Homelessness remains a pervasive problem in Canada despite a superior health system and high health spending (Government of Canada, n.d.) As with other health concerns, there exists a disparity in secure and sustained housing across the social and economic gradient, with low-income Canadians experiencing the worst outcomes (Government of Canada, n.d.) This disparity is compounded by individual and structural factors including, but not limited to, mental illness and addiction, race, indigeneity, gender, and older age (Gaetz et al., 2016; Government of Canada, n.d.; Stafford & Wood, 2017).
It is estimated that at least 235 000 Canadians experience homelessness annually, with 35 000 homeless on any given night (Gaetz et al., 2016). This number is likely much higher when considering those who do not seek shelter or emergency services and are not included in point-in-time (PiT) counts (Gaetz et al., 2016). Canada’s shelter system continuously operates at over 90% capacity with stays of individual users becoming longer over time (Gaetz et al., 2016; Region of Waterloo, 2019).
As recently as September 2021, 1085 people were identified through a PiT count in Waterloo Region, Ontario (where I live and work) as experiencing some form of homelessness (Region of Waterloo, 2021). This represented a stark increase from previous counts completed over the past several years. As peers have suggested, this number likely represents influence of the COVID-19 pandemic, throughout which many Ontarians and Region residents have lost employment, closed, businesses, and been forced to access the shelter system or non-traditional housing arrangements.
Being homeless is associated with shorter life expectancy, higher morbidity, and greater use of emergency services (Stafford & Wood, 2017). Homeless individuals are also less likely to initiate use of primary and preventative services, resulting in later stage diagnoses, poor control of manageable conditions, and greater hospitalisation for preventable conditions (Stafford & Wood, 2017).
Additionally, Canada’s homeless, previously viewed as predominantly older men and addicts, has become increasingly diverse, including greater numbers each year of children, seniors, women, Indigenous, and new Canadians (Gaetz et al., 2016).
The Social Ecological Model:
In recent decades, multilevel models of health have become popular for understanding and intervening into individual, community, and population health. One such model, the Social Ecological Model (SEM), can be used to better understand homelessness and develop an improved approach to its intervention and eradication.
The SEM is an approach to health which recognizes the interconnectedness of and interaction between individual factors and other outward levels of influence (Golden & Earp, 2012; Wold & Mittelmark, 2018). Derived from Bronfenbrenner’s (1979) Ecological System’s Theory the SEM endeavours to shift health from current biomedical understandings and belief in individual motivation and behaviour towards an understanding of health as oriented in the entire population, driven by a wide scope of factors, and rooted in social justice (Cohen et al., 2014; Golden & Earp, 2012; Wold & Mittelmark, 2018).
The SEM defines five levels of influence: intrapersonal, interpersonal, community, organizational and political (Centeio, 2018; Golden & Earp, 2012; Wold & Mittelmark, 2018). Interventions are suggested at each level of influence that are needs based and context-dependent (Cohen et al., 2014). These include change in knowledge, belief, and skill (intrapersonal), change in social and organizational relationships (interpersonal and organizational), education, empowerment of disadvantaged groups, and increased service through partnerships (community) and advocacy (political) (Golden & Earp, 2012). The SEM encourages simultaneous intervention across levels to achieve maximum impact and underscores the need for cross-sectoral collaboration in achieving health promoting behaviours, attitudes, and policies; recognizing that good personal functioning is not enough to overcome unsupportive upstream factors and environments (Centeio, 2018; Gaetz & Dej, 2017; Golden & Earp, 2012; Wold & Mittelmark, 2018).
Understanding Homelessness using the SEM:
There exists no single cause of homelessness, nor a defined trajectory (Gaetz & Dej, 2017; Region of Waterloo, 2019; Stafford & Wood, 2017). Homelessness is usually the result of the interplay between structural factors, system failures, and individual circumstance (Gaetz & Dej, 2017; Stafford & Wood, 2017).
