Hello, I'm Vicky Sturgiopoulos and I'm here with Bushra Khan and Nadine Rehn to talk to you about a recovery education center for adults experiencing homelessness in Toronto and its evaluation. In terms of learning objectives, we're hoping to review with you the purpose of recovery education centers, to be able to appreciate the importance of recovery-based education initiatives for this population, and discuss the differences as experienced by service users between recovery education centers and other services for this population. In a little bit of our context and why this was important to us, and we've worked on it for a number of years, Toronto has the largest cohort of homeless people in Canada, with over 7,000 people that are homeless on any given night, and over 27,000 people using shelters each year, with a large number of them being chronically homeless. People that are homeless, as you well know, experience multiple health conditions and disproportionate burdens of physical health problems, mental health problems, addictions, cognitive impairment, and premature mortality. They're also more likely to experience stigma and discrimination in healthcare settings, and they have poor access to primary healthcare and poor health outcomes. To address some of these issues, our team has worked on a number of studies over the years, including studies to improve coordination of care between hospital and community settings, as well as housing models to improve housing stability, including the largest trial of Housing First worldwide through at-home CSWA and multi-site randomized control trial in five cities across Canada. What we saw in these studies is that although we were able to achieve other things, such as continuity of care, improve housing stability, we were not able to see improvements in recovery as experienced by service users. Hence, we had a great interest in looking at what interventions we can add to existing models of care for this population to specifically improve experiences of recovery. So, through our searches, we came upon recovery education centers that build upon the concepts of recovery that were developed by Anthony et al. back nearly 30 years ago, and they were more recently elaborated in the UK by Mike Slade and his team. They represent a paradigm shift in mental health, and they have been mushroomed worldwide with over 75 recovery colleges across the world these days, and the number is increasing monthly. Many of them are in the UK, but not exclusively. We have recovery colleges in Canada, other European countries, Australia, New Zealand, Japan, Africa. The differences, just as a reminder, in these centers, participants are viewed as students or members. Co-production, co-delivery, and co-learning are key tenets of recovery education centers, and supports are not clinical, but supports are provided through emancipatory adult education, where the individual's strengths and resources are leveraged, and individuals are given full self-determination and control. So, they are not clinical services. Sometimes they are associated with clinical services, but on their own, they do not provide clinical care. So, I'll talk a little bit about the interventions. So, we were lucky enough, back in 2014, to secure a philanthropic gift. These are not models that are funded by funders, health funders, in Canada at this point, and that holds true in other countries as well, and we were able to launch STAR, Supporting Transitions and Recovery, one of the first, one of the few recovery centers in the world and one of the few recovery education centers worldwide to focus on people experiencing homelessness or housing instability. To launch the model, we looked internationally, visited Boston, visited the UK, experienced a number of centers, spoke to a number of key stakeholders, and then what we developed was a model that served the population based also on the local population's input. The college served over 400 people between 2014 and 2018, with many more registering but not attending classes. So, clearly, that's another topic that we'll perhaps explore at another time as we're still that people do register, but they don't always continue on attending. So, what did it look like? Classes were offered morning and afternoon. There were twice a year, at least, we would update the curriculum, but monthly, we would issue the calendar for the month, and we would distribute that widely also on the program's website. Courses, again, were based on the advice of people with lived experience of homelessness and mental health challenges and focused on a variety of themes, from health and wellness to vocational skills to leadership and advocacy or citizenship to hobbies, interests, and life skills to dealing with landlords, managing budgets, keeping housing, a healthy environment, et cetera, as we were seeing a lot of people losing their housing because it was taken over by drug dealers. So, a lot of that, then, was co-developed with the service users. The classes and the workshops were taught both by peers with lived experience, as well as health or social service providers, and individuals were either self-referred or referred by others, but it was completely voluntary. The college worked as a hub and spoke model. The hub was based at a community center locally that also had other services on site, like laundry facilities, shower facilities, lunches, breakfast, so individuals could take advantage of that, of those other services, if they needed or desired. In addition to that central hub, there were satellite classes at a number of other locations, including the public library, to support community integration and the normalizing the experiences, both of the local sector mainstream agencies, like libraries, to hosting this population, but also for the population to gain comfort in joining those activities in these settings. Other settings that we offered classes included primary care, that served people that are homeless, a vocational center for people that are homeless, as well as an adult education center, where people could get a high school equivalency diploma. So, it was important for us to support community integration as best as we could, and that was another area where we hadn't seen tremendous progress in our