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Homelessness & Health in Canada

 | 
Manal Guirguis-Younger
, 
Ryan McNeil
, 
Stephen W. Hwang

Part II-Policy & Programmatic Responses to Homelessness & Health

Chapter 10. Dignity in Design: The Siting and Design of Community and Shelter-Based Health Facilities for Homeless Persons

Ryan McNeil et Manal Guirguis-Younger

Texte intégral

Introduction

1Community and shelter-based health services have emerged as one of the main strategies for improving the health of homeless persons in Canada. One of the earliest shelter-based health services, the Seaton House Annex Harm Reduction program in Toronto, has been in operation since 1997, and community and shelter-based health services have since followed in cities across Canada. These services are intended to reduce the impact of barriers preventing homeless persons from accessing services in hospitals and community clinics, such as geographic isolation, lack of identification cards and family physicians, feelings of unwelcomeness and long wait times (Hwang 2001; Podymow et al. 2006b; Podymow, Turnbull and Coyle 2006a; Wen, Hudak and Hwang 2007). Community and shelter-based health services have also been demonstrated to improve treatment compliance and health outcomes while reducing hospital stays and emergency room visits (Podymow et al. 2006b; Podymow, Turnbull and Coyle 2006a; Schwarz et al. 2008; Stergiopoulos et al. 2008) and play an increasingly prominent role in health services delivery in many Canadian cities. As a consequence, health services are now located in many settings not traditionally associated with health care delivery. This raises many questions for health and social services providers. For example, what are the perceived benefits of community and shelter-based health services delivery? How are community and shelter-based settings adapted in order to accommodate health services delivery? And what factors influence the design of community and shelter-based health facilities?

2Although researchers have increasingly turned their attention toward the relationship between urban planning, design and health and human services delivery to homeless persons (Takahashi and Dear 1997; Graham, Walsh, and Sandalack 2008), these questions remain unanswered. A growing body of research has examined the impact of community opposition to health and human services facilities for homeless persons (see, e.g., Dear and Wolch 1987; Takahashi and Dear 1997; Strike, Myers and Millson 2004); factors affecting the siting of emergency shelters and facilities serving homeless clients, such as aids service organizations and needle exchange programs (see, e.g., Chiotti and Joseph 1995; Takahashi 1997; Takahashi and Dear 1997; Brinegar 2003; Datta 2005); and, lastly, the characteristics of optimum emergency shelter design (see, e.g., Davis 2004; Shier, Walsh and Graham 2007; Graham, Walsh and Sandalack 2008). Yet relatively little attention has been paid to how the social, political and built environment impact the siting and design of community and shelter-based health facilities, despite the steady growth in the number of these facilities over the past decade.

3This chapter examines the interplay of the siting and design of community and shelter-based health facilities across Canada. It looks at the perceived benefits of community and shelter-based health facilities, including increased access to health services and responsiveness to the day-to-day challenges in shelters. It explores the siting of these facilities within the context of categories of urban space (see, e.g., Duncan 1978; Snow and Anderson 1993; Snow and Mulcahy 2001) to shed light on the factors that contain these facilities, as well as how agencies resist containment. It then considers the characteristics of community and shelter-based health facility design, drawing on previous research on emergency shelter design (see, e.g., Davis 2004; Shier, Walsh and Graham 2007; Graham, Walsh and Sandalack 2008). Lastly, this chapter discusses the implications of these findings for those involved in the development of these facilities. It is hoped that this chapter will help to improve the design of community and shelter-based health facilities and, as a result, health services delivery.

Methods

4The authors collected data between April 2007 and July 2008 as part of a study on health and end-of-life care services delivery to homeless persons. Homeless persons receive health services in a range of settings, including hospitals, community health clinics, emergency shelters and harm reduction facilities. The availability of these services is often affected by the local social, cultural and political context, which might or might not support the delivery of health services to this population. This study focused on identifying the characteristics that improved health services delivery to homeless persons, including the design of community and shelter-based health facilities. A section of the questionnaire included the questions about the impact of facility location and building design on health services delivery and clinical practice.

