In my health care career, I have had the privilege of providing care to individuals from a wide array of socioeconomical backgrounds. One of the most notable populations has been individuals from the homeless population. Homelessness has become an increasing gobal crisis, contributing to significant individual health concerns and placing high costs on the health care system (Center for Disease Control and Prevention, 2017). The Canadian Observatory on Homelessness (2012) has defined homelessness as “the situation of an individual, family or community without stable, safe, permanent, appropriate housing, or the immediate prospect, means and ability of acquiring it” (p.1). Many individuals who are homeless suffer from chronic health conditions and live on the fringe of society, either neglecting or being denied adequate access to health care. Often the accompanying challenges of psychological, mental health, or substance use issues take them out of mainstream of society, making it more challenging to access appropriate care.
I have selected the Social Ecological Model adapted from the Center for Disease Control and Prevention (2019) to provide a more comprehensive and inquisitive lens to explore the factors that contribute to homelessness as a health care issue. The Social Ecological Model focuses on factors that in combination can influence health outcomes. The model also stresses that individuals are influenced by each other and their environments (Center for Disease Control and Prevention, 2019). The factors identified are tiered to represent a contextual aspect of each factor on the whole and include; Individual, Relationship, Community, and Societal (Center for Disease Control and Prevention, 2019)
Individual
The first level of the Social Ecological Model focuses on factors which occur at the individual level (Center for Disease Control and Prevention, 2019). For homeless individuals this focus may include, but not be limited to, poor or limited education, poverty, mental health or substance use or a history of abuse (Mago et al., 2013). These individual factors have a significant impact on a person’s ability to maintain health or access the health care system appropriately. A lack of education can impair the health literacy of this population, diminishing their capacity for full understanding of how and when to access health care services (Mago et al., 2013). Poverty can also play a significant role in influencing an individual’s health outcomes as many of the determinants of health (access to food, water, sanitation etc) are not consistently available (Mago et al., 2013). Substance use, a history of abuse and mental health issues can also cause members of the homeless population to demonstrate behaviours that are often difficult for the general population to understand and can result in a significant social divide. Members of the homeless population often experience feelings of suspicion or mistrust of the health care system, due to their background, culture or previous relationship with the system (Rae & Rees, 2015). For example, in Vancouver, there is a disproportionate number of Indigenous peoples who are homeless. The historical history of colonialism and residential school system has led to deep distrust in the health care system and a reluctance to trust social systems of support.
Relationship
The second tier closely examines the individual’s relationships and their subsequent influence on the individual (Center for Disease Control and Prevention, 2019). It is not uncommon for the homeless population to be estranged from family members and childhood friends (Urban Matters CCC & The BC Non Profit Housing Association, 2018). This disintegration of familial and historical relationships can lead to social isolation and withdrawal from societal norms or interactions (Urban Matters CCC & The BC Non Profit Housing Association, 2018). Often social relationships are developed with other members of the homeless community, building a different type of “family” or community relationship. This community can help foster an individual’s identity and provide a sense of support (May, 2015).
Continuity of low barrier, trauma informed, culturally sensitive care can also be difficult to obtain due to individual’s behaviors, logistical challenges and transitory movements (Medcalf & Russell, 2014). The very nature of homelessness also makes maintaining a relationship with a family physician difficult, thereby affecting the complete documentation of a health history or ability to develop a comprehensive care plan that can be supported or sustained in the community.
Community
The third tier highlights the importance of the individual’s relationship with their schools, workplaces and neighborhood (Center for Disease Control and Prevention, 2019). As stated earlier, many homeless people are unable to maintain employment and have a poor or limited educational experience. Additionally, mental health and substance use issues often lead this population to be ostracized from their “traditional” community. This leaves them socially isolated and in greater danger of increasing health problems.
