Canada may be ranked one of the healthiest countries in the world, but where you live in the planet’s 13th-healthiest country matters.

The idea that place affects our health – not just where we live but also our “place” in society as shaped by our income, education or employment – is one of the social determinants of health, a group of key non-medical factors in health outcomes. 

But what if that place you find yourself living in is a long-term care facility? Or a prison? Or foster care? Or living without some kind of traditional housing at all?

Here, four MacEwan researchers share their work and explore the idea of place and its impact on health – and health care.

“Long-term care facilities are becoming dangerous places to live.”

Heart-rending photos of families matching hands on either side of a pane of glass and reports of dangerously low staffing levels were regular occurrences as COVID-19 ripped through long-term care facilities in the early days of the pandemic, causing about 80 per cent of all COVID-related deaths. 

“As a society, we saw what happens when the health-care system is severely overburdened – when there is high demand on resources, and not enough doctors, nurses or equipment,” says Dr. Anna Azulai. 

But for people living in long-term care who are very ill and entirely dependent on the facility where they live, the situation was particularly grave. “These are not places you would want your loved ones to be.” 

Dr. Azulai says it’s an emotional statement but not a revelation for anyone who studies long-term care, including her fellow researchers Dr. Hongmei Tong, Alison Pitcher and Beverly Baluyot. Together, they are conducting a systematic review of social care strategies for older adults during the pandemic with funding from the Social Sciences and Humanities Research Council.

Findings from their first two years of data revealed that inadequate staffing levels and policies negatively impacted the quality of life and care in long-term care facilities, making them dangerous places to live.

One of several challenges in this research, says Dr. Azulai, involves differentiating between the social determinants of health for older adults and staff. “They are intimately connected,” she explains. “The majority of staff were immigrant, racialized women who were underpaid, did not have adequate working conditions, and during the pandemic were restricted to working in a single facility, which meant that many could not make a living from the part-time work available and left.”

In studies incorporating older adults' voices (sadly, the minority of research conducted during the pandemic, says Dr. Azulai), residents had incredible empathy for staff. “Staff could be doing their utmost but were in an impossible situation.”

The fact that services in long-term care are designated as non-essential in the Canada Health Act made matters even worse, says Dr. Azulai. As chronically understaffed and underfunded facilities experienced even further reductions in staff due to the pandemic, family caregivers, who supported staff to close the gaps in care, and social workers, who provided psycho-social support, were deemed non-essential. She describes taking away those social supports from people who are already isolated and dependent as inhumane.   

And seeing data that confirms that adults in long-term care were – and are – excluded from the standard of care we deem essential for everyone else in society is appalling, unethical – and verging on criminal, says Dr. Azulai.  “As a society, we have  been complicit and will continue to be complicit if we know and don’t do anything.”

Making recommendations for change is a critical part of this research. Preliminary findings (the study wraps up in the spring of 2024) point to several directions for change, including increased staff-to-resident ratios, improving working conditions for personal care staff, promoting holistic care, acknowledging that families are essential partners for care and redesignating long-term care services as essential (and funding them accordingly).

“Child welfare policies have extended the residential school experience.” 

Before Dr. Kelsey Reed earned her PhD specializing in Indigenous education, she spent more than a decade working in residential group home care settings and with populations of Indigenous people who were houseless. 

“I was seeing a perfect storm in many of the people I was working with, and the outcomes were not good – suicide, prison, having kids at a young age, not finishing school,” says the assistant professor. 

Witnessing those negative outcomes firsthand and finding them reflected across the literature led Dr. Reed to spend the next six years studying urban Indigenous identity development in survivors of the child welfare system. 

Using a research methodology focused on land, ceremony and developing relationships, she closely followed three participants, ages 25, 30 and 44, who had long-term involvement with the child welfare system. 

Her study revealed that youth in care are struggling and that current child welfare policies – separating siblings, the apprehension process, displacing youth and the lack of cultural mirrors (Indigenous children are placed with Indigenous caregivers only about two per cent of the time) – essentially extend the residential school experience. 

“If you look at residential schools, the Sixties Scoop and the policies and procedures that are in place today, it’s difficult to see where one ends and the next begins,” says Dr. Reed. “I believe we’re working within a system that we will have to apologize for.”

When it comes to displacement, for example, the three individuals in Dr. Reed’s study (who were moved to placements across Edmonton and around the province at least 17 times between them) spoke about how not having a meaningful relationship to place impacted their identity development. 

“Being moved around repeatedly as they were growing up caused longstanding harm,” she says. “Even as adults, they said, when they can find stable housing and jobs, it never feels like it will last.” 

Using the extensive data she collected, Dr. Reed built a theoretical framework to inspire policy changes to enable Indigenous youth to reconnect with their culture. 

“I work in the field, so there is a level of culpability in understanding that today's policies are causing harm in the same way previous policies have,” she says. “As practitioners, we have good intentions but are also complicit. At some point, we need to stop saying, ‘That’s just the way it is,” or that there isn’t enough funding, and start advocating for changes in policy and structures that are causing harm.”

