Chps final paper

Running head SCREENING AND DETECTING DIABETES IN THE HOMELESS

A community health promotion strategy for screening and detecting diabetes in the homeless in North End Halifax

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Brenna Coles B00529042 HPRO 3397- Community Health Promotion Strategies Jacquie Gahagan Dalhousie University December 2, 2011

Table of Contents Introduction

A community health promotion strategy for screening and detecting diabetes in the homeless in North End Halifax A major health issue that was identified for the North End community was diabetes. This community health promotion strategy was developed with the help of the program Coordinator

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for the new Diabetes Screening, Detection & Self-Management Project, Mandy Megan Conyers.

Mandy is employed at the North End Community Health Centre (NECHC). The target population identified for this strategy was the homeless. The homeless are a high risk population because statistics show they do not utilize primary health care services (Hwang & Bugeja, 2000; O'Toole, Buckel, Bourgault, Blumen, Redihan, Jiang & Friedmann, 2010; Macnee, Hemphill & Letran, 1996).

North End community The North End of Halifax, Nova Scotia is in polling district 11 and is a part of the Peninsula Community Council (HRM, 2008; HRM, n.d.). For a map of the North End of Halifax please see the appendix (see Appendix A, p. 26).The estimated population of the North End is 14,893 residences (HRM, n.d.). Historically, the North End has been known for its rich diverse culture. At the northernmost tip of the North End was the location of the community known as Africville. Africville was a black community that had settled in the late eighteenth century.

Unfortunately, in the late 1960’s the community was forced to relocate. Many families moved into public housing and about half of all the Africville residence settled in North End Halifax (The Africville Genealogy Society, n.d). Furthermore, Uniacke Square is an urban residential community centrally located in the North End and is “stigmatized by many Haligonians as a place of drugs, vice and violence; yet with a strong sense of community” (Silver, 2008, p.2). The inequalities of this community are visibly evident but the stigma may be what continues to drive the inequalities.

North End Community Health Centre (NECHC)

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The NECHC was founded in 1971 when North End community members recognized the need for community health service. The NECHC is located at the heart of the North End, on Gottingen Street. Its mandate is to “ support North End Halifax to be a healthy community by offering leadership in primary health care, through health services, education, community development and advocacy” (NECHC, n.d.e, Mandate section) and its vision is to improve the health in everyone they serve. The NECHC is comprised of a wide range of divers’ professionals who work in collaboration with one another. The programs and services offered at the NECHC are developed in response to the community’s needs and requests and all programs are free of change with an emphasises the importance of developing sustainable community-based programs. The NECHC is funded by the “Provincial Department of Health managed through the Capital District Health Authority, MSI and through various grants and charitable donations” (NECHC, n.d.b., About Us section). It strides to build strong partnerships with both community agencies and government agencies. The hope is to reach specific populations with their programs and services, populations include women, children, youth, homeless and individuals struggling with addictions and mental health issues (NECHC, n.d.e).

In 1999, the NECHC developed a project called Community Action on Homelessness (CAH) which focuses on the distribution and direction of the Federal Homelessness Funding in HRM. The Steering Committee which is composed of various stakeholders such as “individuals from various shelters, service providers, federal and provincial government and faith based organizations” (NECHC, n.d.c, CAH section). With input from the community, the Steering Committee develops a strategic plan from the next two years of funding.

The NECHC also provides a service called “Mobile Outreach Street Health” (MOSH) which started in 2009 (Hill, 2011). MOSH aims to provide “accessible primary health care

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services to people who are homeless, insecurely housed, street involved and underserved” in the community (NECHC, n.d.d, MOSH section). MOSH provides a wide range of health care services including access to occupational therapists, nurses, contraceptives and condoms, all sorts of testing, vaccinations, chronic disease management support (such as diabetes), health promotion programs and more. MOSH also helps individuals in other ways such as helping them get a health card, organizing dental and eye exams and by referring them to other health care services. The purpose of MOSH is to be able to “meet people in spaces where there is a greater level of comfort, take primary health care to them, establish relationships and build trust as a means to improve their health outcomes” (NECHC, n.d.d, MOSH section) and individuals do not need to be referred or have an appointment to be able to access MOSH. This service is run six days a week and can be found at a variety of locations including, Adsum House, ARK, Barry House, Brunswick Street Misson, Hope Cottage, Mainline Needle Exchange Outreach, Metro Turning Point, Salvation Army, Stepping Stone Outreach, the streets of Halifax and other locations (NECHC, n.d.d).

