Public Health Initiatives: Shelter Based Services

1. Public Health Initiatives:Shelter Based Services Research SOWK 677 Meaghan Bolack December 7, 2012

2. Context Jordan Heikamp was a 5 week old infant who died of starvation (due to watered down formula) while residing in a Toronto shelter Jordan’s death led to a coroner’s inquest that concluded in 2001, several recommendations were made for social service agencies in Ontario including: Children’s Aid Societies Hospitals Shelters Public Health agencies Etc (Robson, 2005) Jordan Heikamp

3. Context Implementation at Middlesex-London Health Unit (MLHU) meant: the creation of a community plan strategy to coordinate when multiple agencies were involved with the same client; the placement of a Public Health Nurse within shelters Jordan Heikamp

4. Context The Middlesex-London Health Unit (MLHU), through the Healthy Babies, Healthy Children (HBHC) program is responsible for providing public health services in the shelters located throughout London and Middlesex County HBHC program provides services (Public Health Nurse, Family Home Visitor, and Social Worker) to “high risk” families with children under 5 years old (“high risk” can include a number of different factors, for example: teen parents, unstable housing, low income, immigration status, etc) In London and Middlesex county there are 3 VAW shelters, 1 homeless family shelter, 1 shelter for single men and women, 1 shelter for Aboriginal women and children, and 1 drop-in centre for homeless women Overview

5. Context 2010, working group was formed to evaluate the potential for changes to be made to the way Public Health services were provided to shelter residents Working group included: 4 PHNs, 1 manager, and myself as Social Worker Main outcome was that shelter services were divided among 3 PHNs (prior to this 1 PHN had been solely responsible for shelter services for close to 10 years) Brief review of the literature was done, as well as emails sent to other managers of HBHC programs to determine role of public health in shelters result was found to be a gap in both literature and services being offered in shelters Time for Renewal

6. Context Short-term goals of research would be to evaluate the current public health nursing initiatives in local shelters Long-term goals of research would be to examine the long-term health trends and health needs of shelter residents and how these trends relate to the Social Determinants of Health literature “The primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living conditions they experience. These conditions have come to be known as the social determinants of health” (Mikkonen & Raphael, 2010) Purpose

7. Method/Evaluation Choseusea needs assessment because it allows for determining the need for public health initiatives in shelters Individual need of those residing in shelters, as well as the needs of shelter in general would need to be assessed In addition to the working group having input in designing the needs of assessment, it would also be important to receive input from the shelter management or front-line workers as they are familiar with a different perspective of shelter life, not necessarily seen by the public health nurses Needs Assessment

8. Method/Evaluation Would seek to carry out longitudinal design focused on trend studies that “look at different groups of people from the same population at different times” as opposed to cohort studies that “follow a specific group that is linked in some way or that has experienced the same life events over time” (van de Sande & Schwartz, 2011, p. 102-103). The reason for utilizing trend studies over cohort studies is due to the transient nature of the homeless population, as well as the desire to identify health trends that affect shelters over time. Needs Assessment

9. Conducting Research Using a survey would allow us to determine the “attitudes, preferences, knowledge, and behaviour by asking people questions” (Hewson, Class 11, Nov. 2012). Because a quantitative survey collects numerical data it would allow us to collect statistical information re:needforpublic health services in shelters; common reasons for public healthaccessof those residing in shelters; and ultimately how these stats line up with other research on the social determinants of health. Surveys are helpful in that they are relatively cheap to carry out, this is important as there is no additional funding available to carry out this research (aside from reducing PHN caseloads in order for them to carry out shelter work). Surveys also provide an opportunity to generalize information collected Surveys would be conducted using a face-to-face approach (Hewson, Class 11, Nov. 2012; van de Sande, & Schwartz, 2011) Survey

10. Conducting Research Semi-structured vs. Structured survey: semi-structured would be most effective for the purposes of the public health research project, this is because semi-structured allows for a combination of closed and open ended questions, and allows the respondent with space for further comments (Desai & Potter, 2006) Proposed survey design (see attached) *note: because the survey is being conducted in a face-to-face setting the questions are not at a low literacy level, the PHN can reword and provide clarification on questions as needed Survey