5The authors collected data in Halifax, Hamilton, Ottawa, Thunder Bay, Toronto and Winnipeg. Existing relationships with health and social services providers in Ottawa and Toronto helped to facilitate participant recruitment in those cities. Research assistants developed an annotated directory of organizations providing health and social services to homeless persons in Halifax, Hamilton, Thunder Bay and Winnipeg that helped the authors identify key informants in those cities. Potential participants were sent letters outlining the study and inviting them to participate. Fifty-four individuals agreed to participate in this study, including physicians, nurses, social workers, mental health professionals and program directors. All participants worked either full-or part-time in community or shelter-based settings. Semi-structured interviews were conducted with participants at their place of employment or off-site, if they preferred to be interviewed elsewhere. One section of the interview guide concentrated on facility design. Participants were invited to discuss the development of their organizations, how their facilities help or do not help them work effectively with homeless persons and how their facilities may be modified to improve health services delivery. These questions were structured so as to address the questions raised in the chapter introduction. Interviews ranged in length between forty-five minutes and two hours. Informed consent was obtained at the time of the interview.

6Interviews were audio recorded and transcribed verbatim. Data were coded using NVivo qualitative data analysis software (version 8) to identify preliminary themes. Analysis focused on the siting and design of community and shelter-based health facilities, as well as their impact on health services delivery to homeless persons. A coding tree was developed based on these preliminary themes and used to recode data. Hard copies of the coding summaries were reviewed by the authors and used to make further refinements to the coding tree in order to better explicate themes. Once the final categories were established, the authors recoded a section of the data to verify theoretical validity.

7The authors identified the perceived benefits of community and shelter-based health services delivery to homeless persons. They then identified two general categories: (1) the siting of community and shelter-based health facilities and (2) the design of community and shelter-based health facilities. Each of these categories includes several sub-categories that identify characteristics that might optimize the design of health facilities and contextualize the challenges that health and social services providers encounter in planning and developing them.

Findings

Perceived Benefits of Community and Shelter-Based Health Facilities

8Community and shelter-based health services delivery was perceived as an important strategy for improving access to health services for homeless persons. Participants described how community and shelter-based services reduced geographical barriers to health services for homeless persons, as well as responded to the day-to-day challenges encountered by homeless service organizations. In addition, participants indicated that community and shelter-based health services facilitated the development of interdisciplinary strategies to meet the health and social care needs of homeless persons.

9Strategy to overcome geographical barriers to health services. Participants described how community and shelter-based health services allowed them to overcome many of the geographical barriers that prevent homeless persons from accessing health services. One of the main barriers that many participants identified was the inaccessibility of hospitals and clinics. Many participants observed that hospitals in their communities were located in residential or isolated areas. They noted that many homeless persons were unable to access services because they had reduced mobility or were not healthy enough to walk to hospitals or clinics and could not afford to take public transit. One emergency shelter director recalled:

I remember several years ago in our old place, watching an elderly gentleman that had taken his socks off. I saw his bare feet. He was suffering from diabetes and his feet looked like black clubs. I said, "You need to go to the hospital and get those looked at." He just refused. And one level in my naïveté I thought, what happened if I had feet like that? Would I walk to the hospital?

10These neighbourhoods also lacked services used by homeless persons to meet daily survival needs, such as soup kitchens and emergency shelters. Participants observed that community and shelter-based health services, on the other hand, had the potential to minimize these barriers because these services were already a part of the daily patterns of homeless persons. These services were thus perceived as a strategy to overcome geographical barriers by, as one nurse stated, "Meeting clients where they are, wherever they are comfortable."

11Responding to day-to-day challenges in shelter settings. Integrating health services into emergency shelters was not only identified as an optimum strategy for addressing the complex health and social care needs of homeless persons but also as a necessity due to the health challenges of the homeless population. Participants reported that emergency shelter clients had complex health needs—or, as one nurse practitioner observed, were the "sickest of the sick"—that shelter staff lacked the training to address. This contributed to adverse outcomes, including client deaths. An agency director recalled:

Agency Director: They'd come here at night and we'd find, we'd find a dead body at least once a month, in the beds here. They'd be people that would be sick, and the other thing they'd do is that they'd either take a whole bunch of pills some nights, so some of them would just overdose and say 'I'm out of here'. Some of them would just drink, and drink, and drink. Some of them would mix the two, and I'm sure their deaths were accidental. But people who were sick would just not go to the hospital then.
Interviewer: How did you deal with that at the time?
Agency Director: It was really hard on staff. The cleaners got so they wouldn't want to go upstairs. I mean really, it was really difficult....We were doing this work and nobody was trained. I don't even think we did a good grieving piece after. Some young cleaner finding two bodies in a month and saying to him, "Are you okay?"

