Keywords

1 Introduction

The experience of homelessness brings many challenges and has a strong impact on the overall health and well-being of a young person (Schwan, 2018). Despite people affected by homelessness being just over four times more likely to die prematurely than the general population due to health problems (Morrison, 2009), there are still many barriers to accessing and sustaining engagement with services and practitioners (Rodriguez et al., 2020a, b). Support services in general tend to see people experiencing homelessness as “difficult” to engage with. On the other side, those affected by homelessness do not feel welcomed when accessing services. Another shared perception is that services have not been designed for them and therefore are failing to provide the most adequate support at the right time of their journeys. Thus, the involvement of those with lived experience in policy design and implementation of services to prevent and to tackle homelessness is currently necessary and required by policymakers.

In this chapter, we will present a Freireian participatory research approach underpinned by the principles of critical pedagogy to increase young people’s participation in the design of health promotion interventions and social participation in society.

2 Youth Homelessness in Scotland

In 2018–2019, the Scottish Government released statistics on youth homelessness, which showed that 6,996 people aged between 16 and 25 years presented as homeless (Scottish Government, 2019). This represents almost 25% of all applications. Youth homelessness refers to “the situation and experience of young people between the ages of 16 and 25 who are living independently of parents and/or caregivers, but do not have the means or ability to acquire a stable, safe, or consistent residence” (Gaetz et al., 2018, p11).

However, the information gathered by the government is based on self-reporting; due to fear of discrimination or lack of incentive in disclosing the real causes of their homelessness, the official numbers do not present a true picture of the problem. The data collected do not include young people “sofa-surfing” around friends’ or families’ houses, for instance, or those living in overcrowded, unsafe housing conditions. Thus, young people are more likely to be part of the “hidden homeless” population (Homeless link, 2013) with limited chances of government support.

The main cause of youth homelessness remains relationship breakdown or conflict at home (Scottish Government, 2019). However, young people’s journey into homelessness is rarely linear and is often the result of structural factors, system failures and individual circumstances.

Poverty is a central structural factor leading to homelessness, along with lack of accessible housing, lack of education and unemployment. Worryingly, youth unemployment rates are on the rise in the UK, and, with the impact of the COVID-19 pandemic on the economy, there are serious concerns about further deterioration of this situation.

Reducing and eradicating youth homelessness is essential to guarantee their access to and engagement with diverse services and specialized types of support according to the different stages of homelessness. These services must be designed in ways that include young people’s views, needs and aspirations.

3 Government Responses to End Youth Homelessness: Involvement of People with Lived Experience

Scotland has highly progressive homelessness legislation, including the Housing Options approach, to prevent homelessness.

In 2018, the Ending Homelessness Together High-Level Action Plan was launched, and it emphasized that, in addition to homelessness and housing services, partners across health, education, social work, community support, justice and the third sector were necessary to ensure that homelessness would be only rare, brief and non-recurrent (Scottish Government, 2018).

New changes in homelessness policies reduced the use of unsuitable accommodation for more than 7 days for all homeless households from 2021 (Scottish Government, 2020), which, in the past, was only reserved to pregnant women and households with children (Scottish Government, 2017). This certainly will improve the quality of life of those young people requiring an accommodation.

In these processes of designing new policies and legislation, the Scottish Government is aware of the importance of consulting people with lived experience. In 2018, the views of 425 individuals with experience of homelessness were gathered to help identify the best solutions to end homelessness (Glasgow Homelessness Network , 2018).

One of the most influential platforms seeking service user involvement to make co-production a building block in the design of policies in Scotland is “All in for Change” (Scottish Community Development Centre, 2019). This platform is making a collaborative effort in supporting the Scottish Government to tackle rough sleeping, stigma and discrimination faced by homeless people (Homelessness Network Scotland, 2020).

Another example of joint work to develop youth homelessness prevention pathways comes from A Way Home Scotland, a coalition of individuals, organizations and authorities dedicated to ending youth homelessness in Scotland (Way Home Scotland, 2019). Whilst the preventative approaches brought forward by these pathways and endorsed by the Scottish Government are pivotal to end homelessness, the equal, fair and meaningful involvement of people with lived experience must continue to be the voice that shapes and informs policy and legislation.

The leadership shown by the Scottish Government and the unparalleled commitment and expertise brought forward by universities and many third sector organizations are proof that positive changes can be collectively designed and implemented.

