10. Promoting Health for Homeless and Street-involved Youth: Use and Views of Services of Street-involved Youth in Calgary

Catherine Worthington, Bruce MacLaurin

Introduction

Street-involved youth are seen hanging out or living on the streets of most major Canadian urban centers. The economic boom that occurred in Alberta in the early to mid-2000s drew people to the city of Calgary, putting greater pressure on affordable housing, and increasing the number of youth on Calgary’s streets. The number of homeless people in Calgary went up 32% between 2004 and 2006, and youth homelessness grew at a faster rate than the adult homeless population during this period (City of Calgary, 2006). For youth and health service providers in Calgary, the issues faced by street-involved youth were thus of growing concern. Table 1 provides information about Calgary housing and homelessness at the time of the study.

In particular, the health and well-being issues of street-involved youth were a major focus of discussion among Calgary service providers, as the link between homelessness and poor health is clear (Turnbull et al., 2007). The health risks of street-involved youth are many, and may arise from street environmental risks, including inadequate shelter, poor diet, and violence (Dachner & Tarasuk, 2002; Gaetz, 2004). They may also result from experiences while on the street including those related to sexual activity (i.e. survival/obligatory sex or prostitution), such as high rates of sexually transmitted infections (or STIs, such as HIV, Chlamydia, Gonorrhea, or hepatitis B) and high-risk pregnancy (Boivin et al., 2005; Public Health Agency of Canada, 2006a; Weber et al., 2002); substance use, such as drug overdoses, or hepatitis B, C, or HIV infection through sharing of needles or drug injection equipment (Public Health Agency of Canada, 2007; Roy et al., 2007); and isolation and lack of social support, which may lead to mental health problems (including depression and suicide attempts), or worsen existing mental health issues (Boivin et al., 2004; Kidd, 2006). While many street youth use hospital emergency services and health clinics, they typically only turn to these when seriously injured or ill, and often cannot afford medicines (Carlson et al., 2006; Ensign & Bell, 2004; Geber, 1997).

Youth and health service providers in Calgary wanted to understand how to improve services to support health and healthy behaviours for street-involved youth. From 2004-2007, health and social service providers worked together with researchers to conduct a study with street-involved youth in Calgary. One of the goals of the study was to better understand the types of services used by street-involved youth with different levels of street involvement, and to hear the opinions of street-involved youth about services, in order to improve service delivery. In this chapter, we review the results of the Calgary Youth, Health and the Street Study regarding service use by street-involved youth in Calgary, report youth’s views of services, and discuss implications for youth services (Worthington et al., 2008; Worthington & MacLaurin, 2009).

Table 1

Calgary Housing and Homelessness (2006)

Calgary Census Metropolitan Area (CMA) Population (2006)1

1.1 million

Rental households spending more than 50% on shelter
(at risk of homelessness) (2006 census)2

8,605, 8.6% of all households

Average market rent for a two-bedroom apartment in Calgary (2006)3

$960, 16.9% increase from 2005

Rental vacancy rate (2006)3

0.5%

Social (non-market) housing units (2005)4

12,667

Count of homeless people (point in time) – Calgary total (2006)5

Count of homeless people (point in time)– Calgary youth (age 24 and younger) (2006)5

3,436

647 (18.8% of total count)

Emergency Shelter beds – Calgary (2006)6

Transitional Shelter beds – Calgary (2006)6

1,442 available
(of which 1,383 (96%) occupied)

1,635 available (of which 1,440 (88%) occupied)

1. 2006 census. Population and dwelling counts. A portrait of the Canadian population [Internet]. Release no. 1. March 13, 2007. Ottawa: Statistics Canada; 2010 [updated 2010 Dec 8; cited 2011 Jan 31]. Available from: www12.statcan.gc.ca/census-recensement/2006/rt-td/pd-pl-eng.cfm.

2. 2006 census housing series: Issue 8 – Households in core housing need and spending at least 50% of their income on shelter. Socio-economic Series 10-017. Ottawa: Canada Mortgage and Housing Corporation; 2010. Available from: www03.cmhc-schl.gc.ca/catalog/productList.cfm?cat=30&lang=en&fr=1297373382565.

3. City of Calgary Community and Neighbourhood Services, Social Research Unit. Fast facts #08 Trends in the Calgary housing market; Revised 2007 November 19. Available from: www.calgary.ca/CSPS/CNS/Documents/homelessness/ff-08_trends_calgary_housing_market.pdf.

4. City of Calgary Community and Neighbourhood Services Social Policy and Planning Division, Social Research Unit. 2011 Survey of Non-market rental housing in Calgary. Revised 2012 April 4. Available at: www.calgary.ca/CSPS/CNS/Documents/homelessness/Full%20Survey-Non-Market%20Rental%20Housing.pdf.

