Social Work in Public Health, 30:30–37, 2015 Copyright q Taylor & Francis Group, LLC ISSN: 1937-1918 print/1937-190X online DOI: 10.1080/19371918.2014.938391
Using Community-Based Participatory Research to Advocate for Homeless Children Debra L. Fetherman Community Health Education Program, University of Scranton, Scranton, Pennsylvania, USA
Stephen C. Burke Social Work Department, Marywood University, Scranton, Pennsylvania, USA
The social determinants of health represent the societal and economic influences responsible for most health inequities. Advocacy to eliminate health inequities for homeless children oftentimes involves the use of community-based approaches. This article details the Floating Hospital’s (TFH) communitybased participatory research (CBPR) project that resulted in an advocacy brief. Within the project, the community practice concepts of a strengths perspective, empowerment, capacity building, and advocacy are embedded. The brief enhances TFH’s capacity to advocate for the needs of homeless children. This example serves as a guide for social work and public health professionals to use CBPR to address health inequities within their communities. Keywords: Community-based participatory research, homeless, advocacy, social determinants
INTRODUCTION The social determinants of health represent the societal and economic influences that are responsible for most health inequities (Commission on Social Determinants of Health, 2008). The social determinants of health provide a framework to address the health inequities of children and adolescents (Jones et al., 2009; U.S. Department of Health and Human Services, 2013). Many social factors affect children in poverty and their quality of life and health later in life (Holzer, Schanzenbach, Duncan, & Ludwig, 2007). Access to educational programs is one such factor affecting the health of homeless children (Boxill, 1990; Downer, 2001; Holzer et al., 2007; Nunez, 2004, 2001). In fact, access to education is one of the strongest determinants of adolescent health worldwide along with national wealth and income inequality (Viner et al., 2012). To address access to education programs for homeless children and, ultimately, their health, the importance of building coalitions and coordinating services is echoed throughout the literature (Nunez, 2001; Smith, Flores, Lin, & Markovic, 2005). After a systematic review, researchers emphasized the importance of public health professionals to provide information to policy makers to help deter child and family homelessness (Grant, Gracy, Goldsmith, Shapiro, & Redlener, 2013). A recommended public health practice is for community-based prevention services to act as part of a coalition when advocating for services for homeless children (Institute for Children and Poverty, Address correspondence to Debra L. Fetherman, PhD, Human Development, Health Promotion, University of Scranton, Exercise Science and Sport, 143 Long Center, Scranton, PA 18510, USA. E-mail: [email protected]
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2008; Special Master Panel, 2003). Community service agencies oftentimes do not have the capacity to advocate for the individuals they serve due to limited resources or their inability to recognize their resources (Saleebey, 2012). Public health professionals can aid agencies to build their advocacy efforts through community-based participatory research (CBPR). Community-based participatory research is action research that can help agencies discover their capabilities and capacities for social change to reduce health inequities and disparities (Minkler & Wallerstein, 2008). Many community agencies focus on educational reform as a critical component in breaking the cycle of generational poverty and homelessness (Mawhinney-Rhoads & Stahler, 2006). Reducing the barriers that homeless children face in accessing primary education is a focus of the Floating Hospital (TFH) health services and programs. The Floating Hospital is a major provider of primary health care for New York City’s (NYC) families and children in homeless shelters. The TFH was originally chartered in 1872 to “afford relief to the sick children of the poor of the city of New York without regard to creed, color, or nationality” (Tosoro, 1985, p. 1). In School Year 2009 to 2010, TFH provided primary health care to 4,340 6- to 11-year-old children in NYC homeless shelters (I. Gonzalez, TFH communication, Nov. 11, 2010). Thirty-seven percent of these children carried a diagnosis that indicated the necessity to maintain current participation in, or indicated a need for admission to, a school-based health program (I. Gonzalez, TFH communication, Nov. 11, 2010). In general, diagnoses included emotional and behavioral difficulties related to multiple family stressors, individual abuses, and transitions. Multiple family stressors included involvement with child protective services, foster care (separation from parents), parental unemployment, parental substance abuse, physical abuse, molestation, domestic violence, parental deportation, and incarceration. Individual behaviors and problems included speech/language delays, seizure-like activity, “reckless behavior,” cannabis abuse, and academic problems. The TFH promotes school readiness for homeless children through its BUILDING BLOCKS: A Healthy Start to School Success initiative. The initiative provides medical resources so homeless children can meet the NYC Department of Education requirements to enroll into daycare, preschool, and K-12. The TFH provides primary health care services for all ages (including vaccinations), dental care, and mental health care. Part of TFH, the KidZone Learning Center also offers health education services such an individual counseling and group activities to address the nutrition, hygiene, and other health-related needs as a result of shelter living. Other TFH services include providing access to breakfast/lunch subsidies, after-school care programs, participation in extracurricular activities, and school-provided counseling and psychological services. To expand its health prevention initiatives to promote access to primary education among homeless children, TFH staff, including administrators, health educators, and other health professionals, met with academic researchers. The primary CBPR action goal identified by TFH was to be able to advocate at the New York State General Assembly for the preventive health needs of homeless children to access education. An advocacy brief was developed to assist the agency to tell its story as part of advocacy efforts. The advocacy brief can enhance the capacity of those agencies or groups to advocate for policies in support of the individuals and groups served (Jansson, 2011). The intent of this article is (a) to highlight the key social determinants that influence access to education for homeless children and (b) to describe the CBPR project that aided in building TFH’s capacity to advocate for its preventive health services that remove barriers that homeless children face when trying to access education. The role of the community practice concepts of a strengths perspective, empowerment, capacity building, and advocacy are explained as the CBPR project is described. The project resulted in an advocacy brief grounded in the professional literature, capacities of TFH, and the needs of homeless children. The hope is that this example will serve as a guide for other public health professionals to explore the use of CBPR and the inherent community practice concepts within their own community practices.
