“Until You Hit Rock Bottom There’s No Support”: Contradictory Sources and Systems of Support for Mothers Experiencing Homelessness in Southwestern Ontario

Abstract

Nurses are vital community advocates and uniquely situated to support mothers experiencing homelessness. The purpose of this study was to examine the multidimensional nature of social exclusion in the lives of mothers experiencing homelessness in Southwestern Ontario. This article reports findings from one segment of a larger study that critically examined the sociopolitical context, health needs, exclusionary and inclusionary forces, and strategies of resistance demonstrated by mothers experiencing homelessness. Central to the women’s experiences of mothering while homeless were their interactions with “the system.” The contradictory nature of these systems was categorized into four subthemes: (1) “Until you hit rock bottom there’s no support,” (2) “It’s just not enough”: Insufficient support, (3) “Help comes with a price”: Support with surveillance, and (4) “Every shelter is so different”: Organizational philosophies impacting support. The contradictory nature of the system created an illusion of support, but in mothers’ lived realities, it perpetuated experiences of exclusion in spaces ironically designed to enhance inclusion. Implications for nursing practice include action the macro-, meso-, and microlevels. Nurses can advocate for Housing-First initiatives and evidence-informed approaches to poverty reduction while recognizing the system-level barriers to health and providing respective, compassionate care.

Keywords

Mental health social inclusion social exclusion inequalities in health homelessness mothering

Introduction and background

Homelessness is a significant social, health (Hwang, Wilkins, Tjepkema, O’Campo, & Dunn, 2009; Raphael, 2016), and nursing issue in Canada (C. Crowe, 2007; Kelly & Luxford, 2017; Registered Nurses Association of Ontario (RNAO), 2004). Nurses are in prime positions to promote the health and well-being of individuals experiencing homelessness, as we provide vital care across a variety of settings and are often the first point of contact for them within the health-care system (Weber, 2018). Among those experiencing homelessness in Canada, mothers and their families represent a vulnerable and increasingly growing segment of the homeless population due to poverty, lack of affordable housing, and intimate partner violence (Chambers et al., 2014; Gaetz, Donaldson, Richter, & Gulliver, 2013; Human Resources and Skills Development Canada, 2010; Shapcott, 2016). Furthermore, homeless mothers are among those who are socially excluded from the full economic, social, and subsequently, health benefits of society (Labonte, 2016). The purpose of this study was to examine the multidimensional nature of social exclusion in the lives of mothers experiencing homelessness in Southwestern Ontario.

Social exclusion has been identified as an important social determinant of health (Galabuzi, 2016; Labonte, 2016; Raphael, 2016) as well as a significant concept in nursing (Benbow, Forchuk, Gorlick, Berman, & Ward-Griffin, 2015; Watson, 2012). Social exclusion is defined as “an expression of unequal relations of power among groups in society, which then determine unequal access to economic, social, political, and cultural resources” (Galabuzi, 2009, p. 254). Stewart et al. (2008) compared experiences of social exclusion between participants with low-income and high-income in Toronto, Ontario and Edmonton, Alberta. The findings demonstrated that limited financial resources, poor health, and negative societal attitudes impeded community involvement for participants of lower income (Stewart et al., 2008). Watson (2012) employed a social determinants of health lens to understand the experience of social exclusion and health among hidden homeless individuals in Ontario. Findings drew attention to structures of exclusion, such as lack of sufficient housing policies and increasing poverty, while providing an understanding of the health impacts associated with material and social deprivation (Watson, 2012).

Benbow, Rudnick, Forchuk, and Edwards (2014) used qualitative methods to examine social exclusion and poverty as experienced by psychiatric survivors (N = 380) in Southwestern Ontario. The authors applied a capabilities approach to social justice (Nussbaum, 2011). The findings shed light on the multidimensional experiences of exclusion faced by psychiatric survivors. Their analysis yielded four themes regarding poverty, stigma, belonging, and shared concern and advocacy (Benbow et al., 2014). Similar findings were shared by low-income women in a study by Reid (2004) who used feminist action research to explore social exclusion and poverty in women’s health in British Columbia (N = 30). A social determinant of health lens was employed, and findings outlined women’s experiences of exclusion at the cultural, institutional, and material levels. Participants experienced social exclusion in the form of stereotypes and labels, not having their needs met by the system and their lack of access to basic needs (Reid, 2004).

