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Graduate Studies The Vault: Electronic Theses and Dissertations

2015-10-21

Supportive Transitions and Health: A Mixed Methods

Study of Formerly Homeless Persons and Street Exits

Desjarlais-deKlerk, Kristen

Desjarlais-deKlerk, K. (2015). Supportive Transitions and Health: A Mixed Methods Study of

Formerly Homeless Persons and Street Exits (Unpublished doctoral thesis). University of Calgary,

Calgary, AB. doi:10.11575/PRISM/27939

http://hdl.handle.net/11023/2625

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UNIVERSITY OF CALGARY

Supportive Transitions and Health: A Mixed Methods Study of Formerly Homeless

Persons and Street Exits

by

Kristen Desjarlais-deKlerk

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF DOCTOR OF PHILOSOPHY

GRADUATE PROGRAM IN SOCIOLOGY

CALGARY, ALBERTA

OCTOBER, 2015

© Kristen Desjarlais-deKlerk 2015

ii

Abstract

This dissertation explores connections between homelessness, housing, and health.

Drawing on a mixed methods two-phase design presented in a series of three separate

articles, this dissertation demonstrates the changes experienced by formerly homeless

individuals when they transition into supported housing. Health and stress comparisons

are made between currently and formerly homeless individuals, as are changes

experienced by formerly homeless individuals during their first six months of housing

tenure. The findings indicate that individuals who transition from homelessness into

housing appear to experience improvements in their health and wellbeing. But housing

does not appear solely responsible for these positive changes. Rather, the findings

demonstrate the importance of formal and informal social relationships during this status

transition. Caseworkers and physicians operate as formal supporters, and provide

important services to help stabilize and minimize the stresses that accompany this status

transition. Informal social relationships developed away from social service agencies and

shelters aid in developing identities apart from homelessness.

iii

Preface

This dissertation is original independent work completed by the author, Kristen

Desjarlais-deKlerk. The fieldwork presented in Chapters 2-4 was covered by the

University of Calgary Conjoint Faculties Research Ethics Board Ethics Certificates

numbers 7576 and REB15-0002.

DISCLAIMER: This study is based in part on data provided by Alberta Human Services.

The interpretation and conclusions contained herein are those of the researcher and do not

necessarily represent the views of the Government of Alberta. Neither the Government of

Alberta nor Alberta Human Services express any opinion in relation to this study.

iv

Acknowledgements

Completing my doctoral work was imminently important to me when I started this

program. The process has proven arduous, stretching, and at times frustrating, but the

support of my supervisor, my supervisory committee, my friends, and my family has

been unceasing throughout each step. Consequently, I would like to acknowledge my

supervisor Dr. Jean E. Wallace and her constant support through countless revisions of

each of these articles. She has been an excellent mentor and friend, offering

encouragement and feedback throughout every step of this process. I would also like to

acknowledge my supervisory committee, namely Dr. Jenny Godley, Dr. Christine Walsh,

and Dr. John Graham for their feedback and help in submitting each of these pieces to

reputable peer-reviewed journals. Without them, I am not sure I would have necessarily

made it to first reviews with each of these pieces, and I am grateful for their help. I would

also like to thank and acknowledge Alberta Human Services in general and Sherry

Desanko in particular for their help in applying for and vetting each of the papers

contained herein.

I have been blessed with some wonderful peers who have offered their own brand

of encouragement along the way. To this end, I would like to acknowledge Alicia

Polachek, Tamara Nerlien, and Kristin Atwood for providing much-needed friendship

and laughter throughout my graduate studies.

Last, I would like to acknowledge my wonderful husband, Robert deKlerk and my

sister Kimberly Desjarlais for their help in maintaining my sanity through this process. I

am thankful to have such an awesome family and support system around me.

v

Dedication

I dedicate this dissertation to my wonderful husband, Robert deKlerk, to my parents, my

sister, and to Chalupa Batman (also known as Baby deKlerk), who we still have not met

yet.

vi

Table of Contents

Abstract ............................................................................................................................... ii

Preface ................................................................................................................................ iii

Acknowledgements ............................................................................................................ iv

Dedication ........................................................................................................................... v

List of Tables ................................................................................................................... viii

List of Figures .................................................................................................................... ix

Chapter One: Introduction .............................................................................................. 1 1.1 Study Beginnings and Rationale ............................................................................... 5

1.1.2 Housing and Health ............................................................................................ 9 1.1.3 Housing Transition and, Health ....................................................................... 14 1.1.3 Housing Transition and Social Identity ........................................................... 15

1.2 Mixed Methods Rationale ....................................................................................... 18 1.2.1 Methods Undertaken ........................................................................................ 21

1.3 Dissertation Outline ................................................................................................ 23

Chapter Two: Housing and Stress: Examining the Physical and Mental Health Differences Between Homeless and Formerly Homeless Individuals ........................ 23

2.1 Abstract ................................................................................................................... 24 2.2 Introduction ............................................................................................................. 24 2.3 Housing Policy in Canada ....................................................................................... 25 2.4 Housing First ........................................................................................................... 28 2.5 Personal History and Health ................................................................................... 29 2.6 Methods ................................................................................................................... 30

2.6.1 The Data ........................................................................................................... 30 2.7 Analysis ................................................................................................................... 34 2.8 Results ..................................................................................................................... 37 2.9 Discussion ............................................................................................................... 42

2.9.1 Limitations ....................................................................................................... 45 2.10 Conclusion ............................................................................................................ 47

Chapter Three: Healthcare Utilization During the Transition from Homeless to Housed .............................................................................................................................. 49

3.1 Abstract ................................................................................................................... 49 3.2 Introduction ............................................................................................................. 49 3.3 Methods ................................................................................................................... 52

3.3.1 Quantitative Data ............................................................................................. 53 3.3.2 Qualitative Data ............................................................................................... 55

3.4 Results ..................................................................................................................... 56 3.4.1 Theme 1: High Needs, High Commitment ...................................................... 56 3.4.2 Theme 2: Increased Formal Support, Decreased Emergency Use ................... 60 3.4.3 Theme 3: Finally Diagnosed ............................................................................ 65

3.5 Discussion ............................................................................................................... 69

vii

Chapter Four: Identity in Transition: How Formerly Homeless Individuals Negotiate Identity as They Move into Housing ............................................................ 73

4.1 Abstract ................................................................................................................... 73 4.2 Introduction ............................................................................................................. 73 4.3 Methods ................................................................................................................... 77 4.4 Results ..................................................................................................................... 81

4.4.1 Social Distancing from Those in Shelter or on the Street ................................ 81 4.4.2 Social Distancing from Others in Supported Housing Units ........................... 85 4.4.3 Social Embracing: Dissimilar Others ............................................................... 90

4.5 Discussion ............................................................................................................... 94 4.6 Conclusion .............................................................................................................. 97

Chapter Five: Conclusions ............................................................................................. 99 5.1 Specific Research Questions ................................................................................... 99

5.1.1 Health of Formerly Homeless Individuals Living in Supported Housing and Currently Homeless Individuals Living in Shelter ................................................... 99 5.1.2 Longitudinal Health Changes in Formerly Homeless Individuals ................. 100 5.1.3 Identity Changes Experienced by Formerly Homeless Individuals ............... 104

5.2 The Overarching Research Question .................................................................... 107 5.3 Contributions to the Literature and Future Research ............................................ 110

5.3.1 Contributions to the Homelessness/Housing Literature and Future Research110 5.3.2 Contributions to the Social Determinants of Health Literature and Future Research .................................................................................................................. 113 5.3.3 Contributions to the Stress Process Literature and Future Research ............. 116 5.3.4 Contributions to the Literature on Inequality and Health and Future Research ................................................................................................................................. 117 5.3.5 Contributions to the Social Identity Literature and Future Research ............ 120

5.4 Limitations of the Data and Mixed Methods Approach ....................................... 122 5.5 Closing Thoughts .................................................................................................. 126

References ....................................................................................................................... 127

viii

List of Tables

Table 1 Characteristics of the Sample by Housed Status …………………………. 35 Table 2 Zero-Order Correlation Matrix …………………………………………… 36 Table 3 Odds Ratio Results for Mental and Physical Health………………………. 40 Table 4 Mean Differences in Reported Healthcare Utilization Prior to Intake Between Those that Left the Program Before Three Months, and Those that Remained in the Program for Six Months…………………………………………………………… 57 Table 5 ANOVA Mean Differences in Healthcare Utilization at Prior to Intake, 3 Month Assessment, and 6 Month Assessment for Program Stayers………………………. 61 Table 6 Average Intake Assessments of Emergency Healthcare Use Prior to Intake and Demographics of Individuals with New Diagnoses and Individuals Without New Diagnoses…………………………………………………………………………... 67 Table 7 ANOVA of Program Participants with Both Physical and Mental Health Issues at Intake And New Mental or Physical Health Diagnoses Over Six Months ………... 68

ix

List of Figures

Figure 1 Housing Status Continuum Adapted from the CHRN (2012) Definition….10

Figure 2 Flow Chart of Diagnoses at Intake and New Diagnoses for Entire Sample of Stayers Over the First Six Months in Housing…………………………………….. 66

1

Chapter One: Introduction

The purpose of this dissertation is to examine how individuals’ health and social

identity change in their journeys away from sheltered homelessness into supported

housing. Sheltered homelessness refers to those temporarily living in community-based

overnight shelters at no cost to them. Supported housing refers to nonmarket housing that

provides case management and support services designated for individuals who cannot

afford to house themselves. Currently, numerous social service programs and initiatives

aim to end homelessness and one such way is through moving homeless individuals

living in shelters into supported housing. This study aims to understand how individuals

fare when they move from sheltered homelessness into supported housing. Specifically, it

considers differences between those residing in shelter and those living in supported

housing, as well as the ways in which the formerly homeless’ health changes during this

transition.

Many of these programs tout a “housing first” model where sheltered homeless

individuals first move into supported housing, before dealing with other personal issues,

such as addictions or mental illness (Tsemberis, Gulcur, & Nakae, 2004). While this

dissertation references the Housing First model, it is not an evaluation of Housing First;

rather it aims to understand how individuals negotiate street exits, or the move from

being homeless and living in shelters to being housed and living in supported housing. In

doing so, it focuses on the experience of homeless individuals moving into supported

housing, which reflects the basic tenet of Housing First.

Such street exits may mean quick transitions from the shelter way of life into

2

those of the housed, which may translate into comprehensive lifestyle changes for those

undergoing such transitions. For example, one’s social identity may change substantially

through such a dramatic transition. Individuals may experience changes to their social

identities during such life changes because others may view them differently (Trafjel &

Turner, 1979). This is because status transitions such as the move from homelessness into

housing restructure an individual’s day-to-day life that, in turn, may change others’

perspectives of who they are.

Identity negotiation may be particularly challenging for those undergoing

transitions from stigmatized social statuses into non-stigmatized ones (Parsell, 2011).

Homelessness represents a stigmatized social status that often functions as a core identity

for those without adequate housing (Hitlin, 2003). This is because homeless individuals’

connections to other people as well as social institutions become organized around this

centralizing identity. Research demonstrates that stigma negatively impacts the mental

health of those who experience it, often leading to depression, anxiety, and poor self-

esteem (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2014; Link, Struening,

Rahav, Phelan, & Nuttbrock, 1997). Consequently, transitioning from a stigmatized

status into a non-stigmatized one could benefit individuals’ mental health.

Alongside potential mental health benefits, proponents of Housing First assume

that individuals transitioning from homelessness into housing will also see improvements

in their physical health. The general assumption that housing will improve the health and

wellbeing of the homeless has much support in the social determinants of health literature

(e.g., Marmot & Wilkinson, 2005; Raphael, 2003; 2006; 2009; 2011). When individuals

move into supported housing away from shelter, however, they undergo significant

3

lifestyle changes that paradoxically include both stress-relievers as well as stressors.

Stressors are conditions that require people to adjust to their environments and may result

in strain, an emotional response that individuals experience as damaging to their health

and wellbeing (Pearlin, 1989; Thoits, 1986; 1995). Undoubtedly, homelessness is a

stressor. Living in a homeless shelter is also stressful and requires constant adaptation to

circumstances often beyond individuals’ control. For example, shelter-dwellers have little

control over when and where they sleep, eat, and recreate (Calterone Williams, 1996;

DeVerteuil, 2004). Leaving homeless shelters by moving into supported housing can,

therefore, reduce many of the day-to-day stressors associated with homelessness.

Moving into supported housing away from homelessness, however, also represents

a different type of stressor that typically requires complete readjustment of an

individual’s life: a life event. Life event stressors require substantial readjustment to

circumstances and environments (Thoits, 1982; 1986; 1995). For formerly homeless

individuals, moving into supported housing requires adjustment to both new lifestyles

and social statuses—those of the housed. How formerly homeless individuals negotiate

this transition and whether it can be beneficial despite the potential stressors associated

with significant status changes, remains to be seen. Clearly, the transition from

homelessness into supported housing merits further investigation to determine the

efficacy of such changes on the lives of formerly homeless individuals. Therefore, the

primary research question of this dissertation is as follows:

How do formerly homeless individuals negotiate the significant life transition

of becoming housed in supported housing?

This question is important to consider as many non-profit, business, and government-

4

based organizations have called for a nationwide end to all homelessness in Canada

(e.g., Calgary Committee to End Homelessness [CCTEH], 2008; National Alliance on

Ending Homelessness, 2015). These calls stem from beliefs about homelessness’

correlation with addictions, mental illness, diabetes, tuberculosis, and violence, which

translate into generally poor health and wellbeing (City of Calgary 2008; Nicholson,

Graham, Emery, & Waegemakers Schiff, 2010). These organizations argue that

supported housing for homeless individuals is cheaper than the total associated cost of

keeping individuals in shelters, particularly when healthcare costs linked to those living

in shelters are considered (CCTEH, 2008).

The overarching research question posed in this dissertation is examined by three

specific questions that are the basis of the three research articles that comprise this

dissertation. First, the assumption that those living in housing fare better than those in

homeless shelters needs to be explicitly examined. Therefore the first research question

addressed is: Are there significant health differences between individuals residing in

shelter and in supported housing? Understanding health differences between those in

shelter and those in supported housing is important for clarifying whether housing

appears to benefit those residing in a housing program. Second, while current Housing

First policies advocate moving homeless individuals into housing, it remains unclear

whether these transitions enhance the health of the formerly homeless. Consequently the

second research question is: In what ways does the health of the formerly homeless

change during their first six months in supported housing? Last, individuals

transitioning out of homelessness experience a status shift as they move from belonging

to a stigmatized group with a shared social identity (being homeless) to a non-stigmatized

5

group without a shared social identity (being housed). It is unclear how individuals

negotiate such a status shift, consequently the last question is: If formerly homeless

individuals do not identify with the homeless and the housed do not explicitly share

a social identity, how do individuals construct and maintain identities during such a

major life event?

The remainder of this chapter is organized as follows. First, the study beginnings

and rationale for this study are described. This section provides important contextual

information of the housing program and its municipality in which the data were collected,

and their particular enactment of Housing First. Next, it describes connections between

housing and health and the ways in which housing may enhance health, as well as the

transition from homelessness into housing and subsequent health and identity changes.

The methods undertaken in this dissertation to answer the three research questions are

presented next. Finally, this chapter closes with an outline for the remainder of the

dissertation.

1.1 Study Beginnings and Rationale

Over eleven years ago, my doctoral journey began when I took a summer job at

The Mustard Seed Street Ministry (The SEED) as an Employment Program Assistant. I

knew little about poverty and less about homelessness, but despite my ignorance, I ended

up staying long-term with The SEED, and worked in virtually every program area in a

variety of positions. Consequently, I learned a lot about Housing Ready models, which

were the standard practice at the time. This changed, however, when Calgary adopted its

first Ten Year Plan to End Homelessness. A shift towards Housing First transpired, and

my interest in homelessness, housing, and poverty was piqued further.

6

While this dissertation is not an evaluation of Housing First, the data for this

study are based on one particular Housing First program in the City of Calgary.

Therefore, the context of Housing First must be considered, particularly as not all

enactments of Housing First are the same across programs and municipalities. Calgary’s

Plan to End Homelessness (Calgary Committee to End Homelessness 2008) is based on

the Housing First model that originated in the United States (Farrell, 2010; Padgett,

Gulcur, & Tsemberis, 2006). This model urges service providers and governments to

house people prior to addressing other personal aspects associated with homelessness,

such as addictions or mental health problems. This dissertation explores one social

service agency that utilizes a Housing First multi-unit complex scattered site housing

model. Current debates exist between scholars and service providers as to what the

Housing First approach entails.

In Calgary, Housing First has become synonymous with scattered site apartments

located across the city in multi-unit complexes that house individuals of different social

statuses, however most proponents believe it to be a philosophy rather than a specific

program (e.g. Canadian Observatory on Homelessness, 2015; National Alliance to End

Homelessness, 2006). Housing First, according to the Canadian Observatory on

Homelessness (2015), has five basic tenants: (1) housing clients prior to resolving their

other personal issues; (2) encouraging client choice and decision-making about the

location, type, and cost of their housing; (3) allowing clients to use narcotics and alcohol

safely through supervised injection and use sites to reduce harm while supporting client

choices; (4) educating clients about available client-centered formal supports that can

easily be accessed; and (5) empowering clients to integrate into their local communities.

7

As a philosophy, Housing First emphasizes offering homeless individuals choices

when they are moving into housing: choice in location, choice in lifestyle, and choice in

circumstance. These choices are dependent on both client needs and abilities. For

example, some formerly homeless individuals may want to live in housing where they are

regularly tested for drugs or alcohol as this could aid in their sobriety. That is, being

around others who used drugs and alcohol may jeopardize their personal sobriety, and

accountability to ensure their sobriety could help them achieve their personal goals.

Others, however, may choose housing that touts a harm reduction model, and enables

them to safely use drugs or alcohol under medical supervision. Both of these types of

approaches to supported housing could be provided under a Housing First model.

When Calgary first adopted Housing First as an ideal model to end homelessness,

Calgary’s Ten Year Plan to End Homelessness (Calgary Committee To End

Homelessness, 2008) failed to cite the importance of choice, support and community

integration in its particular brand of Housing First. As a plan, it implied that moving

homeless individuals (whether sheltered, couch surfing, or on the street) into housing

would resolve homelessness and its accompanying social issues (including addictions,

mental illness, and physical illness). Essentially, the Calgary Committee to End

Homelessness (CCTEH, 2008) at that time only acknowledged the first tenant of Housing

First philosophy. As time went on, however, further iterations of Calgary’s Ten Year

Plan to End Homelessness (e.g., 2011, 2015) acknowledged the importance of other

forms of support to aid client success in supported housing.

Regardless of its changes and need for revision, Calgary’s original Ten Year Plan

to End Homelessness (2008) formed the basis for the current study and its research

8

questions. Undoubtedly, housing is one important social determinant of health that can

significantly change the lives of formerly homeless individuals as suggested by the plan.

Individuals who move from homelessness into supported housing undergo changes not

only in their living location and situation, but also in their daily patterns that may

subsequently transform their very sense of selves and identities, particularly as others

may see and interact with them differently following such status transitions.

Two specific theories act as frameworks for the entirety of this dissertation. These

are the social determinants of health perspective and stress process theory. Both of these

frameworks offer explanations as to why housing may not be the sole solution for ending

homelessness. They also offer insights into the complications surrounding significant life

transitions, such as the move from homelessness into supported housing.

Proponents of the social determinants of health perspective argue that health and

health-related behaviours vary by socially determined factors (Marmot & Wilkinson,

2005; Raphael, 2003; 2006; 2009; 2011). Specifically, this perspective suggests health is

influenced by social factors alongside biological ones. Social factors include access to

adequate food, water, shelter, and even supportive social relationships. In the case of

formerly homeless individuals, housing itself operates as a social determinant of health

that could influence the health and wellbeing of the formerly homeless. From this

perspective, residing in adequate housing that affords privacy, protection from the

elements, and basic needs would be expected to improve health when compared to

shelter-living.

The stress process theory is used to explain how stressors become deleterious to

mental health and cause distress (Pearlin, Menaghan, Lieberman, & Mullan, 1981;

9

Pearlin, 1989). Stressors are defined as any circumstance that forces individuals to adapt

to their environment. Stress researchers openly acknowledge that not all stressors

ultimately lead to depletions of mental health; rather the influence of stressors on

individuals’ health varies by coping resources, or personal efforts to adapt to stressors,

that may change the experience of stress and its influence on mental health (Pearlin et al.,

1981; Pearlin, 1989; Thoits, 1986; 2011). If individuals do not cope effectively with

stressors, then these stressors could lead to distress,. Essentially, the stress process

accounts for the sources of stress (stressors), the mediators and moderators of stress

(coping resources) that can circumvent the potentially damaging effects of stressors, and

the outcomes of stress (distress). The stress process, therefore, may help explain many of

the complications that could accompany a transition from homelessness into housing.

Many potential stressors accompany life transitions from one status to another. For

example, those moving into social housing must change their entire routine in order to

accommodate their new lifestyles as housed individuals. This adaptation is a type of

stressor. Whether it negatively influences health, however, depends on the availability

and nature of individuals’ coping resources. How housing is related to health and stress

is considered in greater detail below.

1.1.2 Housing and Health

Housing is an important social determinant of health (Marmot & Wilkinson,

2005; Raphael, 2003; 2006; 2009; 2011) but its influence and meaning extends beyond

adequate shelter. As Bonnefoy (2007) notes:

To live in an adequate shelter means more than a roof over one’s head: It means

to have a home, a place which protects privacy, contributes to physical and

10

psychological well-being, and supports the development and social integration of

its inhabitants—a central place for human life. (p. 143)

Housing represents shelter, safety, and a place of belonging for those living in it. Homes

protect residents from inclement weather, violence, and violations of privacy.

Therefore, “homeless” refers to an overall life experience where individuals lack a

sense of security and belonging as well as the roof a home provides (Canadian

Homelessness Research Network [CHRN], 2012). The CHRN (2012) explains that

homelessness is not a choice but reflects systemic barriers, affordable housing problems,

and associated physical and mental health issues.

