A pilot program to address tenants’ complex social, psychological, and medical needs in social housing: lessons learned

ABSTRACT

In this City Short article, we present the case of a pilot program in Hamilton, Ontario, that created a “hub” of services to address the social determinants of health for low-income individuals residing in social housing. Individuals residing in social housing often face multiple, complex challenges that impact their health and wellbeing. Providing services and supports directly within social housing buildings has been one proposed solution, however our understanding of best practices in this area remains underdeveloped. We aim to address this gap by describing the pilot program and the impact to tenants. Lastly, we share important lessons learned for others aiming to engage in similar programs.

KEYWORDS:

• Social housing
• social determinants of health
• housing supports

Introduction

Increasingly, social housing tenants have complex and severe needs and require support to live independently (Marshall et al. 2021). Tenants may experience multiple challenges that impact their health and quality of life, including a history of abuse or trauma, acute and chronic health issues, mental illness, substance use disorders, and food insecurity (Smirl 2019, Wang et al. 2020, Marshall et al. 2021). One approach to these challenges has been to design interventions directly within social housing buildings to address the social determinants of health such as poverty, access to health services, and the social and physical environment (Golden and Earp 2012, Quintiliani et al. 2014, Marshall et al. 2021, Government of Canada 2022) although our understanding of best practices in this area is underdeveloped.

Interventions addressing structural aspects of the environment (e.g. built environment, social features, access to formal resources) and individual-level factors have been theorized to be more effective than the former alone (Freeman et al. 2020, Skodra 2020). Multi-level interventions require collaboration across sectors of community, health, and housing services (Skodra 2020). Localized approaches occurring within a social housing authority may enable the success of interventions and programs as local partners are knowledgeable about the needs of the community (Warwick-Booth et al. 2020) and proximity to health and social care services may address barriers to accessing services (Skodra 2020). Examples of programs include those targeted older adults residing in social housing, with a focus on chronic disease management (Agarwal et al. 2019, Warwick-Booth et al. 2020) and programs like the Healthy Families Study in Boston, United States, which aimed to address food insecurity and improve physical activity (Quintiliani et al. 2014, Bowen et al. 2018).

This paper describes the creation of a social housing support initiative, providing in-house services and programs for tenants in two social housing buildings located in Hamilton, Ontario, Canada. Previous surveys were conducted at these buildings and identified a range of complex challenges facing its tenants (Van Loon and Sanchez 2017, CHH 2019). Many tenants suffered from chronic health conditions, mental health disorders, or substance abuse disorders and did not feel safe living in the buildings. The buildings were in poor physical condition and struggled to manage pervasive issues with pests.

Due to the severity and complexity of the challenges facing tenants at the buildings, the local municipal government and community anchor institutions, responsible for the delivery of social housing, identified these residents as potentially benefiting from increased access and proximity to health and social services. A pilot project was launched to create a “hub”, a multifaceted program aimed to address tenants’ complex psychosocial and medical needs. The program targeted social determinants of health, such as improving access to services, improving the physical and social environment, and promoting healthy behaviors. The goals of the services were to improve tenant safety, sense of belonging, health and well-being, and build relationships between community and service providers to address tenants’ needs.

By detailing the development of the program and its progression over the past few years, we aim to showcase the program’s impact on addressing social determinants of health. We discuss how the Hub impacted the social environment of the buildings, access to meaningful activities, health and wellbeing, and challenges faced with communication and addressing aspects of the physical environment. Lastly, we discuss lessons we learned over the past few years to help others aim to create or improve similar programs related to participation, evaluate the effectiveness of complex interventions, and build relationships with local partners.

The intervention

Context

In Ontario, individuals who live on low incomes and are unable to pay market rent qualify to receive subsidized, rent-geared-to-income housing – often called “social housing” (Ontario Government 2019). Most social housing units in Hamilton, Ontario are in multi-unit apartment buildings, owned and operated by the municipal housing corporation, City Housing Hamilton, or other non-profit housing providers (Marshall et al. 2021). Traditionally, social housing buildings have minimal residentially based services and individuals access services in the broader community on their own initiative and according to the service providers’ eligibility criteria. The hub services are provided in two social housing buildings comprised of mainly single units. The buildings house approximately 565 tenants, most of whom are single adults (aged 25–64) (City Housing Hamilton (CHH) 2019). In 2019, 68% of tenants were male and 32% were female.