5. City of Calgary. 2006. Results of the 2006 Count of Homeless Persons in Calgary: Enumerated in Emergency and Transitional Facilities, by Service Agencies, and On the Streets – 2006 May 10. Calgary: City of Calgary, Community and Neighbourhood Services, Policy and Planning division. 2006 Count of Homeless Persons in Calgary www.calgary.ca/docgallery/bu/cns/homelessness/2006_calgary_homeless_count.pdf

6. City of Calgary Community and Neighbourhood Services, Social Research Unit. Fast facts #07 Facts and stats on homelessness and affordable housing; revised 2007 May 2. Available from: www.calgary.ca/CSPS/CNS/Documents/homelessness/ff-07_facts_stats_homelessness_affordable_housing.pdf

Defining Street-involved Youth for Health Studies

A variety of definitions of street youth have been used, but most health research in Canada focuses on youth under 25 who face some degree of precarious housing (e.g., those ‘couch surfing’ at friends’ homes or staying in hotels) or absolute homelessness (those living outdoors, in abandoned buildings or shelters) over a given time period, and who use street services (Boivin et al., 2005; Public Health Agency of Canada, 2006b). A more inclusive perspective defines street-involved youth as young people under the age of 25 who spend considerable amounts of time on the street, hang out with others on the street, and who may live or have lived independently of parents or guardians in marginal or precarious situations (Brannigan & Caputo, 1993). This approach acknowledges diversity among the street-involved youth population, and includes youth who may not be accessing services, as well as youth who may be street-involved, but who have not lived on the street. This approach also considers factors that lead to street involvement, which typically include family conflict, violence or abuse (Adlaf & Zhanowicz, 1999; Hyde, 2005), individual issues (such as mental health issues and substance use) (Boivin et al., 2005; Martijn & Sharpe, 2006), or child welfare or educational systems issues (Thompson et al., 2004).

Within the last decade, there has been growing recognition within the research literature that for youth, involvement with the street is broken up into episodes, and may consist of one or more cycles on the street where youth become more involved in street life for a period before moving away from street involvement, and then perhaps back again (Adlaf & Zhanowicz, 1999; Auerswald & Eyre, 2002). Studies have thus recently begun to examine health risks, health outcomes, and use of street services according to the levels and types of street involvement to understand the different ways that youth use services and to develop more appropriate services (Carlson et al., 2006; Garrett et al., 2008; Greene et al., 1997).

The Calgary Youth, Health and The Street Study

In order to examine street and health services use by street-involved youth with different levels of street involvement, as well as their views of services, this study used a community-based research approach. Community members (including 3 street-involved youth and representatives of 14 agencies) acted as research team members, and contributed to the drafting of study questions and survey and interview instruments, the administering of surveys, and the interpretation of data. Community-based research is a form of research where community members (in this case, street-involved youth) and service providers collaborate with researchers through the entire research process. Because community members help establish the research questions and the research methods, study results are relevant to the community, and results are used by community agencies. The process also ensures that researchers understand community contexts, and provides research training and skill-building for community members (Israel et al., 1998).

The Calgary Youth, Health and the Street Study included a paper-and-pencil survey completed by 355 street-involved youth, and in-depth interviews with 42 street-involved youth to supplement the survey information. The self-completed survey included questions on childhood experiences, street experiences, health, services use and views of services. Youth targeted for the study were between the ages of 14 and 24 (although participation of youth up to the age of 29 was accepted if they engaged with other youth), and involved in street-life to varying degrees. Thus, in this study, the term ‘street-involved youth’ included youth who were currently living on the street, youth who were not living on the street but who had lived on the street at any time in the past, and youth who were involved with street culture but were not currently living on the street and never had. This last group primarily included youth who spent a large amount of time on the street or in public places during the day. An effort was made to collect surveys in as many areas and locations as possible in order to attract a diverse group of street-involved youth participants. Surveys were collected in all quadrants of the city of Calgary, and were conducted in indoor and outdoor gathering places, agency locations, and shelters.

Of the 355 survey participants, 60% were male (39% were female, and 1% were transgender), 51% were 19 or younger (43% were 20-24, and 6% were 25 or older), and while 62% were White, 26% were Aboriginal (12% said “other”). A total of 47% of survey participants were currently living on the street (Currently on Street); 33% were not living on the street but had lived on the street in the past (Not on street – History); and 20% were involved with street culture (i.e., who spent a good deal of time on the street or in public places during the day) but were not currently living on the street and had not lived on the street in the past (Not on Street – No History).

Purposive (a sample selected in a deliberate and non-random fashion to achieve a certain goal) and snowball sampling (a sampling technique where existing study subjects recruit future subjects from among their acquaintances) were used to recruit youth for interviews from 9 Calgary youth street services. The 42 qualitative interview participants came from various ethno-cultural backgrounds (White, Aboriginal and visible minorities), and ranged in age from early teens to late 20s, but were predominantly in their early 20s. A total of 21 males and 23 females were interviewed. Fourteen interview participants were Currently on Street; 23 were Not on Street – No History; and 5 youth were Not on Street – History.

In the next sections, study results regarding survey respondents’ use and views of street and health services are presented first for the survey respondents. These are followed by the qualitative interview results to provide further commentary on study participants’ views of services.

Survey Results: Street Services Use and Views of Services

Surveyed youth reported using a variety of services within the past three months (see Table 2). Overall, only 11% indicated that they had used no services in the past 3 months. Among services used most frequently were shelters (48%), drop-in centers (44%), medical clinics (41%), outreach services (37%), and food banks (32%). As might be expected, youth Currently on Street reported significantly greater use of shelters (72%), drop-in centers (68%), and outreach services (53%) than other youth. Those Not on Street – History more frequently reported using counselling services (26%), compared to 15% of youth Not on Street – No History, and only 10% of youth Currently on Street. Finally, youth Currently on Street reported the greatest use of services overall, whereas youth Not on Street – No History reported using services the least.