previous studies. So, with that, I will pass it on to Bhusra to talk a little bit about what we did, and I'm happy to also weigh in on the end, if additional information is necessary. When considering the literature, we reviewed and found that there is no evidence outlining the effects of recovery education colleges on individuals experiencing homelessness or housing instability. To our team, this spoke to the need for rigorous research that evaluated the efficacy and cost effectiveness of recovery education colleges. With the aim to complete rigorous research, we considered a randomized controlled trial design, and in conducting this work, we received community input advising against the use of randomization for vulnerable individuals, with their feedback highlighting the importance of choice and self-determination for this study population as being essential. We developed a realist-informed interview guide to answer our research questions, and that explored participants' perspectives on contextual factors, key recovery education college ingredients, and mechanisms through the engagement with STAR. Moving forward, this is a diagram outlining the design for the qualitative arm of our study, including the focus groups and individual interviews. To be eligible for the study in general, participants had to be 16 years or older, experience challenges in maintaining housing within the past two years, have capacity to provide informed consent for research participation, be a new member of STAR during the study recruitment period, have completed at least 10 hours of STAR classes, and demonstrate an ability to provide rich data during the quantitative arm interview. Recruitment for the arm occurred between July 2017 and June 2018, at 6 and 14 months following program enrollment, and continued until data saturation was reached and no new themes emerged. Moving forward, of the 92 participants in the intervention arm of the study, 23 were recruited through purposive sampling to participate in an in-depth, in-person semi-structured interview. They were selected based on their willingness to actually participate, and their ability to reflect on and provide insights into the experiences with STAR, as well as with other services. Of these initial 23 participants recruited, 20, or about 87% of them, consented to participate in the qualitative study. So our semi-structured participant interview guide then explored their motivation for enrollment, their experiences with STAR and other services, the program components they felt were key, the mechanisms of change, and also their outcomes. The interviews in general lasted from 35 to 100 minutes, with about 80 hours being the average participation at STAR among the interviewees. The average age of the participants was about 44.6 years old, and 65% of the majority of our sample identified as female, with over 80% identifying as Caucasian as well. So our team assessed and analyzed the qualitative interview data and focus groups through an inductive thematic analysis approach. Our codebook development began with three research staff coding seven transcripts independently, and we then developed a set of key concepts or codes that were compared to the findings. The codebook was then finalized, incorporating feedback from all the coders and the principal investigator. And in this process, similar codes were grouped into higher-level themes. They were supported with direct examples and quotations from the interviews, and our team then refined the categories through an iterative process of review and feedback to enhance the analytical rigor overall. Once consensus was achieved, all the transcripts were coded by the same three researchers, and we established strong inter-rater reliability with a cap of 0.72. Before publishing any of our work, we also engaged in a checking process with two staff members, including a peer specialist as well. So moving forward to some of the data that we did find. Generally, most participants, 15 in this case, reported few positive experiences with health and social services in general. They described largely negative past experiences with services in the city and highlighted many challenges in accessing their needed services. So specifically, they described a lack of availability of the services they needed when going to different agencies, a lack of awareness in terms of the services that actually existed within the sphere, long wait times to access the services they really needed, and when services were available and accessible, they were time-limited and not geared to meet their specific health needs. And here you'll see participant 62 describe that they accessed a resource when they were homeless and they were given the feedback that they would not receive an appointment for another month and this response essentially left this person wondering what the function of the service was and how they were expected to cope regardless of the changes in weather. Moving forward, participants also shared specific aspects of themselves in the program that they felt were barriers and impacted their engagement with STAR. So here you can see that physical health issues, mental illness were seen to be important in addition to ongoing or previous substance use issues as well. Participants further described a lack of social capital such as a supportive family or education that they felt would have helped them during their time of need or at least facilitate an engagement with resources like STAR. And then finally, they spoke of their experiences of homelessness and precarious housing that impeded their ability to engage and recover in general. You'll see here participant one described their substance use of alcohol commencing as a result of becoming homeless. And at the time they felt that alcohol had made their life circumstance more manageable. And then they also described that perhaps their experience may have been different if they had others present to support them kind of highlighting their lack of social capital that was described earlier. So then moving forward, in contrast to their experiences with other services, participants described overwhelmingly positive experiences with STAR itself. And we'll describe some of the key ingredients of STAR's success shortly. But