Overall, individuals experiencing homelessness experience higher rates of nearly all morbidities than the general population, and even more significantly, have increased mortality rates (Canadian Observatory on Homelessness, 2018; Fazel, Geddes, & Kushel, 2014). For women, unique complexity shapes their homelessness experiences: mothering without a home (Greaves, Chabot, Jategaonkar, Poole, & McCullough, 2006; Milaney, Ramage, Yang Fang, & Louis, 2017), intimate partner violence (Pavao, Alvarex, Baumrind, Induni, & Kimberling, 2007), trauma (Huey, Fthenos, & Hryniewicz, 2013; Lewinson, Thomas, & White, 2014; Torchalla, Linden, Strehlau, Neilson, & Krausz, 2015; Walsh, Rutherford, Krieg, & Bell, 2013), increased rates of depression (Bassuk & Beardslee, 2014; Poleshuck, Cerrito, Leshoure, Finocan-Kaag, & Kearney, 2013; Weinreb, Buckner, Williams, & Nicolson, 2006), and other mental health issues (Chambers et al., 2014), as well as discrimination within health and social sectors (Benbow, Forchuk & Ray, 2011).

Intimate partner violence is considered one of the leading causes of homelessness among women and mothers (Lewinson et al., 2014). Likewise, trauma, in the form of physical and sexual assaults, is common before and during homelessness (Yeater, Austin, Green, & Smither, 2010). Lewinson et al. (2014) conducted a study with 21 women, with and without physical custody of children, who were experiencing unstable housing. The study illuminated narratives of current and childhood trauma, exploitation, physical, emotional, and sexual abuse, increased environmental stressors, and increased exposure to crime. Researchers also noted the protective factors women demonstrated in fleeing unsafe situations to ensure their safety and the safety of their children; however, the very act of becoming homelessness increased further risk of trauma (Lee & Schreck, 2005).

Mothers experiencing homelessness are also at increased risk of experiencing mental health issues, commonly including depression (Bassuk & Beardslee, 2014); substance use (Azarmehr, Lowry, Sherman, Smith, & Zuniga, 2018); as well as bipolar, psychotic disorders, and schizophrenia (Hanrahan et al., 2005). Benbow et al., (2011) conducted a qualitative secondary analysis examining health experiences of mothers with mental illness experiencing homelessness from a social justice lens. The cyclical nature of homelessness, abuse, and illness was illuminated. As well, mothers experienced human rights violations in discriminatory housing practices related to their mental illness/disability status, racial–ethnic background, and mothering status.

Important research has been done with regard to the health of homeless women and mothers (P. Duff et al., 2015; Mill, Singh, & Taylor, 2012; Swick & Williams, 2010) as well as in examining the concept of social exclusion (Labonte, 2016; Reid, 2004; Stewart et al., 2008). However, there is a need to further both of these bodies of the literature. This article reports findings from one segment of a larger study (Benbow, 2015) that critically examined the sociopolitical context of social exclusion and health for mothers experiencing homelessness. The following research questions were addressed in the current article: (1) What are the sociopolitical contexts of mothers’ experience of social exclusion? and (2) How do the experiences of social exclusion and social inclusion shape their health? Strengths demonstrated by mothers who were homeless, their strategies of resistance to their experienced exclusion, and a critical discourse of policy related to study findings are reported on elsewhere (Benbow, 2015; Benbow, Gorlick, Forchuk, Ward-Griffin, & Berman, 2016; Benbow, Forchuk, Berman, Gorlick, & Ward-Griffin, 2018).

Research design: Methodology and methods

This study was conducted within the critical research paradigm. From this perspective, attention is given to the political and structural elements shaping social positioning, life experiences (Carroll, 2004), and ultimately health (Eakin et al., 1996). The criticality of the study ensures that attention to one’s individual story is situated and contextualized within a larger nuanced system of inequity (Berman, Mulcahy, Forchuk, Edmunds, Haldenby, & Lopez, 2009). Thus, a critical orientation to narrative inquiry was employed, informed by the work of a number of scholars (Chase, 2005, 2011; Labov, 1972; McCormack, 2000a, 2000b, 2004). With narrative inquiry, focus is placed on the story, the art of storytelling, and the coconstruction of knowledge between the researcher and participants; emphasis is placed on the meaning and contextual elements of life events shared (Chase, 2005).

