Research Matters Blog

Western University
April 24, 2018

In this bi-weekly blog series, I explore recent research on homelessness, and what it means for the provision of services to prevent or end homelessness. Read the first blog here, and the second blog here. 


Housing is foundational to ending homelessness, foundational as a determinant of health, and foundational to community integration. However, housing itself does not guarantee health or integration.

Chris Chamberlain and Guy Johnson explore the question of community integration as outlined in Housing First models. They use the concept of ‘liminality’ to question integration after homelessness, a term referring to being between two worlds.

To address this question, they analyzed 157 interviews with 64 individuals exiting chronic homelessness through a Housing First program. All participants were housed at the final interview, and majority having been housed for over a year. Half of the participants had their first experience of homelessness as youth, three quarters identified as male, and all were receiving government income support.

Chamberlain and Johnson noted a sense of material “liminality” on first becoming housed, based on three challenges:

  • Participants lacked resources to furnish their new home and meet basic needs
  • Participants felt suddenly lonely in their new spaces
  • Participants were either new to or had been some time since managing a home.

However, the research team observed progress over time as participants gained control, acquired possessions, and settled into new autonomy.

Relational 'liminality’ proved more complex. While participants recognized new friendships and casual acquaintances developed in accessing services for people experiencing homelessness, these were often not built on the same bonds and common values of friendships of familial relationships from which they had become disconnected. While many participants disconnected from relationships built during their period of homelessness, they also struggled to reconnect with prior relationships. Familial relationships were often sources of past trauma, so participants were more likely to reconnect with their own children rather than with parents, siblings, or other blood relatives.

Lastly, participants experienced psychological “liminality” which involved carrying the stigma of the experience of homelessness, feeling both “discredited” and “discreditable.” While this sense declined over time, half the participants still felt this stigma by the final interview, despite having been in housing for a year on average.

The authors conclude that while Housing First programs continue to demonstrate good outcomes for rapid re-housing, that community integration needs to be an intentional process of such programs rather than a presumed outcome. While the material components of becoming housed might be more straight-forward to address (such as through furniture bank programs), the relational and stigma components are more complex. They conclude with a call for funding to be focused on community integration.

Canadian Observatory on Homelessness
April 18, 2018

What is Trauma Informed Care? 

Trauma Informed Care (TIC) is an approach that embraces an understanding of trauma at every step of service delivery. This model requires a compassionate and understanding attitude, in order to address the intersecting effects that trauma can have on people’s lives. It seeks to create a culture of nonviolence, learning, and collaboration in all aspects of treatment, while also recognizing the physical, psychological and emotional importance of clients’ and providers’ safety.

Trauma Informed Care does not have to be directly focused on delivering trauma-related services or treatments. Rather, it is an approach that is incorporated into the structure of a variety of practices, including housing, primary care, mental health, and addictions services. The aim is to provide services in ways that are appropriate and welcoming for those who may have been affected by trauma.

While the effects of trauma frequently have an impact on services and organizations, trauma often goes undetected. Thus, interfering with their recovery and healing, individuals may be re-traumatized by the services and organizations that they interact with.

Many people experiencing homelessness have faced traumatic events, such as being exposed to violence, experiencing losses, and dealing with severed relationships. The experience of homelessness itself is traumatic, as it involves a lack of stability, a loss of safety and the disconnection from one’s community at large.

Research has found that a large proportion of mothers (79%) who accessed emergency shelters, transitional housing and permanent supportive housing programs, experienced traumatic events during their childhoods. Most commonly, mothers reported past experiences of interpersonal violence, physical assaults, and sexual abuse. Many also met the criteria for Post Traumatic Stress Disorder (PTSD). Furthermore, intergenerational trauma affects Indigenous communities, which have been gravely impacted by colonial practices, such as: the destruction of Indigenous institutions, disruption of traditions (including Indigenous systems of governance), linguicide, and the implementation of the reserve system, to name a few. Interwoven in many Indigenous experiences of homelessness are the impacts of individual and community traumas, often leading to high levels of mental, cognitive, behavioural, social and physical challenges.

Trauma, depression and substance abuse tend to occur simultaneously, and also have the potential to impact the ability of mothers to form healthy relationships, work consistently and parent effectively.