Table 2

Use of Street Services by Level of Street Involvement

Current Level of Street Involvement

Services Used in the Past Three Months (N=333)

Not on Street -
No History

Not on Street -
History

Currently on Street

TOTAL

%

#

%

#

%

#

%

#

Food banks

22%

14

38%

43

33%

50

32%

107

Shelters *

19%

12

32%

36

72%

111

48%

159

Drop-in centres *

12%

8

30%

34

68%

105

44%

147

Medical clinics

35%

23

45%

51

40%

61

41%

135

Outreach services *

9%

6

32%

36

53%

81

37%

123

Financial aid

6%

4

15%

17

8%

13

10%

34

Employment services

23%

15

21%

24

29%

44

25%

83

Educational services

20%

13

16%

18

10%

16

14%

47

Counselling services

15%

10

26%

30

10%

16

17%

56

No services used

22%

14

17%

19

2%

3

11%

36

TOTAL

Column totals not provided because participants
could choose multiple responses

Calgary Youth, Health and the Street - Final Report

Based on a sample of 333 responses with information about use of street services and current street involvement

* Significance level p ≤ .05

When asked about problems with each street service, the majority (ranging from 51% to 64%) of youth respondents indicated that they had not had any problems. Overall, only 5% to 12% reported issues with specific types of services. For example, for food banks, 9% overall said that the service was not open when they needed it, and 8% said that the rules were rigid. For shelters, 12% overall said that the staff were not helpful, and 10% said they had been refused service. Where there were differences among youth with different levels of street involvement, youth Currently on Street were more likely to report problems: 11% of Youth Currently on Street indicated they had been refused service at a food bank (compared with 6% of those Not on Street – History), and 18% of youth Currently on Street indicated staff were not helpful, compared with 7% of youth Not on Street – History, and 2% of youth Not on Street – No History.

Figure 1: Use of Medical Services by Level of Street Involvement

Medical Services Use and Views of Services

Types of medical services used varied by level of street involvement (see Figure 1). Overall, 66% had used a walk-in medical clinic, 23% had used a hospital, 19% had used a doctor during business hours, and 17% said “at this time” they did not use medical services. Youth Currently on Street more often reported not using any medical services (22%), compared to 18% of youth Not on Street – History, and only 4% of those Not on Street – No History. Those youth Not on Street – History more often reported using hospitals (32%), while youth Not on Street – No History more frequently reported using a doctor during business hours (35%), and youth Currently on Street more often used a mobile clinic on the street (21%).

Youth were asked what problems they had encountered, if any, when trying to use medical services. Overall, 37% said there were no problems. The greatest problem noted was waiting times (47% of the survey participants said this was a problem), 17% said they had problems due to not having a health card or medical insurance, 16% said they had problems with staff attitudes, and 15% said they were afraid of being judged (see Table 3).

Table 3

Problems with Medical Services by Level of Street Involvement

Current Level of Street Involvement

Problems with Medical Services (N=341)

Not on Street -
No History

Not on Street -
History

Currently on Street

TOTAL

%

#

%

#

%

#

%

#

None

45%

32

35%

39

34%

54

37%

125

Confidentiality

4%

2

12%

14

8%

13

9%

30

Needed a health card/insurance *

7%

5

21%

24

19%

29

17%

58

Fear of being judged

10%

7

20%

23

14%

22

15%

52

Staff attitudes *

6%

4

19%

21

19%

30

16%

55

Rules and regulations

4%

3

5%

6

6%

10

6%

19

Consent

4%

3

6%

7

5%

7

5%

17

Waiting time

47%

33

41%

46

51%

80

47%

159

TOTAL

Column totals not provided because participants
could choose multiple responses

Calgary Youth, Health and the Street - Final Report

Based on a sample of 341 responses with information about problems with medical services and current street involvement

* Significance level p ≤ .05

Most Recent Medical and Dental Care

Surveyed youth were asked about the last time they had used medical or dental care (see Tables 4 and 5). Overall, 19% had received medical care within the past week, while another 17% said they last received medical care over one year ago. For dental care, there was also great variation, with 27% of participants saying they had been to the dentist within the past 6 months, and 19% indicating they had last been to the dentist more than 5 years ago. No significant differences were found between levels of street involvement and the last time youth received medical care. However, youth Not on Street – No History reported seeing a dentist within the past six months significantly more than other youth (50%), compared to 28% of those Not on Street – History, and 15% of those Currently on Street. Youth Currently on Street more often reported seeing a dentist more than five years ago (29%).

