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Participative health promotion and program evaluation with street-involved youth : a Vancouver based… Nixon, Sean Christopher 2009

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    PARTICIPATIVE HEALTH PROMOTION AND PROGRAM EVALUATION WITH STREET-INVOLVED YOUTH: A VANCOUVER BASED CASE STUDY    by   SEAN CHRISTOPHER NIXON  B.Sc., The University of British Columbia, 2007      A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE   in   THE FACULTY OF GRADUATE STUDIES  (Health Care and Epidemiology)     THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)   July 2009   © Sean Christopher Nixon, 2009  ii Abstract  The following document is intended to profile the participative development, implementation and evaluation of a health promotion program for street-involved youth entitled the Youth Wellness Project (YWP). Program planning, implementation and evaluation logic models are applied to this program. In the context of these logic models, we describe the resulting health promotion program and outcomes associated with its evaluation. The results presented in this report draw upon observational data and focus groups conducted with key partners and workshop participants.  This report demonstrates how marginalized youth can make remarkable contributions to advocacy as well as research and educational initiatives when provided with opportunities to take on roles of active citizenship. The youth bring inherent abilities, energy, and new perspectives to health promotion. Providing youth with opportunities to develop tangible skills, make management decisions and contribute to their community instils a sense of social responsibility among these individuals, builds capacity and establishes credibility in the community.  This study provides a best practices model for the development of a respectful and synergistic relationship between academics and community-based participants. It further investigates how this partnership can ultimately transform their lives. The YWP is an example of how street-involved youth and medical students alike can simultaneously gain a capacity to stand back from their world and transform their reality.  iii Table of Contents  Abstract...........................................................................................................................ii Table of Contents ...........................................................................................................iii List of Tables ..................................................................................................................v List of Figures ................................................................................................................vi Acknowledgements .......................................................................................................vii Dedication....................................................................................................................viii  Chapter One: Introduction ...............................................................................................1 Preface ........................................................................................................................1 Key Terms...................................................................................................................2 Synopsis of Chapters ...................................................................................................4  Chapter Two: The Street-involved Youth Experience ......................................................6 Becoming Street-Involved ...........................................................................................6 Street-Involved Youth Characteristics........................................................................11 Life on the Street .......................................................................................................12 Transitioning off the Streets.......................................................................................18  Chapter Three: The Youth Wellness Project ..................................................................21 Overview...................................................................................................................21 Rationale ...................................................................................................................22 Major Collaborators...................................................................................................23 Planning, Design and Implementation........................................................................26 A Process Grounded in Theory ..............................................................................26 A Front Line Perspective on Program Development...............................................32 Workshop Content.....................................................................................................37  Chapter Four: Method of Evaluation..............................................................................39 An Evaluation Grounded in Theory ...........................................................................39 A Front Line Perspective on Participatory Evaluation................................................44 Focus Group Participants...........................................................................................53 Procedures and Ethics................................................................................................54 Analysis ....................................................................................................................54  Chapter Five: Results ....................................................................................................56 Youth Participants .....................................................................................................56 Health Experiences while Living on the Streets .....................................................57 Feedback on the Youth Wellness Project ...............................................................63 VYVC Instructors......................................................................................................72 Reasons for Becoming Involved ................................................................................73 Health science students..............................................................................................79 Focus Group..........................................................................................................79  iv Health Science Student Final Reports ....................................................................85  Chapter Six: Discussion.................................................................................................90  Chapter Seven: Limitations and Conclusions ............................................................... 109 Limitations .............................................................................................................. 109 Conclusions............................................................................................................. 110  Appendix..................................................................................................................... 118 Appendix One: Workshop Summaries ..................................................................... 118 Reproductive Health ............................................................................................ 118 Mental Health ...................................................................................................... 118 Substance Use ..................................................................................................... 119 Nutrition.............................................................................................................. 119 First Aid .............................................................................................................. 120 Appendix Two: Focus Group Scripts ....................................................................... 121 Focus Group Script – Participants........................................................................ 121 Focus Group Script – VYVC Youth..................................................................... 123 Focus Group Script – Health Science Students..................................................... 124 Appendix Three: Ethics Certificate .......................................................................... 125                           v List of Tables  Table 1: Evaluation Planning Phase: Process / Implementation…………………………48 Table 2: Evaluation Planning Phase: Outcomes…………………...…………………….49 Table 3: Indicator Development Phase…………………………………………………..51                                vi List of Figures  Figure 1: Youth Wellness Project Design and Planning Logic Model…………………..27 Figure 2: Youth Wellness Project Implementation Logic Model………………………..29 Figure 3: Program Evaluation: Basic Logic Model Components with Regard to Evaluation of Participatory Action Research with Street-Involved Youth…….………...43                           vii Acknowledgements First and foremost, I would like to thank my advisors Drs. James Frankish, Peter Granger and Sandra Vamos as well as Jenn Dixon and Laura Nimmon for their dedication, direction, and discussion.  Without them I would not have achieved my goals for this thesis. I thank the Division of Inner City Medicine for the experiences that inspired this thesis, as well as for the opportunity to carry out numerous research and advocacy initiatives with street-involved youth. For financial support, I thank the Partnerships in Community Health Research training program. I also wish to thank the many PCHR mentors and learners as well as the medical students who participated in the development and evaluation of this health promotion program.                             viii Dedication  I dedicate this work to the many street-involved youth for sharing their knowledge and expertise and their commitment to health promotion. Without them, none of this would have been possible.                                1 Chapter One: Introduction  Preface  In 2003, I began my work as a research assistant in the Division of Inner City Medicine at the University of British Columbia (UBC) and discovered the world of outreach and marginalized populations. I took on a variety of qualitative and quantitative research projects regarding the health of inner city marginalized populations and soon found myself intrigued by the determinants of health of this population.  In the summer of 2005, I was encouraged by the Division of Inner City Medicine to start a health promotion program for inner city street-involved youth. The mission of the Division is to improve the wellbeing of the inner city marginalized through research, education and advocacy. My initial objectives were to 1) develop a meaningful health promotion program for street-involved youth, 2) provide health science students with exposure to the street-involved youth community, and 3) conduct ongoing evaluation of the program. Through previous work, the value of inter-professionalism, community engagement, harm reduction, service learning, program evaluation, community empowerment and health literacy had become established in my mind and I worked to integrate these concepts into a new health promotion program for street-involved youth.  With the dedication of a youth organization called the Vancouver Youth Visions Coalition (VYVC) as well as UBC students and faculty, the resulting health literacy  2 education program, the Youth Wellness Project (YWP), has flourished into a sustainable entity with clear benefits for all parties involved. I have enjoyed the opportunity to be involved in a project throughout its development, implementation and evaluation. It has been a valuable opportunity for me to pursue both my academic and non-academic interests in health promotion, and I hope that both the academic and street-involved youth communities will benefit through my work.  Key Terms  YWP Participants are youth who self-identify as street-involved and attended the workshop series but are not involved in the development or facilitation.  Youth Leaders / VYVC Youth / Crystal Clear Youth are those street-involved youth who participated in the development and/or facilitation of the YWP.  Students: Health science students from the Community Health Initiative by University Students (CHIUS) and the University of British Columbia who participated in the development and/or facilitation of the YWP workshop series.  YWP Task Force are all individuals (youth leaders and students) who participated in the development and/or facilitation of the YWP.   3 PCHR Learners are graduate and post-doctoral students from the Partnerships in Community Health Research (PCHR) training program at the University of British Columbia.  Partnership is the process of establishing and sustaining a mutually respectful relationship based on the sharing of responsibilities, costs and benefits, with outcomes that are satisfactory to all partners (Macaulay A. et al., 1998).  Empowerment is a social action process that promotes participation of people, organizations, and communities in gaining control over their lives in their community and larger society. With this perspective, empowerment is not characterized as achieving power to dominate others, but rather power to act with others to effect change (Wallerstein & Bernstein, 1988).  Participatory research (PR) is a process which incorporates "systematic inquiry, with the collaboration of those affected by the issue being studied, for the purpose of education and taking action or effecting social change" (Green, George & Daniel, 1997).  Health Literacy is defined as the extent to which people have the ability to obtain, understand, and communicate health information and to assess it (Rootman & Ronson, 2005).     4 Synopsis of Chapters  This thesis critically reviews the experience of street life for youth in Vancouver and documents the development, implementation and evaluation of the YWP.  Results provide insights into the lives of street-involved youth in Vancouver, as well as an innovative approach to health promotion and program evaluation in genuine partnership with street-involved youth.  Chapter two reviews the current literature on street-involved youth with a focus on those youth residing in Vancouver, BC. The first section of this chapter serves to identify risk factors associated with becoming street-involved and common paths to street- involvement among youth. Next, we strive to define “street-involved youth” by identifying characteristics commonly associated with this term in the literature.  This chapter also provides insight into the experience of being street-involved as a youth and describes the process of transitioning off the streets.  Chapter three profiles the participative development, and implementation of a health promotion program for street-involved youth entitled the Youth Wellness Project (YWP). Program planning and implementation logic models are applied to this program. In the context of these logic models, we describe the resulting health promotion program.  Chapter four outlines the methodology of the program evaluation. We describe the process of creating and managing a collaborative research project that includes parties  5 such as academics, physicians, community based organizations, and our street-involved youth partners.  We describe participatory evaluation (PE) as defined by the literature and illustrate how the principles of PE were applied to the evaluation. Finally, we outline the process of analyzing data from multiple sources.  Chapter five presents results from focus groups conducted with each of the three primary partners in the project: the YWP participants, VYVC youth instructors and the student instructors. Data was additionally extracted from final reports completed by health science students involved in the program. Core categories and themes are identified and representative quotes are used to support each theme.  Chapter six serves to compare and contrast key findings from the perspectives of all participants. We discuss findings with regard to both the development of a health promotion program and participatory evaluation with street-involved youth.  Chapter seven draws conclusions from our findings and discusses the implications of these results. Finally, we discuss strategic directions and identify limitations associated with this research.       6 Chapter Two: The Street-involved Youth Experience  The phenomenon of street-involved youth crosses borders and boundaries, and is replete with myths, stigmas, and stereotypes (Sauvé, 2003). Here, we provide a brief introduction to street-involved youth, drawing primarily upon research conducted in the inner city of Vancouver, as well as other major metropolitan areas across Canada. We strive to provide an ecological perspective. This perspective suggests that individual behaviour is better understood when viewed in the context of communities, organizations, policies and societal norms. Emphasis is shifted from the individual to a broader understanding and identifies barriers to behaviour change.  Firstly, we examine the literature with regard to the process of becoming street-involved. Next, we attempt to define this population. Finally, we describe life on the street and the process of transitioning off the street.  Becoming Street-Involved  It has repeatedly been found that certain stressors during childhood and early adolescence create challenges for healthy development into adulthood (Canadian Centre on Substance Abuse [CCSA], 2007). Although homeless youth must cope with adult-type situations on the street, it is important to remember that developmentally they are adolescents (Wallerstein & Bernstein, 1988). To understand street-involved youth, we must imagine the world in the context of their past as well as present experiences; hunger, homelessness, foster care, mental health problems, exposure to substance abuse and physical and sexual violence (Saewyc et al., 2008). Youth who become street-involved are often discriminated against for a number of intersecting reasons such as homophobia,  7 racism and classism (Saewyc et al., 2008), and may have an insufficient social support network (CCSA, 2007).  In the late 1930s and early 1940s, youth homelessness was considered to be primarily due to grossly inadequate home environments (Roesler, 2000). During the 1950s and 1960s however, the literature took a highly paternalistic and simplified approach to explaining the phenomenon of youth becoming street-involved (Timco, 2007). Leaving home was seen as a result of immaturity and delinquency. However, since the 1970s a more accurate understanding of the causes of homelessness has emerged. Youth homelessness is now thought to be caused by a variety of factors beyond of the control of the youth. Nonetheless, street-involved youth remain a disrespected and undervalued segment of Canadian society.  Street-involved youth generally experience alienation and isolation long before becoming street-involved (Brennan, Huizinga & Elliott, 1978). Many experience difficulties in school (Martin et al., 2008) which reduce self worth and often result in parent-youth conflict. For those who drop out of school, it is very difficult to find employment and become independent.  For many youth, not leaving home can be more damaging than leaving. Reasons for leaving home are varied, but violence is a significant issue for most youth. A majority of street-involved youth have experienced significant conflict, emotional abuse and neglect by their parents (Public Health Agency of Canada [PHAC], 2006). Studies have shown  8 that street-involved youth are vastly more likely to report a family history of substance use than youth in the general Canadian population. Among street-involved youth in Vancouver, 63% report having witnessed family violence, almost 60% report having been physically abused and 20% and 24% report that their parents hit them “sometimes” and “often”, respectively, to the point of bruising or bleeding (Saewyc et al., 2008). Many youth, particularly females, also face sexual exploitation in the home (Martin et al., 2008).  Supportive parents and a strong social support network are important for proper growth and development. Youth often have strained relationships with their parents and as a result either leave or are kicked out of their homes (Martin et al., 2008). The average age at which street-involved youth leave home is 13-14 years (Martin et al., 2008). As puberty hits and youth experience new emotions, they begin to explore new identities which can further strain relationships with parents (Martin et al., 2008). At this young age, youth are rebelling and testing boundaries. A large number of youth report leaving home before entering their teen years. 40% of males and 47% of females had first run away at age 12 or younger, and one in three had been kicked out by age 12 (Saewyc et al., 2008).  High rates of family violence coincide with high rates of exposure to foster care. In Vancouver, 42% of those who participated in the McCreary Street Youth Survey report having been in foster care (Saewyc et al., 2008). Furthermore, approximately 50% have been in jail and approximately 50% report that their parents abused each other. Foster care requires moving from home to home, predisposing many at risk youth to depression.   9 Education enables people to lead healthy, fulfilling lives as it gives them the tools and skills to become meaningful contributors to their society (Smith et al., 2007). In a study conducted by McCarthy (1995), the majority of street-involved youth participants believed that schooling had “frequently wasted their time and had not provided them with worthwhile learning experiences.” In fact, 49% of youth surveyed reported that that they thought their schooling had been a waste of time compared to 17% of Vancouver’s general school-attending youth population. Further, the vast majority of street-involved youth report that they had difficulty understanding school material and “often” had trouble with teachers (McCarthy, 1995). Twenty-two percent of street-involved youth reportedly rated their performance as below average compared to only 11% of youth in school (Martin et al., 2008).  At risk youth often miss school because they are dealing with personal problems (Martin et al., 2008). Findings from the BC Adolescent Health Survey have shown that youth who live in unstable or challenging home environments often experience interruptions in their education which can cause them to fall behind academically and subsequently become disengaged from school (Smith et al., 2007). Many youth report that it is hard to go to school when they don’t feel safe or accepted, and many report having experienced bullying at school (Martin et al., 2008). In order to cope with these factors, many youth turn to drug use. It becomes increasingly hard for those who have developed addictions to go to school when they are “hung over” or high on drugs.   10 Youth in unstable housing are less likely to attend school, nonetheless, 1/3 of youth who live in the most precarious housing still attend school (Martin et al., 2008). These youth report going to school because of the social environment and because it prevents them from becoming bored. Many youth report that it is difficult for them to think about their futures when all their energy must be focused on surviving the next day (Martin et al., 2008). The attendance requirements at alternative education programs are more flexible than mainstream school, helping them stay connected and remain enrolled in school and attend part-time even when they are not in stable housing.   