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KEY SOCIAL DETERMINANTS OF HOMELESS CHILDREN CONCERNING ACCESS TO EDUCATION Among the fastest growing segments of the homeless population are families with children (National Coalition for the Homeless, 2008). For example, of the 36,905 people in NYC homeless shelters, 41% of these shelter residents were children (NYC Department of Homeless Services, 2011). The NYC Department of Homeless Services (2009) indicates an increase of nearly 27% in the amount of children admitted to NYC homeless shelters from July 1996 to July 2006. Compounding the initial homelessness, homeless families tend to experience significant spells of housing instability during transitions from shelter to postshelter and back to more permanent housing arrangements (National Coalition for Homeless, 2009). As a result, homeless children have difficulty accessing public school education during these spells of housing instability and homelessness (Mawhinney-Rhoads & Stahler, 2006; National Network for Youth, 2008). There are a variety of obstacles to access public school education for homeless children, such as residential policies, which further complicate a homeless child gaining or maintaining access to educational resources. School districts or schools usually require that a child has proof of residency, a parent or guardian, and proof of required vaccinations to enroll in school (Mawhinney-Rhoads & Stahler, 2006). Proof of residency is difficult to establish while in homeless shelters or other types of transitional housing situations (i.e., living with other relatives, multiple families). Homeless children may be living with a family member who is not a legal guardian or may be a runaway with no legal guardian available (Mawhinney-Rhoads & Stahler, 2006). During transient times, homeless families carry minimal belongings, may lose medical records, or delay immunizations. A retrospective study of the NYC Department of Health records found that homeless children were 4 times underimmunized compared to housed low-income children (Alperstein, Rappaport, & Flanigan, 1988). As a response to the obstacles faced by homeless children to access and sustain an education, in 1987, the U.S. Congress passed the landmark McKinney Education of Homeless Children and Youth Act of 1986 (National Coalition for the Homeless, 2008). The McKinney Act was the first federal act to provide homeless children equal access to education by focusing on the elimination of educational barriers from homeless children (Butler, 1994). In 2002, the McKinney Act was reauthorized as part of No Child Left Behind and renamed the McKinney-Vento Homeless Assistance Act, mandating (among other things) that homeless children be allowed to enroll in school regardless of their ability to meet documentation requirements. The reauthorization also prohibited any type of segregation of homeless students (McKinney-Vento Homeless Assistance Act, 2002). If policy barriers are overcome by homeless children, there are still limitations due to the unique circumstances of homelessness that affect school attendance. Limitations range from transportation, disruption in education, teacher –peer relationships, to other issues (Brown, 1991; Masten et al., 1997; Rafferty, 1999; Stronge, 1993, 2000). Transportation is one of the most frequent barriers. Homeless children often reside in shelters outside their school districts and thus have no transportation to school or must travel quite a distance each day to attend school. The inability to have adequate transportation to school often results in extended absences from school and inconsistent attendance can affect grade progression in school (Bowman, Dukes, & Moore, 2012; Rafferty, Shinn, & Weitzmann, 2004). Homeless children reportedly demonstrate noncompliant behaviors, shorter attention spans, more sleep disturbances, lack of peer acceptance, emotional instability, poor self-concept, and shame (Boxill, 1990; Downer, 2001; Rafferty, 1999; Stronge, 1993) that can affect success in school. Collectively, the unique experiences associated with being homeless create a cumulative stress resulting in high rates of academic as well as mental and behavioral problems for children (National Child Traumatic Stress Network, 2005; Sameroff & Rosenblum, 2006).
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The need for a social determinants approach to addressing the education needs of homeless children is echoed throughout the literature (Julianelle & Foscarinis, 2003). The specific types of educational reforms for homeless children can vary. Stronge (1993) described four general types of educational reform: mainstreamed, supplemental support, transitional, and modified comprehensive approaches. Mainstream reform efforts incorporate homeless children into existing schools. Mainstream policy focuses on the lack of permanent housing as the only difference between homeless and domiciled children and supports the educational values of socialization and stability. Supplemental support services are based on the concept of after-school programs directly targeting the needs of homeless students. Special needs may be either focused academically (i.e., tutoring, school supplies, study areas) or aimed at counseling promoting emotional well-being. Transitional schools are usually attached to shelters and made up of only homeless students. The goal is to provide a temporary education to help children transition to mainstreamed schools while removing the barriers of residency, transportation, guardianship, and medical records. Lastly, modified comprehensive schools are housed at educational institutions that follow transitional approaches with one grade per classroom removing the typical immediate barriers of homeless children. As families seek permanent residence, children are mainstreamed into school. Stronge’s (2000) approach along with other authors emphasizes the need to include a collaboration of agencies and individuals to improve access to education for homeless children regardless of the type of educational reform (Mawhinney-Rhoads & Stahler, 2006; Tobin & Murphy, 2013). The CBPR project detailed next outlines TFH’s use of community practice concepts to address the social determinants in a collaborative way to reduce the access barriers to education that homeless children face.