Table 4

Last Medical/Dental Care by Level of Street Involvement

Current Level of Street Involvement

Last medical care

Not on Street -
No History

Not on Street -
History

Currently on Street

TOTAL

%

#

%

#

%

#

%

#

Within past week

22%

15

17%

20

17%

27

19%

62

Between 1 week and 1 month ago

15%

10

23%

26

17%

26

18%

62

Between 1 and 6 months ago

32%

22

35%

40

32%

51

33%

113

Between 6 months and 1 year ago

17%

12

10%

11

14%

22

13%

45

More than 1 year ago

14%

10

15%

17

20%

32

17%

59

TOTAL

100%

69

100%

114

100%

158

100%

341

Calgary Youth, Health and the Street - Final Report

Based on a sample of 341 responses with information about last medical care and current street involvement

Table 5

Last Dental Care by Level of Street Involvement

Current Level of Street Involvement

Last Dental Care *

Not on Street -
No History

Not on Street -
History

Currently on Street

TOTAL

%

#

%

#

%

#

%

#

Within past 6 months

50%

35

28%

33

15%

24

27%

92

Between
6 months and
1 year ago

13%

9

26%

30

17%

28

19%

67

Between 1 and
2 years ago

19%

13

22%

26

16%

26

19%

65

Between 2 and
5 years ago

7%

5

14%

16

23%

36

16%

57

More than
5 years ago

11%

8

10%

12

29%

46

19%

66

TOTAL

100%

70

100%

117

100%

160

100%

347

Calgary Youth, Health and the Street - Final Report

Based on a sample of 347 responses with information about last dental care and current street involvement

* Significance level p ≤ .05

Qualitative Interviews: Service Views of Calgary’s Street-involved Youth

Street Services for Youth

The 42 youth who participated in in-depth interviews described a variety of agencies that provided services specifically to street-involved youth. They also discussed the range of services these agencies provided including shelter/housing, necessities such as food, counselling and support, skills and employment training, and referrals to other services. The majority of youth spoke positively about many aspects of the services available for street-involved youth. Youth appreciated flexibility of services, positive employee attitudes, a comfortable atmosphere, and a sense of safety and security. Many of the concerns expressed about services were direct opposites: inflexible service policies, poor employee attitudes, inaccessible location of services, and limited hours of service. When views of services were examined by level of street involvement, there were some differences by specific type of service. In the next sections, youths’ general views on the positive and negative aspects of services will be described, and then the differences for some services by level of street involvement will be presented.

Positive Aspects of Service

The youth who were interviewed indicated that they appreciated programs that were flexible. The youth felt that flexibility around curfew times and open meal programs were necessary in meeting individual needs. As one youth explained:

[Agency X] was a lot more lenient. Like if I called them up and I was like, “Yeah, I’m hanging out with a friend for a while. Is that okay?” They’d be like, “Yeah. Stop by at this time then.” Or they’d be like, “Well, what time were you planning on showing up?” And they gave me more leniency – I couldn’t do that every day, but like they’d let me do that every once in a while as a treat so I didn’t have an early curfew.

Flexible program times and full day programs were also appreciated. One youth accessing these services said, “You can come and go as you please and, you know, you don’t have to be there if you don’t want to.”

Positive employee attitudes were another aspect of services that youth described as being essential to a good program. The majority of the youth shared positive experiences in interacting with the staff, describing ease of conversation, mutual respect and support as integral to relationship building. Several youth cited the relatively young age of the staff as a positive factor. They were “really cool, down to earth people.” As one youth described:

But the staff here are very young and friendly and I believe I can trust them. If I have some information or if I need help with something, I wouldn’t be, you know, ashamed or anything. I’d be comfortable to talk to them because they’re so young, and they’re a couple years older than me so they already went through that and their generation is basically the same.

One youth described staff as “friendly. You can sit around there and they listen – Yeah, I guess you could talk to them and they’ll listen, kind of help you out with pointers, which way to go.” Another youth said, “I’ve always been able to talk to them about anything. It’s kept me out of trouble.” Several also shared experiences where staff actively assisted them. One youth explained:

And then I came – I went to [Agency X], and I talked to one of the staff members and she was actually the one that helped me get off crystal meth. She took me to the doctor’s and that same day I saw a doctor and I got sleep after that.

The youth who were interviewed also appreciated when agency staff interacted with them without judgment. Interview respondents stated that agency staff’s non-judgmental attitudes were essential to creating an open and accepting atmosphere and developing trust. One youth explained in detail:

Like I said before, you can hang out, it doesn’t matter who you are, who you’ve been, they don’t – they don’t look at the bad points in you. They just welcome you in and hope you have a good time. You’re safe. You can sit back and just relax, make new friends, and guaranteed, there’s a person in there that’s been through the same things you have. The people that work there or volunteer there, they’re willing to talk to you and it doesn’t matter what time of day, what time of night. They extend their ass to you, and I wouldn’t have it any other way.

Many of the youth interviewed also expressed their appreciation for the direction and guidance they received when they were struggling. The bond created allowed staff to let youth know when they felt they were making a mistake. One youth said, “They gave me a place of a chance,” and another described the style of discipline:

They actually [behaved] like literal adults who, when you’re not doing something, they’re all, “Hey, you’re not doing something.” But you know, yeah, you have fun. Yeah, they can be all fun with you, but when it’s time to work you need to – They’re like, “Hey, it’s time to work.”

Many youth commented that the services they enjoyed were those that offered a comfortable atmosphere and entertainment. In the shelters, the youth appreciated access to a range of activities. As one youth said:

You know, you have a pool table, you have TV, you have a phone, you know, you can check your e-mail. Like it’s just – it’s just like a comfortable environment when I come here.

