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Abstract

Homelessness is an experience of being displaced. Once removed from their personal places, homeless people are barred access to healthy places in which to be. Health clinics for people who are experiencing homelessness offer an opportunity to create health-promoting places. In this study, we explore how place is experienced within a community health clinic for people who are experiencing homelessness. A critical ethnographic methodology was used. Results illustrate how clients and providers contested the space of the clinic. Discourses of safety, health promotion, and privacy were enacted, altered, and resisted in a constant practice of culture-making. Physical components of the space became conceptual components of how place and power in place were understood by clients and providers. Results point to the importance of conceptualizing service users as the key stakeholders in their care, considering how places may be more or less health promoting, and rethinking how safety is conceptualized.
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Journal of Community Health Nursing
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Community Health Promotion
With People Who Are Experiencing
Homelessness
Abram Oudshoorn RN PhD a , Catherine Ward-Griffin RN PhD a , Blake
Poland PhD b , Helene Berman RN PhD a & Cheryl Forchuk RN PhD a
a The University of Western Ontario, London, Ontario
b University of Toronto, Toronto, Ontario
Version of record first published: 05 Feb 2013.
To cite this article: Abram Oudshoorn RN PhD , Catherine Ward-Griffin RN PhD , Blake Poland PhD ,
Helene Berman RN PhD & Cheryl Forchuk RN PhD (2013): Community Health Promotion With People
Who Are Experiencing Homelessness, Journal of Community Health Nursing, 30:1, 28-41
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Journal of Community Health Nursing, 30: 28–41, 2013
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ISSN: 0737-0016 print / 1532-7655 online
DOI: 10.1080/07370016.2013.750204
Community Health Promotion With People Who Are
Experiencing Homelessness
Abram Oudshoorn, RN, PhD and Catherine Ward-Griffin, RN, PhD
The University of Western Ontario, London, Ontario
Blake Poland, PhD
University of Toronto, Toronto, Ontario
Helene Berman, RN, PhD and Cheryl Forchuk, RN, PhD
The University of Western Ontario, London, Ontario
Homelessness is an experience of being displaced. Once removed from their personal places, home-
less people are barred access to healthy places in which to be. Health clinics for people who are
experiencing homelessness offer an opportunity to create health-promoting places. In this study, we
explore how place is experienced within a community health clinic for people who are experienc-
ing homelessness. A critical ethnographic methodology was used. Results illustrate how clients and
providers contested the space of the clinic. Discourses of safety, health promotion, and privacy were
enacted, altered, and resisted in a constant practice of culture-making. Physical components of the
space became conceptual components of how place and power in place were understood by clients
and providers. Results point to the importance of conceptualizing service users as the key stakehold-
ers in their care, considering how places may be more or less health promoting, and rethinking how
safety is conceptualized.
Homelessness is an experience of being displaced, being removed from one’s place. Therefore,
those who offer services to people who are experiencing homelessness need to be attuned to the
nature of the place in which these services are delivered. In this article, the results of a critical
ethnographic study of a health clinic for people who are experiencing homelessness are presented,
with a focus on creating health promoting places.
BACKGROUND
People who are experiencing homelessness are barred access to both public and private places.
Ultimately, by definition, they lack the primary private place in society, a home. Once finding
We disclose receipt of the following financial support for the research and/or authorship of this article: Canadian
Homelessness Research Network, Ontario Graduate Scholarship, and Registered Nurses Foundation of Ontario.
Address correspondence to Abram Oudshoorn, Room H142 Health Sciences Addition, School of Nursing, The
University of Western Ontario, London, Ontario, N6A 5C1, Canada. E-mail: aoudsho@uwo.ca
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COMMUNITY HEALTH PROMOTION AND HOMELESSNESS 29
oneself homeless, a person then faces being removed or banned from public spaces. As such,
society seems more interested in removing people who are experiencing homelessness from sight
than in helping them acquire housing (Kawash, 1998). In being removed or moved along in public
spaces, it becomes clear that there is a legitimate and illegitimate public (Kawash, 1998), meaning
those who are or are not challenged for being present in public spaces. Being constantly uprooted,
homeless individuals are forced to reinvent their sense of place (Vandemark, 2007).