Recruitment

Data were collected at various homeless shelters and programs that provide services for women and mothers who are homeless. Participants were sampled purposefully based on self-identified homelessness and motherhood status and were recruited via flyer distribution, meet and greet sessions, and by word-of-mouth. Snowball sampling techniques were used once interviews were underway, where women who participated shared research contact information with other mothers they knew who were experiencing homelessness. Women who self-identified as mothers, over the age of 18 years, able to speak and understand spoken English, and who were experiencing homelessness or who had experienced homelessness in the past year, were eligible to participate in this study.

Additionally, at the suggestion of participants, individual interviews and focus groups were held with service provider participants. During the interview process, mothers were asked about rules/policies impacting their health. During this discussion, mothers recommended further discussion and follow-up with service providers. Inclusion criteria required that potential service provider participants had provided care to mothers experiencing homelessness in the past year. The inclusion of service provider perspective, at the request of mother participants, further supported an understanding of the sociopolitical contexts within mothers’ lives and was consistent with the research questions and the critical nature of inquiry.

Sampling continued until data reflected the richness and complexity required to meet the study purpose (Patton, 2002). Twenty-six mothers participated in the study. Of the 26 mother participants, 14 women chose to participate in individual interviews, while 12 chose to engage in group interviews. There was a total of three group interviews each consisting of two to four women. Service provider participants (n = 15) also opted for both individual and group interviews, with a total of six individual interviews and one focus group consisting of nine service provider participants. Data collection took place over a period of seven months; the initial four months were heavily focused on initial interviews with mothers experiencing homelessness, while the follow-up interviews and interviews with service providers primarily occurred in the final months. Ethics approval was obtained from the Research Ethics Board for Health Sciences Research Involving Human Subjects at the University of Western Ontario.

Data collection and analysis

In-depth semistructured interviews were carried out with 26 women. Women were able to choose between individual or group interviews and were provided with a $20 honorarium. Interviews lasted approximately 1.5 to 2 h and were guided using open-ended questions with probes. Some questions/probes included: “what is it like parenting while residing in a shelter/group home/with family/friends?” and “how do certain rules/policies impact your health?” Consistent with narrative inquiry, follow-up interviews were offered. Twelve women chose to participate in follow-up interviews. During the follow-up interviews, further interpretations and synthesis of data were shared to gain further insight and to ensure coconstruction of knowledge and shared understandings were achieved (Chase, 2005; N. Duffy, 2007). Fifteen service providers participated. A semistructured interview guide with probes guided the interview, and a $10 gift card was given as honorarium.

The analysis of transcripts from initial, follow-up, and focus group interviews was informed by the processes outlined by McCormack (2000a, 2000b, 2004), which involved developing interpretive stories and viewing the stories through multiple lenses. This process has been referred to as a process of developing interpretive stories or the act of “storying stories” (McCormack, 2004, p. 220). Developing an interpretive story involved identifying and examining the structures of the story; this included reading the transcript line by line and identifying the beginning, middle, and end (Riessman, 1993). This was followed by highlighting the text with a different color for each narrative lens identified and used the “track changes” function within Microsoft Word to add comments regarding my interpreted meaning. In viewing the transcript through multiple lenses special attention to the moments, language, and context in which the stories were produced. These are dimensions in which people construct and reconstruct their stories to give meaning to their lives (McCormack, 2000a). The lens of moments refers to epiphanies and significant moments in the narrative. McCormack (2004) suggests viewing the transcript through the lens of language, wherein attention is paid to “what is said, how it is said, and what remains unsaid” (p. 225). Furthermore, through the lens of context, the sociopolitical, cultural, and structural conditions within the participants’ experiences were analyzed.