The combination of several factors contributed to the development of the program. Changes to housing and healthcare policy led to a complex tenant population without supportive services in place (City Housing Hamilton (CHH) 2019). The buildings began facing safety issues and increased tenant turnover. Previous surveys and reports identified that many tenants in the buildings faced multiple, complex health and mental health challenges (Van Loon and Sanchez 2017, City Housing Hamilton (CHH) 2019). Tenants faced food insecurity, and many had acute and chronic health conditions (Van Loon and Sanchez 2017). One third of tenants reported struggles with addiction and half had been diagnosed with mental illness. Many reported a history of precarious living situations (e.g. jail, shelter, hospital, homeless, or living with friends). Tenants also described the buildings as having an overall poor physical and social environment, with frequent pest infestations and crime, and a general sense of distrust, and in some cases, fear between tenants (Van Loon and Sanchez 2017). The average age of death was 57 years old compared to the city average of 76 years old (City Housing Hamilton (CHH) 2019).

Creating the Hub

The Hub services are constantly updated, and new service partners from community and healthcare organizations are brought in as the need arises. The services included in the Hub were identified as representing areas of high need for tenants. Programs include traditional social and health services, such as food and nutritional support, primary healthcare, mental health and addictions supports, social work, and meaningful activities to engage tenants in their community through social events, recreation programs, volunteer opportunities, and community gardening. Tenant engagement and empowerment have been the central focus of Hub activities, and tenants have been involved in decision-making at all levels of the Hub. Tenant engagement included monthly tenant planning meets, an annual tenant survey, open communication lines with the Hub project manager, and invitations to attend partnership meetings.

Evaluating the Hub

The Hub model had an evaluation strategy since its inception that included annual tenant surveys, emergency services usage data, provider data, and tenant interviews. This article draws primarily on findings from tenant interviews conducted in Fall 2020 to gain an in-depth understanding of the Hub services. University ethics board approval was obtained to conduct qualitative interviews with tenants. Individuals were recruited using a poster placed in both buildings. The study purpose, procedures, and consent form were reviewed before participation. Due to the pandemic, tenants were only able to participate in a telephone interview.

Twelve tenants participated in an interview, ranging from 20 to 50 minutes. Eight men and four women ranging in age participated. Participants varied in their usage of the services. Qualitative description was used to analyze the interview data (Sandelowski 2000). This analysis style stays “close” to the data and is an ideal way to provide understand participants’ perspectives.

Before the pandemic, we aimed to conduct this research in-person. Due to health and safety concerns, the study protocol was changed to over-the-phone interviews. This posed several challenges and limitations. Not all tenants had access to a phone, which restricted participation. We refrained from extensive probing during our questioning as we had limited ability to build rapport with participants.

Impact of the COVID-19 pandemic

The Hub services program was created before the COVID-19 pandemic. The impact of the COVID-19 pandemic was felt acutely by tenants. Many tenants were isolated in their units and lacked access to the internet, which impeded their ability to participate in virtual services. Public health restrictions in Ontario led to the closure of many in-person services and restrictions on social gatherings. Food programs had to quickly pivot to take-away services only, and social programs were cancelled. By the summer of 2021 many programs had returned in modified formats; however, tenant self-reported health and well-being were worse overall in 2021 when compared to previous years. Interviews with tenants were conducted during the COVID-19 pandemic, and we aimed to understand the impact of the Hub services both before and during the pandemic.