IMPLICATIONS FOR PRACTICE: THE USE OF COMMUNITY PRACTICE CONCEPTS In practice, TFH utilized a collaborative community approach to address the educational barriers that homeless children face (Stronge, 2000). The use of a CBPR approach is also compatible with the strengths perspective and the empowerment stance associated with the social work and community practice in public health. The focus on community and agency-level systems is encouraged to actively self-determine relative to project focus, execution, and postproject implementation. All phases of a project require the employment of a range of activities supporting community practice concepts for that project to move to the completion stage. Active listening skills are particularly crucial when negotiating, and reframing, the discussion around the project focus during capacity building. Community-based participatory research embodies the community practice concepts of a strengths perspective, empowerment, capacity building, and advocacy (Minkler & Wallerstein, 2008). TFH project utilized these community practice concepts throughout the process to create an advocacy brief. Outcomes like an advocacy brief can enhance the capacity of agencies to advocate and effect policy changes. Practice concepts were intertwined and interdependent of each other throughout the project. The concepts helped researchers and TFH to organize the project while clarifying the relevant barriers homeless children face when accessing education. In the following subsections, each practice concept is defined and how the concept was used to learn about the needs of homeless children to develop the advocacy brief is explained. Strengths perspective. Saleebey (2012) defined a strengths perspective as helping a client system to discover their resources in the service of assisting them to achieve their goals. The process of creating the advocacy brief required TFH to reflect internally to discover its own resources. By indentifying internal strengths an agency’s capacity to serve others is enhanced (Ayon & Lee, 2009; Saleebey, 2012). The TFH gained perspective by identifying its strengths
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through targeted internal data gathering, utilization of agency archival materials, and individual case summaries. These types of resources are common to most agencies. Internal data. To support the project goal of advocating for the needs of homeless children to access primary education, internal data gathering focused on the needs of at-risk 6- to 11-year-old shelter residents with a mental health and /or physical-related diagnosis requiring participation in a school-based or school sponsored program. Attendance-related data of at-risk children in shelter care was also developed to develop baselines for future outreach initiatives of the agency. Under the supervision of project researchers, TFH executed a random sampling of shelter residents sorted by age and sex in its database. Medical records were also reviewed for indications of participation in special needs school-based school-sponsored programs. Institutional Review Boards approved all data collection. Data detailing participation of homeless children in school-based programs highlighted in the advocacy brief confirmed the need in this area. Archival data. TFH’s historical legacy of service was identified through archival photographs and historical newspaper accounts. TFH’s service began in 1894 when children were treated on a ship located in the harbor. TFH has a compelling history addressing NYC’s cholera, smallpox, and diphtheria epidemics dating back to the 1870s, as well as addressing the general health needs of the city’s poorest of the poor (Bushel, 1966; St. John’s Guild, 1878). The advocacy brief included the photos highlighting the longstanding commitment of TFH to homeless children. Individual case summaries. TFH’s mental health staff submitted three typical case summaries of homeless children that showcased the complexities of the families in shelter care. The case summaries supported the primary issues found in the literature related to access to education for homeless children ranging from emotional, behavioral difficulties to multiple family stressors. Quotes from the case summaries were used to organize the headings and create bullet statements for emphasis in the advocacy brief. Empowerment. Empowerment enables systems to achieve a creative sense of power through enhanced self-respect, knowledge, and skills (National Association of Social Work, 2010). As part of the CBPR approach, a concurrent photovoice strategy was initiated to empower TFH’s parent consumer base. Photovoice can also enhance understanding of community assets, needs, and empowerment (Catalani & Minkler, 2010). “Photovoice is a process in which people identify, represent, and enhance their community through a specific photographic technique” (Wang & Burris, 1997, p. 369). Photovoice created an opportunity for TFH parents to take photographs to record the barriers to accessing education that their children face. The photograph as a visual image enhances a person’s ability to tell a story in his or her own words (Wang & Burris, 1997). The following barriers to accessing education for their children were identified: (a) transportation, (b) housing, (c) school environment, (d) employment, (e) child care, and (f) community support. All data collection was approved by university Institutional Review Boards. By empowering its consumers along with identifying internal data, TFH was able to identify these barriers and define them clearly in the advocacy brief that enhanced its capacity to advocate for homeless families and children. Capacity building. Capacity building is a process in which individuals/organizations gain knowledge, skills, and confidence to improve their lives or that of those they serve. Through the capacity-building process individuals/organizations apply what is learned in political, social, and economic ways (Ayon & Lee, 2009; Easterling, 2008; Gibbon, Labonte, & Laverack, 2002). Knowing its internal strengths, TFH examined its external environment to identify sources of data useful for its advocacy initiative and the potential like-minded agencies that may be interested in collaborative advocacy (Easterling, 2008; Jansson, 2011). The NYC Department for Homeless Services and the NYC Department of Education were identified. These two agencies provided data
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on the average school attendance rates of homeless children categorized by gender. This initial collaboration helped build TFH’s confidence in developing future collaborations. The data was included in the advocacy brief and substantiated the growing number of NYC homeless children needing access to primary education. Advocacy. Jansson (2011) described public advocacy as practices that aim to assist relatively powerless, oftentimes marginalized, groups of people to improve their resources and opportunities. By using the practice concepts of a strengths perspective, empowerment, and capacity building the advocacy brief was developed. The content of the brief was formed by an analysis of the agency’s legacy, case summaries, internal/external quantitative data, and issues supported by photovoice data as well as grounded in the literature. The advocacy brief uses photos and narrative to tell TFH’s story of serving homeless children and the barriers these children face when accessing education. From the impact that extended bus rides from shelter to school have on school attendance and performance to the identification of family risk factors associated with returning to shelter care, each talking point is clearly delineated and succinctly summarized. The brief concludes with a call to support TFH preventive health services and programs that aid in removing the barriers homeless children face when accessing a school education.
