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.
It wasn’t so long ago that I would lament the lack of impact of research on the homelessness crisis in Canada. You often used to hear people say, “We don’t need research – we know what the problem is and we know what the solution is.”
I used to think, well, wrong on all counts. I could understand people’s impatience with the lack of progress, but really, I couldn’t think of any other crisis – whether it be HIV/AIDS, cancer or global warming – where people would see no need for research. What made this crisis so special?
The good news is that things have begun to change in a big way in the last several years. Communities across Canada are starting to see the value of research, and many researchers finding better ways to engage with service providers, communities, government and with people who have experienced homelessness in order to conduct research that contributes to solutions.
There are in fact many clear ways in which research can make an important contribution. First, there is conceptual research. This is research that inspires shifts in how we think about, understand and talk about the problem of homelessness. Research that poses the question, ‘can we and should we do things differently?’ Here I’m thinking of Hal Pawson’s work on homelessness prevention that has been so influential around the world, or Culhane and Metraux’ work on chronic homelessness in the United States. The recent CHRN Canadan Definition of Homelessness, produced through a collaborative process involving researchers, service providers, people in government and those with lived experience, is conceptual work in that it gives us clear language about how to think about homelessness.
The second kind of research that matters is instrumental research. This is research that helps us understand the effectiveness of our responses to homelessness. In other words, we can no longer just assume we are doing the right thing; we need to better understand, what works, why it works, for whom it works and under what conditions. There is growing recognition in the homelessness sector that we need to do more work on evaluating programs, using data management systems to understand the work at the systems level, and develop robust case study analyses of policy, systems and program level responses that will allow communities to share and adapt promising practices. The At Home / Chez Soi project (funded by the Mental Health Commission of Canada) is the most extensive research project on Housing First ever conducted, and is already showing amazing results. This research will help us really understand how Housing First works for different sub-populations, and in different urban and rural community contexts.
Finally, there is the symbolic use of research. That is, we can use research as evidence to help make the case for retaining what works, or what to do differently. Research can inform policy makers, practitioners, politicians and the general public about homelessness, its causes, conditions and solutions. A good example of this is the recent report: The Real Cost of Homelessness – Can we save money by doing the right thing?, which has inspired conversations across the country about the fact that while we might think that addressing homelessness through emergency services allows us to deal with this issue ‘on the cheap,' it is in fact really quite expensive, and not particularly effective.
So research does seem to matter after all. The challenge in making an impact is taking the evidence and having the learnings applied in real world situations. Communities like Calgary have become leaders in taking an evidence-based approach to solving homelessness, as has the Province of Alberta. All of this makes me optimistic that we can solve homelessness, especially if we draw from research evidence, and involve people from different sectors and walks of life working together to create solutions that treat people with dignity and give them hope.
About Stephen Gaetz
Dr. Stephen Gaetz is the Director of the Canadian Homelessness Research Network and an Associate Professor, Faculty of Education at York University.
CALL FOR PAPERS to the International Homelessness Research Conference: Advancing the Policy and Practice of Crisis Response Systems, to be held Monday, June 3 to Tuesday, June 4, 2013 at the University of Pennsylvania in Philadelphia, Pennsylvania. More details here.
What’s the best housing option for young people who become homeless? This is an important question, because when we design programs for homeless youth, we often create what I call “homeless services – junior”. We take the adult system – emergency shelters, etc., and just change the age limit. This is also true of some of our models of housing and support, whether transitional housing or Housing First. Sure, we understand that young people have different needs, and so we build in life skills, mentoring, training, etc. But the fundamentals of the program are all the same. For instance, it is typically the case that we impose time limits on how long someone can stay (one year residency, maybe eighteen months), and because of the pressure to transition youth to independence, a focus on education often takes a back seat to training and work.
So what do homeless youth need? When talking about how to address young people who are homeless, the best place to start is to think about what any young person needs – what my own sons need, for instance. Most of us take it for granted that growing into adulthood takes time, and that to get there, young people learn skills, behaviours, confidence and ways of being, one bit at a time. It's a time of learning, testing, succeeding and failing, and picking oneself up and dusting oneself off. In order to get there, youth need meaningful and respectful relations and encounters with adults and other young people. We know that we need to help young people stay in school for as long as possible, for in this economy, education and credentialism are more important than ever. The failure to complete high school means youth are less competitive in the labour market, as well as at a greater risk for future health problems and dependence on government supports. We know that growing into adulthood takes time. The days when you could leave home at seventeen, get a job and set yourself up in your own place are long gone. Because of changes to the economy (including a lack of full time entry level jobs that pay living wages), young people are staying at home longer and longer. A recent report from Statistics Canada showed that almost 43% of young people between the ages of 20 and 29 still live with their parents!
