Impact case study database
Improving access to health and social care for the homeless
1. Summary of the impact
Multidisciplinary research at the University of Dundee brought together expertise in Dental Public Health, Oral Health Inclusion, and Community Education to address the health and psycho-social wellbeing of homeless people. Among the key impacts were changes in local policy design and service delivery for homeless people, which led directly to recommendations at national and international levels. Insights and tools from the research have directly informed service improvement, professional education and policy making for health services, governments and civil society initiatives. Impact was generated locally (Dundee), nationally (Scotland), and internationally (Brazil).
2. Underpinning research
UN Habitat estimates that 150 million people are affected by homelessness worldwide. People affected by homelessness are particularly vulnerable to health issues and are four times more likely to die prematurely than others. Recently, there has been an increase in complexity of needs and the number of people affected by homelessness in Scotland . This ICS outlines a programme of effective work to address these issues.
The underpinning research was initiated in 2011 by Freeman (UoA03 Allied Health - Dentistry), who conducted the world’s largest survey on oral health/health needs of homeless populations, alongside NHS Scotland, NHS Health Scotland, and Homelessness Action Scotland . It revealed high levels of tooth decay, limited access to services and depression. A national oral health programme (Smile4life) resulted and was implemented across all NHS Health Boards in Scotland [R3]. An evaluative study of the programme was then conducted by Beaton, Coles and Rodriguez [R1].
These studies led, in turn, to further research by Rodriguez, Freeman and Fernandes in a series of linked projects. This programme comprised simultaneous evaluative and data-gathering research alongside the creation of impact. The first of these was a Reflexive Mapping Exercise (RME) of homelessness services in Dundee, which developed from a partnership between Fernandes and Rodriguez with Dundee City Council’s Joint Strategic Commissioning for Homelessness [DCC-JSCH] (2016-2021). It was initially developed as an instrument for conducting a survey of homelessness services in that city [R2]. This was conducted in partnership with Public Health Scotland, Shelter Scotland and Dundee City Council. The RME [E2] involved an innovative and co-productive process of design and data collection involving 25 community organisations, those experiencing homelessness, University of Dundee student volunteers, coordinators of public services and front-line staff. The RME highlighted that it: improved knowledge and communication; encouraged synergies; identified service gaps, and improved multi-agency working [R4].
The next component of the underpinning research combined Knowledge Exchange (KE) and research. It comprised the coproduced design, implementation and evaluation of a workshop programme with young service-users, NGOs and NHS Boards on health promotion and social participation based on Paulo Freire’s critical pedagogy [R5]. The last key element of the underpinning research also combined the aspects of KE, impact and research [R6]. This project, funded by Scottish University Insight Institute (SUII), took a multi-agency approach and, again, involved critical dialogue – with youth participation – to reflect on service provision and professional practice towards young homeless people. The project engaged with over 45 organizations ranging from local authorities, NHS boards and housing services, to national youth organisations (Scottish Youth Parliament) and international NGOs and charities (Barnardo’s, Action for Children, Shelter Scotland, LGBT Youth Scotland). Further funding (GCRF/SFC mobility award, Fortaleza City Council, Oswaldo Cruz Foundation and PUC Rio University, Brazil) enabled the organisation of KE events in two major metropolitan regions in Brazil: Rio de Janeiro, with 7.5 million inhabitants and Fortaleza, with 4.1 million inhabitants, which are respectively 2nd and 3rd in the number of homeless people in the country.
Collectively, the research highlighted that:
there was a need to develop new strategies and approaches – in particular, multi-agency working (across NGOs, health and social care sectors) needed to be more effective in order to improve access to and engagement with services;
co-productive approaches such as service-user involvement were needed in order to support better policy and service design;
the overall distribution of services was unequal;
widespread stigma, leading to self-blame and lower self-esteem in those experiencing homelessness and negative responses from practitioners, resulted in poor user-service engagement and the reinforcement of health inequalities;
the RME approach was an effective approach to improving inter-agency working and as a tool for service development.
These research activities led to national and international impact on policy and practice in Scotland and Brazil.
3. References to the research
[R1] Beaton, L., Coles, E., Rodriguez, A., & Freeman, R. (2016). Exploring the benefits of Smile4life training: findings from a pilot study. Community Practitioner, 89(10), 40-45, 47. [Peer reviewed journal]
[R2] Fernandes, F. & Sharp, G. (2015). The Situation of People who are at Risk of Homelessness in the City of Dundee. Dundee Drop In Survey Final Report. [Reviewed by DDI Drop in Network – a group of 25 members of third sector organizations in Dundee, including Dundee City Council]. Available at: https://discovery.dundee.ac.uk/en/publications/the-situation-of-people-who-are-at-risk-of-homelessness-in-the-ci (Accessed 16 March 2021)
[R3] Coles, E., Edwards, M., Elliott, G. M., Freeman, R., Heffernan, A., & Moore, A. (2009). Smile4life: The oral health of homeless people across Scotland. Dundee: University of Dundee, Dental Health Services Research Unit. Available at: https://discovery.dundee.ac.uk/ws/portalfiles/portal/3399534/smile4life_report.pdf (Accessed 16 March 2021)
[R4] Rodriguez, A.; Aurora, G.; Beaton, L., Fernandes, F.; and Freeman, R. (2020). ‘Reflexive mapping exercise of services to support people experiencing or at risk of homelessness: a framework to promote health and social care integration’. Journal of Social Distress and the Homeless. DOI: 1080/10530789.2020.1808344 [Peer reviewed journal].