The longer youth spend on the streets, the more likely they are to develop relationships with street entrenched youth, thereby facilitating the process of becoming “lost to the streets.” As time passes, many youth begin to feel increasingly unable to interact with mainstream society.  This section provides a glimpse into the past lives of many street-involved youth. We have identified multiple intersecting determinants which, without sufficient support, can put youth at higher risk for homelessness. These include mental health problems, exposure to substance abuse and physical and sexual violence at home and in foster care. This provides a valuable context with which street-involved youth can be discussed in subsequent sections.   11 Street-Involved Youth Characteristics  It is very challenging to adequately capture a population that spans a spectrum as wide as street-involved youth. Here, we consider street-involved youth to be young people who are involved in a street lifestyle. Specific definitions by age do not adequately capture this population, however, many organizations consider youth to be those between 13 and 24 years of age who are engaged in a street lifestyle.  Homelessness, as it applies to youth, has been defined by the U.S. Department of Health and Human Services as “a situation in which a youth has no place of shelter and is in need of services and shelter where he or she can receive help or care” (Grigsby, 1992). UNICEF (1984) describes three categories of street-involved youth. The first, candidates for the street, are youth who are involved in street activities such as panhandling and binning, but live with their biological or foster families. The second, children on the street are those youth who survive with inadequate or sporadic support from their families; UNICEF refers to these youth as being street-involved. Finally children of the street are those youth who function without family support; UNICEF refers to these youth as being street entrenched. For the purposes of this paper, all three categories of youth are considered “street-involved.”  Among the Canadian street-involved youth population, the average age is 19 years and the male to female ratio is approximately 2:1. It is estimated that 60% of street-involved youth are Caucasian while 30% are Aboriginal (PHAC, 2006). Lesbian, gay, bisexual and  12 transgendered youth (LGBT) are highly over-represented among street-involved youth, especially among females. In one study, only 44% of females identified as 100% heterosexual, compared with 77% of males (Saewyc et al., 2008).  This section identifies descriptive characteristics commonly held by members of the street-involved youth community and is built upon in subsequent sections thus providing a valuable context for describing day-to-day life for street-involved youth.  Life on the Street  Street-involved youth generally enter street life resorting to subsistence survival strategies such as selling drugs on the streets, panhandling, and retrieving food from dumpsters (Timco, 2007). These activities often lead to petty theft such as shoplifting which can easily then progress to more serious crime involvement such as burglary and involvement in organized crime (Wallerstein & Bernstein, 1988).  While some street-involved youth maintain regular contact with their family, most have irregular contact or have no family contact at all (Sauvé, 2003).  For many youth, leaving their homes addresses one problem, but immediately introduces many others. Day to day activities must focus on acquiring the basic necessities for life. Youth are at particularly high risk of violence and exploitation when they first enter street life, however, they are more likely to engage in activities such as panhandling which carry relatively lower inherent risks. They exist in a world that can quickly alternate between monotonous and  13 life-threatening. The more time youth have spent on the street, the more entrenched in the life of drugs, violence, crime and prostitution they typically become. Addiction often leads to distrust among members of the street-involved youth community. They come to expect to be disappointed by friends on the street and become increasingly detached from reality.   Street-involved youth typically suffer from significantly higher rates of health related problems compared to mainstream youth (Roesler, 2000). Relatively common health related problems include addictions, hepatitis, sexually transmitted diseases, malnutrition and chronic respiratory infections. Street-involved youth also suffer from high rates of mental health problems such as depression, low self-esteem, suicidal tendencies and other self-injurious behaviours (Roesler, 2000). A recent study found that among street- involved youth, 26% of males and 36% of females seriously considered suicide in the past year. Thirty percent of females and 18% of males had actually attempted suicide at least once during the past year (Saewyc et al., 2008).  Street-involved youth in Vancouver report that they “do not feel a sense of belonging or acceptance at school” (Martin et al., 2008). However, despite problems in school, the majority of street-involved youth harbour high academic aspirations. In fact, 50% reported that they wanted to attend college or university; however, only 26% thought that this was a reasonable expectation (McCarthy, 1995).   14 The daily lives of street-involved youth are consumed by a constant struggle to overcome multiple barriers to health. Once youth find themselves on the streets, they quickly begin to think of themselves as “street kids.” This self-stigmatizing label may lead youth to refrain from accessing social services from which they could benefit. Once set, this label can be hard to remove. As youth become increasingly entrenched in street life, they reportedly begin to perceive themselves as increasingly powerless to bring about change in their own lives or the lives of others (Sauvé, 2003). Considerable research documents the effects of lack of control or powerlessness in disease causation or, conversely, of empowerment in health enhancement. The literature in social epidemiology and social psychology examines the lack of control over one’s life as a risk factor, stemming from overburden of life demands without adequate resources to meet the demands (Smith et al., 2007).  Street-involved youth are constantly balancing their immediate needs and the benefits of short-term coping strategies against the potential risks and future consequences of their actions and decisions (Sauvé, 2003). While the streets are safer than home for many youth, violence remains a constant concern. Those who remain on the streets for extended periods of time quickly learn to be self-sufficient, remaining as safe as possible in a dangerous environment. To stay safe, many street entrenched youth sleep in groups or with dogs. While most prefer shelters to sleeping on the streets, youth report numerous barriers to accessing many forms of housing including emergency shelters, transitional housing and low income housing (Martin et al., 2008). While many youth receive government support for housing, most report experiencing difficulty finding a place that  15 is clean, safe and affordable. Many youth report waiting for months to find housing and resort to living in dilapidated accommodations in neighbourhoods in which they feel unsafe (Martin et al., 2008).  Many youth resort to seeking health related information from peers, however, this practice can result in the perpetuation of false information. Fear of visiting a doctor has been shown to be a significant barrier to care for street-involved youth in Vancouver (McFadyen & Fletcher, 2002). Among the street-involved youth community Vancouver, medical needs are commonly ignored until they become unmanageable.  While some street-involved youth report not using drugs or alcohol at all, research has shown that the health concerns of street-involved youth in Vancouver are primarily related to their drug use (McFaden & Fletcher, 2002). In Canada, 95% and 20% of street- involved youth use non-injection and injection drugs respectively (PHAC, 2006). In Vancouver and Victoria, BC, injection drug use has increased between 2000 and 2006 (Martin et al., 2008). Youth generally begin to inject drugs when they have developed a significant tolerance such that they do not experience a significant effect with other methods of drug use. Many street-involved youth reportedly place their “addictions” before their health and are generally fearful of and mistrust authority figures such as health care professionals (McFadyen & Fletcher, 2002). Many Vancouver youth who participated in one survey reported feeling that they could not even trust their friends. One youth stated, “friends on drugs will always disappoint you” (Martin et al., 2008).   16 Like youth clinics and housing, addiction treatment programs are difficult to access. Approximately 25% of youth report having received drug or alcohol treatment (Martin et al., 2008), however, some youth report having waited a year or more to get into a treatment program. Among those street-involved youth who feel they have an addiction problem, nearly half request detox services, outpatient or residential treatment; however, approximately 9% of youth say these services were not available in their community (Saewyc et al., 2008).  The most common services youth identified as being needed were safe housing (61%), job training (49%), work experience (38%), as well as school programs (33%), life skills programs (29%) and youth clinics (29%) (Saewyc et al., 2008). It is important that these programs remain age specific, as street entrenched adults and youth have varying needs and thus require specialized services. Additionally, creating an environment in which youth are exposed to street entrenched adults can create a potentially dangerous environment for the younger youth.  Approximately 30% of males and 23% of females report having been sexually exploited, and youth who report physical or sexual abuse are twice as likely to be sexually exploited as those who were not abused (Saewyc et al., 2008). Many youth trade sex for money, clothes, food, drugs or a place to stay but do not necessarily consider this sexual exploitation. In one study, only 1 in 20 youth reported income in the last 30 days from the sex trade, however, more than 1 in 3 youth report that they have ever traded sex for money or goods such as drugs, alcohol or a place to stay (Martin et al., 2008).  17  Only one half of 18 year olds report using condoms during their last sexual intercourse compared to 66% of 14 year olds (Martin et al., 2008). Youth report that they get less worried about pregnancy and STI’s over time, so they stop using condoms. Approximately one half of female street-involved youth see themselves as being at little or no risk of becoming pregnant (CS/RESORS Consulting Ltd., 2002). Many street- involved females do not have sufficient stability in their lives to remain compliant to daily birth control regimens. Furthermore, males who are in relationships may refuse to use a condom with their partner. These factors contribute to much higher lifetime pregnancy rates among street-involved youth compared to non-homeless teens, with rates ranging from 40% to 50% among street-living youth and 33% among shelter-residing youth (Slesnick, N., Bartle-Haring, S., Glebova, T., & Glade, AC., 2006).  Sports and physical activities give youth a release from their problems, and also keep them busy and away from drugs and alcohol. As such, promoting participation in sports is particularly important for those youth who are at risk for homelessness. Recognizing this, some drop-in and detox centres offer free recreation passes, but there remains a significant need for opportunities to engage in sports. Once out of school, there are few opportunities for at risk youth to play on sports teams such as softball, hockey and soccer, however, skateboarding and playing hackie sack have been shown to increase after youth become street-involved (Martin et al., 2008).   18 Without proper nutrition, it is difficult for youth to enjoy engaging in sporting activities. Seventy-five percent of street-involved youth report going without food for a whole day “a few times” or “often” (CS/RESORS Consulting Ltd., 2001). Further, they tend to consume a diet “heavy on starches and sugars and low on proteins, minerals and vitamins.” Compared to youth in school, male street-involved youth are more likely to desire a gain in weight (84%), while female street-involved youth are less likely to desire to lose weight (69%).  This section provides a glimpse into the day-to-day lives of many street-involved youth. We discuss the survival tactics of these youth which range from panhandling to involvement in organized crime and prostitution. Once youth have become entrenched in street life, it becomes increasingly difficult for them to integrate into regular society.  Transitioning off the Streets  Transitioning to adulthood is particularly difficult for many street-involved youth as they become ineligible for many youth services. A number of avenues by which youth transition off the streets have been identified. These include: 1) reconciliation with family, 2) involvement with the legal system, 3) enlistment in the military, 4) contact with a social services program, or 5) accomplishing it on their own (Roesler, 2000).  Many youth feel uncomfortable or unprepared to access adult services, and particularly, to stay in a shelter with adults.   19 Violence, drug use, and sexual behaviour during street life can lead to significant and long term health problems. These may include chronic infections, addictions, physical injury and mental problems such as post traumatic stress disorder. In order to address these problems, transitioning youth will need to rely on their health literacy. Hayos, Riley, Hense, & Wiechmann (2008) argue that four knowledge and skills domains are needed with regard to health literacy in order to successfully transition into adulthood. These include the ability to 1) access existing support services, 2) comprehend consequences associated with street involvement, 3) problem solve and critically evaluate challenging situations, and 4) advocate for improved services and communicate personal needs. Hayos argues that integrating the concepts of empowerment and health literacy into support programs may be the key to promoting sustainable life changes that reduce or eliminate youth homelessness (Hayos et al., 2008).  Individuation is an important developmental stage during adolescence, during which youth are guided to become self sufficient in modern society. Many youth transitioning off the street may have lacked this mentorship and will thus require some guidance to ensure a successful integration into regular society. In order to effectively address youth homelessness, community members have to change, including parents, teachers and educational leaders, community health workers and nurses, local employers, political structures, and community-based organizations. Many health care workers must change their attitudes so that youth feel more comfortable accessing health services in their community (Adamchak, 2006). Health programs for homeless youth need to focus on reducing their health risk exposures while providing alternatives to street survival  20 activities. Similarly, if homeless youth are to achieve successful transition off the street, health programs must also facilitate development of life skills and knowledge, enhance social connections with adults and peers, and support youth developmental assets (Wallerstein & Bernstein, 1988).  This section provides a brief description of the process of transitioning off the streets for street-involved youth. Like our understanding of the process of becoming street-involved, the process of transitioning off the streets has not been sufficiently explored in the literature. It is essential that we continue to fill gaps in the literature with regard to factors associated with youth transition off the streets while continuing to identify factors which led to the initial transition onto the streets for these youth. This will allow us to continue to develop and support services that will ease youth transition off the streets while continuing to address the factors which led to the initial street-involvement of these youth.          21 Chapter Three: The Youth Wellness Project Overview  The Youth Wellness Project (YWP) is a collaborative initiative involving University of British Columbia (UBC) health science students and a grassroots coalition of street- involved youth called the Vancouver Youth Visions Coalition (VYVC). These groups participate as equal partners to provide health literacy workshops for street-involved youth residing in the inner city of Vancouver, BC. Topics for these modules include mental health, substance use, reproductive health, nutrition and first aid. The initial objective of the YWP was to determine the most significant and pertinent health literacy needs among Vancouver’s street-involved youth population and address those needs through the development, facilitation, and evaluation of a series of health education modules. These workshops take place on a monthly basis over a weekend at Directions Youth Services Centre or Covenant House in Vancouver's inner city.  Five to seven youth clients are chosen to participate in all modules over the weekend. The modules are delivered and facilitated by health science students and members of VYVC.  Since its inception in the summer of 2006, the YWP workshop series has been presented 17 times. Approximately 40 health science students and 15 street-involved youth have participated in the development and facilitation of this program. The total number of street-involved youth who have participated in the workshop series is estimated to be 120.    22 Rationale  The YWP was initiated with the primary goal of providing effective and culturally sensitive health promotion for street-involved youth in Vancouver. Once youth leave home they may lack basic necessities such as shelter, proper clothing and nutrition, access to health care and safety. They may also be isolated from society, fearful of authority figures, and unprepared and preoccupied with surviving on the streets. The social services targeting these youth are often overwhelmed with, and fall short of meeting even the most basic necessities of life. While scarce resources are poured into sustaining life on the street and getting youth off the streets, equipping youth with the knowledge, skills, and self confidence necessary to survive on the streets is often overlooked.  Few services offer health education programs youth would benefit from and fewer still do so in an effective and culturally sensitive manner. Youth report that many services which target street-involved youth adopt a highly paternalistic attitude towards health literacy education and neglect to collaborate with the youth or capitalize on their individual knowledge. When youth do not collaborate, these programs suggest that the street- involved youth are too hard to work with. The YWP was conceptualized as a genuine partnership between health science students and street-involved youth in which all partners are considered to be experts with complementary knowledge and skills.   23 In addition to addressing the immediate health literacy needs of street-involved youth, we also identified a gap in the literature with regard to guiding models for collaborative health promotion and evaluation. Very few collaborative health promotion programs with street-involved youth exist and even fewer are evaluated. It is hoped that the YWP evaluation will prove useful to those interested in developing or evaluating a health literacy education program targeting street-involved youth.  Major Collaborators  The Division of Inner City Medicine, Faculty of Medicine, UBC, based out of the Three Bridges Community Health Centre in Vancouver, aims to improve the health status of marginalized (underserved) populations in the urban core communities of British Columbia's major centers through advocacy, research and educational initiatives.  CHIUS (Community Health Initiative by University Students) is an inter-professional, student-run program that concentrates on meeting the needs of Vancouver’s marginalized populations in Vancouver’s inner city. The proposal was built on the theory of service- learning, a methodology developed to bridge the gap between students at an academic institution and a marginalized community. The current program has five guiding principles: service, learning, inter-professionalism, reflection and student leadership. CHIUS currently has over 500 active volunteers representing the faculties of medicine, nursing, social work, pharmacy, dentistry, physiotherapy, occupational therapy, dietetics population and public health and audiology.  24  The Vancouver Youth Visions Coalition is a street-involved youth run organization based out of Ray-Cam Community Centre. They provide awareness workshops to community members about street-involved and/or sexually exploited youth, and the services needed for prevention and protection of sexually exploited and/or homeless youth. They provide leadership and facilitation training, information-sharing workshops for youth groups and community members, and are connected with over 250 individuals many of whom are at risk for homelessness or are homeless.  Crystal Clear was a unique youth participation project involving current and former users of methamphetamine (crystal meth) in understanding, participating in and owning their own health. They sought to reduce the harms associated with crystal meth use, both to the individual and the larger community. They provided skills, training, support and meaningful opportunities for young people addicted to crystal methamphetamine. Covenant House is a 22-bed crisis shelter that is open 24 hours a day and helps young people aged 16 - 22. Young people self refer to the shelter on a first-come, first-served basis. When a young person first arrives, their immediate needs are met first, which is often medical care and always food and rest. After three days, a youth worker sits down with the young person and helps them determine a plan for the future. The crisis shelter provides sanctuary from the streets and structure for young people desperately needing to make changes in their lives. Young people meet with a youth worker twice per day and work towards an individualized plan to exit the streets. They make a "covenant" or  25 agreement with each young person that says they will do everything in their power to help, as long as the youth are genuinely trying to stick to their plan. Each young person is treated individually and everything from their cultural and religious needs to dietary restrictions is incorporated into their care. Eligibility includes: 1) adherence to a fairly structured routine with a curfew, 2) no drugs, alcohol or weapons, and 3) no illegal activity or sex trade involvement. Directions Youth Services Centre in Vancouver’s inner city provides Vancouver’s homeless and at-risk youth with a single entry point to access the tools, support, and guidance they so desperately need to work towards reclaiming their lives. This youth services centre strives to be accessible to all youth, regardless of their circumstances and fosters a culture of respect.  The Centre for Population and Public Health at UBC works under different pillars of research, perhaps most readily defined as the five pillars of research outlined by the Canadian Institutes of Health Research: the community, the workplace, schools, the clinical setting, and international settings. The Centre is unique in BC in terms of the breadth and magnitude of its research and teaching efforts in the area of health promotion and population health.    