Youth indicated they often associated these services with “home” or “a homey feeling.” These services were open to all youth and there was no concern about being turned away. As one youth described:

It’s a place to come just to chill out, you know, it’s still like my home until I turn twenty-one, you know? Like, I like coming here just to relax. It gets me away from everybody else. All the stupid shit.

Finally, youth appreciated the safety and security offered by some services for street-involved youth. These services provided not only a drug and alcohol free environment but also an alternative to negative influences and criminal activities. These services provided spaces where youth could relax. As one youth said:

So I like coming here because instead of going out and doing drugs or going out and partying and getting into fights and stuff I come here and I can dance and there’s no alcohol and there’s no drugs here so I can dance, play pool, and hang out with all my friends. I just like this place.

And another said, “There was no fights. No one expected you to act a different way. They never turned you away. It was great. It was an alternate place in my mind to hang out. You were safe.”

Service Concerns

Youth who were interviewed identified a variety of concerns with street-youth services. These included the location of and distance between services, limited hours of service, personal safety issues, employee attitudes, and policies that restricted services to certain youth. As previously noted, many of the concerns expressed contrasted with opinions expressed about the positive elements of service (e.g., sense of security, flexibility, and positive employee attitudes and service environment).

Location was one of the most frequently identified limitations to the services provided to the youth. The services were often described as being in unsafe neighbourhoods or not accessible due to the distance from the main meeting areas for the youth. Many youth stated that they did not use some services or limited their use of some services because the location was not “easy to access for youth on the street.” The youth were undecided about service locations downtown. As one youth said, “That’s another unknown area that I won’t go down… that’s all crack alley basically.” They acknowledge that services provided in the downtown core were accessible but recognized that the location came with negative influences and easy access to substances. One youth described his difficulty:

A lot of the shelters are downtown and that’s just kind of inconvenient for me because I… can’t be downtown right now. So it’s kind of hard, I’ll have no choice but it’s [access to drugs] a risk that I’m taking every time I go.

A few interview participants also noted that services for youth were spread throughout the city. As a means of addressing distances between service locations, youth were given bus tickets and bus passes. Bus passes and bus tickets could often be earned for different chores done around a facility. As one youth said, “Honestly, I don’t mind. If she asked me to both – clean both of the bathrooms for a bus ticket, it’s like, you know, it’s a free bus ticket. It’s my way home, you know.”

Limited hours of operation were identified as a service limitation. Youth stated that many of the shelters woke youth early and then closed for the day. Youth felt this was inconvenient because they needed “a place where you can hang out for the day.” This raised particular concerns during bad weather or when youth were sick. Some other youth programming was closed during the weekends, which youth felt “kind of sucks because it’s usually when kids get into most trouble.” One youth described the issue in detail:

I’m on the street, I have nowhere to go, the shelters, there’s no place to go during the day to sleep. Unless you get, like, a sick pass and say you need days, but if you’re working nights, there’s no place during the day where you can go to sleep. If you’re working nights, you need to have proof that you’re working nights. If you’re working for cash, they’re not gonna let you sleep during the day because there’s no proof that you actually have a job! They’re, like, “You just want to sleep during the day.” [They] say, “Screw it, you don’t wanna go to work, you’re just lazy.” But there’s a lot of people out there, I’m like that, that just need once in awhile they need, like, a day to relax. Today’s my day off, if I was on the streets and I was working full-time, my day off, we need some place you could go sleep.

Availability of shelter was a service limitation identified by a few youth who were interviewed. These youth stated that finding shelter could be difficult some nights because of the number of youth on the streets. Weather played a role in the availability of spaces in shelters especially during “winter, if you try to get into a safe house it’s actually really difficult because there’s really only, like, three youth safe houses.” Youth stated that during bad weather, shelters were “always packed, they’re always full. You’re lucky if you can stay in a bed in [Agency X]”.

Personal safety was identified as another concern about youth services. Several interview participants stated that some services were better equipped than others because of funding. Where some services offered privacy, entertainment, and meals, others were less developed. As one youth described:

Um, you know, [Agency X], I don’t really like the atmosphere at [Agency X]. I understand they don’t have quite the same funding or the situation, right. You know, it feels like you’re sleeping in a warehouse. Like I’ve gone to [Agency X] and um their different warehouses that they have, and that’s what it feels like, you know. You’ve got a mat, but you know, in [Agency Y], you’ve got the little walls and a shower curtain.

Youth said the places with less funding were “dirty” and could be dangerous. One youth described these agencies as places “I would never go [again]. I hated hanging out there, like, after dark. I hated hanging out at [Agency X] after dark, any, like, shady place like that where there’s a lot of crime.” These youth felt that the services that provided only the bare necessities often housed people who were drunk or high. Youth indicated that in these accommodations they feared for their personal safety and worried about losing their personal belongings. One youth recalled a time when he “woke up and a guy was trying to take my boots off my feet.”