In this article, place is considered to be a location that has meanings (Bender, Clune, &
Guruge, 2007); in contrast, space is considered as a physical structure. In this way, place goes
beyond space to encompass the social, psychological meanings ascribed to, and cultural enact-
ment of, the location. A simply geographical understanding of spaces hides the power relations
that give them their social meanings (Soja, 1989). Of particular interest in this study is the power
within place and how homeless clients are observed and regulated in place-mediated power rela-
tions with health care providers. Foucault’s (1977) description of the elimination of private spaces
for criminals to enhance observation and regulation rings true in this context, as well. One of the
roles of health care providers is to assess their clients to form a judgment regarding their fit with
societal norms (Bradbury-Jones, Sambrook, & Irvine, 2008). Those who do not fit the norm must
then be disciplined to conform (St-Pierre & Holmes, 2008). This idea of health care providers
as involved in social control may be difficult for providers to accept in a time when concepts
of empowerment, client-centered care, and partnerships for health are taking precedence within
health promotion research and practice. However, more recent perspectives of health promotion,
consistent with a critical theoretical perspective, encompass ideas of power within social struc-
tures and social relations (Eakin, Robertson, Poland, Coburn, & Edwards, 1996). Use of these
perspectives is informative in terms of understanding health promoting and the idea of place.
Ultimately, there exists the possibility that the spaces which seek to meet the health needs of
people who are experiencing homelessness instead become part of a disempowering system of
control. Keeping in mind the importance of what have been termed the broader determinants of
health, or social determinants of health (Raphael, 2008), if health care providers are to promote
health, they need to think of health promoting places (Carolan, Andrews, & Hodnett, 2006), and
there is a particularly urgent need for health promoting places for people who are experiencing
homelessness (Conradson, 2003).
Review of the Literature
In considering place and homelessness, the aforementioned social question of where people who
are experiencing homelessness should be located both at day and at night has received much atten-
tion. It is important to note that, in addressing this issue, the underlying assumption is often that
in considering the placement of people who are experiencing homelessness, to witness poverty is
an affront to decent society. Recognizing the pressures in high-income societies to remove people
who are experiencing homelessness from visible public spaces, some research has been done on
how individuals respond to these pressures. In particular, researchers who respect the personal
power of homeless individuals in spite of structures of domination have looked at the occupa-
tion of visible public spaces as a form of resistance (Casey, Goudie, & Reeve, 2008; DeVerteuil,
Marr, & Snow, 2009). By refusing to be removed or by bearing their poverty blatantly and visibly,
people who are experiencing homelessness work to assert themselves as legitimate public.
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30 OUDSHOORN ET AL.
Confronted by danger and exposure in public spaces, people who are experiencing
homelessness often turn to service agencies not only to meet their health and material needs,
but also to find some form of privacy and safety. Evans (2010) explored both the positive and
negative aspects in creating spaces for people who are experiencing homelessness to receive ser-
vices, concluding that these spaces serve to politically affirm that people who are experiencing
homelessness matter in society, while also functioning to contain a population deemed by many
to be dangerous and undesirable. Harman (1989) addresses this catch-22 that services within the
volunteer sector created out of compassion to meet the immediate needs of people who are expe-
riencing homelessness also serve to mask homelessness, making the need for such services less
obvious to the public.
There is also a focus in the literature on the links between place and health, recognizing that
settings have a strong influence on how health promotion is enacted and experienced (Poland,
Krupa, & McCall, 2009). This is not to medicalize homelessness, making it a diagnosis that sim-
ply requires a treatment, a risk to which it has been pointed out that many researchers have already
succumbed (Lyon-Callo, 2004), but to recognize that people who are experiencing homelessness
face some of the highest rates of morbidity within high-income nations (Daiski, 2007). To this
end, Johnsen, Cloke, and May (2005) explored the development and inner workings of day cen-
ters for people who are experiencing homelessness in England. Concerned with the continuous
push of people who are experiencing homelessness out of public spaces, they explored whether
day centers are truly offering spaces of care as alternatives. We found that day centers served
service-users as a means both of accessing material resources, and of finding refuge, respite, and
even empowerment. Day centers provided a space where certain behaviors were more tolerated
than in other agencies, although this was balanced by a degree of policing and control. Service
providers were not the only ones who controlled behaviors, as service-users policed each other
and also self-policed. Consistent with St-Pierre and Holmes (2008), we highlighted how the day
centers served as a form of containment for undesirable individuals. To build on the work of
Johnsen, Cloke and May, how clients experience the balance between freedom and discipline in
the context of health care delivery needs to be further explored.
