No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Street Health Report 2007: Community-Based Research for Social Change
Abstract
Homelessness is a devastating social issue that affects a large number of people in Toronto, Canada’s largest city. According
to a survey conducted by the City of Toronto, a minimum of 5,052 individuals were estimated to be literally homeless on one
night in April 2006 (City of Toronto, 2006), and in 2007, at least 24,868 individuals stayed in a Toronto shelter at least
once (City of Toronto, 2008).
... This is not to suggest that Toronto does not have its share of both physical and social disorder. For example, while few homeless people were observed during the study, we know that Toronto has many homeless residents [37]. Rather the tool failed to capture this facet of city life. ...
There is a growing body of evidence that where you live is important to your health. Despite numerous previous studies investigating the relationship between neighbourhood deprivation (and structure) and residents' health, the precise nature of this relationship remains unclear. Relatively few investigations have relied on direct observation of neighbourhoods, while those that have were developed primarily in US settings. Evaluation of the transferability of such tools to other contexts is an important first step before applying such instruments to the investigation of health and well-being. This study evaluated the performance of a systematic social observational (SSO) tool (adapted from previous studies of American and British neighbourhoods) in a Canadian urban context.
This was a mixed-methods study. Quantitative SSO ratings and qualitative descriptions of 176 block faces were obtained in six Toronto neighbourhoods (4 low-income, and 2 middle/high-income) by trained raters. Exploratory factor analysis was conducted with the quantitative SSO ratings. Content analysis consisted of independent coding of qualitative data by three members of the research team to yield common themes and categories.
Factor analysis identified three factors (physical decay/disorder, social accessibility, recreational opportunities), but only 'physical decay/disorder' reflected previous findings in the literature. Qualitative results (based on raters' fieldwork experiences) revealed the tool's shortcomings in capturing important features of the neighbourhoods under study, and informed interpretation of the quantitative findings.
This study tested the performance of an SSO tool in a Canadian context, which is an important initial step before applying it to the study of health and disease. The tool demonstrated important shortcomings when applied to six diverse Toronto neighbourhoods. The study's analyses challenge previously held assumptions (e.g. social 'disorder') regarding neighbourhood social and built environments. For example, neighbourhood 'order' has traditionally been assumed to be synonymous with a certain degree of homogeneity, however the neighbourhoods under study were characterized by high degrees of heterogeneity and low levels of disorder. Heterogeneity was seen as an appealing feature of a block face. Employing qualitative techniques with SSO represents a unique contribution, enhancing both our understanding of the quantitative ratings obtained and of neighbourhood characteristics that are not currently captured by such instruments.
Background
People who use drugs and are structurally vulnerable (e.g., experiencing unstable and/or lack of housing) frequently access acute care. However, acute care systems and providers may not be able to effectively address social needs during hospitalization. Our objectives were to: 1) explore social service providers’ perspectives on addressing social needs for this patient population; and 2) identify what possible strategies social service providers suggest for improving patient care.
Methods
We completed 18 semi-structured interviews with social service providers (e.g., social workers, transition coordinators, peer support workers) at a large, urban acute care hospital in Western Canada between August 8, 2018 and January 24, 2019. Interviews explored staff experiences providing social services to structurally vulnerable patients who use drugs, as well as continuity between hospital and community social services. We conducted latent content analysis and organized our findings in relation to the socioecological model.
Results
Tensions emerged on how participants viewed patient-level barriers to addressing social needs. Some providers blamed poor outcomes on perceived patient deficits, while others emphasized structural factors that impede patients’ ability to secure social services. Within the hospital, some participants felt that acute care was not an appropriate location to address social needs, but most felt that hospitalization affords a unique opportunity to build relationships with structurally vulnerable patients. Participants described how a lack of housing and financial supports for people who use drugs in the community limited successful social service provision in acute care. They identified potential policy solutions, such as establishing housing supports that concurrently address medical, income, and substance use needs.
