- Holding organisation: Infirmiers de rue (IDR)
- Status: Belgian not for profit association (asbl)
- Public: Federal budget (Health Ministry/ Social Integration Ministry); COCOM and COCOF (communities level)
- Private: individual donations/ companies; Alco through Ashoka, Weleda- in kind donations (creams/lotions), other companies giving help for translation needs
- People involved in the project: 13 persons working for the association. Many nurses. One doctor provides medical information for high-risk patients. He is the coordination point for doctors and hospitals. No direct relation with IDR patients; if the patient wants to have a long-term doctor; he would be registered to one specific attending physician. 2 social workers: they work at the local level, help with complex record and can unblock administrative barriers. 2 administrative workers
- Partners: Different public health services and socio-medical associations in Brussels
- Creation Date: 2005
- Contact Persons: Emilie Meessen: info à idr-sv.org
- Main project link: www.infirmiersderue.org
The Association was born in 2005, after a 1 year and a half long field study in Brussels around access to health and care for people in the streets, carried out by two nurses specialising in medico-social health issues (drug addiction/homelessness). Why do so many people no longer come to care associations? How to engage with people living in the streets regarding health issues when they do not believe in their own future?
3 problems identified:
- People living on the streets do not take into consideration their health conditions, or are afraid to face it;
- Medical professionals are discouraged because they usually only intervene in emergency or very serious situations; and
- Many facilities are unknown as well as insufficient during specific time frames (e.g. at night).
By using active street work and a method to reconnect homeless people to their body and their identity, which is succeeded by an intense follow-up, the Association is providing to the most excluded homeless people hygiene services and social reintegration.
The local context
The number of homeless people has exploded in the past years in Belgium. 50,000 people lived in the streets or in unsecure housing in 2011. According to the Flemish association "Dakloze Aktie Komité" (DAK/ http://www.mi-is.be/be-fr/politique-de-lutte-contre-la-pauvrete/daklozen-aktie-komitee-dak / http://daklozen.frontsdf.be), 5,000 people live on the streets permanently, with around 500 in Antwerpen and 2,000 in Brussels. They are more and more visible, but a great part of homeless people, nearly 45,000 persons, are almost invisible. They live partly at a friend's or family relative’s place but come back regularly to the streets or to main train stations.
In spite of the existence of numerous street work citizen organisations and intervention programmes, their health remains a pressing issue. According to Médecins du Monde (doctors of the world), 53% of belgian homeless people have no access to medical care. and 44% of the patients they followed during 2012-13 Winter plan are in very bad health condition and 14% require specific psychiatric care.
The poor monitoring of the health of homeless populations is one of the first causes of street mortality.
The starting point
The project started with 2 nurses, Emilie Meessen and Sara Janssens, who specialise in tropical health and socio-medical health: prostitution/ drug addiction/homelessness. While completing their final studies in Burkina Faso, they worked in very precarious and harsh conditions in small villages: usually people were coming from far away places to get care, and there was a need to adapt health treatment to this situation, e.g. supplying long-lasting bandages to patients.
On their return to Belgium, and after starting to volunteer and work in local care associations for populations at risk, they decided to explore further problems of access to health in their own country. Indeed many socio-medical associations exist but many persons do not go "to the field" or actually know the persons and their precise conditions. Issues of hygiene, while being taboo among professionals, was also a recurrent and transversal issue in the two nurses's daily work. Apart from their work in the local associative life, Emilie and Sara have launched a 1-year study to meet the 30 different socio-medical actors working in the field of health access for marginalised people.
Why focus on Hygiene? From her work experience at La Fontaine asbl, Emilie recalled the importance of appearance and self-esteem for marginalised people. This day care centre for homeless people hangs a mirror at the door entrance; people in care would usually look at this mirror upon leaving the place. She observed that people usually judge homeless people according to their appearance: a person neglecting themselves doesn’t inspire confidence. This has many different consequences, e.g. problems associated with access to regular housing, fear, fatalism or taboo among care professionals when combined with generally grave medical problems. Trust is also key in the methodology: Trust in the future and in oneself.
Two mechanisms for change:
- Regain self-confidence through hygiene and recognition of one's talents. By recalling each person’s talents you valorise the person.
- Regain the notion of “beauty”, re-ignite capacity to be able to envisage the future and to see the importance of being "cured".
The study process: Both contacted and met hospitals, emergency centres, free health centres, CPAS (Belgian Public centres for social action), street workers…They organised individual interviews with persons responsible for the targeted services, and realised that there was a need for more interaction among them. They set a collective meeting to get all these actors together around one table: some didn’t know each other. An interesting point was the breaking of presumptions by inviting all associations, even the ones that had been set apart. The result was convincing, and even though the methods and philosophical approaches were different, there was a common conviction to work all together.
- create a new approach and methodology, rather than associating it with an existing big health structure. It would allow more freedom in philosophical choice and operational decisions;
- strengthen partnership through total transparency in the decisions process and recruitment.