Hodgetts, Radley and Hodgetts (2007) explored how social deprivation is literally embodied
by individuals and evidenced in health disparities. Similar to Johnsen and colleagues (2005), we
speak of accessing spaces of care to meet both social and physical needs. These spaces only par-
tially mitigated the feelings expressed by participants having little choice day-to-day of spending
time in spaces other than those which they deemed to be unhealthy. Kawash’s (1998) descrip-
tion of an illegitimate versus a legitimate public is evident in the findings as Hodgetts et al.
described fear demonstrated in the actions of housed persons toward people who are experiencing
homelessness. Building on Sibley’s (1995) “Geographies of Exclusion,” we suggest that being
feared is used at times as a source of empowerment as displaced persons turn the tables and create
spaces where the legitimate public feel uncomfortable and unwelcomed. Parr (2000) conducted
an ethnographic study of a drop-in center in Nottingham, UK to explore the social geographies
of persons with mental illness in the community. Similar to the preceding researchers, Parr ques-
tioned the lack of spaces where homeless people can genuinely be. Even though the drop-in
center was a more accepting place, with wider social boundaries, the clients of the center were
forced to live out their private identities within a public space. Like Johnsen and colleagues, Parr
spoke to a Foucauldian disciplining of behaviors as there were still limits and norms in the center,
and both staff and fellow clients worked actively to enforce these, “The other members of the
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COMMUNITY HEALTH PROMOTION AND HOMELESSNESS 31
drop-in reinforced the isolation of [a particular member] as too transgressive, too ‘ill’ even for
[the center]” (Parr, 2000, p. 234). Parr highlighted that othering and social distancing exist as
pressures within othered groups, as well as external to them.
To further explore the balance between freedom and discipline, and to shed light on how
norms are enforced within health care with people who are experiencing homelessness, this article
addressed the question of: How is place experienced by clients and providers within a community
health clinic for people who are experiencing homelessness?
Theoretical Perspective and Methodology
This study falls within what has been referred to as a critical theoretical perspective (Campbell
& Bunting, 1991). This perspective encourages academics and practitioners alike to seek social
justice, hence the focus in this study on oppression and making spaces for positive change. A crit-
ical ethnographic methodology was employed to better understand the culture of a health center
as it was experienced in the daily lives of the people who lived it (Crang & Cook, 2007). Poland,
Lehoux, Holmes, and Andrew’s (2005, p. 172) understanding of culture was used:
common/shared beliefs or values at a variety of scales; cultures give meaning to ways of life and
act as a lens through which we look at the world that both affects and represents our behavior; and
cultures produce (and are reproduced through) material and symbolic forms.
Within critical ethnography, it is taken for granted that one of the things produced and repro-
duced in all cultures is oppression (Browne, 2005). Therefore, there is an explicit focus on power
relations and marginalization. Building also on the focus within the critical paradigm of making
spaces for positive change, the critical ethnographer is not content with developing a cultural
critique, but engages with the culture of study to be a catalyst of change (Cook, 2005).
METHODS
The study was conducted in a community health center in a moderate-sized urban area in Ontario.
This center included a health clinic for people experiencing homelessness, which was the focus
of our study. This clinic provides both health and social services, with providers consisting of
one physician, three nurses, one nurse practitioner, two social workers, one community worker,
and two administrative staff. Services include medical appointments, urgent medical care, social
work appointments, washroom and laundry facilities, emergency food and clothing, a telephone,
and various need-specific clinics and groups. Clients were those individuals who qualified as
being homeless, which ran the gamut from being absolutely homeless and living on the streets, to
being in shelter or temporary housing, to being formerly homeless at admission to the clinic but
currently being housed, albeit precariously for most.
Multiple qualitative data collection methods were used to develop a deep engagement with,
and understanding of, the culture of the clinic. Data collection methods ran consecutively, and
included participant observation, in-depth interviews, and focus groups. Participant observation
involved 103 hr over the course of 3 months in the clinic waiting room and observations of
seven client-provider dyads within examination rooms or offices. Participant observation played
an important role in facilitating focused observations of a clinical area that was already familiar
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32 OUDSHOORN ET AL.
to the researcher. Field notes were recorded intermittently throughout the day in a private office
so that they were recorded immediately and also unobtrusively (Groenkjaer, 2002). Observation
also provided an opportunity to identify key individuals for in-depth interviews.
In addition to observation, 22 interviews were conducted, with the total clinic sample of
10 providers being interviewed a total of 12 times (2 providers were approached for second inter-
views to focus specifically on emerging themes) and 11 clients being interviewed in 10 interviews
(2 chose to be interviewed together). Clients represented the spectrum of individuals seen within
the clinic, ranging from being free of addictions to having both drug and alcohol addictions, hav-
ing been born locally to having migrated across the country, from young to old, and both men
and women. As a group, participants did tend to be those who were more chronically homeless
than would be representative of the clinic (Myears homeless =7.9), which was likely an arti-
fact of sampling for clients who would have the most to say about relationships with providers,
which in most cases were those who had been attending the clinic for an extended period of
time.
