Abstract

Popular media plays an important role in bringing health issues and concerns to the attention of the general public. One such issue is that of culturally appropriate supportive housing for Canadians with mental health issues (Roberts, 2006). Understanding of this issue requires a familiarity with cultural competency and supportive housing, to formulate a definition of culturally appropriate supportive housing. The need for culturally competent care is not limited to the provision of health care services. It also encompasses the domain of supportive housing, and together the two have various implications on mental health. The need for culturally appropriate supportive housing is supported by a review and thorough examination of both the literature and two relevant determinants of health. Policies involving both mental health and housing have yet to concretely identify the need for culturally appropriate supportive housing. Therefore, in the future, policy makers should recognize the necessity of including cultural appropriateness into the supportive housing provided to mental health consumers.

---

---

Citation

Cultural Competency and Supportive Housing: A Link to Mental Health. Tanguay, Jennifer . Lethbridge Undergraduate Research Journal. Volume 2 Number 1. 2007.

---

Popular media plays an important role in bringing health issues and concerns to the attention of the general public. One such issue is that of culturally appropriate supportive housing for Canadians with mental health issues (Roberts, 2006). Understanding of this issue requires a familiarity with cultural competency and supportive housing, to formulate a definition of culturally appropriate supportive housing. An examination of two relevant determinants of health reveals the need for culturally appropriate supportive housing, and the associated implications for mental health. Current mental health and housing policies and the need for them to embrace culturally appropriate supportive housing will also be presented.

Cultural Competency

Cultural competency is a conscious process of acknowledging, utilizing, and appreciating cultural values, and the relationship to culturally congruent nursing care (Kozier et al., 2000; Jeffreys, 2005). Culture values have been defined by Leininger (as cited in Leininger & McFarland, 2006) as the “powerful, persistent, and directive forces that give meaning, order, and direction to the individual or group's thinking, actions, decisions, and lifeways” (p. 284). Recognition of these values is imperative when providing culturally congruent nursing care, defined as “those cognitively based assistive, supportive, facilitative, or enabling acts or decisions that are tailor made to fit with individual, group, or institutional cultural values, beliefs, and lifeways in order to provide or support meaningful, beneficial, and satisfying health care” (Leininger, 1991, p. 49). In essence, from a health care perspective, to be culturally competent is to recognize the cultural values which shape and influence individual and group lifeways so that optimal health care can be provided.

Supportive Housing

Supportive housing entails the provision of community support services within community living arrangements (such as group homes, half-way houses, and supervised apartments). Support or rehabilitation is provided by staff who work with mental health consumers regardless of their place of residence, or staff may be attached specifically to the residential setting (Nelson, Hall, & Forchuk, 2003; Wong & Solomon, 2002). Nelson et al. identify three key principles of supportive housing for persons living with a mental illness: Choice and control over where and with whom mental health consumer's live; emphasis on community integration, with integration into housing available to anyone in the community; and financial and social support to ensure a realistic choice in housing within an existing housing market.

Defining features of supportive housing include a permanent living arrangement, regardless of exacerbation of symptoms, and an approach which reflects consumer choice, control, self-help, empowerment, and a de-emphasis of professional services (Parkinson, Nelson, & Horgan, 1999). Carling (1992) focuses on emphasizing social integration (within normalized settings) between mental health consumers and non-disabled community members.

Defining culturally appropriate supportive housing.

Based on the definitions of cultural competency and supportive housing, culturally appropriate supportive housing can be defined as housing that facilitates community integration, maintains consumer choice and control, and provides social support in a way that respects and acknowledges the mental health consumer's cultural values. Since culture impacts every facet of an individual's life, from a health care perspective, it is imperative that supportive housing is provided in a way that is culturally congruent and appropriate to the individual being served. For example, Barrio (2000) acknowledges that although Western European cultures are characterized as individualistic and independent, ethnic minority cultures are “typically centered on the family and supported by extended family networks, which generate emotional and instrumental supports for family members in need” (p. 880). Barrio recognizes the need for culturally congruent interventions and services to incorporate those family networks or group modalities, as the results of his research has shown that following Western models of rehabilitation may produce adverse effects when used with mental health consumers from various ethnic minority backgrounds.