As well, homelessness is not a single condition, but falls along a continuum that

includes the unsheltered (those who are absolutely homeless and living on the streets), the

sheltered (those temporarily living in overnight shelters at no financial cost to

themselves), the supported housed (those temporarily living in subsidized housing

situations as an interim stage to permanent, sustainable housing), the insecurely housed

(those individuals who are at risk of losing their housing), and the sustainably housed

(those who have successfully moved into permanent, affordable housing). Figure 1

displays a diagram of this continuum.

Figure 1: Housing Status Continuum Adapted from the CHRN (2012) Definition

Clearly, individuals located along this continuum vary considerably in terms of their

health and access to resources. While several types of “homeless” individuals have roofs

11

over their heads (including those residing in shelters), many lack the sense of security and

safety tied to having a home. With each move towards the right on the continuum,

individuals should experience increases in their both privacy and security. While the

continuum exists and is important to understand, this study focuses on individuals

experiencing sheltered homelessness as well as individuals living in supported housing,

and the shift between the two living situations.

Research has already demonstrated the importance of housing to individuals’

health and wellbeing (Marmot & Wilkinson, 2005), and suggests that housing influences

many other social determinants of health, including access to clean water, good air

quality, exposure to humidity and mould, as well as exposure to toxins such as lead,

radon, and volatile organic compounds (Bonnefoy, 2007). Furthermore, housing affords

residents privacy, a sense of belonging, and stability, all of which could positively

influence mental health (Marmot & Wilkinson, 2005; Raphael, 2003; 2006; 2009; 2011).

Residential stability may also influence social relationships with others as it may allow

individuals to develop stronger ties.

In contrast, while shelter-living is unlikely to expose individuals to toxins in the

shelter, it also does not afford personal protection or privacy (Calterone Williams, 1996;

DeVerteuil, 2004). Most shelters impose strict rules that all shelter-stayers must abide by.

These rules have become so stringent that many have argued shelters to act as “total

institutions” (Goffman, 1961), controlling the lives of clients across multiple boundaries,

including when and where they can eat, sleep, smoke, and recreate (Calterone Williams,

1996; DeVerteuil, 2004). Shelters have also been cited as places of violence where bodies

nearly inevitably enact harm on one another (Wenzel et al., 2004). Last, when people live

12

in close-quarters such as homeless shelters, infectious diseases may spread rampantly

(Hwang, 2001). The social determinants of health literature on housing clearly suggests

that homeless individuals moving from shelters into support housing should, ultimately,

experience improvements in their health.

While homelessness has been associated with generally poorer health compared to

housed populations, moving into housing represents a stressor in the lives of those who

undergo such a transition. Research has demonstrated that stressors’ negatively impact on

both mental and physical health (Pearlin, 1989; Thoits, 1995; 2011). Undoubtedly,

individuals who live in homeless shelters are exposed to different stressors than those

residing in supported housing. These stressors may be more or less challenging for

transitioning or individuals. Furthermore, when considering transitions away from

homelessness, individuals may still be influenced by past life stressors that may have led

to their homelessness in the first place. Current stress exposure alongside past life event

stressors accumulate to impact individuals’ mental health across the lifetime (Menzies,

2006; Montgomery, Cutuli, Evans-Chase, Treglia, & Culhane, 2013; Wheaton & Clarke,

2003). In fact, the cumulative effect of stressors over time may matter more to health and

wellbeing than any one specific or unique stressor. Consequently, transitioning away

from homelessness may not necessarily enhance the health of formerly homeless

individuals, particularly as past life stressors and cumulative stress may continue to

influence the health of the formerly homeless.

While research has already found health differences between those experiencing

homelessness and the housed (Hwang, 2001; Hwang, Tolomiczenko, Kouyoumdjian, &

Garner, 2005), it is unclear whether these differences perpetuate following moves into

13

supported housing. Claims that homeless individuals will automatically experience

improvements in their health when they move into supported housing require further

inquiry, particularly because many of these individuals remain economically

disadvantaged even after becoming housed and may continue to experience the harmful

effects of cumulative stress. Consequently, questions remain as to whether individuals

integrate into society once they move into housing or whether they remain in a state of

continual poverty that effects their basic, recreational, and social needs and ultimately

their health and wellbeing (Marmot & Wilkinson, 2005).

This dissertation’s first research question stems from this literature, and

specifically it asks:

RQ1: Are there significant health differences between individuals residing in

shelter and in supported housing?

This first paper seeks to understand whether those in supported housing fare better than

those living in homeless shelters. If the assumptions surrounding Housing First policy are

correct, and housing enhances the lives of formerly homeless individuals, then those in

housing should be in better health than those in shelter. Utilizing Homelessness

Management Information System (HMIS) data, Chapter 2 seeks to answer this question

and explore the mental and physical health differences between shelter-dwellers and

those who have moved into support housing. To examine differences between these two

groups, the stress process model is used to consider exposure to life history stressors

experienced by these two groups. It then considers the ways in which cumulative stress

exposure may be related to the health, as well as the influence of housing on the lives of

those who have left shelter living.

14

1.1.3 Housing Transition and, Health

Research suggests that the transient lifestyles of the homeless means they often

rely on emergency drop-in care rather than ongoing primary care (Kushel, Gupta, Gee, &

Haas, 2006; Kushel, Perry, Bangsberg, Clark, & Moss, 2002; Health Care and

Homelessness, 2006; McGuire, Gelberg, Blue-Howells, & Rosenheck, 2009; Robertson

& Cousineau, 1986; Weinreb, Goldberg, Bassuk, & Perloff, 1998). As outlined above,

housing is an important social determinant of health, but it does not operate in isolation of

other important factors. While formerly homeless individuals likely experience

improvements in their health following their move into housing, this improvement may

be partly due to being housed and partly due to better access to healthcare and social

services as a result of the stability that housing offers and the case management support

they receive in supported housing programs (Kushel et al., 2002; Lang et al., 1997).

Transient lifestyles may complicate continuity of health care services, whereas the

stability afforded by supported housing, in conjunction with the support and referrals of

caseworkers, may reduce reliance on inappropriate and/or emergency healthcare services

(Kushel et al., 2002; Lang et al., 1997). Research has demonstrated that individuals who

access emergency departments as primary health care resources frequently lack both

social support and housing stability, therefore the provision of formal support and

supported housing could increase continuity of care as well as access to primary care

providers such as family doctors (Lang et al., 1997). Consequently, housed individuals

could experience improvements to both their health and reductions in their emergency

healthcare use. The second research question stems from this idea:

RQ2: In what ways does the self-reported health of the formerly homeless

15

change during their first six months in supported housing?

While current Housing First policies advocate moving homeless individuals into housing,

it remains unclear whether these transitions enhance the health of the formerly homeless.

Consequently, it is important to explore whether the health of the formerly homeless

changes following their move into supported housing. More specifically, this chapter

seeks to understand how the health and emergency healthcare usage of formerly homeless

individuals change during the first six months living in supported housing. Chapter 3 of

this dissertation builds on the results of Chapter 2, by analyzing longitudinal, self-report

health data from HMIS and interviews with formerly homeless individuals who were

moved into supported housing. This chapter assesses changes in self-reports of health and

emergency healthcare use over the first six months in supported housing. Three themes

are derived from the interview data, each of which demonstrates the importance of

caseworkers, primary care physicians, and healthcare specialists as formal supports to

those transitioning from homeless to housed. These formal supports offer referrals,

information about accessible services for those in supported housing, and specialized

healthcare for often-complicated healthcare concerns, which may connect the recently

housed with more appropriate health care services that ultimately improves their health.

1.1.3 Housing Transition and Social Identity

Transitioning from one social status to another may be accompanied with other

challenges, particularly in redefining the self as well as developing and maintaining

relationships with others, two processes closely tied together (Hall, 2000; Hull & Zacher,

2007; Parsell, 2011). When individuals move from homelessness into housing, they

16

transition from a centralizing social identity of being homeless that governs their

interactions with people and social institutions into a non-stigmatized, non-identity of

being housed (Hitlin, 2003). Conventionally-speaking, few would describe “the housed”

as a social group, yet “homelessness” reflects a social identity and social status that

influences individuals’ relationships with other people as well as with social institutions

such as healthcare, education and family (Hull & Zacher, 2007). It is therefore unclear

what happens to the social identities of formerly homeless persons following transitions

away from homelessness.

While not explicitly examined in this dissertation, social integration provides a

useful lens for understanding how individuals negotiate their identity during status

transitions. Social integration refers to “the existence, quantity, or frequency of specific

relationships” (Umberson et al., 1996, p. 841). These relationships include formal and

informal ties as well as connections to formal organizations or groups (Umberson &

Karas Montez, 2010). Individuals may be considered highly integrated if they regularly

associate with groups, clubs, or other formal organizations. A supported housing tenant

may struggle with re-integration and defining their identity following their move away

from homelessness, particularly if their friends and/or family remain in homelessness.

Finding social groups with which to connect may be challenging for those making such a

significant status transition. This becomes even more problematic when considering

homelessness as both a social status and an identity. Homelessness as a particular type of

social status links similar individuals together through shelter-living and basic proximity,

but moving into housing does not automatically provide an identity or social group in

which individuals may feel they belong. Questions remain as to the ways in which the

17

formerly homeless construct identities when they move away from homelessness into

supported housing:

RQ3: If formerly homeless individuals do not identify with the homeless and

the housed do not explicitly share a social identity, how do individuals

construct and maintain identities during such a major life event?

Chapter 4 seeks to explore the ways in which formerly homeless individuals negotiate

their identities through the significant life transition as they become housed. In doing so,

it considers the ways in which people embrace or distance themselves from their previous

social statuses through their interactions with others.

The third article presented in Chapter 4 extends from the results of the first two

articles by demonstrating the ways in which formerly homeless individuals redefine

themselves in their new social status. While the first two articles examined health

changes following the transition from homelessness into housing, the third considers

changes to individuals’ senses of selves. From an inductive thematic analysis of

longitudinal interview data collected over six months from seven individuals transitioning

out of homelessness into supported housing, it considers the ways in which individuals

interact with and relate to others during the significant status transition from

homelessness to housed. In doing so, it examines identity shifts during such a significant

status shift, and the ways in which formerly homeless individuals negotiate identity.

Understanding status transitions and the ways in which individuals navigate them

provides insight into social structure and relationships. This is sociologically important

because relationships may help individuals access resources, and are important to the

health and wellbeing of those in them. Furthermore, from a sociological perspective,

18

social relationships often reflect individuals’ positions in the social structure, and may

influence their level of advantage or disadvantage in a society. Individuals who undergo

changes in their social statuses may reorganize their social relationships, their

connections to social institutions (such as education and healthcare), and their very sense

of self, all of which are of sociological interest. These shifts may reduce or exacerbate

inequalities that could then increase sites of difference between individuals. While this

particular project explores the status transition from homelessness to housing (a

marginalized status to one of greater stability and privilege), these findings may be

relevant to other types of status transitions, particularly those that involve restructuring of

routines, and, potentially social structures and institutions themselves.

1.2 Mixed Methods Rationale

To explore the effects of housing on health and wellbeing, this project undertook

a mixed methods approach. Generally speaking, mixed methods refer to a series of

methodologies where the researcher “combines elements of qualitative and quantitative

research approaches... for the purposes of breadth and depth of understanding and

corroboration” (Johnson, Onwuebuzie, & Turner, 2007, p. 123). Mixed methods

approaches, however, involve more than simply combining qualitative and quantitative

methodologies together. Rather, they are designed to pragmatically draw on multiple data

sources to create a better understanding from multiple viewpoints to facilitate

triangulation, explanation, and exploration (Bryman, 2006; Creswell & Plano Clark,

2007; Jick, 1979).

For this project, a complementary, sequential mixed methods approach was

deemed necessary to elaborate both types of data while minimizing limitations and

19

maximizing the benefits of each (Greene, Caracelli, & Graham, 1989). Complementary

approaches enable researchers to develop more in-depth knowledge about the subject

matter. Sequential mixed methods approaches draw on different methodologies to

examine different, yet connected, aspects of social phenomena (Greene et al., 1989). In

this case, interview data and HMIS data were collected independently of one another.

Analysis, however, was multi-stage. It began with analysis of the quantitative data, and

had further exploration of this dissertation’s questions through qualitative data. In other

words, the quantitative analysis raised questions relevant to the qualitative data analyses

and question.

This dissertation project employed statistical analyses of agency-collected,

closed-ended questionnaire data as well as qualitative thematic analyses of longitudinal

interview data collected by the author. There were numerous reasons for this approach,

including the unique advantages of both secondary questionnaire and interview data.

Both secondary survey data and interview data have obvious strengths (Neuman,

2011). For example, secondary survey data typically involves relatively datasets for

sometimes hard-to-reach populations. This is useful as it allows researchers to perform

statistical analyses on relatively large groups of people without needing to speak with all

of them individually. Also, secondary data is inexpensive for secondary researchers.

Because the data has been collected by other people, secondary researchers have little or

no financial costs associated with data collection and data analyses (Neuman, 2011).

Interview methodology has multiple strengths as well as it allows for in-depth data

collection as interviewers can probe and acquire more information on a subject of interest

(Neuman, 2011). That is, interviews allow for semi-structured explorations of topics

20

through open-ended questions that enable interview participants to answer questions with

some measure of depth. Furthermore, interviews allow research participants to describe

their lives in their own words, thereby ensuring understanding and clarity (Neuman,

2011).

Secondary survey data, like that used in this dissertation, also has several distinct

limitations however (Neuman, 2011). First, researchers are restricted by the quality of the

primary data collectors and the ways in which they asked questions. For the secondary

data user, this translates into a lack of flexibility in the types of analyses that may be

conducted on the data as well as the ways in which the primary collectors operationalized

their concepts (Neuman, 2011). This, in turn, may have implications for the validity and

reliability of the data. Some questions may not ask what the primary data collector

believed them to be asking, and others may lack clarity, thereby effecting respondents’

answers (Neuman, 2011). Second, secondary data may not always be suited exactly to

the research question of interest (Neuman, 2011). In this dissertation, the secondary

survey data had no measures of social relationships and failed to consider the ways in

which individuals integrate into communities following major status transitions.

Interview methods also have several limitations (Neuman, 2011). First, while

interviews allow researchers to probe and glean more information based on what

participants share, they typically involve relatively small sample sizes. Consequently,

findings are not generalizable to greater populations. Interviews provide in-depth

understanding of the individuals an interviewer speaks to, but data saturation may be

problematic. It may be difficult to determine if findings are particular to the interview

sample or to the population of interest. Additionally, interview bias may be problematic

21

depending on the researcher’s perspective and understanding of the subject matter

(Neuman, 2011). In particular, interviewers may phrase questions that predispose

participants to certain answers. Additionally, bias may occur when interviewers

misinterpret the information provided to seek confirmation. This subjectivity may hamper

the validity and reliability of interview data. The data may not reflect what the

interviewer thinks it reflects (validity), and another analyst or interviewer could ask

similar questions and have different results (Neuman, 2011).

No one piece of data may be suited to explore every facet of a phenomenon,

thereby requiring supplementation to fill in gaps. Because of the limitations of each, a

mixed methods approach was deemed appropriate to both supplement and further explore

connections between housing, health, and identity. This was particularly important as the

agency-collected secondary data could, potentially, provide generalizabile findings while

the interview data could, potentially, provide an in-depth understanding of individuals’

experiences.

It should be noted that while the entire dissertation is a mixed methods project,

two of the three data chapters that follow are based on mono-methods analyses and only

one is based on a mixed methods approach. The specific questions that each chapter

focuses on are addressed within each of the individual articles where Chapters 2 and 4 are

mono-method pieces and Chapter 3 represents a mixed methods analysis. The final

chapter of this dissertation (Chapter 5) will integrate the results of these three papers and

consider them together in addressing the overarching primary research question.

1.2.1 Methods Undertaken

All data were collected from a single homeless service agency in Calgary, Canada.

22

The Agency, a pseudonym, has been working with the homeless for over 30 years, and

provides a number of services to their clients, including shelter, housing, and

employment services. Two different types of data are used throughout this dissertation:

agency collected survey data from shelter and supported housing clients maintained in

HMIS; and longitudinal interviews with homeless transitioning into supported housing.

Consequently, this project incorporates two types of data collection. The first

relied on secondary survey data that was collected by the shelter’s caseworkers. These

data fulfill two purposes, namely they are used to demonstrate differences between those

in shelter and those in supported housing (RQ1 addressed in Chapter 2), and to document

changes in the health of housed clients over the first six months of living in supported

housing (RQ2 addressed in Chapter 3). Alongside the statistical analyses of HMIS data,

longitudinal interviews were used to explore the ways housed clients’ negotiated their

transitions into housing and the ways in which their health, relationships, and senses of

selves changed during these transitions. In addition, in the interviews participants were

asked to reflect on their general wellbeing and how they feel during the initial months of

housing and the street exit process (RQ3 addressed in Chapter 4).

Taken together, these multiple data sources provide a wealth of information

telling a rich story of changes in health during and after homelessness and the street exit

process. The quantitative data provides statistical evidence of the connection between

housing status and whether the physical and mental health of the homeless improves

upon moving into housing. Additionally, the qualitative interviews enable participants to

tell their stories in their own words as well as identify who they see as significant people

during their street exit experience. Each data source helps create a mosaic to better

23

understand the lives of both sheltered and housed individuals.

The data collection methods are described in greater detail in the subsequent

chapters of this dissertation. Details about HMIS data, its measures, and the ways in

which it operationalizes mental and physical health are discussed in depth in Chapters 2

and 3. Similarly, details about longitudinal interviews, the participants, the data, and its

analysis are presented in Chapter 4.

1.3 Dissertation Outline

The data, methods and results are presented in each of the three subsequent

chapters of this dissertation as separate articles that highlight some of the most important

findings from this project. Chapter 2 uses HMIS to make comparisons between

individuals remaining in shelter and those in housing. Chapter 3 uses both HMIS and

interview data to understand changes in emergency healthcare use during individuals’

first six months in housing. Chapter 4 explores identity and relationship changes

individuals experience when they move into housing by drawing on longitudinal

interview data. This dissertation concludes with a discussion of the overall findings of

this dissertation as well as the limitations of the research, and directions for future

research in Chapter 5.

Chapter Two: Housing and Stress: Examining the Physical and Mental Health

Differences Between Homeless and Formerly Homeless Individuals

Under Revision for Resubmission at the Canadian Journal of Social Policy

24

2.1 Abstract

This paper examines differences in physical and mental health between homeless

individuals living in shelters and formerly homeless individuals living in government-

assisted housing. Utilizing Homelessness Management Information System (HMIS) data

from Calgary, Canada, this study finds no significant difference in mental health between

the two groups, but formerly homeless individuals in housing were more likely to

reporting having a physical ailment compared to those in the homeless shelter.

Furthermore, individuals in housing appeared to have had greater exposure to stressors,

yet their mental health is no worse than those in the homeless shelter. Housing may

protect against the deleterious effects of cumulative stressors on current physical and

mental health, which appears to support Housing First policy. Regardless of housed

status, past stress exposure negatively influences both current physical and mental health.

2.2 Introduction

Housing policy influences the lives of individuals under its purview by dictating

who is entitled to social housing, how entitlement changes over the course of their

lifetime, and the extent to which social housing is supported in a community (Bramley,

1988; Miron, 1988; Niner 1989; Bacher, 1993). Housing First, a specific housing policy,

has gained momentum in the last ten years (Tsemberis & Eisenberg, 2000; Tsemberis,

Gulcur, & Nakae, 2004). According to Housing First, in order to prevent homeless

individuals from experiencing the deleterious effects of homelessness, they should be

placed into housing before any other personal issues are addressed. This model differs

from other housing policies where individuals must first prove their merit or ability to

maintain housing (Dordick, 2002).

25

This paper seeks to understand whether those in housing fare better than those

living in homeless shelters. If the assumptions surrounding Housing First policy are

correct, and housing enhances the lives of formerly homeless individuals, then those in

housing should be in better health than those in homeless shelters.

2.3 Housing Policy in Canada

In the last twenty years, housing policy in Canada has undergone major shifts,

particularly in adopting the Housing First model. These shifts seem to coincide with

changes in rhetoric around homelessness and its causes (Hulchanski, 2004). Policies that

primarily address individual causes of homelessness focus on personal merit or

worthiness for acquisition of housing, while policies that focus on the structural causes of

homelessness consider system issues such as housing stock or unemployment rates

(Peressini, 2009; Watts & Grimshaw, 2009; Sealy, 2012). Different causes result in

different proposed solutions.

Canadian housing policy has often been credited with relatively steady rises in

homelessness since the 1960s, when deinstitutionalization began (Anucha, 2006;

Peressini, 2009; Sealy, 2012). Deinstitutionalization involved returning psychiatric

inpatients to the community, often without adequately addressing their housing needs. As

deinstitutionalization progressed, the Federal government moved away from social

housing. Social housing began as a public good to meet the needs of Great Depression

victims and WWII veterans, into the 1960s, the CMHC (Canadian Mortgage and Housing

Corporation) changed its role, becoming a regulator of mortgages rather than a lender and

provider of social housing (Miron, 1988). This shift translated into governmental conflict

around social housing and its provision. Primary responses to poverty and the need for

26

centralized social housing developed through partnerships between the Federal

government and municipalities (Bacher, 1993; Miron, 1988; Rose, 1980). However, as

provinces cultivated greater autonomy and better means of governance, social housing

became controversial in terms of who had a responsibility to care for the poor.

Meanwhile, governmental obligations to poor Canadians shifted through increased

neoliberal policy. These policies suggested that while homeless Canadians needed

dwellings away from the streets in order to endure Canada’s long cold winters,

government’s obligations to such Canadians were limited.