In analyzing the data, Lather’s (2007) work on understanding validity post-poststructuralism
was used to enhance quality. Data analysis occurred as an ongoing process during participant
observation as field notes evolved from simple transcription of what was observed, to reflections
on themes, inconsistencies, tensions, and concerns. These preliminary thoughts then informed
the in-depth interviews, which were audio recorded and transcribed by a transcriptionist. The
transcripts were read and edited while simultaneously listening to the interviews to try to cap-
ture the nuances of language in a manner most meaningful to those doing the analysis. A loose
coding structure was created to identify the passages most pertinent to our research questions,
which was then used to pull out a series of quotes. This served as a way to make the 22 tran-
scripts and 35 pages of field notes manageable, but also represents our choices regarding what
was important about their words. Although various social locations—such as race, class, gender,
sexual preference, and others—had an impact on the interactions within the clinic, for the sake of
coherence and length, the primary focus of this article is the difference in status as a client or a
provider at the clinic. Data analysis was enhanced by three focus groups, two with providers and
one with clients, in which preliminary results were brought back to original participants or other
clients and providers to solicit their feedback. This feedback was not primarily for the purpose
of collecting new data, but was to help refine the organization, interpretation, and presentation of
results to be more meaningful to those most invested in the results.
RESULTS
The results section focuses on contesting space, looking at what is contested, and making place,
looking at how clients and providers exert power to make place. There is an inherent structural
tension to the clinic where multiple, and often divergent, accountabilities toward funders, the sur-
rounding community, and clients must be balanced. Certain clients will present with some needs
that do not fit the mandates of the clinic, making conflict inevitable. Interestingly, in navigating
this conflict, clients and providers often drew upon the same narratives of safety and consistency.
The positive veneers of getting along in some ways mask the contested nature of the physical
space in the clinic, and the ways in which clients and providers assert themselves to create the
meanings of place.
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COMMUNITY HEALTH PROMOTION AND HOMELESSNESS 33
Contesting Space
The clinic can be seen as a contested space, with clients and providers asserting themselves
to create and recreate a physical space that best suits their sometimes mutual and sometimes
competing needs. Although, in observations, this contested space evidenced itself as personal
struggles between clients and providers, it speaks more to structural considerations and the set-
up of a clinic in which power struggles are inevitable. This will be demonstrated by exploring four
areas around which clients and providers assert formal and informal power: the clinic atmosphere,
what is deemed appropriate use of the clinic, safety, and private spaces.
Both clients and providers spoke to the atmosphere of the clinic, which seems to center on
the concept of chaos. Providers accepted that some level of chaos/confusion/distraction can be
anticipated when working with large numbers of individuals experiencing such challenges as
addictions and mental illness. However, many providers conceptualized the purpose of the clinic
space as delivering medical services, and therefore the level of chaos often experienced within
the space is seen as detrimental. For example, the physician described trying to work with clients
in the exam room while there were “bodies bouncing off my door.” Of note is that much of
the chaos has to do with the flow of clients through the clinic, and is, therefore, inextricably
connected with physical space. Prior to the commencement of this study, clients had free access
to all providers and to all facilities in the space of the clinic. This free movement provided more
of a sense of ownership among clients regarding the space, but proved challenging for some
providers, particularly for the physician. Clients would use the open access to the physician to
talk to him when he moved between his office and the exam rooms, or waited for him to open
the exam room door. Some providers saw this level of freedom as detrimental to the quality of
care, “I mean, we try to build barriers in the system I guess, on appropriate access. Because of
the excessive need for clients, whether they, whether it be emotional neediness or drug-seeking
or whatever.” The movement of clients in the space was, therefore, seen by some providers as
something that needed to be controlled.
It is inevitable that space will be contested when there is a discrepancy between the goals of
an agency and the needs of its clientele, in this case the discrepancy between the clinic focus on
meeting medical needs versus the need of people who are experiencing homelessness to have a
somewhat private space in which to be. This is evident in the discourse around the appropriate
use of clinic space. The previous configuration of the clinic as a more open space also led to what
some providers and clients considered a misuse of the space, particularly using the bathrooms to
consume alcohol or use illegal drugs, and dealing drugs in obscured corners. This is a contentious
issue in the clinic, as some see increasing barriers to drug and alcohol use as increasing harm by
pushing people to use in unsafe places and unsafe ways, where others see facilitating drug and
alcohol use as both harmful and as putting the clinic at risk of losing funding if found to be con-
doning illegal activities. Interestingly, neither of these positions was supported by evidence, as,
for example, there was no way of knowing how funders, in this case the Local Health Integration
Network, would react to drug use in a public washroom. One provider captured the issue well,
The bathrooms were such a problem because people were using [drugs] in there so we cut it down
to one. So it got to, it was at one point I thought we were going to have a flashing light in there or
something, that it was going to be so controlled. And that kind of stuff drives me crazy; there’s fine
lines sometimes between power tripping and using your authority.