MOSH has gained the community`s trust mainly by partnering will already well established services known to the homeless population and by continuously providing friendly non-judgmental service to anyone who needs it. A barrier usually preventing the homeless population from seeking primary health care services are the misconceptions and stereotypes people have of the homeless. Often times the homeless feel judged and know they will not be treated the same as the rest of the housed population (Hill, 2011). A few homeless individuals interviewed for Hill`s (2011) newspaper article agreed that the services MOSH provides are both well needed and appreciated by the homeless community. In the article, one man explained that MOSH gives a sense of security for the homeless knowing they have access to friendly health

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care services (Hill, 2011). MOSH can sometimes see up to 270 patients per month, the demand is huge. In another quote from Hill’s article, Rene Ross who is the Executive Director at Stepping Stone explains that MOSH is filling a needed gap in services, “"They're really making a real difference on the street"(Hill, 2011, para.12).

The NECHC also provides a new program called “Diabetes Screening, Detection and Management Project” (DSDMP). The project has been implemented because diabetes has been identified as a major health problem in the North End due to its multicultural diverse background (NECHC, n.d.a). The project is carried out in junction with the Canadian Diabetes Strategy and the NECHC received a grant from the Public Health Agency of Canada Canadian Diabetes Strategy to fund the project. The Canadian Diabetes Strategy (CDS) was developed in 1999 and it was “Canada's first-ever attempt to deal with diabetes comprehensively and collaboratively” (Public Health Agency of Canada, n.d., Background and Rationale section). It objective is to develop a long-term collaborative approach with stakeholders for the prevention and management of diabetes. The DSDMP “aims to increase the number of affected community members, who are “living well” with diabetes” (NECHC, n.d.a). The project values community involvement, inclusion, capacity building, community input, empowerment, cultural diversity, education, collaboration and improvement.

The DSDMP had partnered with the First Cornwallis Baptist Church, Parenting Resource Centre, MOSH and is currently in the process of adding the Mi'kmaq Native Friendship Centre as one of their partners. In addition the DSDMP is also receiving resources from capital health such as medical supplies. Another resource is the diabetes advisory group, it consists of six individuals, only one is a registered patient (M. M Conyers, personal communication, November 29, 2011). This group works towards evaluating and assessing tools and resources for diabetes

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education, care and management. This advisory group was created in hopes of stimulating community engagement in the planning process and others are encouraged to join (NECHC, n.d.a).

Problem statement “Powerlessness and lack of social support are key risk factors for ill health� (Fitzsimons & Fuller, 2002, p. 481).The homeless community in the North End feel they have little control if any over their health. The various risk factors, barriers and lack of resources enable them to properly manage their health. Screening and detection for diabetes is essential for the homeless population because of the circumstances and barriers enabling them from accessing proper and adequate health care services. The problem is the lack of homeless individuals accessing the DSDMP even though the projects objective is to target high risk populations such as people of African and aboriginal decent and the homeless. There needs to be different strategies implemented in order to fill this gap.

Review of the Literature Homelessness is increasing in Halifax and it is estimated that in 2010, 1,700 Haligonians were homeless (CBC News (Nova Scotia), 2010). An individual who is homeless can be defined as someone who done not have a fixed, regular, and adequate night time residence or their primary night time residence may be a shelter that offers temporary accommodations (Strehlow, Kline, Zerger, Zlotnick & Proffitt, 2005). The homeless face many challenges, including those related to health. The homeless often self report poorer health status compared to their agematched counterparts. Homelessness is associated with higher mortality rates' which may also be influenced by their perceived low health status (White, Tulsky, Dawson, Zolopa & Moss, 1997).

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Chronic diseases are found to be more prevalent among homeless people and diabetes in particular is likely to be higher in the homeless population as it is in the low socio-economic status population (Arnaud, Fagot-Campagna, Reach, Basin & Laporte, 2010; Hwang & Bugeja, 2000; Jones, Hepburn, Man, Ridout & Gable, 2011). The homeless encounter barriers to health care compared to the general population and it directly influences the underutilization of primary care services among the homeless population (Hwang & Bugeja, 2000; O'Toole, Buckel, Bourgault, Blumen, Redihan, Jiang & Friedmann, 2010). The homeless population is both high risk and hard to reach with various barriers preventing them to improve their quality of life.

Often times there are underlining causes for homelessness including “lack of affordable housing and health care, increase in poverty, domestic violence, addiction disorders, and mental illness” (Strehlow et al., 2005, p. 434). These cofounding variables play an important role on homelessness; mental health issues and addiction will be explored further.