12One factor that exacerbated this situation was poor discharge planning—or, to be more specific, the practice at some hospitals of discharging homeless patients directly to shelters or the street. Many participants reported that this commonly happened, despite the fact that many emergency shelters lacked the capacity to care for these clients. Another agency director recalled:

We recently had a death here at the shelter of a gentleman who came to us mentally ill. He was really a mess. He was discharged [from hospital] to us at 11 p.m. on a Friday evening and he was not well at all. My staff had big concerns with him, but they kept him here. He was exhibiting signs of his mental illness and he was dead by 1 a.m. the next morning. He went and committed suicide over here.

13Participants identified cases such as these as one of the driving forces behind the development of shelter-based health services.

14Furthermore, several participants reported that community and shelter-based health services responded to clients' desire to receive health services in shelter settings. An agency director recalled, "[The client] came and asked if he could die here. He knew he had aids. He knew he was going to be dying, and he did not want to go into the hospital." Previous research has, likewise, suggested that emergency shelters are a preferred site of usual care for homeless persons and result in higher levels of satisfaction with care received (O'Toole et al. 1999). However, participants of this study went further and reported that shelters were often a preferred site for receiving palliative care because clients considered dying in the shelter to be dying at home. As a consequence, many participants felt that it was important to develop these services in order to accommodate these wishes.

15Harmonizing health and social services delivery. Integrating health services into community and shelter-based settings harmonized health and social services delivery, allowing both health and social services providers to benefit from greater access to potential clients. Many participants reported that they were able to gain access to new clients and provide them with services responsive to their needs, while maintaining continuity with health or social services received in other settings. For example, participants referred clients directly to services delivered on-site—or by nearby community agencies— and had clients referred to them by these services. One of the added benefits of this, according to participants, is that they were able to better respond to changes in the health status of clients. For example, a program manager observed:

Often with our Managed Alcohol people, they will do very poorly. If we can't care for them in that setting, we will move them to the hospice and then often stabilize them. I'd say 50 percent of them stabilize enough to come back.

16Participants observed of this continuity helped them to develop interdisciplinary strategies to address client needs and implement these strategies across settings.

Siting Health Facilities for Homeless Persons

17The siting of community and shelter-based health facilities is impacted by the interplay of community values, health systems, infrastructure and the distribution of homeless persons. This interplay is most evident in the factors that contribute to the siting of community and shelter-based health facilities in prime and marginal spaces—that is, areas that have use value to the majority of community members and areas that have little or no use value to the majority of community members, respectively (Duncan 1978; Snow and Anderson 1993). It is useful, then, as a point of departure, to identify the strategies that contribute to the successful siting of community and shelter-based health facilities in each these categories of urban space, as well as the challenges encountered.

18Siting facilities in marginal spaces. Marginal spaces have little or no use or economic value to the majority of community members and, as a consequence, are largely abandoned to homeless persons and other marginalized populations (Duncan 1978; Snow and Anderson 1993; Snow and Mulcahy 2001). Many of the common characteristics of marginal spaces, such as high concentrations of homeless service organizations, single-room occupancy hotels and abandoned buildings (Snow and Anderson 1993; Snow and Mulcahy 2001), were apparent in neighbourhoods with community and shelter-based health facilities. In fact, the majority of community and shelterbased health facilities surveyed in this study were concentrated in marginal spaces—or, to be more specific, in impoverished inner-city neighbourhoods or near industrial areas. But what accounts for the concentration of these facilities in these spaces?