The effects of trauma have serious health outcomes for individuals, families and communities, and services must recognize the role they play in creating supportive and welcoming environments. As there are many different types of trauma affecting people of all ages, and across all socioeconomic backgrounds in society, a trauma informed care approach should be an essential component for all services and organizations.

Solutions

Traditionally, responses to homelessness in Canada have placed a great deal of emphasis on emergency services, such as shelters and temporary housing. However, since the challenges that many people experiencing homelessness face are complex, the necessity for different approaches to address their needs have become clear. One example of this includes the integration of trauma informed care (TIC) practices into service delivery and housing programs.

Adopting a TIC approach as a service provider, organization or system involves:

In addition to providing permanent supportive housing for trauma survivors, individuals with serious mental illnesses (SMI) need programs that directly address their mental health needs. One suggestion involves the developmental assessment of children, and mental health assessments for all members of families. Mental health services that address the needs of both mothers and their children are a recommendation for trauma informed care approaches. As research has indicated the experiences of trauma in early childhood are different from trauma experienced later on in life, trauma informed care takes into account age-appropriate service delivery. For mothers, these services may include dealing with major depression and Post-traumatic Stress Disorder (PTSD). For children, services should include therapy or supportive services to address their learning and emotional needs, a safe and supportive environment, and the presence of continuous and nurturing caregivers.

Furthermore, case management should address both individual, short-term needs along with the long-term needs of clients. Some examples of short term needs include: income, education, and employment, whereas long-term needs may involve addressing histories of trauma, health/ mental health, and emotional difficulties.

It has also been suggested that organizations make a number of changes to their overall service delivery structure, in order to incorporate a Trauma Informed Care approach. Organizations should include written statements and policy implementation that express their commitment to delivering Trauma Informed Care, such as:

Overall, housing that quickly stabilizes families while also ensuring that the individual needs of those accessing services have better outcomes for the long-term stability of families; that includes taking the affordability of the placement into consideration.

Ontario is gearing up for a provincial election on June 7th, and Quebec isn’t far behind. While some people may already know who they plan to vote for this time around, others may still be feeling unsure of how (or if) they will vote on Election Day.

For those of us in youth-serving sectors and related fields, and for young people with lived experience of homelessness, A Way Home Canada and Eva’s Initiatives for Homeless Youth in Toronto have collaborated to create an overview of how to navigate the provincial political landscape around election time and to inform your decision making process.

Who can vote?

If you’re a Canadian citizen, resident of the province where the election is being held, and are 18 or older, you can vote. If you’re under 18 or currently not eligible to vote, this information is still valuable and can help you make decisions both now and in the future. There have also been public discussions about lowering the voting age, which is something to think about for young people who want to have a say. 

Whom or what am I voting for?

There are three orders of government, each with its own areas of responsibility: municipal, provincial, and federal. The issues surrounding youth homelessness are complex and each order of government addresses them in multiple ways.

In June, residents of Ontario will be voting for their provincial government. Individuals don’t vote for the party’s leader directly, but instead choose whom they would like to be their Member of Provincial Parliament (MPP)1, the representative in your area of the province or “riding”. However, in Canada’s electoral system, your vote also indicates that you are in favour of your chosen candidate’s party.

Each party has its own priorities that are put into a ‘platform’. The platform explains what the party might do if it were to lead the government. It can tell you what its supporters value, whose interests it represents, and how it plans to will achieve its goals 2. Looking at a party’s platform, the goal is to figure out what it all means to you, your family, or your community.

What matters to me?

Putting government and politics aside for a moment, think about the issues or challenges that affect you and your community on a regular basis. When it’s functioning well, the government should reflect and try to address the issues that matter to its communities and constituents (that’s you!). When it comes to youth homelessness, there are a number of policy areas in the provincial jurisdictionto pay attention to in each party’s platform or when hearing from your local candidates. Below are some key areas Eva’s came up with that are important to think about in upcoming elections, which we expand on with some questions to help inform your thinking. 

Mental Health: Homelessness has direct impacts on developing adolescents’ mental health and wellbeing, requiring specialized supports to equip them with healthy coping mechanisms and tools for success.