Diabetes is a serious health epidemic that has broken out worldwide and continues to rise (Casey, 2011). In 2006, “the UN recognized diabetes as a global threat” and since then November has named Diabetes Awareness Month (Calculations, 2010, p.8). Canadians who have diabetes are twice as likely to have a premature death compared to those who do not have diabetes (NECHC, n.d.a). Statistics show that more than two million Canadians have been diagnosed with either type 1 or type 2 diabetes (T2DM) and each year 41,500 individuals die with diabetes being a contributing factor (Calculations, 2010). In Nova Scotia alone there are an estimated 74,000 cases of diagnosed diabetes. It is estimated that one in three people living in Canada have diabetes but do not know it (NECHC, n.d.a). In recent years there has been a dramatic incline of reported diabetes especially in the lower-middle income population with a 93 percent increase in diagnosed diabetes from 1994 to 2005 (Chronic disease by the numbers,

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2010). Different ethnicities have a high risk for developing diabetes these include Hispanic, Asian, South Asian and individuals of African descent. The North End is very multicultural and includes a definite population of these various ethnicities.

This strategy will be focusing on Type 2 diabetes and the barriers the homeless in North End Halifax may face. Type two diabetes is a “chronic disorder” (Casey, 2011, p.16) is defined as a “metabolic disorder characterised by high plasma glucose concentrations (PGC) and abnormal insulin activity in the body” (Beattie, 2009, p.22). Diabetes is caused by “periptieral insulin resistance along with an insulin-secretory defect... persons with type 2 diabetes retain the ability to secrete some endogenous insulin and are not absolutely dependent on it” (Beattie, 2009, p.22). The normal PGC levels are from 4–6 millimoles per litre (mmol/L) in a healthy individual. However with type 2 diabetes the PGC “is consistently elevated above11mmol/L (random) or above 7mmol/L when fasting” (Casey, 2011, p.16). Pancreatic beta cell dysfunction appears to be key in the development of type 2 diabetes. There are several theories that try to explain the dysfunction; nevertheless researchers are still looking for the cause (Casey, 2011).

Diabetes is a complex condition and research is still ongoing. As Casey (2011) describes it “regulation of glucose involves a complex interaction of many hormones and feedback mechanisms, the disordered glucose metabolism evident in T2DM is also multifactorial. Key players are insulin, glucagon, amylin, and the incretins” (p.17). The cause of the dysfunctions resulting in type 2 diabetes is still unknown.

There are countless risk factors that contribute to the development of type 2 diabetes. Some risk factors are in an individual’s control such as personal choices with others that are outside a person’s control. For example, geneticists have identified at least 27 genes that put people are a greater risk of developing Diabetes (Casey, 2011). Risk factors that are outside an individual’s

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control include family history, age, gender, ethnicity, and women who have delivered a baby weighing more than 9 pounds, or were diagnosed with gestational diabetes mellitus. Risk factors that people have control of include hypertension, physical inactivity, High-density lipoprotein (HDL) cholesterol level, overweight or obese, and diet. However, an individual that is homeless may not have access to nutritious meals on a daily basis and most likely does not have access to recreational facilities. These barriers reframe the homeless from keeping active and getting their required amount of physical activity. In addition, history of cardiovascular disease is also a risk factor (Beattie, 2009). There is a misconception regarding who develops type 2 diabetes, the stereotype is that obese, inactive people with poor diet develop this disease. However type 2 diabetes “is not exclusively associated with obesity and that people without the genetic predisposition, even if obese, do not develop T2DM” (Casey, 2011, p.17) The signs and symptoms of type 2 diabetes are excessive urination, increased thirst, excessive eating and fatigue, however these symptoms may not be as severe as in type 1 diabetes and type 2 diabetes can often be asymptomatic (Casey, 2011). The more common symptoms of type 2 diabetes “are due to the presence of excess glucose: this can predispose a person to recurrent infections, such as skin infections and vaginal thrush, accompanied by pruritis” (Casey, 2011, p.19). Moreover, changes in vision such as blurred vision is a sign of type 2 diabetes “due to osmotic changes in fluid levels in the eye” (Casey, 2011, p.19). Many of these symptoms can be interpreted as normal signs of aging or be contributed to the conditions the homeless are faced with, such as not having access to regular meals and sleeping conditions.