26 Planning, Design and Implementation A Process Grounded in Theory   Several factors contributed to the initial development of the YWP in the summer of 2005. Vancouver based studies had clearly demonstrated that a large and growing population of street-involved youth currently reside in the inner city of Vancouver (Martin et al., 2008). These marginalized youth suffer from a significantly poorer health and quality of life than the general population.  Several assumptions were made during the initial development of the YWP. It was presumed that 1) health literacy is a barrier, and in some cases a significant barrier, to health and quality of life among street-involved youth, 2) UBC volunteers and members of the street-involved youth community would be willing and able to participate in a health literacy education program, and 3) financial support from community based organizations and funding bodies would be available to fund a health literacy education program for street-involved youth.  In figure 1, a program design and planning logic model is utilized to demonstrate how the proposed participative health literacy education program could achieve the ultimate goal of the program; increased health and quality of life among street-involved youth residing in Vancouver.   27 Given that our initial assumptions were correct, we identified three avenues by which the short term and long term health and quality of life of street-involved youth could be improved. These include 1) increasing street-involved youth health literacy, 2) providing youth with empowering leadership opportunities, and 3) providing health science students with experience working with street-involved youth.   Figure 1: Youth Wellness Project Design and Planning  A lack of health literacy in the context of street life may be a significant barrier to engaging in more healthy behaviours among this population. We hypothesized that health Strategies -Create a health literacy education workshop series for street- involved youth, by street-involved youth, residing in Vancouver, BC. -Crystal clear, a methamphetamine awareness group was previously successful in engaging street-involved youth in both teaching and participating in health literacy education workshops. Assumptions -UBC volunteers and VYVC members are willing and capable of participation in the proposed program. -Community based organizations and funding bodies will provide in kind and financial support. -Health literacy is a significant barrier to health and quality of life among street-involved youth. Influential Factors -There is a documented need for health literacy education targeting street-involved youth in Vancouver. -There is strong support for health literacy education from both academic and community based organizations. Problem or Issue - Poor health and quality of life among street- involved youth residing in Vancouver, BC. -Poor working knowledge regarding marginalized populations among health science students at the University of British Columbia. Community Needs/Assets -At any given time there are approximately 500 street-involved youth residing in the Greater Vancouver area. Relatively frequent use of health care services among this population suggests poor health and quality of life among this population.  Desired Results -Provide 150 hours of health literacy education to 120 street-involved youth. -Engage street-involved youth and health science students in project planning and facilitation. -Empower and improve health literacy among street-involved youth. -Provide health science students with experience working with marginalized youth. -Change health related behaviour among YWP participants and facilitators. -Increase health and quality of life of street-involved youth.   28 literacy could be improved among this population by engaging them in a series of health literacy education workshops. This could increase the frequency of healthy behaviours or conversely decrease the frequency of unhealthy behaviours among this population, ultimately increasing the health and quality of life.  In figure 2, causal linkages demonstrate how inputs which are resources such as funding and personnel, have resulted in more than 150 hours of health literacy education seminars being provided to approximately 120 street-involved youth in Vancouver. Regular meetings have also taken place. It is hoped that these program outputs result in the following outcomes: empowerment and improved health literacy among street-involved youth, more expertise among health science students regarding work with Vancouver’s marginalized youth and changes in health related behaviour among YWP participants and facilitators. We hypothesize that these changes will contribute to improved health among street-involved youth in both the short and long term.   29  Figure 2: Youth Wellness Project Implementation Logic Model  A lack of primary care practitioners who are trained to provide culturally appropriate care for street-involved youth has additionally been identified as a barrier to health and quality of life among street-involved youth in Vancouver (Smith et al., 2007). Health science students currently receive little training in the care of marginalized populations such as street-involved youth. It was hypothesized that this project could provide health science students from the University of British Columbia with knowledge regarding the complex health needs of street-involved youth and increase their comfort working with this population. This could increase the availability of culturally sensitive care for street- involved youth in the future, ultimately leading to improved health and quality of life.  Impact: Improve the health and quality of life of street-involved youth  Outcomes: Empower and improve health literacy among street-involved youth; Provide health science students with experience working with Vancouver’s marginalized youth; Change health related behaviour among YWP participants and VYVC facilitators. Outputs: Provide 150 hours of instruction to 120 street-involved youth; Engage 40 street-involved youth and 30 health science students in project planning and facilitation.  Activities: Regular Meetings; Development of Workshops; Facilitation of Workshops  Inputs: Personnel: Staff, Mentors, Volunteers; Funding; Supplies; Space   30 Vancouver currently provides few opportunities for street-involved youth to take on legitimate leadership roles within their community. We hypothesized that by generating paid leadership opportunities in the community, we would empower street-involved youth; enhancing their self-esteem, leadership, and life skills. Empowerment could have a significant impact on more distal determinants of health and could lead to increased health and quality of life among our street-involved youth partners.  The development of the YWP was strongly influenced by the work of Paulo Freire, Albert Bandura and other social scientists who have developed theories with application to health promotion program development, facilitation and evaluation.  Paulo Freire’s theory of participatory education proposes that the full participation and empowerment of the people affected by a problem is essential in order to enact change (Wallerstein & Bernstein, 1988). The YWP was conceptualized with the intent to make each step in the development of the program as participatory as possible while taking into consideration the need to capitalize on the respective capacities of community partners. According to the diffusion of innovations theory, influential leaders and respected individuals influence norms by disseminating information through one-to-one contacts and group discussions. Friendship groups and social networks are also important routes of communication and change (Adamchak, 2006).  This theory highlights the value of VYVC youth as workshop facilitators.   31 Albert Bandura’s social learning theory emphasizes that people learn through direct experience, as well as through the observation of role models (Roesler, 2000). The YWP encourages participants and instructors to take on both the roles of learner and educator. In doing so, it encourages participants to view the behaviour of their peers as well as their own behaviour from an extrinsic vantage point, as a peer educator. This change in perspective can alter attitude and beliefs thus contributing to healthy behaviour changes.  The theory of reasoned action states that the intention to adopt a new behavior is influenced both by the subjective beliefs of an individual and by his or her normative beliefs, i.e., how norms or community standards influence an individual (Adamchak, 2006). We propose that among YWP participants, observing the promotion of health behaviour by peers will have a more significant impact on normative beliefs than the promotion of health behaviour by non-peers. It is reasonable to assume that among street- involved youth, the health related beliefs of peers will at least to some degree influence their actions. The YWP creates an environment in which street-involved youth are surrounded by individuals they identify with as peers. It creates an environment in which the youth are reportedly comfortable discussing issues and sharing personal stories which may otherwise be considered off limits. For example, youth may be more comfortable accessing mental health services if they are aware of their peers struggles with mental illnesses and experiences with the mental health care system.    32 A Front Line Perspective on Program Development  A commitment to community engagement ensures that programs remain grounded and applicable to the population of interest. Furthermore, it enhances the support of the population of interest and community based organizations. As such, when we set out to develop health literacy curricula pertinent to street-involved youth in Vancouver, and an effective methodology by which to disseminate this information, our intent was to maximize the engagement of street-involved youth.  We connected with a group of youth who called themselves the Vancouver Youth Visions Coalition (VYVC). While a standard recruitment process would likely pass over these youth due to their lack of work experience and academic success, they are the ideal candidates for staff members in our program. They 1) demonstrate a genuine concern for their peers and are committed to bringing about social change, 2) demonstrate potential to learn, develop and grow, and 3) are somewhat representative of the very demographic the YWP is intended to target and support. While these youth describe themselves as having been “entrenched” in street life in the past, they have since gained sufficient stability in their lives to attend meetings and workshops on a regular basis. They are somewhat older than the YWP participants, they have regular access to a computer and have basic computer literacy skills which allows for regular communication via email. They are well known and respected among the street-involved youth community in Vancouver and demonstrate an internal commitment to improving the health and quality of life of their street-involved youth peers.  33 During initial stages of development, the YWP engaged a large number of street-involved youth in workshop planning and facilitation, however, there was a high turnover rate among the youth, which slowed the development of this initiative. Commitment to the YWP among the majority of these members was initially low, as reflected in irregular attendance at meetings and workshops.  Initial consultations with members of the VYVC suggested that Vancouver’s street- involved youth would participate in, and benefit from, an interactive, workshop based, health literacy education program. VYVC youth further reported that they 1) don’t always know how to best take care of their own health or the health of their peers, 2) don’t always know how to access health care services, and 3) are not always comfortable visiting a health care professional.  During the initial stages of project development, meetings occurred between members of CHIUS and VYVC. In collaboration with VYVC, an initial needs assessment and literature review was undertaken. A questionnaire was distributed among the street- involved youth community by several VYVC members. In this manner, we were able to access and obtain information from a population which would have otherwise been exceedingly difficult to access. Youth leaders were employed at the commencement of this project to oversee the development of the project and advocate for the street-involved youth. One VYVC member was hired to take on a lead role in this project. He was responsible for ensuring that as many VYVC youth as possible attended the meetings and  34 he attended all workshops to ensure the project ran smoothly. Every effort was made to include VYVC members in all significant program management decisions.  The best approaches to creating an inviting and welcoming environment for students and street-involved youth were determined in order to foster relationships and facilitate the brainstorming process. The initial meetings took place at a youth drop in centre. Here, street-involved youth would presumably be familiar and comfortable. During the initial stages of this initiative, it was suggested that the YWP should create a comfortable and safe setting, where barriers can be broken down between the street-involved youth community and the university / professional community. At initial meetings, the VYVC youth agreed to participate in the development and facilitation of the YWP given that we agreed to several conditions: the voice of street-involved youth and students would hold equal weight, a harm reduction oriented approach would be employed, full confidentiality would be assured for everyone involved and the youth leaders would be fully involved throughout the decision making process.  At initial meetings, CHIUS students agreed that while life trajectories are very different between them and the VYVC youth, they have a common goal which allow for efficient and effective team work. Between 10 and 20 individuals generally attended each meeting with an approximately equal number of university students and street-involved youth in attendance. A number of activities were employed to ensure that the street-involved youth had an opportunity to become familiar with as many university students as possible. In this setting, VYVC youth were willing to stumble through the difficulties associated  35 with differing communication styles. The VYVC youth learnt from the students, but perhaps more importantly the university students were able to personally connect and learn about the realities of life for street-involved youth.  One CHIUS student reports:  “In the beginning, I didn’t know what to expect. I was intimidated by the differences between myself and the street  youth and wondered if we would be able to understand and work with each other. For example, when working on the substance abuse workshop, the university students and street youth were coming from very different paths – some had never seen street drugs before and had only learned about them in class while some had experienced them first hand. After a few meetings though, as the new faces became more familiar and I realized that like all other relationships, it takes openness and time to learn how to work with each other. We spent time together on the workshops, but it was even more valuable spending time chatting over coffee and learning about each other. This really helped us to find out where each person was coming from and how we could support and respect each other in the project.” Fostering these initial relationships was integral to the success of this initiative. The VYVC youth describe the development of personal relationships as an integral first step in developing a working relationship with street-involved youth. In one street-involved youth’s words, “I’m not working with anyone if I don’t know where they’re coming from.”   36 A list of the health literacy related needs and concerns among street-involved youth were generated by the task force, and these were grouped. Four working groups were initially formed, with an approximately equal number of health science students and street- involved youth in each group. Over a four month period, these groups met on a regular basis to develop and practice presentation of their workshops. First aid and fitness working groups were later added.  Over the course of the project’s first year, a small group of committed youth naturally developed, and this committed group of youth now leads workshop development and facilitation. One previous participant returned to the program this year as a VYVC instructor. This core working group has demonstrated a strong commitment to the YWP as reflected by regular attendance at meetings and workshops and YWP related work outside meetings and workshops. This core group of youth has demonstrated clear leadership and workshop facilitation skills since the inception of the YWP, however, these skills appear to have flourished in this setting. Each time the workshop series is presented, the VYVC members take on an increasingly prominent role in facilitating the workshops. Over time, the primary responsibility of many CHIUS students has become one of “quality control”. Our current team demonstrates a strong sense of loyalty to the youth and to the communities they serve. Despite low wages and a lack of job security they remain strongly committed to this project.  The YWP planning committee currently consists of a core group of university students and street-involved youth. The YWP currently employs members of the VYVC who play  37 a central role in the facilitation of a series of workshops designed to meet the needs of youth living on Vancouver's streets. The workshop series is provided on a monthly basis.  Ongoing evaluation of the YWP workshop series has informed month-by-month modification to the curriculum. As such, evaluation has allowed us to develop curricula increasingly representative of the health literacy needs of Vancouver’s street-involved youth population.  Workshop Content  Each one hour module is delivered and facilitated by health science students from CHIUS and VYVC members.  Briefly, the Mental Health module provides youth with an opportunity to talk openly about their experience with mental illness and how to deal with it in themselves or in their peers.  During the Substance Abuse module the youth are encouraged to share their knowledge about and experiences with substance use. Techniques for avoiding over-dose and infection are discussed including needle exchange and vaccination.  Finally, potential methods for detoxification and recovery from addiction are introduced to the youths.  During the Reproductive Health and Pregnancy module the group discusses pregnancy, birth control methods, and STI prevention, transmission and presentation.  The new Physical Health module teaches youths the importance of physical fitness and some every day fitness exercises such as how to carry large backpacks without causing back strain.  The Nutrition module provides information about the dietary content of certain foods and how to get a balanced diet for very little  38 money.  Finally, the First Aid module is aimed at an interactive introduction of the basics of first-aid such as the ABC's, wound care, and the role of 911.                   39 Chapter Four: Method of Evaluation  An Evaluation Grounded in Theory  This section describes the process of creating and managing a collaborative research project that includes parties such as: academics, physicians, community based organizations, and our street-involved youth partners. Rather than thinking of street- involved youth as a problem to be solved, we consider all partners to be experts with complementary knowledge and skills. Collaborative research with communities increases the collective research capacity of the group and contributes to the overall functioning of the evaluation process (Macaulay et al., 1998). When, as researchers, we consider ourselves obliged to provide for youth all the knowledge that we believe they need, without considering what they already know and their own opinion, it is because we view them as empty.  CBPR has been found to be particularly useful in descriptive research that attempts to identify or elucidate the social determinants of health (Lantz, Israel, Schulz, & Reyes, 2005).  CBPR in public health is a partnership approach to research that involves, for example, community members and researchers in all aspects of the research process (Isreal et al., 2003). The partners contribute individual strengths and shared responsibilities (Green et al., 1995) to enhance understanding of a given phenomenon and the social and cultural dynamics of the community and integrate the knowledge gained with action to improve the health and well being of community members (Hatch, Moss, Saran, Presley-Cantrell, & Mallory, 1993).  40  One form of CBPR, participatory evaluation (PE), is a process of reflection which combines the technical expertise of academics with the local knowledge of community members (Mullings et al., 2001).  As such, a key element in participatory research (PR) involves developing realistic expectations about what each group can or cannot contribute. PR does not follow a restricted and rigid research methodology, rather, it changes the power relationship between academics and the community, integrating ongoing evaluation into project work and allowing us to learn from experience to inform future action. Rather than considering individuals and communities to be "subjects" or "objects" of health research, in PE community members are considered partners (Macaulay et al., 1998). This entails a shift in personal and professional attitudes of those practicing conventional research. PR involves 1) collaboration between researchers and the researched, 2) a reciprocal process in which both parties educated each other, and 3) a focus on the production of local knowledge to improve the health promotion workshop series (McTaggart, 1991).  PR is differentiated from other forms of research "in the alignment of power within the research process." This research process breaks down the rigid boundaries between those doing research and those being researched. This form of community based participatory research allows traditionally excluded groups to take control of factors that promote good health (Green, George, & Daniel, 1997). PR attempts to negotiate a balance between the development of valid generalizable knowledge and meaningful community benefit (Macaulay et al., 1998).  41  From a surveillance perspective, street-involved youth are considered a hard population to reach, as they often have no permanent home and have little interaction with the health care and education systems. As a result, they are mostly excluded from telephone, school, clinic or residence-based studies leading to a gap in information available on this population (PHAC, 2006).  In Vancouver, a great deal of research is conducted on the street-involved youth community; however, youth are commonly excluded from the development and facilitation of these studies beyond participation as subjects in focus groups and surveys. In fact, people from economically disadvantaged and marginalized communities, such as Vancouver’s street-involved youth, typically perceive university researchers to be people who only wish to study them and provide no service to their community (Harper & Carver, 1999). Many communities distrust researchers because in many cases findings have been of little use to community members (Taubes, 1995).  CBPR strives to build on strengths, resources and relationships that exist within communities of identity to address their health concerns (Israel et al., 2003).  