Joyce Bredesen, DNP, RN

Transcription

1 A Comparison of Recommended Practice Guidelines for Health Care of the Homeless and the Current Health Status of Homeless Individuals and Families in an Urban Community as Assessed Through the Use of Photovoice Methodology Joyce Bredesen, DNP, RN

2 Identified Problem: Homelessness and Health Care Challenges Nationally, 3.5 million people experience homelessness within a given year. Thirty seven percent of the homeless populations are families, and the numbers are growing. There are approximately 9,300 people who experience homelessness on a given night in Minnesota, with the majority of them within the metro area of St. Paul and Minneapolis. Inaccessibility to health care can be related to financial issues, lack of resources and personal issues. (Bonin et al., 2010; HUD, 2009; NCH 2008; Wilder Foundation, 2009)

3 Purpose of Project Increase awareness of health care needs of homeless families within the community Comparison of National Guidelines for delivery of care to the homeless Empowerment of the participants Promote dialogue; involving local leaders, policy makers and the community that may lead to improvement of delivery of services to the homeless

4 Clinical Question Does a community forum increase community member awareness of service gaps through a comparison of practice guidelines and the actual experience of health care services of homeless families in St. Paul, Minnesota?

5 National Guidelines for Care of the Homeless Adapting Your Practice: General Recommendations for the Care of Homeless Patients (Bonin et al., 2010) Compared Guideline recommendations with the current health care experience of homeless adult family members within the city of St. Paul, Minnesota (Photovoice Assessment) Three areas of Guideline were addressed: Access and continuity of health care (including barriers and services) Basic needs (food, shelter, and safety) Social support

6 Methods Subjects: After Institutional Review Board Approval through the Minnesota State University, Mankato, 15 subjects were recruited to take part in the assessment. The subjects were homeless care providers of at least one child and were between the ages of 18 and 45 years old. Thirteen participants completed the assessment. Assessment: Through a photovoice assessment, participants were directed to take photographs of things that affect their health in relationship to the areas that are addressed in the Guideline. Three main areas of the Guideline were the focus of the project. These areas included: (a) access and continuity of health care (including barriers and services), (b) basic needs (food, shelter, safety), and (c) social support systems. Analysis: A comparative analysis was completed on the identified health care experiences as expressed through the photovoice assessment of the participants and the recommendations for delivery of care of the national Guideline. Intervention: A community forum was presented to share results of assessment and analysis, increase awareness, promote dialogue, and encourage change. Method for Evaluation: Likert Scale questionnaire given at Forum to determine intervention effectiveness.

7 Theoretical Framework Modeling and Role Modeling Theory (Erickson, 2006): Identifies the integration of the clients view of their world and the community where they live. The community surrounds the homeless client; it is the context of the client s world. An assessment process (Photovoice) helps to identify health needs and barriers experienced by the client. The Community Engagement Model: (International Association for Public Participation, 2005): Recognizes the importance of community partnerships. Health needs are identified and shared, empowering the community through the process of informing, consulting, involving, and collaborating.

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9 Photovoice Photovoice Methodology: Dr. Carolyn Wang Participatory Research method Elicits in-depth descriptions of a person s realities through pictures Intended Outcomes of Photovoice: Empowerment of Participants Increase community awareness Promote dialogue to bring about change *Cameras for this project donated by National Camera Exchange

10 Photovoice Assessment and Results 13 adult homeless care providers utilizing services in St. Paul 4 Males, 9 Females, years old 1 Caucasian, 1 Hispanic, 11 Black Total of 24 children Met with participants 3 times Results (Guideline areas) Health Care Access-11 of 13 participants had insurance Barriers included co-pays, transportation, follow-up, primary care Food- All 13 participants had access to food at least 2 meals/day lack of nutritional choices Safety- 7 discussed concerns of safety for self and belongings Support- All stated they had good support systems when initially homeless ( Used up support system and resources over time) Shelter- Of the 13 participants, only one family spent one night together on the street (homeless time period-1 month to 10 years)

11 Intervention: Community Forum-Results Approximately 120 people attended the Community Forum. 83 completed the likert questionnaire-(69%) Of those who completed the questionnaire: o 92% agreed or strongly agreed that the Forum increased their awareness of homeless individuals and family s needs o 89% of those who completed the questionnaire agreed or strongly agreed that the Forum increased their awareness of the National Guidelines for the homeless in delivery of healthcare and services. o 92% of those who completed the questionnaire agreed or strongly agreed the forum encouraged them to talk to their policy makers and leaders regarding the needs of those who are experiencing homelessness.