It is imperative that supportive housing encompass cultural needs, as well as the mental health needs of the consumers using these types of services. The defining role that culturally appropriate supportive housing would play is echoed by the humanitarian philosophy of care. In keeping with this view, “services should be individualized, empower clients, incorporate natural supports, and focus on strengths; they should be flexible, normalized, accountable, racially and culturally appropriate, and effectively coordinated to ensure continuity of care” (Barrio, 2000, p. 879).

Why There is a Need: Looking at the Determinants of Health

Over the past several decades, a great deal has been learned in regard to health and what makes people healthy. Kozier et al. (2004) highlights Canadian initiatives in health promotion. Initiatives beginning in 1974 with the publication of the Lalonde report, which introduced the view that health was influenced by a variety of factors, such as: human biology, lifestyle, health care system's, and one's social and physical environment, with considerable emphasis on lifestyle. The Lalonde report's perspective on health failed to include the impact of one's socioeconomic environment, which was later identified by the World Health Organization (WHO) during the Alma Ata conference in 1978. The WHO suggested that “the prerequisites of health go beyond medical and behavioural health determinants to include economic, social, psychological, and environmental responsibilities of communities” (Kozier et al., 2004, p. 148). It is the complex interactions between these various determinants of health and their combined influence that determines health status (Public Health Agency of Canada [PHAC], 2003). Physical environments and culture are two determinants of health that support the need for culturally appropriate supportive housing.

Physical environments

Shelter was recognized as a basic prerequisite for health in the Ottawa charter for health promotion (WHO, 1986), presented during the First International Conference on Health Promotion in 1986. The PHAC (2004) reports that Canada is experiencing a rising housing crisis, marked by a lack of affordable accommodations available for rent and an increase in homelessness. This housing crisis may have a profound effect on immigrants, refugees, and mental health consumers because of their inability to provide credit and other references when looking for housing (PHAC). Furthermore, the fear of homelessness and concerns about substandard housing are psychological stressors than can lead to or exacerbate mental health problems (Krieger & Higgins, 2002).

Socioeconomic environment

People may be faced with additional health risks because of their socioeconomic environment. A socioeconomic environment is largely determined by cultural values that contribute to the continuation of conditions through stigmatization, marginalization, loss or devaluation of language and culture along with a lack of culturally appropriate health care and services (PHAC, 2003). Krieger and Higgins (2002) identified that people of color and with low income are disproportionately affected by substandard housing across populations. Implications include making tradeoffs between living in adequate housing, having ample food, and staying warm. The possible resulting effects on health are adverse, and multiplied in the presence of mental illness.

Implications for mental health

A qualitative study by Nelson, Clarke, Febbraro, and Hatzipantelis (2005) evaluated supportive housing for formerly homeless people with serious mental illness. The findings of their study illustrate the positive effects of supportive housing, evidenced by participants' acknowledgment of increased stability in their lives, the recovery of positive personal identities, development of supportive relationships, and the reclaiming of vital resources needed to live life with dignity and meaning (Nelson et al., 2005). Overall, participants in this study stated their quality of life had improved immensely since being in supportive housing, also a reflection of their improved mental health.

A similar study conducted by Decker, Cary, and Krautscheid (2006) provides additional insight, as their findings show that some people experience “relocation stress syndrome... characterized by anxiety, depression, apprehension, loneliness, increased confusion, and physiological symptoms” (p. 20). Relocation stress syndrome, an approved nursing diagnosis, (North American Nursing Diagnosis Association, 2001) suggests that initially, people may experience manifestations of stress following relocation, but with appropriate intervention, adaptation can be successful and quality of life improved. Tracy and DeYoung (2004) suggest such interventions as: affirming the decision to move, encouraging individual's to reminisce and keep cherished possessions, and promoting social interaction.