Consistent with various critical narrative approaches (see, e.g., Caxaj, Berman, Varcoe, Ray, & Restoulec, 2014; Caxaj & Gill, 2017; Haldenby et al., 2007), narratives were given a title based on the interpreted meaning and these titles served as the initial codes. The initial codes were then refined, revised, and collapsed into themes as interviews and analysis continued. Themes were organized in an Excel file, which identified the theme, the corresponding/collapsed codes, as well as the direct quotes that supported the respective themes. During follow-up interviews, the emerging codes were discussed with the participants. Special attention was paid to collective and contradicting meanings of and within stories and across study participants, while understanding how these realities are shaped by social and political systems (Berman, Irias Giron, & Marroquin, 2006). Consistent with qualitative research, analysis began at the outset of the interview; however, formal “line-by-line” analysis began by analyzing the mothers’ transcripts. Once emerging and recurring themes were identified, service provider transcripts were analyzed and integrated to illuminate and support the contextual and systemic factors shaping mothers’ experiences of social exclusion.

Findings

Participants who were mothers (n = 26) with an average age of 27.4 years. On average, women had 1.6 children; the majority of children were under five years of age. Most mothers had physical custody of at least one of their children (n = 19). Nineteen mothers self-identified as having or having had a mental illness, including depression, anxiety, posttraumatic stress disorder, panic disorder, and addiction. Seventeen mothers were born in Canada. While 10 mothers identified as Caucasian, mothers with a variety of racial and ethno-cultural identities participated in the study. Twenty-one mothers were receiving social assistance in the form of financial support (n = 21). All service provider participants (n = 15) were women, working with mothers who were experiencing homelessness. The service providers’ consisted of counsellors (n = 10); housing and community advocates (n = 2); and nurse and social worker case managers (n = 3) (Benbow, 2015).

Contradictory sources and systems of support

Central to the women’s experiences of mothering while homeless were their interactions with “the system.” The system, as they discussed it, referred to the federal, provincial, and municipal policies as well as organizational, institutional, and social support services accessed or attempted to be accessed by the mothers. The way in which mothers referred to the system was as an interactive entity, an active participant in shaping their lives. Because all mother participants were currently experiencing homelessness, they all expressed interaction with some aspect of the system. Among the systems within which they interacted were shelter, housing, social assistance, child welfare, and health care. The various social safety nets were described by participants as necessary for their survival.

Mothers discussed organizations that enhanced their sense of inclusion and facilitated empowerment by offering resources, a sense of community, and increased access to basic needs, such as food and housing. The mothers noted that they would not have survived without certain agencies such as shelters and drop-in centers. However, these same organizations at other times could contribute to their exclusion. The contradictory nature of these systems was categorized into four themes: (1)“Until you hit rock bottom there’s no support,” (2) “It’s just not enough”: Insufficient support, (3) “Help comes with a price”: Support with surveillance, and (4)“Every shelter is so different”: Organizational philosophies impacting support.

“Until you hit rock bottom there’s no support”

A predominant concern raised by mothers was the notion that “you are only let in when you’re so far out” or that “until you hit rock bottom there’s no support.” This concern referred to the dire state one had to be in to be able to access necessary support for survival. Many mothers reported that the detrimental impacts of unavailable services resulted in extreme crises, which could have been prevented had they been able to access supports sooner. As a mother shared,

… it’s unfortunate that it has to get to the point where you have to go to a shelter, instead of having a support system up before that … I did call a shelter … “we can’t really do much for you unless you come in here” … If women have a place to go, a safe place to talk to somebody for that hour they would probably make healthy choices before it got to the point where they had to come here [shelter].

The women and service providers alike emphasized the magnitude of extreme crisis needed to access support, rather than the availability of adequate support to avoid crisis. Service providers made special note of the overwhelming demand and need for mental health support and services for women experiencing homelessness. They reported limited support available until a woman is in such extreme need that she requires emergency hospitalization for mental health stabilization and safety. For example, in a focus group, service providers reported that a mother who desperately needed psychiatric care was unable to acquire the necessary supports until her illness was so severe that she attempted to die by suicide; it was only then that she was able to receive the mental health care she needed and had been tried previously to access.

“It’s just not enough”: Insufficient supports

Furthermore, service providers often felt helpless to best support women due to broader systems’ issues such as the lack of available general and specialized mental health supports and lack of affordable housing. Service providers reported the challenges in supporting women to access housing. A service provider indicated that the public housing wait list “is pushing the 10 year mark … So then people are forced to go to slumlords.”