Conclusions
Broad policy changes are required to improve care for structurally vulnerable patients who use drugs, including: 1) ending acute care’s ambivalence towards social services; 2) addressing multi-level gaps in housing and financial support; 3) implementing hospital-based Housing First teams; and, 4) offering sub-acute care with integrated substance use management.
Understanding the specific factors associated with poor health is critical to improve the health of homeless people. This study aimed to analyze the influence of personal variables, interpersonal relationships, and the influence of social services on the health of homeless people. A secondary analysis was applied to cross-sectional data from a sample of 1382 homeless people living in the Basque Country (Spain) (75.69% male). Multinomial logistic regression modelling was used to analyze the relationship between health and personal variables, interpersonal variables, perceived help and use of the social services. Relationships with the family, using a day center, and a sufficient and high perceived help of the social services were significant factors associated with good health. On the other hand, spending the day alone or using mental and health care services are associated with poor health. In the same way, the longer a person has been homeless, the worse their expected state of health is. Addressing housing exclusion, promoting interpersonal relationships, using a day center, and developing the use and perceived helpfulness of social services stand out as key factors in improving health status. Social policies are usually focused on housing. However, this paper also highlights the relevance of developing interpersonal relationships and using day centers to improve homeless people’s health.
Background
Diabetes is a chronic medical condition that requires patients to be actively engaged in intensive self-management to achieve optimal clinical outcomes. Unfortunately, individuals who are experiencing homelessness often struggle to manage diabetes and consequently suffer numerous and severe complications—both acute and chronic. There are many barriers to optimal diabetes self-management among this population, and this may be exacerbated by the lack of tailoring and customization of care to this unique population. Given this disconnect, it is likely that many organizations have attempted to provide specialized innovations for this population—which may or may not be reported in the formal literature. Our objective is to perform a scoping review to summarize and synthesize the experiences of those who have attempted to provide tailored interventions.
Methods
We propose a mixed methods scoping review that will include both a formal search of the published literature (MEDLINE, CINAHL, EMBASE, Web of Science, Scopus) and a thorough search of the grey literature. Eligible articles and documents are those that report on an intervention or guideline for the management of diabetes among those experiencing homelessness. All titles and abstracts will undergo duplicate review, as will the full article/document. We will include any report that either includes a description of an intervention or provides recommendations for the treatment of individuals who are homeless with diabetes. We will extract both qualitative and quantitative data for analysis and interpretation. Meta-analysis will not be performed.
Discussion
Those experiencing homelessness who also have diabetes often struggle to manage their chronic condition. When care is tailored to suit their needs, it is feasible that outcomes may be improved. By collating and synthesizing information from diverse organizations and jurisdictions, we hope to facilitate the sharing of knowledge with others who wish to provide this type of care.
Electronic supplementary material
The online version of this article (10.1186/s13643-019-1020-x) contains supplementary material, which is available to authorized users.
Being homeless has a negative effect on health and the health needs of individuals experiencing homelessness are complex and challenging to address. As a result of limited access to and use of primary healthcare, the main point of entry into the healthcare system for individuals experiencing homelessness is often hospitals and emergency departments. Persons experiencing homelessness are commonly discharged from hospital settings to locations that do not support recovery or access to follow‐up care (e.g. shelters or the street). This can be costly to both the healthcare system and to individuals' health and quality of life. We conducted a scoping review of the literature published between 2007 and 2017 to identify the types of health supports needed for persons experiencing homelessness who are discharged from the hospital. Thirteen literature sources met inclusion criteria and thematic data analyses by two researchers resulted in the identification of six themes related to the types of health supports needed for persons experiencing homelessness who are transitioning (i.e. being discharged) from the hospital. Using a community consultation approach, the scoping review themes were validated with 23 health and shelter service providers and included in our integrated findings. Themes included: (a) a respectful and understanding approach to care, (b) housing assessments, (c) communication/coordination/navigation, (d) supports for after‐care, (e) complex medical care and medication management, and (f) basic needs and transportation. These themes were found to resonate with participants of the community consultation workshop. Recommendations for trauma‐informed care and patient‐ or client‐centred care approaches are discussed.
