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

在英国，无家可归是一个越来越大的挑战，特别是因为它对健康有严重影响：无家可归的人可能比人口平均寿命少30年。尤其是伦敦，无家可归的人很多，而且人数还在不断增加，其中包括露宿的人，但也有住在招待所和临时住所的人。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。这项研究将聚焦于这种复杂性的一个组成部分：耻辱。污名指的是在社会眼中，人们被“标记”为地位较低、不值得尊敬或丢脸的人。这种污名往往集中在无家可归的人身上，是解决健康不佳和无家可归问题的持久障碍。这可能意味着人们不寻求护理和支持，如果他们这样做了，得到的支持质量也很低；结果是健康状况恶化，结束无家可归的机会减少。耻辱是医疗保健、福利支持和社会其他部分以及人们所依赖的系统中的一个问题。重要的是，这些独立领域的污名联系在一起并导致复杂的问题；例如，福利方面的问题可能会导致医疗保健机会方面的问题。我们对耻辱的这些社会方面及其复杂性有一些了解，但还不足以理解如何应对和防止它。防止耻辱的努力可以支持无家可归者获得保健、住房和其他形式的福利和支助。如果我们能防止耻辱，我们的公共卫生和卫生保健反应就能更有效、更有效率，改善健康，增加结束个人无家可归的可能性。本研究旨在完善我们对污名复杂性的理论和解释。基于这一解释，这项研究将开发一种干预措施，试图在导致这种疾病的许多系统中防止耻辱。这项研究的重点将是在伦敦进行深入研究，以了解无家可归者面临的耻辱的复杂性。我们将花时间采访无家可归的人，通过采访了解他们的经历，并研究支持他们(或羞辱他们)的制度。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团队将包括来自伦敦南部各地的专家。耻辱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耻辱及其背后的复杂系统。通过与加拿大的团队合作，我们还希望开发出我们可以扩展到其他地方的想法和工作方式，包括世界各地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、政策制定者和普通公众密切合作。这种密切的公众参与将确保这项研究实际上是对人们所拥有的重要问题和需求的回应，也是为了让人们了解我们的发现，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。该研究计划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”；这将是一项战略，旨在对影响无家可归者生活的许多系统进行改变。通过多重和协调的变革，我们希望能够对耻辱产生重大影响，并防止它。我们最初将在伦敦南部制定干预措施，然后在努力了解其影响后，我们将尝试将任何成功推广到其他地方，无论是在英国还是在全球。

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.