[R5] Rodriguez, A.; Beaton, L.; and Freeman, R. (2019). Strengthening social interactions and constructing new oral health and health knowledge: the co-design, implementation and evaluation of a pedagogical workshop program with and for homeless young people. Special Issue: Promoting Inclusion Oral-Health. Social Interventions to Reduce Oral health Inequities. Dentistry Journal, 2019, 7,11. DOI: 10.3390/dj7010011 [Peer reviewed journal]
[R6] Rodriguez, A.; Biazus, C.; Fernandes, F., Freeman, R.; and Humphries, G. (2020). Helping young people feel at home in Scotland. Building collaborative and integrated services for youth homeless through a reflexive mapping approach for health and social care integration. Final report, SUII. [Final review and additions by members of A Way Home Scotland, and youth representatives of Aff the Streets – a Scottish Government youth steering group for homelessness]. Available at: https://discovery.dundee.ac.uk/ws/portalfiles/portal/52610549/SUII_report_v7_SCREEN.pdf (Accessed 16 March 2021)
4. Details of the impact
The adoption and implementation of the RME in Scotland and Brazil
In addition to its function as a survey instrument, the Dundee RME was shown to have increased knowledge about what is available to support homeless populations and to encourage multi-agency cooperation and better communication between NGOs, service users and health and social care sectors [R4, E2]. Consequently, the findings from the evaluation of the Dundee RME, alongside the recommendations from the Health and Homelessness workshop report [E4] – part of the RME project in Dundee – were adopted by DCC-JSCH in their five-year strategic plan to prevent and tackle homelessness in Dundee [E1]. Furthermore, as a result of the success in Dundee, the RME became a model for the development of multi-agency homelessness strategies in three more Scottish cities as well as in Rio de Janeiro, Brazil [E2, E5]. The RME approach was commended for its affinity with Scottish Government objectives in tackling homelessness:
“The commitment to a community level, inequalities informed and accountable method of working with the most marginalised has rightly garnered local support through reflexive mapping…” [E10]
As part of the international KE programme, Rodriguez co-organised a series of activities in Brazil including an international seminar in Rio de Janeiro, through which our local partner at PUC-Rio University was able to advance the RME approach via membership of the State Forum of Homeless Population. This led to further partnership-working with a city councillor, and ultimately, to a proposal (Emenda Aditiva nº 117 de 18/06/2020 – Municipal Policy for people affected by homelessness) resulting in an addition in June 2020 to the city’s proposed Budget Guidelines Law of 2021 to introduce the RME approach to Rio de Janeiro [E5].
Youth Homelessness Prevention Pathway
The research findings from the projects focussing on young people [R5, R6] informed the work of two national committees: Scottish Health and Homelessness Group and A Way Home Scotland – a national coalition to end youth homelessness. In recognition of their work on homelessness, Rodriguez was invited to join the working group for A Way Home Scotland project, commissioned by the Scottish Government in 2019 to develop a pathway to prevent homelessness for care leavers. In this capacity, she advanced the approach developed in the RME, as well as other principles and findings from the University of Dundee research. The Policy and Influencing Coordinator noted:
“The programme created key essential recommendations to reduce homelessness among young people. The contact of youth participants with policy makers and practitioners was remarkable. The impact on practitioners was also perceived...and all participants benefitted from an increased knowledge of policies, systems, and practices” [E8]
The recommendations from the KE programme [R6] informed the resulting Youth Homelessness Prevention Pathway report [E3], of which Rodriguez is one of the contributors and signatories. This work is part of the Scottish Government priorities for delivery of the Ending Homelessness Together action plan; it has informed Scottish Government policy recommendations to prevent youth homelessness for care leavers and has been adopted by the Scottish Government Housing Minister [E11].
Professional education
The findings of the Smile4Life evaluation [R1] – that practitioners lacked knowledge and soft skills for working with homeless people (regarding causes, context, health needs and access and engagement with services) – led directly to the provision of annual training in oral health/health promotion and homelessness for staff and services users in the third sector, and practitioners from all NHS Scotland Boards. This resulted in increased homelessness health-related knowledge and capacity building of practitioners from health and third sectors. [R1] Since 2013, a total of 7 national training events have been held by NHS Education for Scotland and the University of Dundee. More than 360 health and social care participants have benefited from training.