Consequently, shelter rather than housing became a centralized response to those

without dwellings (Bacher, 1993; Gaetz et al., 2006; Miron, 1988; Rose, 1980). In both

Canada and the United States, responses to rising homelessness revolved around creating

warehouse-style homeless shelters where individuals could sleep on mats in large rooms

alongside others (Bauhmohl, 1996). In the 1970s, these shelters became the go-to

response to homelessness across North America.

With the development of the homeless shelter system, including the highly

institutionalized lifestyles coincide with shelter living programs, social housing became

dependent on municipalities for their development and continued existence (Bacher,

1993; Miron, 1988; Rose, 1980). Governmental partnerships and jurisdictional conflict

meant reductions in social housing development. As a result, few social housing projects

developed in Canada until after deinstitutionalization in the 1960s, and these varied by

province with Alberta generally lagging behind provinces like Ontario (Hudson & Graefe,

2011; Miron, 1988).

27

For many years, Alberta took a very conservative stance towards social housing,

and the shelter system became the primary means of addressing homelessness in Alberta

(Miron, 1988). Subsequently, homeless Albertans were socialized into what many have

called a “total institution” (Goffman, 1961) that regulates every part of individuals’ lives.

Furthermore, the shelter system frequently drew lines between the “deserving” and

“undeserving” by prioritizing shelter for some and not others (de Schweinitz, 1943). The

“deserving” were characterized as those who were not responsible for their poverty such

as children or those with physical or mental disabilities, whereas the “undeserving” were

those deemed responsible for their circumstances. This created a hierarchy of

homelessness where individuals were prioritized based on their gender, age, and level of

disability. This is not to say social housing disappeared altogether, but it was based on

meritocracy and individuals’ housing ‘readiness’ (Dordick, 2002).

A homeless individual’s housing readiness refers to their capacity to maintain and

be responsible for their home (Levy, 2000; Montgomery, Hill, Kane, & Culhane, 2013).

Housing readiness involved medicating individuals’ mental health issues, controlling

their addictions, and acquiring employment according to individual agency standards.

Housing readiness critics argue that because of the shelter conditions that the homeless

were socialized to accept, they were not automatically ready to move into independent

housing following shelter life (Dordick, 2002). Proponents suggested that social housing

was best suited for those already changing their lives prior to moving into housing,

thereby representing the best opportunity for “housing success.” Housing ready programs

were often coupled with goal setting (with consequences when goals are not met), case

management, and other assistance programs (Dordick, 2002; Montgomery et al., 2013).

28

2.4 Housing First

Recently, housing ready models have begun to decline in prevalence and

popularity and are being replaced with Housing First policies. Housing First was

introduced in the United States by Sam Tsemberis as a response to individuals

experiencing homelessness who have a dual diagnosis of mental illness and addiction

(Tsemberis, Gulcur, & Nakae, 2004). The Housing First model has three primary

philosophical goals. The first goal is to ensure that homeless individuals with dual

diagnoses have the means available to them to successfully manage and negotiate their

mental illnesses and their addictions. Shelter living, despite its control over dwellers’

lives, may be chaotic, and could inhibit progress towards personal independence (Grigsby

et al., 1990). Tsemberis & Eisenberg (2000) argue that such conditions make it difficult

for homeless individuals to address these issues before moving into housing. Therefore,

Housing First accommodates those with the most severe mental health and addiction

issues to achieve mental stability.

The second goal of the Housing First model is to improve the safety of shelters

and shelter living. By helping those with a dual diagnosis move away from shelters, and

removing the most chronically homeless individuals from the shelter, Housing First may

make shelters safer for those experiencing homelessness for the first time. Newly

homeless individuals may be less at risk for becoming trapped in homelessness and the

shelter system through the elimination of chronically homeless people and shelterization

(Grigsby et al., 1990). Shelterization causes individuals to adapt to the often-regimented

scheduling that accompanies sheltered homelessness in a way that may stifle independent

living. Furthermore, shelter and street living may harm health and increase the likelihood

29

of developing mental illness, so moving individuals quickly is ideal (Grigsby et al., 1990;

Hannappel, Calsyn, & Morse, 1989).

The third goal of the Housing First model is to save government and taxpayer

money (Gaetz, 2012). While shelter living may seem inexpensive, caring for the

homeless may actually make shelters more expensive than social housing. For example,

consider the case of Million Dollar Murray (Gladwell, 2006). Million Dollar Murray

lived in the United States and had a number of physical and mental health problems. He

lived in a homeless shelter, and had many encounters with police and ambulatory care as

a result. Because he constantly required emergency services rather than preventive

medicine, Murray cost the social system millions of dollars. Murray’s case is one that

Housing First proponents regularly reference as an example of how social housing could

actually save taxpayers money (Gladwell, 2006). Reallocation of funds suggests that

when police, ambulatory, and medical costs are accounted for that social housing is

indeed cheaper for taxpayers than shelter living. Laird (2007) suggests that emergency

services around homelessness cost Canadians between $4.5 to $6 billion dollars per

year—funds that could be allocated to social housing. Yet the impact of housing on the

mental and physical health of homeless individuals remains in question.

2.5 Personal History and Health

A large body of literature suggests that while housing influences health, it is

poverty, rather than homelessness, that continues to be the biggest threat to individuals’

health (Daniels, Kennedy, & Kawachi, 1999; Raphael, 2003; Marmot, 2005). It is

important to understand whether moving into housing actually improves the health of

formerly homeless individuals, particularly if they remain in poverty and experience

30

many of the same stressors they experienced before being housed. Even if individuals

experience different stressors once in social housing, they may have been exposed to

similar life events as those in shelters. Present and past life event stressors accumulate to

impact individuals’ mental health at any point in time (Menzies, 2006;; Montgomery,

Cutuli, Evans-Chase, Treglia, & Culhane, 2013; Wheaton & Clarke, 2003). In fact, the

cumulative effect of stressors over time may matter more than a specific or unique

stressor. Therefore, the first hypothesis proposed is:

Hypothesis 1: A history of stress exposure will have a negative effect on both

homeless and formerly homeless individuals’ physical and mental health.

Clearly, Housing First policy is based on the assumption that housing will

generally benefit the lives of formerly homeless individuals. From this perspective,

homelessness and living in shelters is perceived as unhealthy. Therefore, the second

hypothesis is:

Hypothesis 2: Net of history, formerly homeless individuals living in housing will

have better current physical and mental health compared to homeless individuals

living in homeless shelters.

2.6 Methods

2.6.1 The Data

Data are from a single agency, Agency X, contained in Alberta’s Homelessness

Management Information System (HMIS) in the city of Calgary. HMIS is a database

utilized to track individuals’ cross-agency usage over an entire system of homelessness

service provision. It helps policymakers and service providers understand how homeless

individuals move throughout the social services system in Alberta. While cross-agency

31

data will eventually become available in Calgary, currently only one agency has both

their homeless shelter and housing data on the system, making it the only option for

comparing shelter living and assisted apartment dwelling individuals. The data utilized in

this paper are from both general intake data and the database’s Universal Data Elements

(UDEs). The UDE includes information on all individuals who access the agency. They

are asked a series of questions completed on an intake form with a worker. Individuals

living in government-supported housing units, however, have to complete these items at

three-month intervals to track their progress over time. Shelter-dwelling individuals only

complete the intake once when they first access the shelter. It is important to note that

while individuals accessing the system are asked the questions, sometimes they refuse to

answer, thereby generating missing data for some questions.

Because homeless individuals frequently move across services, and some are

moving into housing, data were recalled for all users from one particular day, thereby

ensuring that each individual was only represented once in the data set. That is, the data

only includes individuals who were accessing agency services on one particular day in

2013. While more individuals exist in the HMIS system, it is not possible to recall intake

data from everyone as there is overlap between shelter and housed data. Choosing one

particular day of the year ensures that each individual is only represented once. This day

was selected because it was the middle of a colder month, thereby guaranteeing that the

shelter was near capacity and could provide the largest data yield possible. As a result,

data for 391 clients living in the shelter and 73 clients in assisted housing were collected

and are analyzed in this paper.

32

Health Outcomes: Mental health issue is a self-reported question that asks

respondents whether they currently have any mental health issues. Answers are divided

between no mental health issues, yes--treated, yes--untreated, and both treated and

untreated. In this paper, and due to sample size, these were recoded into a dummy

variable where having a mental health issue is coded as 1 and responses indicating no

mental health issues are coded 0.

Similarly, physical health issue is a self-report question that asks respondents

whether they currently have any physical health problem. Answers include no physical

health issue, yes--treated, yes--untreated, and both treated and untreated. Again, due to

sample size, these were recoded into a dummy variable where having a physical health

issue is coded as 1 and responses indicating no physical health issues are coded 0.

Current housed status is coded such that individuals living in government-

supported apartments are considered housed and coded as 1 and individuals living in the

shelter are coded as 0.

Personal History Variables: Personal history includes a summation stress score,

measures of past housing experiences, and number of months in shelter over the last year.

The cumulative stress history index, following LaGory, Ritchey, & Mullis (1990), is a

summation of seven stress-related dummy variables, namely: has an addiction, served in

military, experienced family violence, spent time in prison, recent (last twelve months)

mental health facility admission, recent (last twelve months) health care system

admission, and currently unemployable. The stress history index score ranges from zero

to seven, thereby representing an individual’s cumulative stress exposure.

33

Housing prior to coming to Agency X is measured through a series of dummy

variables that include unsheltered, institutional living, and housed. Unsheltered

individuals are those sleeping outside or in a vehicle prior to their connection to Agency

X. Institutional living includes those living in a different shelter, were in treatment for a

mental or physical health issue, or were incarcerated before coming to Agency X. Last,

the housed group includes those in either a rental unit or their own house prior to coming

to Agency X, and this is the reference group for this measure.

Number of months in shelter this year is based on the number of months the

individual has stayed in Agency X over the last twelve months. This variable is measured

based on nightly check-ins for an individual’s bed assignment in shelter. Check-ins

typically took place prior to intake assessments, although this is not always the case. Note

that those living in government support apartments may have spent no time in the shelter

in the last year depending on how long they have lived in said apartments. Others,

however, may have spent time living in the shelter at Agency X.

Control Variables: Control variables included sex (men=1), age, race

(Caucasian=1), has an income source (this includes paid employment or government

social assistance), and education (completed some high school=1).

Interview Data: Along with HMIS data, interviews were conducted with 7

individuals who had moved into a government supported housing program in order to

corroborate findings. Interview questions focused on individuals’ health and relationships

to better understand changes during the transition from homelessness to housing.

34

2.7 Analysis

Mean difference tests were conducted to determine variability across housed

statuses for all variables included in the analyses, as displayed in Table 1. A zero order

correlation matrix was also constructed to determine relationships across variables and

check for multi-collinearity, as displayed in Table 2. Logistic regression analyses were

utilized to address the hypotheses posited and the results are presented in Table 3. Three

logistic regression models were constructed for each of the dependent variables. The first

model examines the relationships between housing and each of the health variables. The

second model repeats that logistic regression, and incorporated all of the control variables.

The third model added the stress history index variable, and the fourth model (results not

shown) incorporated interaction effects between housed status and each of the seven

cumulative stress variables. These were entered in a stepwise fashion to assess changes in

significance level when controlling for each of the cumulative stress variables.

Additionally, a fifth model (results not shown) included an interaction term between the

cumulative stress variable and housed status to assess the cumulative influence of stress

and whether housed status changed the influence of the cumulative history on physical

and mental health.

35

Table 1. Characteristics of the samples by housed status

Sheltered (N=391) Percent

Housed (N=73) Percent

t-Value Two

Tailed Mental Health Issues (% with Mental Health Issue)

20.7 (2.50) 32.4 (5.60) 1.903

Physical Health Issues (% with Physical Health Issue)

37.0 (3.00) 63.9 (5.70) 4.16***

Cumulative Stress Scorea 1.27 (.079) 1.58 (.136) -1.960* % Has Addiction 34.0 (47.5) 36.1 (48.4) -.333 % Served in Military 6.5 (24.7) 5.5 (22.9) .332 % Experienced Family Violence 11.1 (31.5) 26.1 (44.2) -2.70** % Spent Time in Prison 13.7 (34.4) 6.9 (34.4) 1.83 % Recent Mental Health Facility Admission 14.1 (34.9) 4.2 (32.6) 3.065*** % Recent Health Care System Admission 31.9 (46.7) 47.2 (50.1) -2.339* % Currently Unemployable 20.4 (40.4) 38.7 (49.1) -2.717** Housing Prior to Utilizing Agency X % Unsheltered 12.7 (33.4) 1.4 (11.7) 4.992*** % in Institutional Living 32.2 (46.8) 58.9 (49.5) -4.201*** % Housed 40.2 (49.1) 28.8 (45.6) 1.922 Average Months in Shelter this Year 3.96 (3.72) 1.42 (2.31) 7.72*** Control Variables Sex (% Male) 86.2 (34.5) 64.4 (48.2) 3.691*** Age in Years 43.82 (.608) 46.82 (1.27) 0.982* Race (% Caucasian) 63.4 (48.2) 76.7 (42.6) -2.395* % Has Income Source 57.1 (49.6) 90.1 (3.6) -7.005*** % has Some High School 31.9 (2.9) 32.9 (47.3) -.153 a sum of individual stressors * p < .05 ** p < .01 *** p < .001

36

Table 2. Zero-order correlation matrix (N=464) Mental

Health Issues

Physical Health Issues

Housed Status

Stress Index

Institutional Living

Months in

Shelter

Sex Age Race Income Source

Some High

School Mental Health Issues

1.00

Physical Health Issues

.247*** 1.00

Current Housed Status (1=Housed)

.114* .224*** 1.00

Cumulative Stress .381*** .344*** .100 1.00 Institutional Living -.004 -.001 .211*** .073 1.00 Months in Shelter -

.180*** -.021 -.254*** -.171** -.047 1.00

Sex (1=Male) -.183***

-.139* -.210*** -.187*** .045 .180*** 1.00

Age -.081 .173 .092* .036 .082 .257*** .078 1.000 Race (1= Caucasian)

.018 .140* .102* .070 .124* .124** .089 .221*** 1.00

Has Income .094 .152** .283*** .098 .074 .085 -.062

.179** .137** 1.00

Some High School -.009 .029 .008 -.015 -.015 .067 -.001

-.054 .006 .009 1.00

* p < .05 ** p < .01 *** p < .001

37

2.8 Results

The results in Table 1 show that there was no significant different in mental health

between the two groups, with roughly 21% of sheltered individuals and 32% of housed

individuals reporting mental health issues. However, significant differences can be found

in physical health across housed status with 37% of those living in shelter reporting

having a physical health issue compared to 64% in housing.

The overall stress history index score indicates a significant difference in stress

exposure with those in housing (Mean=1.58) reporting higher levels of stress exposure

than those in shelter (Mean=1.27). Specifically, four stress variables significantly differed

by housed status. These were experiences of family violence, recent mental health facility

admission, recent health care system admission, and currently unemployable. About 11%

of those in shelter had reported experiencing family violence compared to 26% of those

in housing. Significantly more individuals in shelter reported recent mental health

facility admission (14%) compared to those in housing (4%), but significantly more

individuals in housing (47%) reported recent health care admission compared to those in

shelter (32%). Last, more individuals in housing reported they were currently

unemployable (39%) compared to those in shelter (20%). These results suggest that

individuals in housing have had greater stress exposure compared to those in shelter.

Turning next to their housed status prior to current shelter, a greater number of

housed respondents (59%) came from institutional living situations before coming to

Agency X compared to those in shelter (32%). As well, 13% of those living in shelter

were unsheltered before coming to shelter, compared to 1.4% of those in housing.

38

From the control variables, it appears that the average age of housed respondents

(Mean=43.82) was about three years younger than those living in shelter (Mean=46.82).

A greater percentage of those in housing (76%) were Caucasian compared to those in

shelter (63%). Those in housing were more likely to have an income source (90%)

compared to those in shelter (57%). Lastly, there was no significant difference in

education with 32% of those in shelter and 33% of those in housing having completed

high school.

The correlation matrix displayed in Table 2 demonstrates no multicollinearity

among the variables. Significant correlations are displayed between housed status and

both mental (r=.114) and physical health (r=.224) conditions. Additionally, the stress

index has positive moderate correlations with both mental (r=.381) and physical health

(r=.344) issues, indicating a connection between health and cumulative stress exposure.

In order to test Hypothesis 2, logistic regression analyses were conducted to

determine if there are any significant differences in health between those living in

supported housing units and those residing in a shelter. The odds ratio results for both

mental and physical health are summarized in Table 3. Mental health was analyzed

through a series of four models. In Model 1, housed status has a significant association

with mental health, demonstrating that those in housing were about twice as likely as

those living in shelter to have mental health issues. However, when sociodemographic

controls are introduced in Model 2, the association becomes non-significant, indicating

there is no difference in mental health between those living in housing and those living in

shelter when controlling for sociodemographic variables. Other factors, namely gender,

make greater contributions to mental health than current housed status. The only

39

significant variable in Model 2 is sex. The odds ratio for sex (.421) indicates that men are

half as likely as women to report having a mental health issue.

Model 3 includes all personal history variables as well as housed status and all

control variables to examine their influence on mental health. In this model, the stress

history index has a significant association with mental health, regardless of housed status

and all control variables. For each accumulated stressor, individuals are two times as

likely to report having a mental health issue. That is, for every stressor they have

experienced in the index, individuals are approximately twice as likely to report a mental

health issue as those without such exposure. Cumulative stress appears to have a strong

association with individuals’ mental health. Additionally, number of months in shelter

over the last year has a significant effect on mental health. For every month an individual

spends in shelter, they are 0.88 times as likely to report experiencing a mental health

issue as individuals who did not spend that month in shelter or mentally healthier

individuals tend to have longer shelter stays. In other words, longer shelter stays are

positively related to mental health. The negative effect cumulative stress has on mental

health supports Hypothesis 1, regardless of individuals’ housing status. None of the

interactions between housed status and personal experience were significant (results not

shown).

40

Table 3. Odds ratio results for mental and physical health issues a b

Mental Health Issues

N=305 Physical Health Issues

N=309 Model 1

Odds Ratio (Std. Err)

Model 2 Odds Ratio (Std. Err)

Model 3 Odds Ratio (Std. Err)

Model 1 Odds Ratio (Std. Err)

Model 2 Odds Ratio (Std. Err)

Model 3 Odds Ratio (Std. Err)

Current Housed Status (Housed=1)

1.84 (.54)* 1.45 (.48) 1.21 (.48) 3.00 (.83)*** 2.21 (.67)** 2.68 (.95)**

Personal History Cumulative Stress Score

1.98 (.24)*** 1.76 (.19)***

Prior Housingb: Institutional .827 (.28) .619 (.18) Unsheltered 1.09 (.59) .892 (.42) Number of Months in Shelter this Year

.882 (.05)* 1.00 (.04)

Control Variables Sex (Male=1) .421 (.14)* .700 (.27) .424 (.14)* .626 (.23) Age .983 (.01) .986 (.01) 1.02 (.01)* 1.03 (.01)* Race (Caucasian=1) 1.46 (.47) 1.32 (.46) 1.92 (.57)* 1.92 (.60)* Has Income 1.34 (.42) 1.32 (.46) 1.28 (.35) 1.19 (.35) Education (Some High School=1)

.955 (.28) 1.11 (.36) 1.21 (.32) 1.24 (.34)

Pseudo R-Squared

.011

.044

.177

.036

.089

.161

a Has Mental Health Issue = 1; Has No Mental Health Issue = 0; Has Physical Health Issue = 1; Has No Physical Health Issue = 0 b Housed is reference Group * p < .05; ** p < .01; *** p < .001

41

Similarly, Model 1 for physical health (N=309) tests Hypothesis 2 and

demonstrates that current housed status has a significant relationship with physical health,

but not in the way expected. Individuals living in government supported housing were

about three times as likely to report having physical health issues as those living in the

shelter. Model 2 adds all sociodemographic control variables to the model. In Model 2,

current housed status continues to have a significant association with mental health with

an odds ratio of 2.21, meaning that individuals in housing were about twice as likely to

report having physical health issues controlling for the sociodemographic variables.

Several control variables also had significant relationships with physical health, including

sex, age, and race. Men were about half as likely as women to report having a physical

health issue. The odds ratio for age indicates that for every year increase in age,

individuals were 1.02 times as likely to report having a physical health issue. That is,

older individuals were more likely to report physical health issues compared to younger

ones, and yearly increases in age increased an individual’s chances of reporting a

physical health issue by 2%. Last, the odds ratio for race (1.92) suggests that Caucasians

in the sample are twice as likely as all other races to report having a physical health issue

when compared to other races.

To test Hypothesis 1, Model 3 incorporates all personal history variables into the

model. The inclusion of the personal history variables reduces the impact of current

housed status on physical health. Individuals living in housing were about two and a half

times as likely to report having a physical health issues as those living in shelter

controlling for both the sociodemographic and the personal history variables. The stress

history index score also had a significant association with housed status with each

42

accumulated stressor reducing physical health. For every stressor an individual

experienced, they were 75% more likely to experience a physical health issue. Age and

race remained significant in Model 3. Men were .62 times as likely as women to report

having a physical health issue, and yearly increases in age continued to make individuals

3% more likely to report physical health issues controlling for the personal history

variables and housing status. Last, Caucasian people were nearly 2 times more likely to

report a physical health issue when compared to individuals of other races controlling for

all other variables. None of the interactions between housed status and personal

experience were significant (results not shown).

2.9 Discussion

Based on the principles of Housing First, this paper hypothesized that individuals

living in government-supported housing would have better mental and physical health

than those living in shelter. While the results of this study do not support this hypothesis,

they do support the concept of Housing First. The results found no significant difference

in mental health between those living in shelter and those living in government-supported

housing. There is, however, a difference in physical health between these two groups

with those in housing reporting more physical health issues than those in shelter. The

distinction between housed status’s effect on mental and physical health could be because

individuals become more aware of their health once living in stable housing. Research

has found that health stability relates to personal stability, which could impact an

individual’s awareness of their physical health issues (Brunswick, 1980).

