A Scoping Review Examining Interventions Intended to Help LGBTQIA+ Youth Transition Out of Homelessness

Objective: Youth self-identifying as lesbian, gay, bisexual, transgender, questioning/queer, intersex, asexual, and other identities (LGBTQIA+) are overrepresented among the homeless youth population in western countries. Although scholars have documented the situations and events contributing to disproportionately high rates of homelessness among LGBTQIA+ youth compared to cisgender peers, researchers have not as thoroughly examined the efficacy of services available to this group to assist their transition from homelessness to stable residency. The purpose of this scoping review was to examine the peer-reviewed literature to determine how many journal articles have been generated that addressed (a) the assessment of client satisfaction or (b) the effectiveness of intervention designed to help LGBTQIA+ homeless youth transition from homelessness to stable tenancy. Method: A database search of six peer-reviewed, health care publication indexes, with 50 key search terms was performed. The database search spanned publication years with no beginning year, but ended in January 2021. Results: Nineteen articles were identified that described programming, reported intervention outcomes, or outlined policies and recommendations intended to help LGBTQIA+ youth transition out of homelessness. Of the 19 studies, only five (26.31%) reported program evaluation (n=1, 5.26%), the assessment of intervention effectiveness (n=2, 10.52%), or an analysis of client satisfaction (n=2, 10.52%). Findings exemplify the dearth of scholarship and research examining this area of academic inquiry and public health need. Discussion: Without empirical research investigating service provision for the LGBTQIA+ homeless youth population, service providers have little data upon which to inform practice based on an understanding of the services that are needed and desired by this population to transition out of homelessness, the effectiveness and perceived satisfaction of those services, and whether services should be modified to better meet the needs of those for whom it was intended. Scholars and researchers are called upon to generate this needed public health research, which should include service recipient perspectives to target outcomes and interpret findings.

COVID-19 and the Homelessness Support Sector

This exploratory study sought to uncover service provider perspectives on the early response to COVID-19 in a small community in an advanced industrialized country - the homelessness support sector of the Central Okanagan, British Columbia. Following a case study approach, snowball sampling was utilized in May and June 2020 to achieve a sample size of 30 through a mix of one-on-one interviews and open-ended surveys. Qualitative thematic analysis was used to uncover commonalities among interview responses. Common themes are discussed in relation to three areas of questioning including challenges, successes, and mitigations/areas for future support. While the community came together to support the response, there were challenges and concerns regarding safety and personal protective equipment supplies, social distancing and knowledge transmission within the homeless community, access to food and water, and lack of space for isolating positive cases. The findings illustrate possible research, practice, public health policy, and emergency planning considerations within smaller communities.

Mental Readiness for Frontline Workers in Homelessness Services in Ottawa, Canada

This study investigated factors related to competency by assessing the mental readiness among highly recognized frontline workers in homelessness services (FWHSs) by means of self-completed questionnaires. A total of 35 highly respected FWHSs in Ottawa, Canada were identified by their peers and supervisors as “exceptional” for various specialty areas: addictions, mental health, hoarding, trauma and post-traumatic stress disorder (PTSD). An Operational Readiness Framework was used to examine how FWHSs perform at their best in challenging situations. A series of questionnaires were completed at a Think Tank to determine their mental readiness before, during and after challenging situations. Quantitative and qualitative analyses of mental readiness were performed to prioritize identified challenges. The study findings were then compared to the “Wheel of Excellence” based on results from elite athletes and other high performers such as surgeons, police, and air traffic controllers. The analysis revealed that mental readiness is required to achieve peak performance in addressing the challenges of homelessness. The balance between readiness (physical, technical and mental) and performance contributed to their competency and resiliency. Common elements of success were found: commitment, self-belief, positive imagery, mental preparation, full focus, distraction control and constructive evaluation. This investigation confirmed many similarities in mental readiness practices engaged by excellent FWHSs and other top professionals. This study offered, for the first time, a comprehensive understanding of specific high-performance readiness practices through a streetwise, frontline-worker perspective. Practical recommendations for training and assessment were provided relevant to excellence in homelessness services.