12 Recommendations for Community related to Guideline, input from Community (focus groups), and input from Photovoice Assessment Participants Housing/Shelter: Easier access to housing that is available. More affordable housing opportunities. Address spend down issue in relationship to housing opportunities. Safety: Address resources needed to keep families safe and make sure information and resources are available to homeless families. Food/Nutrition: Make more nutritious food choices available for families experiencing homelessness. Educate both community and those experiencing homelessness on nutritional needs. Encourage communities to meet needs. Resources/Support: Centralize resources, have all in one place. Do more outreach, awareness and education within community to address the needs. Coordinate services and referrals. Health Care Access/Concerns: Offer integrated, interdisciplinary services at multiple points accessible to the homeless population (shelters, drop-in centers, clinics, churches, schools).

13 Clinical Practice Implications Improved delivery of services through application of guidelines. (Written recommendations share with local healthcare and service providers) Community partnerships. Future plan- replicate project in other communities to promote better health outcomes for the homeless.

14 Slide Show The Face of Homelessness Within our own Community

15 Acknowledgements Thank you to the participants for sharing their photographs and stories. Thank you to the Wellness Center and the community for offering support and resources for the families and individuals who are experiencing homelessness. Thank you to Dr. Marcia Stevens, Dr. Sue Ellen Bell, and Dr. Marjorie Schaffer for their support during this DNP project. Financial support: The Becky Taylor Scholarship, Minnesota State University, Mankato.

16 QUESTIONS?

17 References Acosta, O., & Toro, P. (2000). Let s ask the homeless people themselves: A needs assessment based on a probability sample of adults. American Journal of Community Psychology, 28(3), Bonin, E., Brehove, T., Kline, S., Misgen, M., Post, P., Strehlow, A. J., Yungman, J. (2010). Adapting Your Practice: General Recommendations for the Care of Homeless Patients. Nashville: Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc. Burns, N., & Grove, S. K. (2005). Practice of nursing research: Conduct, critique, and utilization. St. Louis: Elsevier Saunders. Catalani, C., & Minkler, M. (2009). Photovoice: A review of the literature in health and public health. Health Education and Behavior, Doi: / Cluzeau, F., Burgers, J., Brouwers, M., Grol, R., et al. AGREE Collaboration. (2003). Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: The AGREE project. Quality & Safety in Health Care, 12 (1), Coopey, M., Nix, M. P., & Clancy, C. M. (2006). Translating research into evidence-based nursing practice and evaluating effectiveness. Journal of Nursing Care Quality, 21(3), Daiski, I. (2007). Perspectives of homeless people on their health and health needs priorities. Journal of Advanced Nursing, 58(3), Emanuel, E. J., & Titlow, K. (2002). Evaluating community-based health initiatives: Identifying the characteristics of successful initiatives and evaluations. Journal of Health Politics, Policy and Law, 27(1), Erickson, H. (2006). Model and Role-Modeling: A view from the clients world. Cedar Park, TX: Unicorns Unlimited. Erickson, H. C., Tomlin, E. M., & Swain, M. P. (1983). Modeling and Role-Modeling: A theory and paradigm for nursing. Englewood Cliffs, NJ: Prentice-Hall. Flick, U. (2007). Homelessness and Health: Challenges for health psychology. Journal of Health Psychology. 12(5) Gasper, P. (2009). Research quality review form. Gillis, L. M., & Singer, J. (1997). Breaking through the barriers: Healthcare for the homeless. The Journal of Nursing Administration 27(6), Goodhart, W., Hsu, J., Baek, J. H., Coleman, A.L., Maresca, F.M., & Miller, M.B. (2006). A view through a different lens: Photovoice as a tool for student advocacy. Journal of American College Health (55)

