan and feel assured that they will be supported. Here are practical things we can do to get there.
- Offer young people a substantial snack after sunset hours. When Ramadan happens in the spring and summer months, sunset can be late in the day and food practices in youth-serving spaces may have to adjust accordingly.
- Provide takeout containers at mealtimes for youth to be able to store some food for later.
- Put together some portable food packages for people to take whenever they need it during the month.
Lots of youth may take advantage of these helpful offerings during the month of Ramadan, observing or not, and that’s a good thing!
Tip 3: We can have culturally appropriate foods on hand.
When it’s time to break their fasts, many people do it with something sweet. Dates and coconut water are both common items people consume. But these are not necessarily everyday snacks in youth spaces, including shelter and transitional housing spaces. Having these items on hand and creating some flexibility around purchasing specific items youth may ask for can go a long way!
Tip 4: We can host Iftar opportunities for youth.
Iftar is a time for people to get together and break their fasts in community. Creating opportunities for youth to do this together and share what Ramadan is about can be an amazing way of building community connection.
This blog post has been republished with permission from the Eva's website.
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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.