These resources may include networks of relationships characterized by trust, cooperation, and mutual commitment (Israel & Schurman, 1990). “CBPR explicitly acknowledges and aims to support or expand social structures and social processes that contribute to the inherent ability of community members to work together to improve health” (Israel et al., 2003). While some researchers see youth as being 'insiders' even if they serve only as a source of data, we argue that only those who are involved in the initial development of the research question and throughout the research process can be considered full  42 participants in the research process. We demonstrate that marginalized youth can make remarkable contributions when engaged in evaluation which would benefit from the combined technical expertise of the evaluator, and the presence and local knowledge of community representatives.  As one might expect, collaboration between such diverse groups can introduce significant professional and personal issues during the course of a lengthy program evaluation. If left unaddressed, these issues can threaten to negate the added value of the collaborative partnership. Collectively identifying, acknowledging and discussing these issues can help ensure a successful evaluation. We propose that those engaging in PE should ensure that those issues identified in this paper are addressed at the onset of the evaluation and throughout the research process.  Some researchers consider results from PR to be less valid than more traditional research methods. Others argue, however, that PR actually increases content and cultural validity. Content validity is increased by inclusion of contextual factors which would not necessarily be possible without the presence of community members thus increasing the depth and variety of data collected. Cultural validity, the relevance and consistency of the cultural framework in which the research in conducted, is also thought to be increased through the PR methodology (McDuff, 2001).  In figure 3, causal linkages demonstrate how inputs, which are resources such as PCHR learners, VYVC youth, and funding, have led to three focus groups with YWP  43 participants (facilitated by street-involved youth partners), one focus group with VYVC instructors, and one focus group with health science student instructors. It is hoped that this evaluation will empower and improve qualitative research abilities among street- involved youth partners, provide PCHR learners with participatory research experience with street-involved youth, and improve the efficacy of the YWP. We hypothesize that these changes will contribute to improved health among street-involved youth in both the short and long term. Figure 3: Program Evaluation: Basic Logic Model Components with Regard to Evaluation of Participatory Research with Street-Involved Youth.  A need for both formative and summative evaluative data was identified by the research team, however, a focus was placed on improving the content and methodology of the program. There were several reasons for choosing this focus. First, our VYVC youth partners suggested that if the outcome of the focus group was not inherently clear, there might be resistance to participation from the YWP participants. Secondly, the program Impact: Improve the health and quality of life of street-involved youth  Outcomes: Empower and improve qualitative research abilities among street-involved youth partners, Provide PCHR learners with participatory research experience with street-involved youth, Improve efficacy of the YWP Outputs: Three focus groups (FG) with YWP participants (facilitated by street-involved youth partners), One FG with VYVC instructors, One FG with health science students, Presentation of results at AFMC Conference Activities: Engage street-involved youth, Development of focus group script, Focus group facilitation, Transcription, Data analysis  Inputs: Personnel: PCHR Learners and Mentors, Street-involved youth, Funding, Supplies, Space   44 was not under significant pressure from funding agencies to demonstrate the effectiveness of the program in achieving its desired goals, allowing us the flexibility to focus our evaluation on improving the quality of the program. Finally, it quickly became clear that demonstrating a causal relationship between participation in our program and our desired impact, improved health and quality of life was unrealistic.  It was hypothesized that the outcomes identified in figures 2 and 3 could associate participation in the YWP with short and long term changes in health and quality of life among street-involved youth.  The proposed outcomes, as shown in figures 2 and 3 include: empowerment and improved health literacy among street-involved youth, improved ability to provide care for Vancouver’s marginalized youth among UBC health science students, and changes in health related behaviour among YWP participants and facilitators. More distally, it was hypothesized that building research capacity among the street-involved youth community would facilitate future participatory health promotion research, improving the quality of these programs.  A Front Line Perspective on Participatory Evaluation  In September of 2007, Partnership in Community Health Research (PCHR) learners identified an opportunity to conduct an evaluation of the YWP in partnership with the YWP’s street-involved youth partners. The YWP’s reputation as a youth operated organization allowed us to take advantage of facilitating factors. By building upon a prior history of collaboration with the community and positive relationships that already  45 existed, PCHR gained immediate access to this otherwise difficult-to-reach population. Lantz et al. (2005) demonstrate that many social epidemiologists find that they are not permitted access to a community without giving community members a voice in or shared power regarding the project. We resolved to engage our street-involved youth partners at all levels of organization; during the initial stages of planning, throughout the research process and in the dissemination of any knowledge acquired.  Learners from the PCHR program met with the street-involved youth partners on a regular basis to exchange ideas and build the collective research capacity of the team. Four street-involved youth were hired on a part-time basis to conduct research among their peers. The youth received training and support from PCHR academic learners in basic qualitative research skills. In collaboration with PCHR, the Vancouver Youth Vision Coalition (VYVC) developed a focus group script, conducted focus groups with YWP participants, and carried out transcription and data analysis.  We found that research which addressed our objectives naturally lent itself to qualitative methods. A verbal assessment was agreed to be more appropriate than written procedures given varying levels of literacy among subjects. Informed consent was emphasized at the outset of the focus groups. The purpose of the research was discussed and the primary facilitator answered any questions participants had. It was explained that participation was completely voluntary and participants could refuse to answer any questions. Permission was obtained to audiotape the focus groups and participants were ensured that pseudonyms would be used to protect their confidentiality. Participants were paid $10 in  46 appreciation for their time participating in the focus groups which ranged in length from one half hour to one hour.  PCHR learners were initially concerned that the youth would not recognize the potential value of investing significant time and resources into program evaluation. Rather, they might see the PCHR learners as being more interested in “studying street-involved youth” and “evaluating the participatory research process” than improving the educational quality of the YWP. While the youth were initially motivated to participate in the research process by the prospect of making money, as they became increasingly comfortable working in an academic setting with the PCHR learners, they became increasingly invested in this project.  The YWP evaluation has been a valuable opportunity to apply knowledge that benefits both sides of the partnership. During the initial stages of development of the evaluation instrument, the team took their time to generate a set of research questions which addressed the interests of all parties. While our street-involved youth partners were primarily interested in evaluating and improving the YWP workshop series, PCHR learners were able to use the data to explore the determinants of health risk behaviour among the YWP participants  The energy and enthusiasm among YWP participants is thought to stem from a broader commitment to the reduction of health disparities, specifically among the street-involved youth whose everyday lives continue to be infused with experiences of social exclusion  47 and marginalization. By structuring the research-community relationship within PCHR, learners have been successful in instituting a sustained commitment to the youth.  In table 1, we provide a sample of questions with regard to both process and implementation while in table 2 we provide outcomes which would presumably be of interest to each of the primary stakeholders in this program: YWP participants, UBC health science students, VYVC youth instructors, community based organizations, academic mentors and funders. While funder questions are important for ensuring continued resources (inputs), the majority of questions focus on improving and evaluating outcomes as an indicator of outputs as in figure 2.               48 Table 1: Evaluation Planning Phase: Process / Implementation Evaluation Focus Area Stakeholder Questions Use Process/ Implementation YWP Participants Is the workshop series facilitated in a fun and non- judgemental manner? Decisions about continuing participation, program improvement and planning  UBC Health Science Students What are the most significant gaps in health literacy among street-involved youth? What are best practices for providing health literacy education to marginalized youth? Programming decisions regarding curriculum development and improved methodology  VYVC Youth Instructors What methodology can be utilized to most effectively engage my street-involved youth peers? Programming decisions regarding improved methodology  Community Based Organizations How will hosting the YWP change the way in which the community and funding bodies view my organization? How much time and resources will I need to invest? Decisions regarding continued support  Academic Mentors How will street-involved youth engagement influence the development and operation of this initiative? Decisions regarding the promotion of health promotion programs which utilize similar methodology  Funders/Donors Does this program qualify for funding from my organization? Decisions regarding financial support     49  Table 2: Evaluation Planning Phase: Outcomes  Table 3 lists formative and summative questions which were selected as priorities for our evaluation. We recognized a need to identify the most significant gaps in the health related knowledge of street-involved youth in order to inform the continued development of curricula in each of the respective workshops. We also identified a need to develop more effective methodology. Ongoing modification of our workshops, informed by Evaluation Focus Area Stakeholder Questions Use Outcomes YWP Participants Will participation in the workshop series result in my improved health and quality of life and that of my peers? Decisions about program recommendations  UBC Health Science Students Are we addressing the most significant gaps in health literacy among street-involved youth? Will I be better equipped to provide care for street-involved youth? Decisions about commitment and continuing participation.  VYVC Youth Instructors Have I improved my ability to engage street-involved youth in health literacy education? Decisions about commitment and continuing participation.  Community Based Organizations Are participants and instructors satisfied with the workshop series? Decisions regarding continued support  Academic Mentors Has community engagement improved the quality of the program? Are health science student instructors more likely to work with marginalized populations or go into primary care having participated in the YWP? Knowledge about the utility and feasibility of the program approach.  Funders/Donors What is the program budget? Is the program cost effective? Is what was promised being achieved? Accountability and improvement of future grant writing efforts.  50 feedback from these focus groups, has allowed us to more effectively engage our youth participants.  In order to address questions with regard to our intended outcome (see figure 2), we identified questions which address our three primary indicators (outcomes). We investigate whether the program is providing the most pertinent health related knowledge for street-involved youth, whether we are building facilitation capacity among our VYVC youth partners, how engaging street-involved youth in the facilitation process has affected the program and how the program has influenced the ability of health science students to engage street-involved youth in health literacy education. Many health promotion programs have the goal of promoting behavioural or normative changes, but these are very difficult to measure (Adamchak, 2006).             51 Table 3: Indicator Development Phase Focus Area Question Indicators Formative What are the most significant gaps in health literacy among street- involved youth? Focus groups with YWP participants and VYVC youth, Participant survey  What methodology can be utilized to most effectively engage street- involved youth? Focus groups with YWP participants, VYVC youth and UBC health science students, Participant survey Summative Will participation in the workshop series result in improved health and quality of life among street-involved youth? Focus group with YWP participants, Participant survey  Are we addressing the most significant gaps in health literacy among street-involved youth? Focus group with YWP participants and VYVC youth, Participant survey  Has participation in the YWP improved the ability of instructors to engage street-involved youth in health literacy education? Focus group with UBC health science students.  Has community engagement improved the quality of the program? Focus group with VYVC youth, YWP participants and UBC health science students  Will participation improve the ability of health science students to engage street-involved youth in health literacy education? Focus group with UBC health science students  It was agreed that these questions would be most effectively addressed through focus groups with each of the participating partners. That is, the VYVC members, health science students and street-involved youth participants. Health science student reports were also utilized as a data source.   52 The focus groups with YWP participants were facilitated by a team of four VYVC youth. The VYVC youth also participate in the facilitation of the YWP, so they have already established a good report with participants prior to the focus groups. Youth participants are asked about their experiences on the street with regard to health and then asked specific questions about the workshop series. Participants were asked to comment on their personal and collective knowledge, attitudes and behaviours with regard to staying healthy while living on the street. They were additionally asked to identify the main challenges which youth face in trying to stay healthy while living on the street. Participants were asked what they liked, did not like, and what they would change about each of the workshops. Finally, they were asked if and how they might consider acting as “health ambassadors” by passing along any of the health information they obtained in the YWP workshop series to their peers.  PCHR learners carried out focus groups in which VYVC youth instructors and the UBC health science students were participants. The focus group with VYVC facilitators similarly had both formative and summative components. We initially focused on establishing a more concrete role for VYVC facilitators in the program; one that would meet the needs of all stakeholders involved. VYVC youth were asked to identify both benefits and challenges with regard to working with street-involved youth participants and UBC health science students. Finally, the VYVC youth were asked to identify individual and collective, past and present goals for their participation in the YWP and asked whether those goals were being met.   53 The focus group with UBC health science student facilitators similarly focused on identifying individual expectations or goals for the project and whether these goals were being met. It was also designed to identify best practices in order to improve both the quality of the program and the quality of the experience for health science students in subsequent years.  Ongoing evaluation of the YWP workshop series has informed month-by-month modification to the curriculum. As such, evaluation has allowed us to develop curricula increasingly representative of the health literacy needs of Vancouver’s street-involved youth population.  Focus Group Participants  The two major collaborators in the development and facilitation of the YWP, VYVC and CHIUS, both participated as subjects in focus groups. (For background information on these groups, please see Chapter 4: The Youth Wellness Project – Major Collaborators). Street-involved youth who participated in the YWP workshop series at Covenant House, and Directions Youth Services Centre were also invited to participate in focus groups. (For background information on this population, please see Chapter 2: The Street- involved youth Experience).     54 Procedures and Ethics  Focus group participants were eligible to participate in the evaluation process only if they had self-selected into the program as a youth participant, VYVC member or as a UBC health science student. Thus, participants were not randomly selected and therefore results can not be generalized to a larger population. Prior to focus groups being conducted, this research project was reviewed and approved by the University of British Columbia Behavioural Research Ethics Board on May 11th, 2007 (see appendix 3). Steps were taken to ensure that the rights of participants as research subjects were upheld. Participants were assured anonymity, informed that they were free to withdraw from the interview at any time and were asked to sign a consent form. Signed consent to conduct the YWP evaluation was additionally obtained from management at Directions Youth Services Centre and Covenant House where the program and evaluation took place.  Focus group audio recordings were transcribed verbatim and data analysis was undertaken.  Analysis  Focus groups were audio recorded and transcribed after which a discourse analysis was performed. In this method, transcripts of interviews are searched for common patterns, uncommon patterns and unique information (Kirby, Greaves, & Reid, 2006). Integrated reliability was achieved through line by separate line coding of the transcripts by two students. Themes were identified by each student and then compared to identify final  55 themes. Reviewing the transcripts allowed for identification of common themes within single focus groups and across focus groups with each of the three populations; that is health science students, VYVC members and youth participants. Representative quotes from each identified thematic area are provided.                56 Chapter Five: Results  Focus groups were conducted with each of the three primary partners in the project: the youth participants, VYVC youth instructors and the health science student instructors. Data was additionally extracted from final reports completed by health science students. Core categories and themes were identified for each population. Representative quotes are used to support each theme.  Youth Participants  Recruitment for participation in the YWP and thus recruitment for the evaluative focus groups occurred on a monthly basis from February through May, 2008. Between four and seven participants were recruited each month for a total of 22 participants over the four month period. Nine participants (41%) were male and 13 participants (59%) were female. 16 participants provided us with their ages which ranged from 16 to 23 years with a mean age of 17.5 years. Focus groups ranged in length from 25 minutes to one hour.  Coded categories were created and themes were identified after all focus groups were completed. The survey was composed of two sections: 1) health experiences while living on the streets, and 2) feedback from the YWP. Regarding health experiences while living on the streets, two categories were identified. These include: 1) internal factors associated with maintaining health while street-involved and 2) external factors associated with maintaining health while street-involved. With regard to feedback on the YWP, two categories were identified: 1) general feedback, and 2) workshop specific  57 feedback. Each section, category and theme is described below and representative quotes are provided.  Health Experiences while Living on the Streets  In this section we examine the impact which both internal and external factors have on the health of street-involved youth. This section is based upon responses to questions two and three in the participant focus group script (see appendix 2.1).  Characteristics Associated with Maintaining Health while Street-Involved This category refers to specific skills, knowledge and other internal factors which youth participants consider relevant to staying healthy while living on the streets. The following five themes emerged from this category: 1) networking and social skills, 2) health literacy skills, 3) feelings of helplessness, and 4) rejection of mainstream culture. Each theme is described and relevant quotes are provided below.  Networking and Social Skills This theme refers to interpersonal skills such as verbal and nonverbal communication, negotiation and assertiveness skills necessary for maintaining health while street- involved. Participants report that forming relationships with other street-involved youth is essential to surviving street life and highlights the importance of developing a trusting relationship with street-involved youth before a working relationship can be established. The youth report that “the entrenched form core groups that are like families on the street.  58 They back each other up, but they’ll also be the first to stab you in the back.” One youth mentioned that “when you’re on the street all you have is your word.” The street- involved youth report that “if you’re on the street and you don’t have friends backing you up, you can wind up dead. People need to know if they mess with you there will be consequences.” Youth participants agreed that in order to survive on the street “you got to have someone to take you under their wing and show you the ropes. If you know the right people you’ve got food and shelter and safety.”  The youth participants had clearly been raised in a social context of violence and poverty. While most appeared to have a strong social structure, they had come to almost accept that their friends would betray their trust, and that violence is a necessary survival mechanism. When asked about how they survive street life, several youth reported “you’ve got to live by DTA - Don’t Trust Anybody, or you’re going to end up hospitalized.”  