Impact of the Hub

Social environment

Two of the Hub’s goals were to address the social environment at the buildings and bolster opportunities for social engagement. The social activities had secondary goals of improving the dynamics between tenants and building their ability to manage social conflicts. Before the COVID-19 pandemic, there were regularly scheduled social events hosted at the buildings (e.g. community BBQ/fair, bingo nights, movies nights, and art programs). Results from our interviews with tenants found that participants enjoyed these casual events. In participants’ words, they wanted experiences where they could “mingle”, “go for a coffee”, or “see what others are up to”. Participants described that they enjoyed casually meet others in the building. These relaxed environments helped address the tendency of some participants to isolate themselves in their apartments.

While social events prior to the pandemic were well attended and overall positively received, the general social environment of buildings remains a persistent challenge. Interviewees described negative social interactions with other tenants in the building. Some tenants reported that they had recently witnessed a disturbing event or violence in the buildings. Others described having disagreements with some tenants or experienced bullying or harassment. These experiences ranged from seeing unpleasant and loud disturbances (e.g. screaming, fighting, and yelling), to vandalism and criminal activity (e.g. drug use or activity, physical altercations, and stealing), resulting in regular police calls to the buildings. Other participants described it as challenging to meet others. A small number of participants had friendships often described as informal relationships. In a social setting like this, barriers to stronger social ties may include both the social skills of tenants and the risks (real or perceived) posed by other tenants, owing to anti-social behaviours common in the buildings.

Efforts to address safety and security included the addition of security guards to reduce what tenants referred to as “piggy backing” (i.e. non-tenants who enter the building behind a tenant who resides there) and at times, intervened when there were altercations in the common area of the buildings. Despite the presence of security, these two apartment buildings continued to make up between 18 and 20% of police calls to all social housing properties while representing only 4.5% of tenants.

Meaningful activities

One objective of the Hub was to increase tenants’ access to meaningful activities. A recent addition to the buildings was the First Start Farm, a social enterprise hydroponic, vertical, and year-round farm that provides fresh produce and meals to the local community. The farm was discussed as a positive, calming, and fun experience by those who used it. The farm provided an opportunity for physical activity, access to nutritious food, and learning new skills.

Some participants discussed their experiences volunteering in the buildings or local community. These participants found varying benefits from these roles. For some, volunteering was a way to meet others in the building. For another participant, volunteer roles provided an opportunity for meaningful activity in replacing paid employment. Another participant mentioned that volunteering provided a way to find out more about the services offered in the building.

Many participants in the interview study stated they needed further support to improve their lives. As one participant described, they wanted help “to progress, not just standstill”. Several participants discussed an immediate need for job training, support to finish secondary and tertiary education, and knowledge about basic finances (for example, setting a budget).

Health and wellbeing impact

Another primary focus of the Hub was to address tenants’ access to health services and provide an on-site foodbank. Food security was a significant issue for tenants, with 50% of tenants reporting being unable to afford food within the previous year. The food pantry and take-away meal services were well attended. Providing food at events or programs enhanced participation in other programs within the buildings by providing low-engagement opportunities for tenants to access services.

Direct health services make up a third of services provided by the Hub, and include services such as: primary care services, social work counselling, peer support for mental health and substance use, and occasional special events (e.g. hearing clinics, rapid hepatitis C testing). Efforts to improve the health and mental care services in the building are ongoing due to high demand. Participants described other tenants in the building as demonstrating anti-social behaviors and struggling with mental health or addiction issues that, in their view, needed more support. Participants in our interview study also described negative or traumatic experiences using health or social services in the past, or being able to get after-work hours appointments with on-site doctors that impeded their ability to use the services.

Communication challenges

During the interviews with tenants, we learned that communicating information about the Hub services was a challenge. Despite ongoing efforts to provide multiple avenues for tenants to access information about the Hub, participants described the current communication strategy as complicated and inconsistent. Participants described that the Hub services were posted on calendars in the buildings, and these were often out-of-date or different information was posted between the buildings. Many participants had minimal knowledge of most of the programs offered at the Hub. They also explained that there were many different services involved in the Hub, and they had difficulty keeping track of services. Others discussed how they often relied on peers to tell them about the services provided at the buildings. Some participants described inconsistent follow-up when trying to access services, which for some decreased future participation.