The way forward, says Dr. Reed, must acknowledge that Indigenous identity and connection to place is innate. “We need to tap into the people already in community and their connection to who they are. I really do believe in the power of identity development. If people can find pride and connection within their identity and community, it can drastically change the outcome of their lives. I’ve seen it. That’s how I found my own way back.”

“Youth often end up where they do because they are looking for community.” 

Dr. Cynthia Puddu has spent the past several months speaking to Edmonton youth living in encampments. She’s trying to understand their experiences, why they’re living where they are, and the support they might need to transition to a different kind of housing. 

“When we provide people with shelter, that’s a house, not necessarily a home. We need to look at whether the places people live address their mental, physical and spiritual health needs,” she explains. “Often, when we ask young people why they live in encampments, they tell us that it’s because that is their community.”

Another of Dr. Puddu’s community-engaged research partners, NiGiNan Housing Ventures, perfectly illustrates the difference a true sense of community can make. At the Indigenous-led registered charity’s building, Omamoo Wango Gamik, residents receive support for all areas of their lives, including access to Indigenous ceremony and cultural support.   

Since it opened in 2020, three babies have been born to mothers living at Omamoo Wango Gamik – babies that Dr. Puddu says in other circumstances would have likely been apprehended by Child and Family Services. “These women have been able to keep their children because of the sense of place that has been created there – it’s truly a community.”

Families are surrounded by staff and Elders – aunties and uncles who are not blood relatives, explains Dr. Puddu, but who offer land-based activities, spiritual support and parenting help and care for children when mothers need time to do laundry, a break from a crying baby or time to deal with their issues, which can sometimes include addictions. 

“Even if it is not safe for a baby to be with mom right now, the people there ensure the baby remains in the community,” says Dr. Puddu. “Not only have all of these babies stayed with their moms, but 15 women have been able to get their children back – something that does not often happen.” 

The sense of community NiGiNan has created is something many young people who are unhoused crave. It’s also a key ingredient in preventing youth homelessness. 

“People with lived experience often tell us that if their mothers had been given the money and support that their foster families received, they probably would not have had to leave,” says Dr. Puddu, who nominated the organization for the 2023 MtS Youth Homelessness Prevention Awards. “The work that NiGiNan is doing is true prevention. They are keeping children with their parents by supporting families.” 

That support could mean that 15 years from now, when the babies born to mothers at Omamoo Wango Gamik are teenagers, they won’t find themselves living in encampments. 

“I’m hopeful that our research will ultimately impact policies that reflect the need for community. Throughout my research, I’ve found that young people end up where they do – whether in a gang or an encampment or other places – because they are looking for community.”

“Health-care providers have the opportunity to redefine negative associations with place each time we meet with an inmate.” 

When Dr. Morgan Wadams began working at the Edmonton Remand Centre as a registered nurse in 2015, he immediately gained a new appreciation of the incredible complexity of the places where incarcerated people live.

“Even though we are working in correctional facilities – places that are historically connected to negative experiences of racism, discrimination and exclusion – health-care providers have the opportunity to redefine negative associations with place each time we meet with an inmate,” says the assistant professor in the Department of Nursing Practice. 

Looking at the role of relationships is the focus of Dr. Wadams’s research. Over two years, he worked closely with two previously incarcerated individuals who were living with HIV, trying to understand their experiences transitioning in and out of correctional facilities. 

The resulting narrative inquiry raised several questions about social practices, stigma, correctional nursing and life within correctional facilities. One of the key ideas that emerged, says Dr. Wadams, is the idea of relational agency – the sense of having control over your life – can be enhanced through relationships with others. 

For individual practitioners, building relational agency means forming authentic relationships that people can lean back on when they leave a correctional facility. People with HIV, for example, often see their medication adherence drop when they are released. Why? If you don't have a roof over your head or your backpack is constantly being stolen, says Dr. Wadams, medication adherence isn't likely your biggest priority. 

“This work looks at how to create relationships that can continue when someone returns to the potential chaos of their previous life,” he says. “The goal is that they remember they have a relationship with someone they trust and can connect with when they need to, and that is a person who can help them interpret the world differently.”

In the future, Dr. Wadams hopes to explore further the idea of relational agency and how it can be implemented in practice to create interventions and develop skill sets that health care and other service providers can use to support individuals going in and out of correctional institutions. 

It’s essential to consider when educating future nurses, he adds. “There can be a degree of hopelessness or frustration when working as a health service provider – you can feel like a small cog in a huge machine. Learning how to build relationships that can create opportunities to make real change and create something better is hopeful.”

Helping students working with vulnerable populations – no matter their “place” in society – is something Dr. David Danto, dean of the Faculty of Health and Community Studies, says is a critical part of a university education for students pursuing fields connected with health and health care. 

“We can’t prepare each graduate for every possible future context, but we can educate our students about the importance of humility, multi-perspectivity, and diversity of epistemologies so that when they arrive at exciting new places in their lives, they are equipped with both the disciplinary training and respect for others that will make them truly welcomed and valued members of their communities.”