Service providers and mothers indicated that the support to get out of crisis was insufficient to help them thrive or even survive. The majority of the women were receiving social assistance. However, prominent in women’s stories and based on the accounts from service providers was the assertion that insufficient financial support was allotted to mothers. Service providers and mothers alike recognized the limited financial supports from social assistance. Service providers noted, the struggles women experienced were worsened due to

the amount of money they are getting from Ontario Works. It’s not enough for somebody to live on, so in terms of financially being able to afford to buy their food for the month … you know it’s just not enough money.

No matter their current source of income—financial assistance from the government, sex work and/or other forms of employment—their income was insufficient to meet basic human needs. A participant shared this perspective of Ontario Works (OW):

Anything is better than nothing and it beats having to sell yourself on the streets, but I need more money for food and shelter … Ask any mom on OW, food is an issue. We don’t have enough money. I have to ask my mom to bring me food, but I’m still left without.

Buying groceries and clothing, paying for electricity and transportation, and accessing safe housing were simply not possible.

Furthermore, lack of sufficient supports played out in women’s lives from one generation to another:

I’ve just witnessed it, I’ve seen it all over the place … like a lot of my friends struggling, some of my friends can’t even come to school cause moms working two or three jobs to get the bills proper, get the lights back on … so there you go, she’s missing out on her education … she’s gonna end up in the same lifestyle her mom’s doing, and it just keeps continuing, continuing, continuing. There’s no help …

This woman emphasized not only the responsibility placed on mothers to care for and provide for their children while living in poverty but also the way in which the cycle of poverty easily perpetuates across generations. When insufficient financial and social support exist, responsibility must be placed on children to contribute to the survival of their families.

Common among many women’s stories was food insecurity—past, present, or as a serious concern for the future. Many women shared the common experience of going without meals to ensure their children were fed. Women shared that “food was scarce” and “a really stressful and scary thing.” Participants’ mothering was at the forefront of conversations about food insecurity. One young woman emphasized that while she and her children were in shelter, she knew they would be fed. She contrasted this with her experiences prior to shelter residence, where she was never certain she would have food for each meal. System inadequacies, such as insufficient income support, created enforced dependence on … for many participants while residing in shelter. Service providers and women alike reported the great benefit to being in shelter in terms of access to resources and advocacy. As a service provider noted,

They do become healthier while they are here … we have nurses come, a nurse practitioner, and a public health nurse, once a week, so I mean that is good for women, they can access, if they don’t have a doctor, it is a way they can get connected, and they don’t have to leave the building … they are safe here, the service comes to them …

Women reported that while in shelter they had increased access to health-care services, but that access was contingent on their homelessness status. Women discussed their fear of leaving the shelter because once they leave many shelter supports and resources were no longer available. A woman noted:

I finally have the help I need here. I can see a counsellor everyday if I need to. My son sees a nurse and counsellor. They saved my life, well me mentally I mean. But when I leave we won’t have them, you know. I trust them, you know? It just sucks.

Service providers expressed the increased complexity mothers with mental illness faced in accessing supports:

If you have children, women downplay their symptoms because they are afraid their children will be taken, or arranging childcare you know, what to go to an appointment or to sit in emerg [the emergency room], like we have had women say, “I will not go to emerg because I don’t have anyone to watch my child.”

Community workers and women alike recognized the unique need for specialized services for mothers experiencing homelessness at the intersection of many vulnerabilities.

“Help comes with a price”: Support with surveillance

Women expressed the existence of a false sense of support within a system that is meant to be supportive. For example, a mother with two children residing in shelter noted: “. … once you have the support you need, you have to constantly prove you need it.” This was common when participants discussed gaining access to social assistance in the form of financial aid, mental health support, and access to housing. In proving that they deserved these services mothers had to demonstrate their worthiness of some services, despite the fact that such supports were provided to meet basic human needs, such as access to a livable income, or shelter.

The women also reported that often times “help comes with a price.” For many, the cost was the relinquishing of a private life, with their day-to-day living being placed under scrutiny. They feared the consequences of system interactions, such as child welfare system involvement, increased stigma and discrimination, and surveillance. Women noted that some organizations, which were supposed to offer refuge, protection, and support, did the opposite. Women expressed their experiences with these particular services as repeated “markers of mistakes,” “jail like,” controlling, and provoking fear and judgment. The negative aspects added to the fear of system involvement, so much so that women were reluctant to seek much needed help and support.

