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

在英国，无家可归是一个日益严峻的挑战，特别是因为它对健康有严重影响：无家可归者的寿命比人口平均寿命短30年。尤其是伦敦，无家可归的人越来越多，其中包括露宿街头的人，也包括住在青年旅社和临时住所的人。无家可归和健康状况不佳的原因很复杂，可能包括一个人的生活史，也可能包括住房供应等社会过程。这项研究将集中在这种复杂性的一个组成部分：耻辱。污名指的是人们在社会眼中被“标记”为低人一等、不值得或不光彩。这种污名往往集中在无家可归者身上，是解决健康不良和无家可归问题的持久障碍。这可能意味着人们不寻求照顾和支持，即使他们这样做了，也会得到低质量的支持；其结果是健康状况恶化，结束无家可归的机会减少。耻辱是贯穿卫生保健、福利支持和社会其他部分以及人们所依赖的系统的一个问题。重要的是，这些不同领域的耻辱联系在一起，并导致了复杂的问题；例如，福利方面的问题可能会导致医疗保健方面的问题。我们对耻辱的社会方面及其复杂性有一些了解，但还不足以了解如何应对和预防它。防止污名化的努力可以帮助无家可归者获得保健、住房和其他形式的福利和支助。如果我们能够防止污名化，我们的公共卫生和保健对策就可以更加有效和高效，从而改善个人的健康状况，增加消除无家可归现象的潜力。本研究旨在完善我们对病耻感复杂性的理论和解释。基于这一解释，该研究将开发出一种干预措施，试图在导致这种情况的许多系统中防止耻辱。研究的重点将是在伦敦进行深入研究，以了解无家可归者所面临的耻辱的复杂性。我们将花时间与无家可归的人进行访谈，了解他们的经历，并研究支持他们（或侮辱他们）的系统。有过无家可归经历的研究人员将成为研究小组的一员。致力于制定干预对策的小组将包括来自南伦敦各地的专家。污名是世界各地的一个问题。为了确保我们在伦敦的研究在其他地方产生影响（并从其他地方的经验中学习），我们将与加拿大的一个研究团队密切合作。通过比较经验，我们可以更好地解释病耻感及其背后的复杂系统。通过与加拿大团队的合作，我们还希望开发出可以扩展到其他地方的想法和工作方式；包括世界上的低收入和中等收入国家。在整个研究过程中，我们将与无家可归者、政策制定者和公众密切合作。这种密切的公众参与将确保这项研究真正回应了人们的重要问题和需求，同时也让人们意识到我们的发现，从而确保这项研究对人们的生活、健康和福利产生积极影响。研究项目的最终成果将是与人们、政策制定者和其他利益相关者合作，开发一种“复杂的干预措施”；这将是一项在影响无家可归者生活的许多系统中做出改变的战略。通过多方协调的改变，我们希望能够对耻辱产生重大影响并预防它。我们将首先在伦敦南部开展干预，然后在了解其影响之后，我们将尝试将任何成功推广到英国乃至全球其他地方。

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.