Physical environment

The goal of the Hub was to improve the physical environment and features of the buildings. Improvements were made to the buildings that included new signage, improved elevators, and a new kitchen/common area. A pervasive issue impacting the buildings was pest infestations, animal feces, garbage, and rodents. Pest infestations continued despite regular pest control due to underreporting. Results from the interview study found that pest problems were a barrier to having friends and family visit tenants and prevented some participants from visiting others. Several participants discussed that even if they had pest control in their apartments, the problems would persist because pests were in other units and more could be done to proactively address this persistent problem.

Lessons learned

Table

Enabling Participation	The Hub services support the literature that proximity to services can enhance participation (Skodra 2020); however, the complexity of tenant needs requires finding diverse solutions and programs. Many tenants wanted to be proactive in changing their lives for the better, rather than be stagnant. There was a desire for programs and training in financial security, support groups/classes/events on self-care, and possibly addressing the continuum of care/coordinated care for tenants across physical and mental health. Gender-focused programing were identified as a gap, however plans to include it were stalled due to COVID-19. Communication was a challenge. Consistent advertising, providing explanations of what the services entail or its benefits to tenants, and consistent follow-up were identified as important factors.
Demonstrating Effectiveness	We had challenges with demonstrating the effectiveness of the Hub, as reported in the literature (Freeman et al. 2020). In our case, the programs changed, the tenant population was somewhat transient, and several important outcomes were ambiguous and challenging to track change. There was also considerable change to the Hub as a result of the COVID-19 pandemic that required a flexible strategy. Our approach was tenant-centered, which prioritized tenant lived experiences and needs. We engaged with tenants through the interview study, and by examined objective measures, such as the number of emergency calls to the buildings.
Community Engagement & Collaboration	Providing programs directly within social housing benefits from collaboration across community support services, healthcare agencies, and housing services (Skodra 2020, Marshall et al. 2021). Localized approaches, such as those occurring within social housing authorities, enabled the success of interventions as local partners were knowledgeable about the needs of the community (Warwick-Booth et al. 2020). Further, providing opportunities for community building amongst tenants was important. Casual, relaxed social events encouraged participation and may have helped address social isolation, however addressing complicated social dynamics remains a challenge.

Conclusion

In many cities, there is a growing need for supports for people living in social housing. Some cities have experimented with residentially based services to reduce access barriers and ensure residents’ well-being and improve the overall functioning of the building. By describing the Hub services, we aim to provide insight about a social housing intervention to improve the social determinants of health and subsequent health outcomes for adults in Hamilton, Ontario, Canada. The Hub aimed to integrate diverse services in one location to improve safety, bolster tenant’s sense of social connectedness, and improve access to health and wellbeing services. For some tenants, the Hub made an impact in these areas, although the complexity of multi-level interventions combined with a transient target population makes understanding and evaluating the effectiveness of this intervention difficult. The COVID-19 pandemic has only exacerbated these challenges. Thus, we aimed to share lessons learned for others engaging in similar programs: consider a wide range of factors that enable participation, have a multifaceted evaluation plan to determine effectiveness, consider a range of indicators, and engage with local community partners. In an ideal world, determining the effectiveness of these types of services would include a co-design approach with short- and long-term outcome measures. Long-term integration of data sets, such as health services and emergency services usage data, would allow for a robust analysis to inform future policy in this area. Lastly, a firm funding commitment is imperative for the long-term sustainability of these types of programs.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data used in this paper cannot be made publicly available as the qualitative interviews that informed the paper contain identifying information.

Additional information

Notes on contributors

Jim Dunn

This paper was authored by members of a research and data working group that was brought together to understand the effectiveness of the pilot program discussed in this paper. Members of the working group are comprised of housing and health researchers from McMaster University and the University of Colorado Denver and the program lead from the municipal housing organization. The paper presented is a snapshot of the collaborative work this group has been engaged with over the past several years. We hope others implementing similar programs can learn from the insights and lessons we present below.