Health Literacy Skills This theme refers to the participant’s ability to access and understand healthcare information to make health related decisions in the context of street life. Participants reported that a primary factor in gaining health literacy was the amount of time spent living on the streets. One participant reported “when I first got down here I didn’t have a clue, you know, I was walking around like a blind man basically, then as time goes on you start learning things from people, you know, you run into.” Participants agreed that there are valuable resources available for increasing health literacy in Vancouver. For example, it was noted that “you can go to Gathering Place and get lists for, like, shelter and free food and food banks and showers and everything, you just have to look for it or  59 ask.” Unfortunately, many youth lack sufficient structure in their lives to seek out necessary resources. One youth shared that “there are services but you have to look for them. They aren’t going to come to you and say ok we’ll help you.” Participants agreed that word-of-mouth is the most common way youth gain health literacy knowledge. One participant noted that “a person who is starving is not going to go to a library and go sit down and look at a newspaper or look on the internet [for resources].”  Feelings of Helplessness This theme refers to the feelings of helplessness and feelings of control in maintaining health while street-involved. Most youth agreed that it is possible to remain healthy while street-involved, but it takes significant time and effort which often get redirected to meet more immediate needs such as alcohol and drugs in order to prevent withdrawl symptoms. One youth stated “I think you can be pretty healthy if it was very, very important to you.” Most youth immediately identified addictions as a primary contributor to feelings of helplessness in maintaining health. In addition, many youth feel that due to a lack of education, criminal records and other mental health issues, they do not have any hope of leading a healthy life. One participant reported that “a lot of the time when you are homeless you lose hope so you don’t care how healthy you are or what you’re eating or what drugs you are using.” Addictions appear to have a significant impact on the ability of youth to feel they have control over their own lives. Another participant reported that “I think a lot of people’s health takes a back seat to their addiction, I find, I see that a lot.” Some youth even find themselves unable to travel far from the city due to their addictions. One youth shared that “if you are doing heroin you’re less likely to go do  60 something else because you could get sick from not doing the heroin, so they put that first before they do something else.”  Several youth also referred to services not following through on their promises or unmet expectations as a significant contributor to feelings of helplessness. One participant reported that “a lot of places make promises to street kids that they don’t keep, and eventually you stop believing it and you don’t want to extend your vision beyond what you know already on the street.”    Rejection of Mainstream Culture This theme refers to the rejection of mainstream social values by street-involved youth. One participant reported that “street kids are just as judgmental as anyone else because they’ve been judged and they’re under constant scrutiny by society.” One YWP participant noted that “a lot of people [street-involved youth] have to take the stigma away from the people who are not on the street too…some street-involved youth don’t want to communicate with university students because they feel they are being judged or they have nothing in common.” Activities conforming to mainstream society are rejected by much of the street-involved youth population. Street-involved youth in Vancouver reportedly view the general public as “cookie-cutters in suits who know little about the real world.” Healthy activities such as exercise may be perceived as conformist. As such, the peer pressure to remain nonconformist may pose a barrier to remaining healthy while street-involved.  61 External Factors Associated with Maintaining Health while Street-Involved This category refers to external factors in the environment in which street-involved youth interact which may influence their health. The following three themes emerged from this category: 1) access to shelters and drop in centres, 2) access to health care, and 3) access to nutrition. Each of these themes is described and relevant quotes are provided below.  Access to Shelters and Drop in Centres This theme refers to barriers to accessing shelters and drop in centres for street-involved youth. Youth identified limited access to shelters as a significant barrier to health for street-involved youth.  Many suggested that “when you sleep you are at risk and so is everything on you.” While this applies to both sleeping on the street and in shelters, the danger of physical violence and theft is reportedly significantly higher on the street. The youth identified age limits, policies at drop in centres regarding sleep and high demand as primary factors limiting access to places to sleep. Youth shared that age limits can be a significant factor in accessing shelters. One youth stated that “if you are between the age of 25 and 14 or 16 it’s easier for the resources to come to you than if you’re over 25, then it’s a lot harder to get more stuff.” Another youth shared that policy changes regarding sleep at drop in centres would help to make sleeping safer for street-involved youth. “Some places, like the gathering place, you are really overtired and you, like, fall asleep and then you get kicked out for like a week because you fell asleep.” The high demand for places to sleep was also identified as a major barrier. “You don’t have any place to  62 sleep like drop in centers and shelters a lot of the time because there are so many homeless people down here that its hard sometimes, to get into them.”  Access to Health Care This theme refers to barriers to accessing health care while street-involved. We gathered the perspectives of homeless youth regarding their relationships with health care providers. We found that street-involved youth often choose not to seek medical help due to embarrassment and because they fear being penalized because they live on the street and are addicted to drugs. One participant shared that “most street kids don’t deal with doctors. I was scared when I had to go, I was like, I really don’t want to go to the doctor. I don’t want to know if there’s something wrong with me, I face too much stress in day to day life just trying to survive.” Some youth are unaware of the availability of free clinics. One youth stated that “sometimes people aren’t on medical. They don’t have coverage, so they don’t really have control [over their health].”  Access to Nutrition This theme refers to barriers influencing access to nutrition for street-involved youth. High demand for free food and competing priorities were identified as a significant barriers to maintaining a nutritious diet. One participant stated that “you’ll see huge line ups for food, so you cant really get into there. You’re more concerned about where you are going to sleep that night.”   63 Feedback on the Youth Wellness Project  General Feedback This category refers to general feedback from YWP participants referring to the workshop series as a whole rather than a specific segment. With regard to general feedback, the following themes emerged: 1) reasons for participating, 2) impact of VYVC presence, 3) impact of student presence, 4) impact for participants, 5) facilitation style, and 6) curriculum. This section is based upon responses to questions four through seven in the participant focus group script (see appendix 2.1).  Reasons for Participating This theme refers to the self-identified motivation of youth participants to register and remain involved in the YWP throughout its duration. Given the difficulties many street- involved youth experience with school, it is not difficult to imagine that many would harbour reservations regarding participation in any educational program. One participant shared that “my experience with high school was horrible, but now that I’m older I know what I’m interested in and I’m more interested than ever in getting involved in educational programs.” While honoraria may initially be necessary to encourage participants to register for the program, their sustained commitment to the program is thought to derive from their perceived value and enjoyment of the program. Several participants agreed that “most youth come at first for the money and then realize, hey this is cool and I’m really learning something here.”   64 Impact of VYVC Presence This theme refers to the perceived impact of VYVC youth participation from the perspective of the street-involved youth participants.  Participants were quick to recognize the value of having street-involved youth take on facilitation roles. One participant noted that “the VYVC youth meet people where they’re at. They know they can’t make you go there if they’re not ready for it.” By leading the focus groups, youth partners were able to increase “buy-in” among participants and create a safe environment in which the broader youth community were more willing to actively participate. Many participants report learning more effectively from individuals they identify with as their peers. One participant stated “if you haven’t lived on the street, you have no credibility, because they have no other way to relate.” Another participant stated that “it’s easier for us to believe those people [VYVC] than some professor or some doctor where we are like, how would you know? You haven’t been through this.” It was added that “VYVC is more respected automatically than the CHIUS students because kids [street-involved youth] know that these kids [VYVC] have been on the street and they’re more likely to follow through than someone who doesn’t know anything about being on the street.” Participants suggested that “when you have organizations that have the life experience of being on the street it makes it something a lot more genuine, it’s harder to trust an organization that hasn’t had that experience.”  We found that often the VYVC youth were more effective at engaging the street-involved youth in discussion than CHIUS students, suggesting that street-involved youth learn most effectively from their peers. Each time the workshop series was presented, the  65 VYVC members took on an increasingly prominent role in facilitating the workshops. When VYVC members played a more prominent facilitative role than health science students, we found that while less curriculum was covered, participants appeared to be more effectively engaged.  One YWP participant reported that “seeing how the VYVC people have pulled their lives together and seeing the contrast of VYVC youth and the participants really makes you want to make changes in your life.” It was added that “it seems more real when it’s peers telling you how bad drugs can be for you rather than health professionals.” One YWP participant noted that “that’s why workshops like this one is important, it helps to bridge the gap between mainstream society and street life.” It was further suggested by participants that “having VYVC presenting made it easier to hear…they keep it real.”    Impact of Student Presence This theme refers to the perceived impact of health science student participation from the perspective of the street-involved youth participants.  It is hoped that by encouraging street-involved youth to interact with CHIUS students, who are not yet adults, nor health professionals, the distrust among street-involved youth may be lessened, and this significant barrier to care may be addressed. One participant added that “I see the CHIUS students as peers because they are relatively young.” Another stated that “if the CHIUS people are the right type of people then maybe being around them will make street kids more comfortable around health professionals.”   66 Generally, feedback on the role of health science students in facilitating the workshop series was very positive. One participant stated “you guys had university students who answered questions and it wasn’t in a teacher way.” However, there were circumstances in which the students were perceived as judgemental. One participant noted that “the university students need to show that they’re not judging people automatically, but I can understand how they feel when they come into a group where they can’t really relate to anyone.” It was added that in order for university students to work effectively with street- involved youth they need to “reach a middle ground where they don’t have an uptight attitude and at the same time that they don’t try to look like they’re trying too hard to look cool.”  Impact for Participants This theme refers to the perceived impact of participation in the YWP on participants from the perspective of the street-involved youth participants.  One participant reported that “giving education is like giving someone the opportunity to make positive changes in their lives that otherwise they wouldn’t be able to make. It opens up possibilities that should be available to everyone.” We have found that there is a significant interest and need for health literacy education among Vancouver’s street-involved youth population. One participant shared that “I have learned a lot about some of this stuff that I’ll tell my friends about.”  It is hoped that through participation in this program, youth will become more at ease and confident in educational settings. “I think that it’s really good that this program came  67 here because it did bring all of us a lot closer and it did help people speak about things and also get some stuff off of their chests that they might have been stressed out about”    Facilitation Style This theme refers to methods employed in the facilitation of the YWP from the perspective of street-involved youth participants.  Participants agree that they respond positively to a discussion based format because it acknowledges the value of their individual life experiences, and creates an environment in which participants and facilitators play equal roles in leading the discussion. One participant stated that “I liked that you guys didn’t lecture us. Cause sometimes people do that. Like when people do drugs they will lecture you, oh it’s bad and this and this will happen to you, but we already know that, like we’re not dumb.” Another participant stated that “we got to talk about our own issues and not just listen to someone who thinks they know what our issues are.” Thus, promoting discussion became an increasingly prominent responsibility for facilitators. Participants did, however, recognize the value of some lecture based instruction in each workshop. One participant stated that it needs to be “a 50-50 thing.  It can’t be too teacher like, and it can’t be too open. It needs to have both aspects in order for it to work.”  We also attempted to make the presentation of material as visual as possible to more effectively engage the youth participants. One participant stated that “visuals are great; it helps drive the verbal message home.”   68 A primary goal of the YWP is creating a safe learning environment for the participants. One participant stated that “you need to create an environment where people are comfortable and they can leave their beefs [interpersonal issues] on the street.” While interpersonal issues did arise during workshops over the course of the year, they were all quickly and effectively addressed by other participants and facilitators. Some individuals were surprised with the rarity of violence during the workshop series. One participant stated that “often the participants are from different groups that have a lot of hostility between them, like you brought together some drunk punks [alcohol users] and tweekers [stimulant users], and the fact that this project can bring them together in a situation where they can find common ground, and they sat there without any violence happening for two days is really amazing.”    Curriculum This theme refers to general feedback regarding curriculum presented during the YWP from the perspective of street-involved youth participants. The most common criticism was that the material was too basic. One participant stated that “I found all the modules interesting, but mostly they just reconfirmed what I already knew.” Another participant had similar feedback “we are going over a lot of stuff that we have been learning for the last 10 years. I’d say that 75% of what we talked about was something that we already knew.”  Participants stressed the importance of focusing on curriculum pertinent to their lifestyle. One participant noted that “it’s really important for street kids that the information is  69 relevant to our lives.”  Participants found it interesting to reflect on relationships between the various workshop topics. One participant stated that “it was good to discuss how they [the workshop topics] all connect and intertwine with each other.”  Workshop Specific Feedback This category refers to participant feedback regarding specific workshops. Topics are as follows: mental health, substance use, reproductive health, nutrition and first aid. The fitness workshop was not available for evaluation at the time of this study.    Mental Health The Mental Health module provides youths with an opportunity to learn about and discuss their personal experience with mental illness or the experiences of family or friends. A great deal of stigma appears to exist among the street-involved youth community and, while initially hesitant, participants appreciated the opportunity to openly discuss mental health issues. One participant shared that:  “Mental health in society is kind of shunned, you know, it’s looked down upon and I liked the fact that we got to talk about it in an open forum where it was free flowing and we got to say and learn without feeling any oppression…it just felt good, being able to talk about things and learn about things that generally never get talked about.”   70  Many youth came to the mental health workshop with very little background knowledge. One youth shared that “I just thought everyone was crazy or something, I didn’t know there were different kinds of issues.” The workshop teaches basic coping mechanisms for issues such as stress and depression and how to identify mental illnesses among their peers. We discuss mental health issues which are more prevalent among the street- involved youth population with a particular focus on the relationship between mental health and addictions. One participant stated that “it makes you very aware of using drugs and that there is a danger of getting psychosis and other health problems.” Participants appreciated the relevance of this information. One student shared “I think the information about identifying people who might be suffering from a mental illness is really important.” It also provides participants with knowledge regarding mental health resources.    Substance Use The substance use module encourages participants to share their knowledge and experiences regarding substance use. Participants appreciated the opportunity to share substance use information in an open and non-judgemental environment. One youth shared that “we don’t feel like we are being judged. Which is good. We can talk about how we have used this drug and that drug and we know we aren’t going to be judged because most of the people in the room have used at one point in their life.”  Techniques for avoiding over-dose and infection are introduced. We discuss needle exchange and vaccination as well as methods for detoxification and recovery from  71 addictions.  A safer shooting demonstration was also provided with mixed reviews. While some youth appreciated the demonstration - “I liked the safer shooting demonstration, I think that’s important” – others found it to be offensive - “I don’t like the safe injection stuff. It doesn’t belong here.”  Reproductive Health The Reproductive Health module provides youth with an opportunity to learn about and discuss their personal experience with reproductive health. The group learns about pregnancy, birth control methods, and STI prevention, transmission and presentation. While some youth stated that they had not learnt anything new during this workshop, others reported having gained a great deal of new knowledge. One female youth shared “I didn’t know there were so many kinds of birth control.” While a male participant shared that “I learned what a period is” and “I didn’t know that you didn’t show symptoms [despite having some STI’s]. I didn’t know that at all. It’ll make me thing twice about having unprotected sex and about who with.” Photographs of STIs were distributed to ensure participants were capable of identifying a variety of STIs. While some participants agreed that “the pictures were really good because a lot of people don’t know what it looks like when you have an STD,” others shared that “the shock factor is good but you don’t want to scare youth into not being comfortable with their own bodies.” Most youth agreed that the curriculum was highly relevant to their own lives. One female shared “all the symptoms of STDs and stuff I passed along to my boyfriend because he cheats on me a lot.”   72 Nutrition The Nutrition module provides youth with an opportunity to learn about and discuss their personal experience with maintaining a healthy diet while street-involved. Information is provided about the dietary contents of certain foods and how to ensure a healthy diet on a budget. One youth shared that “it was a great refresher on what you should have to be a healthy body, mind and spirit, just a great refresher you know because society doesn’t really tell you what to eat.”    First Aid The First Aid module is intended to serve as an interactive introduction of the basics of first-aid. Youth appreciated the opportunity to guide the curriculum and its relevance to their lives. One youth shared “I thought it was an amazing group because she asked what we wanted to learn about. It was more street-involved youth oriented. It was things that we might have to deal with in the future.” Skills such as the wound care and basic CPR are covered. One youth stated “I didn’t have a clue about any of the CPR stuff…if anyone needs help, I could help now.”  VYVC Instructors  Recruitment for participation as youth instructors in the YWP and thus recruitment for the evaluative focus groups occurred between May, 2006 and August, 2007. A total of four youth participated in the focus group. Two were male and two were female. The average age of participants was 24 years. The focus group was 35 minutes in duration.  73 This section is based upon responses to the VYVC youth instructor focus group script (see appendix 2.2).  Seven distinct themes were identified. These include: 1) reasons for becoming involved, 2) VYVC presence, 3) facilitation style, 4) curriculum, 5) impact for participants, 6) program structure, and 7) challenges. Each theme is described and representative quotes are provided below. Reasons for Becoming Involved  This theme refers to the primary motivators which led to VYVC participation in the development and facilitation of the YWP. The VYVC youth identified two primary motivators for participation in the YWP: 1) supporting VYVC and 2) supporting the Vancouver street-involved youth community. One VYVC youth shared that “for us it’s something we can do towards becoming a larger and more productive organization. And the main thing is providing support for youth, so we saw the need to do this.”  VYVC Presence This theme refers to the impact of the presence of VYVC youth in the development and facilitation of the YWP. Feedback from VYVC instructors suggests that their participation in the YWP has been a very positive influence in their lives. The VYVC youth report having gained valuable knowledge and experience while instructing the workshops. One youth shared that “we also learn as well by doing these workshops, like something say we had no idea about you know was brought up by a participant. So like  74 it’s also learning experience for us to come in and do these workshops.” The program has also reportedly helped to address self-stigmatization among the VYCV youth.  