Despite this refutation of the first hypothesis, the principles of the Housing First

model appear to be supported in that personal history and historical stress exposure have

43

negative effects on individuals’ mental health. The historical stress exposure hypothesis

(Hypothesis 1) appears supported for both mental and physical health as the cumulative

stress score significantly reduced health regardless of housed status. This is important to

note, particularly as poverty may increase exposure to each stressor included in the index.

Perhaps more importantly, individuals living in housing had greater stress exposure

overall, that is, higher scores on the stress history index, yet no difference in mental

health when compared to those in shelter. This suggests the importance of housing to the

mental health of those experiencing homelessness, and appears to support the Housing

First model. Research demonstrates that higher levels of stress exposure are generally

associated with lower levels of mental health (Pearlin, 1989; Thoits, 1982; 1986; 1995).

However, in this circumstance those in housing reported no significant difference in

mental health compared to those in shelter, even when stress exposure is not controlled

for (as in Model 2), suggesting that housing may limit the impact of cumulative stress on

individuals’ health.

This is important to consider, particularly in light of residents’ comments around

how they feel once housed. In the second part of this study, interviews were conducted

over six months with individuals living in both shelter and housing. When asked how he

felt now that he was housed, Robert, a middle-aged man who had lived in shelter for

several years, explained:

Much less stress, much less anxiety. Um, a lot more positive thinking, um

somewhat physically healthier just because I’m eating better, getting more

exercise, getting more sleep. Um, so yeah those things have improved

dramatically since moving out of the shelter and being on my own.

44

Similarly, Sheila, a middle aged woman who had resided in shelters for much of her life

discussed how she felt in her apartment compared to the shelter:

Oh way better, like, there’s so much more privacy, there’s so much more

freedom... You can come and go whenever you want there’s no set curfew you

don’t have to be home at a certain time... You can, you know, just a lot more

freedom… Yeah way better than a shelter, you don’t have to get up at six thirty in

the morning.

In both cases, residents describe feeling better than when they lived in the shelter. Robert

specifically relates his experience to anxiety and the stress associated with shelter living,

while Sheila relates hers to the privacy associated with her independent residence.

Housing may be important to mitigate the harmful effects that stressors have over time.

In the case of Agency X, housing appears to have minimized the effect of both

past and current stressors on individuals’ mental health. Furthermore, the mental health

results suggest that housing readiness programs may not be practical options for those

experiencing homelessness. The cumulative stress history score, for both those in housing

and those in shelter, influenced mental health, and if individuals are expected to have

mental health issues treated prior to entering housing, they may never move away from

homeless shelters and street life.

Additionally, the higher stress exposure experienced by those in housing may

demonstrate a need for support and greater intervention to maximize residents’ coping.

While some Housing First models assume that Housing First translates to “housing only,”

others, such as the one employed by Agency X, provide important mental health and

addictions services to their clients, consistent with the original ideals of Tsemberis et al.’s

45

(2004) model. High levels of stress exposure require strong support systems and

relationships to minimize the impact of stress on both physical and mental health (Pearlin,

1989;; Thoits, 1982;; 1986;; 1995). It could be that these supports will improve individuals’

success in their residence and their ability to maintain their housing over time.

Cumulative stress exposure needs further exploration in future research. Stress research

suggests that recent stressors may influence mental and physical health differently

compared to long-term ones (Pearlin, 1989). Further defining and considering differences

between long term and recent stressors could reveal even greater differences in mental

and physical health between shelter-dwelling and supported housed individuals.

Additionally interactions between stress variables and housing status were not significant

(results not shown). Future research should further explore these connections and whether

long term and recent stressors change the effect of housing on mental and physical health.

Last, the mean difference tests indicate that many individuals currently residing in

housing would be unlikely residents in a housing ready model. Housing ready models

assume a lower level of personal acuity and require individuals to have addressed their

unemployment, addictions, and health issues (Dordick, 2002). If the goal is to house

homeless individuals regardless of their personal issues, Housing First appears to be

succeeding where housing ready models likely fail.

2.9.1 Limitations

This study has a number of limitations. First, all data presented in this paper are

self-report data relayed to staff at a shelter or in a housing program. It is possible that

individuals did not answer all questions honestly as they may have believed it could

impact their access to shelter or housing, even though they were told it would not. Even

46

though is moving away from the housing ready model, many individuals in the system

have been socialized to believe their housing and shelter usage is contingent on presumed

progress, which may influence responses.

Second, at the time of this study, HMIS was a very new system. This complicated

the length of stay variable: number of months in shelter. Prior to the use of HMIS,

everyone staying in shelter completed nightly check-ins. This means that many

individuals in the data had data on their shelter stays prior to completing the rest of their

intake data. Other individuals, however, may have come to the shelter later and thus had

their intake data measured before their number of check-ins. Unfortunately, the nature of

the HMIS data did not allow for confirmation of when intake transpired relative to check-

ins for each individual.

Third, the sample size in this paper is relatively small. It is possible that mental

health differences could be found between those living in shelter and those living in

housing if the sample size was larger. While citywide data is being collected, it is not

currently available for analysis.

Fourth, while those living in housing have data updated every three months on

each of the UDEs, those in shelter only provide this information at intake, therefore,

providing a less accurate picture of the effect of shelter living on those staying at the

shelter. Data collected over the course of a stay could provide a more accurate picture of

the influence of shelter stays on mental and physical health. Furthermore, updated data on

those in housing may reflect the cumulated impact of prior shelter stays on mental health.

Longitudinal research is needed on the influence of shelter-living over time, and

subsequent moves into housing.

47

Fifth, HMIS data provides limited data in terms of scope and information

available. Generally speaking, stress research considers social support and relationships

since social support is vitally important to both mental and physical health (Thoits 1982;

1986; 1995; 2011). Furthermore, Jones, Shier, and Graham (2012) suggest that intimate

relationships, namely those with significant others, may be important to consider when

moving individuals out of homelessness. HMIS data, however, has no measures of

relationships in terms of number or quality. It is possible that relationships and social

support may at least partially explain differences in health between those living in shelter

and those living in housing, particularly when considering the extensive relational

changes individuals may undergo when moving from shelter into housing.

Lastly, the data in this paper are cross-sectional. This means that while individuals

in housing appear to have worse health than those living in the homeless shelter, this data

cannot speak to the causality of the housed condition. It is unclear whether physical

ailments came before individuals moved into housing or during their tenure. Furthermore,

the stressors utilized in the cumulative stress score may determine individuals’

admittance into housing programs. Longitudinal data are required to better comment on

the effect of housing on both physical and mental health.

2.10 Conclusion

In conclusion, housed status appears to directly affect physical health but not

mental health. Indirectly, however, housing appears to protect housed individuals from

the deleterious effects of accumulated stressors, thereby supporting the Housing First

model. Overall cumulative stress and shelter living negatively impact both mental and

physical health. More policy-informing research is needed to understand the interplay

48

between housed status, health, and stress, particularly with larger sample sizes (Gaetz,

2006). Further research could explain the role of relationships and social support in health

status as well as the ways in which stressors influence health for both homeless and

formerly homeless individuals. Finally, it is imperative to understand the implications of

housing policy on both the lives of the homeless and formerly homeless. Changing

policies may greatly impact life and health outcomes for these individuals, particularly

through the ways in which policies are enacted and taken up in practice.

49

Chapter Three: Healthcare Utilization During the Transition from Homeless to

Housed

Under Review at The Journal of Social Distress and the Homeless

3.1 Abstract

A wealth of research suggests that individuals experiencing homelessness have

poorer health compared to the general population and tend to rely on emergency

healthcare services instead of ongoing primary care. Many plans to end homelessness

argue that housing the homeless could reduce system costs because of this reliance.

Despite this argument, few studies have examined how formerly homeless individuals

access healthcare services once they are housed and how the transition to housing

impacts their health. The current mixed methods study draws on quantitative Homeless

Management Information System (HMIS) data (N = 233) and longitudinal interview data

(N = 7) to assess changes in health and emergency healthcare use over six months in one

supported housing program. Three themes are presented, each of which demonstrates the

importance of caseworkers, primary care physicians, and healthcare specialists as formal

supports that aid those transitioning from homeless to housed.

3.2 Introduction

Homeless individuals appear to have poorer physical and mental health compared

to the general population, as indicated by higher incidences of diabetes, tuberculosis, HIV,

depression, and serious mental illness (Hwang, 2001; Khandor, Mason, Cown, & Hwang,

2007; Weinreb et al., 1998). Research suggests that the transient lifestyles of the

50

homeless means they often rely on emergency drop-in care rather than ongoing primary

care (Kushel et al., 2006; Kushel et al., 2002; Health Care and Homelessness, 2006;

McGuire et al., 2009; Robertson & Cousineau, 1986; Weinreb et al., 1998). Because of

their poorer health and the costs to the system, many policymakers have advocated

moving homeless individuals into supported housing (Larimer et al., 2009). Questions

remain, however, whether homeless individuals’ health improves when they move into

housing, and whether their reliance on emergency healthcare services decreases

following such a transition.

Proponents of the social determinants of health perspective argue that housing is

an important factor that influences individuals’ health (Marmot, 2005; Marmot, Friel,

Bell, Houweling, Taylor Commission on Social Determinants of Health, 2008; Raphael,

2006; 2009; Wilkinson & Marmot, 2003). Housing represents more than a home to

residents: it acts as a source of protection from inclement weather, a barrier between

public and private lives, a place of stability, and a source of comfort and belonging

(Raphael, 2009; 2011; Wilkinson & Marmot, 2003). Any of these could influence

individuals’ health and wellbeing, yet many other social determinants also influence

health. For example diet, social networks, relationships, and recreation are all important

social determinants of health (Marmot et. al, 2008; Raphael, 2009; Wilkinson & Marmot,

2003). Fortunately, supported housing is generally paired with case management, a form

of formal social support where individuals work with an assigned caseworker through the

duration of their programs to address their often complicated social situations (Pearson,

Montgomery, & Locke, 2009; Watson, Wagner, & Rivers, 2013). Caseworkers, also

known as case managers, act as referral experts who have access to large, formal support

51

networks. They connect clients to other formal support resources, including food banks,

recreation, and even specialized medical care (Griswold, Servoss, Leonard, Pastore,

Smith, Wagner, Stephan, & Thrist, 2005; Mueser, Bond, & Resnick, 1998). Essentially,

caseworkers operate as gatekeepers to other formal supports. Therefore, caseworkers, and

by extension, supported housing programs, may influence many social determinants of

health for program clients. Furthermore, caseworkers have ongoing relationships with

clients (Mueser et al., 1998). Over time, these relationships may become increasingly

trusting and may offer informal emotional support alongside the formal support mandated

by the relationship (Crocker & Canevello, 2008).

Phelan and Link (1995) have argued that poverty influences all health

determinants directly and indirectly, and is, therefore, the most powerful social

determinant of health. It is imperative to understand the influence of supported housing

on the health of individuals. Questions arise when considering that many residents remain

in poverty, but access formal social support that may alleviate some of the effects of

poverty (Pearson et al., 2009; Watson et al., 2013).

For homeless individuals, housing represents a source of stability and place

(Tomas & Dittmar, 2009). Research on homelessness suggests that being homeless is not

a stable status and individuals who experience it tend to transition in and out of different

housing situations (Phelan & Link, 1999; Wright & Devine, 1995). Additionally, many

homeless individuals move between cities depending on weather conditions, employment

forecasts, and social policy changes (Wolch, Rahimian, & Koegel,1993). This instability

may make it challenging to establish social networks, receive ongoing treatment for

physical or mental health conditions, and navigate social service systems, particularly as

52

different cities, even within the same region, have different policies regarding systems of

care. Again, caseworkers may be particularly important to individuals’ success and

continuity in supported housing (O’Connell, Kasprow, & Rosenheck, 2008).

Caseworkers understand how to navigate social services in ways in which clients do not,

thereby offering their expertise to those who often have few supports outside their

supported housing program (Pearson et al., 2009).

While current policies advocate moving homeless individuals into housing, it

remains unclear whether these transitions enhance the health of the formerly homeless.

Consequently, this paper asks in what ways does the health of the formerly homeless

change during their first six months in supported housing? More specifically, this paper

seeks to understand how the health and emergency healthcare usage of formerly homeless

individuals changes following moves into supported housing. To do so, a mixed methods

approach is used. First, quantitative data from the Homelessness Management

Information System (HMIS) are analyzed to document emergency healthcare use and

new diagnoses for individuals who recently entered a supported housing program (N =

233). Second, longitudinal qualitative interviews (N = 7) are analyzed to explore

healthcare utilization and how individuals feel after moving into housing.

3.3 Methods

All data (both qualitative and quantitative) were collected from a single social

service agency in a large Western Canadian city. The Agency, a pseudonym, provides

shelter services for those currently experiencing homelessness and supported housing for

those attempting to leave homelessness. Under the supported housing model, individuals

meet regularly with caseworkers when transitioning away from shelter life and are highly

53

subsidized by the government to enable them to remain in supported housing (Tsemberis

& Eisenberg, 2014). Ethics approval for this study was obtained from the appropriate

Institutional Review Board for both portions of the project, and all qualitative interview

participants provided informed verbal consent prior to participation. All names in this

paper are pseudonyms chosen by the author to protect study participants’ identities.

3.3.1 Quantitative Data

Sample: The quantitative HMIS data include all individuals who participated in

The Agency’s supportive housing program between 2010 and 2015. This includes 455

clients with complete intake data regarding demographic information (e.g., sex, age) as

well as whether they had any physical and/or mental health issues. The majority of the

quantitative dataset in this paper is restricted to clients with complete data during their

first six months in supported housing (N = 233). The sample of 233 clients included 169

men (73%) and 64 women (27%) whose ages ranged from 19-74 (average = 48 years; SD

= 11.14 years).

Measurement: Most of the data collected through the HMIS is standardized across

many North American cities (Poulin, Metraux, & Culhane, 2008). This electronic

database tracks homeless individuals across multiple systems of care, which allows

policymakers to assess how individuals move through various systems of care.

All HMIS data are self-reported to a caseworker. To assess client progress, the

Agency has caseworkers complete assessments every three months with clients in the

supported housing program. This paper draws on three different data points: intake, three-

month assessment, and six-month assessment. Intake refers to the point in time when

individuals move into supported housing and caseworkers collect information that

54

reflects clients’ initial assessments when entering housing. These initial assessments

include the same questions at subsequent assessments that ask clients to consider their

health and healthcare use over the prior three months. For the purposes of this paper,

clients reports on whether they were hospitalized, called emergency services, and visited

the ER over the previous three months are examined.

At intake, HMIS collects descriptive information about clients, namely their age

and sex. At intake clients are also asked whether they have any ongoing physical or

mental health conditions or not. At intake, clients are also asked about their emergency

healthcare usage in terms of how many times they were hospitalized, called Emergency

Medical Services (EMS), and visited Emergency Rooms (ERs) over the last year. The

same questions are asked at each three-month assessment where clients are asked report

their emergency healthcare use since their last assessment. Instead of relying on counts

(and potentially faulty memory about the specific number of times), these were coded

dummy coded where any hospitalizations, any EMS calls, any ER visits were each coded

1, and none for all three variables were coded 0. In addition, at each three-month

assessment, clients are asked whether they had a new physical or mental health diagnosis

since their previous assessment. For new physical health diagnoses, their three- and six-

month assessments were summed and dummy coded, and indicate whether clients

experienced any new physical health diagnoses during their first six months in supported

housing or not. The same approach was used for any new mental health diagnoses.1

1 Clients who left the program after three month assessments (but before six month assessments) were also examined, however there were no significant differences between these individuals, program stayers, and program leavers before three-month assessments.

55

Analysis: Analysis began by using mean difference -tests to compare emergency

healthcare use in the year before intake between program stayers (those who stayed at

least 6 months in the supported housing program) and program leavers (those who left the

supported housing program prior to 3 months) (Table 4). ANOVA was then used to

examine differences in program stayers’ emergency healthcare use in the year before

intake, three-month assessment, and six-month assessment (Table 5). Following this,

mean difference comparisons were made between clients (stayers) with and without new

diagnoses in the first six months (Table 6). These comparisons also examined differences

in hospitalizations, EMS calls, ER visits, gender, and age in the year prior to intake. Last,

ANOVA was used to assess differences between intake assessments, three-month

assessments, and six-month assessments for clients (stayers) with physical and mental

health issues at intake and new mental or physical health diagnoses over their first six

months in housing (Table 7).2

3.3.2 Qualitative Data

Sample: Five women and two men moving into The Agency’s supported housing

apartments were interviewed three times each over the course of six months. They ranged

in age from 25-60. At the first interview, participants had been in their apartments for six

months or less, but had housing experience to gauge against their prior experiences in

shelter. All had spent time in homeless shelters. Subsequent interviews transpired three

and six months after the initial interview at public locations of the participants’ choosing.

Six of seven participants remained in housing for at least the six months while they

2 While differences were tested, no significant differences were found between three and six month data.

56

participated in the interviews. The seventh involuntarily withdrew from the program days

before their second interview.

Measurement: The semi-structured, face-to-face interviews included questions

that focused on study participants’ health and wellbeing, how they feel now that they are

housed, and whether and where they access medical services. Participants were

encouraged to share their experiences since moving into housing and the ways in which

they felt their health did or did not change following this transition.

Analysis: The data from these interviews were examined utilizing pragmatic

thematic analysis (Aronson, 1994). All interviews were transcribed and then coded

thematically (Charmaz, 2002). Thematic coding is a systematic method where similar

ideas are grouped together to create themes and subthemes. This method allowed themes

to emerge across questions and to provide a vivid picture of whether participants’ felt

their health and healthcare use changed over their housing tenure.

3.4 Results

The results from the quantitative and qualitative analyses are presented together

below and are organized into three themes: (1) high needs, high commitment; (2)

increased formal support, decreased emergency use; and (3) finally diagnosed. To best

outline the study results, each theme begins with a summary of the quantitative findings

and then draws on the qualitative data to offer further interpretations of the findings.

3.4.1 Theme 1: High Needs, High Commitment

High needs, high commitment refers to stayers’ tendencies to remain in the

supported housing despite having more initial physical health issues than program leavers.

This is illustrated by the quantitative data through comparisons of stayers and leavers’

57

health issues and emergency healthcare use (Table 4). The interview participants also

reported extensive health issues that they sought help from primary care physicians and

this may explain their reduced reliance on emergency medical services.

Quantitative Summary: There is a large drop out rate for individuals registered in

the housing program, evident at three months and again at six months. For example, the

number of housing clients drops from 455 individuals at intake to 333 at 3 months (26%

reduction) to 233 at 6 months (52% reduction from intake). There were, however, no

significant differences in reported emergency medical service use prior to intake between

those who dropped out and those who stayed in the program. That is, leavers and stayers

had nearly the same proportions of hospital visits, EMS calls, and ER visits prior to

intake. Clients who remained in housing to six months were more likely to report

physical health issues prior to intake compared to those who left the program prior to

three months (58% vs. 43%, p < .01). This demonstrates stayers’ higher health awareness.

See Table 4 for more details. Stayers appeared more aware of their health and may have

had higher health needs at intake compared to program leavers.

Table 4: Mean Differences in Reported Healthcare Utilization Prior to Intake Between Those that Left the Program Before Three Months, and Those that Remained in the Program for Six Months Variable at Intake Program Leavers N = 122

Percent (SD) Program Stayers N = 233 Percent (SD)

% Hospitalized 35 (48) 34 (48) % Calls to EMS 24 (43) 29 (3) % ER Visits 38 (49) 48 (50) % Physical Health Diagnoses 43 (50)** 58 (49) % Mental Health Diagnoses 32 (47) 40 (49) ** There is a significant difference between the groups, p < .01 Program Leavers are those who left before their three-month assessment Program Stayers are those who stayed for at least their six-month assessment

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Qualitative Interpretation: Six out of seven of the housing program participants

who were interviewed remained in housing over the course of the interviews (6 months),

and one involuntarily withdrew from the program. The majority had self-identified health

issues upon entering housing that ranged from diagnosed mental illness to chronic pain.

One study participant, Clint, explained his physical health concerns at his first interview:

“Got a broken knee, broken neck, bad shoulders, all kinds of stuff so, um, physically I

don’t feel in very good shape… I could be in a lot better shape but, I’m I’m feeling all my

sore spots.” Later, in the same interview, when asked how he felt living in housing

compared to in shelter, Clint explained: “Much less stress, much less anxiety. Um, a lot

more positive thinking, um somewhat physically healthier… Um, so yeah those things

have improved dramatically since moving out of the shelter and being on my own.”

Much like Clint, Pete explained he felt better when he moved into housing and stated,

“I’m feeling I never want to go back [to shelter]… I never want to succumb to that level

[of being in the shelter] again.”

Study participants who required ongoing care for physical or mental health issues

indicated that they accessed healthcare through family physicians and specialists rather

than hospitals. When asked about her health, Gail stated, “Healthy but okay. [laughs] I

know that doesn’t make sense. It contradicts itself. It’s because I have some very...

major… health issues that need to be monitored.” Healthcare monitoring was the

responsibility of several specialists that Gail saw regularly. Similarly, Trisha stated, “I’ve

got my own doctor” when asked where she accesses healthcare services.

When study participants could not see their family physicians or specialists, they

reported seeking care at walk-in clinics close to their apartments or urgent care facilities

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rather than emergency departments. One client, Pete, who did not have his own family

physician or report any ongoing health issues, explained how he used walk-in healthcare

services when he needed them: “I go to the walk in clinic at [urban location] when I need

something.” None of the participants suggested ambulatory care or ERs as appropriate

venues to seek care for non-emergency health concerns, although they were not asked

this directly.

