Experiencing Homelessness Research Articles

Invisible Deaths — Mortality among People Experiencing Homelessness

Invisible Deaths — Mortality among People Experiencing Homelessness

How People With Lived Experiences of Homelessness and Sex Trades Become Social Service Leaders in Sex Trafficking, Sex Trading, and Youth Organizations: A Community-Engaged Study.

Organizations that work with people who trade sex for compensation (including sex work and trafficking) and who are homeless employ lived experience experts to enhance the relevance and utility of services. We sought to understand how lived experience experts become social service leaders and the conditions that influence their pathways and well-being. Influenced by anti-capitalism and anti-white-supremacy, we used an intersectional, community-engaged, constructivist grounded theory approach to conduct semi-structured, in-depth interviews with 26 adults with lived experiences who were currently employed in an organizational leadership role. Participants were ages 22-43; 50% people of color; 26% trans and gender expansive; and 62% queer. We found that lived experience experts were mostly situated either within an individualist or collectivist organizational context. Participants in the individualist context typically began their trajectories through storytelling, which contrasted with those in the collectivist context who began by organizing around a cause or policy. A cycle of internal and external validation (e.g., mentor affirmation and increased self-worth) and invalidation (e.g., insufficient pay; exploitation of their stories; and identity-based exclusion) resulted. Emerging conflicts were perceived and addressed differently depending on participants' contexts, with some additional barriers for those advocating for sex work decriminalization. Findings suggest that there may be insufficient funding structures, mentorship, and leadership development practices and policies to support lived experience experts. Left unaddressed, lived experience experts, especially those who are multiply minoritized, may transition to other roles and/or out of advocacy movements. Anti-capitalist practice, policy, and research implications that counteract harms and support employees' mental health are discussed.

Homelessness and fears of harm: exploring the experiences of persecutory fears and safety behaviors in unstable housing

ABSTRACT Purpose Fears of being harmed (persecutory worries) may contribute to, perpetuate, and result from homelessness. We aimed to explore the content of such fears in people who experienced homelessness, the use of safety behaviors, and the impact on housing. We further aimed to investigate whether individuals wanted to be asked about and supported with fears of being harmed. Method Twenty-three people with experience of homelessness and at least moderate-severe persecutory worries completed a mixed-methods questionnaire. Results Fears of being harmed explicitly related to previous stable living situations for eleven participants, with seven fearing harm from landlords or neighbors. An additional six participants reported fears related to living situations while homeless. All participants used avoidance strategies and at least six safety behaviors. Fifteen participants stated that there were links between fears, safety behaviors and unstable housing. Most participants reported that they would have wanted support with their fears. Conclusion This study provides evidence that for some individuals the content of persecutory fears specifically relates to their living situation. Such fears, understandably, prompt avoidance and safety behaviors. Most participants wanted support with fears. These findings have clinical implications for improving the support available for people experiencing fears of being harmed and housing difficulties.

Self-reported lifetime Hepatitis B virus testing, and vaccination uptake among people who inject drugs in Iran: a nationwide study in 2020.

Hepatitis B virus (HBV) infection is a silent epidemic among people who inject drugs (PWID). HBV testing and vaccination are important for PWID to reduce the risk of infection, prevent chronic complications and contribute to public health efforts in addressing HBV transmission. Our objective was to assess the self-reported lifetime uptake of HBV testing and vaccination among PWID in Iran and their associated factors. This cross-sectional study was conducted among 2,684 PWID in 11 large cities from July 2019 to March 2020 using a respondent-driven sampling method. Participants were interviewed face-to-face and asked about their lifetime experience of HBV testing and vaccination uptake as the outcome. Logistic regression models were built to identify related factors for reporting HBV testing and vaccination uptake. The prevalence of HBV testing and vaccination uptake among PWID was 14.2% (95% confidence intervals [CI]: 12.8-15.6) and 16.4% (95% CI: 14.9-18.1), respectively. Shared needles, syringes, or equipment in the past 12 months decreased the odds of reporting lifetime HBV testing uptake (Adjusted odds ratio [AOR]:0.46, 95% CI: 0.29-0.72). However, having an academic education (AOR: 1.89, 95% CI: 1.09-3.30) and lifetime experience of homelessness (AOR: 1.58, 95% CI: 1.21-2.06) increased the odds of reporting lifetime HBV vaccination uptake. Our study highlighted the low prevalence of HBV testing and vaccination uptake among PWID in Iran. It is essential to understand and address the obstacles preventing PWID from getting tested and vaccinated for HBV. Addressing these barriers could significantly reduce the burden of HBV among this socio-economically marginalized population.

Results of a Randomized Wait-List Controlled Trial of CAYA: A Nurse Case Management HIV Prevention Intervention for Youth Experiencing Homelessness.

Youth experiencing homelessness (YEH) face challenges that increase their susceptibility to HIV/STIs. Nurse case management is effective in managing the complex needs of populations experiencing homelessness and reducing HIV risk. A randomized wait-list control study conducted between September 2019 to May 2023 evaluated the CAYA "Come As You Are" intervention. This nurse-led HIV prevention for YEH aged 16-25 years focused on the uptake of HIV prevention methods: pre- and post-HIV exposure prophylaxis (PrEP, nPEP), HIV/STI testing and treatment, sober sex, and condom use. Secondarily, we examined intervention impact on housing stability. Descriptive statistics were calculated by study arm. Multiple imputation (m = 10) was used for missing values and intervention effects were estimated from Bayesian multilevel models with noninformative priors. Participants (N = 450) were 21.1 years old on average, 62% Black, 11% Hispanic, 11% White, and 10% other race and reported being homeless for an average of 3 years. An intervention effect was found for PrEP use, which showed a larger increase from baseline to first follow-up (OR = 3.27; 95% Cr.I.: 1.13 to 10.14). No intervention impact was found for nPEP use, HIV and STI cases, sober sex, or condom use. Sheltering arrangements improved from baseline to the first follow-up in both groups with increase in shelter stability (OR = 3.85; 95% Cr.I.: 1.61 to 10.30) and decreased shelter transiency (OR = 0.29; 95% Cr.I.: 0.14 to 0.60). This study demonstrates that a personalized, nurse-led HIV prevention approach increased uptake of some but not all HIV prevention strategies among YEH. CLINICAL TRIAL REGISTRATION NUMBER: NCT03910218.