4 Health Promotion for Young People Experiencing Homelessness: The Use of Critical Pedagogy

Critical pedagogy is an educational approach that was developed by Paulo Freire (1972). This approach has been extensively used by education and social work disciplines, with a fruitful field still to be explored more within health promotion studies. Critical pedagogy endorses marginalized groups' ability to critically think about their life situation and to question the structures of power in society. It highlights the principles of popular education, community development (Ledwith, 2016) and emancipatory research action for health promotion (Wallerstein et al., 2018).

Participatory research processes that seek social transformation following Freire’s approach start from the assumption that if we want to be more effective as agents of social change, we must be able to understand the context in which we live and the impact of the actions we take. Health promotion interventions that create good opportunities for people to critically reflect on their experiences of health care are essential. In doing this, participants are encouraged to raise their voices on issues that affect their lives and to recognize connections between their individual problems and the social contexts of inequalities in which they are embedded.

Co-designed health promotion interventions tailored for and with people and communities with lived experience are of central importance to this study, as the knowledge production “with” young people’s input can contribute to reducing the health and social inequalities of those who are socially excluded.

Phelan and colleagues (2010), writing on the theory of the fundamental causes of inequality, pointed to the importance of developing health knowledge together with significant factors in health and social inequities. This study adopted Freire’s approach to health promotion intervention development in which young people experiencing homelessness were invited to co-produce knowledge on eight health promotion and social participation topics.

A typical feature of the Freireian-type education used in this epistemological and ethical framework understands people as social agents of change, and, for that reason, more opportunities need to be created in community settings for them to bring their own views and experiences to the table to produce knowledge and change in issues that affect their lives. The concept of knowledge production not just “at” but “with” young people adopted in this chapter reflects our belief in health promotion interventions that must work under the principle of “no hierarchization” of knowledge. In this case, there is no space for processes that use a top-down approach . Individuals, when experiencing freedom to express themselves and receiving appropriate encouragement to develop a critical dialogue and reflection with peers and practitioners tend to make an effort to bring about change in their lives. On the other hand, when they are perceived as just recipients of policies, services and formal bodies of knowledge, their process of taking ownership of their lives and choices can be suppressed.

Knowledge production together “with” people recognizes them as the experts of their lives, and their expert knowledge and life experiences combined with other types of knowledge and information obtained from dialogues with different actors such as practitioners, policymakers, health bodies and/or formal higher educational institutions form a vital and integral part of this intervention development. The dialogue in Freire’s perspective (Freire, 1996) is an act of existential creation.

The work presented in this chapter is underpinned by the principles of critical pedagogy (Freire, 1996), co-production (Walker, 2019) and community development. A joint agenda to promote the right to health of marginalized groups addressed the need to place the young person at the centre of a health promotion intervention that is inclusive, emphatic, collective and comes from their life experiences/contexts.

5 The Research Process: Aims and Partner Engagement

The Scottish Government’s broad goal to reduce health inequalities and poverty through the health and social care integration strategy (Scottish Government, 2014) inspired this project with young people and a wider range of partners.

The main purpose of this research was to co-produce a youth-led workshop programme committed to provoke critical consciousness and collective action towards a fairer, healthier and more equal society. The workshop programme aimed to: (1) expand young people’s knowledge of wider health-related homelessness topics to orient social change and to improve health; (2) collect their experiences with services from different areas of care; and (3) use critical dialogue and thinking to increase the participants’ awareness on health promotion linked to socio-political engagement.

The partners involved in this research process comprised four groups from the health and social care sectors and included:

  1. 1.

    National Health System (NHS) Health Boards: health practitioners that provide oral health, health promotion and health education sessions for people experiencing homelessness.

  2. 2.

    Public health researchers working in the Smile4Life programme (the Scottish oral health and psycho-social well-being improvement programme for people experiencing homelessness, funded by the Scottish Government and located at The University of Dundee).

  3. 3.

    Young people aged 16–25 years, experiencing homelessness and living in temporary and supportive accommodations provided by a third sector organization in Edinburgh.

  4. 4.

    Front-line staff and managers from third sector organizations working in the following fields: youth housing support, professional training on substance misuse and professional training on conflict mediation for families and young people either at risk of or experiencing homelessness.

The research participants were selected and engaged by following elements of a reflexive mapping approach developed by Rodriguez, Arora, et al. (2020a). This involved a series of steps such as online searches to identify key youth organizations, followed by several informal phone calls, face-to-face meetings and visits where the principal researcher shadowed youth workers and practitioners and discussed service provision challenges and limitations in an informal and friendly way. This path of networking was a rich experience for all involved as it created a good professional and conceptual bond towards the cause of homelessness and social transformation.