Many complications both acute and long term arise from developing type 2 diabetes including hypoglycaemia, retinopathy, peripheral neuropathy and nephropathy, diabetic ketoacidosis (DKA), and hyperosmolar hyperglycaemic non-ketotic syndrome and microvascular

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or macrovascular defects (Casey, 2011). The homeless population may not have adequate well balanced and regular meals which may promote hypoglycaemia (Arnaud et al., 2010). Continued hypoglycaemia damages the blood vessels in the retina causing vision lose. Bilateral sensory disturbances often affecting the hands and feet is a classic complication of type 2 diabetes (Casey, 2011). For the homeless, physical elements, poor footwear, standing and walking for extended periods of time and poor foot hygiene already put them at risk for developing foot problems (Arnaud et al., 2010; Muirhead, Roberson, & Secrest, 2011). Furthermore, “damage to the kidneys with prolonged exposure to hyperglycaemia causes proteinuria, hypertension and renal failure” (Casey, 2011, p.20). Some of these complications are life threatening for example, “macrovascular complications include stroke, cardiovascular disease and peripheral vascular disease, and are the major cause of mortality for people with T2DM” (Casey, 2011, p.19).

Diabetes can be a serious health condition if not diagnosed early and properly managed (NECHC, n.d.a).

Rationale statement If left undiagnosed diabetes has the potential to become life threatening. It is imperative that screening and the detection of diabetes be promoted and implemented in all high risk populations, especially the homeless. Past initiatives to increase the screening and detection rate among the homeless population have come up short and the problem still exists.

Community-based health promotion strategies The vision for the strategy is “working together to improve the health and quality of life for the homeless community”. The goal of the strategy is to “increase the number of homeless

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accessing diabetes screening and detection services offered by the NECHC’s DSDMP.” The strategy will be guided by seven principle objectives. They include the following: (1) Prioritize and promote diabetes screening and detection; (2) Promote community engagement; (3) Promote a trusting relationship with the homeless community; (4) Promote the development of effective strategies to reach the homeless community; (5) Provide education and awareness about diabetes; (6) Establish partnerships with agencies, resources centres and religious centres; and (7) Promote health equity.

The proposed strategy focuses on sustainable community development, mobilization of services and education session to combat against the underutilization of screening and detection services offered by the DSDMP.

Community development: “Doing with” The NECHC develops and implements programs based on the concerns of their community members. Actions have been taken and the DSDMP has been developed and implemented in the community with the help of the community advisory group. However, there is a gap in the program; the homeless population is not utilizing the DSDMP services for

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screening and detection. To properly address the issue the creation of a new “homeless health advisory group” comprised of local homeless individuals may be a step in the right direction.

The members of this group will be sought through word of mouth, by flyers and hand outs. The flyers will be strategically placed in locations frequented by the homeless such as shelters, churches, other local agencies, MOSH, and other allied health care services. The handouts will accompany the flyers and will be free to take or can be handed out to the homeless during their stay at a shelter, while seeking the medical services MOSH provides or easily accessible at other agencies and health service centres. The flyers and handouts will include information about the new “homeless health advisory group” that will give a voice to the homeless. It will advertise four predetermined meeting times over the course of a four week period, which will act as a pilot test. Also, advertised will be complimentary snacks and beverages severed at all meetings as an added incentive. The flyers and handouts will be easy to read and in a larger print. If attendance is high (more than 15) the advisory group will continue past the four week pilot test period. The meetings will take place during the day time hours therefore the competition at the shelter will not be an issue.

Getting the homeless community involved in the planning stages of developing a strategy that targets their population will be critical, feedback and ideas from the target population proves to be very valuable. The meetings will be focused around brainstorming different approaches to increase the use of diabetes screening and detection services offered by the NECHC’s DSDMP and these meetings will be facilitated by a health care worker. This type of community involvement approach is closely aligned with Rothman’s “Social Action” but does incorporate some of the characteristic of “Locality Development” (as cited in Author Unknown, n.d). The characteristic of the “Social Action” approach displayed by this approach include, gaining the

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participation of the homeless, aimed at solving health issue, but it also takes into account the process. Participants can feel personal satisfaction by engaging in the advisory group and give them a sense of worth and purpose in addition to the feeling of inclusion, belonging, and a sense of community, which is a characteristic of the “Locality Development” approach (Author Unknown, n.d; Kim, Koniak-Griffin, Flaskerud, & Guarnero, 2004). New relationships will be formed within the homeless community and with the DSDMP staff and increases trust. The “homeless health advisory group” will also enhance community capacity through the participant of the homeless and empower them by taking control and impacting their health.

