Research Matters Blog

Homeless Hub
July 27, 2016
Categories: Topics

On July 28, the World Health Organization will mark World Hepatitis Day to raise awareness of worldwide efforts towards the elimination of viral hepatitis by 2030. With 400 million people living with hepatitis B or C worldwide, this year’s campaign theme in Canada is “Know your Status? Get Tested – Learn Your Options”.  While the general population in Canada is at lower risk of contracting hepatitis compared to people living in other parts of the world, it is a serious health concern that disproportionately affects homeless people worldwide

Hepatitis is one of a number of infectious diseases caused by viruses or bacteria that are spread between people or from animals to people. Most infectious diseases cause mild short-term effects, while others cause serious long-term effects which could lead to life-threatening complications. Researchers on homelessness and infectious disease often focus their investigation on hepatitis A, B and C, tuberculosis (TB), HIV/AIDS and a range of sexually transmitted infections. 

Homelessness has an impact on the spread, severity and treatment of infectious diseases. Because of their compromised immune system due the inability to maintain personal hygiene and adequate nutrition, people who are homeless are more vulnerable to illness than the general population. Having to stay in overcrowded and sometimes poorly ventilated spaces with other vulnerable people also raises the likelihood of spreading infectious diseases. In addition, transitioning between prison and homelessness, engaging in sex work and using intravenous drugs also increases the risk for infectious diseases to spread.

One study found that hepatitis C rates among homeless people in Toronto are 29 times higher than in the rest of the Canadian population. 23% of the homeless people surveyed in the study reported having hepatitis C, compared to less than 1% of the general population.  Researchers believe that the percentage is actually much higher as people tend not to experience symptoms for many years and/or they fail to be diagnosed. 

An American study looking at the links between affordable housing, homelessness and HIV/AIDS reported that people experiencing homelessness have HIV infection rates up to 16 times higher than those living in stable homes. For people living with HIV or AIDS, having a stable home decreased emergency room visits by 35% and slashed hospitalization by 57%, resulting in reduced health care costs.

In Canada, 70% of new cases of active TB reported every year occur among foreign-born individuals and 20% among Indigenous Peoples. Although active TB rates in Canada are among the lowest in the world, it has remained consistent for the last 30 years. In Toronto, a longitudinal study led by St. Michael’s Hospital found that one in five homeless people with active TB die within a year of their diagnosis. Homelessness not only delays treatment but also results in treatment complications for patients.

Treatment of infectious diseases among people who are homeless is complicated by the fact that many homeless people face barriers in accessing health services, lack funds for medication, and may not easily be able to follow treatment schedules. Further challenges include not having ID or a health card, feelings of stigmatization and/or the lack of transportation to health visits. The reality is that people experiencing homelessness have few options but to continue using emergency services or staying in unhealthy environments, meaning that even if they have access to treatment, they are still at high risk of contracting other infectious diseases. 

In England, the National Institute for Health and Clinical Excellence recommends the following guidelines to better treat, control and decrease the cases of TB, hepatitis C, and HIV among the homeless population and those at-risk:

  • Simultaneous screenings for TB, hepatitis C, and HIV
  • Transportation and housing supports as well as ensuring adequate nutrition
  • Active case-finding screenings (should not be restricted to symptomatic patients)
  • Needle exchange programmes
  • Free condom distributions
  • Community health centres in large cities
  • Better access to health care

While these are important recommendations, addressing the inequalities experienced by homeless people and their impact on social determinants of health is also a critical component of a wider public health strategy.

In 2014, the Government of Canada announced the Tuberculosis Prevention and Control in Canada: A Federal Framework for Action. The Framework for Action addresses the high rates of TB among Indigenous communities and foreign-born populations with high incidence of TB. It also deals with the underlying risk factors related to social determinants of health. While it may be too early to determine the outcomes of the Framework, the federal government plays a key role in building best practices in collaboration with provincial and territorial governments and other stakeholders in the global response to preventing and controlling TB.