19In many cases, participants reported that these were the only spaces available to them for facilities due to community opposition to their facilities in other neighbourhoods. One participant, for example, remarked that when his organization attempted to move to a downtown area, local business owners persuaded the city to deny their re-zoning application. Another participant noted that the only site that the city agreed to zone for the facility was in a poor neighbourhood, adjacent to a highway on-ramp. Participants, however, noted that these locations were not without their benefits. They reported that the siting of community and shelter-based health facilities in marginal spaces often improved their capacity to deliver health services to homeless persons— whom they reported were largely concentrated in these areas—while minimizing community opposition. One of the key benefits of siting community and shelter-based facilities in marginal spaces, according to participants, is that they are most likely to be frequented by homeless persons. Participants believed that this increased their visibility and, hence, their accessibility to clients and potential clients. For example, many participants reported that they were better able to provide services to clients on the street, as well as advertise their services to potential clients, due to their location. A nurse recalled:

We walk our catchment area with harm reduction kits. We hand out kits, socks, whatever, but we're also there to advertise the nursing clinics. We'll walk by most, if not all, of the shelters at some point in our outreach, plus we'll do alleys and places we know people are—parks in the summer—so in that way we're able to advertise our clinic and what we do and it's all within walking distance.

20Other participants reported that their close proximity to single-room occupancy hotels and low-cost housing helped them provide services to clients at risk of homeless and, in several cases, provide them with health services that helped them maintain housing. Another nurse noted:

We've had palliative people in [the social housing complex] right beside us, which is this big high rise. Those are people who are going to come to us, but are still able to remain in their own home. ccac [Community Care Access Centre] alerts us of those people, or the community agencies will.

21Another key benefit, according to participants, is that siting community and shelter-based health facilities in marginal spaces results in reduced community opposition. Participants reported little opposition to their facilities and, in some cases, noted that their cities seemed most receptive to siting their facilities in these areas. This echoes previous research suggesting that these neighbourhoods are least opposed to homeless service organizations, but, while this research—and, indeed, several participants—warns that this might result in service-dependent ghettos (Wolch and Dear 1993), the majority of participants emphasized the benefits of increased access to clients and lower rent and property costs. Several participants suggested that low rent and property costs played a crucial role in allowing them to expand and diversify their services in order to increase their responsiveness to the needs of their target population. An agency director of a recently relocated inner-city shelter recalled:

When we bought this building, we bought it with the idea that it could do a lot of programs that weren't being done. As we developed the first floor, our architect drew up the floor plans and he had a large space that was supposed to be used for storage for our clothing bank. But, as our construction guys were building it, I said just leave that space alone because someday I am going to have a health centre there.

22Siting facilities in prime space. A small number of community and shelter-based facilities in cities surveyed in this study were located in prime space—that is, areas with use or exchange value to most community members, including spaces used for residential, economic and navigational purposes (Duncan 1978; Snow and Anderson 1993). These organizations typically had long histories—in some cases, reaching back more than one hundred years—and remained in their locations even as the surrounding areas gentrified, while others were affiliated with hospitals or community health clinics. Participants reported community opposition to these facilities was most likely due to negative attitudes toward homeless persons among people living in these neighbourhoods, which is a well-documented dynamic of community opposition to homeless services facilities (Takahashi and Dear 1997; Takahashi 1997). However, they also identified strategies that minimized the impact of community opposition. One of the key strategies involved shifting the terms of the debate by emphasizing that the organizations provided health services, not emergency housing. A nurse at a community-based health facility recalled:

Nurse: [Community members] were afraid that this was going to be a shelter and there would be lots of homeless people roaming the neighbourhood, possibly breaking into their houses. That was what their greatest concern was and, note, today we haven't had a single complaint in fifteen months.
Interviewer: What were some strategies that were used to overcome that perception?
Nurse: We held a community meeting where about 300 people showed up. The Executive Director of [Community Ministry Organization] spoke. The program manager of [the proposed facility] spoke about the program. I spoke about the program and the alderman of the neighbourhood spoke in favour of the program. He got it and explained to his constituents that it's not a shelter, it's a residential facility.

23Another strategy was to site health services in existing facilities—or, to be more specific, to integrate health services into emergency shelters. Participants reported that doing so allowed their organizations to expand and diversify their services, while avoiding applications for re-zoning and community opposition.

Designing Community and Shelter-Based Health Facilities

24Participants reported that the design of community and shelter-based health facilities has a significant impact on the delivery of health services to homeless persons. Participants identified design features of the community and shelter-based health facilities that improved the delivery of services to their target populations, as well as shortcomings that prevented some clients from accessing services.