Planning Shelter Service Spaces and Structures for Resilience: A Spatial Analysis of Women’s Shelters During COVID-19

Objective: Globally, domestic violence against women increased in severity over the course of the COVID-19 pandemic. Shelters supporting women experiencing temporary homelessness due to violence had to make major changes in service delivery to accommodate pandemic protocols, including how many families could stay in shelter, where they were allowed to reside, and how they were, and were not, able to interact with shelter staff and the outside world. The present study used a novel approach to spatial analysis to understand how pandemic protocols affected shelter space use. Method: Floor plans and written pandemic protocols were submitted by 15 women’s shelters in Ontario, Canada. Each pandemic protocol was analyzed and mapped onto its respective floor plans to determine how much space was lost under different modes of operation: normal (pre-pandemic), physical distancing (using pandemic protocols), and quarantine (using pandemic protocols during an outbreak). Three types of shelter space were analyzed to understand what types of spaces shelters were losing: Primary (bedrooms, bathrooms, and laundry areas), Secondary (community areas and staff offices), and Tertiary (hallways and storage). Findings: All 15 shelters lost space, with an average of 27% of net area lost overall (range 7%-56%). Within the three types of space, 18% of Primary, 48% of Secondary, and <1% of Tertiary space was lost. Key factors influencing space loss were the type of protocol used and the existing layout of the shelter space. Conclusions: Recommendations for shelter space planning in the context of rapidly evolving public health requirements are provided.

Hospital-to-Shelter/Housing Interventions for Persons Experiencing Homelessness

Persons with lived and living experiences of homelessness (PWLEs) commonly use hospitals and emergency departments to access healthcare yet support for transitions from hospital to shelter/housing can be challenging to access. To improve the continuity of care and health outcomes for PWLEs who are being discharged from hospital, a more complete understanding of two hospital-to-shelter/housing programs in Metro Vancouver, Canada was sought. Using a community-based participatory research approach, we conducted in-depth interviews in-person or by phone. Participants included eight healthcare and shelter/housing decision-makers and providers and a convenience sample of ten program participants (two females and eight males who ranged in age from 31 to 74 years old; average = 50 years old). Data were analyzed in NVivo 12 to identify successes including: 1) achieving health stability and recovery following hospital discharge; 2) having privacy and freedom while in the program; 3) building relationships with providers; 4) having formal support to find housing; and 5) cross-sector relationships between providers. Challenges included: 1) limited availability of affordable and appropriate housing; 2) other guests’ ways of life; 3) complex needs versus limited after-care resources; and 4) inequities in program access. While hospital-to-shelter/housing programs can serve as intervention opportunities to connect PWLEs to permanent housing, discharge plans need to acknowledge the local limitations on housing availability and offer short-term options for patients who require sub-acute rest and convalescence.

Lessons Learned: COVID 19 and Individuals Experiencing Homelessness in the Global Context

The coronavirus disease (COVID-19) pandemic has affected all our lives but did not affect all parts of societies equally. This study uses a systematic literature review approach to examine the experiences of homeless populations during COVID-19. Our literature review identified lessons learned and promising practices from the field at a global level, and summarizes academic studies in order to promote future efforts to prepare homeless populations for potential extreme events in the future. Forty-one of 209 articles were selected to prepare this literature review. Following the academic database search, grey literature from various organizations were also identified to enrich the literature results and analysis. Findings from these articles were grouped under three main themes to better illustrate the results: (1) impact of COVID-19 on people experiencing homelessness (PEH), (2) support mechanisms, and (3) promising practices. A comparative approach also was used to examine how PEH responded during two previous pandemics (severe acute respiratory syndrome [SARS] in 2003 and Swine Flu 2009) compared to the COVID-19 pandemic. Findings showed that there was continuous improvement in the disaster preparedness for PEH during COVID-19 when compared to past pandemics. In addition, promising practices have emerged. However, ongoing issues, such as lack of personal protective equipment (PPE), staff shortages, and communication problems, still persist in the field. More research regarding PEH during pandemics is needed, and their voices should be included.