With better access to quality health care, including harm reduction programs and further support services, infectious diseases can be successfully managed, treated and prevented. To join the conservations on social media and raise awareness on hepatitis, use the hashtags #worldhepday, #WHDCanada2016, #LightsUp4Hep, and #Nohep. You can also visit the Canadian Society for International Health’s website to access their campaign toolkit including posters, template letters to politicians, logos and further information for those organizing an event.  

 Photo Credit: Canadian Society for International Health, World Hepatitis Day 2016

University of Toronto; Canadian Observatory on Homelessness, York University
July 25, 2016

One of the unfortunate contradictions of our time is that we have more knowledge and the ability to share our knowledge faster with greater numbers of people in the world than ever in our history – and yet we still have poverty, homelessness, climate change, hatred and war. – Gary Meyers

For decades, Canada has largely responded to homelessness through emergency services and supports. It is now evident that this approach has not been effective at reducing homelessness. In fact, homelessness has continued to increase in some parts of Canada despite years of such efforts.

In contrast, research has persuasively shown that homelessness can be reduced through the expansion of affordable housing and responses focused on prevention, supports, systems coordination, and rapid re-housing. Cities such as Medicine Hat have made significant strides in reducing homelessness through such strategies. Although homelessness is a complex problem, we have many of the answers we need to address it. This forces us to ask: why haven’t we ended homelessness in Canada?

One barrier to ending homelessness is that policy and programming is often developed without the benefit of research. While there is lots of research on innovative, evidence-based solutions to homelessness, this research often fails to reach or be used by policy makers and practitioners. When governments fail to use research, they lose the opportunity to benefit from past experiences, build on community knowledge, and implement policies that are evidence-based. In view of this, we need to foster stronger links between research, policy, and practice.

What Prevents Research from Impacting Policy and Practice? 

There are many reasons that research may not reach or be used by policy makers, practitioners, or the public. Some of these reasons include:

  • Researchers primarily publish in academic journals that policy makers, practitioners, and the public don’t have access to
  • Practitioners and policy makers often juggle many competing priorities and have limited time to keep up with new research findings
  • Research is often presented in technical or academic language that is inaccessible to many audiences
  • Knowledge users may not feel that research is relevant, timely, or important, or they may feel excluded from helping to create knowledge
  • There are limited opportunities for collaboration between researchers, policy makers, practitioners, and the public

These challenges often create a gap between the creation of knowledge and the use of knowledge, making it difficult for policy makers, practitioners, researchers, and the public to learn from each other and pursue shared goals.

Addressing the Gap between Knowledge and Action 

Fortunately, in the last decade there has been a growth of research institutions, NGOs, and community-based organizations focused on making research “count” in the fight to end homelessness. These organizations are often engaged in what we call “knowledge mobilization.” 

Knowledge Mobilization refers to efforts to bridge the gap between research and action. Organizations that mobilize research often try to:

  1. Use unique strategies to share knowledge with a range of knowledge users,
  2. Work with various knowledge users to determine what research is needed and how researchers can help meet the needs of their communities, and
  3. Build partnerships between research producers, research users, and intermediaries to increase the impact of existing knowledge.

Knowledge mobilization is all about building relationships and making research active when addressing problems like homelessness.  

The process of translating research into action.

Knowledge mobilization is at the core of what we do here at the Canadian Observatory on Homelessness (COH). Collaboration between researchers and the communications team is critical to our goal of making research more accessible, understandable, useable, and relevant. To do this, the COH produces content in “layers”, giving our audience the option to get a quick overview of the research or dive as deep as they’d like. For example, when we release a research report, it can be accompanied by infographics, a blog post, a plain language summary and/or a video. As host of the largest web-based library on homelessness (the Homeless Hub), the COH employs a unique communication strategy that includes social media, a blog, an online community forum, and the creation of resources such as toolkits, infographics, research summaries, and free e-books. The Homeless Hub is a great place to get you thinking about translating research into action!  

How can you use research to help end homelessness in Canada?