Caseworkers frequently connected program clients to specialized care. For

example, when Helen described her relocation to the Western Canadian city, she used

mostly negative terms, but when probed about it further, she explained, “…but now it’s

turning positive. And well it’s, like with uh getting connected with [The Agency] and

housing.” Later in the interview, Helen also mentioned how she was referred to a

psychiatrist through her caseworker. Interview participants’ healthcare needs seem to be

taken care of by family physicians and specialized physicians to which the interview

participants report they were referred after moving into housing. This highlights the

importance of caseworkers and the need to receive ongoing primary healthcare as well as

more specialized care and support. Undeniably, housing is an important social

determinant of health, but supported housing represents more than simply providing

shelter, it represents a formal support network that may ensure clients remain housed

despite ongoing health issues. Those interviewed had extensive physical and mental

health issues, but specialists and primary care physicians addressed these issues. In turn,

ongoing access to treatment may have increased overall commitment to the housing

program.

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3.4.2 Theme 2: Increased Formal Support, Decreased Emergency Use

Increased formal support, decreased emergency use refers to the ways in which

program stayers access healthcare when living in supported housing. The quantitative

data shows reductions in the proportion of stayers accessing emergency medical and

hospital care, and the interview data illustrates the ways in which participants accessed

healthcare when they required it. Interview participants accessed food banks and

specialized care through caseworkers, therefore drawing on a formal support networks.

Quantitative Summary: Table 5 shows whether program stayers were hospitalized,

called EMS, and had ER visits over the six-month period. Emergency visits at three- and

six-month assessments were significantly lower from intake assessment for those who

remained in housing for at least six months, but there were no significant differences

between three and six month assessments. Although, it should be noted that the time

individuals reflected on at intake (12 months) was longer than each of the assessments (3

months). While some individuals continued to require hospitalizations, EMS, and ER

visits, these numbers significantly decreased over time.

These patterns may indicate that initial support provided by caseworkers when

individuals enter housing sufficiently meets their current health needs. From a system

standpoint, the role of caseworkers is to provide ongoing support through ongoing

referrals to other professionals, which may serve as preventive healthcare for clients.

Furthermore, client reductions in using emergency health services suggests that

individuals who remained in the program experience improvement in either their physical

and mental health or the ways in which they seek healthcare (i.e. they could be visiting

their own physicians instead of emergency services), while low incidents of new physical

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and mental health diagnoses indicate stability in their overall health. The patterns in the

quantitative data demonstrate reductions in clients’ hospital and emergency healthcare

use.

Table 5: ANOVA Mean Differences in Healthcare Utilization at Prior to Intake, 3 Month Assessment, and 6 Month Assessment for Program Stayers, N = 233

Variable Intake Assessment

Percent (SD)

3 Month Assessment Percent (SD)

6 Month Assessment Percent (SD)

% Hospitalized 34 (48) 10 (31)*** 8 (27)*** % Calls to EMS 29 (45) 12 (32)*** 13 (34)*** % ER Visits 48 (50) 16 (37)*** 15 (54)*** % Physical Health Intake vs. New Diagnoses

58 (49) 13 (34)*** 16 (37)***

% Mental Health Intake vs. New Diagnoses

32 (47) 3 (18)*** 4 (20)***

*** Significantly different mean from intake, p < .001

Qualitative Interpretation: After moving into supported housing apartments, all

participants purported feeling better physically and mentally than they had while living in

shelter. They also described their housed lifestyles as more conducive to healthy living.

This included changing one’s diet, having the ability to exercise, creating social ties apart

from the shelter, and having an improved sense of wellbeing.

A number of the study participants reported improvement in their diets and,

consequently, their physical health, following their moves into supportive housing.

Additionally, two purported getting more exercise once they moved away from shelter.

At the first interview, the participants who reported better diets appreciated increased

choice in their diets and the kinds of foods they consumed. While many participants

continued to need the formal support afforded by food banks, they recognized that the

food bank allowed for greater flexibility in their diet than the shelter had. Clint explained

his diet changes and ties to the local food bank:

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I get to choose the foods that I eat. Um, I’m eating a lot more fruits and

vegetables, um, compared to what they serve at the the Shelter… So I know that

when I cook for myself I’m eating, you know, 300% healthier food than I was at

the [The Shelter]. [My diet is] pretty good. I would still... and again it comes

down to lack of money on what I would like to be eating and what I actually am

eating. Um, because I’m still accessing the food bank. So, you know, so I was

hoping that this month would be my last month, hopefully it will. Um, it’s just,

some of the more nutritious food that I would like to be eating I can’t really afford

it on, you know, the budget that I have.

While Clint recognized his need for the food bank and his ability to control what he was

eating, he did not cite how he managed to access the food bank. In order to access the

food bank in The Agency’s municipality, clients must have referrals from caseworkers.

Accessing formal support requires referrals from social services. In this way, caseworkers’

duties may actually be invisible to their clients, but referral services and formal support

remain important to their lives and successes.

Another participant, Trisha, over the course of six months in housing, had

experienced visible weight loss, which she believed to be a good thing. When asked

about her health since moving away from The Shelter, at her second interview, she

expounded:

Yeah I feel different. I feel lighter. ‘Cause, because when I was [in The Shelter], I

kept on eating and eating because their food was always different and I was so

tired all the time eating and all of a sudden now I’m more … energetic …

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Following her move into supported housing, Trisha came to recognize her limitations in

time and purchased predominantly high-nutrient food compared to what was served at the

shelter. Both Clint and Trisha’s experiences highlight the lifestyle changes tied to

supported housing. In particular, Clint explicitly cites accessing the food bank as an

important avenue for change in his lifestyle, demonstrating that formal social support that

allowed him to even use the food bank was vital in his lifestyle changes.

Several participants received specialized mental healthcare from psychiatrists

over the course of the interviews, which illustrates another form of formal social support

accessed by those in supported housing. Others recognized new potential health problems

during the study, including sleeplessness and chronic back pain (that had previously been

attributed to sleeping on a two inch mat on a cement floor), which they brought to the

attention of their caseworkers and physicians. Again, there are a number of potential

reasons for this use of formal social supports, including an increased awareness not only

of their health problems, but also of available resources that they can access through their

formal support network. Consequently, once they are comfortable in housing, clients may

be more likely to seek and access services which they previously would not have

considered, this increasing their use of formal support services.

Clint, one participant with a family doctor prior to his move into housing,

explained that even for severe conditions he would rather see his family doctor than use

emergency care. When describing an injury he had incurred where he had actually broken

several ribs from a fall on an icy sidewalk, he described the inconvenience of waiting to

see his family doctor:

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Yeah. So like I said it’s a little inconvenient, um, when I broke my ribs I was

questioning whether I should go to the hospital or not, but I realized other than

loading me with painkillers, there’s nothing that they could do, so... um... I didn’t

go see him that Wednesday just because I was in too much pain, I didn’t leave my

apartment for four days because I could hardly move.

Clint describes accessing his family doctor as challenging, yet he still insisted on seeing

his physician. He openly recognized his ability to visit the hospital, but still chose to wait

to see his family doctor.

The homelessness literature suggests that increased homelessness tenure makes it

more difficult to access primary care physicians (Khandor, Mason, Chambers, Rossiter,

Cowan, & Hwang, 2011; McGuire et al., 2009). Those living on the street or residing in

shelters have few options for healthcare and frequently have to access care through

emergency departments and urgent care facilities (Khandor et al., 2011; McGuire et al.,

2009). The majority of the interview participants in this study had family doctors in

community clinics apart from service providers. Furthermore, of the three who did not

have a family doctor, two reported using walk-in clinics when they required healthcare.

Interestingly, of those who had a family physician, three had found their practitioner prior

to moving into supported housing, while one accessed their physician following their

move into housing. None of the housed participants accessed emergency services or

required hospitalization over the six months of interviews.

Those interviewed did not access the ER, but rather relied on their own family

physicians, like Clint (seen above), which may represent continuity of care. Housing

support services seemed to help participants access more specialized medical care (e.g.,

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accessing psychiatrists) that often requires referrals and could account for fewer hospital

visits. Individuals in housing regularly meet with caseworkers who are tasked with

ensuring clients are thriving in housing and have adequate supports. As mentioned above,

these formal supports may include access to services that meet basic needs such as

nutrition that may operate as preventive care options and reduce the need for emergency

services. In summary, caseworker support seems to allow clients to pursue healthier

lifestyles and practices. The formal support afforded by supported housing enabled

interview participants to alter the ways in which they carried out their day-to-day lives

such that they did not have to rely on emergency health care services.

3.4.3 Theme 3: Finally Diagnosed

Finally diagnosed demonstrates that some individuals receive new diagnoses

during their first six months of housing tenure. The quantitative data illustrates the

patterning of who receives formal diagnoses while the interview data demonstrates how

these diagnoses can be reassuring for those who receive them.

Quantitative Summary: Figure 2 presents a flow chart that demonstrates new

diagnoses across four groups of program stayers: (1) those with no physical or mental

health issues at intake; (2) those with only physical issues at intake; (3) those with only

mental health issues at intake; and (4) those with both mental and physical health issues

at intake. Upon entering housing, approximately one third (32%, N = 75) of those who

stayed in the program at least six months had no physical or mental health issues.

Roughly 28% (N = 65) purported to have an ongoing physical health issue and 10% (N =

23) had an ongoing mental health issue (40%, N = 93). Last, 30% (N = 70) of the clients

had both mental and physical health issues upon entering housing. Over the first six

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months in housing, one quarter (23%, N = 53) of stayers, including those with diagnoses

and those without, had new physical health diagnoses and 7% (N = 17) had new mental

health diagnoses.

Figure 2: Flow Chart of Diagnoses at Intake and New Diagnoses for Entire Sample of

Stayers Over the First Six Months in Housing (N=233)

Clients who had no physical or mental health issues at intake (N = 75) generally

did not experience new diagnoses during their first six months of housing. That is, only

1% (N = 1) had a new mental health diagnosis and 4% (N = 3) had a new physical health

diagnosis. This suggests that living in supported housing does not result in more health

diagnoses for clients who enter without any at intake.

Of those who had only ongoing physical health issues upon entering housing

(N=65), approximately one third (32%, N = 21) had a subsequent new physical health

diagnosis and none had new mental health diagnoses over the first six months in housing.

Of those with only a mental health diagnosis upon entering housing (N=23), 9% (N = 2)

experienced a new mental health diagnosis and 4% (N = 1) experienced a new physical

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health diagnosis in the first six months. This indicates relatively stable mental health

overall for those who had health diagnoses at intake.

Finally, individuals who had both physical and mental health diagnoses when they

entered housing (N=70) received the most new diagnoses with 20% (N = 14)

experiencing a new mental health diagnosis and 40% (N = 28) a new physical health

diagnosis within six months of becoming housed. See Figure 2 for a summary of these

data.

Significant differences in intake assessments were found between those who

received new diagnoses and those who did not over their first six months in housing (see

Table 6). A significantly greater proportion of individuals with new diagnoses were

hospitalized (53% vs. 29%), had called EMS (45% vs. 24%), or had visited the ER (62%

vs. 44%) prior to entering housing compared to those who had no new diagnoses once in

housing. It is possible that those with later diagnoses had endured poorer health and

suffered from undiagnosed (or misdiagnosed) illnesses before their entry into supported

housing.

Table 6: Average Intake Assessments of Emergency Healthcare Use Prior to Intake and Demographics of Individuals with New Diagnoses and Individuals Without New Diagnoses N = 233 Variable Clients with New

Diagnoses Percent (SD) Clients Without New Diagnoses Percent (SD)

% Hospitalization 53 (50)** 29 (45) % Calls to EMS 45 (50)* 24 (43) % ER Visits 62 (49)* 44 (50) % Male 57 (50)** 78 (42) Age (Years) 49 (10.7) 48 (11.1) ** Significantly different means between groups p < .01 * Significantly different means between groups p < .05

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Finally, in order to better understand the group with the most health issues,

analyses were conducted for individuals who had both physical and mental health issues

at intake and experienced a new mental or physical health diagnoses over their first six

months in housing. Specifically, this examined how their emergency healthcare use

changed over time as presented in Table 7. Comparisons presented in Table 7 are relative

to intake and no significant differences were found between three month and six month

assessments. The patterns demonstrate that despite continued health issues, these

individuals report significantly less emergency and hospital use compared to intake,

although percentages of participants calling emergency medical services and visiting

emergency rooms increased from three months to six months, but these differences were

not significant. While they may have experienced the most health issues at intake and

during their tenure in the housing program, fewer accessed emergency services than prior

to beginning the program. In other words, despite the complexity of their health issues,

they rely less on emergency healthcare services.

Table 7: ANOVA of Program Participants with Both Physical and Mental Health Issues at Intake And New Mental or Physical Health Diagnoses Over Six Months N = 32

Variable Intake Assessment Percent (SD)

3 Month Assessment Percent (SD)

6 Month Assessment Percent (SD)

% Hospitalization 69 (47) 22 (7)*** 15 (7)*** % EMS Calls 56 (50) 25 (44)** 41 (50) % ER Visits 75 (44) 38 (49)** 41 (50)** *** Significantly different mean from intake, p < .001 ** Significantly different mean from intake, p < .01

Qualitative Interpretation: Following their move into their apartments, three of

the seven interview participants received new mental health diagnoses and two received

new physical health diagnoses. In addition, each of these participants received

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nonemergency treatment for their conditions over the course of six months in housing.

Mental health conditions ranged from severe depression to personality disorders and were

treated under the care of specialized physicians. Physical health conditions included

diabetes and long-term chronic pain. Age was not a factor in diagnoses, but all

participants who received a diagnosis were women. One female participant, Holly,

explained how connection with the Agency and her move into housing were positive

changes:

I connected with a psychiatrist, got diagnosed, and now I’m in the process of

getting into [specialized therapy for diagnosed mental illness]. And when she

gave me the diagnosis I was like well what is this? Because I mean I know a lot of

like the disorders, but I didn’t—not [disorder] right? So I went researching… I

found it and I was like that is so me! That is so me! And like it explains

everything. It’s been hell, you know, and now I know why. So now there’s like

hope.

Moving into housing may act as an important source of stability for individuals

who have lived transient lives. Participants credited the move into housing and the aid of

their caseworkers as critical in receiving their formal diagnoses. Interview participants

who experienced new diagnoses had seemed to suffer from many health issues-long term,

and being finally diagnosed was reassuring to them.

3.5 Discussion

This paper reports findings that reflect three themes related to health and

emergency healthcare use of individuals transitioning away from homelessness, namely:

high needs, high commitment; increased formal support, decreased emergency use; and

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finally diagnosed. Each of these themes suggests that individuals who remain in

supported housing for at least 6 months initially reported more physical health diagnoses

than those who leave within three months. However, those who remain in supported

housing appear to reduce their hospitalizations and emergency healthcare use by drawing

on a formal support network—including both healthcare specialists and caseworkers—

that offers stability and resources to help them maintain their health and their housing.

Overall, the data suggest that supported housing decreases reliance on emergency

healthcare use for those who stay in the program. Even clients with ongoing mental and

physical health issues experienced significant reductions in their reliance on emergency

healthcare services. Furthermore, few clients experienced new diagnoses while living in

supported housing, and interview participants all reported feeling healthier in housing

than they had in shelter.

The stability that housing affords when compared to shelter living may enhance

clients’ accessibility to systems of care, and particularly primary care and specialist

services (Khandor et al., 2011; McGuire et al., 2009). The transient lifestyle characteristic

of homeless individuals (Khandor et al., 2011) may make it particularly difficult to

develop continuous relationships with healthcare providers, receive diagnoses, or

undergo ongoing healthcare treatments and as a result they tend to rely more on drop-in

and emergency health care services. It is important to note, however, that housing does

not appear solely responsible for positive changes in health. The combination of housing

and formal support, which may be possible through stability and program access, appears

to have an important influence on the health and wellbeing of those accessing the housing

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program. Furthermore, caseworker referrals appear to connect clients to important

preventive healthcare resources, such as food banks and specialized healthcare.

While some participants did not view their caseworkers favourably, and many

described caseworker meetings as fraught with anxiety, caseworkers frequently

connected participants to community resources they may not have been aware of

otherwise. Overall reductions in emergency usage are substantiated by the ways in which

interview participants accessed healthcare. Even those with new diagnoses were less

likely to access emergency and hospital services. Formal support that participants

received may have stabilized their health and reduced the need for emergency services.

There are several limitations to this study. First, all HMIS and interview data are

self-report. Clients may over- or under-report their emergency healthcare use to their

caseworkers and the interviewer or they may inaccurately recall their healthcare use.

Second, the qualitative data primarily reflects experiences since moving into housing

rather than experiences prior to such moves. Also of note, the quantitative and qualitative

samples were relatively small, and the program had a high drop-out rate. Not all data

were available for the 270 individuals who left within the first six months of the program

or their reasons for leaving supported housing. Last, this paper did not draw comparisons

across gender, race, or ethnicity. Future research should consider these covariants.

This study suggests that formal social support from both physicians and

caseworkers is an important factor in the success of housing formerly homeless

individuals. Many housing models advocate for such supports, however, they often put

time limitations on support to create cost effectiveness for the system. While the current

study only spans across the first six months of housing tenure, formal support appears

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vital to clients’ health and healthcare use. Consequently, policymakers must consider the

role of program support in the lives of formerly homeless individuals and weigh costs of

using caseworkers against those of reliance on emergency healthcare services. Ultimately,

preventive and ongoing primary care may be contingent on housing stability as well as

case management that enhances the life and well being of clients in supported housing

programs.

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Chapter Four: Identity in Transition: How Formerly Homeless Individuals

Negotiate Identity as They Move into Housing

Article Under Review at The European Journal of Homelessness

4.1 Abstract

It is unclear what happens when stigmatized individuals (such as the homeless)

undergo status transitions into non-stigmatized groups (such as being housed). This paper

explores changes in housing status, identity, and social relationships over time. Drawing

on longitudinal qualitative interview data collected over six months from seven

individuals transitioning out of homelessness and into government supported housing,

this paper examines identity changes during such a status shift. Analysis shows that

individuals distanced themselves from both homeless and formerly homeless people, and

connected with others through groups not affiliated with homelessness or shelter life.

When exiting a stigmatized status, like homelessness, social distancing may be

particularly important as it helps redefine the self as apart from that previously held

stigmatized status. Relational associations may be based on future ideal selves, or the

selves individuals want to be, as they transition from a stigmatized status. Implications

for research and policy are discussed.

4.2 Introduction

Homelessness3 may be considered a stigmatized social identity that reflects an

individual’s housing situation (Parsell, 2011). Public biases around homelessness often

3 Homelessness is a social status that sees individuals as housing-poor (Canadian Observatory on Homelessness, 2012). While homelessness is best understood in a spectrum with rough sleepers, who sleep outside on one end, and those at risk of losing

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suggest that individuals are viewed as responsible for their homeless status (Sparks,

2011). Because of this stigma, homeless individuals often practice social distancing from

other homeless people by emphasizing the ways in which they are different from others

who share their homeless status (Snow & Anderson, 1987; Osborne, 2002). Social

distancing refers to finding differences between oneself and another group of people, and

it may be more common among individuals in stigmatized groups (Hodgetts et al., 2010).

That is, stigmatized individuals may see themselves as distinct and different from others

who occupy the same stigmatized social identities (Snow & Anderson, 1993; Wasserman

& Clair, 2011; Jin Lee & Brotman, 2011). In this way, individuals experiencing

homelessness may not identify themselves as members of “the homeless” group who

share the same homeless status, while simultaneously insisting “the homeless” operates

as an important social identity for others (Osborne, 2002). While individuals rarely claim

homeless identities for themselves, others’ interactions with those experiencing

homelessness ascribe the social identity of homelessness onto them (Boydell, Goering, &

Morell-Bellai, 2000). That is, even if homeless individuals claim to be different from

others experiencing homelessness, their homelessness operates as a core identity, an

identity that is central to an individual’s sense of self, because of the ways in which other

people interact with them (Hitlin, 2003).

While being homeless is considered an undesirable social identity, being housed

is generally not viewed to be a source of identity. The majority of Canadians would be

classified as housed, yet “the housed” are not generally seen as belonging to a social

group. It is unclear how a change in one’s housing status, such as transitioning from

their housing on the other. For the purposes of this paper, homeless refers to individuals dwelling in shelters.

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homeless to being homed in a government supported housing program, affects one’s core

social identity. As indicated above, individuals who are homeless may not self identify as

homeless or identify with other homeless individuals. Similarly, formerly homeless

individuals who move into independent housing away from shelters may not form an

identity around their newly acquired status as a housed person. It is also unclear how

individuals reconstruct their social identity through such a significant life transition if

they do not identify with those in their previous status and their newly acquired status

does not offer a salient social identity. If formerly homeless individuals do not identify

with the homeless and the housed do not explicitly share a social identity, how do

individuals construct and maintain identities during such a major life event?

Sociologically speaking, individuals construct meaning and a sense of self through

repeated interactions with others (Hull & Zacher, 2007). Therefore, identity formation

and maintenance in the move from one social status to another may be particularly

important to individuals’ sense of self and wellbeing, especially as their relations with

others change during such transitions.

Identity reflects a plurality of multiple selves that individuals may enact at once

(Hall, 1995;; Lawler, 2008;; Parsell, 2011). Identity encompasses individuals’ cognitive

and emotional understandings of who they are (Schouten, 1991). For example, an

individual may simultaneously be female, heterosexual, and married, and attach

meanings to each of these identities. Therefore, the process of identity formation does not

happen without others. Rather, identities are performed (Parsell, 2011), and develop

through interactional processes or enactments where meanings around the self can be

applied, lived, and understood (Lemke, 2008). As Hall (2000) argues, the self is

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“strategic and positional,” and always considered in relation to others, therefore

emphasizing the importance of constantly developing and changing identities (17). The

interactional nature of identity means that others become an important locus of

comparison and development of the self, and that identities are formed “sometimes in

concert with people, sometimes in opposition to them, but always in relation to them,”

(Hull & Zacher, 2007, p. 75). The relationships and company that individuals keep are

therefore important to the development and maintenance of identity (Stets & Burke,

2005).

