RESPONDING TO HOMELESSNESS, MULTIPLE EXCLUSION AND STIGMA: DEVELOPING A COMPLEX PUBLIC HEALTH INTERVENTION APPROACH

Homelessness is a growing challenge in the UK, particularly because it has severe impacts on health: people who are homeless can live 30 years less than the population average. London in particular has a high and growing number of people who are homeless, including people rough sleeping, but also in hostels and temporary accommodation.

The causes of homelessness and poor health are complex, and can include a person's life history but also social processes like housing availability. This research will focus on one component of this complexity: stigma. Stigma refers to people being 'marked' - in society's eyes - as lesser, unworthy or disgraced. This stigma that often focuses on people who are homeless is a persistent barrier to addressing ill-health and homelessness. It can mean people don't seek care and support, and receive poor quality support if they do; a result is worsening health and reduced chances of ending homelessness.

Stigma is a problem across health care, welfare support and other parts of society and the systems that people rely on. Importantly, the stigma across these separate areas link and cause complex problems; for instance, problems with benefits can cause problems with health care access. We have some understanding of these social sides of stigma and their complexity, but not enough to understand how to respond and prevent it. Efforts to prevent stigma could support people who are homeless in accessing health, housing and other forms of welfare and support. If we could prevent stigma our public health and health care responses can be more effective and efficient, improving health and increasing potential to end homelessness for individuals.

This research aims to improve our theory and explanations for the complexity of stigma. Based on that explanation, the research will develop an intervention that will try and prevent stigma across the many systems that cause it. A focus for the research will be in-depth study in London to understand the complexity of stigma that people who are homeless face. We will spend time with people who are homeless using interviews to understand their experiences, and also study the systems that support them (or stigmatise them). Researchers who have experience of homelessness themselves will be part of the research team. The team working to develop an intervention response will involve experts from across south London.

Stigma is a problem around the world. To try and ensure our research in London has impact in other places (and also learns from experiences elsewhere), we will work closely with a research team in Canada. Through comparing experiences we can develop better explanations of stigma and the complex systems behind it. Through working with the team in Canada we also want to develop ideas and ways of working that we can expand to include other places; including low and middle income countries around the world.

Throughout the research we will work closely with people who are homeless, policy makers and the general public. This close public engagement will ensure the study is actually responding to the important questions and needs people have, but also to make people aware of our findings, and so through that ensure the study has positive impact on people's lives, health and welfare.

The final output of the research programme will be to work with people, policy makers and other stakeholders to develop a 'complex intervention'; this will be a strategy to make changes across the many systems that influence the lives of people who are homeless. Through multiple and coordinated changes we hope to be able to make significant impacts on stigma and prevent it. We will initially develop an intervention in south London, and then after working to understand its impacts, we will try and scale-up any success to other places, across the UK but also globally.

The overall impact sought through the fellowship is reduced stigma as it affects people who are homeless, to then allow access to health care, welfare and support, including housing. Priority beneficiaries for this impact are then people who are homeless, and also people working in public health and services seeking to enhance the efficacy and efficiency of their work. Within the first 4 years of the fellowship we will produce a novel intervention strategy to seek impact on stigma; by the end of the 7 year period an aim is to have an intervention strategy implemented and under evaluation within south London. Through these processes we aim to directly impact on stigma, and so support the welfare of people who are homeless, and the work of stakeholders across health care, welfare services and other housing and support services. This group of stakeholders will in particular include collaborators such as Groundswell, a south London charity working with people who are homeless, and then Southwark Public Health Division. The theoretical developments and related intervention strategy will enhance their work and the achievement of their goals.

The theoretical outputs from the fellowship - theoretical models of the system complexity of stigma - in tandem with evidence of intervention process and impact, will have potential indirect impact across London, other urban settings in the UK and globally. Our aim will be to support generalizability of rigorous theory and so to enable application in other settings, whilst attending to system complexity. We will seek to engage with services and stakeholders across the UK with the study outputs of peer reviewed articles and linked reports, through presenting research at local and national conferences, but also through targeted engagement as directed by study collaborators; for example, Groundswell, a study partner, support people centred services for the homeless across the UK, and have extensive networks in cities such as Manchester, Newcastle and Birmingham, through which to build impact across the UK. The fellowship will also seek impact internationally, through partnership with the International Network of People who use Drugs and other collaborators; this will be driven in the first instance by extending the comparative analyses between London and Vancouver to other cities, notably those in low and middle income contexts; through such analysis, and then continued links to tintervention development, we aim to explore the application of the intervention approach in these other settings.

A range of public audiences will benefit from the research. In the short term, participants involved in data collection will benefit from the opportunity to represent their views, and through public engagement processes influence their articulation within research; following these, the experiences will be presented to policy stakeholders at the workshops, and also more widely through public exhibitions. As elaborated in the pathways to impact, we will be using a range of strategies to engage young people and the wider public in south London in dissemination activities, particularly involving the Museum of Homelessness and Groundswell. A principal target is to increase awareness of the social complexity of homelessness, and so address prevailing public discourses that understand homelessness as resulting from choice and individual responsibility; such an impact with wider public understanding in turn has indirect impacts for people who are homeless and policy makers, through creating more enabling environments for support services, welfare and policy advance.