So, if we know all of this to be true, why do we treat young people so differently when they become homeless? Why does education get tossed out the window, and why the rush to living independently? Does it make sense to take traumatized youth and rush them into the responsibilities of adulthood, when they lack the necessary life skills, confidence, supports and the ability to compete in the job market? We need to rethink how we deal with homeless youth.
What if the goal of accommodation and supports was a transition to adulthood, rather than simply to independence? If we did that, things would look a lot different. One promising model that could be adapted in the Canadian context is the Foyer. This is a transitional housing model that is quite well developed in the United Kingdom and other European countries, and has been adapted and transformed in Australia. This is a model we can make work in Canada, by blending it with things we have learned about how to address youth homelessness here. The Canadian Homelessess Research Network report on Foyers (and accompanying toolkit) lays out in great detail what a Foyer is, what the research says about its effectiveness as a model of accommodation and supports, and how we can develop it here. What makes the Foyer an effective model of transitional housing is the following: first, it needs to be designed to meet the needs of developing adolescents and young adults. It is more than a roof over one’s head. Second, young people should be able to stay as long as they need to. Foyers in the UK typically have a two-year limit. Ideally, it should be open ended. After all, I don’t give my children a time limit on moving out. Third, education is at the centre of the Foyer model. While young people can also participate in training and employment, engagement in education will have the longest lasting impact on their lives. Fourth, the Foyer supports meaningful engagement. This means learning to establish solid relationships with adults and other youth, opportunities to get involved in the community, and to engage in activities – whether sports, arts, cooking etc. - that inspire and are fulfilling in their own right. The Foyer experience in the UK and Australia demonstrates that this model can be adapted and implemented in urban and rural areas, and that different models of housing can be used, whether a more institutional setting with multiple rooms, or a dispersed housing model.
The Foyer promises to change the way we respond to the needs of young people who become homeless. It is a model of accommodation and supports built to nurture the transition to adulthood in a safe, respectful and meaningful way. I would want nothing less for my own children.
I’ve had this cartoon (below) on my office wall for years. I like its cheeky commentary on how wealth relies upon poverty for its existence, and how the rich are generally oblivious to that fact.
But mostly, in my office, the cartoon plays a cautionary role. It reminds me what kind of researcher I don’t want to be. It’s not just that his gender, clothing, skin colour, and portly physique mark the cartoon researcher as a member of the rich guy’s club. More than anything, it’s his eyes that scare me – so shrewdly focused on the numbers on his ruler, they don’t see the person right in front of him.
Cartoon by Nicholson from “The Australian” newspaper: www.nicholsoncartoons.com.au
It’s a painfully true and humbling caricature of the researcher as bystander. I learned about the bystander role in a graduate course on the ethics of witnessing trauma, but these days, even my school-age kids are taught in their anti-bullying curriculum that the bystander is almost as bad as the bully. Just as wealth relies upon poverty, bullying relies upon people’s willingness to stand by and allow it to happen.
When I wrote my first article about the ethics of research on women’s homelessness, I was a student. Now that I am paid to do research on homelessness, poverty and social exclusion, I—like many of my colleagues—feel a strong responsibility to reflect on the contradictions of this work. To what extent does it make a difference? Are we bystanders to systemic “bullying”? How can we know that we aren’t just contributing to the problem?
Many of us have reached a similar conclusion: research is most likely to make a difference when it’s done not ABOUT, but ALONGSIDE people facing poverty and homelessness. But doing research in this way raises many challenges and questions as well.
Research that is done by, for and with communities facing exclusion is often referred to as Community-Based Participatory Research (CBPR). Though CBPR has been around for decades, it is enjoying something of a renaissance right now, especially in the health sciences. I find it encouraging that many research and advocacy projects focused on women’s homelessness in Canada are using a participatory methodology.
In a report released today on Homeless Hub, Janet Mosher and I share what we learned from a panel of experts involved with some of these projects. With travel funding from the Canadian Homelessness Research Network, they came together at a conference to discuss the ideals of CBPR, their experiences undertaking it, and their recommendations for how research can contribute to action on women’s homelessness. These experts, all of whom are women facing homelessness, brought unique insights to evaluating the strengths of CBPR and addressing its weaknesses.