11. Sampling & Recruitment Because purpose of the research is to identify long term trendsofpublic health concerns in shelters, we would be looking to generalize the information to a much larger populations, therefore, we would need to identify a representative sample of the broader population (van de Sande & Schwartz, 2011) Non-random sampling using a convenience strategy would be best approach to use as it is based on those who are available, those who approach PHN while in shelter(Hewson, Class 11, Nov. 2012) Sampling

12. Sampling & Recruitment One potential strategy for recruitment would be for PHNs to attend house meetings at shelters to explain research purposes and processes, and inform of when surveys would be conducted Because there would be 3 PHNs obtaining data at their assigned shelters it would be important to come up with a type of recruitment script in order to ensure common messages Aiming for around 100 participants, would give us enough information to make accurate generalizations about the shelter population, much more than 100 people would result insaturation, as well as a great deal of time to survey much more than 100 people. The number would ultimately depend on the number of individuals vs. families, want to have a representation of both groups. (Hewson, Class 11, Nov. 2012) Recruitment

13. Research Considerations Other MLHU departments: may be helpful in framing survey questions, could provide researchers with information re: how their departments could provide to shelter initiatives (immunization, sexual health, health promotion) Shelters (including front-line staff, management, and the larger organizations funding shelters): front-line staff could be helpful in developing trust between residents and PHNs, as well as encouraging residents of shelters to attend PHN drop-in sessions; shelter management, in addition to front-line staff can provide feedback re: survey development; partnering with larger organizations could be helpful when it comes to disseminating research findings to a larger audience Businesses: could assist in providing items that could be given to participants Other health units: helpful in providing us with information about any shelter initiatives they conduct Partners

14. Research Considerations Shelter management: control access to shelters and ability to conduct research based on their clients, need to include shelter management in research process – especially by providing them with copy of proposed survey in order to get their feedback. HBHC management, and Family Health Services director: need them to provide time for staff to conduct research (Hewson, Class 12, Nov. 2012) Gatekeepers

15. Research Considerations Researchers need to consider that in VAW shelters,and other shelters, women and children are there because they left an abusive relationship, they may have also had negative experiences with other service providers. Need to ensure a level of trust is developed. This is difficult given the short-term, transient nature of shelters. Developing trust will be helped by explaining confidentiality and thoroughly explaining how information will be used. Need to also consider the inherent power inequalities that exist between PHN and respondents One of the shelters is a shelter for Aboriginal women, need to be aware of the potential forpower inequalities that may exist in this context (Hewson, Class 12, Nov. 2012) Ethics: Power Relationships

16. Research Considerations Shelter populations generally tend to be very culturally diverse Semi-structured, face-to-face survey can allow for an increased level of flexibility (more so than a structured survey) Recruitment is voluntary: those that choose to see the PHN do not have to participate in the research Interpreter services can be arranged through the health unit as PHN services are not solely in place to conduct research but to also attend to needs of shelter residents (Hewson, Class 12, Nov. 2012) Ethics: Cultural Awareness

17. Research Considerations Only shelter residents at the time of research can be surveyed, because of transient nature as well as confidentiality between shelter and former residents it is impossible to follow-up on those who have previously residedin the shelter Anyone residing in shelters can take part in research and can access PHN services. However, we need to carefully document those who meet the HBHC criteria (families with children under 5) and those who do not. By allowing those who do not meet criteria to participate could have the potential for some interesting statistical comparisons Ethics: Inclusion/Exclusion

18. Research Considerations Voluntary – involvement will be voluntary, if providing incentives need to be aware of the fact that providing an incentive to participate may take away some of the voluntariness of participation. Those who choose not to participate in the research will still be able to access PHN services Withdrawal – because method of data collection is a survey completed at one time, the respondent can choose to stop answering questions at any time, respondent can also decide at a later date that they do not want their information included (Hewson, Class 12, Nov. 2012; Tri-Council Policy Statement) Ethics: Consent Process

19. Research Considerations Informed/Documented - respondents will sign a consent form explained to them by the PHN, showing their agreement to participate in research. Discussion around consent and participation will also occur following survey completion to ensure respondent still wants to have their information included (Hewson, Class 12, Nov. 2012; Tri-Council Policy Statement) Ethics: Consent Process