18 References (cont.) Halifax, N.V. D., Yurichuk, F., Meeks, J., & Khandor, E. (2008). Photovoice in a Toronto community partnership: Exploring the social determinants of health with homeless people. Progress in Community Health Partnerships: Research, Education, and Action 2(2), Hergenrather, K. C., Rhodes, S. D., Cowan, C. A., Bardhoshi, G., & Pula, S. (2009). Photovoice as Community-Based participatory research: A qualitative review. American Journal of Health Behavior, 3(6), Hertz, J. E. (1997). Modeling and Role-Modeling Theory: An introduction. Retrieved from Hodgetts, D., Radley, A., Chamberlain, K., & Hodgetts, A. (2007). Health inequalities and homelessness: Considering material, spatial and relational dimensions. Journal of Health Psychology, 12(5), Hwang, S.W., Tolomiczenko, G., Kouyoumdjian, F. G., & Garner, R. E. (2005). Interventions to improve the health of the homeless: A systematic review. American Journal of Preventive Medicine, 29(4), Joanna Briggs Institute (2008). Retrieved from Jurkowski, J. M., & Paul-Ward, A. (2007). Photovoice with vulnerable populations: Addressing disparities in health promotion among people with intellectual disabilities. Health Promotion Practice, 8(4), Martins, D. C. (2008). Experiences of homeless people in the health care delivery system: A descriptive phenomenological study. Public Health Nursing 25, National Center on Family Homelessness (2010). Retrieved from National Coalition for the Homeless (2007). Health care and homelessness. Retrieved from National Coalition for the Homeless (2008a). NCH Fact Sheet #8: McKenny-Vento Act. Retrieved from National Coalition for the Homeless (2008b). NCH Fact Sheet #1: Why are people homeless? Retrieved on October 23, 2008 from National Coalition for the Homeless (2008c). NCH Fact Sheet #2: How many people experience homelessness? Retrieved from National Guideline Clearinghouse (2008). Retrieved from National Health Care for the Homeless Council (2008). Health care for the homeless: Comprehensive services to meet complex needs. Retrieved from Power, R., & Hunter, G. (2001). Developing a strategy for community-based health promotion targeting homeless populations. Health Education Research, 16(5), Powell, D. L., Gilliss, C. L., Hewitt, H. H., & Flint, E. P. (2010). Application of a partnership model for transformative and sustainable international development. Public Health Nursing, 27(1),

19 References (cont.) Rhodes, S. D., Hergenrather, K. C., Wilkin, A. M., & Jolly, C. (2008). Visions and voices: Indigent persons living with HIV in the southern United States use Photovoice to create knowledge, develop partnerships, and take action. Health Promotion Practice, Doi: / Roche, B. (2004). Multiple health needs and homeless people. Primary Health Care, 14(7), Smith, S. P. (1999). Homelessness as a lifestyle: A risk factor. Home Health Care Management Practice 11(4), Strack, R., Magill, C., & McDonagh, K. (2004). Engaging youth through Photovoice. Health Promotion Practice, 5(1), Strehlow, A. J., Kline, S., Zerger, S., Zlotnick, C., & Proffitt, B. (2005). Health care for the homeless assesses the use of adapted clinical practice guidelines. Journal of the American Academy of Nurse Practitioners, 17(11), U.S. Department of Housing and Urban Development [HUD], (2009). The 2009 Homeless Assessment Report. Retrieved from U. S. Department of Health and Human Services. (1998b). Health Care for the Homeless Outcome Measures: A Chronicle of Twenty Pilot Studies. Washington, DC: HRSA/BPHC/DPSP/HCH Branch. Wang, C. C. (2006). Youth participation in Photovoice as a strategy for community change. Youth Participation and Community Change, Doi: /J125v14n01_09 Wang, C. & Burris, M. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24(3), Wang, C. C., Cash, J. L., & Powers, L. S. (2000). Who knows the streets as well as the homeless? Promoting personal and community action through Photovoice. Health Promotion Practice, 1(1), Wang, C. C., Morrel-Samuels, S., Hutchison, P. M., Bell, L., & Pestronk, R. M. (2004). Flint Photovoice: Community building among youths, adults, and policymakers. American Journal of Public Health, 94(6), Wang, C. C., Yi, W. K., Tao, Z. W., & Carovano, K. (1998). Photovoice as a participatory health promotion strategy. Health Promotion International, 13(1), Wilder Foundation (2006). Addressing homelessness: A needs assessment and plan for the seven county metro area. Retrieved from Wilder Foundation (2009) Minnesota Homeless study Fact sheet. Retrieved from

20 Thank You!