If participation is still strong after the four week pilot test, the health care worker who facilitates the meetings will work to find several willing individuals and train them to help facilitate and eventually fully run the advisory group meetings and act as a liaison between the homeless population and the NECHC. This will help ensure the sustainability of the advisory group. After the four week pilot test the group has the freedom to discuss any topic they feel is health concern to the homeless population, but one topic will be discussed over a four week period to allow full evolution. The homeless health advisory group will have access to resources and professionals to help them develop and implement the meaningful indicatives they created.

The goals are to empower the homeless, give them a voice, and let them indicate the best tools to use for reaching the homeless population. The objective is to identify effective means that will be instrumental in tailoring the strategies to the homeless community.

Mobilizing Sites Due to the success of MOSH, the objective is to mobilize screening and detection sites.

The idea is to bring the services to the homeless in a place where they feel comfortable. To

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increase the diabetes screening and detection services offered by the DSDMP the mobilized sites will have to be sites where the homeless visit on a frequent basis or where partnership has already been established. Mobile sites could include local shelters, food banks, the First Cornwallis Baptist Church, the Parenting Resource Centre, soup kitchens and other local agencies. Increasing partnerships with other community organizations, resources centres and churches will likely add to the success.

A resource that could be greatly utilized would be the MOSH service van allowing for true mobility, luckily partnership with MOSH is already established. Organizing mobile sites for diabetes screening and detection will be based on a rotational schedule. Mobile sites can occur once a week during daytime hours, and change locations each week. Co-operation and communication with MOSH will be critical for the success of this strategy.

Education and outreach Educational approaches include improving knowledge, giving health advice and support, and teaching new skills. Interactive education and outreach sessions pertaining to diabetes will be implemented in shelters and soup kitchens in the North End. Education session will include information about diabetes, the signs and symptoms and the complications that arise from undetected or unmanaged diabetes. Sessions being held in shelters will be in the evening hours and session being held at soup kitchens will be at the appropriate scheduled time. Education and outreach sessions will be implemented twice a week at various locations. An educational component in addition to mobilizing screening and detection sites may yield better results because educational sessions can increase the understanding and awareness of the seriousness of

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diabetes, and hopefully empowering the homeless to take control of their health. In addition, capacity building also involves an educative and consciousness-raising process.

Theory-driven The Health Belief Model (HBM) The HBM is a psychological model made up of four major components, they are: (1) Perceived susceptibility to problem, (2) perceived seriousness of consequences of problem, (3) perceived benefits of specific action and (4) perceived barriers to taking action. The first two major components to this model are linked to the perceived threat and the last two major components are connected to the outcomes expectations. Studies have identified the “perceived barriers as the most influential variable for predicting and explaining health-related behaviors” (as cited in Denison, 1996). All of these elements connect to the individuals’ perceived ability to attain a certain goal, also known as self-efficacy (Denison, 1996; Nutbeam, Harris, & Wise, 2010).

The HBM applied to diabetes screening and detection in the homeless community may look something like this: The perceived susceptibility to diabetes may be low because a lack of knowledge of factors that put them at risk. If they do not show any signs or symptoms then they do not have to be concerned. They may think that because they do not have regular access to meals then they are not at risk for diabetes because it is a “sugar disease”. The perceived seriousness of consequences of diabetes may not fully be known due to a lack of knowledge that diabetes can be life threatening. The perceived benefits for screening is knowing if they have the disease, detecting diabetes before serious complications develop, taking action may improve their overall health, save them from a premature death and help them to properly manage their

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health. However the perceived barriers for the homeless population include: lack of accessible health care (due to a lack of identification, no fixed address so cannot apply for a health card) or knowledge of health services available, no income to buy medication and supplies, fears of discrimination by medical providers, unpredictable schedules, does not view their health as a priority and may be reluctant to acknowledge any signs and symptoms of ill health, fear diagnosis (Hill, 2011).

Due to a lack of knowledge, they may think all individuals with diabetes are insulin dependent and will be forced to coordinate their meals around the treatment and that can be a daunting task when regular meals are not always available. However, by recognizing diabetes as a serious health issue but can be properly managed this might increase the likelihood of an individual taking action. If the service is easily accessible or comes directly to them the rates of diabetes screening and detection should increase. With the support of the DSDMP fears of managing diabetes may decrease.By educating and removing some of those perceived and physical barriers the hope is to increase diabetes screening and detection among the homeless.