CONCLUSIONS The TFH project illustrates that CBPR research that utilizes the practice concepts of a strengths perspective, empowerment, capacity building, and advocacy can have a role in social change with researchers, public health professionals, and community working together. The key social determinants affecting access to education for homeless children identified through this approach were used to develop the advocacy brief. The TFH discovered its ability to use resources such as its legacy, case summaries, and quantitative reports to support advocacy efforts. Collaboration with researchers and other organizations aided the effort. Developing the advocacy brief through the CBPR process gave TFH new skills and knowledge. The capacity of TFH to advocate for preventive health services to help homeless children access education was enhanced. This example serves as a guide for public health professions and social workers to use CBPR to address health inequities and health disparities in their communities through a social determinants approach.
REFERENCES Alperstein, G., Rappaport, C., & Flanigan, J. M. (1988). Health problems of homeless children in New York City. American Journal of Public Health, 78(9), 1232–1233. Ayon, C., & Lee, C. D. (2009). Building strong communities: An evaluation of a neighborhood leadership program in a diverse urban area. Journal of Community Psychology, 37(8), 975 –986. Bowman, D., Dukes, C., & Moore, J. (2012). Summary of the state of research on the relationship between homelessness and academic achievement among school-aged children and youth. National Center for Homeless Education. Retrieved from http://srvlive.serve.org/nche/dowsloads/nche_research_pub.pdf Boxill, N. A. (1990). Homeless children: The watchers and waiters. New York, NY: Haworth. Brown, P. A. (1991). Educating homeless children and youth. Journal of Healthcare for the Poor and Underserved, 2(1), 189–195. Bushel, A. (1966). Chronology of New York City Department of Health (and its predecessor agencies) 1655–1966. New York, NY: New York City Department of Health. Butler, S. S. (1994). Middle-aged, female and homeless: The stories of a forgotten group. New York, NY: Garland. Catalani, C., & Minkler, M. (2010). Photovoice: A review of the literature in health and public health. Health Education & Behavior, 37, 424– 451. doi:10.1177/1090198109342084
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Commission on Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on the social determinants of health (Final report of the Commission on Social Determinants of Health). Geneva, Switzerland: World Health Organization. Downer, R. T. (2001). Homelessness and its consequences: The impact on children’s psychological well being. New York, NY: Routledge. Easterling, D. (2008). The leadership role of community foundations in building social capital. National Civic Review, 97(4), 39 –51. Gibbon, M., Labonte, R., & Laverack, G. (2002). Evaluating community capacity. Health & Social Care in Community, 10(6), 485 –491. Grant, R., Gracy, D., Goldsmith, G., Shapiro, A., & Redlener, I. E. (2013). Twenty-five years of child and family homelessness: Where are we now? American Journal of Public Health, 103, e1–e10. doi:10.2105/AJPH.2013.301618 Holzer, H. J., Schanzenbach, D. W., Duncan, G. J., & Ludwig, J. (2007). The economic cost of poverty in the United States: Subsequent effects of children growing up poor. Washington, DC: National Poverty Center. Institute for Children and Poverty. (2008, August). Failure at the four-year mark: A look at New York City’s plan to end homelessness. New York, NY: Author. Jansson, B. (2011). Becoming an effective policy advocate: From policy practice to social justice (6th ed.). Pacific Grove, CA: Brooks/Cole. Jones, C. P., Jones, C. Y., Perry, G. S., Barclay, G., & Jones, C. A. (2009, November). Addressing the social determinants of children’s health: A cliff analogy. Journal of Health Care for the Poor and Underserved, 20(4, Suppl), 1– 12. Julianelle, P., & Foscarinis, M. (2003). Responding to the school mobility of children and youth experiencing homelessness: The McKinney-Vento Act and beyond. Journal of Negro Education, 72(1), 39–54. Masten, A. S., Sesman, A., Si-Awar, R., Lawrence, C., Miliotis, D., & Dionne, J. A. (1997). Educational risks for children experiencing homelessness. Journal of School Psychology, 36(1), 28 –46. Mawhinney-Rhoads, L., & Stahler, G. (2009). Educational policy and reform for homeless students: An overview. Education and Urban Society, 38, 288–306. McKinney-Vento Homeless Assistance Act, 42 U.S.C. 722 –725, G. (2002). Minkler, M., & Wallerstein, N. (2008). Community-based participatory research for health: From process to outcomes (2nd ed.). San Francisco, CA: Jossey-Bass. National Association of Social Work. (2010). Encyclopedia of social work (2nd ed.). Washington, DC: National Association of Social Work Press. National Child Traumatic Stress Network. (2005). Facts on trauma and homeless children, Rockville, MD: Author. National Coalition for the Homeless. (2008). Education of homeless children and youth. Washington, DC: Author. National Coalition for the Homeless. (2009, July). Homeless families with children. Washington, DC: Author. National Network for Youth. (2008). Issue brief: Education barriers for homeless youth. Washington, DC: Author. New York City Department of Homeless Services. (2009, June). Critical activities report: Family services-fiscal year 2009. New York, NY: Author. New York City Department of Homeless Services. (2011, July). Statistics and reports. New York, NY: Author. Nunez, R. (2001, Autumn). Family homelessness in New York City: A case study. Political Science Quarterly, 116(3), 367 –379. Nunez, R. (2004). A shelter is not a home . . . or is it? New York, NY: White Tiger Press. Rafferty, Y. (1999). Legal issues in educating homeless children. Journal for a Just and Caring Education, 5, 19–33. Rafferty, Y., Shinn, M., & Weitzmann, B. C. (2004). Academic achievement among formerly homeless adolescents and their continuously housed peers. Journal of School Psychology, 42(3), 179–199. Saleeby, D. (2012). The strengths perspective in social work practice (6th ed.). Boston, MA: Pearson. Sameroff, A. J., & Rosenblum, K. L. (2006). Psychosocial constraints on the development of resilience. Annuals of the New York Academy of Sciences, 1094, 116–124. Smith, N., Flores, Z. D., Lin, J., & Markovic, J. (2005). Understanding family homelessness in New York City: An in-depth study of families’ experiences before and after shelter. New York, NY: Vera Institute of Justice. Special Master Panel. (2003, November). Family homelessness prevention report. New York, NY: Author. Stronge, J. H. (1993). Educating homeless students in urban settings: An introduction to issues. Education and Urban Society, 26, 314 –322. Stronge, J. H. (2000). Educating homeless children and youth: An introduction. In J. H. Stronge & E. Reed-Victor (Eds.), Educating homeless students: Promising practices (pp. 1–19). Larchmont, NY: Eye on Education. St. John’s Guild. (1872–1878). Board Minutes. (Meeting minutes). Meeting presented at St. John’s Guild, New York City, NY. Tobin, K., & Murphy, J. (2013). Addressing the challenges of child and family homelessness. Journal of Applied Research on Children: Informing Policy for Children at Risk, 4(1), 1– 29. Retrieved from http://digitalcommons.library.tmc.edu/chi ldrenatrisk/vol4/iss1/9
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Tosoro, L. J. (1985). The origin of the Floating Hospital of St. John’s Guild: The retelling of a story in historical, medical perspective (Master’s thesis). Yale University. U.S. Department of Health & Human Services, Office of Disease Prevention and Promotion. (2013). Healthy People 2020. Washington, DC: Author. Retrieved from www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid¼2 Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., & Currie, C. (2012). Adolescence and the social determinants of health. Lancet, 379(9826), 1641–1652. Wang, C., & Burris, M. A. (1997). Photovoice: Concept, methodology, and use for participatory needs assessment. Health Education & Behavior, 24(3), 369–387.
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Using Community-Based Participatory Research to Advocate for Homeless Children Debra L. Fetherman Community Health Education Program, University of Scranton, Scranton, Pennsylvania, USA
Stephen C. Burke Social Work Department, Marywood University, Scranton, Pennsylvania, USA
The social determinants of health represent the societal and economic influences responsible for most health inequities. Advocacy to eliminate health inequities for homeless children oftentimes involves the use of community-based approaches. This article details the Floating Hospital’s (TFH) communitybased participatory research (CBPR) project that resulted in an advocacy brief. Within the project, the community practice concepts of a strengths perspective, empowerment, capacity building, and advocacy are embedded. The brief enhances TFH’s capacity to advocate for the needs of homeless children. This example serves as a guide for social work and public health professionals to use CBPR to address health inequities within their communities. Keywords: Community-based participatory research, homeless, advocacy, social determinants
INTRODUCTION The social determinants of health represent the societal and economic influences that are responsible for most health inequities (Commission on Social Determinants of Health, 2008). The social determinants of health provide a framework to address the health inequities of children and adolescents (Jones et al., 2009; U.S. Department of Health and Human Services, 2013). Many social factors affect children in poverty and their quality of life and health later in life (Holzer, Schanzenbach, Duncan, & Ludwig, 2007). Access to educational programs is one such factor affecting the health of homeless children (Boxill, 1990; Downer, 2001; Holzer et al., 2007; Nunez, 2004, 2001). In fact, access to education is one of the strongest determinants of adolescent health worldwide along with national wealth and income inequality (Viner et al., 2012). To address access to education programs for homeless children and, ultimately, their health, the importance of building coalitions and coordinating services is echoed throughout the literature (Nunez, 2001; Smith, Flores, Lin, & Markovic, 2005). After a systematic review, researchers emphasized the importance of public health professionals to provide information to policy makers to help deter child and family homelessness (Grant, Gracy, Goldsmith, Shapiro, & Redlener, 2013). A recommended public health practice is for community-based prevention services to act as part of a coalition when advocating for services for homeless children (Institute for Children and Poverty, Address correspondence to Debra L. Fetherman, PhD, Human Development, Health Promotion, University of Scranton, Exercise Science and Sport, 143 Long Center, Scranton, PA 18510, USA. E-mail: [email protected]