25Using building design to promote client confidentiality. Participants reported that buildings ought to promote client confidentiality by blending in with the surrounding neighbourhoods. Many of the buildings visited by the authors were consistent with the architectural style of their neighbourhoods, because existing buildings had been renovated to accommodate health and social services delivery, while newer buildings had been designed to blend in with their surroundings. Participants believed that this consistency with neighbourhood design helped to promote client confidentiality by making it less obvious to passersby that clients entering and exiting the building were homeless. Participants reported additional design features that helped clients remain anonymous—something that, according to participants, is particularly important when providing services to stigmatized populations, such as persons living with hiv/aids, sex workers and injection drug users. For example, many buildings did not post signs on their property identifying their organization. One social worker remarked:

If you notice outside of the building, there are no signs that say hiv and aids. Some people feel comfortable coming here and we're kind of out of the area of the hiv circle. Most of it is on [street name]. Well we're a little outside of it so people do feel comfortable coming here.

26Nondescript entrances helped clients to retain anonymity. A harm reduction specialist noted that having separate entrances at a community clinic allowed clients to access harm reduction services while remaining anonymous to clients receiving other services. The use of one-way glass also ensured that these clients could not be seen by passersby.

27Improving accessibility for clients. Participants reported that physical disabilities might decrease the ability of homeless persons to access their facilities, if appropriate actions were not taken improve accessibility. Many buildings included ramps, automatic doors, elevators and wide doorways. Participants reported that these mobility aids helped them work with clients. A nurse explained how these mobility aids improved client care:

They have a wheelchair right in the shower—everything now is so user-friendly and easy. Before, how were we to get a person down the stairs to shower them? That's what we were faced with. You took them into the bathroom and pretty much hosed them down in the bathroom and sponged bathed them. It has only been in the last few years that we have had an elevator. You used to have to go down a very steep flight to the bathroom, so it wasn't about [the client's] problems....We needed a place that is full serviced, that provides all the level of care of all the other agencies.

28Several of the facilities the authors toured were less accessible, and participants reported challenges providing care to clients. Participants drew attention to the fact that they had difficulty providing services to clients in wheelchairs and, in some cases, could not provide them with services. The challenges of an intake coordinator and outreach worker illustrate the challenges faced:

Intake coordinator: There are certain things I have to think about in this house. Because three of the rooms at the back of the house have four steep steps to get to them, those ones can only be used by people who are mobile enough to get up the stairs to the elevator. I have to look at mobility.
Outreach worker: We just don't have the resources to be as inclusive as we'd like. As you notice there's no ramp out front but we do have actually several clients that are confined to wheelchairs. There are so many different types of sex workers.

29Using safety precautions and security systems to ensure staff safety. Another important consideration is staff safety, which many participants identified as a chief concern. These participants reported that, due to the high incidence of mental illness and addiction among clients, they believed that safety precautions needed to be taken. Many of the facilities had complex security systems, including security cameras and safety buttons, and sightlines allowing staff to monitor the facilities. Several participants indicated that this minimized the likelihood of disruptions, as well as the impact of these events. Several facilities, however, lacked safety precautions, and participants in these settings reported concerns about personal safety. For example, a physician explained:

There's a safety concern amongst physicians on an individual level, which I think can be a pretty intimidating environment to step into. You're dealing with a pretty rough clientele and you're in a setting that is fairly variable. The offices we work in aren't set up with individual safety in mind. When you work in isolation many of the times, we can't just have someone in the room when we're dealing with sensitive issues. The office that I work in is at the end of a hallway behind two closed doors and I've asked over and over again for a safety button to be put in there to call for help.

30Participants who perceived themselves as being at risk due to the absence of safety precautions and security reported higher levels of stress—in some cases, implying a link to staff burnout.

31Improving the design of clinical spaces. Participants reported that, because of the wide range of functions carried out in their settings, clinical spaces needed to provide sufficient space and flexibility to serve multiple purposes. Many of these spaces were originally intended only for treatment and rehabilitation but also needed to address unanticipated health and social care needs. A nursing station at a shelter-based facility, for example, had originally been intended to serve mainly clinical functions, such as intake, charting and dispensing medication, but in practice served a variety of other functions, including preparing meals, organizing social activities and, often, monitoring the movement of clients in and out of the shelter. When the facility was later redesigned, the nursing station was expanded in order to better accommodate this wide range of functions. Other clinical spaces, including exam rooms and offices, often had to be flexible in order to meet client needs and address emergency situations. Participants reported that the space and flexibility to move equipment, including beds and medical equipment, in and out of rooms improved the efficiency and efficacy of clinical spaces.