Withdrawal of investment by government in affordable housing and social supports over the past 25 years is believed to have created the current housing crisis and fostered a belief in individualism (Bryant et al., 2011, Gaetz et al., 2016; Raphael et al., 2008). This has created public apathy and an increasing disbelief in community and societal responsibility for what are seen as individual choices (Bryant et al, 2011; Cohen et al., 2014; Gaetz et al., 2016; Raphael et al., 2008; Wold & Mittelmark, 2018). This ignores the structural barriers to homelessness and role of social policy in achieving positive health outcomes, and creating societal value systems, both of which serve to change the trajectory of homelessness nationally, provincially in Ontario, and in Waterloo Region specifically (Bryant et al., 2011; Gaetz et al., 2016; Raphael et al., 2008).
Improving Intervention using the SEM:
While support to end homelessness has gained traction in recent years, strategies remain largely rooted in the provision of emergency services and short term supports focused on lifestyle intervention, which fail to examine the factors that cause and perpetuate homelessness (Wold & Mittelmark, 2018). Larger scale initiatives have emerged (eviction prevention, financial subsidy) but have been inconsistent and underfunded based on current statistics and regionally identified need (Gaetz et al., 2016; Schinn & Cohen, 2019). Historically, these programs have also created barriers to entry by imposing behaviour and treatment expectations, impossible to meet with out other necessary supports (Gaetz et al., 2016; Gaetz & Dej, 2017).
Use of the SEM serves to improve homelessness in Canada through simultaneous intervention across levels of influence and targeting of upstream and downstream factors; cultivating intra-personal resources (resilience, autonomy, feelings of self-efficacy) through leveraging extra-personal assets (family support, organizational and community initiatives, citizen participation, advocacy, and mobilisation towards political change) (Gaetz et al., 2016; Gaetz & Dej, 2017; Government of Canada, n.d.; Wold & Mittelmark, 2018).
As an initial step, a SEM approach redefines homelessness as a social issue, removing the notion of individual fault and tendency to victim-blame, and creating an appreciation for multidimensional roles and impact (Golden & Earp, 2012; Stafford & Wood, 2017; Wold & Mittelmark, 2018). Redefinition also removes the prevailing views of the homeless population and fosters an understanding of its diversity (Gaetz et al., 2016).
Foremost focus of a SEM approach to homelessness targets multiple levels of influence through prevention, with additional resources placed in systems response and early intervention (Gaetz et al., 2016; Gaetz & Dej, 2017; Golden et al., 2015; Government of Canada, n.d.; Raising the Roof, n.d.; Schinn & Cohen, 2019; Stafford and Wood, 2017; Wold & Mittelmark, 2018).
Prevention, the “policies and strategies that impact homelessness at a structural level, as well as early intervention practices that address individual and situational factors” occurs at three levels: primary, secondary, and tertiary (Gaetz et al., 2016; Gaetz & Dej, 2017; Government of Canada, n.d.; Raising the Roof, n.d.).
Primary prevention minimizes entry into homelessness through an examination of and intervention into upstream factors that predispose and increase risk of homelessness (Gaetz et al., 2016; Gaetz & Dej, 2017; Government of Canada, n.d.; Raising the Roof, n.d.; Schinn & Cohen, 2019; Stafford & Wood, 2017). Secondary prevention targets early stages of homelessness, often through addressing interpersonal factors. Activities include helping to find or retain housing, mediation with a landlord, the use of local or regional support programs, and leveraging of family supports (Gaetz et al., 2016; Raising the Roof, n.d.; Schinn & Cohen, 2019). Tertiary prevention targets recurring homelessness by offering ongoing and consistent support to individuals and families once housing has been established, thereby improving health promoting behaviours, and individual capacity to cope and sustain housing (Gaetz et al., 2016; Government of Canada, n.d.; Raising the Roof, n.d.; Schinn & Cohen, 2019; Stafford & Wood, 2017).