A culturally relevant system of care can also ensure positive effects on mental health. It is imperative that individual cultural orientations are addressed, facilitated by an understanding and honoring of the attitudes, values, and behaviors unique to each individual. This is of utmost importance, as these factors influence both service use and outcomes (Barrio, 2000; Repper, 2000).

Current Mental Health Policies

In Canada

The Canadian Mental Health Association's (CMHA) mandate can be broadly described as promoting the mental health of all people (CMHA, 2006). The fundamental principles of empowerment, family and peer support, participation in decision-making, citizenship, and inclusion in community life base their involvement in a variety of mental health issues (CMHA, 2006). Specific policies on mental health services highlight the need for living arrangements and supportive housing to promote personal autonomy, an important aspect of rehabilitation and health promotion (CMHA, 1995).

Policies on cross cultural mental health address the need for culturally appropriate services to be provided in a relevant, accessible manner for all people (CMHA, 1996). As our population becomes more and more diverse, this aspect becomes increasingly important. The Canadian Task Force on Mental Health Issues Affecting Immigrants and Refugees reports that migration in and of itself does not increase the incidence of mental health issues (CMHA, 1996). However, when migration is coupled with one of seven factors (a drop in socioeconomic status, inability to speak the host country's language, separation from family, lack of friendly reception from the host country, lack of cultural community support, experiencing a traumatic event prior to migration, or migrating during adolescent years or after the age of 65), it does become a risk factor for mental illness (CMHA, 1996).

The CMHA (1996) has set out to achieve the following: To ensure their programs are culturally sensitive and accessible to all people in Canada; to increase staff knowledge and skill in order to provide culturally appropriate services; to actively recruit people from various backgrounds, reflecting the Canadian population's diversity, to serve on Boards and work as staff and volunteers; and to thoroughly examine policies and procedures with the intent of eradicating systemic racism.

Worldwide

The WHO (2003) reports 40% of countries do not have a mental health policy and over 30% have no mental health programs. In response, the WHO's Department of Mental Health and Substance Dependence has created the Mental Health Policy Project (MHPP), aimed at addressing a wide variety of issues in relation to mental health policy and services development (WHO, 2003). The goal of this project is to aid countries in developing policies and services, and putting them into practice, which will lead to improved mental health care, treatment, and promotion (WHO, 2003; WHO, n.d.).

This project consists of four components: The mental health policy and service guidance package, training program, international network of experts, and support to countries. The MHPP was developed to help countries around the world develop the capacity needed to establish effective and comprehensive mental health services, accomplished through “access to educational materials, practical guidance and collaborative consultation with WHO experts” (WHO, n.d., p. 1). The result will be the creation and implementation of national mental health policies, plans, legislation, and services needed to effectively address the mental health needs of all countries around the world.

Current Housing Policies

In England

Johnson (2005) outlines policy developments in England that reflect the role housing plays in promoting and maintaining mental health. In 1999, the government called for increased inter-agency planning and developed a continuum of accommodation for mental health service users in its National Service Framework for Mental Health (Johnson, 2005). This included “staffed and supported housing, long-stay accommodation, crisis and refuge places, service user-run sanctuaries, family placement and respite services, and supported living options” (Johnson, 2005, p. 24). In recognition of those who wish to live in their own homes, floating support was developed and provided to those individuals, enabling them to continue or take on independent living (Johnson, 2005).

The Supporting People program was also launched the same year, setting out to co-ordinate funding while identifying the needs of supported housing services. Johnson (2005) identifies that this program was re-established in 2005 as one of the key government initiatives geared at ensuring integrated care and support for all mental health consumers.