One youth discussed how participation in the YWP has helped to bridge the perceived divide between VYVC youth and university students.  “I personally was really stigmatized against academia. I had no inkling of going to school for more than one reason, one reason was the stigma and two is I didn’t think I could handle it. Working with CHIUS and working with all you guys, I think I went to school after we started the CHIUS project anyways, right, and I think that breaks down, it broke down my personal stigma and brought me to a point where I thought I could go to school, which I’m surprisingly able to hand part-time.”  VYVC stress that sustainability and continuity are important for the success of the YWP. We have worked since the initiation of this project to transfer decision-making power to the youth and they have adopted these roles with great drive  Facilitation Style This theme refers to the effectiveness of the facilitation style utilized by the VYVC youth and health science students from the perspective of the VYCV youth. VYVC members stress that “street-involved youth react very negatively to a top down approach to instruction because we have endured having little control over life choices.” VYVC  75 youth agree that “street-involved youth are more comfortable and thus more effectively engaged in a setting that resembles a co-learning experience where participants and facilitators all learn from each other.” Further, they agree that the potential for learning and psychosocial development is enhanced when an interactive discussion based format is employed. Thus, promoting discussion became an increasingly prominent responsibility for facilitators.  The YWP workshop series took place at two community centers which generally work with different groups of street-involved youth. One VYVC member stated that “the groups at the two locations definitely require different facilitation styles.” Facilitators found that youth at Covenant House were significantly more interested in participating and learning throughout the workshop series, resulting in “a smoother and more productive educational experience.” VYVC youth suggested that “at Covenant House, the participants had eaten and slept and have regular access to supportive mentorship.” One VYVC member suggested that “this allows them to be comfortable sitting for longer periods of time and makes them more tolerant of facilitators without street experience.” In comparison, VYVC youth said that “the Directions youth have access to food and mentorship, but are sleeping on the street in wet and cold conditions where they have the stress of having to deal with harassment and immediate health risks. This results in their needing more breaks and a more open, unstructured style of teaching. The Directions youth are far less tolerant of facilitators without street experience.”    76  Impact for Participants This theme refers to the impact of participating in the workshop series on youth participants from the perspective of the VYCV youth instructors. While some VYVC youth stated that “this project, it’s an important step in improving the health of street kids,” others stressed that many determinants of health in addition to health literacy must be addressed in order to effectively improve the health of street-involved youth. One youth stated that “you have to have the services and support so that they can take this knowledge and actually do something with it.” VYVC youth agreed that it is too optimistic to presume that participation in this workshop series alone will have a significant effect on the health or quality of heath of participants. One VYVC youth suggested a more modest outlook on the potential impact of participation on participants.  “I know we’re not going to change the world but what we are doing is maybe changing somewhat how people think about their bodies or how they treat themselves while they’re on drugs. I think we’re doing what we should be doing, I think we can improve upon it and make it better, but for the most part what we’re doing is valuable and I’m happy with it.”  One VYVC member suggests that many street-involved youth have little trust for anyone they can not immediately identify with. This includes adults and authority figures such as health professionals. It was suggested that the YWP helps to promote mutual respect  77 between the youth participants and the health science students and addresses stigma and classism between these populations.  “Most of the time people are speaking down to them and are trying to teach them how to live their lives and like, you know, sometimes it’s not a bad thing, but other times it changes somebody’s state of mind and makes them be less open to learning things. So when you bring them into a situation like this and they get to meet with the UBC  students and, like  nobody’s trying to push things down their throat, it kinda teaches people that people aren’t so bad all the time and you don’t always have to think that there’s an agenda to like push you into some life you don’t want to live.”  Program Structure This theme refers to feedback regarding the structure of the YWP from the perspective of the VYVC youth instructors; specifically, the diverse group of partners who have been involved in the development and implementation of this initiative. One VYVC member stated “what’s special about the workshop is the combination of people that put it on.” They suggest that the collective knowledge and skills of the UBC students and VYVC youth creates a synergistic relationship. One VYVC youth said the “I think the CHIUS people need the VYVC people just as much the VYVC people wouldn’t be able to without the actual, or a single part of it without the CHIUS people.”   78 During the development of the YWP, VYVC members stressed the importance of ensuring long term sustainability for such a program. One VYVC member reports that when developing a working relationship with street-involved youth, “it’s all about consistency, these youth have had everyone in their life give up on them and so they assume you’re gonna do the same. You have to prove to them you’re not going anywhere and that they can trust you.”  Challenges This theme refers to challenges with regard to the development of the YWP from the perspective of the VYCV youth instructors. Maintaining open lines of communication between the health science students and the VYVC youth was identified as a common challenge. One VYVC youth shared that “they [health science students] could be a little bit too hard on us with their opinion sometimes, saying, well, I don’t understand why I can’t get a hold of this person and that person.”  Some VYVC members shared that they felt there needed to be more opportunities for VYVC youth and health science students to get to know each other. One VYVC member stated   “I don’t think there’s enough understanding as there could be about who we are and what we do and what we put on the line to do this work and what they are and what they do and I think there would be a lot more mutual respect.”   79 VYVC youth also stated that at times they felt that their skills and knowledge was not acknowledged or appreciated by the health science students. One VYVC member said:  “I get the picture that maybe some of the CHIUS students don’t understand us, they might think oh we might come in and do this workshop just hanging out with this group of youth and stuff and maybe don’t understand the fact that, you know, we’re not hanging out, these are not our friends, we’re being extremely professional to create that friendliness…. we have the skills to make this friendly seeming environment that makes everything go smooth, and that’s actually a big effort for us to do that.”  Health science students  Health science student recruitment for participation as instructors in the YWP and thus recruitment for the evaluative focus groups occurred during May through August, 2007 and 2008. All students were recruited through the Community Health Initiative by University Students (CHIUS). Data was drawn from both final reports and a focus group with the health science students. Focus Group  A total of three health science students were available to participate in the focus group. One student was male and the other two were female. The average age was 25 years. The  80 focus group was one hour in length. This section is based upon responses to the health science student focus group script (see appendix 2.3).  From the focus group, five themes were identified. These include: 1) reasons for getting involved, 2) VYVC presence, 3) program facilitation, 4) implications for future practice, and 5) challenges. Each theme is described below.  Reasons for Getting Involved This theme refers to primary motivators which led to health science student participation in the development and facilitation of the YWP. The students suggested that they receive insufficient exposure to marginalized populations in the traditional undergraduate medical curriculum. One student reported that “we talked in the first year about marginalized populations but it was nice having an opportunity to work hands on and not just talk about it.” Students suggested that they prefer learning about marginalized populations in a setting in which they can simultaneously provide a service for communities.  One student stated “we are people like to ‘do’ instead of just learn about.” Students were also motivated by the prospect of improving the health of street-involved youth. One participant shared that initially she had planned to “just go out and present it [a workshop] and it will work really well and make a real difference.”     81 VYVC Presence This theme refers to the perceived impact of VYVC participation from the perspective of the health science students. The students expressed appreciation for the role which the VYVC youth play in the facilitation of the workshop series. One student stated “the VYVC youth can communicate with the street-involved youth so you don’t feel like outsiders. They act as a liaison or a bridge for us.” Another said “[without VYVC] you’re there and you’re standing in front of these youth and you don’t know them and then you start asking them to share their mental health problems and its really hard when you don’t have that bridge.”  Program Facilitation This theme refers to the facilitation methods conducive to the needs of street-involved youth from the perspective of the health science students. Students found themselves pushed outside their comfort zones when they came to realize that a lecture based format of instruction was inappropriate when working with street-involved youth. A student stated,  “In school, students are taught lecture based; consequently, when students present, we tend to naturally present in a lecture based style. Working with street- involved youth, we had to change the way we usually present topics and engage the audience by involving them with their street knowledge.”   82 Another student shared having learned that “a lecture based format is perceived as a sign of disrespect [by the street-involved youth]. It presumes that we know more than the participants do regarding these topics which is often not the case.” All students agreed that street-involved youth were more effectively engaged when a discussion based approach was utilized. One student reports,   “We are trying to facilitate a discussion in which the youth are the primary participants and thereby the primary beneficiaries. In one of our first workshops we tried the educator approach and essentially regurgitated acquired knowledge, the youth were not very receptive to this approach and we had to switch gears and try to make our discussions more open ended so that the youth felt they were ‘in charge.’”  Students found that the most successful workshops were dominated by street-involved youth sharing health related information with each other. One student stated:  “It’s amazing to see how much the workshop participants have experienced and how they can encourage each other. As workshop leaders, we give information about where detox centres are but in the end, it seems like the time the workshop participants spend talking about detox together and the tips that they give each other probably help more than anything else.”    83 Implications for Future Practice This theme refers to the impact which participation in the YWP may have had on the future practice of participating health science students. Students agreed that participation in the YWP had provided them with valuable knowledge with application to the medical care of street-involved youth. One CHIUS student reported that “I could now feel more comfortable if I was to work at a clinic in the Downtown Eastside.” One student stated “I think that I have learned a lot in terms of how to approach these youth as patients in your office….I found there were lots of things that surprised me that they didn’t know, or they didn’t understand.”  Other students agreed that participation in the program was a reminder of the importance of not making assumptions about patients and their needs.   “One of the most valuable things I’ve learned from working with the street- involved youth that I will take wherever I go in my career is to avoid stereotyping people or judging people, I need to treat everyone with respect. When I make a point of treating the people I meet with respect, taking the time to ask about them and listening to the answers, I find that I am less likely to make assumptions about them which may be false.”  “Often times what you think they need is often different from what they believe they need.”  84  “I think that I have become more tolerant. I think it’s inevitable, that it’s harder to pass judgment on things that you have had exposure to.”  Participation in this project has allowed health science students to make more informed decisions regarding their capacity and interest in a career path associated with the care of marginalized populations. Several health science students have expressed interest inn pursuing careers which would allow them to provide primary care for street-involved youth. One students shared:  ‘It wasn’t a career goal I was even considering before but I feel like this project has really opened me up to different ideas and possibilities and even like different kinds of family practice. You can deal with these kinds of populations and that’s really exciting. It has definitely changed a lot of my ideas about certain ways of doing medicine.”  Another student expressed a common concern with regard to the care of marginalized populations.  “I don’t know if I would want to work in this community full time because it’s really easy to get burnt out and it is frustrating but I would really love to be able to incorporate working in the community as part of whatever else I’m doing.”   85 Challenges This theme refers to challenges with regard to the development and facilitation of the YWP from the perspective of participating health science students. Many of the health science students found that the lack of stability in the lives of VYVC youth made working with them frustrating at times. One student shared that “a lot of the time they [VYVC Youth] would say I can do this or I can do that and inevitably they would come back and have done none of it, which was a bit frustrating.” Another student added that “many of the VYVC youth don’t feel, or don’t have the opportunity perhaps, the desire perhaps to put in time outside of the meetings. And so that became a bit of a challenge.”  Students also found themselves frustrated at times with how little information they were able to convey during a workshop. One student stated:  “Maybe my original ideas were a little too idealistic: we would be interacting with these youth and putting on these great workshops. We were going to just go out and present it and it will work really well and make a real difference. And then you come in and it is mild chaos.”  Health Science Student Final Reports  Participating health science students were required to complete a multidisciplinary course entitled Doctor, Patient and Society (DPAS). This course examines critical issues in health care. Problem-based tutorials address the patient-doctor relationship, health care  86 systems, research, epidemiology, prevention, ethics, behavioural and social sciences, resource allocation, multiculturalism, and marginalized populations. Rather than attend a weekly lecture, students enrolled in the YWP elected to complete the Community Service Learning Option (CSLO). In partial fulfillment of their CSLO, participating health science students are required to keep a weekly journal regarding their CSLO experience. At the end of the year, students complete a final report in which they reflect upon their journal entries from throughout the year. During the 2008-2009 academic year, 13 health science students participated in the YWP in partial fulfillment of their DPAS course requirements. Data was extracted from these reports from which four key themes were identified. They are as follows: 1) street-involved youth perceptions of the health care system, 2) perceptions of street-involved youth, 3) working in the street-involved youth culture, 4) implications for future practice.  Street-involved youth Perceptions of the Health Care System Students found that there are two significant barriers to improving access to health care in the street-involved youth population: trust and judgment. One student recalled a YWP participant stating “If you are ever given a diagnosis of mental illness and then have a baby, the doctors will take the baby away from you.” A student noted that for this YWP participant to make the generalization to all people with mental illness shows a clear distrust in the health care system.  Other similar attitudes prevailed in other workshops – one youth said he “trusts his drug dealer over any pharmacist.” It becomes clear that street-involved youth simply do not trust doctors to take care of them. One youth was  87 quoted saying “I do not go back to doctors because who is he to sit there and judge me?” Students came to realize that while judgement is a necessary component of being a physician, it can also be a detriment.  They learned that in order to work with the street- involved youth it was important to make sure they did not pass judgment on how the youth led their lives.  Perceptions of Street-involved Youth Health science students joined the YWP with many preconceived notions regarding what street-involved youth would be like. While the students were not surprised to find the youth to be heavy users of drugs and alcohol, lacking in basic hygienic, and having a negative attitude towards the health care system, they were surprised to find that the youth accepted them. They found the youth to generally be very pleasant to be around, polite and respectful.    Furthermore, having worried about low literacy, the students were generally impressed with the level of education of the youth.  The youth surpassed the expectations of health science students by engaging in significant discussion and asking interesting questions.  Working within the Street-involved youth Culture The health science students have come to understand how diverse the street-involved youth population is. “They come from different cities. They’re in different stages of recovery. Some have just started living on the streets while others have been on the streets for years. Some are incredibly open and some are shy.” The students also became  88 more aware of the lack of stability in the lives of street-involved youth. They learned that street-involved youth rarely have watches or an appointment book, so keeping a doctors appointment or complying to orders is nearly impossible.  Students came to realize that if they want to really improve street-involved youth access to health care, they will need to devise methods to work with youth instead of trying to get the youth to conform to the current health care system.  Furthermore, students recognized the need to take a harm reduction oriented approach to the street-involved youth lifestyle. “I want to convey to them that although I cannot condone the use of illicit drugs, I am there to support them through the physical, mental and health challenges associated with it. By being open and non judgmental, it is my hope that they will learn to trust me and not be afraid to come to me for medical attention.”  Some students found that due to their natural tendencies to lead, they frequently found themselves leading the workshops while the VYVC youth took a back seat to the facilitation process. They recognized that continuing to take on this responsibility would be a detriment to a major YWP objectives: the empowerment of VYVC. While some students found that the VYVC youth were superior facilitators, others thought that the health science students were often more effective. One student wrote that “students were able to establish rapport equally well if not better than the VYVC youth at times. I think as students, we were very conscious of what and how we said things. And rather, the VYVC at times were abrupt with the youth and turned them away from the discussion rather than promote interaction.” All students found themselves redefining the role of an effective communicator and leader following participation in the YWP. One student  89 shared a realization that “you need to talk to them [street-involved youth] at their level, not lecture them on complicated material as a health science student, and to try and do it so they see you as an equal, not someone who is “dumbing it down” to them.”  One student stated that, “being a part of this project was a reminder that not everyone I come in contact with will be a health science student.” Interacting with street-involved youth in a casual environment and learning about their unique experiences reminded students not to make assumptions about the lifestyles / characters / personalities they encounter in the examining room.  Students lament that due to time constraints, they do not have opportunities to interact with street-involved youth in such a manner in the family practice offices where their primary objective is to “efficiently sum up the patient in a few sentences.” Students recognized that they have to treat each patient as an individual and get to know them as a person in order to establish a trusting relationship.  Implications for Future Practice Some students found that work with street-involved youth was a niche they were interested in pursuing in their future careers. Many others shared that they feared burn- out from full time work with marginalized populations but expressed interest in continuing to work with this population.     90 Chapter Six: Discussion  The problem of youth street involvement is clearly a multilayered problem requiring a multitude of services. In order to effectively reduce rates of youth homelessness we must continue to support services which help prevent at risk youth from needing to leave home as well as services for those who have fallen through the cracks. In addition to shelter, clothing and food, we must ensure that harm reduction oriented, health promotion programming such as the YWP are available to these youth.  The following chapter examines the impact of the YWP on each of the respective partners as well as the impact that each of the YWP partners had on the YWP.  Reasons for participating, the YWP facilitation methodology, and challenges are also discussed.  