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34 OUDSHOORN ET AL.
What the provider is referring to is one of the proposed solutions that was implemented by
management: eliminating one washroom and increasing the monitoring of washroom use. This
process evolved while this study was being conducted. Another potential solution was imple-
mented approximately 3 years prior to this study, which was to reconfigure the space so that most
of the clinic was behind a locked glass door controlled by reception. This locked door is col-
lectively referred to as The Wall, and featured prominently in in-depth interviews as a contested
reconfiguration of the space.
In contesting space, the concept of safety was used almost as a form of currency, with any con-
ceptualized improvement in safety trumping other client and provider needs. When working with
individuals who experience the desperate needs of absolute poverty, and who are often also deal-
ing with addictions, mental illnesses, or both, people are bound to assert themselves physically.
The clinic has been host to numerous altercations, ranging from more benign verbal altercations
to assaults with weapons. Although most violent altercations occur between clients, there has
been the intermittent incident of a provider being assaulted. However, what is important to note
is that safety is connected to the physical design of space, but it is also connected to the quality
of relationships between clients and providers. Therefore, the manager spoke to promoting safety
by creating a wall with a locked-door access. Conversely, clients spoke of the safety afforded to
providers by working in a clinic in which clients felt respected and treated well. Clients spoke
of another facility that had much higher levels of security and surveillance, but in which staff
were still assaulted much more frequently as clients felt like they were in jail, rather than treated
respectfully there. Therefore, it is contested whether more control necessarily equates to more
safety, and whose safety is given priority.
The fourth issue around which clients and providers asserted themselves was that of private
space. People who are experiencing homelessness are displaced from their private spaces, and
forced to live entirely within public space. This, for example, means being without a private
space in which to make phone calls, sleep, use the toilet, be intimate with a loved one, or consume
alcohol and drugs. All of these activities, and others, instead were observed to occur within the
clinic. On one occasion, a health provider chastised a client for popping another client’s pimples
in the waiting room. Clients were also observed discreetly consuming alcohol and drugs, or would
be banned from the clinic for the day when caught drinking in the shower. Those who had been
outside all night, or those who were very intoxicated, would often try to rest in reclining chairs:
We’re walking around these people sleeping. I don’t know why they’re sleeping; I don’t care. I just
know they’re not getting the proper care that I would give them as a human being, to make them sit
up in a chair to sleep. Let them lay down. Okay, you don’t have to staff it per-se but just a cot would
do. That’s all they want; they don’t want a bed with covers and pillows and drapes on the windows.
This issue of privacy is inherently tied to dignity, particularly as it relates to the use of washrooms.
Clients consistently expressed concern with being timed in the bathroom and how this made them
feel as if they were being treated like a child or a prisoner. Thus, behaviors that are considered
appropriate for a private space are deemed as inappropriate or a misuse of clinic space.
Making Place
Place, or the meanings attributed to the physical space, is inextricably linked to this physical
space. There have been explicit and deliberate efforts by providers and management to create a
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COMMUNITY HEALTH PROMOTION AND HOMELESSNESS 35
place that is optimized for the delivery of health care services. However, the institutional logic of
managing the movement of people and creating an environment that facilitates task-completion
collides with the logic of everyday life of the homeless clients and the meanings they ascribe
to the clinic. The Wall’s the most obvious of these, and still represents much tension within the
clinic:
There continues to be a lot of resistance to the structure. Physical structure and scheduling structure
enhances the work. There are other members of the, of the care team here that would say exactly the
opposite but I think it’s certainly, for the type of work I do, I have to do it in a thoroughly structured
way, or otherwise I’m not serving my clients very well.
This provider went on to state how strong the feelings are around the Wall: “It’s like the storming
of the Bastille. ...There are people on staff here that would tear that wall down in a moment
if they could.” Both providers and clients try to negate the existence of, and reconceptualize the
meanings of, the Wall by holding the door open for others rather than making them go through
reception. With the washrooms on the other side of the locked door, there is a constant enough
flow that this occurs frequently, leaving the receptionists with the difficult decision of whether
or not to confront those who go through without permission. In this way, it is reasserted that the
clinic is the clients’ place, and they should not, therefore, require permission to move through-
out it. Providers also resist the restructuring of the space by maintaining flexible schedules and
accommodating clients who drop in at their office door, rather than scheduling through reception.