Diffusion of Innovation Theory (DIT) New ideas are the foundation which the DIT is based upon and how different populations or communities adopt these new ideas is how the DIT works. These ideas could involve adopting new technology like the “IPad 2”or health behaviour practices such as deciding to receive the “Gardasil” vaccine or in the this case to receive screening for the detection of diabetes. DIT is defined as “the process by which an innovation is communicated through certain channels over time among members of social systems” (as cited in Nutbeam, Harris, & Wise, 2010, p.24).

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There are certain factors that must be considered to fully understand the DIT and they are: “the characteristics of the potential adopters; the rate of adoption; the nature of the social system; the characteristics of the innovation; and the characteristics of change agents� (Nutbeam, Harris, & Wise, 2010, p.24). Consequently, due to these factors they produce a variety of different outcomes in different individuals. These groups of individuals were given specific names; listed in order from the individuals who are the first to adopt the new idea to the individuals who are last or never adopt the new ideas are the, innovators, early adopters, early majority, late majority and the laggards (Nutbeam, Harris, & Wise, 2010). The breakdown of percentages for each group usually is as follows: two to three percent are the innovators, ten to 15 percent are the early adopters, 30 to 35 percent are the early majority, 30 to 35 percent are the late majority and the laggards account for ten to 20 percent of the population (Nutbeam, Harris, & Wise, 2010).

The idea is the homeless adopting the new health practice- screening for diabetes. Once the strategy has been implemented the people who are first to be screened will be the innovators, these people will not hesitate and will be excited about this relatively new service. The next flow of people will be the early adopters, not the first to be screened but close. Then comes the early majority and late majority, a large percentage of people will fall into this group. Usually they will have to be persuaded or educated in order to take action. The last group, the laggards comprises of people who are very hesitant to take action or may include people who never get screened for diabetes.

Community health promotion strategy evaluation

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The research and evaluation process will be an integral and ongoing part of the strategy.

Finding an effective and appropriate tool to be used to gather data of the program’s effectiveness is crucial.

Formative Formative evaluation will be hard to conduct because the existing program is already developed. Tool to incorporate a formative evaluation are a program logic model and keeping record of activities. The formative evaluation will help determine if the strategy is using effective and appropriate materials and procedures. The strategy will be revised periodically as needed.

Process Process evaluation will examine the procedures and tasks involved and determine what services are actually being delivered and to what target population. Quantitative and qualitative data will be collected by tracking the number of people accessing the services and what type of people are reached, tracking the number of mobile sites visited, descriptions of how services are provided, descriptions of what actually occurs while providing services, descriptions of quality of services provided and implementation evaluations. The process evaluation will be carried out by the DSDMP staff every six months for the first two years after implementation. If any discrepancies are found the strategy will be revised as needed.

Impact Impact evaluation will examine what impact or differences the strategy made. Data collected can include changes in peoples attitude, knowledge or behaviour towards screening and detection of diabetes, if the there were changes in the rate of screening for diabetes, changes in

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the community, and other analysis can be completed to determine the cost-benefit and/or costeffectiveness of the strategy.

Outcome Outcome evaluation will determine if the goals and objectives were met. The goal is to increase the diabetes screening and detection rate among the homeless. The objectives were to (1) Prioritize and promote diabetes screening and detection; (2) Promote community engagement; (3) Promote a trusting relationship with the homeless community; (4) Promote the development of effective strategies to reach the homeless community; (5) Provide education and awareness about diabetes; (6) Establish partnerships with agencies, resources centres and religious centres; and (7) Promote health equity. Methods evaluating the outcome for this strategy will include formal and informal feedback from members of the “homeless health advisory group�, participants from the mobile sites and education sessions collected through questionnaires and semi-structured interviews. Records or documentation will also be used to quantify service utilization.

Conclusion This proposed community health promotion strategy aims to fill the gap by increasing diabetes screening and detection rates among the homeless. Diabetes screening and detection is essential for the homeless population because of the circumstances and barriers enabling them from accessing health care services. This sustainable strategy will increase community development by collaborating with the homeless community in all stages of development, implementation and evaluation. Mobilized screening and detection sites will eliminate the perceived and physical accessibility barrier. Education and outreach sessions offered at various

SCREENING AND DETECTING DIABETES IN THE HOMELESS local shelters and soup kitchens will increase knowledge about the susceptibility and risks associated with diabetes. Together these interventions will create an appropriate strategy to increase the utilization of screening and detection services offered by the NECHC’s DSDMP.

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Appendix A

SCREENING AND DETECTING DIABETES IN THE HOMELESS Polling District 11: Halifax North End (HRM, 2008).

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