Interview participants felt that using some services indicated that they had “hit rock bottom” and that after using certain services it “was a very downhill step” as it was easy to get “into a lot of criminal activities.” Youth indicated that criminal activity was associated with some services and not others. One youth said, “The parents send them to [Agency X]. Now they’re stealing cars and doing drugs. It’s not – it doesn’t help.” Youth stated that they would avoid certain services because of the reputation clients had for substance use and criminal activity on site. Some of the youth felt that using these services might lead them to negative influences. Several made connections such as “I started smoking weed when I was in [Agency X]” or “I learned more about the street at [Agency Y].” As one youth described:

I went back to Grade ten at [School X], which was a wonderful place except for some of the people were there – uh, I kind of frowned upon the situation that I was getting myself into. The people – there was like ex-peelers [exotic dancers] and all kinds of people there. Like it was a great school, but the drugs that were going through it on the down, though, was insane.

Another concern youth expressed about services had to do with some staff characteristics and attitudes. Youth identified staff with high caseloads, employee turnover and negative attitudes towards the youth as issues they faced in some youth services. Some youth felt that at times the staff could be disrespectful and impatient with them and that this behaviour impacted their experience of services. One youth described his impression:

The other ones [other staff members] were assholes. They used to yell at me all the time for not doing things. They always – staff would always pick on me. Like I asked to use the phone and they’d make smart remarks towards me and I just didn’t like it. I was never rude to any of them. I don’t understand why they were rude to me.

Program rules also presented a barrier to use of services by the youth interviewed. Many youth felt that they had left previous living situations because they could not live up to the rules and expectations. As one youth described:

You were put on discipline notices pretty much, and if you did something bad, they’d give you this and you couldn’t have like seconds at meals, you couldn’t have coffee in the morning, you couldn’t do this, you couldn’t do that, couldn’t do this, couldn’t do that.

Rules and expectations that were considered to be unreasonable included “can’t go out for a smoke after six pm” or “can’t smoke at all,” chores, curfews, and sobriety regulations. An inflexible curfew was difficult for those who smoked, as one youth explained:

I’m stuck in the house for thirteen hours. I at least need to go out for a cigarette. This morning, oh, I almost freaked out this morning. I got up, I was supposed to have a meeting, my social worker was supposed to come and meet me at nine-thirty, but she didn’t, and I was waiting, they’re like you have to be out of the house at nine, and I was like my social worker is supposed to come, so we were started like a whole bunch of times and I was like, I just need to go out for a cigarette. They’re like, “If you go, you have to go out all day.” I’m like, “But we’re trying to get a hold of my social worker.” I’m like, “I just need to go outside.”

Another youth said, “[Curfew] is, like, actually the hugest problem I have with the shelters… I don’t know why you would expect your kids to be coming back at six and sitting around with one another and like just talking to other street kids all the time.”

Youth also identified different program policies that limited access to services. Policies restricted some services to those who were not using alcohol or drugs, to those who were referred by child welfare or justice programs, or to those who were in a certain age group. Youth reported that shelter services providing accommodations often did not allow youth access when they had been using drugs. Interview participants indicated that shelter was especially important during times when they have been using or were high because “if they [a shelter] sends them away and they go somewhere and they have a bad trip or they don’t know where they are and something happens to them, then well, wouldn’t they rather them be somewhere safe when they’re high than on the streets?” A few youth also said that some programs that were available to help youth required youth to first be stable for a period of three months before getting access. These youth felt that program policies that required a period of stability before receiving assistance were setting youth up for failure. As one youth said, “You have to be stable for three months, but where can you be stable for three months?”

Other youth expressed the concern that the benefits of the programs they were attending were limited because they were obligated to attend by child welfare or justice programs. These youth stated that freedom of choice was essential in order for them to commit to certain programs. One youth said, “My social worker, like, forced me to go there and I wasn’t addicted to drugs, really.” Another said that youth were not committed to a program they were forced to attend:

Nobody really wanted to be there. Most of us were forced to be there. I was there so that I had food, had a place to live for a while.

A final concern about services was that services were sometimes restricted according to age or child welfare status. As one youth said, “Basically they bounce you between [Agency X] and [Agency Y] unless you have [child welfare] status, then you can stay at [Agency X].” Another explained:

I think, uh, that kind of stuff for people it isn’t fair, because if your fifteen days are up, and there’s no other place for you to go, and you haven’t been doing a whole lot there, they do kick you out, and you’re stuck out on the street, because there’s some, there’s some kids, that you know, don’t look sixteen, seventeen [years old] to get into the [Agency X].

Views of Street Services by Level of Street Involvement

When the views expressed by street youth about street services were examined according to their current level of street involvement several differences were noted (see Table 6). These views are organized by type of service that youth commented on most frequently, including shelters, drop-in centers/outreach services, and food banks (other types of services were not mentioned frequently enough to make comparisons by level of street involvement).