Objective:
This study examines health and service use outcomes and associated factors among homeless adults participating in a brief interdisciplinary intervention following discharge from hospital.
Method:
Using a pre-post cohort design, 223 homeless adults with mental health needs were enrolled in the Coordinated Access to Care for the Homeless (CATCH) program, a 4- to 6-month interdisciplinary intervention offering case management, peer support, access to primary psychiatric care, and supplementary community services. Study participants were interviewed at program entry and at 3- and 6-month follow-up visits and assessed for health status, acute care service use, housing outcomes, mental health, substance use, quality of life, and their working alliance with service providers. Linear mixed models and generalized estimating equations were performed to examine outcomes longitudinally. Additional post hoc analyses evaluated differences between CATCH participants and a comparison group of homeless adults experiencing mental illness who received usual services over the same period.
Results:
In the pre-post analyses, CATCH participants had statistically significant improvements in mental and physical health status and reductions in mental health symptoms, substance misuse, and the number of hospital admissions. The strength of the working alliance between participants and their case manager was associated with reduced health care use and mental health symptoms. Post hoc analyses suggest that CATCH may be associated with statistically significant improvements in mental health symptoms in the study population.
Conclusions:
A brief interdisciplinary intervention may be a promising approach to improving health outcomes among homeless adults with unmet health needs. Further rigorous research is needed into the effectiveness of brief interventions following discharge from hospital.
This study examined the relationship between victimization and mental health functioning in homeless individuals. Homeless populations experience higher levels of victimization than the general population, which in turn have a detrimental effect on their mental health. A sample of 304 homeless adults and youth completed one-on-one interviews, answering questions on mental health, past victimization, and recent victimization experiences. A hierarchical linear regression showed that experiences of childhood sexual abuse predicted lower mental health functioning after controlling for the sex and age of individuals. The study findings are applicable to current support programs for victims in the homeless population and are relevant to future research on homelessness and victimization.
This article describes recent research on the prevalence of alcohol, drug, and mental (ADM) disorders and the characteristics of homeless substance abusers and persons with mental illness. Methodological problems in homelessness research are reviewed, particularly in relation to definitions of homelessness and sampling- and case-ascertainment methods. Prevalence rates of ADM disorders are much higher in homeless groups than in the general population. As is true of homeless people in general, homeless substance abusers and mentally ill persons are characterized by extreme poverty; underutilization of public entitlements; isolation from family, friends, and other support networks; frequent contact with correctional agencies; and poor general health. Knowledge of these disadvantages should be used to advocate for better services to prevent homelessness and support homeless people.
This paper offers a conceptual framework for establishing a science of transdisciplinary action research. Lewin's (1951) concept of action research highlights the scientific and societal value of translating psychological research into community problem-solving strategies. Implicit in Lewin's formulation is the importance of achieving effective collaboration among behavioral researchers, community members and policy makers. The present analysis builds on Lewin's analysis by outlining programmatic directions for the scientific study of transdisciplinary research and community action. Three types of collaboration, and the contextual circumstances that facilitate or hinder them, are examined: (1) collaboration among scholars representing different disciplines; (2) collaboration among researchers from multiple fields and community practitioners representing diverse professional and lay perspectives; and (3) collaboration among community organizations across local, state, national, and international levels. In the present analysis, transdisciplinary action research is viewed as a topic of scientific study in its own right to achieve a more complete understanding of prior collaborations and to identify strategies for refining and sustaining future collaborations (and their intended outcomes) among researchers, community members and organizations.