20. Research Considerations Confidentiality and safeguarding of information will be implemented with the same regulations as that of the broader health unit. Confidentiality is paramount and information will be locked in briefcase for transport to and from shelter and MLHU office, once in the office all paper data will be locked in filing cabinet; digital data will be secured on the MHLU server Identifiable Information – Coded data is most effective for public health research goals, allows for data to be removed from study if requested, it also allows for the potential for additional research, given that PHNs collect basic information on individuals/families that seek PHN services in order to chart, coded data would allow us to track self-reported health and number of times PHN services sought (Hewson, Class 12, Nov. 2012; Tri-Council Policy Statement) Ethics: Confidentiality

21. Research Considerations Justify need for Public Health services to be implemented in shelters for a longer term (currently the shelter services are not stable, they are at risk of being cut every year) Shelters benefit because of increased effectiveness of public health services in shelters Participants may not directly benefit from research results but future residents of shelters would also benefit from public health services delivered in shelters that are based on an understanding of how homelessness in general and residing in a shelter in particular may impact ones health, as well as services that are delivered in a way that was directed by previous residents (Hewson, Class 12. Nov. 2012; Tri-Council Policy Statement) Ethics: Benefits

22. Research Considerations Overall, fairly minimal risk research study Some questions may be sensitive in nature, however, respondents are able to choose if they do not want to answer certain questions Participants may feel obligated to participate if they want to access PHN services, because PHN is delivering survey some participants may feel they cannot be critical of public health services A further risk is that because those accessing shelters are also usually involved with a number of service providers, to the participant the PHN becomes just another service provider, or the participant feels they are just another research participant, due to the transient nature of the shelter population they may never find out the results of the research (Hewson, Class 12, Nov. 2012; Tri-Council Policy Statement) Ethics: Risks

23. Research Considerations Registered Nurses Association of Ontario (RNAO) provides: Best practice guidelines on a number of different topics (including homelessness and nursing, lacking best practice guidelines related to PHN role with homeless and shelter populations) Ethical guideline framework Middlesex-London Health Unit has internal Research Advisory Committee (RAC): Identifies ethical considerations Ensures research undertaken is consistent with the MLHU’s mission and values Ethical Guidance

24. Dissemination • Findings would compiled into research paper that could then be sent to related journals (Public Health journals, Nursing journals) and hopefully be published • Also important to apply to present at related conferences • Would also want to share our findings with shelter management and larger organizational bodies of the shelters • Share findings with other HBHC programs throughout province

25. References Canadian Institute of Health Research, Natual Sciences and Engineering Research Council of Canada, and Social Sciences and Humanities Research Council of Canada, Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, December 2010. http://www.pre.ethics.gc.ca/pdf/eng/tcps2/TCPS_2_FINAL_Web.pdf Desai, V., & Potter, R.B. (Eds). (2006). Doing development research. Thousand Oaks, CA: SAGE Publications Inc. Hewson, J. (2012, October 26). Class 7:Evaluation part 1: Community assessments, environmental scan, gap analysis [PowerPoint slides]. Hewson, J. (2012, November 2). Class 8: Evaluation part 2 [PowerPoint slides]. Hewson, J. (2012, November 9). Class 9: Qualitative data collection methods and analysis [PowerPoint slides]. Hewson, J. (2012, November 30). Class 12: Research considerations [PowerPoint slides].

26. References Hewson, J. (2012, November 23).Class 11: Surveys, natural environments [PowerPoint slides]. Hewson, J. (2012, November 23).Class 11: Sampling for quantitative research [PowerPoint slides]. Mikkonen, J., & Raphael, D. (2010). Social determinants of health: The Canadian facts. Toronto, ON: York University School of Health Policy and Management. Robson, K. (2005). “Canada’s most notorious bad mother”: The newspaper coverage of the Jordan Heikamp inquest. CRSA/RCSA, 42(2), 217-232 van de Sande, A., & Schwartz, K. (2011). Research for social justice: A community-based approach. Winnipeg, MB: Fernwood Publishing