During a 3 year period, collaboration meetings were organised every 3 months with the associations. From time to time, direct contacts with specific associations were set up according to the required needs, and less collective meetings occurred as a result of tailored agreement and trust among partners. The Challenge “Impact Ashoka” Belgium also helped the structuring of the association.
In 2005: Infirmiers des rue (IDR) status, in writing. January 8th 2006: first meeting in the streets.
How does it work today?
- pre-follow: identifying people at risk with different partners (Social Emergency Service). Once every two months they meet with the responsible persons on the search for homeless people. Information gathering takes a lot of time.
- follow-up: 40 places in weekly follow-up care. When a person starts the process, IDR works with the person and his/her network (social or familial network: street workers, shopkeepers, doctors, etc.). The main point is to motivate everyone to collectively work together for the same person.
The person needs to feel supported; the care process is aligned with their rhythm and desire to proceed further. Nevertheless, IDR is proactive in proposing activities and asking the person what they are ready to do the day they meet. Personal objectives are set up with the patient otherwise professionals can also work out to find a balance in which the person feels at ease. The follow-up period depends on the person. Once the person finds housing, the follow-up continues until stabilisation (hygiene and food habits within the housing) and the identification of a new support network to take over.
- Post follow-up: IDR maintains regular contact with the patients after the follow-up period: once a month initially, then once every 3 months and finally, twice per year. IDR also maintains contact with the support associations in order for them to be able to intervene on-time and avoid any drop outs from the school.
Participation and Governance
Target people: Persons who have been living in the streets all the way from 8 up to 20 years. 80% are male and mostly are Belgian (for administrative problems rather than motivational ones, a partnership with MdM has been set up in aid of foreigners). Among the persons who have been in housing for 6 years, none of them has gone back to the streets. 38 patients are presently living securely in housing in post follow-up; 12 persons in housing are in the stabilisation process (relearning hygiene/ how to busy oneself, etc.).
Governance:In the beginning, every decision was made collectively. Today, thematic meetings associated with specific patients are first organised and then presented to the entire IDR team and partners. Twice a year, for 3 days in January and July, a team building session with the inner IDR team is organised to discuss further problems encountered and recall the association’s values and projects for the year. Partners: The different local socio-medical actors.
Added value of the project and making resources available
- Ensuring access to care and health services for people outside of mainstream care channels;
- Creating a holistic pathway to self-awareness and physical, mental and environmental health;
- Strengthening the environment of street-workers to make the system more efficient by reinforcing existing infrastructure and improving their accessibility (i.e. street maps and lists of places where it is possible to take a shower, drink water or use toilets);
- Valuing people by identifying and putting emphasis on their competences and interests: every team of IDR going onto the streets to meet a patient has documentation of the person’s hobbies/interests.
Difficulty in dealing with person’s motivation: everyone –from the patient to the care team- needs to determine what they are up to and how communication will be organised. Sometimes a patient already has a large team intervening around him/her. Fatigue or disillusionment of the inner IDR team: specific focus on the team’s well-being. The persons are idealist and passionate and may be struck by bad news, it is important therefore to manage emotions and resources. In 2010, decisions to follow-up more than 50 people at the same time; this idea turned into a mistake as it was more difficult to see the patients as regularly and rapidly. Following this failed attempt the IDR team decided to focus on a rotating flow with a limit of 32 patients per week. The post follow-up may be sometimes difficult: by checking in every 2 or 3 months to get news of/from the patient, some associations may feel like they are being controlled.
Key success factors
- Trainings to strengthen the impact of a network of watchdogs working in the streets for the empowerment of homeless people;
- Strategy to progressively build trust and, step-by-step, bring the homeless closer to the mainstream health system and regular housing;
- Creation of individual Passports : the team workers of IDR have a passport for each person they follow, with a list of their qualities/competences/interests which they can update anytime on one side, whilst putting the weekly objectives on the other side. It is a practical way for rotating teams to better know each individual and stress their inner qualities and resources to them, or in meetings with other medical partners (i.e. dogs like him/ he can talk 3 languages). Indeed there is no referal nurse for patients to help the person develop herself in a multiple environment with different care stakeholders. It is also a way to find an occupation/job when secured in safe housing (i.e. dogsitter/ societal role as watchdog in a brassband, gardener);
- Creation of specific tools to assess priorities of intervention for each patient (BCB "Body-Clothing-Behaviour" score);
- Longterm follow-up and emphasis on the good co-ordination of actors; and
- Inner IDR team building : organising « good news » meetings : dealing with emotions and ways to cope with better, situations of longterm work.
- Re-adaptation of the strategy according to local needs: two Belgian cities asked to develop an affiliate IDR project but the replication process didn’t work out. In one city insufficient political support led to restrictions in operational freedom, in the other the local associations didn’t help in the methodology setting and impeded the project's development.
- Trainings around Hygiene and IDR methodology are called for in other Belgian cities (Liege/Charleroi).
- IDR methodology is unique as it continues up until housing reinsertion.