A woman with a long history of homelessness described her frustrations of seeking help and the subsequent interaction with the child welfare system:

… a couple of times we were in the shelter and [child protection services] was called and we weren’t doing anything … they come to a person who has like two or three kids … and they are going to apprehend their kids, and I just think, … you have no clue what it is like to have to raise a child, and to go through struggles every day … how dare you look down your nose at me … from mothers who are so trying.

This woman further discussed how she did not feel supported to maintain custody of her children and spoke about the subsequent trauma of having her children apprehended. Women’s interactions with the child welfare system were complex. Distrust in the child welfare system was common to the mothers’ experiences of parenting without a home. Women expressed their fear of child welfare system involvement, rather than viewing it as a source of support and a resource. While a few women noted the positive help, guidance, and support they received from child welfare services for themselves as children and/or for their children, this was the exception and was not common to most women. Mothers expressed that compounding vulnerabilities, such as young age, living in poverty, experiencing mental health crises, and parenting without a home placed them in precarious and powerless positions when working with child protection services. Another woman reported feeling targeted due to her age and lack of employment:

[Child protection services (CPS)] picks on mothers, targets younger moms. If you don’t have support they target you. I was 18 years old when I had my daughter … They harassed me for 3–6 months. Like, I take care of my daughter. There is food for her in my fridge; there isn’t a bruise on her. I put my foot down—I said, “You guys have no reason to come here.” If I was a woman who was older and had a job they wouldn’t have targeted me. They shouldn’t target us because we have no family or are in shelter. These moms should not have their kids removed for things beyond their control … I thought CPS was there to support us? Well then support us!

Sharing this woman’s concerns, one service provider challenged the accepted social norms regarding apprehension of children and supporting mothers and reiterated the detrimental impact of support that came too late:

I think that as a society, we would be much more comfortable with the notion of taking women’s children away from them, than providing the background services that would facilitate that woman continuing on in a mothering capacity … so they’re in crisis, so it looks like they’re incompatible with parenting but it just has to be the place in which we’ve intervened is too late because they’re that much further off.

“Every shelter is so different”: Organizational philosophies impacting support

At a shelter/organizational level, service providers noted that organizational philosophies, values, policies, procedures, and regulations shaped women’s interactions with support services. For example, several women working in a shelter for women experiencing domestic violence noted their organization’s feminist intersectional philosophical underpinnings, and the ongoing examination of current policies and procedures to ensure the needs of women were met, and power differentials addressed. These service providers noted their women-centered values and discussed the ways in which the organization was striving to ensure the values, voice, and autonomy of the women they worked with were incorporated into their approaches to care. Other service providers working within agencies not guided by feminist or intersectional philosophies noted that a more explicit women-centered and anti-oppressive approach was needed to better support women. Two service providers felt at times that their organization’s authoritative approach further inhibited women’s power and control and created distrust and less effective care. These service providers desired to work within an anti-oppressive organization where the agency would be required to create and enact policies that challenged current power differentials and valued the inclusion of women’s voices in shaping the care provided.

Many mothers noticed a difference in how they were treated within and across various agencies, indicating how the autonomy and treatment of clients varied from agency to agency. The underlying philosophies or intrinsic values of the agencies influenced women’s desire to seek support and help as well as either trust or distrust in the system. For example, a woman shared her fear of disclosing her drug addiction, out of worry that she would not be able to remain in shelter and that she would not be able to see her daughter. She discussed the negative interactions she had with multiple counsellors and service providers from a variety of agencies, who made her feel “like shit,” about her addiction as a mother. She knew she needed help but at the same time felt she had to hide her addiction so as not to compromise shelter access. After she overdosed, she was referred to a shelter that was inclusive of women suffering from addictions. Not only did this shelter allow her to stay, despite her addiction, but they were able to support her through her addiction. She emphasized that they treated her “like a person” and did not “talk down” to her. Within this agency, she noted that she felt heard, valued, respected, and supported. Service providers echoed the importance of inclusivity in services. They reported the struggle in having turned women away from services, based on policies, due to addictions or sex trade involvement (and the subsequent inability for women to meet “curfew”), or not being able to locate adequate support for mothers due to the exclusion criteria within other agency policies.