As part of the international KE Programme, three training workshops for 120 street educators (working with street children) and one training workshop for 30 Child Protection Officers have been organised in collaboration with Fortaleza City Council, Brazil. The workshops, facilitated by Rodriguez and a local partner from the Federal University of Ceará, helped “to identify challenges and new approaches.” [E6] The training activities were positively evaluated and brought about enhancements in “professional values, the need to pay attention to professional emotions in the interaction with vulnerable people, and the need to produce a more systematic record of activities to facilitate better monitoring, evaluation and replication of good practices”. [E6]
The KE programme included a subtitled (English, Portuguese and Spanish) video documentary [E7] for use in the education of students and practitioners. Since its release in August 2020, the innovative community-based approaches showcased in the video are already being used to inform practitioner and student education in two universities in Brazil – Schools of Nursing and Social Work at Federal University of Ceara and PUC Rio University – and at University of Dundee – Schools of Dentistry, Medicine, and Education and Social Work. Between August and December 2020, the video was played 332 times. Feedback received from students, academics and practitioners was overwhelmingly positive, with three-quarters stating that the video was helpful to address training regarding homelessness and related issues. An academic partner from PCU in Brazil, using the video in multi-disciplinary settings, stated that,
“increased knowledge about the use of this innovative and creative methodology [the RME] in different contexts/cultures was reached by the video.” [E9]
From its origins in a project on oral health and homelessness, a programme of impactful research at the University of Dundee around homelessness and wellbeing has significantly expanded, nationally and internationally. The issues identified in the research, and the subsequent development of the RME approach and the KE activities, have made significant contributions to the general promotion of health and wellbeing for people affected by homelessness. These contributions have encompassed policy development, professional education, co-productive working and a new approach to addressing homelessness.
“The programme has strengthened the national profile of oral health as a beachhead for all wellbeing, mental health in particular has been increased greatly in the commitment by the project to the national Health and Homelessness Group.” [E10]
5. Sources to corroborate the impact
[E1] Dundee City Council. Joint Strategic Commission for Homelessness (2016). Housing Options and Homelessness Support Strategic Plan (2016 – 2021). Dundee: Dundee City Council. [PDF Available]
[E2] Rodriguez, A., Arora, G., Fernandes, F.L. & Freeman, R. (2019). Smile4life Reflexive Mapping Exercise: Better Health and Social Care for Homeless People. Edinburgh: NHS Health Scotland. 122 p. [Reviewed and approval given by a panel with members of the by Dundee City Council’s joint commissioning for homelessness, Shelter Scotland and Public Health Scotland] Available at: https://learn.nes.nhs.scot/18180/oral-health-improvement-for-priority-groups/smile4life/reflexive-mapping-exercise [Accessed 19 March 2021]
[E3] Scottish Government, Centre for Excellence for Children’s Care and Protection, A Way Home Scotland. (2019). Youth Homelessness Prevention Pathway: Improving Care Leavers Housing Pathways. Available at: https://www.rocktrust.org/wp-content/uploads/2015/09/Youth-Homelessness-Prevention-Pathway-Care-Leavers.pdf [Accessed 19 March 2021]
[E4] Rodriguez, A.; Beaton, L.; Freeman, R.; Fernandes, F.; McLachlan, A. & Harrow, M. (2016). Health and Homelessness Discussion Forum and Workshop: “Building collaborative work for homelessness, health and social care integration”. December 2016. Edinburgh: Shelter Scotland. Available at: https://discovery.dundee.ac.uk/en/publications/health-and-homelessness-report-discussion-forum-and-workshop-buil [Accessed 19 March 2021]
[E5] Letter from Clr., Workers Party, Rio de Janeiro City Council in relation to parliamentary amendment being proposed (Emenda Aditiva nº 117 de 18/06/2020)
[E6] Letter from Head of Foundation for Children and Family (Funci), part of Fortaleza City Secretary of Human Rights and Social Development
[E7] Helping young people feel at home in Scotland: Building Collaborative and Integrated Services for Youth Homelessness through a Reflexive Mapping Approach. Video documentary. University of Dundee, SUII, 2020. Available at: https://www.scottishinsight.ac.uk/Programmes/ThemedCall201819/YoungPeopleatHome.aspx [Accessed 19 March 2021]
[E8] Letter from A Way Home Scotland
[E9] Letter from Pontifical Catholic University of Rio de Janeiro
[E10] Letter from Inclusion Health (Organisational Lead), Public Health Scotland
[E11] Scottish Government (2019) Greater protection for care leavers welcomed. Available at https://www.gov.scot/news/greater-protection-for-care-leavers-welcomed [Accessed 19 March 2021]
Additional contextual information
Grant funding
Grant number | Value of grant |
---|---|
N/A | £17,915 |
N/A | £2,000 |
N/A | £3,000 |
N/A | £2,200 |