We draw upon data from the focus groups and final reports as well as observational data. During analysis, we found many common themes begin to emerge between participating partners, that is, between the youth participants, the VYVC members and the health science students. Thus, we discuss components and outcomes of the YWP from the perspective of all partners. Both similarities and differences in perspective and opinions between partners are discussed.   Reasons for Participating Both the VYVC members and health science students suggested that helping street- involved youth in their community was a primary motivator for becoming involved in the  91 YWP. The VYVC youth reported being motivated by the prospect of “supporting the youth” while health science students reported being initially motivated by the prospect of “making a real difference.” This choice of language suggests that the VYVC youth believe that the only individual who can change the health related behaviour of street- involved youth are the youth themselves. They recognize that health literacy knowledge, while important, is not always the deciding factor in the health related behaviour of street-involved youth. Conversely health science students suggest they were initially motivated by the prospect of improving the health or quality of life of street-involved youth. As health science students gained experience providing health promotion for street-involved youth, however, their expectations regarding the impact of the program were adjusted and their motivation to continue participating reportedly changed. Students identified other motivators for participation in the YWP as follows: 1) they found the concept of youth peer to peer education inspiring, 2) they recognized it as a valuable opportunity to learn more about the challenges that street-youth face, and 3) it allowed them to develop communication skills with youth.  The literature clearly demonstrates that the needs of street-involved youth for money often supersede their desire to live healthy and safe lives. While most participants report initially being motivated by the YWP honoraria, they report having later found themselves enjoying the workshops. Many youth are able to make significantly more than the YWP honoraria over a weekend through a variety of street life related activities. As such, we presume that the youth’s continued participation in the YWP indicates a motivation beyond monetary gain.  92  Program Facilitation The YWP is designed not only to equip street-involved youth with the necessary knowledge to identify the signs and symptoms of illness or drug addiction but also to create an environment in which the students and street-involved youth could share their collective knowledge and discuss issues such as these and their solutions openly. To Brazilian educator, Paulo Freire, the health educator’s role is to contribute information after the group raises its themes for mutual reflection (Roberts, 2000). Rather than impose their own cultural values, educators should enter into “authentic dialogue” so people emerge from their cultural silence and self-blame to redefine their own social reality (Wallerstein & Bernstein, 1988). We have found that educational programs targeting street-involved youth are most effective if the principles of adult education are embraced. In adult or popular education, the student is seen as an equal participant (Merriam and Caffarella, 1991). This interactive methodology encourages the teacher to act as an enabling guide rather than giver or knowledge.  During initial workshops, the YWP curriculum was relatively dense with information and employed a somewhat lecture based format of instruction. We found that the street- involved youth were more effectively engaged and the potential for learning and psychosocial development was enhanced when an interactive discussion based format was employed. Similarly, a United Nations Youth Peer Education Toolkit found evidence suggesting that peers 1) are often trusted more than non-peer informants, 2) are better  93 able to address issues related to sexuality than are non-peers, 3) often have an effect on knowledge, attitudes, norms, motivation, and behaviour, 4) are able to access marginalized or vulnerable groups, and 5) can spur community mobilization (Adamchak, 2006). The VYVC members, street-involved youth participants and the health science students all recognized the value of a discussion based methodology during focus groups. Interestingly, it was only the street-involved youth participants who shared that lecture based components are also important in health promotion with street-involved youth.  When VYVC members played a more prominent facilitative role than CHIUS students, we found that while less curriculum was covered, participants appeared to be more effectively engaged. Accordingly, when CHIUS students took on a more prominent role, more curriculum was covered, but participants appeared less engaged in the workshops and thus presumably took in less information.   Impact of Collaborators on the YWP The YWP demonstrates how marginalized youth can make remarkable contributions to advocacy as well as research and educational initiatives when provided with opportunities to take on roles of active citizenship. The youth bring inherent abilities, energy, and new perspectives to health promotion initiatives. Furthermore, the involvement of VYVC has enhanced the support of the street-involved youth community and community based organizations and improved the perceived credibility of this  94 initiative. This project has facilitated collaboration between UBC and Vancouver’s street- involved youth community and strengthens volunteerism within the UBC student body.  Like the involvement of VYVC, partnership with health science students is thought to increase the legitimacy of the YWP. It is unclear whether their involvement increases credibility in the community, however, among funding bodies and the academic community, the presence of health science students is thought to be integral to ongoing support for this initiative. Health science students are able to address the more technical questions which workshop participants may have. They are also able to correct false information which is commonly shared among street-involved youth during discussion periods. In addition, they help to ensure that youth are held accountable to participate and the workshop series is sufficiently structured.   Impact of YWP on Collaborators Results from our study strongly suggest that street-involved youth mistrust authority figures such as health care providers and this presents a major barrier to accessing appropriate health care. For some youth, their history of troubled relationships with authority figures contributes to a stance of defiance and control over how, when, and from whom they will accept help. This can be problematic when youth are unable to reach out to case managers, primary health care providers, or mental health professionals (Hudson, Nyamathi & Sweat, 2008). The YWP is thought to break down significant  95 barriers to health among street-involved youth such as fear of visiting a health care centre and a lack of knowledge regarding available health care services.  VYVC members who participated in this project reportedly gained many valuable skills throughout the development, facilitation, and evaluation of the YWP. In addition to improving their health related knowledge, the VYVC members gained valuable public speaking, workshop development and presentation skills. The YWP has been a valuable source of income for VYVC members.  The VYVC youth demonstrate improved self- esteem, leadership, and life skills following participation in this program. This program has helped to develop among VYVC a sense of purpose, accomplishment, and pride. Providing youth with opportunities to develop tangible skills, make management decisions and contribute to their community instils a sense of social responsibility among these individuals, builds capacity and establishes credibility for them both as individuals and collectively as VYVC in the community.  Several VYVC members have given a series of talks to UBC’s first year medical class regarding the YWP and life on the streets of Vancouver. They have developed a reputation as conduits between the UBC and the homeless youth of Vancouver. Some street-involved youth have reportedly fostered very valuable connections and found allies among the CHIUS community.  In the medical field, service learning has emerged as an effective method by which universities can respond to the needs of marginalized populations. Rather than an effort  96 based upon personal values, service learning has become a core value of the health profession (Goldstein et al., 2005). The YWP provides health science students and street- involved youth alike with an opportunity for active engagement rather than passive learning. This provides them with a sense of personal accomplishment and self esteem.  For health science students, learning in the community affords them the ability to develop valuable skills which may be unattainable in more academic or clinical environments. Beyond serving as an act of charity, the YWP allows students to think critically about the complex health needs of street-involved youth and how those needs can be most effectively addressed. This project has provided participating health science students with exposure to the street-involved youth community, allowing them to make a more informed decision regarding their capacity and interest in a career path associated with the care of marginalized populations. It has additionally allowed health science students to build relationships with, and develop valuable skills required for effectively working with street-involved youth. For example, health science students learnt to translate and simplify their language such that their message would be clear and well received by street-involved youth. Students report that they will be better prepared to provide care to street-involved youth in their future careers as health professionals having participated in this program.     97 Challenges Peer education programs face unique challenges and require specific strategies to avoid common pitfalls and ensure effectiveness and efficiency (Adamchak, 2006). The development, facilitation and evaluation of the YWP has not been without a significant number of challenges for all parties involved. These included intra-personal, interpersonal, organizational and structural challenges. Overcoming these barriers has been a valuable leaning experience for students, VYVC members, street-involved youth and management alike.  Health science students are accustomed to a great deal of structure in their day-to-day lives which clashes starkly with the relatively unstructured world of street-involved youth. As such, when the VYVC youth were responsible for taking on leadership roles, whether it was in planning meetings of workshop facilitation, health science students found the lack of structure to be frustrating at times. Future health science students participating in the project will be encouraged to learn the skills of flexibility and commitment in order to build more positive relationships with the VYVC youth.  In most peer education programs, the peer educators are paid, however, the participants are not. The YWP is built around the concept of peer education and it is presumed that this would further differentiate the peer educator from their social group, possibly changing the dynamics of their relationship with the youth participants. In order to address this concern, both the peer educators and the participants are paid equally for  98 their time during the workshops. The YWP policy of providing both youth instructors and youth participants with honoraria has proven to be controversial. Some individuals have expressed concerns that youth may seek to become peer educators or workshop participants solely for monetary gain and not be motivated by a desire to support their community or learn about their health. Others fear that the funds will be used to support drug or alcohol habits.  Compensating our peer educators has also allowed us to maintain a low rate of VYVC youth turnover, which we believe to be essential for effective functioning of a program such as the YWP. By providing compensation, we are recognizing the value of their time and providing them with a valuable means of income. Furthermore, if the youth consider their peer educator position to be a job, they become more dependable and are willing to take on increasing responsibility.  Over the course of the year, disagreements arose regarding what type of street-involved youth should be targeted by the YWP. The general consensus from CHIUS members was that the youth at Covenant House were at a stage in their lives at which they could benefit most from this particular health literacy education initiative. VYVC youth, however, stressed that the higher risk youth at Directions are “perhaps in even greater need of actively engaging in programs such as the YWP.” It was agreed that all street-involved youth deserve equal opportunity to engage in this program. As such, the workshop series currently alternates between Directions and Covenant House.   99 Through regular meetings, ongoing dialogue and the commitment of all YWP partners, these challenges have been openly discussed and effectively addressed.  Conducting Participatory Evaluation with Street-Involved Youth The YWP evaluation has been a valuable opportunity to apply knowledge that benefits both sides of the partnership. This project has reportedly been a valuable learning opportunity for participating CHIUS students and has allowed the PCHR team to explore the successes and challenges of developing and facilitating participatory research with street-involved youth.  People from economically disadvantaged and marginalized communities typically perceive university researchers to be people who only wish to study them and provide no service to the community (Harper & Carver, 1999). We have found that using a collaborative health promotion model, such as that utilized by the YWP, we can help facilitate the break down of barriers to health among marginalized populations. Placing the research in the context of a clear advocacy initiative allows research participants to immediately see the potential value of this research.  Placing research in the context of a community based health promotion initiative and ensuring that participants see their peers as guiding the research project increases “buy in” among participants.  The YWP evaluation has been a valuable opportunity to apply knowledge that benefits both sides of the partnership. During the initial stages of development of the evaluation  100 instrument, the team took their time to generate a set of research questions which addressed the interests of all parties. While our street-involved youth partners were primarily interested in evaluating and improving the YWP workshop series, PCHR learners were able to use the data to explore the determinants of health risk behaviour among the YWP participants. It is hoped that this experience will empower and improve qualitative research abilities among street-involved youth partners, provide PCHR learners with participatory research experience with street-involved youth, and improve the efficacy of the YWP.  While conventional research tends to employ external experts, PE strives to engage community members as project staff in leadership roles throughout the research process. Nonetheless, academics are often the ones who decide who the PE partners will be early in the research process. The YWP is innovative in that it was initiated by one university student and one community representative who collaboratively selected academic and community partners. As the program developed and the number of partners grew, the group responsible for selecting participants became increasingly representative of the street-involved youth community. By ensuring that community members play a key role in selecting community representatives, we are able to capitalize on their intrinsic capacity to define their community. In CBPR, all parties participate and share control over all phases of the research process, including problem definition, data collection, interpretation of results, and the application of the results to address community concerns (Lantz et al., 2005). These partnerships focus on issues and concerns identified by community members and create processes that enable all parties to participate and share  101 influence in the research. In attempts to distribute power equally, there is an emphasis on creating an empowering process that includes sharing information, decision making power, resources and support among members of partnership (Lantz et al., 2005). For example, researchers can learn from community members theories, understandings commonly held about their community and place their research in the broader social context.  When conducting PE we must be cognizant of who community representatives in the PE are and how they compare to members of the actual community (Minkler & Wallerstein, 2003). Through prior relationships established during the development of the YWP, we were able to identify key community experts and representatives with whom to partner. Steuart (1993) recognizes that even within marginalized communities, not all members are going to be impoverished or have little formal education. It is often those with more formal education and income who are best suited to participate in CBPR efforts, while having the inside view of what it is like to live in that community (Steuart, 1993). During the YWP PE, those youth who did not have stable enough lives to attend meetings on a regular basis naturally self selected out of the program. We found that developing a sufficient relationship with community partners requires a sustained, long term commitment.  In fact, identifying a small group of appropriate and committed community partners took over a year, but once a strong relationship with these individuals had been achieved, it became easier to develop more meaningful partnerships with other organizations.  This approach to research is consistent with the values of CBPR because of it attempts to acknowledge issues of trust, power and dialogue.  102 We recognize that while our street-involved youth representatives all report a history of homelessness, none of those who demonstrate a sustained commitment, remaining involved in the project, self identify as currently being homeless. Collectively, we agree that we are more successful carrying out our evaluation if we engage a more dependable but less representative group of youth as opposed to engaging a less dependable but more representative group. We conclude that in PE, the research team should strive to collaborate with community members who collectively are as representative of the community as possible, while taking into consideration individual capacity, interest and life stability. Once the research team has been selected, one must determine how to most effectively draw upon the diverse abilities and interests that exist within the research team. Academics may play the role of initiator, consultant or collaborator in a project, depending upon the situation and preferences of the community (Stoeker, 2003). While one should strive to ensure some level of participation by both community and academic partners in all aspects of the research process, we found it ineffective and unnecessary to demand equal participation, given the varying technical knowledge, community connections and levels of commitment of partners.  While conventional research utilizes predetermined indicators of success, in PE, the community identifies their own indicators (Lantz et al., 2005). Complications may arise when those indicators identified as priorities by the community, are merged with those identified by academic partners. Community partners tend to be more interested in addressing specific, tangible issues that are more amenable to change than trying to address broad scale policies associated with cultural determinants of health (Minkler &  103 Wallerstein, 2003). During evaluation of the YWP, community members were primarily interested in utilizing PE to inform further development of the health promotion program. Academics were also interested in the production of knowledge from which action could be taken to improve health and/or to reduce health status disparities, but also interested in exploring the cultural determinants of street-involved youth in order to contribute to the academic literature. The research team collectively developed a focus group script which addresses the priorities of both the academics and community representatives, meeting the needs of all involved.  In addition to issues in selecting indicators of success, PE may introduce considerable disagreement over the methodology used, as well as disagreements over the manner in which results are disseminated (Minkler & Wallerstein, 2003). Community expertise can provide very useful direction regarding data collection strategies, operationalization of variables, and measurement approaches (Lantz et al., 1995).While individual indicators may be of more interest to one partner, the value of the project as a whole needs to be apparent to all stakeholders. PCHR learners expressed concerns that the youth would not recognize the potential value of investing significant time and resources into program evaluation. Rather, they might see the PCHR learners as being more interested in “studying street-involved youth” and “evaluating the participatory research process” than improving the educational quality of the YWP and thus improving the health of street- involved youth.   104 The YWP presented challenges with regard to the equitable distribution of resources. A true participatory approach fairly compensates community partners and organizations for their time, contributions and expenses (Lantz et al., 2005). In this case, however, significant discrepancies between PCHR learners and street-involved youth were noted. Through equal participation in developing the project budget, we were able to prevent discrepancies in financial compensation for becoming a barrier to successfully conducting our PE. Furthermore, we found it useful to set mutual expectations to ensure financial accountability. The youth acknowledged that this activity caused them to become increasingly invested in the evaluation process.  It is important to invest a significant amount of time at the onset of a PE to ensure that a relationship exists which allows decisions to be made as collectively as possible, involving as many stakeholders as possible (Minkler & Wallerstein, 2003). Furthermore, it is important to ensure that all partners are involved throughout the research process without overburdening them, and while maintaining trust and open lines of communication (Johnson & Johnson, 2003). All partners should develop the skills and the willingness to address conflicts that may arise (Nyden & Wiewel, 1992). Ensuring that equal weight is given to all partners in the decision making processes can be challenging. It is important to remain conscious of the power imbalance that may exist between academics and community representatives and thus the importance of maintaining respect and trust between academics, community members and community based organizations (CBO) throughout the research process. During the YWP evaluation, the research team identified low self esteem and a lack of leadership experience among  105 street-involved youth as significant threats to the participatory nature of the research process. These factors may have caused some street-involved youth to side with their academic partners despite harbouring differing viewpoints. Aware of this threat, academic partners have found themselves withdrawing too extensively from some aspects of the research in an effort to keep from dominating the decision making process. The level of involvement exercised by academics must be carefully considered in order to ensure that the PE is not being driven by academics while ensuring that the technical expertise which academics bring to the table is capitalized upon.  