However, this is less manageable for some providers, such as the nurses, who have to carefully
manage a constant flow of individuals attempting to get access to the physician to receive pre-
scriptions. What was apparent in comments from providers is that not all providers have benefited
from the building of The Wall.
So, the clinic is changing, as clients and providers attempt to create and recreate a place that
best meets both their mutual and competing needs. However, there is a general sense among
clients that the change is not driven by their needs, and a sense among providers that the change
is not driven by provider consensus. Participants spoke to four concerns that still exist: barri-
ers to accessing providers, an institutional aura, access to bathrooms, and the lack of privacy.
Recalling that it is the people that have the greatest influence on the meanings of a place, there is
considerable concern amongst clients that they were now separated from providers.
You put [Provider 1], [Provider 2], people like this in bubbles, they’re unapproachable. These are the
people that can help the most, and yet they’re the most unattainable. Why? I found it different when
they did put that wall up. It cuts you off from the staff and other things like that.
Working with a very heterogeneous population, the Wall was never going to be a popular change
for all clients. However, three years after its construction, the majority of clients do not see The
Wall serving the purpose that was suggested when it was built. One client suggested a possible
solution that doesn’t involve removing The Wall completely,
I’d really like to see somebody out in the [waiting room]. I’d like to see an outreach worker [in the
waiting room] that was available for those, you know, “I need to get to court;” “I need to get Ontario
Works;” “I need, I can’t read the paper work;” “I can’t do this;” “I need this housing assistance;” and
a lot of these things. ...You know, an advocate there, right there, that’s what I’d like to see.
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36 OUDSHOORN ET AL.
The Wall changed the very meanings and feel of the space, decreasing the size of the area
in which people are free to circulate in the clinic. One client saw a need for more control, but
expressed how this same control conceptually equates for a lot of clients with their experiences
of prisons,
You know, I’m still against that front wall thing. I used to like the open concept, but I realized as this
place grew, popularity wise, and how many people you’re dealing with now, you had to have some
sort of block structure. ...It was a little rough, it felt like we were walking into a probation office or
an institution that was, you know.
Many clients did express how things are better in terms of the chaos and some even discussed how
they personally feel much safer since The Wall was built. They recognize that the doctor could
see more people more efficiently this way, and that equates to less time that they have to wait
for an appointment, which they tentatively appreciated: “I can see how they needed [The Wall].
I didn’t need it but they needed to do it. They needed control and it certainly worked. ...Maybe
it helps the doctor and the nurses out.” This next quote illustrates the tension, as some desire to
regain the flexibility of movement, while at the same time agreeing that providers should be able
to work uninterrupted,
You need to open up the offices again. You need to cut down The Wall so people can mingle through.
If you want [Provider 1] and [Provider 2] and [Provider 3] and the doctor to be in a separate room sort
of thing, put them in another room somewhere, but give the people here more room here to mingle.
This is too tight at the front.
The same concern was demonstrated around what it means to have to ask permission to get to the
washroom, and the closing of one of the washrooms. There was a shared opinion between clients
and providers that clients need a safe place to use drugs, recognizing that the washroom is not the
ideal place to do so.
The Wall did improve one component of a feeling of privacy in that by decreasing the number
of people in the open area behind The Wall, those who were there sleeping in chairs had more
privacy. However, it also aggravated the congestion in the waiting area. And, by moving the phone
from a corner by the bathrooms to the front area, people’s phone calls are no longer private. One
of the things that is appreciated about the clinic is that clients understand it is a place where they
can vent some of the frustrations in their day-to-day lives. Because rules about behavior are not
as strict as other agencies, clients come in and often talk loudly and swear about something that
is bothering them. They usually receive support from their peers through agreement with their
concern.
That’s where you get people flipping out and having some episodes out there and it’s a place for
people to do that. Take that as a good thing. Here’s a place where people can vent and not get arrested
for it.
Decreasing the space for people to circulate freely has a negative impact on the sense of the place,
as one client stated,
I get upset out there in that front hallway, now in a smaller enclosed area that we’re all bunched into.
You guys should ...give these people more room so that when they go off, there’s a place that they
can go. There’s no place to hide in that small room up front.