The shared commitment and work to end youth homelessness helped researchers, policymakers, young people and practitioners from health and third sectors connect in varied ways during the research process. A common research agenda was agreed upon, with shared principles of empathy and collaborative work creating the perfect environment for a community-based participatory research to be developed. This work addressed the need for academics to go to communities, to interact with people with lived experience and to listen and learn from them to improve the social participation of the voiceless groups in society.

To guarantee the genuine participation of young people and other partners, a series of meetings occurred through different phases of engagement, as previously described by Rodriguez et al. (2019). A summary of these phases is presented in Table 5.1.

Table 5.1 Phases of the participants’ engagement
Full size table

This research process strengthened the idea of academic environments being open to build more connection with grassroots communities and health promotion services that address complex social problems in society. Non-academic partners must be involved as much as possible in participatory research processes as well as in joint publications and other ways of research dissemination.

6 The Research Framework

Based on the principles of critical pedagogy (Freire, 1996) and using a participatory art-based approach, this research framework involved the co-production of eight workshops on the following themes: oral health, mental health, substance misuse, healthy diet, resilience, stigma, education for the future and youth homelessness trajectory. These topics were selected by the young people and their youth workers. Details of each workshop session and participant’s evaluation were described in a previous publication (Rodriguez et al., 2019).

As critical pedagogy according to Freire (1974) means empowering people to question their realities and the structures of power in society that discriminate against certain groups, young participants were invited during the workshop to identify relationships between their conceptions of health promotion, their experiences with health services and their contexts of inequalities. In Freire’s social theory, the practice of dialogue helps form a critical consciousness that is integrated with people’s reality. Within this critical consciousness, individuals or groups begin to see themselves and their society from their own perspective and they become aware of their own potentialities. Thus, a critical attitude for change can be developed to overcome passivity related to various aspects of young people’s lives, including health care and social exclusion: “Society now reveals itself as something unfinished, not as something inexorably given; it has become a challenge rather than a hopeless limitation” (Freire, 1974, p.10).

To assure equal participation in the research process, a substantial amount of time was allocated to the research timeline. This was essential to allow the participants and research partners time to get to know each other, to align their interests and to build trust. A continuous process of evaluation was put in place during and after the workshop programme delivery, with young people being consulted about each individual workshop session as well as the full programme. This allowed the researchers and workshop facilitators to make positive changes regarding the content, resources and facilitation of the workshop sessions based on the constant feedback from the participants.

The art approach used during the sessions was also used in follow-up projects (Rodriguez, 2020b, c) and was proved to achieve a positive response from the young people and helped them raise and discuss sensitive issues through drama activities, collage making, educational games, video debate, photovoice, graffiti, capoeira and cultural exchange.

The research data collection was based on participant observation during the eight workshop sessions (3 hours each), delivered at a non-governmental organization (NGO) base in Edinburgh city. Recordings of the group discussions during the sessions were also made. The evaluation of the programme included participant observation, post-workshop questionnaires (of each session and after the programme ended) and in-depth semi-structured interviews with the young participants and staff members about the key issues on homelessness trajectories, health needs and service provision. Content analysis was used to explore qualitative data.

7 Results

This theoretical framework, inspired by Paulo Freire (1974), created a safe and encouraging environment to form critical consciousness and critical attitude related to the participants’ health choices as well as critical thinking for action and participation in society. The workshop programme increased the participants’ confidence about their rights to health, expanded knowledge on health promotion issues related to homelessness and encouraged critical discussions on accessibility of youth services with staff members and their peers.

Each workshop session captured the young people’s definitions, conceptions and experiences regarding the eight topics developed during the programme. Their previous knowledge on health concepts and experiences with healthcare and health practitioners were heard, legitimated and valued in each workshop, without any other health promotion-related information being transmitted. Thus, the group had enough time to think about the topic and to express themselves using their own references and ways of communication. Feeling genuinely recognized in their knowledge, they could exchange ideas and experiences inside the group with freedom and no judgement.

After this first phase, the researcher added new information related to each topic that came from formal bodies and organizations such as the WHO and scientific studies. This subsequent addition of knowledge was made in a respectful and empathic way so as to not minimize or diminish the young people’s previous knowledge and experiences but to expand their horizons, opinions and health information.