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2008; Special Master Panel, 2003). Community service agencies oftentimes do not have the capacity to advocate for the individuals they serve due to limited resources or their inability to recognize their resources (Saleebey, 2012). Public health professionals can aid agencies to build their advocacy efforts through community-based participatory research (CBPR). Community-based participatory research is action research that can help agencies discover their capabilities and capacities for social change to reduce health inequities and disparities (Minkler & Wallerstein, 2008). Many community agencies focus on educational reform as a critical component in breaking the cycle of generational poverty and homelessness (Mawhinney-Rhoads & Stahler, 2006). Reducing the barriers that homeless children face in accessing primary education is a focus of the Floating Hospital (TFH) health services and programs. The Floating Hospital is a major provider of primary health care for New York City’s (NYC) families and children in homeless shelters. The TFH was originally chartered in 1872 to “afford relief to the sick children of the poor of the city of New York without regard to creed, color, or nationality” (Tosoro, 1985, p. 1). In School Year 2009 to 2010, TFH provided primary health care to 4,340 6- to 11-year-old children in NYC homeless shelters (I. Gonzalez, TFH communication, Nov. 11, 2010). Thirty-seven percent of these children carried a diagnosis that indicated the necessity to maintain current participation in, or indicated a need for admission to, a school-based health program (I. Gonzalez, TFH communication, Nov. 11, 2010). In general, diagnoses included emotional and behavioral difficulties related to multiple family stressors, individual abuses, and transitions. Multiple family stressors included involvement with child protective services, foster care (separation from parents), parental unemployment, parental substance abuse, physical abuse, molestation, domestic violence, parental deportation, and incarceration. Individual behaviors and problems included speech/language delays, seizure-like activity, “reckless behavior,” cannabis abuse, and academic problems. The TFH promotes school readiness for homeless children through its BUILDING BLOCKS: A Healthy Start to School Success initiative. The initiative provides medical resources so homeless children can meet the NYC Department of Education requirements to enroll into daycare, preschool, and K-12. The TFH provides primary health care services for all ages (including vaccinations), dental care, and mental health care. Part of TFH, the KidZone Learning Center also offers health education services such an individual counseling and group activities to address the nutrition, hygiene, and other health-related needs as a result of shelter living. Other TFH services include providing access to breakfast/lunch subsidies, after-school care programs, participation in extracurricular activities, and school-provided counseling and psychological services. To expand its health prevention initiatives to promote access to primary education among homeless children, TFH staff, including administrators, health educators, and other health professionals, met with academic researchers. The primary CBPR action goal identified by TFH was to be able to advocate at the New York State General Assembly for the preventive health needs of homeless children to access education. An advocacy brief was developed to assist the agency to tell its story as part of advocacy efforts. The advocacy brief can enhance the capacity of those agencies or groups to advocate for policies in support of the individuals and groups served (Jansson, 2011). The intent of this article is (a) to highlight the key social determinants that influence access to education for homeless children and (b) to describe the CBPR project that aided in building TFH’s capacity to advocate for its preventive health services that remove barriers that homeless children face when trying to access education. The role of the community practice concepts of a strengths perspective, empowerment, capacity building, and advocacy are explained as the CBPR project is described. The project resulted in an advocacy brief grounded in the professional literature, capacities of TFH, and the needs of homeless children. The hope is that this example will serve as a guide for other public health professionals to explore the use of CBPR and the inherent community practice concepts within their own community practices.