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COMMUNITY HEALTH PROMOTION AND HOMELESSNESS 37
DISCUSSION
Clients in this study compared the clinic to other agencies they frequented, and found it to be gen-
erally more comfortable than those that placed a greater focus on behavioral control. However,
clients and providers contested the space, exerting themselves to meet both mutual and conflicting
needs. Participants spoke to the strategies that have been implemented over time, but highlighted
the lack of consensus amongst both clients and providers around these solutions. Last, they iden-
tified that many challenges still exist, or that the solutions have simply led to new challenges.
In particular, they highlighted barriers to accessing providers, the change in the feel of the clinic
to being more institutional, the lack of access to bathroom facilities, and that there are still no
private spaces for clients to utilize. The discussion is framed around three questions: (a) Whose
space is it? (b) What constitutes a health promoting place? (c) Is safer always healthier?
Whose Space is it?
Fisk, Rakfeldt, Heffernan, and Rowe (1999) conducted a study of an outreach project for persons
experiencing a mental illness and homelessness. They found that the location of care influenced
the ability of workers to set boundaries. In particular, when outreach workers went outside the
outreach project facility to visit individuals who were sleeping on the streets, they found it diffi-
cult to set boundaries around intrusive sexual comments. This demonstrates the importance that
meaning of space has in health-promoting interactions, leading to questions in this study of who
owns the clinic space, whose space is it, and who makes the rules in the space? In this study,
we observed the implications of policy-setting being done by providers to address challenges
of space, but often having negative implications on the meanings of place. The same questions
around ownership of space can be asked of the health clinic, and are pertinent reflections in
the context of the aforementioned results that speak to providers as gatekeepers, permitting or
denying access to some or all of the clinic space.
All health and social systems contain an element of social control, order, and compliance.
However, in the context of homelessness, and having no space of one’s own, the sense of being
policed is felt more acutely. This invites reflection on how service providers and service users
might work together in a more mutual manner, sharing ownership for the management and func-
tion of the space. This is supported by a reflection that, as a publicly funded health service,
the clinic is owned by the public and the providers are paid from the public purse. Therefore,
providers are being paid by the public to provide a service to a portion of the public, the homeless
clients, hence the terminology of client rather than patient. Unfortunately, at times it felt that the
use of this terminology was somewhat tokenistic (Boyce, 2001), as control over official decisions
on how to both arrange and manage the space rested almost solely with providers. Decisions
around care delivery must not only reflect accountability toward funders and the surrounding
community, but, more important, reflect the needs and desires of the clients. However, this is not
a simple solution due to the heterogeneity of the clients that makes consensus an impossibility.
Therefore, questions must be asked regarding how clients are to participate in, and, based on the
concepts of capacity building and empowerment (Holmes, Perron, & Savoie, 2006), ideally lead
decision-making processes, and how decisions will be made in light of diverse opinions. Clients
made it clear that they felt the clinic to be their space in how they shared the control of space with
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38 OUDSHOORN ET AL.
providers. Although only providers had formal power to ban clients from the space, clients also
enforced norms by verbally berating those who went beyond what was considered reasonable
behavior, and resisted undesired policy or structural changes by subverting the rules.
What Constitutes a Health Promoting Place?
Health is more than the absence of disease, it is a resource for everyday living (World Health
Organization [WHO], 1986). Promoting health must take into account the determinants of
health, such as income and social status, social support networks, education and literacy,
employment/working conditions, social environments, physical environments, personal health
practices and coping skills, healthy child development, biology and genetic endowment, health
services, gender, and culture (Raphael, 2008). As such, the food, clothing, washrooms, phone, and
bus tickets provided in the health clinic are as much a part of promoting health as the prescrip-
tions, stitches, and annual health examinations. This is well understood in the clinic, but what we
add to this conceptualization is that the place, the meanings attributed to the space, of the clinic
is also an essential part of what makes it health promoting. Taking the WHO (2005) definition of
health promotion being to have increased control over one’s health and the social determinants of
health, a health promoting place involves self-determination in care. If clients feel uncomfortable,
infantilized, and unheard, then although a visit to the clinic may yield the client a pair of socks,
they may be left feeling less healthy based on the experience of the space. An important point
to highlight here is the need for privacy and the need for spaces in which clients feel free to act
naturally without unwanted limitations on their behaviors (Kawash, 1998). Perhaps the clinic is
not the appropriate space for this, but many clients identified the lack of these features as limita-
tions. There is a need for clinic staff to continue to define its purpose, to determine how they will
choose to be health promoting, and how they will make clear their purpose to clients and other
agencies. Clients and providers need to mutually consider how clients will be involved in all of
these choices. This has implications for local, clinic-level policies that set the context of whether
decision-making will be a mutual process or be top-down.