Individuals have both personal and social identities. Social identity refers to the

groups to which individuals consider themselves members and in which they formulate

their personal identity (Trajfel & Turner, 1979). Specifically, social identity reflects an

idea of belonging with similar others by recognizing who is, or is not, part of the ‘in-

group’ (Parsell, 2011). It encompasses an array of groupings to which individuals have

characteristics in common that help individuals categorize themselves and others around

them. Social groups, therefore, categorize similar, or ‘like’, individuals, and social

identities create feelings of belonging and self-esteem (Trajfel & Turner, 1979).

In contrast, stigmatized social identities may result from membership in groups

deemed undesirable (Goffman, 1963; Link & Phelan, 2001). Stigma is enacted upon

individuals who belong to such groups by others outside the group and is considered a

core, or centralizing, identity for those experiencing it (Osborne, 2002). As social actors,

individuals generate meaning and action based on their interactions with others, and

stigmatized statuses are no different (Blumer, 1986). Individuals are stigmatized, and

learn the meaning of their role as stigmatized individuals, through the words and actions

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of those in the out-group (Parsell, 2011). Consequently, individuals belonging to

stigmatized groups frequently attempt to minimize their own social stigma by actively

demonstrating differences between themselves and other group members (Halsam et al.,

2008; Parsell, 2011). Stigma, then, is both a social identity and a social structure imposed

by others that shapes all other social relationships (Roschelle & Kaufman, 2004).

A wealth of research has examined social identities during some significant life

transitions such as marriage (Pals, 1999; Stets & Burke, 2005), divorce (Bisagni, &

Eckenrode, 1995; Madden-Derdich & Leonard, 2000), adolescence (Meeus, Oosterwegel,

& Vollebergh, 2002; Mullis, Mullis, Schwartz, Pease, & Shriner, 2007), and parenthood

(Minton & Pasley, 1996). This research suggests that those undergoing life transitions

attempt to enact ideal selves that they would like to be in the future (Prince, 2014;

Schouten, 1991). During such transitions, stigmatized individuals may distance

themselves from their previous social identities, embrace or distance themselves from

others experiencing similar status transitions, or develop social identities around their

newly acquired status. This paper seeks to explore the ways in which formerly homeless

individuals negotiate their identities through a significant life transition as they become

housed. In doing so, it considers identities during important life transitions and the ways

in which people embrace or distance themselves from their previous social statuses.

4.3 Methods

Participants were recruited through a Housing First4 affordable housing program,

referred to as The Agency, which helps individuals living in homeless shelters to

transition into affordable housing units. The Agency is located in a large Western 4 Housing First is a particular type of affordable housing where homeless individuals are provided housing before addressing any of their other needs (Tsemberis, 2000).

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Canadian city and is well known for its social services for both homeless and low-income

individuals. The Agency offers a supported housing approach where thirty percent of

residents’ income goes toward their rent, and The Agency and its government funders

provide any additional rent monies. Program participants are selected based on their time

in being homeless, their homeless acuity (indicating their inability to exit homelessness

without help), and their past histories (such as military service, addictions, or experience

of domestic violence). Residences are “scattered site apartments”, meaning that not

everyone in residents’ apartment buildings have come from homeless shelters and there is

more than one apartment offering supported housing in the city. Generally speaking,

because of The Agency’s limited budget for Housing First programs, most participants

live in apartments alongside lower-income individuals.

Over the course of six months, five women and two men transitioning out of

homelessness into this supported housing program were interviewed three times with

approximately three months between each interview. The first interview acted as ‘time

zero’ while subsequent interviews transpired at approximately three and six months,

subsequent to the first interview. Participants’ ages ranged from 30-59, they had spent

anywhere from five months to decades being homeless, and all had been in the supported

housing program less than six months prior to their first interview. In the semi-structured

interviews, participants were asked questions about their health, wellbeing, relationships,

and attitudes towards their housing. Additionally, using an ego-centered network

approach5 (Newman, 2003), participants were asked to name up to ten people who were

important to them and up to ten people they had spent time with in the last two weeks.

5 Ego-centered networks are personal social networks of individuals of interest (Newman, 2003).

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They were also asked about social activities they attended in general and whether they

connected with anyone from these groups. In the context of the interview, participants

revealed much about their social ties and themselves. When asked about those with

whom they interact, they described these relationships in depth, as well as provided

details about those they cared about, and, while not asked, what they admired about those

with whom they identified. All interviews had the same interview agenda each time to

explore changes in answers and social relationships longitudinally. Ethics approval was

acquired from an institutional review board and all participants provided informed verbal

consent to accommodate participant literacy (Ensign & Bell, 2004).

Data analyzed for this paper were drawn from the entire longitudinal set of

interviews to provide rich contextual details of individuals’ lives and experiences.

Interview transcripts were coded through inductive thematic coding that focused on

themes rather than questions (Charmaz, 1990; 2006). Themes were identified through a

method of constant comparison where participants’ comments were considered similar or

dissimilar to one another both within and between participants, and following Charmaz’s

(1990; 2006) grounded theory methodology, interviews were coded at multiple levels to

allow themes to emerge. The first level involved basic coding that summarized data

points into short phrases (Charmaz, 2006). The second level coding began grouping

together similar or related ideas. The third level, which was the last level for these

analyses, grouped together similar level-two themes. Participants’ language and attitudes

towards themselves, their housing, and the people around them were considered through

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a phenomenological frame6 that focuses on individuals’ subjective experiences. Drawing

on grounded theory practice (Charmaz, 2006), these comparisons were then built

upwards towards a centralizing theme of identity that emerged from the data itself. Direct

quotations from participants are used as evidence of these themes, and all names

presented below are pseudonyms chosen by the author.

While the analysis is thematic in nature, following Miles and Huberman (1994), a

“case-oriented” rather than a “variable-oriented” approach is used to present the results of

the thematic analysis of the interview data. Variable-oriented approaches tend to focus on

the themes contained in the data (Mirchandani, 2000), thereby cross-cutting each of the

cases without illustrating a complete contextualized account of participants’ lives. Case-

oriented approaches, unlike variable-oriented approaches, enable rich contextualized

accounts of participants’ lives while outlining themes in their most typified examples

(Miles & Huberman, 1994; Mirchandani, 2000). While the themes outlined were

demonstrated across multiple participants, a case-oriented approach is useful for

providing insight into the themes as well as the lives of the participants themselves. Thus,

rather than examining the number or nature of a particular experience across the

interviews, the case-oriented approach offers a strategic way to contextualize participants’

experiences as they undergo the significant life transition of moving into housing and

reconstructing their identities.

Three profiles are presented below in the findings as instrumental case studies.

Each of the selected cases presented in the results section below operates as a strategic

6 Phenomenology refers to a perspective that accounts for individuals’ subjective meanings, and seeks to understand their experiences from their vantage points (Smith, 2004).

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illustration, thereby providing rich contextualized accounts to describe each of the themes.

While these cases are not numerically representative, they are conceptually representative

of the other individuals’ experiences. As well, they capture the diversity in their homeless

experiences, ages, and genders of the others interviewed. All participants had spent some

time in shelter, and were new to supported housing. All participants described themselves

as either underemployed or unable to work because of physical and mental health

problems and some had contact with members of their families. All underwent changes to

their social networks during the course of their housing tenure.

Three key themes that emerged from the data and related to identity are presented

below. These themes reflect social distancing from homeless individuals, social

distancing from those in supported housing units, and social embracing of presumably

dissimilar others. Each of these themes illustrates the different types of social groups that

individuals did or did not identify with as they settled into their transition into supported

housing and reconstructed their social identity.

4.4 Results

4.4.1 Social Distancing from Those in Shelter or on the Street

Tim is a middle-aged, Caucasian male resident of The Agency’s housing program.

He described himself as a long-time shelter stayer with The Agency. From the first

interview, he described the shelter as “hell” and those residing in it as highly negative

individuals. He appreciated being away from this negative atmosphere once he had

moved into his apartment and felt that departing from the shelter environment

substantially improved his wellbeing. In fact, when asked about the difference between

housing and shelter he stated:

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Um, I would say the thing that is better about it [being housed] is I don’t have to

listen to all the negative chatter and, um, kind of bad attitudes, stuff like that, from

around the [shelter]. And that was one of my biggest stresses at the [shelter] just,

you know, listening to everybody’s, kind of BS stories there… Oh, it’s just. You

know it’s just street talk and jail talk and, you know everybody is so negative and,

they hate everything and… You know, 90% of the conversations at the shelter

were all negative, and I would much rather surround myself with positive people.

While Tim critiqued the negativity that encompassed shelter living in the first

interview, those whom he described as friends were all shelter-dwellers. He frequently

went for coffee with those who lived in shelter, and would get together with them

whenever he could. By his third interview, however, Tim only described one homeless

individual as a friend, and this fellow, Jason, no longer resided in shelter. Instead, he had

been admitted to hospital for an indefinite stay..

To maintain his sobriety after leaving the shelter, Tim attended regular Alcoholics

Anonymous (AA) meetings. This became a primary source of social interaction and

friendship for him. By the third interview he identified several friends he met through

attending (AA), which he became better acquainted with over time. From his

descriptions, it appears that individuals he met at the meetings provided him with

important emotional and instrumental social support. As an example of the latter, one

fellow repaired Tim’s computer when it malfunctioned. Tim described those whom he met

at the meetings as professionals.

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In his second interview, Tim expressed his concerns about individuals lingering

near his apartment building, but also emphasized his general comfort with the

neighborhood:

And like I say it’s kind of a rowdy area [where I live], you get, you know, people

who are drunk walking up and down the streets and... like yesterday there was a

guy passed out underneath the tree just out front of the apartment.. [I am] maybe

a little bit fearful, at times, but most of the time I’m comfortable with the

neighbourhood.

When probed about the neighbourhood and the “rowdies” in the area, he further

explained:

You know it’s... the neighbourhood is a little noisy um, you get partiers going up

and down the alleys and stuff like that too… So you know occasionally I get

woken up during the night by sirens or people yelling outside or things like that.

As someone who has struggled with addictions issues and public intoxication, based on

his tone and body language, Tim appeared unsettled at seeing others in substance-altered

states. His history with alcohol and AA may have contributed to these concerns, perhaps

even around his ability to maintain his own sobriety while living in a community so

exposed to substances.

Every person interviewed had lived in a homeless shelter at some point, and some

for the majority of their adult lives like Tim, yet they frequently defined themselves as

different from those living in shelter or on the streets. This distinction became

increasingly acute over the course of the six months of interviewing and those living in

shelters became viewed distinctly as ‘Others’ (Johnson et al., 2004). Othering was

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apparent through various modes of conversation including circumstances where shelter

dwellers were seen as distinct and different, and, at times, unworthy of help from society.

Tim othered those who lived in shelter through a number of techniques. He labelled

shelter dwellers as “negative” and described his time in shelter as “hell,” in terms of the

environment, and the attitudes of shelter dwellers. The negativity was presented in

various complaints about the shelter, its staff, and the circumstances in which residents

found themselves.

Overall, seeing individuals sleeping in their apartment’s parking lot seemed to

make participants feel less safe in their apartments. While some managed to maintain

contact with a few shelter friends, these friendships become increasingly distant and

viewed as one-sided, where the shelter dweller became viewed as the receiver of support

that drained the housed person’s resources. At the time of his first interview, one

participant had invited still-homeless peers into his home to sleep on the couch for short

periods of time, however, by his last interview, he no longer felt he could provide such

support to his former peers. Over time, fewer and fewer of these ties were maintained by

those who had moved into housing unless these individuals also moved into supported

housing units. Also, these relations were characterized as less important over time. While

three participants named current shelter-dwellers as individuals with whom they had

contact during the first interview, by the third interview, only Tim named a shelter-

dweller (Jason) as someone with whom he had contact, and this shelter-dweller was only

provisionally homeless7 as he had been admitted to hospital during the course of the

resident’s housing tenure. While Tim never explicitly discussed the merit of moving out

7 Provisional homelessness refers to individuals who have a non-permanent place to sleep indoors at night (Canadian Observatory on Homelessness, 2012).

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of homelessness, other participants suggested that those in shelter were looking for

handouts and were unwilling to help themselves move beyond the shelter and shelter

living. Jason, however, as a terminally ill middle-aged man, from the author’s perspective,

appeared to be excused from his responsibilities in acquiring and maintaining housing.

Snow and Anderson (1987) and Wasserman and Clair (2010) found that homeless

individuals frequently distanced themselves from other homeless people so as not to be

associated and stereotyped with this group. Other research has suggested that within

homeless communities there is a hierarchy of homelessness that transpires through social

comparison to assess how well someone is doing. At the lowest rung are those who are

currently rough-sleeping, that is sleeping outside on park benches, under bridges, or in

makeshift campsites, and at the top rung are those who are in supported housing (Boydell,

Goering, & Morell-Bellai, 2000). This social comparison acts as reference point to

understand how well individuals are doing in their lives. By their six-month interview, all

participants socially distanced themselves from homeless individuals. At time zero, one

participant had suggested that it was important to offer a couch for homeless friends to

sleep on when the temperature went below freezing, however, by the last interview, the

same participant asserted he had to take care of himself, and that his homeless

acquaintances had to do the same. This attitude was shared by the other participants.

4.4.2 Social Distancing from Others in Supported Housing Units

Sally, a middle-aged Aboriginal female, has had multiple physical and mental

health issues and sought treatment for these during her housing tenure. Sally’s family

was important to her, but she noted that she had little to no contact with them. This she

described was mostly due to being unable to emotionally handle their problems and she

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did not want to burden them with her own. She frequently talked fondly about her two

adult sons who were both partnered and her one grandchild.

While interviews did not take place at Sally’s apartment, she frequently suggested

the interviewer come over to see it. She was extremely proud of her home, and defined

herself with reference to her cleanliness and the apartment’s consistent upkeep. Shortly

before her second interview, as a result of a natural disaster, Sally and the other

residents in her building were evacuated from their apartments for several weeks. When

asked about the events around her evacuation, Sally was quick to assert that even though

her apartment and the refrigerator was without power for many weeks, her cleanliness

kept the apartment odour-free, an important feat when food was rotting in the

refrigerator. In making these claims, Sally separated herself from her neighbours, and

asserted that they had not fared as well, and had to air-out their apartments following the

disaster. It was interesting that Sally identified so closely with her own apartment, but

that this did not transfer to the people in her building. Sally took pride in her residence,

but did not develop a strong sense of community with those living in her building.

Prior to her move into her apartment, Sally lived in a women’s homeless shelter,

and had formed relationships with several women there. To Sally, the few ties she formed

with others in the building she currently resided in had some instrumental value, but trust

was not commonly identified in these relationships. For example, Sally frequently went

grocery shopping with Kate, a woman she had known since both had lived in the same

homeless shelter. Sally however, described Kate as having “poor boundaries”, as she

expected those around her to complete the day-to-day tasks associated with maintaining

her home. That is, Sally asserted that Kate believed it was Sally’s responsibility to do

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chores in Kate’s home. When probed further about her relationship with Kate, Sally

explained that the pair were not close: “Yeah she’s just kind of there.” When asked for

more details of this relationship, Sally explained:

Sally: Most people are just kind of there right now I just don’t really put a huge

significance on anybody being around.

Interviewer: Right. Is she there for you when you need her?

Sally: I don’t go there with her.

Interviewer: Okay. You’re starting to talk about… okay. And in what ways if any

does she make your life better?

Sally: Well she makes it easier for me to go shopping. [laughs]

Sally’s relationship with her Kate has a distinct boundary drawn around it for Sally.

Sally does not speak to Kate about her struggles or her current physical and mental

health issues. Furthermore, Sally draws similar boundaries with her other neighbours

and even noted that her interactions with Kate were “hit and miss.” But she further

explained, “she’s actually the only one I let into my apartment. And again I still take her

in short doses, she’s not someone I totally confide in.” When probed further about this

relationship, Sally denied that this relationship made her life better or worse, she further

explained, “She’s just there.” While Sally may have distanced herself from Kate had the

pair been living in shelter, regardless of their shared status, Sally sees herself as

distinctly different from Kate, and draws attention to these points of difference.

Furthermore, whenever Sally would mention Kate in the interviews, it quickly turned to a

discussion of the problems associated with their relationship. A similar pattern happened

every time one of her neighbours or formerly homeless peers came up in conversation.

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This did not, however, happen when she described her relationships with her family or

other people important in her life who did not live in shelter or supported housing.

While Anderson and Snow (1987) suggest that social distancing from homeless

individuals may be expected, even among the homeless themselves, physical proximity

suggests that those who dwell in supported housing units would likely identify and

interact with those who are experiencing similar life situations. Frequently, when

discussing relationships and those who they interacted with, other residents living in their

apartment buildings would come up in conversation. These relationships were not

generally described as supportive or important, and other residents in the building were

frequently viewed as untrustworthy. In fact, only one participant purported to trust

anyone in the building, and this trust was described as tenuous in that it enabled the

resident to have a friend with whom to do things with.

The study participants also emphasized the need to have strong boundaries when

it came to interacting with and forming relationships with other people in the supported

housing program. As Sally explains: “Yeah well I’ve always had that boundary up that

nobody knocks on my door…Um I just don’t mix.” Here, she suggests that she not only

has strong boundaries with other people, but also purposively does not mix with her

neighbors in the building. Contact with those in the building was generally restricted to

casual interactions described as vague and generic, but “pleasant” (Tim). When

discussing some of these exchanges, participants emphasized that while their neighbours

were friendly, they were not really engaged with one another.

The literature on social identity suggests that individuals define themselves based

on in-groups and out-groups (Tajfel & Turner, 1979). In-groups are those that individuals

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identify with because of shared characteristics, social statuses, or values. In contrast, out-

groups are those viewed as distinctly apart from the self because they are deemed

different from the self. Even though the participants in this study lived in government-

supported housing units, they did not seem to view themselves as members of an

identifiable social group as in they did not identify with others living in the same

apartment or community, nor the formerly homeless who they knew from shelter living.

This is important to consider because policies, such as governmental plans to end

homelessness, describe individuals experiencing homelessness as social groups and

depictions of those residing in supported housing units frequently refer to these

individuals as a social group. For example, Canada’s efforts to end homelessness

(Canadian Alliance to End Homelessness, 2015) suggest that homeless individuals

exhibit a number of shared characteristics that should be addressed. Importantly, the data

presented here suggest that the homeless do not identify with one another nor necessarily

recognize their shared characteristics or situation. The formerly homeless participants in

this study explicitly and purposively viewed those in similar social circumstances,

whether living in shelter or in supported housing, as inherently different from them.

Like Sally, participants typically had weak relationships with others in supported

housing programs. They were generally portrayed as untrustworthy or problematic.

Fellow supported housing dwellers could be sources of social connection, such as that

between Kate and Sally, but participants drew attention to the ways in which they were

different from others who shared their current housing status.

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4.4.3 Social Embracing: Dissimilar Others

Kim is a thirty-something Caucasian resident of The Agency’s housing program.

She explained that she became homeless because of domestic abuse and spent an

undisclosed amount of time in a women’s shelter. Kim has significant physical health

issues that led The Agency to prioritize her move into housing, as per Agency policy8.

Shortly before her first interview (approximately one week after she moved into her

apartment), she had started attending religious meetings close to her new home. By the

second interview, Kim had a mental health diagnosis in addition to her physical health

issues.

Kim expressed serious concerns about her apartment such as its urban location,

and individuals that loitered in the neighbourhood. For the first few months in her

apartment, people she deemed “unseemly” visited her apartment, looking for the

apartment’s last resident. She asserted that the former owner was a drug dealer, however,

when questioned about this further she provided no evidence to substantiate this belief.

Despite her qualms about the apartment’s location, she enjoyed being close to her place

of worship. Over the course of the next two interviews, Kim’s life shifted substantially as

she became increasingly involved with her religious community. At the first interview, she

attended worship services once a week and by the last interview, she visited her place of

worship five days a week, twice to volunteer. Furthermore, with the exception of her

contact with her family which she described as weekly, her entire social life was

reorganized around her church. The church’s young adult group was particularly

important to her, as it connected her to people whom she described as “mentors”,

8 The Agency prioritizes those with higher acuities into supported housing, including those who have physical or mental health issues.

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“friends”, and even “a significant other”. When asked to describe the situations where

she interacted with these people, she explained:

Kim: We would just do a small bible study and we would have different social get

togethers and, you know, we’ve been to [a local pizza place] a couple times

and…

Interviewer: That’s kind of fun.

Kim: Yeah. We’ve gone out for a couple different like dinners we went out for a

birthday party prior to worship--prior to church service one Sunday.

Kim’s church community became her primary source of social interaction and

seemed to fulfill her with a sense of purpose. She explained how housing had allowed her

to become more involved with her church community:

Kim: I’m more involved in, um, my church, because I am quite religious so I am

more involved in my church than I was before. And, um, I’ve gotten, like I said

I’m just more involved like with the church community.

Kim’s case illustrates how interacting with dissimilar others as a result of moving

out of the shelter and into housing may result in embracing a new identity. When she and

other participants associated with groups that were not linked to the shelter or apartment,

they began to view themselves as similar to others who were initially thought to be quite

different from them in many ways. Participants appeared to become more like others in

these groups over time, and described shared interests in latter interviews compared to

earlier ones. That is, relationships developed through social groups and activities such as

church, employment, volunteer organizations, or AA seemed to be considered important

or ideal when compared to relationships they had with other formerly homeless

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individuals. Having activities to meet and associate with people not attached to the shelter

or supported housing provided a sense of purpose and meaning to participants’ lives and

gave foundations for diverse relationships.

Perhaps the most salient pattern among all of the participants’ experiences is that

these normalized, non-stigmatized identities, such as those linked to religion or

employment, seemed to define the individual’s new sense of self as well as their social

connections. Kim spent the majority of her interviews describing her church life, those

involved at her church, and how she associated with them on a nearly-regular basis. She

kept close contact with people she met through church, frequently texting them or being

interrupted by them during the course of her interviews. Furthermore, her church

activities provided her with much needed social ties. Kim felt her physical health issues

frequently prevented her from developing relationships with people her own age, but her

church community easily adapted to meet her needs such as providing transportation to

attend young adult events.