here we describe the aspects of STAR that generated the positive experiences. And these were numerous with some notable aspects being the attractive and dignifying physical space, the low barrier to access, the seamless experience with registration enrollment, and just how welcoming the interpersonal environment has been as well. Participant 109 describes being nervous about engaging in their recovery, but appreciating the gorgeous space where the programming actually took place. And then participant 160 commented on the lack of a wait list, the straightforward and approachable process, and how all of it really felt supportive to them as well. So in these next set of slides, we'll review the aspects of STAR that participants felt were key ingredients and supported their engagement in the process of recovery. Primarily, most participants described lived experience as important and how valuable it was to see this being incorporated really into every level of the program with histories of mental health, addiction, and or homelessness and housing challenges being openly shared and discussed as STAR as very important. So participants reflected that including staff and volunteers with lived experience made the program also feel more relevant, more practical, more approachable and effective in general. And here participant 133 appreciated coupling the theoretical knowledge that they described as quote book smarts with also lived experience as well. Moving forward, the participatory approach to teaching and learning was noted as well. Members really appreciated having their voices and their opinions be respected. And this was an important aspect in their perception of the program. They described sharing their opinions and proposing programmatic changes and meetings such as the town hall and being encouraged to even do so. And here participant 160 describes that there was no hierarchy with participant one describing the importance of the lack of a hierarchy in the program staff never kind of giving the perception that they were superior to the general membership either. And finally, the majority described the ability to self-direct what they did in the program and their overall recovery is key. The individualized learning plan specifically where participants sat with the program coordinator at the outset of the semester selected courses as vital. They described this as very important in terms of their self-determination and self-management and goal setting. Here participant 109 describes the ability to make a choice and choosing the path they want to take as really important to them with participant 88 underscoring ownership that this provides and the idea of essentially being in charge. And now I'll hand it over to my colleague, Dr. Nadine Reed. Hello everyone. So now that we've examined the context in which our RAC operates, we're going to look at the program mechanisms which under a realist framework essentially seeks to describe what it is about the program, what processes are operating that produce the outcomes that we're seeing. So mechanisms often involve some sort of interaction between a sort of program resource and then participants reasoning in response to that resource. So for example, take our first mechanism theme. This is a judgment-free zone. So the majority of our participants described our recovery education center as a judgment-free environment. They valued feeling accepted and not feeling judged by others whether that was the members or their program staff. Participants often said things like they participated more often because they were not judged or told that they couldn't. One participant said that it was a healthy learning environment that they thrived in because it felt so positive and encouraging and like a very safe space. So in response to this type of environment, participants really reasoned that they were, because they were made to feel unjudged and more comfortable, they were really able to fully engage and appreciate their experience and focus on their recovery without worrying about feeling judged by others. So this type of environment really removed a lot of the stress and intimidation that they had experienced in other healthcare settings previously. So that was one of the most important themes to come out of our mechanism research. The second one was that within this very judgment-free zone, participants were able to develop supportive relationships and really experience mutuality and role modeling from the other members and the program staff. So nearly all of our participants talked about how much they valued the relationships they developed in the program. And not only were these relationships multiple, they were also very high quality relationships. And I think this had to do with the fact that because it was such a judgment-free zone and participants were encouraged to open up and interact with each other, they did that and they were able to develop these meaningful relationships, which really helped them to feel connected to the community within the program. Beyond the sense of social support and lack of isolation that this helped participants with, it also provided practical assistance. Participants described their experiences sharing information, networking resources, and that this was very valuable to them. Relationships with staff and members who had relatable lived experiences and then positive outcomes also provided a very important opportunity for role modeling. Participants reflected on how seeing a good example of where they could be was inspiration and helped them to feel more hopeful about their own potential to recover and succeed in their endeavors. So moving on, the deconstruction of self-stigma was another theme that we identified as a program mechanism. And really what this refers to is the process of overcoming stigma and especially the extreme dual-pronged stigma of mental illness and homelessness, and then rebuilding a sense of self and self-worth. So perhaps this is related to role modeling and seeing so many positive examples in people with similar lived experiences. Our participants talked a lot about learning to overcome shame and reframe previous negative perceptions they'd had of themselves and their own experiences. For example, one participant's logic was