While conventional research distances the evaluator and participants, PE utilizes simple methods which are adapted to the local culture (Minkler & Wallerstein, 2003). For example, we found that survey distribution is a very ineffective method of data collection among street-involved youth. During evaluation, the quality and quantity of feedback was significantly higher when focus groups were conducted by our youth partners. Furthermore, we found that in PE, it is important to establish a language that is mutually understandable for all stakeholders involved. During the YWP evaluation, the vocabulary of academics was infused with “street slang,” while community representatives learned qualitative research terminology allowing for more effective communication. Therefore, we found that PE meetings were most successful when conducted in a manner respectful to the language of all partners while remaining conducive to the research process.  While conventional research is generally done to ensure the accountability of a program, PE is intended to empower local people to initiate, control and take corrective action.  106 Perhaps due to the regularity of conventional research, which has been unsuccessful in improving health or wellbeing of street-involved youth, many youth resist participation in research.  We have found that street-involved youth bring inherent abilities, energy, and new perspectives to health promotion program evaluation. The enthusiasm among YWP participants is thought to stem from a broader commitment to the reduction of health disparities, specifically among the street-involved youth whose everyday lives continue to be infused with experiences of social exclusion and marginalization. By structuring the research-community relationship within PCHR, learners have been successful in instituting a sustained commitment to youth. Providing youth with opportunities to develop tangible skills, make management decisions and contribute to their community clearly instils a collective sense of social responsibility, builds capacity and establishes credibility. While our street-involved youth partners gain knowledge and experience in the basic principles of qualitative research, PCHR learners gain “real-world experience” conducting participatory research with street-involved youth.  We have found that when the time is taken for community members to take on legitimate roles of equal partnership, a sense of ownership develops which may further enhance community participation and cultivate community trust. A literature review conducted by Viswanathan, Ammerman, Eng, Gartlehner, & Lohr (2004) found that in 11 of 12 intervention studies which were reviewed, evidence demonstrated enhanced research quality in studies which utilized CBPR. Most studies also reported increased research  107 capacity among both community and academic partners. This suggests that PE is indeed an effective approach in program evaluation.  Although there has reportedly been an increased interest in the concept of community- based research, there has not been a lot of research conducted and disseminated on how this type of research occurs in practice in peer-reviewed journals (Buysse, Sparkman, & Wesley, 2003).  The challenge for researchers is to shift the focus from knowledge as residing within the experts to knowledge as residing within the practice community (Lave & Wenger, 1991).  One of the main approaches central to CBPR is an attempt to blur the lines between the researcher and the researched.  Furthermore, it is noted that CBPR also aims to strengthen people’s awareness and their own capabilities as researchers and as agents of change (Minkler & Wallerstein, 2003).  In fact, as Green and Mercer (2001) suggest, CBPR should effect a change in balance of power in a way that the research subjects become more than research objects. For example, the research subjects give more than informed consent, but rather they give to many other aspects of the research process.  The YWP invited the VYVC participants to co-construct the workshop modules and also co-deliver the workshops. In this sense the project embodied the fundamental characteristics of a CBPR project by engaging community members and researchers in a joint process where they both contributed equally. The YWP’s biggest strength was that the VYVC participants were able to co-construct the project, using their own world view and thereby co-construct meaning.  108  The YWP illustrates how a respectful and synergistic relationship between academics and community-based participants can ultimately transform the lives of community members. The YWP is an example of how street-involved youth can simultaneously gain a capacity to stand back from their world and transform their reality.                   109 Chapter Seven: Limitations and Conclusions  Limitations  Rigorous evaluation is often hampered by the informal structure of peer education programs, making the task of identifying program strength and outputs more challenging (Adamchak, 2006). Without concrete data demonstrating the effectiveness of these programs, it remains difficult to ensure the sustainability of the YWP.  Based on our results, we can not conclude that participation in the YWP will have a significant impact on the health or quality of life of participants. Similarly, without longitudinal data, we can not infer that health science student participation in the YWP will influence their future practice. Nonetheless, satisfaction and corroborating evidence do support this opinion.  The convenience sampling as well as the small sample size utilized in this study significantly influences the generalizability of results. Youth were enrolled in the program and thus eligible for participation in the study if they were attending one of the drop-in centres or shelters at which the YWP operates. Youth who more recently became street-involved may be less aware of available services and thus may have been unavailable to participate. Additionally, while the YWP was exempt from age limits imposed at community centres, sampling may have been squewed towards the younger youth who would have been more accessible for recruitment by the staff.  110 Critics argue that having youth leaders participate in focus groups which evaluate the very program they have just facilitated introduces a potentially significant source of self interest bias. We argue, however, that the youth are clearly dedicated to producing the best possible quality research, as demonstrated by meticulously prepared transcripts, and appear open to constructive criticism.  In addition, participants may be less likely to bias their responses if speaking to a peer rather than an academic who may be perceived as an authority figure. Furthermore, our youth leaders’ intrinsic capacity to identify indicators of success are likely to improve the quality of the research.  Conclusions  We have found that collaboration between university-based organizations such as CHIUS and community-based organizations such as VYVC is an effective method by which health literacy education programs for street-involved youth and perhaps other marginalized populations can be developed and facilitated. Furthermore, engaging the community throughout the evaluation process, from the initial stages of planning to dissemination, helps to keep research grounded and applicable to the population of interest. If we see street-involved youth as having something to offer rather than as empty vessels needing to be filled and helped, we must intentionally build programs that translate this belief system into action (Sauvé, 2003). If we want to really improve street- involved youth access to health care then we need to devise methods to work with them instead of trying to get them to work with us.   111 We have found that street-involved youth are more effectively engaged in health literacy education when an interactive, discussion-based approach is employed. Rather than send youth the message that they have little to offer and should come to our workshops only to receive and learn, workshops should be designed to facilitate mutual sharing of health related information between participants.  Furthermore, these youth learn most effectively from individuals they identify with as their peers. While peers are meant to be similar in basic characteristics to those in their target audience, we have found it advantageous to collaborate with youth who are slightly older and have relatively more stability in their lives. These practices should thus be embedded within the framework of health promotion programs targeting street-involved youth.  With regard to participatory evaluation with street-involved youth, steps must be taken to ensure that 1) the youth are treated as experts in their own right rather than “subjects,” 2) their unique set of skills and knowledge is both recognized and utilized, 3) the youth become invested in the quality of the evaluation and 4) trust between the academics and youth is developed and maintained (Poland, 1996).  A number of questions arose over the course of the YWP evaluation which could not be answered in this study, but open the doors to future research. Limited research exists in the area of health promotion program development facilitation and evaluation with street- involved youth. Without concrete data demonstrating the effectiveness of these programs, it remains difficult to ensure the sustainability of these programs. Future research could strive to establish whether participation in the YWP had a significant impact on health  112 related behaviour or associated markers such as intention, attitude and knowledge change. Future research could additionally investigate the impact which YWP participation has on health science students. A longitudinal study could determine whether an association exists between participation in the YWP and later career work with inner city populations or marginalized youth. There is also a need for ongoing evaluation to ensure that the curriculum and methodology utilized by the YWP continues to be culturally appropriate and valuable for street-involved youth participants.                 113 References Adamchak, S. E. (2006). Youth peer education in reproductive health and HIV/AIDS: Progress, process and programming for the future. Youth Issues paper 7. Washington, DC: Family Health International.  Brennan, T., Huizinga, D., & Elliott, D. S. (1978). 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R. (2003). Critical issues in developing and following community based participatory principles. In M. Minkler and N. Wallerstein (Eds.), Community-based participatory research for health (pp. 53-76). San Francisco, CA: Jossey Bass/Wiley  Johnson, D.W., & Johnson, F..P. (2003). Joining Together: Group Theory and Group Skills (8th ed.). Boston, MA: Allyn and Bacon.  Kaufman, J.G., & Widom, C.S. (1999). Childhood victimization, running away, and delinquency. Journal of Research in Crime and Delinquency, 36, 347-370.  Kirby, S., & Greaves, L., & Reid, C. (2006). Experience, Research, Social Change: Methods Beyond the Mainstream. Peterborough, ON: Broadview Press.  Lantz, P.M., Israel, B.A., Schulz, A.J., & Reyes, A. (2005). Community-Based Participatory Research: Rationale and Relevance for Social Epidemiology. Methods for Social Epidemiology. San Francisco, CA.: Jossey-Bass Press.  Lave, J. & Wenger (1991). Situated learning: Legitimate peripheral participation. NewYork: Cambridge University Press.  Macaulay, A., Gibson, N., Commanda, L., McCabe, M., Robbins, C., Twohig, P. (1998). Responsible research with communities: participatory research in primary care. http://views.vcu.edu/views/fap/napcrg.html. North American Primary Care Research Group.   115 Martin, S., Smith, S., Podmore, S., Peled, M., Simon, S. & the McCreary Centre Society. (2008). Improving the Odds: Next Steps Workshops with Marginalized and Street- Involved Youth in BC. Vancouver, B.C.: McCreary Centre Society.  Merriam, S. and Caffarella, S.R. (1991) Learning in Adulthood. A comprehensive guide, San Francisco: Jossey-Bass.  McCarthy, B. (1995). On the Streets: Youth in Vancouver. Victoria: Ministry of Social Services, Province of British Columbia.  McDuff, M.D. (2001). Building the Capacity of Grassroots Conservation Organizations to Conduct Participatory Evaluation. Environmental Management. 27, 715–727.  McFaden, L., and Fletcher, M. (2002). From Our Side of the Street: Vancouver Street Youth Discuss Health Needs, Health Care Accessibility, and Medical Clinic Experiences.  McTaggart, R. (1991). Principles for participatory action research. Adult Education Quarterly, 41, 168-87.  Minkler, M. & Wallerstein, N. (2003).  Community based participatory research for Health. San Francisco: Jossey-Bass.  Mullings, L.,,Wali, A., McLean, D., Mitchell, J,. Prince, S., Thomas, D., Tovar, P. (2001) Qualitative methodologies and community participation in examining reproductive experiences: the Harlem Birth Right Project. Maternal & Child Health Journal. 5(2):85- 93.  Nutbeam, D. (2000). Health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int, 15, 259-67.  Nyden, P.W. & Wiewel, W. (1992) Collaborative research: Harnessing the tensions between researcher and practitioner. American Sociologist, 24(4): 43-55.  Poland, D.P. (1996). Knowledge development and evaluation in, of and for Healthy Community initiatives. Part II: potential content foci. Health Promo Int, 11(4): 341-9.  Public Health Agency of Canada. (2006). Street-involved youth in Canada: Findings from Enhanced Surveillance of Canadian Street-involved youth. Ottawa.  Roberts, P. (2000), Education, Literacy, and Humanization Exploring the Work of Paulo Freire, Westport, Connecticut: Bergin & Garvey.   116 Rootman, I., & Ronson, B. (2005). Literacy and health research in Canada: Where have we been and where should we go? Canadian Journal of Public Health, 96(Suppl. 2), S62-77.  Roesler, A.L. (2000). Overcoming the Streets: An Exploration of the Unique Wisdom of Youths. Masters dissertation, San Jose State University, August, 2000.  Sauvé, S. (2003). Changing Paradigms for Working with Street-involved youth: The Experience of Street Kids International. Children, Youth and Environments, 13(1).  Saewyc, E., Bingham, B., Brunanski, D., Smith, A., Hunt, S., Northcott, M., & the McCreary Centre Society. (2008). Moving Upstream: Aboriginal Marginalized and Street-Involved Youth in B.C. Vancouver, B.C.: McCreary Centre Society.  Slesnick, N., Bartle-Haring, S., Glebova, T., & Glade, A.C. (2006). Homeless Adolescent Parents: HIV Risk, Family Structure and Individual Problem Behaviors. Department of Human Development and Family Science, The Ohio State University, Columbus, Ohio.  Smith, A., Peled, M., Albert, M., MacKay, L., Stewart, D, Saewyc, E., & the McCreary Centre Society. (2007). Making the Grade: A Review of Alternative Education Programs in British Columbia. Vancouver, BC: McCreary Centre Society.  Steuart, G.W. (1993) Social and cultural perspectives: Community intervention and mental health. Health Education Quarterly, 20 (Supplement 1).  Stoeker, R. (2003) Are academics irrelevant? Approaches and roles for scholars in community based participatory research. Community-Based Participatory Research for Health. San Francisco, CA: Jossey-Bass.  Taubes, G. (1995) Epidemiology faces its limits. Science, 269:164-9. Taylor-Seehafer, M.A. (2004). Positive youth development: Reducing the health risks of homeless youth. The American Journal of Maternal Child Nursing, 29, 36-40.  Timco, K.L. (2007). Not Everyone Who Wanders is Lost: Exploring Street Youths’ Decision Making Processes in Relation to the Problematic Use of Substances and its Possible Solutions. Masters dissertation, Carleton University, July 27, 2007.  Training of Trainers Manual. Youth Peer Education Toolkit. (2005). Family Health International. Arlington, VA, 15-18.  UNICEF. (1984). Latin American seminar on community alternatives for street children. Brasilia, Brazil. November 12–15..  Viswanathan, M., Ammerman, A., Eng, E., Gartlehner, G., Lohr, K.N. (2004). Community-Based Participatory Research: Assessing the Evidence. Evidence  117 Report/Technology Assessment No. 99. Rockville, MD: Agency for Healthcare Research and Quality.  Wallerstein, N. & Bernstein, E. (1988). Empowerment Education: Freire’s Ideas Adapted to Health Education. Health Education Quarterly, 15(4).                          118 Appendix Appendix One: Workshop Summaries  Reproductive Health  The pregnancy workshop begins with a candid discussion about why it is important to know about pregnancy with a focus on why male participants need to know about pregnancy and what they can do to help their female peers. The formal talk starts with a summary of birth control methods. We focus on various options and discuss why some are better than others in terms of efficacy, availability, and convenience. The discussion continues with sexually transmitted illnesses, focusing on how to prevent infection and transmission and what to do if you or someone you know has symptoms. The last part of the seminar revolves around pregnancy, signs and symptoms, the importance of obtaining health care and from whom, and what to expect at a community health centre and why. We discuss how to have a healthy pregnancy, including a discussion about diet, vitamin supplements, exercise, and abstinence from drugs and alcohol. We summarize with a brief look at the developing fetus and the changes that take place. The education is provided by a youth representative at VYVC through interactive games, didactic teaching, and formal discussion. We encourage questions and provide detail where necessary. The goal of our presentation is not to cover everything there is to know about pregnancy but to highlight the need to get in touch with the health care system and why, how to be responsible with safe sex practices, and how to seek out and provide support in the community if a pregnancy does occur.  Mental Health  The mental health workshop is organized as a "round table" discussion and is kept as interactive as possible through role playing. During this workshop we attempt to enhance the general understanding of mental health among participants. We discuss how to  119 maintain good mental health, such as through breathing exercises and grounding techniques. Various mental illnesses are discussed including their causes, presentation, and available treatments. Mental illnesses that are discussed include: psychosis, ADHD, post traumatic stress disorder, depression, dual diagnosis, and bipolar disorder. Society's stigmas and misconceptions regarding these mental disorders are discussed. Participants are taught how to determine whether someone they know is suffering from a mental disorder and how they can help. Challenges faced by people living with a mental disorder are also discussed. Finally, a list of resources has been prepared which includes the contact information of major centres providing counselling and other resources for youth.  Substance Use  The substance use workshop provides youth with information regarding various harm reduction programs. The youth learn about needle exchanges throughout the downtown core, and information is provided regarding safe injection. The youth learn what steps to take if they encounter an individual who is suffering from an overdose and a number of medical treatments such as treating infections from injection drug use, what signs and symptoms to look for and how/where to get appropriate treatment for a number of conditions. Availability and importance of vaccinations such as the Hepatitis A/B, and meningitis vaccines are discussed. Additionally options for detoxification and rehabilitation treatments are noted.  Nutrition  The nutrition workshop strives to provide youth with practical nutrition information, to address nutrition related questions or concerns and to discuss resources for youth to obtain low cost or no cost food. During this workshop, youth learn about the importance of eating foods from each of the four food groups outlined by Canada's Food Guide to  120 Healthy Eating. Common nutrition questions relating to youth living on the Downtown Eastside are addressed. First Aid  Finally the first aid workshop introduces participants to the key action steps of emergency preparedness, gives participants the chance to learn and practice basic first aid skills such as CPR. First aid kits are distributed to participants.                        121 Appendix Two: Focus Group Scripts  Focus Group Script – Participants  INTRODUCTIONS 1. Please take one minute to tell us about yourself, including your age, where you are from,  where you are living, and your favourite...(pick an icebreaker topic)  HEALTH EXPERIENCES 2. What does everyone think about staying healthy on the street?     a. How much knowledge do youths have?     b. What are youth's attitudes towards staying healthy?     c. How much control do youths have over their own health?  3. What are the main challenges that youths face in trying to stay healthy?  HEALTH WORKSHOP 4. What did you all think about the workshop in general?     a. What did you like the most?     b. What didn't you like?     c. What would you change?     d. Other topics?  5. In what ways has the workshop helped you to think differently about your health than you did before?     a. Mental health     b. Drug use     c. Reproductive/sexual health     d. First Aid     e. Nutrition  122  HEALTH AMBASSADORS 6. Part of the purpose of the workshop this weekend was that we are hopeful that you will be able to become a sort of 'Health Ambassador', to share the knowledge you have gained with your friends on the street. How confident to you think you are in being a Health Ambassador?     a. Your knowledge about health     b. Your attitudes about staying healthy and avoiding risks     c. The sense of control you have over your own health  7. Is there anything else that you think would be important to discuss?                     123 Focus Group Script – VYVC Youth  FOCUS GROUP GUIDE – VYVC FACILITATORS EVALUATION  INTRODUCTIONS Please take a moment to tell us something about yourself. Be sure to include your name, age, and how long you have been involved with the workshop series.  QUESTIONS 1. What are some of the reasons why you became involved with the youth wellness project? 2. What do you like about the youth wellness project? a. It’s purpose? 3. How do you feel about your role in the workshop? 4. How do you find working with the CHIUS students? a. Challenges? b. Benefits? c. Suggestions for improved facilitation? 5. Do you feel your expectations or goals for being involved are being met? 6. What have you learned from your experience with workshop? 7. Suggestions for next year?           124 Focus Group Script – Health Science Students  FOCUS GROUP GUIDE – CHIUS FACILITATORS EVALUATION  INTRODUCTIONS Please take a moment to tell us something about yourself. Be sure to include your name, what you are studying, and how long you have been involved with the workshop series.  QUESTIONS 1. What are some of the reasons why you became involved with the youth wellness project? 2. What do you like about the youth wellness project? a. It’s purpose? 3. How do you feel about your role in the workshop? 4. How do you find working with the VYVC facilitators? a. Challenges? b. Benefits? c. Suggestions for improved facilitation? 5. Do you feel your expectations or goals for being involved are being met? 6. What have you learned from your experience with workshop? 7. Would you change anything about CHIUS students’ involvement? 8. Suggestions for next year?        125 Appendix Three: Ethics Certificate  

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