In the third phase, the young people reflected together on this additional knowledge, meanings and perceptions and a new critical dialogue was generated with these two fields of knowledge, namely, a “formal” knowledge and a knowledge derived “from experience”, without making any kind of hierarchical differentiation. When young people were invited to combine/merge these two types of knowledge using different methods of art, a co-produced new knowledge was then observed through their art production and collective commitment. More clarity about the structures of power in society and how contexts of poverty may prevent certain groups from achieving better health and quality of life was perceived. The participants’ strategies to overcome these challenges and to combat stigma from health services were critically discussed as well. Explanations of which aspects the group had changed or increased knowledge via the workshop sessions and group interaction were shared. The most important experience for the participants seemed to be having the chance to see that similar understandings, feelings and experiences were common to other members of the group, including staff members. This generated a sense of belonging and a group identity for hope and change. At the end of each workshop, the participants made a collective and individual commitment to change certain aspects of their lives. The verbalization of these commitments for their peers and support workers produced a powerful atmosphere.

The discussions during the workshops enabled the young people to critically reflect on their views, health needs and experiences in accessing services while being affected by homelessness. There was a construction of a new knowledge of wider health promotion issues and social participation for the young people. The process of critical thinking and dialogue formulated by Freire led to the creation of a “new knowledge”, which formed a strong base for their social behaviour change. Further contact with staff members after conclusion of the research confirmed adoption of new choices and attitudes related to health care. Trust building and collective engagement with the service providers were highlighted, and improvements were noted in the young people’s relationships with their peers attending the NGO as well as their wider social interactions.

This research co-created knowledge that came from the common concerns and experiences of young people. It was based on the diverse experiences and knowledge of the participants rather than on the top-down dynamics of health education that make people feel like passive consumers of information. This new knowledge emerged from listening to the young people and the front-line staff working in youth services, from letting them lead the process and being comfortable to explore their own beliefs and values regarding their trajectories through services. This work shows that universities are not unique places to produce knowledge. There are infinite types of knowledge that must be acknowledged and integrated in policies and services protocols. To address this, more inclusive and safe spaces of critical dialogue should be created.

8 Limitations

The substantial amount of time required to fit in this type of research can be challenging for research participants and institutions. Within the homelessness context of service provision, there are complex and frequent demands that necessitate staff responses. Research timelines should respect that and be flexible, being prepared for inevitable delays. A culture of collaboration among the health and social care sectors should be strengthened as well to permit more staff involvement in interdisciplinary research.

A relatively small number of young people (13 participants distributed across 8 workshop sessions) took part, and this project does not allow wider generalization of the findings. However, while acknowledging the small sample size, this responded to the principles embedded in the theoretical and methodological approaches as the nature of these activities requires a reduced number of participants. In addition, we were not able to examine longer-term behaviour change and actions towards social transformation. This should be done in future studies.

9 Final Reflections

In this chapter, a methodological and theoretical framework – inspired by Freire’s formulation (1974) – that fostered a common agenda for the right to health of marginalized groups was suggested and discussed.

This experience placed the young person at the centre and enabled researchers to understand health promotion linked to social justice from the perspective of young people experiencing homelessness.

The production of knowledge “with” and not just “at” young people was another key element of this research. A co-created knowledge came from the common concerns and experiences of these young people regarding health promotion and homelessness. This work highlighted the value of this knowledge in co-designed and implemented health promotion and health education programmes that used multi-agency collaboration.

The principles of critical pedagogy applied to health promotion research were perceived as essential to create good opportunities for young people to develop critical consciousness of societal inequalities, critical dialogue and change towards better engagement with health services.

In the authors’ experience, one of the current challenges of health promotion research is associated with a lack of service users’ involvement. Disconnections between research production and the expectations of individuals who face health and social problems in their communities without being deeply consulted regarding their priorities and what is needed from their perspective have led to disappointing results. This type of research challenges the idea that traditionalist paradigms of positivist research are capable of appropriately representing the nature and complexity of health promotion issues linked to contexts of poverty and inequities in society.

The process of conducting research that was inclusive, multidisciplinary and diverse was reflected in the writing process of this chapter. The authors came together from different sectors (two researchers from university, a young person from the third sector and a policy officer), with different professional paths, life experiences and areas of knowledge/practice , to share their views and learnings on the topic.

The culture of critical health promotion inside third sector organizations and health services should be strengthened on a daily basis.

This work permitted young people to play the role of active participants, becoming agents of social change with increased health learning capacity and critical consciousness. Future follow-up projects with young people to implement progressive change in health policies and practice can make a substantial difference to their lives.