The past 15 years have seen a growing interest in transdisciplinary research approaches across academic disciplines. This approach is starting to infiltrate work and health research. Some suggest that a transdisciplinary approach may overcome some of the obstacles in understanding complex pathways between working conditions and health, and may overcome some of the barriers in translating research evidence into action. However, a greater understanding of exactly what transdisciplinary research is (and what it is not) is needed so that the term ‘transdisciplinary’ is not abused or misused. In this paper the author outline the key tenants of a transdisciplinary approach as it applies to research on work and health. He then outlines some of the challenges and benefits of engaging in such an approach across three broad areas: integrating academic disciplinary perspectives; partnering with non-academic groups; and moving research into sustainable solutions. It is hoped that on reading this paper researchers, research participants and funding bodies can weigh up the benefits and challenges of engaging in truly transdisciplinary approaches to different work and health research questions. It is suggested that a truly transdisciplinary approach has both considerable benefits and considerable challenges for the people involved. As such, a transdisciplinary approach might not be the best approach to every research question or situation.
There is a shifting landscape for knowledge generation in contemporary societies that suggests a bright future for transdisciplinary (TD) research. Interestingly, however, there is currently no clear consensus on what transdisciplinarity is or how its quality can be evaluated. This paper uses three avenues to advance and clarify our understanding of transdisciplinarity. Firstly, we survey the theoretical literature and identify key characteristics used by authors in the field to distinguish transdisciplinarity from related research approaches. These characteristics are problem focus, evolving methodology and collaboration. In our discussion of these we highlight variations in description that have significance for practice. Secondly, we explore three interesting quandaries that transdisciplinary researchers face (integration, reflection and paradox) discussing how these quandaries manifest in different dimensions and their potential as both challenge and opportunity for practice. Finally, we use our synthesised characteristics and challenges to shape two alternative frameworks for evaluating the quality of TD endeavours. Our first framework is based on strategic questioning and is potentially useful to individuals seeking to improve the quality of their work. Our second framework adapts an existing quality schema to the unique challenges of transdisciplinarity and may be more appealing to those seeking to compare TD research projects.
This article clarifies the distinction between unidisciplinary, multidisciplinary, interdisciplinary and transdisciplinary research about environment and human behaviour. One objective is to consider the challenges and opportunities transdisciplinarity offers in terms of the emergence of new ideas for theory and application. The costs and benefits, as well as the advantages and constraints of a transdisciplinary approach in the field of urban studies are then considered, and compared with multidisciplinary and interdisciplinary approaches. First, a brief history of the concept of transdisciplinarity is presented. Second, the scientific context (the unit of analysis, application and theoretical goal) is identified. Third, conclusions are drawn about the perspective that researchers need to adopt if a transdisciplinary approach is to be effective (looking for coherence versus paradoxes). All of these reflections on transdisciplinarity are supported by the research experience gained in studies on Canadian (Quebec) and French (Strasbourg) suburbs. The paper focuses on the representation and perception of urban space.
The Street Health report
- E Ambrosio
- D Baker
- C Crowe
- K Hardill
- E. Ambrosio
Failing the homeless: Barriers to the Ontario disability support program for homeless people with disabilities
- Street Health
Wellesley Institute backgrounder: Physical and sexual violence rates for homeless many times higher than housed
- Wellesley Institute
- Wellesley Institute
Report on the status of women and girls in Canada
- Ywca Canada
- YWCA Canada
2009 Per Diem rates for the purchase of service shelter system and related matters. Appendix D: Total number of unique individuals using the shelter system –
- Staff City Of Toronto
- Report
Integrating community based research: The experience of Street Health, a community service agency
- J Wood
- J. Wood
Homeless women in peril
- L Monsebraaten
2006 Street needs assessment: Results and key findings
- City Of Toronto
- Shelter
- Housing Support
- Administration
Street Health survey peer researcher component - Focus group report: Responses, quotes, key points and overall impressions
- P Gardner
- P. Gardner
The Street Health report
- E Khandor
- K Mason
- E. Khandor
Women and homelessness research bulletin #2
- Street Health
- Street Health
Street needs assessment: Results and key findings
- City Of Toronto
- Shelter
2009 Per Diem rates for the purchase of service shelter system and related matters
- Toronto City Of
Methods in community-based participatory research for health
- B Israel
- E Eng
- A Schulz