32Using private rooms to help clients feel 'at home'. Multiple participants reported that the design of their facilities helped clients feel 'at home'. Many of these facilities not only had a home-like atmosphere—that is, they were located in formerly residential buildings—but also provided clients with private or semi-private rooms. Participants indicated that providing clients, many of whom had lived on the streets and in shelters for decades, with private and semi-private rooms helped them feel 'at home', leading to greater satisfaction with care. Participants explained that clients were often pleasantly surprised to find out that they would have a private room and, in some cases, expressed that they wished they had arrived there sooner. A nurse remarked:

Some of them would think that our hospice is like heaven—I mean, it's just beautiful. They're amazed that they have a private room and they're amazed they have a TV. They're amazed they've got a beautiful dresser to put their things in and that there's endless juice and there's endless coffee, you know.

33Furthermore, multiple participants observed that, because palliative clients considered their facilities to be their home, they wanted them to be their place of death. A program manager observed:

What we have really noticed is that some of our long-term residents— who have been with our organization for the last 10 or 15 years—don't necessarily want to go. We have been trying to do our very best in maintaining a place of dignity for them during their last days, but it is not easy.

34Participants, therefore, suggested that private rooms and a welcoming environment allowed clients to construct home spaces.

35Using common areas to create a social atmosphere. Participants reported that common areas, such as television rooms and lounges, improved the atmosphere in residential care settings by allowing staff to host social activities, as well as facilitating relationship-building among clients and staff. Many of the facilities that provided complex long-term care had multiple common areas. Common areas allowed participants to host a range of social activities, including teas, movie nights and games, as well as provide a venue for unstructured interaction between clients. One clinical manager explained how this helped to create a caring atmosphere among clients:

I watched them play bingo the other day and I thought this is so much more than bingo. Bingo is one thing, but the fact that they're all together in the room, that they're respectful of the caller, that they're quietly playing bingo, that it's something to test their mind, right, their ability to connect. One of the guys in the room he's mentally ill, he has dementia and he has hiv, and they set him up and he has a card and he has a dabber and he has a snack and he can't dab the numbers but he's there with them. And so she'll bring out a prize and maybe they'll be two prizes and one of them is like a chocolate bar and she'll say to the group, "Can [client name] have the chocolate bar?" And they'll all say, "Yeah that's okay." Like he didn't win it but he can have it, so then they give the chocolate bar to him.

36But also, multiple participants described how creating a caring atmosphere improved the self-efficacy of clients. They reported several ways in which clients became increasingly engaged in the day-to-day operations in their setting by volunteering, helping each other and taking a leadership role in social programming. One program coordinator observed:

I think that the atmosphere now is a very uplifting, very positive atmosphere. It is a very family-like atmosphere. It has come a long way over the last seven years. We have a resident mayor. So, they elect their own mayor. They have resident meetings. If they have any issues, they will go the mayor. The mayor will come to us. As I mentioned with Social Initiative the volunteering is very important part of the program. They have certain residents that make breakfast every day with staff supervision. Make lunch, make dinner, do all of the laundry, clean the sheets, and disinfect the mattresses. They really have taken a sense of ownership of their own program.

37Aligning design with organizational values. Participants explained that the design of health care facilities should be congruent with the values of their organizations. This included mandates to provide homeless persons with the same quality of care as the housed population received but in a way that is congruent with organizational values and the experiences of homeless persons. One health administrator observed:

We just painted our office. It's freshly painted and we put new rugs down. For the first five years that we were here, we just had primer on the walls. We've never had paint before. It's a big symbolic thing, to get paint but, you know, that is how our clients live. It's very hand to mouth and it hasn't done us any harm. I do think that there's a certain way that a program that works with the clinically homeless needs to be. We can't have big fancy offices. It is just incongruent with the work that we're doing.