  • What will your candidate/party commit to around ensuring youth have access to mental health and addictions/substance use supports?

Colonization and Discrimination: Many young people are at higher risk of homelessness, including Indigenous youth, racialized youth, and trans youth. The impacts of intergenerational trauma from colonization continue to be a barrier to young Indigenous people in Canada. Racism, both overt and systemic, put Indigenous, Black and newcomer youth, in particular, at significant disadvantage to their non-racialized peers, requiring culturally appropriate and specialized supports to help them thrive. Trans youth face discrimination and transphobia and need safe and accepting spaces to go for help. 

  • What steps will your candidate/party take to implement the Calls to Acton from the Truth and Reconciliation Commission, address social discrimination, promote equitable treatment, and provide specialized supports for young people who face higher risk of homelessness?

Child Protection: In Canada’s first national survey on youth homelessness, Without A Home, 57.8% of young people experiencing homelessness had been involved with child protective services to some degree in their lifetime4. Child protective services can be a first line of support for young people and their families to do early intervention and prevention work to keep families together, where safe and appropriate. This requires adequate funding, standards, and policies to support programs, such as kinship care, that focus on family reunification and healing and reduce the number of young people entering the system. For those young people who are in the child protection system, we need to ensure they are supported to make healthy and safe transitions out of care and toward adulthood.

  • How will your candidate/party support families, children, and youth to prevent them from becoming involved with child protection, adequately fund the child protective services that are needed, and provide ongoing supports to youth that are exiting or have left the system?

Housing and Income: Affordable, safe, and appropriate housing for young people and families is a crucial foundation for success, but is increasingly difficult come by, and costs of living are rising. Young people are also discriminated against when they try to access rental housing. Shelters are not long-term solutions, and we need to do a better job of preventing young people from becoming homeless in the first place. Young people need housing options that match their unique stage in life and the care and supports to maintain their housing. They should be able to stay in the communities they know and feel safe in, not pushed further to the margins of society to access housing, jobs and services.

  • What measures will your candidate/party take to alleviate poverty, and ensure that there is adequate affordable housing supply to meet the demand (e.g. Incentives for developers; Matching federal rent supplements; social procurement; Inclusionary zoning; etc.)?

Education: The 2016 Without A Home Study found that 65% of young people that experience homelessness are have not completed high school. Today’s job market increasingly requires higher education in order to secure a sustainable income and future, however the cost of post-secondary schooling is rising. Additional challenges such as learning disabilities and previous experiences of being bullied in school can limit young people’s educational achievements without proper supports in place.

  • What will your candidate/party do to ensure young people with all levels of income and backgrounds have access and supports to pursue and complete secondary and post-secondary studies without a high burden of debt? 

Of course, this list is just to get you started. There are many other topics and issues surrounding youth homelessness that aren’t on this list and you’ll likely come up with more as you start working through party platforms and thinking for yourself. For example, public transportation infrastructure and accessibility, and crime prevention and restorative justice can enhance young people’s resilience and/or impact their risk of homelessness. You may also want to know whether these issues could be impacted by funding cuts if your candidate’s party comes into power.

Where else can I look for information?

Party platforms are a good starting point, but they don’t necessarily list all issues the party cares about or that your candidates may have an opinion on. Particularly if your candidate has been your riding’s representative before, you can do some online research and look into their track-record on a particular subject or issue.

When internet searches fail, it doesn’t hurt to reach out and ask candidates about the topics that are important to you! Call, email, or contact them through social media with your questions. How (or if) they respond to you may give you a hint about how responsive they’ll be if elected.

If you’re concerned that a candidate might not connect with or fully understand your issue, take a look at what they are campaigning on. Do they say they support families? Mental health? Education? Try re-framing your message from these perspectives. Showing how your issue relates directly to their campaign, may make your candidate more inclined to be responsive and champion that issue when elected.

Don’t candidates just say what they think I want to hear?

For the most part, absolutely - candidates want your vote, after all!  However, when you talk to your candidates you can get a sense of whether someone really hears what you’re saying and shows interest in pursuing further conversations and information. Your candidate may not be an expert on youth homelessness, but if they show genuine interest in learning more and doing something about it, that’s an attitude you can work with!