Table 6

Service Opinions by Level of Street Involvement (42 in-depth interviews)

Not on Street
- No History

Currently on Street

Not on Street
- History

Shelters

• Dislike of all shelters: beneath them

• Dislike of adult shelters

• Don’t like policies on smoking, curfews

• Too dirty

• Don’t like locations

• Lots of complaints

◦ Dislike policies about curfew, smoking, and age restrictions

◦ Didn’t like rules and chores

◦ Discomfort of the facilities

• Policies make it difficult for youth to have stability

• Many comments about staff being helpful: counseling, referrals

• Adult shelters are unsafe

• Lots of complaints

◦ Not enough rooms & beds

◦ Generally not helpful/ “crappy”

• Generally found them helpful-staff, referrals

• Recommendations: Need more beds/rooms, cleaner, later curfews, allow smoking

Drop-In Centres/

Outreach Services

• Common comments: safe, helpful, relaxing

• Liked to access school programs at centres

• Many comments about liking them as places to hang out with friends

• Common comments: safe, helpful, relaxing

• Most comments positive:

◦ caring staff,

◦ practical life necessities being met (laundry, shower, hygiene products, food)

• Common comments safe, helpful, relaxing

• Commented on practical assistance: food, showers

• Accepting

• Dirty, unsafe

Food Banks

• Most had not used them

• Found them easy to access

• Had good experiences

• Didn’t know about them

• Lied to access them (re: housing requirement)

• No comments

Youth Not on Street – No History disliked shelters, and found them particularly unappealing because they were seen as “scary”, and “dirty”. Adult shelters were seen as particularly “scary” as they were crowded and places where youth could be victimized. But fundamentally, youth Not on Street – No History disliked the notion of using shelters because they did not want to be identified as a “street kid”:

Staying in a shelter is not an option for us because we don’t want to be known as street kids, you know? We don’t want to stay [inaudible]. We’re trying to be healthy. We want to live somewhere instead of staying in a shelter and carrying our one bag around and all that.

Youth Currently on Street and youth Not on Street – History had favourable comments about shelter staff, but had more specific issues with policies (curfews, smoking, age restrictions), the physical environment of shelters (cleanliness and safety issues), and the availability of shelter beds. One of the key issues identified by youth Currently on Street and youth Not on Street – History were policies that restricted youth to staying at a facility for a particular number of days before having to move to a different agency (see quotations in the previous section).

Drop-in centers/outreach services were favourably viewed by most interview participants, although the emphasis of their comments was somewhat different. For youth Not on Street – No History, drop-in centers/outreach services were seen as safe, relaxing, drug free places to hang out with friends. Youth Currently on Street and youth Not on Street – History had the same range of positive comments about the service environments (safe, relaxing, friendly), but they tended to comment more on practical assistance and necessities provided by the drop-in centers/outreach services like food, showers, and laundry facilities.

Many interview participants did not know about food banks. Food bank services were not mentioned by youth Not on Street – History, and had been used by very few youth Not on Street – No History, but for those youth Not on Street – No History who had used them, they reported they were easy to use:

I used the food bank if I was out [of food]. If I’m four days away from being paid, I got no food, my kids have to eat, so that way, it’s a last minute thing, like okay... Right now, in five hours, my daughter would still have enough milk for one more drink, I’d go pickup food and come back and she’ll have more milk.

Youth Currently on Street who knew about food banks found them difficult to access as they required a permanent residence. Once youth said,

I lied ‘cause I said that I had a place so that was pretty good... But I wanted the food because I was hungry. But I lied because I didn’t have a place. It was just that half the stuff I ended up giving away because uh – the box of cereal and bread – lots of bread.

Health Services

Many youth who were interviewed reported using health services on an as-needed basis. There were few differences noted in the views that street youth had of health services by level of street involvement. This is likely because youth had a more extensive history with use of health services throughout their lives, and so spoke about health services generally, and not specifically about their current situation.

The majority of the youth were aware of the health services provided in the community and the specific services provided at each clinic. One youth said:

So like [Agency X] helped me get my health care for free and everything and if like – if I thought something was wrong, I could go to the doctor. Plus they also had clinics there for people who were using it [drugs] intravenously specifically.

Information and basic medical care were accessed through street friends and outreach workers, as well as from a street survival guide provided by shelters and outreach workers. One youth described services provided by street nurses:

They have street nurses there, though, too, and they just wander around and help people out and give them, like, Polysporin if they have infections or anything, and if you have bugs, they’ll give you some bug juice, and if you have a problem you can just go see the nurse and she’ll tell you probably what it is and what would be the best place to go to, which is good.

Feedback regarding health care was primarily positive, with some concerns expressed about wait times and cost of care. A few respondents identified finances as a major barrier to accessing health services. Interview participants indicated that youth may not have personal identification or health coverage and often cannot afford to pay for treatment. Some health personnel offered “samples when you don’t have money to pay for the actual product.” Youth described how finances influenced interactions with the health care systems, as medical clinics that provide free service and treatment were crowded, and wait times made youth hesitant to seek treatment. One youth related a hospital emergency wait:

I spent nine hours sitting in the hospital gasping for air turning white. Ready to pass out... It was like oh no, I’ve just got three broken ribs and for all I know, I could be bleeding through my lung. Like, thanks. And there’s some woman there that did like – did something to her knee – and she was in [treatment] there like four and a half hours before me. And it’s like, Okay, she can sit there and she’s not in pain. I’m sitting here and I don’t know if I’m going to be able to stand up. Like come on.