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KEY SOCIAL DETERMINANTS OF HOMELESS CHILDREN CONCERNING ACCESS TO EDUCATION Among the fastest growing segments of the homeless population are families with children (National Coalition for the Homeless, 2008). For example, of the 36,905 people in NYC homeless shelters, 41% of these shelter residents were children (NYC Department of Homeless Services, 2011). The NYC Department of Homeless Services (2009) indicates an increase of nearly 27% in the amount of children admitted to NYC homeless shelters from July 1996 to July 2006. Compounding the initial homelessness, homeless families tend to experience significant spells of housing instability during transitions from shelter to postshelter and back to more permanent housing arrangements (National Coalition for Homeless, 2009). As a result, homeless children have difficulty accessing public school education during these spells of housing instability and homelessness (Mawhinney-Rhoads & Stahler, 2006; National Network for Youth, 2008). There are a variety of obstacles to access public school education for homeless children, such as residential policies, which further complicate a homeless child gaining or maintaining access to educational resources. School districts or schools usually require that a child has proof of residency, a parent or guardian, and proof of required vaccinations to enroll in school (Mawhinney-Rhoads & Stahler, 2006). Proof of residency is difficult to establish while in homeless shelters or other types of transitional housing situations (i.e., living with other relatives, multiple families). Homeless children may be living with a family member who is not a legal guardian or may be a runaway with no legal guardian available (Mawhinney-Rhoads & Stahler, 2006). During transient times, homeless families carry minimal belongings, may lose medical records, or delay immunizations. A retrospective study of the NYC Department of Health records found that homeless children were 4 times underimmunized compared to housed low-income children (Alperstein, Rappaport, & Flanigan, 1988). As a response to the obstacles faced by homeless children to access and sustain an education, in 1987, the U.S. Congress passed the landmark McKinney Education of Homeless Children and Youth Act of 1986 (National Coalition for the Homeless, 2008). The McKinney Act was the first federal act to provide homeless children equal access to education by focusing on the elimination of educational barriers from homeless children (Butler, 1994). In 2002, the McKinney Act was reauthorized as part of No Child Left Behind and renamed the McKinney-Vento Homeless Assistance Act, mandating (among other things) that homeless children be allowed to enroll in school regardless of their ability to meet documentation requirements. The reauthorization also prohibited any type of segregation of homeless students (McKinney-Vento Homeless Assistance Act, 2002). If policy barriers are overcome by homeless children, there are still limitations due to the unique circumstances of homelessness that affect school attendance. Limitations range from transportation, disruption in education, teacher –peer relationships, to other issues (Brown, 1991; Masten et al., 1997; Rafferty, 1999; Stronge, 1993, 2000). Transportation is one of the most frequent barriers. Homeless children often reside in shelters outside their school districts and thus have no transportation to school or must travel quite a distance each day to attend school. The inability to have adequate transportation to school often results in extended absences from school and inconsistent attendance can affect grade progression in school (Bowman, Dukes, & Moore, 2012; Rafferty, Shinn, & Weitzmann, 2004). Homeless children reportedly demonstrate noncompliant behaviors, shorter attention spans, more sleep disturbances, lack of peer acceptance, emotional instability, poor self-concept, and shame (Boxill, 1990; Downer, 2001; Rafferty, 1999; Stronge, 1993) that can affect success in school. Collectively, the unique experiences associated with being homeless create a cumulative stress resulting in high rates of academic as well as mental and behavioral problems for children (National Child Traumatic Stress Network, 2005; Sameroff & Rosenblum, 2006).
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The need for a social determinants approach to addressing the education needs of homeless children is echoed throughout the literature (Julianelle & Foscarinis, 2003). The specific types of educational reforms for homeless children can vary. Stronge (1993) described four general types of educational reform: mainstreamed, supplemental support, transitional, and modified comprehensive approaches. Mainstream reform efforts incorporate homeless children into existing schools. Mainstream policy focuses on the lack of permanent housing as the only difference between homeless and domiciled children and supports the educational values of socialization and stability. Supplemental support services are based on the concept of after-school programs directly targeting the needs of homeless students. Special needs may be either focused academically (i.e., tutoring, school supplies, study areas) or aimed at counseling promoting emotional well-being. Transitional schools are usually attached to shelters and made up of only homeless students. The goal is to provide a temporary education to help children transition to mainstreamed schools while removing the barriers of residency, transportation, guardianship, and medical records. Lastly, modified comprehensive schools are housed at educational institutions that follow transitional approaches with one grade per classroom removing the typical immediate barriers of homeless children. As families seek permanent residence, children are mainstreamed into school. Stronge’s (2000) approach along with other authors emphasizes the need to include a collaboration of agencies and individuals to improve access to education for homeless children regardless of the type of educational reform (Mawhinney-Rhoads & Stahler, 2006; Tobin & Murphy, 2013). The CBPR project detailed next outlines TFH’s use of community practice concepts to address the social determinants in a collaborative way to reduce the access barriers to education that homeless children face.