Summary and Implications

38Community and shelter-based health services are an important strategy for improving the health of homeless persons in Canada and, as the recent growth in the number of these services suggests, they play an increasingly vital role in health services delivery to this population. In this chapter, the authors have explored the context of community and shelter-based health services delivery, drawing attention to the fact that it developed out of necessity to address the dire situation in many emergency shelters and offered an opportunity to overcome barriers that homeless persons face to accessing traditional services. Previous research echoes these claims and points also to the demonstrated cultural competence that community and shelter-based health services have in providing care to homeless persons (Podymow et al. 2006b; Podymow, Turnbull and Coyle 2006a; Guirguis-Younger, McNeil and Runnels 2009).

39This chapter also examines the impact of community opposition to the siting of facilities serving homeless clients and, as a result, can be situated within the growing literature on this topic (Wolch and Dear 1993; Takahashi 1997; Brinegar 2003; Strike, Myers and Millson 2004; DeVerteuil 2006). Previous research has charted the evolution of the 'Not In My Backyard' (nimby) syndrome and discrimination against homeless persons on the basis that they are dangerous, undeserving of services and hurt property values (Takahashi 1997; Takahashi and Dear 1997). This body of research has drawn attention to strategies that communities have used to limit the development and expansion of health and human services facilities, such as the use of zoning by-laws, echoing statements made by study participants (Smith 1998; Brinegar 2003; Ranasinge and Valverde 2006). But, as is the case when the need is so great, these facilities are built and this chapter has outlined some of the considerations of the siting of these facilities. Of note, although facilities are often pushed into marginal spaces, they might benefit from closer proximity to potential clients. Also, siting health facilities in shelters might allow organizations to circumvent community opposition.

40Lastly, this chapter explored the characteristics that might improve the design of community and shelter-based health facilities. Several of these characteristics have been previous described in the literature on emergency shelter design (Davis 2004; Shier, Walsh and Graham 2007; Graham, Walsh and Sandalack 2008). This research identified several characteristics of optimum shelter design that were also described in this chapter, including using building design to promote client confidentiality and improving accessibility for clients (Shier, Walsh and Graham 2007; Graham, Walsh and Sandalack 2008). This chapter, however, is the first to describe these characteristics within the context of health facilities for homeless persons and consequently identified previously overlooked characteristics. These include the characteristics that improve clinical services and increase client satisfaction and self-efficacy, such as flexible clinical spaces, private rooms and social spaces. Together, these findings have several key implications for decision-makers and future research.

41First, this chapter documents some of the factors that have contributed to the evolution of shelter and community-based health services in Canada. It situates their emergence within the context of the health needs of the client population, as well as the Canadian social and political environment. This is an important factor that helps us better understand why these facilities emerged and the problems that they were intended to address.

42Second, these findings have the potential to inform the development of community and shelter-based health facilities. They identify characteristics that planners, designers and decision-makers might want to consider in order to optimize the design of these facilities. For example, what impact would health services have on the operations of the shelter? What changes need to be made to the building to accommodate health services? Is community opposition to the proposed facility expected and, if so, what can be done to minimize its impact? Is the proposed facility accessible to potential clients? Does the building promote client confidentiality? And does the facility account for the personal and social needs of potential clients?

43Lastly, this research opens up the possibility for future research on the design of facilities intended for use by homeless and marginalized populations. There are many questions regarding the impact of health facility design on the health of homeless and marginalized populations that go unanswered. For example, how do private rooms affect the health of homeless clients? What characteristics do clients feel are most important about these facilities? What changes do they feel would improve them? It is hoped that this chapter represents a step in this direction and will pave the way for future improvements in the design of community and shelter-based health facilities.

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Auteurs

Postdoctoral Fellow at the British Columbia Centre for Excellence in hiv/aids and Faculty of Health Sciences at Simon Fraser University. His current research focuses on the socialstructural production of harm among drug-using populations. His previous work explored the intersection of homelessness and health, and in particular interventions to improve health outcomes among homeless populations

Full Professor in the Faculty of Human Sciences at Saint Paul University and an affiliated researcher with the Centre for Research on Educational and Community Services at the University of Ottawa. Dr. Guirguis-Younger’s research focuses on the delivery of palliative and supportive care to homeless and marginalized populations

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