Services Implications

The Calgary context at the time of the study was unique and challenging for street-involved people and for service providers. It was a time of rapid economic growth in the city, which put stress on affordable housing, street services and other social services. Even so, in our study, only 11% of street involved youth had accessed no services in the previous 3 months. Thus, our study, as well as other studies conducted in other centres, suggests that the large majority of street-involved youth access services (Carlson et al., 2006; Worthington, et al., 2008; Worthington & MacLaurin, 2009). It is also clear from the study results that youth with different levels of street involvement may access different types of services, use them in different ways, and have different views of services. Service providers need to take this into account when designing services for youth in order to minimize risks and maximize benefits for street youth while they are becoming engaged in street life, while living on the street, or after transitioning off the street.

The survey results showed clearly that those with different levels of street involvement used street and health services to different degrees based on their specific circumstances (see also (Worthington et al., 2008; Worthington & MacLaurin, 2009). For example, shelters were more likely to be used by youth Currently on Street, while counselling services were more likely to be accessed by youth Not on Street – History. Youth Not on Street – No History were more likely to visit a physician during office hours, while youth Currently on Street were more likely to use a mobile street clinic (van).

The qualitative interview results confirmed that there are some elements of services that are important for all street youth – particularly services that had caring, non-judgmental staff, were accessible, and had flexible rules. (Conversely, concerns noted by youth included issues related to difficulty accessing services, employee turnover, negative staff attitudes, and rigid program rules). These are also aspects of services that have been found to be important in other studies (Carlson et al., 2006; Ensign & Bell, 2004; Garrett et al., 2008; Gerber, 1997; Greene et al., 1997). Service providers need to pay attention to these service elements and develop criteria to assess the quality of services, with the input of youth, to ensure that services are being delivered in ways that make them accessible and acceptable. In terms of physical accessibility (i.e., location, hours), youth had a range of opinions about whether being located in the downtown core close to other street services was a good (ease of access) or bad (promoted risk behaviours) thing. A mix of service locations would appear to be an ideal solution.

It is also clear from the qualitative interview results that services are seen differently and used differently by youth with different levels of street-involvement – this has also been found by a few other studies (Carlson et al., 2006; Garrett et al., 2008). The key service implication here is that service providers need to be aware of where a youth is in terms of his or her level of street involvement in order to best understand what types of services and contact he or she will appreciate (Carlson et al., 2006; Garrett et al., 2008). Thus, service providers need to be aware of their role in providing prevention, safety or stabilization services for youth at different stages of street life in order to maximize their health and well-being.

Services are required to assist young people at different points, specifically, before youth become regularly involved in the streets; during street involvement; during a transition from the street to stable housing; and as a follow-up to street-involvement (Silbert &Pines, 1983). Services also need to be multifaceted, and address physical needs (food, clothing, shelter) of young people involved in street-life, as well as needs related to their physical and mental health, education and employment (Kufeldt & Burrows, 1994). Thus, many sectors need to be engaged in services for street-involved youth, including street services (shelters, food banks, drop-in centers, etc.), mental health and addictions services, education, child welfare, public health, and the criminal justice system. Service providers therefore have the opportunity to connect with youth in a number of different capacities. These points of contact provide an opportunity to support youth who are continuing to live on the street, or youth who may be interested in exploring options for getting off the street. For example, one recent study has suggested that for youth living on the street an effective approach is a comprehensive drop-in centre model that provides safe facilities to bridge the gap between the street and transitional or permanent housing (Shillington et al., 2011).

However, with the exception of a few studies (like the Shillington et al., 2011 study cited above) there is currently very little research on interventions to assist street-involved youth, and even less research has been done on the best way to provide services to different sub-groups of street-involved youth (Toro et al., 2011). Nonetheless, there have been some recent suggestions, both internationally and locally, about how to best meet the needs of different groups of youth who are street-involved or homeless (Calgary Homeless Foundation, 2011; National Alliance to End Homelessness, 2012). For youth who have not yet lived on the street, family interventions, life skills development, and information and outreach through educational and social activities (e.g., sports teams, community centres) have been suggested as key strategies (Calgary Homeless Foundation, 2011; National Alliance to End Homelessness, 2012). For those youth who are leaving a care system (e.g., foster homes, correctional services, mental health and addiction facilities), discharge planning needs to be done so that youth are placed into transitional housing, or reunited with families. Similarly, for youth who are new to living on the street, family reunification or transitional housing support are key strategies, along with outreach services and case management services (Winland et al., 2011). For the smaller group of youth with more severe mental health, addictions or life challenges who remain street-involved into adulthood, permanent supportive housing is suggested as a strategy (Calgary Homeless Foundation, 2011; National Alliance to End Homelessness, 2012). At the policy and service systems level, this type of service approach requires a well-coordinated system of components linked through a shared understanding of goals, quality standards, a common assessment framework and central referral processes, and shared tools and resources. In Calgary, such a plan has recently been proposed (Calgary Homeless Foundation, 2011).

Communities need to promote and support positive life choices among street-involved youth while respecting their independence. Research has shown that while street-involved youth are at higher risk for a variety of problems related to survival, safety and health, these youth possess resilience and a strong desire to develop a future for themselves (Carlson et al., 2006; Garrett et al., 2008). A male street-involved youth eloquently described this hope for the future during a study interview in Calgary:

It’s not a dark road. I mean, it’s whatever I want to make of it. Wherever I want to go, I know I can get there. It’s gonna take work, it’s gonna take discipline, it’ll take a lot of things, but it’s not unreachable. So, I’m not hopeless.

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