that they felt bad about themselves, but if they looked at a member with similar experiences and didn't see that person as a bad person, maybe they didn't in fact need to feel so bad about themselves either. And perhaps there is a more positive way and a productive way of reframing their experiences so that it would have a more positive impact on their sense of self. Also relatedly, participants talked about how over the course of their participation in the program, they came to an understanding that it was them, they were the ones in charge of their own recovery and that it was their story to write. And through the program actually began the process of writing that own story. It's really related to the program's emphasis on their participatory processes and the focus on self-determination, really giving participants a sense of power and responsibility for their own recovery. What this looked like differed depending on the participant. For some, it was learning very basic functional skills like getting up in the morning and at a specific time, making it to appointments on time. And they talked about the responsibility this engendered and that was new for some of our participants. Others valued learning the importance of self-care and the opportunity for self-improvement. Several participants described wanting to focus on gaining knowledge and building skills and competencies in specific areas of interest. And then there was a subset of participants who were highly focused on gaining employment and they used the program as an opportunity to pursue education and skills training that could help them advance in that respect. So as a result of these experiences, our participants described a range of outcomes and these occurred at personal, interpersonal and social levels. Our participants described multiple mental and physical health improvements as a result of their involvement. Physically, our participants were more active and knowledgeable about managing their physical health. Mentally, participants described improving their mental health symptoms and improving their management and coping skills with many referencing the educational courses specifically for self-management and coping. And as with the physical fitness, that was a very important component for a lot of our participants and that helped to inspire participants to maintain their physical health and wellbeing. In addition to health, our participants described significant improvements in their self-esteem, their confidence and their sense of self after becoming involved with the program. One participant said that it changed them totally. She used to hate herself and now she feels that she is an individual, that she's not worthless. And she said that she learned that from the program. And so I think that was a very powerful outcome for us to observe among our participants. And lastly, our participants described feeling a greater sense of empowerment and that was related to feeling in control over and personal responsibility for their recovery and their livelihood. And essentially our participants described becoming active agents in their own recovery by virtue of their enrollment in the program. On an interpersonal level, following from their experiences in safe, supportive and enabling environment, almost two thirds of our participants described marked improvements in their interpersonal relationships and that included in their social relationships with friends, also with families and their ability to advocate effectively for themselves with other healthcare providers. Participants described increased self-awareness and better communication skills within the relationships as a result of the work they did in the program. They noted less fighting and more self-advocacy and generally improved relationships overall. Positive social skills were also learned from members' role modeling and participants talked about that experience rubbing off on them, so to say. And so finally, our outcomes at the social level, our participants described really having a sense of hope and direction for the future and their potential to live happy, healthy, meaningful lives and recovery going forward. So our participants described personal goals like giving back to the community or maintaining their physical and mental health and wellbeing. They described career goals, which often included things like going back to school, finding meaningful work and several participants had the clear goal of becoming peer support workers to help others as they'd been helped by the peer workers in our program. Most often, however, was just a general sense of hopefulness and future directedness. And so as one participant said, this was number participant 88, I started thinking more about my future and the direction I want to take it and that makes me really happy because I have not been thinking about my future for a really long time. So just briefly, some of the strengths and weaknesses of our current work. We do offer a fulsome description analysis of a unique program to the literature. Our findings are consistent with previous research and then unique in identifying several key program ingredients and mechanisms. The fact that we offer high fidelity to the REC model of care means our findings, although they are based on a single sites context are more likely to be relevant to other settings. A few weaknesses to note include the cross-sectional single site design and then our sample size and composition, which was somewhat small and not necessarily representative of the larger REC membership. In conclusion, we think our work offers a unique and in-depth examination of Canada's first REC and one specifically designed for individuals with mental health needs transitioning out of homelessness. We hope to inspire continued innovation and person-centeredness in community-based care for this and related populations. And we expect our findings will be helpful in guiding program and policy development with the goal of providing higher quality person-centered care. So we'd like to thank you for your attention and it's been a pleasure presenting our work today. Thank you. Thank you.

recovery education center

Toronto

homelessness

non-clinical supports

emancipatory adult education

person-centered care