Discussion

The participants expressed their view that the system played a monumental role in their lives. In this way, the system was an active participant in their lives, thus drawing attention to the structures of exclusion that shaped participants’ health experiences. As advocates, nurses are able to recognize the immense injustice within the system itself and help shift dominant discourses of individual blame to instead critique a flawed system. Our advocacy efforts can target change at the macro-, meso-, and microlevels.

At the macrolevel, poverty and the lack of affordable housing were central in the way in which social exclusion was enacted in mothers’ lives. The majority of participants received financial support in the form of social assistance, yet study participants remained in the depths of poverty. Existing poverty reduction strategies within Canada have focused primarily on job readiness and training, in addition to incremental, and insufficient, increases to social assistance (Government of Ontario, 2014) without notable success at actually reducing poverty (Plante, 2018). That is, employment and job readiness do not necessarily eliminate poverty but may in fact result in added stress and caregiver strain for lone mothers. Instead, poverty reduction advocates and researchers alike have advocated for an evidence-informed approach to poverty reduction that would support access to a Guaranteed Basic Income (Benbow et al., 2016; Ontario Public Health Association, 2015; Smith-Carrier & Lawlor, 2016). Such a strategy would ensure that mothers, and others living in poverty, would have sufficient financial security to access basic human needs, such as food and housing, which would ultimately yield positive health and social outcomes (Forget, 2011; Smith-Carrier, 2017).

Furthermore, homelessness has detrimental effects on all other determinants of health and its existence is reflective of extreme social exclusion (Watson, 2012). Nurses have a role in advocating for increased access to affordable housing for all, inclusive of special considerations for specific populations, such as mothers experiencing homelessness. Nurses can advocate for evidence-informed solutions to ending homelessness, such as Housing-First initiatives. Housing-First involves “the immediate provision of permanent housing and wraparound supports to individuals experiencing homelessness” and encompasses five overarching principles: “(the) immediate access to housing with no housing readiness conditions, consumer choice and self-determination, recovery orientation, individualized and person-driven supports, and social and community integration” (Geller, 2014).

Nurses, as part of larger nursing bodies, such as Canadian Nurses Association, and the RNAO, hold incredible advocacy power (Duncan, 2015). These bodies have streamlined access to public marketing tools, lobbying efforts, and familiarity with policy change, and political action. RNAO’s position statement on homelessness and health (RNAO, 2004) as well as basic income (RNAO, 2017) promoted awareness among nurses and demanded action at a governmental level. As nurses, we can engage in advocacy efforts within our associations to unite our voices in advocating for access to affordable housing and basic income in Canada. Furthermore, we can participate in political action through the voting process, engaging in activism, and holding political office in challenging ideologies negatively impacting the health of marginalized groups (Burnett, 2012).

At the meso- and mircolevels, mothers expressed much gratitude for available social programs and supports. However, participants’ expressed feelings of inclusion and support were experienced within the context of exclusion. The simultaneous nature and nonlinear relationship between inclusion and exclusion is noted in the nursing and health literature (Caxaj, 2010; Pease, 2009; Reid, 2004; Yanicki, Kushner, & Reutter, 2014). However, participants expressed that experiences of inclusion existed within the circumstance of exclusion. In this way, exclusion and inclusion were inextricably linked; however, within the context of this study and in the lives of study participants, social inclusion was predominantly experienced only within spaces of exclusion, as emphasized in the quote: “You are only let in when you are so far out.” This speaks to the continued need for nurses to advocate for upstream health promotion initiatives aimed at promoting the health and well-being of families and communities prior to them being in crisis. In promoting health, nurses can embrace health promotion approaches aligned with the Ottawa Charter for Health Promotion, with ideological underpinnings of social justice and health equity (World Health Organization, 1986). In doing so, nurses can engage in health promotion practices that challenge the status quo and the entrenched ideologies that marginalize and exclude certain populations. Nurses can begin this anti-oppressive practice by recognizing the role they may play as actors within the system.