Identifying Challenges and Solutions to Providing Diabetes Care for Those Experiencing Homelessness

Introduction: Health care providers face a multitude of challenges in providing care to patients with diabetes who are experiencing homelessness. Considering the unique circumstance faced by this population, mainstream services must be adapted and tailored to meet patients’ needs. The objective of this study was to explore both the barriers faced by providers and programs in offering comprehensive diabetes care to these patients, and their suggested areas for improvement. Methods: We conducted semi-structured interviews with providers who care for patients who have diabetes and/or who experience homelessness. Participants included primary care providers, specialist physicians, dietitians, shelter staff, outreach workers, and diabetes educators in five Canadian centres (n=96). Responses were analyzed using qualitative thematic analysis. Results: Barriers most frequently cited by providers were a lack of resources for staff. Other challenges included policy barriers (restrictions on billing codes, care professionals’ scope of practice, and the structure of financial support for this population), duplication of services, and alternative priorities of care. Participants identified several strategies to improve care, which targeted the following spheres: location of service provision and coordination of care, policy changes, and extending funding and resources for staff, such as augmented funding to hire allied health professionals in outpatient settings and increasing outreach capabilities. Conclusion: Programs that strive to address the unique needs of clients experiencing homelessness face numerous challenges. Unique potential solutions to these barriers, such as service provision in a convenient location involving social and health services, incorporating allied health care providers in care to a greater extent, and updating policies to reflect the social complexity of the population can improve diabetes care.

Ethical Arguments for Providing Access to Mental Health Care through Longitudinal Relationships

A focus on access to mental health care is critical for beneficent and just care of individuals experiencing homelessness. The delivery of this care is strengthened through building longitudinal relationships between clinicians and persons experiencing homelessness—relationships that are best understood, perhaps, through the lens of attachment theory. In this paper, we look at the prevalence of mental illness among individuals experiencing homelessness and the history of deinstitutionalization of the mentally ill. We then evaluate how three modern-day interventions—street medicine, community health clinics, and supportive housing programs—play integral roles in providing mental health care and constructing a trusting relationship. We conclude with a call for increased funding to support the expansion of these essential mental health care interventions, especially in the aftermath of COVID-19.

The Best Thresholds for Rapid Identification of Episodic and Chronic Homeless Shelter Use

This paper explores how to best identify clients for housing services based on their homeless shelter access patterns. We utilize the number of shelter stays and episodes of shelter use for a client within a specified time window. Thresholds are then applied to these values to determine if that individual is a good candidate for housing support. Using new housing referral impact metrics, we explore a range of threshold and time window values to determine which combination both maximizes impact and identifies good candidates for housing as soon as possible. New insights are also provided regarding the characteristics of the “under-the-radar” client group who are typically not identified for housing support.

Navigating and Negotiating Health and Social Services in the Context of Homelessness: Resistance and Resilience

In this article, we draw upon a case study exploring social inequality and homelessness in homeless-oriented services in a large health and social services centre in Montreal, Quebec, Canada. We take up professionals’ (working in homelessness services) and service users’ (people experiencing homelessness) (N=12) perspectives exploring slippery notions of empowerment/disempowerment using a stigma, resistance, and resilience lens. We mobilize the concepts of navigation and negotiation to better understand participants’ experiences of stigma and the dialogical tensions in empowerment/disempowerment constructs moving beyond simple worker/service user dichotomies of powerful/powerlessness. We explore the more nuanced ways professionals and people who experience homelessness (often described in passive terms) understand these tensions and the dynamics at play within professional relationships, systems, and structural constraints. We unpack professionals’ “silent practices” in their effort to “empower” service users and resist institutional forged by neoliberal pressures. We make the case that systemic and structural constraints manifested in institutional practices push people experiencing homelessness to adopt strategies of resilience.