IMPLICATIONS FOR PRACTICE: THE USE OF COMMUNITY PRACTICE CONCEPTS In practice, TFH utilized a collaborative community approach to address the educational barriers that homeless children face (Stronge, 2000). The use of a CBPR approach is also compatible with the strengths perspective and the empowerment stance associated with the social work and community practice in public health. The focus on community and agency-level systems is encouraged to actively self-determine relative to project focus, execution, and postproject implementation. All phases of a project require the employment of a range of activities supporting community practice concepts for that project to move to the completion stage. Active listening skills are particularly crucial when negotiating, and reframing, the discussion around the project focus during capacity building. Community-based participatory research embodies the community practice concepts of a strengths perspective, empowerment, capacity building, and advocacy (Minkler & Wallerstein, 2008). TFH project utilized these community practice concepts throughout the process to create an advocacy brief. Outcomes like an advocacy brief can enhance the capacity of agencies to advocate and effect policy changes. Practice concepts were intertwined and interdependent of each other throughout the project. The concepts helped researchers and TFH to organize the project while clarifying the relevant barriers homeless children face when accessing education. In the following subsections, each practice concept is defined and how the concept was used to learn about the needs of homeless children to develop the advocacy brief is explained. Strengths perspective. Saleebey (2012) defined a strengths perspective as helping a client system to discover their resources in the service of assisting them to achieve their goals. The process of creating the advocacy brief required TFH to reflect internally to discover its own resources. By indentifying internal strengths an agency’s capacity to serve others is enhanced (Ayon & Lee, 2009; Saleebey, 2012). The TFH gained perspective by identifying its strengths
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through targeted internal data gathering, utilization of agency archival materials, and individual case summaries. These types of resources are common to most agencies. Internal data. To support the project goal of advocating for the needs of homeless children to access primary education, internal data gathering focused on the needs of at-risk 6- to 11-year-old shelter residents with a mental health and /or physical-related diagnosis requiring participation in a school-based or school sponsored program. Attendance-related data of at-risk children in shelter care was also developed to develop baselines for future outreach initiatives of the agency. Under the supervision of project researchers, TFH executed a random sampling of shelter residents sorted by age and sex in its database. Medical records were also reviewed for indications of participation in special needs school-based school-sponsored programs. Institutional Review Boards approved all data collection. Data detailing participation of homeless children in school-based programs highlighted in the advocacy brief confirmed the need in this area. Archival data. TFH’s historical legacy of service was identified through archival photographs and historical newspaper accounts. TFH’s service began in 1894 when children were treated on a ship located in the harbor. TFH has a compelling history addressing NYC’s cholera, smallpox, and diphtheria epidemics dating back to the 1870s, as well as addressing the general health needs of the city’s poorest of the poor (Bushel, 1966; St. John’s Guild, 1878). The advocacy brief included the photos highlighting the longstanding commitment of TFH to homeless children. Individual case summaries. TFH’s mental health staff submitted three typical case summaries of homeless children that showcased the complexities of the families in shelter care. The case summaries supported the primary issues found in the literature related to access to education for homeless children ranging from emotional, behavioral difficulties to multiple family stressors. Quotes from the case summaries were used to organize the headings and create bullet statements for emphasis in the advocacy brief. Empowerment. Empowerment enables systems to achieve a creative sense of power through enhanced self-respect, knowledge, and skills (National Association of Social Work, 2010). As part of the CBPR approach, a concurrent photovoice strategy was initiated to empower TFH’s parent consumer base. Photovoice can also enhance understanding of community assets, needs, and empowerment (Catalani & Minkler, 2010). “Photovoice is a process in which people identify, represent, and enhance their community through a specific photographic technique” (Wang & Burris, 1997, p. 369). Photovoice created an opportunity for TFH parents to take photographs to record the barriers to accessing education that their children face. The photograph as a visual image enhances a person’s ability to tell a story in his or her own words (Wang & Burris, 1997). The following barriers to accessing education for their children were identified: (a) transportation, (b) housing, (c) school environment, (d) employment, (e) child care, and (f) community support. All data collection was approved by university Institutional Review Boards. By empowering its consumers along with identifying internal data, TFH was able to identify these barriers and define them clearly in the advocacy brief that enhanced its capacity to advocate for homeless families and children. Capacity building. Capacity building is a process in which individuals/organizations gain knowledge, skills, and confidence to improve their lives or that of those they serve. Through the capacity-building process individuals/organizations apply what is learned in political, social, and economic ways (Ayon & Lee, 2009; Easterling, 2008; Gibbon, Labonte, & Laverack, 2002). Knowing its internal strengths, TFH examined its external environment to identify sources of data useful for its advocacy initiative and the potential like-minded agencies that may be interested in collaborative advocacy (Easterling, 2008; Jansson, 2011). The NYC Department for Homeless Services and the NYC Department of Education were identified. These two agencies provided data
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on the average school attendance rates of homeless children categorized by gender. This initial collaboration helped build TFH’s confidence in developing future collaborations. The data was included in the advocacy brief and substantiated the growing number of NYC homeless children needing access to primary education. Advocacy. Jansson (2011) described public advocacy as practices that aim to assist relatively powerless, oftentimes marginalized, groups of people to improve their resources and opportunities. By using the practice concepts of a strengths perspective, empowerment, and capacity building the advocacy brief was developed. The content of the brief was formed by an analysis of the agency’s legacy, case summaries, internal/external quantitative data, and issues supported by photovoice data as well as grounded in the literature. The advocacy brief uses photos and narrative to tell TFH’s story of serving homeless children and the barriers these children face when accessing education. From the impact that extended bus rides from shelter to school have on school attendance and performance to the identification of family risk factors associated with returning to shelter care, each talking point is clearly delineated and succinctly summarized. The brief concludes with a call to support TFH preventive health services and programs that aid in removing the barriers homeless children face when accessing a school education.
CONCLUSIONS The TFH project illustrates that CBPR research that utilizes the practice concepts of a strengths perspective, empowerment, capacity building, and advocacy can have a role in social change with researchers, public health professionals, and community working together. The key social determinants affecting access to education for homeless children identified through this approach were used to develop the advocacy brief. The TFH discovered its ability to use resources such as its legacy, case summaries, and quantitative reports to support advocacy efforts. Collaboration with researchers and other organizations aided the effort. Developing the advocacy brief through the CBPR process gave TFH new skills and knowledge. The capacity of TFH to advocate for preventive health services to help homeless children access education was enhanced. This example serves as a guide for public health professions and social workers to use CBPR to address health inequities and health disparities in their communities through a social determinants approach.
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