Candidates have a lot to learn during the campaign and after the election. Once elected, we can continue to build relationships with our representatives by reaching out and having conversations to help them understand the issues that affect their community (what we call ‘Politicking’). 

I don’t want to/cannot vote. What can I do instead?

Some people are not eligible to vote. Others decide not to vote, and that’s a valid choice. Those that do not vote may feel that none of the candidates represent them, or that they’ve been failed by the political system and don’t want to participate. Regardless of why an individual doesn’t or cannot vote, there are many other ways to be involved in the political process and have your voice heard. You can join political conversations in person and online, sign petitions, participate in public demonstrations/protests, and volunteer, to name a few options.

For those of us who can and do want to vote, we can show solidarity by challenging our candidates to address the concerns of those that feel left behind or unheard by our political system - these may be the communities that are the most marginalized. It’s our duty as allies to show our candidates that the issues that matter to those communities, matter to all of us.

After the election, is there anything else I can do?

When the polls are closed and the new government is announced, your work is just beginning! Your newly-elected MPP will be going to the legislature to represent you and should be accountable to you. If they or their party don’t seem to be acting in the interests of young people at risk of or experiencing homelessness, you can reach out to voice your concerns. If there’s a bill or piece of policy that you hope they will support, contact them and let them know why it matters to their community5.


Conclusion

The government puts tax dollars toward programs and services you and your neighbours use every single day, from hospitals, to schools, to transportation systems, and beyond. When we don’t invest in proactive solutions to prevent issues like youth homelessness, not only does it have a human cost of suffering and unmet potential, but the financial cost of managing the issue only grows larger. We have to ask our political leaders to have the vision and sense of urgency to help our province and the people in it to thrive both now and in the future.

We hope that over the coming months and beyond the election date you are able to meaningfully engage with your local candidates in order to determine whom will best represent you, your community, and the young people that need our support!

Have other ideas on how to engage with the provincial political system leading up to and beyond election season? Or perhaps you or your organization are helping youth at-risk of and/or experiencing homelessness to engage with their local candidates and the political system? We’d love to hear what you’re doing! Please comment below or on social media - we may follow-up for more information in order to enhance this body of knowledge for other individuals and communities.


1. Or Member of Legislative Assembly (MLA) in some provinces.

2. In Canada, the mandate of political parties is put to the test by government bureaucrats. Bureaucrats are unelected professionals who try to put the government’s priorities into action. Bureaucrats have policy and research expertise, and sometimes, what the party wants to do looks good on paper, but is a lot harder to put into action. That’s part of the reason why not everything in a party’s platform becomes a reality when that party comes into power.

3. The Canadian Constitution Act, 1867 sets out the Division of Powers for the Federal and Provincial governments. This indicates what is within the jurisdiction of each order of government. Note that municipalities are not a constitutionally mandated entity, but are developed under the purview of provincial governments (often referred to as ‘creatures’ of the provinces). Read more about the Division of Powers here: https://www.canada.ca/en/intergovernmental-affairs/services/federation/distribution-legislative-powers.html

4. Take a look at A Way Home Canada’s Child Welfare Policy Brief for more analysis and recommendations.

5. If you are a non-profit organization, or acting on behalf of one, there may be more constraints around advocacy for particular pieces of policy. Be sure to be clear on what activities are allowable, and what are considered advocacy or lobbying activities in your province and at the federal level (they are different). 

Western University
April 10, 2018

In this bi-weekly blog series, I explore recent research on homelessness, and what it means for the provision of services to prevent or end homelessness. Read the first blog here.


It has been stated that “political will follows public will.” And those who work in fundraising will tell you that a hopeful story generates more funds than a story of distress. Within these two issues lie a challenge for us in solving homelessness: if the general public feels that homelessness is a hopeless situation, there will be limited will to do anything about it. And if the public sees no benefit in taking action on homelessness, then there is less motivation for governments to act. 

Ligia Teixeira tackles this dilemma by exploring public opinions on homelessness, and how those within the sector communicate about the issue.

“We asked ourselves – how might we talk about homelessness in a way that deepens public understanding and builds demand for change?” she asks.