The report considers CBPR from the perspective of women facing homelessness who have been involved in it as participants, “peer” researchers, activists or service providers who use research. All agreed that CBPR on homelessness and poverty must lead to action, and that people with lived experience have a vital role to play in this process. As one expert said, “It’s important that women are part of the team. Our knowledge and skills and strengths may be different than a university professor’s, but it’s important to acknowledge that experience. That is what will turn into action.”
At the same time, women pointed out, entrenched inequities in power and authority mean that institutions and professionals usually reap more of the benefits from research, even when it’s CBPR. In the words of one CBPR participant, “The University gets the money and funding to do it, they get the recognition for the ideas and questions, when women came up with it at the kitchen table of a drop-in.”
Researchers with lived experience hold a strong sense of responsibility for participants’ well-being, for honouring participants’ contributions through advocacy and action, and for ensuring that research funds are well-spent on worthwhile projects. “Lived experience researchers become advocates because we know the experience,” explained one peer researcher from a university-based project. If CBPR is to live up to these responsibilities, projects need to provide the training, resources, skills and power that community members need to use research products for action.
In the end, women want allies in the academy to think carefully about the worth of proposing new research, when so much research has already been done on poverty and oppression. "Stop repeated projects," insisted one expert. "We need to look at all the research that has been done and is going to be done, and implement it. Take the story, take the needs, and DO something."
In helping to support young people move out of homelessness – or indeed to avoid homelessness in the first place – labour market integration presents both one of the greatest challenges, but at the same time, an incredible opportunity. The benefits of employment for at risk youth should be self-evident: income that can support housing and improved nutrition, positive engagement with adults and other employed youth, improved self-esteem, health and well-being. The barriers to employment, however, are not always so obvious.
And for young people who are homeless, there is much that gets in the way of obtaining and maintaining employment. It is sometimes assumed that young people who are homeless are lazy, attracted to the freedom the streets offer, and not properly motivated to ‘help themselves’. That is, they aren’t really looking for work. So, would employment training help? Mainstream employment training programs focus on building hard skills (marketable skills) and soft skills (how to find a job, create a resume, deal with employers and colleagues), and increasing motivation.
While there is no doubt that a lack of skills contributes to the underemployment of homeless youth, there is much more to this story, as the reality of life on the streets is much different than the stereotypical depiction of youth homelessness suggests. Canadian research highlights that motivation isn’t really the problem, as the overwhelming majority of homeless youth would much rather have a regular job than earn money through panhandling, squeegeeing or criminal activity, which is seen as demeaning and humiliating to many young people who have to rely on such activities for income.
Rather, in order to work or even successfully participate in employment training, such youth need what any young person needs. They need permanent housing (with necessary supports) that is safe and appropriate, so they can rest, recover, have privacy and maintain hygiene (this is generally not the emergency shelter model). They need income, to ensure they have food, transportation and supplies for work, while they are waiting for their first pay cheque. They may need a range of necessary supports – based on individual circumstances - if they are dealing with health issues, disability, mental health challenges and addictions. They need positive engagement with adults – to provide support, mentorship and direction. And significantly, they need opportunities to advance their education, which as we know will have the longest lasting benefits in terms of enhancing the employability and lifechances of marginalized young people.
This latter point is important, because when young people become homeless in Canada, the goal of educational engagement is often a low priority in the rush to support them to become self-sufficient.
The Canadian Homelessness Research Network, with support from the Homelessness Partnering Strategy, is releasing an ebook on youth homelessness in early 2013, with a dedicated section on labour market integration. These chapters, which draw on the latest research, provide communities that are working to address youth homelessness with solid evidence regarding what works. The first chapter focuses on what we know about youth homelessness and employment, the most significant barriers to labour market participation, and key elements of a successful strategy for training and integration into the workforce. The second chapter highlights the role of corporate engagement in labour market integration for homeless youth. Here, the authors highlight the major findings from Raising the Roof’s Private Sector Engagement Project. The final two chapters present ‘promising practices’ in employment training for homeless youth. Case studies of “Train for Trades" in St. John’s, NL, and “BladeRunners” in Vancouver highlight successful and innovative program models that address the barriers that homeless youth face; models with potential for adaptation elsewhere in Canada. Look for these chapters and others in the New Year when the CHRN launches our latest ebook: Youth Homelessness in Canada: Implications for Policy and Practice.
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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.