The “community” that homeless individuals may associate with is often through non-traditional meeting areas such as shelters, non-profit food dispensaries and inner-city park areas (Urban Matters CCC & The BC Non Profit Housing Association, 2018). While many social service organizations intersect to provide support to the homeless community, the absence of an integrated approach to addressing the community factors creates additional complexities for the individuals receiving health care. Tracking of, and providing care to, homeless individuals with episodic or chronic health care challenges is further compounded by logistical complexities associated with silos between acute and community care resources and the lack of a complete health history and gaps in community support (Urban Matters CCC & The BC Non Profit Housing Association, 2018). Discharging from acute care or planning additional ongoing treatments for homeless individuals with a fragmented community support network often leads to less than optimal health outcomes and reluctance to sustain treatments due to barriers in access, availability or resources.
The purpose of this post is to explain how a multilevel model of health can be used to explore homelessness as a health issue. The Social Ecological Model was utilized, and the factors of Individual, Relationships, Community, and Societal influences were examined separately and are evidently interrelated. Clearly homelessness is a growing concern which requires a multifaceted approach to address all levels of factors that contribute to this health issue.
Societal
The final tier of the model focuses on the societal impact and influence on individual’s health, including available resources, media coverage, laws and policies and social norms (Center for Disease Control and Prevention, 2019). There has been increasing media coverage of homelessness as a growing societal crisis (Urban Matters CCC & The BC Non Profit Housing Association, 2018). Additionally, the political platforms of most parties have increasingly emphasized an urgent need to address homelessness (Urban Matters CCC & The BC Non Profit Housing Association, 2018). Policy reform and increased public awareness has leveraged some improvement in addressing the factors that contribute to homelessness but further exploration and collaboration between levels of government are needed to create a more sustainable solution for the future.
The purpose of this post is to explain how a multilevel model of health can be used to explore homelessness as a health issue. The Social Ecological Model was utilized, and the factors of Individual, Relationships, Community, and Societal influences were examined separately and are evidently interrelated. Clearly homelessness is a growing concern which requires a multifaceted approach to address all levels of factors that contribute to this significant health issue.
References
Canadian Observatory on Homelessness (2012). Canadian definition of homelessness. Retrieved from: https://www.homelesshub.ca/sites/default/files/COHhomelessdefinition.pdf
Center for Disease Control and Prevention (2017 March 2). Homelessness as a public health law issue: selected resources. Retrieved from: https://www.cdc.gov/phlp/publications/topic/resources/resources-homelessness.html
Centers for Disease Control and Prevention (CDC). (2019 January 16). The social-ecological model: a framework for prevention. Retrieved from: http://www.cdc.gov/violenceprevention/overview/social-ecologialmodel.html
City of Vancouver (2018) Trend in Vancouver. Retrieved from: https://www.straight.com/news/1068636/vancouvers-indigenous-people-are-again-heavily-overrepresented-among-citys-homeless
Mago, V. K., Morden, H. K., Fritz, C., Wu, T., Namazi, S., Geranmayeh, P., ... & Dabbaghian, V. (2013). Analyzing the impact of social factors on homelessness: a Fuzzy Cognitive Map approach. BMC medical informatics and decision making, 13(1), 94.
May, J (2015) ‘Gone, leave, go, move, vanish’: race, public space and (in)visibilities, Social Identities,21(5), 489-505, DOI: 10.1080/13504630.2015.1093468
Medcalf, P., & Russell, G. K. (2014). Homeless healthcare: raising the standards. Clinical Medicine, 14(4), 349-353.
Rae, B. E., & Rees, S. (2015). The perceptions of homeless people regarding their healthcare needs and experiences of receiving health care. Journal of advanced nursing, 71(9), 2096-2107.
Times Colonist (2018) The Homeless in British Columbia. Retrieved from: https://www.vancourier.com/2.2067/of-7-655-people-without-homes-in-b-c-1-884-on-the-island-1.23533499
Urban Matters CCC & The BC Non Profit Housing Association (2018). Vancouver homeless count 2018. Retrieved from: https://vancouver.ca/files/cov/vancouver-homeless-count-2018-final-report.pdf
Woodvine, S (2018). Bundled-up sleeper. Retrieved from: https://www.straight.com/life/1087231/homeless-vancouver-etiquette-checking-street-person-signs-life
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