To do this analysis, they conducted 15 interviews with topic experts, 50 interviews with the general public using different methods to glean understanding, and analysis of 333 materials about homelessness put out by the media or homeless-serving organizations.

A number of key points came from this study are:

  • Raising awareness alone is not enough to create change, and can actually have unintended negative impacts (such as enhancing hopelessness)
  • The public is too much locked into a single understanding of homelessness as the “middle-aged, chronically homeless man”
  • We need to push the discussion away from individual causes of homelessness to societal causes
  • We need to be explicit on what homelessness prevention means, what it looks like, and how it works
  • We need to speak of homelessness as a solvable problem

Dr. Teixeira, consistent with the message within her research of focusing on hopefulness, is hopeful when looking at how we communicate about homelessness in order to win the hearts and minds of the general public and policy-makers.

She points out that these recommendations for improving communication are relatively straightforward and easy to adopt, and that many organizations and individuals in the sector are already communicating in this way (see, for example, the Urban Institute in the U.S.). As she concludes, communicating more effectively won’t solve homelessness by itself; but neither can we, if communities and governments do not believe in the cause.

 

Canadian Observatory on Homelessness
April 05, 2018

People experiencing homelessness are at an increased vulnerability of being exposed to and/or contracting various infectious diseases. This is because of difficulties related to their experiences of homelessness including: maintaining personal hygiene, obtaining adequate nutrition, staying in crowded and poorly ventilated environments, engaging in sex work, using intravenous (IV) drugs, and transitioning between imprisonment and homelessness. These factors make it more likely for some individuals, compared to the general population, to face problems with their immune systems.

Research regarding infectious diseases in relation to homelessness tends to focus on Hepatitis, Tuberculosis (TB), Human Immunodeficiency Virus (HIV), Acquired Immunodeficiency Syndrome (AIDS) and Sexually Transmitted Infections (STI). In this blog, we take a look at what these diseases are, and how they affect individuals experiencing homelessness. 

hospital bed stock image
Media Folder: 

Hepatitis

According to the World Health Organization (WHO), Hepatitis B is a viral disease that attacks the liver, which can cause both acute and chronic disease. The overall prevalence of acute and chronic Hepatitis decreased between the years 2005-2013 in Canada. Hepatitis B (acute) has reportedly gone from 1.0 to 0.5 per 100,000 people. There was also a decrease in the reported numbers of chronic Hepatitis B between 2009-2013, down from 13.6 to 12.0 per 100,000 people.

Those who are experiencing homelessness are much more likely to contract Hepatitis B. One study found that 32.5% of individuals experiencing homelessness and using substances or facing mental health problems, tested positive for the Hepatitis B virus (HBV). As the vaccination for the prevention of Hepatitis B is administered in three doses, people experiencing homelessness often face barriers in completing their full dosage of treatment within the required 6-month period.

Hepatitis C, on the other hand, is a liver disease caused by the Hepatitis C virus. The virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness.

Overall, like Hepatitis B, there have been decreases in the reported incidences of Hepatitis C in the general population. For example, between 2005-2013, rates have dropped from 40.3 to 29.6 per 100,000 people in Canada.

However, those experiencing homelessness are still at an increased risk of infection. One study reported that among Torontonians experiencing homelessness, their risk of infection by the Hepatitis C virus was 29 times higher compared to the general population. 

Even within the population of individuals experiencing homelessness, those who have Hepatitis C are more likely to experience adverse symptoms related to their infection such as regularly being in pain and in discomfort (61% versus 35%), or being “so tired [they] did not have the energy to walk one block or do light physical work” (72% versus 48%).

Tuberculosis (TB)

According to the World Health Organization (WHO), Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that most often affect the lungs. Tuberculosis is curable and preventable.

In Canada, the risk of contracting Tuberculosis is relatively low compared to other nations on a global scale. However, certain individuals have a higher risk of contracting TB, which is largely attributable to their living conditions and individual health circumstances.