Here are a few ways that different groups and organizations can mobilize research to end homelessness in Canada:

Agencies

  • Use research to shape the practices and policies in your organization (e.g., RENT’s Housing First: Best Practices for Managers)
  • Collaborate with researchers, community members, and other partners in the sector to increase knowledge about the needs of the community you serve
  • Invite researchers to help you evaluate your organization’s programs and identify areas for growth

Researchers

  • Share your findings through social media, a blog, the media, and/or plain language reports (the Ontario Centre of Excellence for Child and Youth Mental Health has a great guide to get you started)
  • Design studies in which agencies, organizations, and people experiencing homelessness are partners or collaborators
  • Create easy-to-use tool kits and resources for agencies and government so that findings can be easily understood and put into practice (the Canadian Housing First Toolkit is a great example)

Governments

  • Collaborate with researchers and build on existing research when designing policy and making funding choices
  • Build on the knowledge of agencies and people with lived experiences of homelessness when designing policy (e.g., Lived Experience Advisory Council’s seven principles)
  • Invite researchers and the public to consult on proposed policy, providing sufficient time for individuals and groups to offer feedback 

Advocates

  • Use research findings to educate the public about homelessness and encourage public engagement
  • Invite researchers, politicians, and policy makers to meet with affected communities and listen to their needs and proposed solutions
  • Use research findings when developing petitions, writing letters to your local MP, or deputing at your local city council meeting

The Public

  • Use research to inform your opinions about homelessness in your community (e.g., when a new shelter is being built in your neighbourhood)
  • Challenge stereotypes about people experiencing homelessness using evidence from research (e.g., many people experiencing homelessness want to work or are employed)
  • Use research to learn about the needs of community members who are homeless and get involved with local groups who are addressing those needs

Using Research to Impact Policy: The National Housing Strategy

It is a great time to start flexing your knowledge mobilization muscles because the federal government is currently seeking feedback on its proposed National Housing Strategy. Through letstalkhousing.ca, you have the opportunity to show the government that homelessness is a priority for Canadians.

Fortunately, the government has identified homelessness as a key outcome. The question becomes how? How can we put an end to homelessness through a National Housing Strategy? We know, by leveraging existing research, the answer lies beyond affordable housing. A successful National Housing Strategy will couple improved access to housing with evidence-based strategies to prevent homelessness. Stay tuned for the Canadian Observatory on Homelessness prevention-focused response to the consultation.

Remember, by using research findings in your feedback you can strengthen your argument and demonstrate that homelessness is a solvable problem.

If we want to end homelessness in Canada, let’s use all the tools available to us - that includes research!

Canadian Observatory on Homelessness/Homeless Hub: York University
July 22, 2016
Categories: Ask the Hub

As Canada’s aging population and rates of chronic and terminal illnesses rise, palliative and end-of-life care services will be more and more in demand.

Palliative care helps people live the best lives they can while facing life-threatening illness. It focuses on relieving pain, easing confusion, and considers the emotional and spiritual needs of the patient and their families. As Dr. Dosani pointed out in his blog post a few years ago, there’s increasing evidence that early palliative care (upon diagnosis) should be a priority for everyone.

According to research by Donna Wilson and others, most Canadians want to die at home, or in places that feel like home (cabins, somewhere in nature, etc.), with only a small percentage of people saying they want to die in a hospital or nursing home (where most people do end up dying). This discrepancy has inspired much conversation about the rising importance of hospices, palliative care, and making it more affordable for people to die at home. But what happens to someone who is terminally ill and doesn’t have a home?

People experiencing homelessness, especially chronically, are more likely to have a wide range of health issues and a much lower average mortality age than people who are housed. Despite having high needs, many have a hard time accessing mainstream health services due to stigma, discrimination, past negative experiences, inflexible programming, and location. While there isn’t much research on people experiencing homelessness and palliative care, we know that many are interested in advanced care planning and choosing location of death. One 2007 study found that among its 53 participants:

  • Many had experiences with death (of friends, family and other street-involved people).
  • There was a lot of interest in advance directives and end-of-life care, but participants felt that programs were inaccessible.
  • Many echoed the same sentiments about dying that have come up in other studies with the general population (being reunited with family), but others had more unique concerns, like dying anonymously, alone or undiscovered.