In Canada

Alberta Community Development has been making proactive steps to resolving housing issues, such as its development of a Housing policy framework for Alberta: Family and special purpose housing (2000), which focuses on supporting people in need, promoting their independence, and providing help to those Albertans who are unable to provide for their basic needs. Alberta's vision is “that all its citizens have access to: adequate, safe, and affordable housing consistent with a socially acceptable standard of living; and the necessary support to maximize independence and self reliance” (Alberta Community Development, 2000, p.3). In recognition that each community is unique, the government of Alberta is calling on communities to take the initiative in determining what their current and future housing requirements are while identifying local solutions and using the social housing that is available. It asserts that “solutions will depend on partnerships, breaking down the traditional barriers, and developing a common agenda with a clear understanding and respect for the specific roles and responsibilities of each partner” (Alberta Community Development, 2000, p. 4).

Regarding supportive housing, Alberta Community Development recognizes that not all who require this type of housing receive it; which is of concern because of the implications that has on both physical and mental health (Alberta Community Development, 2000). In response, a strategy has been implemented that will: review services to determine gaps, needs, and potential solutions; identify what needs are or are not being met; and develop a supportive housing plan that addresses the needs of all individuals who require it (Alberta Community Development, 2000).

Conclusion

Mental disorders are a common and growing health concern, affecting 25% of people worldwide at some point in their lives (WHO, 2001). One could infer that given this high rate of prevalence, individuals of many different cultural backgrounds will be affected by mental illness. Individuals who face housing difficulties are at even greater risk for both physical and mental health problems, “stemming from a lack of basic essentials such as adequate nutrition, shelter, employment, and social support” (Decker, Cary, & Krautscheid, 2006, p. 20). The positive effects of supportive housing include “reduced homelessness, increased residential stability, reduced hospitalization and fewer service gaps, reduced symptoms, improved social and personal functioning, improved quality of life, and increased satisfaction with housing” (Wong & Solomon, 2002, p. 14). These positive effects can only be potentiated when cultural values are taken into consideration and used to serve the individual's best interests.

The need for culturally competent care is not limited to the provision of health care services. It also encompasses the domain of supportive housing, and together the two have various implications on mental health. The need for culturally appropriate supportive housing is supported by a review and thorough examination of both the literature and two relevant determinants of health. Policies involving both mental health and housing have yet to concretely identify the need for culturally appropriate supportive housing. Therefore, in the future, policy makers should recognize the necessity of including cultural appropriateness into the supportive housing provided to mental health consumers.

Acknowledgments

I would like to thank Suzanne Harris, RN, BN, and David Gregory, RN, PhD, for all of the assistance and encouragement they have provided me throughout this endeavor.

About the Author

Jennifer Tanguay is a 3 ^rd year nursing student at the University of Lethbridge who believes that health care should be provided holistically with an understanding of people's spirituality and individual uniqueness. She is an executive member of the Health Sciences Undergraduate Association and the U of L's Associate Delegate for the Canadian Nursing Students' Association.

References

Alberta Community Development. (2000, August). A housing policy framework for Alberta: Family and special purpose housing. Retrieved September 26, 2006, from http://www.seniors.gov.ab.ca/housing/family_special/supportive_housing/PolicyFramework.pdf

Barrio, C. (2000). The cultural relevance of community support programs. Psychiatric Services, 51(7), 879-884.

Canadian Mental Health Association. (1995, November). Mental health services. Retrieved September 26, 2006, from http://www.cmha.ca/bins/content_page.asp?cid=5-33-166

Canadian Mental Health Association. (1996, December). Cross cultural mental health. Retrieved September 27, 2006, from http://www.cmha.ca/bins/content_page.asp?cid=5-33-173

Canadian Mental Health Association. (2006). Policy statements. Retrieved September 26, 2006, from http://www.cmha.ca/bins/content_page.asp?cid=5-33&lang=1

Carling, P. J. (1992). Homes or group homes?: Future approaches to housing, support, and integration for people with psychiatric disabilities. Adult Residential Care Journal, 6(2), 87-96.