For example, the Government of Canada lists the following groups as having a higher risk of TB contraction in Canada:

  • Those who live inshelters
  • People on First Nations reserves
  • People living in densely populated areas of cities
  • Those living in refugee camps
  • Those staying in long-term facilities
  • People who previously used certain illegal drugs (through inhalation or injection)
  • Individuals with certain conditions or diseases such as HIV/AIDS
  • Those who have had TBin the past (but were unable to complete the full course of treatment)

In 2012, there were six reported cases of persons diagnosed with Tuberculosis, who were underhoused or experiencing homelessness in Toronto. Five were male and one was female. As of July 2013, one out of these six individuals had died of causes directly related to their Tuberculosis. One other person died due to their HIV-positive status, as AIDS had compromised their immune system. Furthermore, one person experienced success after treatment, whereas three others were still in the process of receiving treatment during the time of the Toronto Public Health report.

Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)

The World Health Organization (WHO) defines HIV as a virus that “targets the immune system and weakens people's defence systems against infections and some types of cancer. As the virus destroys and impairs the function of immune cells, infected individuals gradually become immune deficient.”

The most advanced stage of HIV infection is Acquired Immunodeficiency Syndrome (AIDS), which can take from 2 to 15 years to develop depending on the individual. AIDS is defined by the development of certain cancers, infections, or other severe clinical manifestations.”

In a Canadian context, certain groups of people are overrepresented in the HIV/AIDS statistics, including Indigenous Peoples, and individuals who have migrated from countries where HIV/AIDS is highlyprevalent. While the overall prevalence of HIV in Canada is low (0.2% in 2011), there are a number of sub-populations within Canada that are most affected, including:

  • Gay men (or other men who have sex with men)
  • People who use injection drugs
  • People from countries with a high HIV prevalence rate
  • Indigenous Peoples
  • People in prison
  • Youth at risk
  • Women

Studies have found that one’s socioeconomic status and housing stability can have an impact on the treatment that individuals receive when living with HIV/AIDS. For example, individuals who experienced homelessnesswhile living with HIV/AIDS experienced more discrimination, compared to people who had a higher socioeconomic status (who encountered less discrimination).

Furthermore, regardless of the income that one has before being diagnosed with HIV, living with HIV/AIDS often significantly impacts a person’s income in the long haul. This is likely due to a number of factors, including the necessities required for HIV-positive individuals to manage their health. Some examples include: medications, therapies, general prescription or non-prescription medications, dispensing fees, nutritional supplements, special foods, transportation, parking for medical appointments and other services. Some individuals with HIV/AIDS also experience a reduction in their regular income, due to their inability to work because of health-related problems. Overall, many people with an HIV/AIDS diagnosis are living below the low-income cut-offs. Many also find that the benefits they receive are insufficient in supporting their needs.

A study that included a sample of 91 Canadian families who had HIV-positive mothers reported that:

  • 60% of the families had to deal with income-loss after the HIV-diagnosis
  • 31% had an income that was stable, but their expenses had increased

Future Directions

Although Canada is generally a nation that has relatively low prevalence rates for infectious diseases like Hepatitis, Tuberculosis and HIV/AIDS, it is also important to take into account the ways specific populations, particularly those who are marginalized within society, are more vulnerable to becoming infected due to a variety of social factors. As well, it is also crucial to consider the associated stigmatization that occurs with certain diagnoses, and the barriers that different people face in terms of accessing adequate treatment.

While the prevalence of various forms of Hepatitis have decreased in the past decade, for example, which is largely attributed to Canada’s Universal Immunization Program, it is also true that at-risk groups, such as people experiencing homelessness, face barriers in obtaining these vaccinations. This is sometimes due to the time constraints and multiple dosage requirements involved with infectious disease prevention methods. Other barriers also include lacking funds for medication, not having an ID or health card, feeling stigmatized and not having access to transportation for medical visits.

Some suggestions to make vaccinations and medical help more accessible to people experiencing homelessness include increasing the funding for preventative vaccines (such as the HBV vaccine), offering immunizations in locations that are easily accessible, and creating more programming such as  case management centred programs.

Finally, as there is an established link between the adherence of individuals to treatment plans when they have stable housing, it is important to consider the crucial role of approaches such as Housing First. This approach helps to quickly move people out of their situations of homelessness and into secure housing. The main concern and top priority when addressing homelessness should be to place individuals into permanent housing. All other concerns can then be dealt with more effectively after they’ve attained suitable shelter.

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The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.