Despite expressing a desire for choice, most people experiencing homelessness die in acute-care settings.

Barriers to palliative care

A 2013 Toronto-based study assessed how people experiencing homelessness accessed palliative care. The participants, nurses and outreach workers, highlighted the following as important barriers:

  • Housing sector staff are rarely trained in end-of-life care, and don’t have sufficient access to medical professionals.
  • Many people experiencing homelessness have had past negative experiences in healthcare and don’t feel comfortable seeking it.
  • Many echoed the same sentiments about dying that have come up in other studies with the general population (being reunited with family), but others had more unique concerns, like dying anonymously, alone or undiscovered.

In another study, participating housing workers outlined four main recommendations to help improve access to palliative care: “(1) increasing positive interaction between the health care system and the homeless, (2) training staff to deal with the unique issues confronting the homeless, (3) providing patient-centered care, and (4) diversifying the methods of delivery.”  

Types of palliative care

There’s a few different ways people experiencing homelessness can get palliative care, depending on where they’re located:

Shelter-based programs

Some hostels and shelters coordinate with other organizations and medical staff to provide palliative care when needed, though there are limitations to what can be offered in many cases. Many residents are expected to leave during the day for cleaning – not a possibility for the very ill – and guests are often only allowed within specific timeframes. Exceptions can be made but it is at the discretion of shelter staff.

Even so, there is evidence that this model is not only effective at reducing pain, improving comfort and – sometimes – helping patients reconnect with friends or family, but is also more cost effective than if patients sought treatment elsewhere. In one 2006 study, 28 patients who were terminally ill and homeless were admitted to and died in a hospice.  Researchers compared the hospice to other care locations and projected $1.39 million in savings for these patients’ care.

One of the challenges of these programs is that partnerships with health professionals aren’t always strong enough, resulting in role confusion and a burden of work placed on shelter workers. Another is the devaluing of end-of-life and palliative care in general, resulting in unpaid overtime and heavy emotional stress for shelter workers. The participants of Webb’s U.K-based study all identified situations in which they’d gone beyond the call of duty for residents:

‘That weekend when I spent 17 hours at the hospital it was in my own time.’ Participants had even visited dying residents while they were off duty in order to meet their emotional needs. Two had worked unpaid in order to be there for the resident’s final moments of life and one staff member described a scenario where she took complete responsibility for arranging the resident’s funeral (p. 242).

While it’s wonderful that there are people willing to provide such care, these stories speak to a greater need for funding and training for end-of-life care in the hostels and shelters that provide them.

Mobile programs

Another less common, but more flexible model of palliative care is mobile programs, which meet people in need whether they be on the street or sheltered. In Toronto, PEACH (Palliative Education and Care for the Homeless) is one such program (its principles listed below). In May of this year, The Toronto Star ran a story about nurse Namarig Ahmed, who coordinates PEACH, and secured a bed for a man dying of cancer in the shelter he spent most of his time in. Though PEACH is doing much to give people experiencing homelessness the dignity of choosing how to die and minimizing their pain, there is much more work to be done. As Alex Newman wrote in the article:

Although the PEACH program is “one step closer to dying with dignity, and with as little pain or discomfort as possible, we’re still trying to find better way to deal with this,” Ahmed says. “Having conversations with other health-care providers is a vital first step to find a solution and make this care accessible to all."

PEACH Principles


Improving access to palliative care

Of course, both shelter- and mobile-based programs are usually only available to people living in urban centres. Hospices, shelters, and hostels are in much smaller supplies in rural and remote areas. There, people almost always need to go to hospitals or pay for personal care – options which are often unavailable to people experiencing homelessness.