During her first interview, Kim seemed sceptical that she would be able to build

lasting relationships in her church community, but by the last interview she had

reorganized the majority of her social network around her church. While she still had ties

to her family after residing six months in The Agency’s housing, she had rearranged

familial activities, such as regular family visits, around her church life. Kim embraced the

people she met through her church. While she asserted that when she initially met many

people at church she saw herself as having little in common with them, particularly

because of her experiences with homelessness and domestic abuse, as time went on, she

viewed these social ties as the most important in her life. These connections became

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increasingly reflective of her own definition of self. This should, perhaps, be expected as

she noted that she shares important values and beliefs with those she attends church with,

yet these individuals may not understand her life experiences. This did not seem to be a

problem for Kim in forming and maintaining these relationships.

Additionally, the affinity participants feel towards those with whom they

participate in social groups could reflect participants’ notions of their future selves or

who they aspire to be (Prince, 2014). Prince (2014) found that “future selves” develop in

contexts of place. That is, future identity desires are shaped by the places in which

individuals currently find themselves. Furthermore, individuals seek contexts to develop

these desirable future selves, thus context both shapes and is shaped by desired notions of

one’s future self. Participants sought social environments consisting of individuals with

whom they wanted to identify. In doing so, they discovered, drew attention to, or seemed

to change so that they shared similar attitudes, behaviours, or pasts, and identified with

individuals who appeared to have more stability than they did. Furthermore, these groups

contained individuals who did not appear to experience the same schism of consciousness

between self and others. Participants’ descriptions of members in these groups did not

acknowledge differences between themselves and group members. Instead, seemingly

dissimilar relational others were viewed favorably and similar to the self.

Interacting with individuals of other social statuses may make it easier for the

formerly homeless to redefine and formulate their lives apart from shelters and shelter-

living. Furthermore, interacting with individuals of other social statuses may affirm their

beliefs in their ability to live away from homelessness. In this way, acquiring new

relationships may simultaneously formulate and sustain identities apart from

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homelessness. Recognizing similarities between the self and others can affirm who the

self is and who it wants to be, thereby leading to changes in the self.

Overall, individuals who formed relationships apart from The Agency staff did so

to create ideal selves. They formed their identities through work, AA, and religious

organizations, among others. In contrast to Kim, those participants who did not ascribe to

an outside identity described themselves as socially isolated. When asked to name people

they had seen in the last two weeks, these isolated participants struggled to name one

person, and those who were named were workers helping the participant such as

caseworkers, mental health professionals, and, on one occasion, the interviewer herself.

4.5 Discussion

This paper set out to explore connections and changes between housing status,

identity, and social relationships over time. Specifically, it aimed to understand how

formerly homeless individuals negotiate their identities as they move from a stigmatized

identity to a non-stigmatized one as they become housed people.

Three major themes emerged from the data that illustrate how the formerly

homeless’ social relationships and sense of self changed as they settled into their new

situation of living in affordable housing. These reflect social distancing from homeless

individuals, social distancing from those in supported housing units, and social

embracing of presumably dissimilar others. Each of these themes illustrates the different

groups that the formerly homeless developed or detached important social ties with in

this process.

All individuals interviewed in this study socially distanced themselves from those

experiencing homelessness as they physically transitioned away from this group by

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moving into housing. In this way, the homeless, as a stigmatized group, was viewed as an

out-group that was different from the participants themselves, while other social identities

were embraced or became important fixtures as members of their newly formed in-groups

(Trafjel & Turner, 1979). Distancing occurred through various narrative devices that

purposively othered homeless individuals and drew attention to the differences between

participants and the homeless. While researchers might expect empathy and compassion

for those experiencing homelessness from people who have previously experienced

homelessness, this was not common among those transitioning into housing. Leaving

homelessness seemed to invoke and exaggerate feelings of difference rather than feelings

of empathy, particularly as participants recognized the hard work required to leave shelter

life.

Perhaps more surprising, the new residents also socially distanced themselves

from other residents in supported housing. Participants viewed other residents in these

programs as problematic, troubled, and undesirable despite their shared housing status,

homeless histories, and/or personal troubles. This study found, consistent with

Wasserman, Clair, and Platt (2012), that identities of formerly homeless individuals

appear to exist in dual-consciousness where residents observed stigmatized behaviours in

their neighbours and claimed to be inherently different from these individuals, even

though they engaged in many of the same behaviours and shared a similar status. Often

social service agencies emphasize their own importance in the lives of those they serve,

but the data suggests that the formerly homeless want to develop connections and

relationships outside The Agency and its supported housing program and apart from

others affiliated with it (Halsam et al., 2008).

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Individuals going through the significant life transition into housing connected

and identified with people in social groups to which they wanted to belong, thereby

encompassing visions of their ideal selves (Prince, 2014). The residents strongly

identified with those in groups of shared interests. These groups included church, work,

and AA and, when residents belonged to these groups, they became the primary source of

relational contact and social identity. In this way, participants typically formed

relationships with individuals from less stigmatized social groups and seemed to form

bonds with those they aspired to be like. Furthermore, goals and norms associated with

these groups chosen by individuals going through a transition seemed to be internalized

and relevant to their identity formation (McLean & Rollwagen, 2008).

By associating and identifying with individuals they wanted to be like,

participants developed identities apart from homelessness, other residents in supported

housing, and The Agency. In this way, they entered contexts and relationships that could

enable them to enact new identities of possible selves that they desired. Ultimately, they

tended to identify with individuals in these contexts more than those living in supported

housing and experiencing the same transition they were. In many respects, this could

reflect a self-fulfilling prophecy (Merton, 1948) where these individuals believe

themselves more like those they spend more time with. That is, individuals may identify

more strongly with members of these groups in hopes of becoming like them.

There are, however, a number of limitations to this study. First, the sample size is

small. All of the participants, except one, underwent all three interviews. Some

individuals may return to homelessness within the first three months following their

move into supported housing, but none of the current sample did. The participants in this

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study remained in supported housing for at least six months and therefore could be

exceptional in their desire to remain housed, and may have chosen to participate in the

study as a result. Furthermore, social distancing could be an important component in

choosing to remain in housing, and individuals who do not distance themselves from

homelessness may return to homelessness (Grigsby et al., 1990). Second, while

longitudinal in nature, it would be useful to follow individuals undergoing status

transitions over a longer time frame. Six months may not be a long enough timeframe to

encompass the scope of identity changes individuals go through during a major life

transition and its permanency. Third, this sample consists of only formerly homeless

individuals. Future studies should consider transitions of other stigmatized groups and

their processes of identity change.

4.6 Conclusion

When moving from a stigmatized social status that they did not identify with into

a non-stigmatized status without a social identity, the formerly homeless did not identify

with either their former status or their new status. These results suggest that formerly

homeless individuals moving into supported housing may build ties with groups entirely

apart from homeless service agencies that allows them to form identities outside of

shelters and street life. Furthermore, this process of distancing themselves from similar

others may be particularly important to enable individuals to form social relationships

and avoid potential social isolation as well as move beyond their former homeless

identities, as they become housed. Moving beyond their homeless identities may be

particularly important to form new identities and maintain their housed status.

Practitioners and researchers need to further explore the links between community, social

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isolation, and identity, and strategies to better support those experiencing such similar

housing transitions.

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Chapter Five: Conclusions

The purpose of this dissertation was to examine the ways in which formerly

homeless individuals’ health and social identity changed when they moved into supported

housing. It fulfilled this objective through a mixed methods study that drew on both

quantitative analyses of secondary survey data and qualitative analyses of longitudinal

interview data presented in three chapters. Each of these chapters contributed to a broader

understanding of housing, homelessness, and health.

This chapter reviews the findings of this dissertation and opportunities for future

research. It first outlines the findings of each of the specific research questions, proceeds

to explain the findings of the overarching research question, identifies its contributions to

the literature and avenues for future research, discusses limitations of the data and mixed

methods approach, and finishes with some concluding thoughts.

5.1 Specific Research Questions

This section considers the specific research questions posed by each of the

chapters and their results. It also links the research questions and results to one another,

thereby demonstrating a cohesive story across the three chapters.

5.1.1 Health of Formerly Homeless Individuals Living in Supported Housing and

Currently Homeless Individuals Living in Shelter

Before considering any changes formerly homeless individuals underwent in

supported housing, it was useful to compare the mental and physical health of formerly

homeless residing in supported housing when they moved into housing and currently

homeless individuals living in shelter when they first accessed shelter. Consequently, the

research question addressed in Chapter 2 was:

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RQ1: Are there significant health differences between individuals residing in

shelter and in supported housing?

Chapter 2 of this dissertation drew on HMIS data to understand health and stress

differences between 391 formerly homeless individuals residing in supported housing and

73 currently homeless individuals residing in shelter. No significant differences were

found in the mental health between these two groups, but the sample in supported

housing were more likely to report having a physical ailment compared to those living in

the homeless shelter. This indicates that when first admitted to the shelter, shelter-stayers

were less likely to report a physical ailment than individuals in their first few weeks of

moving into supported housing. Furthermore, individuals in housing appeared to have

had greater exposure to cumulative life stressors overall, yet their mental health was no

worse than those in the homeless shelter.

The findings in Chapter 2 indicate that, overall, supported housing appears to aid

individuals who have poor physical and mental health prior to entering housing, which

offers support for the main tenant of the Housing First policy. That is, those in supported

housing often experienced more stress exposure in their lives and had poorer physical

health than those currently living in shelter. Those in supported housing did not have

better mentally and physically prior to being housed, and they had higher stress history

scores than those residing in shelter. Following Chapter 2, questions remained as to the

long-term influence of housing on health and wellbeing.

5.1.2 Longitudinal Health Changes in Formerly Homeless Individuals

The health and stress differences between those in shelter and supported housing

demonstrated in Chapter 2 warranted further investigation of the changes that formerly

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homeless individuals may experience when they move into supported housing.

Specifically, Chapter 3 asked:

RQ2: In what ways does the self-reported health of the formerly homeless

change during their first six months in housing?

In order to understand health changes experienced by formerly homeless

individuals during their first six months of supported housing tenure, Chapter 3 reports

the results of a mixed methods study that drew on two data sets. The data include

longitudinal HMIS from 233 supported housing clients and interview data with seven

individuals transitioning out of homelessness into supported housing. These data were

used to assess the ways in which self-reports of health and emergency healthcare use

change after individuals move into supported housing.

Three themes emerged from the data that were labeled: (1) High Needs, High

Commitment; (2) Increased Formal Support, Decreased Emergency Use; and (3) Finally

Diagnosed. The theme High Needs, High Commitment illustrated how those who

remained in the supported housing program for at least six months (labeled as program

stayers) often reported higher health needs than those who left the program prior to three

months (program leavers). Interview participants had numerous physical and mental

health issues, but the majority had family physicians from whom they sought care.

Participants’ caseworkers connected them to specialized healthcare services when needed,

demonstrating the complex network of formal support provided by supported housing,

and, potentially reducing the need for emergency services while increasing commitment

to the housing program. In other words, having a physical health issue that can be

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addressed by specialists many not only improved their health but also may have increased

their likelihood of remaining in the supported housing program.

Increased Formal Support, Decreased Emergency Usage refers to the ways in

which program stayers accessed healthcare during their time in housing. Program stayers

reported reductions in their emergency healthcare use over their housing tenure, and

those interviewed reported that they accessed healthcare mainly through their primary

care physicians. Housing support services, specifically in the form of caseworkers,

alongside family physicians, acted as important sources of formal support that appeared

to maintain participants’ health. In turn, that health continuity may have translated to

fewer hospital and emergency room visits. This formal support helped interview

participants access preventive health resources (e.g., through food banks and recreation)

and ongoing treatment (e.g., specialized care from highly qualified physicians when

necessary).

Last, from the HMIS data Finally Diagnosed demonstrated that many in

supported housing reported new diagnoses during this time, but also indicated reductions

in their emergency healthcare use. Similarly, the majority of the interview participants

received new diagnoses over the course of the interviews. Receiving specialized

healthcare seemed to relate to diagnoses for conditions that participants had long-

endured—this brought a sense of relief to those that experienced it. All of the themes

suggest that the formerly homeless experienced improved healthcare support and more

appropriate healthcare use during the first six months of living in supported housing.

Overall, the findings suggest that supported housing reduces the need for

emergency healthcare for those who stay in the program for at least six months. Despite

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the ongoing mental and physical health issues identified by both the survey and interview

samples, neither sample appeared to rely solely on emergency healthcare services for

their healthcare needs. Supported housing, through a formal support network of

caseworkers and physicians appears to provide stability for those transitioning away from

homelessness. Based on the findings, it appears that taken together housing and formal

support together enhance the health and wellbeing of the formerly homeless. Findings

from both data sets imply that formal support appears to be an important factor in

successfully housing formerly homeless individuals.

These findings, in conjunction with those from Chapter 2 that indicate that even

though those in supported housing are more likely to report a physical ailment than those

in shelter, housing individuals with poorer health may, in fact, reduce emergency

healthcare system use for formerly homeless. Subsequently, reductions in healthcare

system costs could follow. If housing does reduce healthcare costs associated with

homelessness, then housing individuals even when they have numerous healthcare needs

would have the greatest impact on the system as a whole, including reducing wait times

in emergency rooms. Additionally, increasing access to primary care physicians for those

residing in shelter could further reduce healthcare system costs as having this type of

social support appears important to the wellbeing and health of those interviewed. Early

intervention and prevention of health problems could prevent them from becoming

exacerbated to emergency proportions.

While research indicates that housing is an important social determinant of health,

the findings presented in Chapters 2 and 3 indicate that formal support, that is the

services provided by caseworkers and physicians in particular, is an important factor in

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successfully housing formerly homeless individuals and to the well being of those in

supported housing. Housing may be important to health, but access to the resources that

formal networks provide appears to be vital to thriving in supported housing. Chapter 2

found that housing might be a protective factor for mental health against cumulative

stress. It could be, however, that the formal support described in Chapter 3, alongside the

provision of housing, operated as an important combination of protective factors. In the

social support literature, many scholars suggest that there is a potential buffering effect of

social support on the connection between stressors and mental health (Cohen & Patten,

2005; Pearlin, 1989; Turner & Lloyd, 1999; Yang, 2006). That is, social support may

reduce the potentially deleterious effects of stressors on mental health. Supported housing

could essentially be operating as an important buffer, particularly as it has associated with

it a network of qualified professionals offering various types of support above and

beyond simply moving into a house.

5.1.3 Identity Changes Experienced by Formerly Homeless Individuals

Finally, after considering health differences between formerly homeless

individuals living in supported housing and currently homeless individuals living in

shelter, as well as the changes in health experienced by formerly homeless individuals in

supported housing, other longitudinal changes were also considered. It is unclear from the

literature as to what happens when stigmatized individuals (such as the homeless)

undergo status transitions into non-stigmatized groups (such as being housed). This paper

explores changes in housing status, identity, and social ties over time. The research

question addressed by Chapter 4 was:

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RQ3: If formerly homeless individuals do not identify with the homeless and

the housed do not explicitly share a social identity, how do individuals

construct and maintain identities during such a major life event?

Drawing on longitudinal qualitative interview data collected over six months from

seven individuals transitioning out of homelessness and into supported housing, this

paper examined identity changes during the status shift from homeless into housed.

Thematic analyses of these data yielded three identity-related themes: (1) Social

Distancing from Those in Shelter, (2) Social Distancing from Others in Supported

Housing Units, and (3) Social Embracing: Dissimilar Others.

Social Distancing from Those in Shelter involved creating sites of difference

between interview participants and those currently residing in shelter. While all interview

participants had experienced homelessness and lived in shelter at some point, they all

defined themselves as inherently different from those currently living in shelter. These

differences appeared to become more pronounced over time, and current shelter dwellers

were “othered” by those interviewed.

Social Distancing from Others in Supported Housing, much like the first theme,

involved citing differences between themselves and those perceived to be in supported

housing units. Interview participants had little or no interest in developing relationships

with neighbours who they assumed were formerly homeless much like themselves. On

several occasions, other apartment residents were deemed untrustworthy, and therefore,

not worth forming social links with.

Lastly, Social Embracing: Dissimilar Others reflects the venues where interview

participants formed social relationships. Interview participants pursued social

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connections with other individuals based on what they perceived as similar values and

similar interests rather than shared histories or former social statuses. These connections

often centered on groups not affiliated with homelessness or shelter life.

This analysis demonstrated that when exiting a stigmatized status, like

homelessness, social distancing may be particularly important as it helps redefine the new

self as apart from that stigma. Individuals in this study did not want to retain ties to their

shelter-dwelling contacts, and did not want to form new relationships with those in

similar housing situations to themselves. Instead, they focused on forming ties with

people who appeared to reflect their future ideal selves (the selves individuals want to be)

as they transitioned from a stigmatized status into a non-stigmatized one. Furthermore,

participants may have identified with individuals from specific groups because they

wanted to be more like them.

Some programs have argued that individuals who transition away from

homelessness into housing require an enormous amount of services to expand their

informal networks and enable them to successfully move into housing (Forchuk, Ward-

Griffin, Csiernik, & Turner, 2011). Many of these recognize the importance of peer

support from others who have undergone such transitions. The data presented in Chapter

4, however, suggests that those who move into supported housing do not necessarily want

to associate with peers or others who have undergone that same transition. Instead they

appear to want to establish new ties with different people who they feel have shared

interests, hobbies, and values. This indicates the importance of forming socially-

acceptable social identities that seem to contribute to a sense of normalcy for those

seeking them.

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The participants interviewed in this study shared similar histories with each other,

but varied considerably in their values and interests from one another. They entered

contexts and social ties that enabled them to build identities entirely apart from their past

homelessness and shelter life, and purposely distanced themselves from their past

identities. Connecting formerly homeless individuals to community resources that will

enhance and support their values may be particularly important to their continued housed

status. If transitioning individuals do not distance themselves from shelter dwellers, they

may become socially isolated (as seen by two participants in the interview sample) or

return to shelter life. Developing relationships apart from shelters and social service

agencies may be critical in enabling them to create a new sense of self.

Alongside the findings in Chapter 3, these results suggest that social relationships

are pivotal to the transition from homelessness into housing. Chapter 3 found that formal

support appears vital to the health and wellbeing of those residing in supported housing.

Similarly, Chapter 4 highlights the importance of informal social relationships for

identity negotiation. Those in supported housing defined themselves and developed

identities apart from homelessness through their informal relationships. Taken together,

Chapters 3 and 4 suggest that both informal and formal social relationships are vital to

the transition away from homelessness.

5.2 The Overarching Research Question

The research questions addressed in Chapters 2, 3 and 4 contribute to answering

the overarching research question of this dissertation:

How do formerly homeless individuals negotiate the significant life transition

of becoming housed?

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This question stemmed from policymakers’ assumptions about Housing First, the

literature on stress, and the all-encompassing identity changes that status transitions may

entail. Each of the specific questions addressed in Chapters 2, 3, and 4 ultimately inform

this larger, overarching question, and inquiry about the assumptions tied to housing,

homelessness, and health. Chapter 2 clearly demonstrated health and cumulative stress

differences between those in supported housing and those dwelling in shelters. Chapter 3

longitudinally documented health improvements in supported housing residents over their

first six months of housing tenure. Chapter 4 illustrated how social integration and social

relationships of formerly homeless individuals changed over time and how they

negotiated subsequent identity formations. Each of the specific research questions

examined differences in health and/or social identity in order to better understand the

changes individuals experience when they transition from homelessness into housing.

The findings from these chapters illustrate the important interplay between

housing, health, and social identity. Housing enhances health, but the findings indicate

that, as suspected, transitioning away from homelessness into supported housing involves

more than the provision of an apartment. This transition is characterized by reliance on

formal support and changes to informal social relationships that enable individuals to

redefine themselves apart from homeless shelters and homeless peers. These findings

more generally signify that individuals who undergo status transitions may experience

changes in their day-to-day patterns of living, resources, social connections, and

consequently, sense of selves.

Early discussions of Housing First in Calgary failed to recognize the significant

lifestyle transformation supported housing presented for those who previously dwelled in

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shelters (CCTEH, 2008). Later iterations of Calgary’s Ten Year Plan to End

Homelessness (e.g. CCTEH, 2015), however, managed to cite the importance of formal

supports during the transition away from homelessness. This dissertation’s findings

substantiate the critical role of these formal supports to successfully housing individuals

who have experienced homelessness. Formal supports appeared to augment health or

change healthcare use through community resources and treatment while informal social

relationships clarified and redefined identities apart from shelters and homelessness. The

findings suggest that identification apart from shelters and shelter living heralds a desire

never to return to shelters and shelter living.

Individuals who transition from stigmatized social statuses into non-stigmatized

ones may experience improvements to their wellbeing. This is because individuals

making these transitions enter into realms of social acceptability that enable them to cast

off some of their former disadvantage. The findings of this dissertation reinforce the

importance formal supports during status transitions, and indicate that moving into

supported housing does not solely improve the health of formerly homeless individuals.

Rather, improvement in health and redefinition of the self are seen through a complex

matrix of informal and formal social relationships. Moving into housing just represents a

catalyst for lifestyle changes that can then be bolstered by formal support and social

integration provided through community ties. As evidenced by the results of this study,

both formal and informal social connections are paramount to health, wellbeing, and

housing success.

Housing for the homeless is, essentially, an important first step in reducing

disadvantage and moving beyond poverty. Poverty, while primarily considered an

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economic condition, is also a social status that encompasses an individual’s connection to

everyday social relationships (e.g., how others perceive and interact with them), housing,

health and wellbeing (Walker, 1987). In supported housing, residents seemed to

experience reduced stigma, and managed to form social ties with individuals apart from

social services. Poverty reduction strategies should continue to find ways to integrate

disadvantaged individuals into communities. Establishing new social connections along

shared interests and values could reduce divisions between haves and have-nots. These

new social relationships can then act as a foundation for new identities apart from poverty

and homelessness.