Decker, S., Cary, P., & Krautscheid, L. (2006). From the streets to assisted living: Perceptions of a vulnerable population. Journal of Psychosocial Nursing & Mental Health Services, 44(6), 18-27.

Jeffreys, M. R. (2005). Clinical nurse specialists as cultural brokers, change agents, and partners in meeting the needs of culturally diverse populations. Journal of Multicultural Nursing & Health, 11(2), 41-48.

Johnson, R. (2005). Mental health and housing: Making the links in policy, research and practice. Journal of Public Mental Health, 4(4), 21-28.

Krieger, J., & Higgins, D. L. (2002). Housing and health: Time again for public action. American Journal of Public Health, 92(5), 758-768.

Kozier, B., Erb, G., Berman, A. J., Burke, K., Bouchal, D. S. R., & Hirst, S. P. (2004). Fundamentals of nursing: The nature of nursing practice in Canada. (1 ^st Canadian ed.). Toronto, ON: Prentice-Hall, Inc.

Leininger, M. M. (Ed.). (1991). Culture care diversity & universality: A theory of nursing. New York: National League for Nursing Press.

Leininger, M. M., & McFarland, M. R. (Eds.). (2006). Culture care diversity and universality: A worldwide nursing theory (2 ^nd ed.). Sudbury, Massachusetts: Jones and Bartlett.

Nelson, G., Clarke, J., Febbraro, A., & Hatzipantelis, M. (2005). A narrative approach to the evaluation of supportive housing: Stories of homeless people who have experienced serious mental illness. Psychiatric Rehabilitation Journal, 29(2), 98-104.

Nelson, G., Hall, G. B., & Forchuk, C. (2003). Current and preferred housing of psychiatric consumers/survivors. Canadian Journal of Community Mental Health, 22(1), 5-19.

North American Nursing Diagnosis Association. (2001). Definitions and classifications, 2001-2002. Philadelphia: Author.

Parkinson, S., Nelson, G., & Horgan, S. (1999). From housing to homes: A review of the literature on housing approaches for psychiatric consumer/survivors. Canadian Journal of Community Mental Health, 18(1), 145-164.

Public Health Agency of Canada. (2003, June 16). Population health approach: What determines health? Retrieved October 1, 2006, from http://www.phac-aspc.gc.ca/ph-sp/phdd/determinants/index.html

Public Health Agency of Canada. (2004, March 24). Housing as a determinant of health. Retrieved September 26, 2006, from http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/ overview_implications/09_housing_e.pdf

Repper, J. (2000). Adjusting the focus of mental health nursing: Incorporating service users' experiences of recovery. Journal of Mental Health, 9(6), 575-587.

Roberts, A. (2006). Searching for home: Addressing the need for culturally appropriate supportive housing. Crosscurrents, 9(4), 14-15.

Tracy, J., & DeYoung, S. (2004). Moving to an assisted living facility: Exploring the transitional experience of elderly individuals. Journal of Gerontological Nursing, 30(10, 26-33.

Wong, Y. L. I., & Solomon, P. L. (2002). Community integration of persons with psychiatric disabilities in supportive independent housing: A conceptual model and methodological considerations. Mental Health Services Research, 4(1), 13-28.

World Health Organization. (1986, November 21). Ottawa Charter for Health Promotion . Retrieved October 1, 2006, from http://www.who.int/hpr/NPH/docs/ottawa_charter_hp. pdf

World Health Organization. (2001, December). Mental and neurological disorders. Retrieved September 24, 2006, from http://www.who.int/mediacentre/factsheets/fs265/en/

World Health Organization. (2003, November). Mental health policy fact sheet. Retrieved September 27, 2006, from, http://www.who.int/mental_health/policy/MHPolicy_ factsheet.pdf

World Health Organization. (n.d.). WHO mental health policy project: Addressing needs, improving services (MHPP). Retrieved September 27, 2006, from http://www.who.int/ mental_health/ policy/MHPP_brochure_English.pdf