Systems response aims to streamline access to supports and services through interorganizational and intersectoral collaboration which improves knowledge sharing and reforms the current siloed approach to health-related intervention (Gaetz et al., 2016; Golden & Earp, 2012; Golden et al., 2015; Government of Canada, n.d.; Raising the Roof, n.d.). This coordinated approach ensures that those experiencing homelessness receive responsive support regardless of what area of the system they access. Further, a coordinated systems response improves consistency, minimizes duplication of service, improves stability, and increases the amount and accuracy of information collected (useful in soliciting support from government towards funded interventions) (Gaetz et al., 2016; Raising the Roof, n.d.).
Early intervention into homelessness can be seen through movement from a Housing Ready to a Housing First approach (Gaetz et al., 2016; Raising the Roof, n.d.). In this approach housing is viewed as a precondition to recovery with no imposed behaviour or treatment expectations (Gaetz et al., 2016; Raising the Roof, n.d.; Stafford & Wood, 2017). Once housing has been established, support is implemented that is individualized, recovery oriented, and enhances self-determination (Gaetz et al., 2016). These supports (including life skills development, counselling, substance abuse intervention, employment services, etc.) look beyond housing to address interconnected factors of homelessness (Gaetz et al., 2016; Raising the Roof, n.d.).
The path forward:
Through use of a SEM approach the prevention and eradication of homelessness in Canada is within reach. In Waterloo Region specifically, there exists committment to end chronic homelessness by 2025, in keeping with a similar provincial committment (Region of Waterloo, 2021). Progress, though slow to start, and undoubtedly stalled by the COVID-19 pandemic, continues to be actively sought; evident through continued use and expansion of coordinated supports including regional housing and homelessness programs (shelters, help lines, resource centres, street outreach), federally and provincially-funded community housing, supportive housing, and housing affordability programs, and shelter diversion efforts, many of which integrate additional supports to address the complex factors perpetuating homelessness (Region of Waterloo, 2019). Despite current efforts, however, there exists significantly more that must be done, if housing is not only to be achieved, but sustained.
Committment to a SEM approach can direct attention towards current societal and policy failings and encourage reform, intervention, and prevention, achieved through the simultaneous targeting of upstream and downstream levels of influence, and recognition that intervention into the acute issues of homelessness (i.e., the provision of housing) lacks impact if underlying social structures are not addressed (Bryant et al., 2011; Golden & Earp, 2012; Golden et al., 2015; Shinn & Cohen, 2019; Stafford & Wood, 2017).
However, despite a growing awareness of health as multi-leveled, uptake of and committment to SEM and similar approaches to address homelessness (and other societal health concerns) remains relatively low, and will require ongoing work, including a social and ideological shift that supports system redesign and encourages citizen advocacy (Cohen et al., 2014)
To ensure future success, research, and examination of the homeless population, including the unjust and modifiable factors which predispose one to becoming homeless, must continue and increase. Research in this area should be community-led or community-involved and solicit the lived experiences and opinions of those affected, and weigh this information just as, if not more, heavily than empirical data when defining national and provincial direction and regional needs (Gaetz et al., 2016; Raphael et al., 2008; Schinn & Cohen, 2019; Stafford & Wood, 2017). Additionally, the development of consistent measurement tools will be needed which support observation of the impact of SEM prevention and intervention activities (both short and long-term) and build a deeper pool of research from which to draw when lobbying for government interest and (financial) support (Gaetz & Dej, 2017; Golden & Earp, 2012; Golden et al, 2015; Wold & Mittelmark, 2018). An understanding of these interconnected factors, developed through ongoing evaluation and measurement, will assist in the formation of improved participation in and advocacy for homelessness intervention, including a joint vision for change and further support the development of policy and programs that not only secure housing for those at risk but work to sustain it (Gaetz et al., 2016; Gaetz & Dej, 2017; Schinn & Cohen, 2019; Wold & Mittelmark, 2018).
References
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