As the writers of this 2015 literature review point out, we need more models of intervention for advanced care planning, palliative care, and end-of-life care that address the needs of people experiencing homelessness. More importantly, as Huynh, Henry and Dosani proposed in a recent article, a national strategy is needed to “address this glaring gap in our healthcare provision,” and promote policy development around ensuring everyone has access to palliative and end-of-life care.  

This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at thehub@edu.yorku.ca and we will provide a research-based answer.

Graphic credit: Juxta Magazine

Canadian Observatory on Homelessness/Homeless Hub: York University
July 20, 2016

This week’s infographic is from Rock Trust, an Edinburgh, UK-based organization that educates and supports homeless and at risk youth to enable them to build the skills required to make a positive and healthy transition to adulthood. The infographic, based Rock Trust’s Beyond Homelessness report, demonstrates the positive impact both formal and informal relationships can have for young people.   

The Beyond Homelessness report studied the everyday experiences of youth over a three-year period. The study found that the social networks directly impact a youth’s resiliency to homelessness, wellbeing and need for formal support while homeless. Access to informal supports, such as family members or friends, were proven to help youth become more resilient and feel less isolated, leading to an increase in their overall wellbeing. When youth were homeless, there was a decrease in the amount of contact with informal supports. As a result, youth would depend on formal supports such as individuals from organizations or agencies, who could provide help or assistance through homeless services or programs.

Youth who were homeless were highly dependent on formal support networks to help with housing issues, physical health, depression and for general advice. In many cases youth were equally as likely to approach formal or informal networks for support. There was a balanced distribution of sources of informal and formal support concerning wellbeing, addictions and relationship issues; however, there was a large number of those interviewed who did not know where they would go to for help on a range of issues.

The area where youth felt they would like more support were additional monies (48%), housing (44%), legal matters (30%), and mental health (26%). Creating stronger relationships with family members and friends, or with personal feelings were one of the least areas needing additional support (11%).

In a follow-up interview, the key skills interviewees felt they had developed were confidence, self-esteem, overcoming addictions, reducing their negative networks, better self-awareness, better understanding of relationships, patience, money awareness, socializing/opening up, help to pick oneself up/keep going, and life skills such as cooking/cleaning/budgeting. Of those interviewed, 85% felt that there had been an improvement in their wellbeing, 78% felt that they had been able to make good use of the support offered and 93% felt more able to support themselves compared to year prior.

The Beyond Homelessness report aimed to act as a resource for those working within the homelessness sector to develop an understanding and awareness into the integral role social networks can play in developing paths out of homelessness. 

Beyond Homelessness Report Infographic

Canadian Observatory on Homelessness/Homeless Hub: York University
July 15, 2016
Categories: Ask the Hub

We received this question from Raymond W.: “Can you please provide me with any statistics on people who are working and experiencing homelessness in Canadian cities?”

Many people experiencing homelessness struggle to find and keep employment for all kinds of reasons: the difficulty of staying in shelters, facing discrimination from employers and colleagues, being unable to wash up regularly, lacking professional clothing, missing key identification and/or equipment, and many others. Furthermore, sudden job loss and precarious employment are sometimes the triggers that lead to homelessness. So we tend to assume people experiencing homelessness are also unemployed, but this isn’t always true.

In the past few years, journalists have drawn attention to the high numbers of “working homeless” in the U.S. The New York Post profiled city workers in New York City, of which 300 were currently experiencing homelessness. A 2013 story in The New York Times interviewed people working full-time jobs (sometimes more than one) and estimated that 28% of families experiencing homelessness included at least one working adult, and 16% of homeless individuals had jobs. Jeffrey Jones, executive director of the National Coalition Against Homelessness, told Al Jazeera that of the 3.5 million Americans who experience homelessness each year, 25% are employed.