5.3 Contributions to the Literature and Future Research

The findings of this dissertation contribute to several different literatures, as

specified in the following sections. Below, it describes the contributions to the

homelessness/housing literature, the sociology of health literature, the literature on

inequality and health, and the social identity literature. Each of these sections also

highlights future directions for research, and questions worth further exploration.

5.3.1 Contributions to the Homelessness/Housing Literature and Future Research

Housing First has emerged as an important social policy to address homelessness.

Many of the claims posited by Housing First proponents, however, have not been

adequately tested in the literature. For example, housing is often presented as the primary

solution to homelessness, yet status transitions entail more than simple moving homeless

individuals into new residences. Additionally, measuring change following moves into

housing continues to be problematic for academics and advocates alike, particularly as

most studies of homelessness and housing use cross-sectional, rather than longitudinal,

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data (Macknee & Mervyn, 2002; Patterson & Tweed, 2009; Zlotnick et al., 2003).

Consequently, some experts have recommended the creation of longitudinal studies

(Maycock et al., 2011; Shinn, Knickman, & Weiztman, 1991). Alongside calls for

longitudinal studies, broader perspectives and new frameworks have been sought to

expand the literature on homelessness and housing.

This dissertation addressed two gaps in the existing literature identified by

homelessness and housing scholars. First, it used longitudinal data to assess individuals’

experiences in their first six months of housing tenure following homelessness. Second, it

utilized social determinants of health and stress-process frameworks to understand the

impact of housing on the lives of formerly homeless individuals. As theorized in the

introduction of this dissertation, housing alone does not appear to be solely responsible

for changes in formerly homeless individuals’ health. Rather, formal and informal social

supports during this transition seem to provide important resources that can improve

health and wellbeing.

This study corroborates the claim that supported housing improves the lives of

formerly homeless individuals for those who remain in the supported housing for at least

six months. The move into supported housing was accompanied by positive life changes

such as treatment for ongoing ailments, the formation of new social relationships, and the

use of appropriate venues for healthcare. Many of these changes appeared to result from

formal social support provided by caseworkers and family physicians, as well as informal

connections to non-homeless people and groups in the community. Future research

should measure these changes in larger quantitative studies longitudinally to see both

changes in and effectiveness of both formal and informal social support.

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This dissertation only studied formerly homeless individuals in one scattered site

supported housing model run by one social service agency, and only had six-month

longitudinal data on those who remained in supported housing. Future studies should

consider other housing models and their influence on the health of formerly homeless

individuals. Different types of housing may be paired with different changes in the lives

of formerly homeless individuals partially because programs are often tailored to specific

homeless populations such as youth, women, or those with certain conditions (e.g., dual

diagnoses) (Frederick, Chwalek, Hughes, Karabanow, & Kidd, 2014; Tsemberis &

Eisenberg, 2000; 2014; Tsemberis, Gulcur, & Nakae, 2004). Thus far, research on

transitions from homelessness into housing has predominantly focused on certain

homeless populations rather than certain types of housing. For example, Forchuk and

colleagues (2011) found that housing supports such as access to psychiatric care were

important for individuals with severe mental illness, regardless of housing type. Mentally

ill individuals who had inadequate formal supports did not find sustainability in any form

of social housing—whether scattered-site or centralized—but variation in housing type

was not studied.

To the author’s knowledge, only one housing type has gained academic attention.

The Pathways to Housing offers extensive support services for individuals with dual

diagnoses of mental illness and addictions, and houses them in scattered site apartments

across municipalities (Tsemberis & Eisenberg, 2000; Tsemberis, Gulcur, & Nakae, 2004).

Studies of Pathways have demonstrated improved client health stability with housing

tenure, but have not considered whether social identity or social relationships change

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during such a transition (Tsemberis & Eisenberg, 2000; Tsemberis, Gulcur, & Nakae,

2004).

Housing type may also influence wellbeing through client engagement and

empowerment. Nelson and colleagues (2011) argue that individuals with severe mental

illness prefer living in independent housing in locations of their own choosing when

accompanied by appropriate mental health support. It is possible that restricting clients’

choice in housing location and personal lifestyle (as seen in the Calgary model) may also

inhibit potential benefits to health and social relationships, particularly as such

restrictions may limit contact with social supporters. This dissertation found that both

formal and informal social relationships appear integral for housing success by

developing identities apart from homelessness and enhancing and feelings of wellbeing.

Consequently, future research must consider the relevance of client choice, housing type,

and subsequent effects on both health and social relationships.

5.3.2 Contributions to the Social Determinants of Health Literature and Future

Research

This dissertation drew from the social determinants of health literature as a

framework to theorize about the health changes individuals experience when they move

from homelessness into supported housing. The social determinants of health literature

draws attention to population differences in health across social statuses, contexts, and

structures (Bonnefoy, 2007; Marmot & Wilkinson, 2005; Raphael, 2003; Raphael et al.,

2008). Social determinants of health scholars argue that variations in health exist because

of differential access to high-nutrient food, clean water, appropriate shelter free from

moisture and mould, the ability to form strong social relationships, among other social

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factors. Proponents believe that improvements in population health over time that have

coincided alongside medical breakthroughs have been, in part, due to improvements in

living conditions, even among the poor (Marmot & Wilkinson, 2005). Stemming from

this particular literature, the fundamental causes of disease theory, a particular social

determinants of health theory, posits that poverty, as a social status, is the most powerful

social determinant of health because of its impact on so many other social determinants

of health (Link & Phelan, 2005). For example, individuals living in poverty may have

inadequate access to appropriate accommodation, recreation, food, and social

relationships.

The findings of this dissertation lend support to the fundamental causes of disease

theory (Link & Phelan, 1995). Formerly homeless individuals residing in supported

housing reported improvements in their health and wellbeing alongside their moves. But

this status transition was accompanied by changes in other social determinants of health,

including access to formal social supports that enabled them to utilize specialized

healthcare, to eat higher nutrient food, and to take advantage of recreation services.

Moving into supported housing, as a poverty reduction strategy, seemed to minimize the

stigma participants felt surrounding their level of poverty. Reducing homeless individuals’

relative levels of poverty by providing them a home and access to formal supports

seemed to empower them to form social ties apart from service providers and homeless

shelters, when, in turn, appeared to further reduce their level of disadvantage. That said,

this study did not measure changes in poverty aside from housed status. To develop a

complete understanding of changes in poverty, it would be useful to measure income

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level as well as quality of accommodation as individuals move away from homelessness.

Future research should empirically examine both.

Supported housing facilitated study participants’ access to formal social supports

that could help them address their ongoing issues that, in turn, provided them with much-

needed healthcare and ongoing health support. These formal supports also helped them

navigate recreation options that could enhance their health and establish informal social

relationships that could boost their mental health and wellbeing. While housing the

homeless remains the goal of supported housing, it entails more than the provision of a

home, and, consequently, also influences many other social determinants of health.

This dissertation contributes to the social determinants of health literature by

considering a particular context (i.e., supported housing) that facilitated other changes in

the lives of formerly homeless individuals. While the provision of housing certainly

improved the lives of study participants, formal and informal social support, alongside

housing provided, bolstered the health and wellbeing of formerly homeless individuals.

Longitudinal survey data that includes measures of social support, strain, and

social integration would be useful to assess the ways in which each of these influence

health for both homeless and formerly homeless individuals. This dissertation established

the important connections between housing, health, and social identity through a

combination of qualitative and quantitative sources, but it would be helpful to test these

connections statistically with larger samples and specific questions aimed at the content

of relationships. Furthermore, longitudinal survey data that tracks changes in individuals

currently residing in shelters and those who leave supported housing could help establish

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whether housing situation moderates the association between social relationships and

health.

5.3.3 Contributions to the Stress Process Literature and Future Research

Stress process theory served as an important framework for understanding the

potentially negative health effects for homeless individuals moving into supported

housing. The stress process argues that while individuals are consistently exposed to

stressors, or circumstances that require adaptation, over the course of their lives, not all

stressors damage health and wellbeing (Pearlin et al., 1981; Pearlin, 1989; Thoits, 1995;

2011). Rather, coping resources such as social relationships or self-efficacy can minimize

the potentially negative impact on health.

This dissertation found that formal social relationships were particularly

important to the health and wellbeing of those transitioning away from homelessness.

Interview participants reported drawing on the expertise of both specialized physicians

and case managers in order to meet both their day-to-day and healthcare needs. These

formal social relationships may be particularly important during this transition as they

alleviated stressors such as food provision through food bank referrals and formal

diagnoses for mental health conditions.

Future research should draw on the stress process model to statistically analyze

the transition from homelessness into supported housing. A large scale survey that

accounts for personal self-efficacy, formal and informal sources of social support, and

whether respondents found specific circumstances stressful or not would be useful in

determining how individuals transitioning from homelessness into housing navigate their

transition.

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5.3.4 Contributions to the Literature on Inequality and Health and Future Research

Poverty, as a specific type of disadvantage, has been posited as the most

important social determinant of health as it impacts so many other determinants (Link &

Phelan, 2005). Economic disadvantage bears with it insufficient food, housing, and social

relationships (Marmot & Wilkinson, 2005). Little research on poverty and health,

however, has examined the influence of poverty reduction strategies on the health and

wellbeing of those they aim to help (Mackenback & Bakker, 2003). This dissertation

examined what happens to individuals’ health when they move from one disadvantaged

status (homelessness) into a less disadvantaged one (supported housing), and found that

reducing disadvantage appears to have health benefits for those experiencing such status

transitions.

Supported housing residents are not in privileged social statuses, yet their moves

away from homelessness were associated with improvements in their feelings of health

and wellbeing. Furthermore, statistical evidence found that those in supported housing

reported reductions in their emergency healthcare use over the course of their housing

tenure. The advantages that supported housing afforded extended beyond movement

away from homeless shelters and saw residents accessing formal supports and forming

new social relationships as a result. This access may have further reduced formerly

homeless individuals’ disadvantage.

This dissertation contributes to the literature on inequality and health by

demonstrating the importance of relative inequality on health. Those in supported

housing often remained beneath the low-income cut-off (LICO), which is a threshold

which demonstrates a family’s inability to afford life necessities such as food, clothing,

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and shelter (Statcan, 2009). They would be labeled poor despite the change in their

social status, yet they still experienced improvements to their health through relative

reductions in their disadvantage. Whereas they previously had no resources, following

their moves into housing, they had a few more. The reduction of their disadvantage was

followed by reported improvements in their perceptions of health and reduced reliance

emergency healthcare services.

Future research should consider other governmental and non-governmental

strategies to reduce disadvantage for those in poverty and subsequent effects on health.

While this dissertation only examined homelessness as a particular type of disadvantage

(i.e., poverty), efforts to reduce inequality may be met with positive health effects for

other disadvantaged groups. For example, affirmative action policies aimed at

minimizing racial inequalities facilitate employment for minority groups (Kalev, Dobbin,

& Kelly, 2006). Alongside housing, employment has been cited as one of the most

important social determinants of health with unemployment as a health risk factor

(Raphael, 2009). Consequently, health risk factors alongside homelessness should be

considered together in future studies.

Additionally, future studies should examine different types of inequality and the

intersectionality of ethnicity and homelessness. In particular, a timely issue has

highlighted the relevance of Aboriginal status to the study of poverty in Canada. Recently,

the Truth and Reconciliation Commission (TRC, 2015) released a report about the

influence and impact of the Indian Residential School system on the lives of Aboriginal

people in Canada. The goal of the report was to document and detail the reality of Indian

Residential Schools through survivor, community, and family accounts from those who

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were affected. The report found Canada responsible for cultural genocide against its

Aboriginal people, and suggests that efforts to transform and assimilate Aboriginal

people into Western Canadian culture have had sweeping consequences for several

generations of Aboriginal people (TRC, 2015). This dissertation project was designed

prior to the creation of the report, and did not purposively attempt to recruit Aboriginal

people in its samples. Consequently, comparisons between Aboriginal and non-

Aboriginal people were not possible. Based on the TRC (2015) report, however, further

explorations of Aboriginals’ experiences of homelessness and transitions to supported

housing are needed to assess cultural differences as well as the continued influence and

generational stress of the Indian Residential School system on the lives of Aboriginal

people experiencing homelessness.

Furthermore, some have found that scattered site models as examined in this

study may be inappropriate for Aboriginal people (Schiff & Waegemakers Schiff, 2010).

In their study of single Aboriginal women with addictions, Schiff and Waegemakers

Schiff (2010) found that these women preferred “housing ready” programs that allowed

them stages of change as they moved towards housing, and enabled them to remain

housed with their families. Housing Ready models are in opposition to Housing First

models in that the former enable incremental change, and require individuals to meet

certain requirements prior to being housed. Future research should consider the

experiences of Aboriginal people transitioning away from homelessness and the influence

of different housing models on their health and wellbeing.

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5.3.5 Contributions to the Social Identity Literature and Future Research

Social identities are enacted through social relationships (Trajfel & Turner, 1979).

Undeniably, identity becomes salient only in relation to others. That is, individuals

become aware of their own identities by recognizing who they are and are not like.

Drawing attention to similarities and differences between groups of individuals enables

people to determine who they are (Parsell, 2011). Consequently, strong associations with

in-group members bolster these lines of similarities, while citing differences and othering

out-group members exacerbates differentiation and establishes an individual’s sense of

belonging and sense of self (Osborne, 2002; Parsell, 2011). These two processes define

the self.

Unsurprisingly, then, individuals tend to view themselves as similar to those they

wish to be like, and they may seek relationships based on their perceptions of their ideal

selves or even future selves (Prince, 2014; Schouten, 1991). This study found that

individuals transitioning away from homelessness into supported housing did just that.

Study participants formed relationships with individuals they saw as similar to

themselves, while portraying differences between themselves and both homeless and

formerly homeless individuals despite their shared status as formerly homeless.

This dissertation contributes to the literature on social identity by demonstrating

the ways in which identities are negotiated during major status transitions. Redefining the

self appears to involve a significant restructuring of relationships and who one seeks to

associate with. The findings indicate that developing social ties apart from disadvantaged

statuses could be essential for successfully moving beyond these statuses. Individuals

who formed relationships through other interests and groups adjusted well to supported

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housing, while those who did not remained relatively isolated following their moves.

Individuals did not want to identify with still-homeless peers and still-homeless family,

and they spent less time with them as their housing tenure increased. Participants did,

however, seek out relationships with individuals outside of their circle of social service

providers and homeless shelter clients. This has important implications for identity

negotiations following transitions into supported housing. When individuals formed

social ties apart from their disadvantaged status, they distanced themselves from The

Agency, which could have implications for long-term housing success.

Future studies should explore the interplay between housing, health, social

identity, and social relationships for homeless families undergoing the transition from

homelessness into housing at the same time. Homeless families refer to a type of

generational homelessness that includes at least one related adult and at least one child

(Shinn & Weitzman, 1996). While in shelter, family composition is often in a state of

flux where adult members engage and disengage in family life at their leisure, and a

family’s size can vary considerably from one month to another (Shinn & Weitzman,

1996). Homeless families dwell in shelters together, and, consequently, transition away

from homelessness into housing together. This is particularly interesting as this

dissertation found that connections with homeless and formerly homeless individuals

were often terminated following individuals’ moves into supported housing. Yet

homeless families undergoing transitions into housing maintain some social ties with

formerly homeless individuals (i.e., the family members transitioning with them) when

they transition away from homelessness (Proffitt & Raschke, 2012). The implications for

identity negotiations are unclear. Additionally, research suggests that homeless families

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residing in shelters rely on other homeless mothers for help in guarding and protecting

their children (Hodnicki & Horner, 1993; Styron, Janoff-Bluman, & Davidson, 2000).

Whether these relationships remain important following transitions into housing is

unclear. Furthermore, questions remain as to whether all members of the family unit

experience changes in their identities or social ties following this transition. The

instability of moving from homelessness into housing has been associated with poorer

academic achievement and mother-reported school troubles, but the impact on children’s

social identities and health remains unclear (Rafferty, Shinn, & Weitzman, 2004). Better

understanding this life transition for children could make such a shift easier for them, and

could further scholarship on identity negotiations following status transitions.

It should also be noted that participants had experienced different lengths of

homelessness prior to entering supported housing. For example, some have been

homeless for as little as five months and others as long as ten years. Individuals who had

lived in housing for less than one year would not be considered entrenched in the shelter

system, however, those that had spent many years residing in shelter would likely have

formed closer ties with other individuals living in shelter (Grigsby et al., 1990).

Consequently, length of homelessness prior to housing may have influenced the extent to

which participants internalized homeless identities prior to exiting shelter life. Future

research should explore variability in the internalization of homeless and housed

identities based on individuals’ length of homelessness experience.

5.4 Limitations of the Data and Mixed Methods Approach

There are several limitations to the findings presented in this dissertation. First,

the HMIS survey data was secondary data, meaning that the author did not have an

123

opportunity to influence, change, or otherwise reinterpret the questions posited by the

survey instrument. Consequently, some measures included in HMIS were not ideal. For

example, measures of emergency healthcare use had participants reflect on the number of

times they had spent in hospitals and emergency rooms over the last three months. Often

memory can be fallible, and remembering specific days or incidents can be challenging,

particularly for individuals who have poorer health and experience more of these

incidents than the national average (Neuman, 2011). It would also have been helpful to

include measures of social support in the HMIS instrument, particularly as these could

have been empirically examined in terms of their association with health outcomes.

Additionally, other measures of health aside from participants self-reports of their health

and emergency healthcare use, such as blood pressure, and glucose levels would be

helpful to ascertain changes in health over housing tenure. HMIS currently remains,

however, the most comprehensive database for information about both currently

homeless shelter dwelling and formerly homeless supported house-living individuals

(Poulin, Metraux, & Culhane, 2008). It provides the most extensive information about

both of these groups and enables comparisons between them.

Second, the qualitative sample was drawn from a hard to reach population.

Finding individuals moving away from homelessness into supported housing required

reliance on caseworkers to pass on the investigator’s contact information. It is possible

that not all caseworkers referred clients to the author, and, consequently, interview

participants may have been skewed to two or three caseworkers instead of representing

clients from the entire case management staff. As it stands, the author did not explicitly

ask for caseworkers’ names in the interviews, although some participants did refer to

124

their caseworkers by name during the course of the conversations. It would be helpful to

recognize whether clients’ reliance and relationships with their caseworkers varied by

caseworker characteristics such as gender, age, or ethnicity. Additionally, questions that

explicitly asked about services provided by caseworkers would be useful to best

understand formal support afforded by these individuals.

Third, the sample sizes for both the qualitative and quantitative data were

relatively small. Larger sample sizes would have been helpful to potentially increase the

representativeness of the samples as well as make more generalizable conclusions, and

ensure that the samples were not a biased representation of the populations of interest.

That said, current spaces in supported housing and shelter are quite limited, and

population to draw samples from was relatively small. When the study was first proposed,

300 supported housing spaces were supposed to open up in a single apartment in

downtown, but the building received its occupancy permit much later than anticipated.

Consequently, it was not possible to rely on those moving into this building to generate a

larger sample for the current study. Additionally, comparisons across groups were not

really possible because of the small total sample size of both the quantitative and

qualitative data, and the small sub-sample sizes of different sociodemographic groups

(e.g., across genders, ages, races, or ethnicities). In particular, as mentioned above, this

project could not address the experiences of Aboriginal people transitioning away from

homelessness or make comparisons between them and those of other ethnicities.

Fourth, the mixed methods approach was a two-phase design, where the

qualitative data was used to expand on findings in the quantitative data. While this is

common practice in many mixed methods approaches, it limited the analytic scope of the

125

qualitative data. In other words, at times, particular attention was paid to specific

questions, answers, and themes in the qualitative data in order to supplement the

quantitative findings. This means that in Chapter 2, open coding was restricted to specific

questions about health, wellness, and how individuals felt in their housing. Other

questions may have yielded information about the themes of interest, but were not given

the same level of attention. Consequently, the qualitative data contains a level of richness

that was not completely considered because of this methodological approach. It may have

been helpful to complete all qualitative data analyses prior to completing quantitative

analyses as this could have helped the author to be open to different themes than being

limited to those found in the quantitative data.

Fifth, the sample is from one social service agency in one municipality. This may

limit the generalizability of the results, especially as these findings may only pertain to

the specific agency, city, or group of homeless studied. This social service agency

predominantly helped Caucasian middle-aged men. This means that comparisons to other

groups were not possible due to their extreme under-representation. Other service

agencies may specialize or cater to other homeless populations such as youth, Aboriginal

people, or families. Drawing from samples across a wider array of agencies could be

useful to enable comparisons across programs as well as across different homeless

populations. Results may have varied if the sample had been drawn from a different

agency. For example, some ethnic cultures are more collective than others and

consequently, individuals from these cultures could have greater reliance on homeless

and formerly homeless peers when transitioning away from homelessness.

126

5.5 Closing Thoughts

The results of this dissertation suggest important connections between housing,

health, and social identity. Social relationships appear critical during the transition into

supported housing. Moving away from homelessness into supported housing included

increased access to formal supports through caseworkers and physicians, and the

potential to establish relationships with people outside of social service agencies through

community groups, organizations, and employment. According to participants’ accounts,

they felt their health was positively influenced with their moves from homelessness into

housing. However, because moving away from homelessness into housing reflects a

status transition that also includes changes in social relationships, the transition process in

conjunction with supportive ties rather than solely the provision of housing appears

pivotal for such improvements.

Individuals undergoing status transitions from highly disadvantaged statuses into

less disadvantaged ones appear to experience improvements in their health and wellbeing,

despite exposure to potential stressors during such a comprehensive life change. These

improvements are associated with many highly interconnected social determinants of

health that are also transformed during such transitions. Overall, minimizing the complex

web of disadvantages associated with homelessness has positive implications for health

and wellbeing.

127

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