While mothers expressed great praise of some services, they also noted the inadequate, subpar, and discriminatory treatment they received in accessing other services. Such treatment can result in poorer health outcomes for those who need it most (EQUIP Health Care, 2018). Nurses can engage in critical reflection and challenge any personal stigma or discriminatory values held or enacted in providing care for marginalized groups, such as mothers experiencing homelessness. Recognizing the need to improve the care provided to marginalized groups, nurse researchers and colleagues have identified that health-equity approaches to care actually improve health outcomes of marginalized groups, such as those living in poverty (Browne, Varcoe, Ford-Gilboe, & Wathen, 2015; Ford-Gilboe et al., 2018). Browne et al. have created education modules (https://equiphealthcare.ca/modules/) that foster a health-equity approach to care to enhance the health and health-care experiences for marginalized groups (EQUIP Health Care, 2018). Based on the premise of compassion and respect, simple shifts in our approach can make a difference: instead of asking “what’s wrong with people,” nurses can ask, “what’s happened to people” (Wathen, as cited in Bieman, 2018) and while employing a violence and trauma-informed, culturally sensitive, and harm reduction approach (Ford-Gilboe et al., 2018).

Study rigor

Consistent with the epistemological values of the critical paradigm, research analysis was coconstructed and validated in a reflexive and dialogic manner, as knowledge was jointly constructed. Patti Lather’s (1995, 2007) transgressive validity was employed to further ensure study quality and rigor met standards relevant to feminist and critical methodologies. To achieve this form of validity, consensus forming was problematized, and instead paradoxes, diverging views, complexities, and overall “messiness” of data and findings were embraced (Lather, 2007). Furthermore, emphasis was placed on the resonance and relevance of findings to participants. This was attended to during the dialogic interviews where interpretations were shared in the moment for transparency as well as to ensure interpretations were reflective of the participants’ meaning and purpose. Although follow-up interviews were employed, the intent was not to ensure truth or consensus but rather to ensure coconstruction of findings (Guba & Lincoln, 2005). Likewise, an audit trail was employed to ensure that interpretations were grounded in participant voice, research context, and philosophical underpinnings of the study (M. Crowe, 2005). The tracking consisted of recording key decision points and what was used to inform them allowing for a logical and transparent linking of data source and analysis.

Limitations and future research directions

Future research specifically examining social exclusion in the lives of mothers doubled up with family or friends, or who are living on the street, would offer further insight into the unique barriers faced by this particular subgroup. Furthermore, despite sharing findings via follow-up interviews to several participants, not all participants chose to pursue follow-up interviews and thus were not provided with an update of findings where their input could further shape. Finally, future studies inclusive of participant who do not speak English would allow an enhanced understanding of such challenges as it relates to mothering while homeless.

Conclusion

Through critical narrative inquiry, the contradictory nature of supports and the monumental role that the system played in mothers’ lives were emphasized. In our advocacy and care efforts, we as nurses must consider the broad and systemic forms of exclusion that further compromise the health of mothers experiencing homelessness. We can advocate for evidence-informed solutions to systems-level issues, such as poverty reduction and Housing-First initiatives. We can also employ health-equity approaches to care that ensures compassion, respect, and shared power are achieved (Browne et al., 2015; EQUIP Health Care, 2018; Ford-Gilboe et al., 2018).

Declaration of Conflicting Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Ontario Graduate Scholarship Program (Total of $61 500 over four years).

Author Biographies

Sarah Benbow is a Professor in the School of Nursing at Fanshawe College in London Ontario, Canada. She has published on a variety of topics including: mothering while homeless, social exclusion and health, public policy and health, mental illness and poverty, social justice and health equity, and conducting research with criminalized women. In her research she employs critical methodologies, with particular focus on feminist and intersectional theories.

Cheryl Forchuk is a Distinguished University Professor and Associate Director of Research at Arthur Labatt Family School of Nursing, Western University, as well as a Scientist and Assistant Director at Lawson Health Research Institute.

Carolyne Gorlick was Professor in the department of Social Work at King's University College, Western University

Helene Berman is a Distinguished University Professor in the Faculty of Health Sciences, Arthur Labatt Family School of Nursing; a Fellow in the Canadian Academy of Health Sciences, and founding Academic Director of the Centre for Research on Health Equity and Social Inclusion.

Catherine Ward-Griffin is Professor Emeritus in the Arthur Labatt Family School of Nursing at Western University.

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