Wage gap and job growthStatistics on Canada’s “working homeless”


Though not given the same media coverage, many people experiencing homelessness in Canada are also employed. A lot of area-specific data is collected during Point-in-Time Counts, which are done by different agencies in each area, and many past surveys have not asked about sources of income or employment. This year marked the first Co-ordinated Point-in-Time Count, which included a core question about how people make money, so newer counts should give us more information about people who are employed and homeless. That said, we have some numbers available from past counts:

Vancouver

  • Overall employed: 23%
  • Binning: 4%
  • Panhandling: 4%
  • Sex work: 1%
  • Self-employment: 1%

Source: Vancouver Homeless Count 2016

Kelowna

  • Overall employed: 6%
  • Informally employed: 12%

Source: 2016 Point-in-Time Count, Kelowna, British Columbia

Calgary

  • Full-time: 18.3%
  • Part-time: 10.4%
  • Casual: 28.3%
  • Self-employment: 0.8%

Source: 2008 Count of Homeless Persons in Calgary

Regina

  • Full-time: 6.3%
  • Part-time: 7.8%
  • Panhandling: 6.3%
  • Under-the-table jobs: 4.7%
  • Binning: 3.1%
  • Crafting/painting: 1.6%
  • Informal (sex work, dealing): 1.6% 

Source: Regina 2015 Homeless Count Final Report

Winnipeg

  • Overall employed (including temporary and part-time): 16.5%
  • Self-employed or informally employed: 18.5% 

Source: Winnipeg Street Census 2015

Toronto

  • Overall employed: 20%
  • Full-time: 5%
  • Part-time/casual/seasonal: 12%
  • Informal: 6%

Source: 2013 Street Needs Assessment

Montreal

  • Full-time: 3%
  • Part-time: 4%
  • Unreported full-time: 1%
  • Unreported part-time: 4%
  • Panhandling (informal): 6%

Source: I Count MTL 2015 / Je Compte MTL 2015

Halifax

  • Full-time: 4%
  • Part-time: 7%
  • Casual: 9%
  • Informal: 18%
  • Other (sex work, petty theft, metal collection): 16%

Source: 2015 Halifax Homeless Point-in-Time Count

Things to consider


I’ve included informal employment (sex work, binning, etc.) because they are often important income sources for people experiencing homelessness. Finding and maintaining formal employment involves many more barriers (like access to professional clothing or equipment) than informal work, and the chaotic nature of being homeless often makes keeping a regular schedule difficult. In many of the surveys, people living on the streets were more likely to report sources of informal income than those who were sheltered.

It’s also important to remember that Point-in-Time Counts only give us a snapshot of who is experiencing homelessness and that they are typically underestimates – especially when it comes to people who are experiencing “hidden homelessness” like staying with friends/family, in hotels or hostels, or couch-surfing; who are also likely to be employed.

How is it possible that working people can be homeless?


While having a stable income is generally key to both finding and keeping housing, having a job isn’t a safeguard against homelessness. A 2013 report by Citizens for Public Justice found that in 44% of poor households, there is at least one working person. Across North America, there’s been growing income disparity and an increasing number of people are classified as “working poor:” people who work but don’t make a living wage. As Richards, Cohen, and Klein wrote in Working For a Living Wage (2010):

A living wage is not the same as the minimum wage, which is the legal minimum employers must pay. The living wage sets a higher test—it reflects what earners in a family need to bring home, based on the actual costs of living in a specific community.

The days of stable, well-paying jobs with good benefits are long gone for many Canadian workers. For a number of years now, the marketplace has trended towards precarious and low-wage employment, which doesn’t offer security or living wages. For people with disabilities or mental health issues, securing and keeping any kind of employment can be extremely difficult, putting them at a higher risk of experiencing homelessness.

These (and other) factors create the conditions of poverty: people living paycheck to paycheck and at the whim of the labour market. With housing prices (both to buy and rent) soaring in most Canadian cities, it's not hard to see why one change in circumstance can result in homelessness. Though the causes of homelessness are complex and often include more than employment status, we must look to income supplements and more affordable housing to help people live above the poverty line and avoid homelessness.

This post is part of our Friday "Ask the Hub" blog series. Have a homeless-related question you want answered? E-mail us at thehub@edu.yorku.ca and we will provide a research-based answer.

Photo credit: Workers Action Centre

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