Is Safer Always Healthier?
What is considered safe and how is safety assured? Poland et al. (2005) captured well the tension
between care and safety: “Often, therapeutic demands (care) and security imperatives collide”
(p. 174). Many of the policy and physical changes that clients and providers were reacting to neg-
atively were made under the auspices of enhancing safety. Where providers operate within the
rhetoric of safety, clients seek more essentially to find a place where they can simply be. As high-
lighted in the results, there were some significant concerns around both clients and providers
having been physically assaulted in the past. The question is, to what extent do health care
providers enforce behavioral control before they create an unhealthy place?
Behavioral control is inseparable from a secondary question of safety. As well, behavioral
control complicates the question of whether safety is solely the mandate of providers, or if clients
have a role in it as well? In fact, clients worked hard to discipline the behaviors of other clients for
fear that further freedoms would be lost in the clinic if things were considered to be too unruly.
Again, there is no easy answer to these questions as the heterogeneity of clients and providers
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COMMUNITY HEALTH PROMOTION AND HOMELESSNESS 39
means that each will define safety and a health promoting place differently. Karabanow and Rains
(1997) highlighted well how the enforcement of rules upon a youth shelter to enhance safety and
personal development was interpreted by the youth as uncaring, and the worst thing about the
shelter. Insofar as health promotion is about increasing control over one’s health, then spaces
that limit control create challenges for those seeking to enact health promotion. In our study, a
provider suggested that differences between clients and providers in conceptualizing safety may
be because many clients have a higher tolerance for risk based on the other contexts in which they
live. Critical reflection is required to explore what level of risk is deemed appropriate in order to
facilitate a health promoting place.
CONCLUSION
To conclude, recommendations are offered relevant both to this particular clinic, and to other
health care facilities that provide services to persons who are homeless, and highlight areas for
future research.
People who are experiencing homelessness are in urgent need of health-promoting places
(Vandemark, 2007). Driven from public spaces to spaces in agencies that provide little privacy
and strictly regulate behaviors, homeless persons experience acutely social control. Agencies
that serve people who are experiencing homelessness must reflect on their location within the
lives of their clients: What meanings do clients and providers attribute to their space, and how
do they fit within the broader spectrum of client services? For example, do clients have other
spaces that they can go to to meet private needs such as drug use or intimate relations? In
addressing the health needs of clients, on what components of health should health providers
focus? How will services for people who are experiencing homelessness delivered under the
auspices of health care be configured to respond to the broader/social determinants of health?
What role will clients play in the development and management of their services? This last
question requires deep reflection as client involvement in managing services can be done well,
but it can also be tokenistic or poorly adopted (Boyce, 2001). In fact, one could go further to
suggest that, in answer to the first discussion question of “whose space is it,” one finds some
help in answering the other questions of “what constitutes a health promoting space” and “is
safer always healthier?” By building client ownership and control into the processes and poli-
cies of the clinic, one moves closer to both a health-promoting and a safer space. It is telling,
and unfortunate, that although client involvement in services is discussed at the clinic where
this study was conducted, it has not been embraced to date beyond feedback forms and annual
questionnaires.
Enhancing spaces to be more health promoting must also be set within the context of the
broader health care system. Within the Canadian context of this study, health care agencies are
facing increasing pressures to demonstrate quantifiable outcomes to support requests for funding.
These outcomes are most often individual medical indicators, rather than nuanced changes at the
population level in such areas as a sense of place, or involvement in one’s own health care. These
system pressures can make such processes as building client ownership and control less attractive
if they increase the complexity of decision-making and include risk of clients making decisions
that don’t align with the directions of funding bodies. A shift to thinking of health promoting
places must be supported at a system level if it is to be attractive to individual agencies.
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40 OUDSHOORN ET AL.
This study was limited in that it was a cross-sectional picture of one clinic at one point in time.
Further research needs to be conducted to explore novel ways of providing health promoting
places for people who are experiencing homelessness. In this study, clients were able to iden-
tify how agencies were doing in meeting their needs. Understanding these differences in quality
would be beneficial. Client ratings of the quality of services from different agencies would not
be collected with the intent to conform all agencies to one type of practice, but to assist each one
individually to provide the best possible care. In this light, individual municipalities or neigh-
borhoods would benefit from utilizing a lens of space and place for identifying possible gaps or
limitations in existing services. Last, much of the analysis in this study has focused on the clinic,
but we are mindful that there are many opportunities to also explore how individual providers and
clients work to create spaces of empowerment.
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