A Systematic Review of Cash Benefit Programs for People Experiencing Homelessness in the United States

A Systematic Review of Cash Benefit Programs for People Experiencing Homelessness in the United States

Building trust and inclusion with under-served groups: a public involvement project employing a knowledge mobilisation approach.

Certain groups are commonly under-served by health research due to exclusionary models of research design/delivery. Working in partnership with under-served groups is key to improving inclusion. This project aimed to explore the use of a knowledge mobilisation approach to start building partnerships with under-served groups based on trust and mutual understanding. This co-produced public involvement project employed a knowledge mobilisation approach. The project team involved public contributors from four community organisations and staff from two Universities. A series of 'community conversations' were co-produced. These involved open discussions with local people in community settings. The conversations provide an informal space to engage in a multi-directional dialogue about health research and incorporated approaches such as prompt questions, live illustrations, and themed boards. The findings were reviewed collectively. Dissemination/feedback activities and lessons learned for future engagement with community organisations and under-served groups were also co-produced. Over 100 people attended the community conversations. Attendees varied widely in their sociodemographic characteristics (e.g., socioeconomic status and ethnicity) and brought diverse lived experiences (e.g., experiences of homelessness and disability). A strong appetite for change and desire to mobilise public knowledge were evident. Attendees reported wide-ranging barriers to inclusion in health research and suggested ways to address them. Three inter-related take-home messages were identified: ensure relevance, appreciation, and trust; prioritise language and accessibility needs; and maximise flexibility in all research-related activities. Feedback about the community conversations and dissemination activities was largely positive, with all parties planning to continue the partnership building. The lessons learned provide practical suggestions for promoting inclusion in research and highlight the importance of addressing research teams' training/support needs. Knowledge mobilisation was a valuable approach for facilitating multi-directional dialogues and relationship building between local communities and university teams. This approach enabled co-creation of new knowledge related to inclusion and partnership working in health research. The project has provided a firm foundation to build upon. However, creating sustainable, inclusive public partnerships is likely to require systemic changes, such as weighting of fundings schemes to projects that prioritise inclusion of under-served groups throughout the research cycle.

A response to Jindra, Jindra, and DeGenero’s “Contrasts in Religion, Community, and Structure at Three Homeless Shelters: Changing Lives”

The book Contrasts in Religion, Community, and Structure at Three Homeless Shelters: Changing Lives seeks to explore the role of religion and personal transformation in people's experiences of homelessness. While the goals show promise, this response offers a critique of the claims provided by the authors. Here, I suggest that binary thinking around 'structural' and 'individual' causes of homelessness, methodological challenges, missing clarity on what amounts to 'success,’ and a lack of sensitivity to the narratives and experiences of people who are homeless does not advance the scholarship on homelessness. Instead, I point to concerns about how longstanding myths and stereotypes about homelessness may be reinforced through this form of analysis that individualizes and blames people for experiences that are ultimately driven by and mediated through structural barriers. The response also offers insight into where to take research of this nature, including an emphasis on how spirituality and caring for the whole person offers an opportunity to make a meaningful contribution to homelessness literature.

The Intersecting Effects of Lifetime Experiences of Homelessness and Incarceration on Cognitive Aging and Dementia Risk Factors in the United States.

Alzheimer's disease and related dementias (ADRD) remain a pressing concern in the US, which also has one of the highest incarceration rates worldwide. Existing research has analyzed dementia risk and care among currently incarcerated and homeless populations; this paper fills a gap by examining later-life cognitive disparities facing formerly incarcerated and/or homeless individuals. Using Health and Retirement Study data (HRS; 1998-2018), we tested whether formerly homeless and/or incarcerated people had earlier onset of cognitive decline, and whether they were more likely to have modifiable risk factors for ADRD than those without such experiences. We estimated prevalence of mild cognitive impairment (MCI), dementia, and self-reported ADRD diagnosis. We also used repeated observations of cognitive functioning coupled with nested nonlinear regression to examine the onset of accelerated cognitive decline. Adjusting for demographic variables, formerly homeless and/or incarcerated participants have increased odds of having risk factors for dementia, including smoking, drinking alcohol, depression, mental illness, and discrimination from healthcare providers and police. Diagnosis of MCI and ADRD were more common among participants reporting a history of incarceration or homelessness. Nested nonlinear regression revealed that previous experiences of incarceration or homelessness-alone or together-are associated with earlier onset of accelerated cognitive decline compared to those who experienced neither. This study suggests that, even if they occur earlier in life, homelessness and incarceration experiences may increase risk of poorer cognitive health in late life. Future work is warranted to understand the lifelong consequences linked to this adversity.

Understanding Experiences of Street Addiction Among People Experiencing Homelessness: A Qualitative Research Study

ABSTRACT Homelessness is a global concern and there is no sufficient information on the question of why some people repeatedly return to living and hanging out on the street even after rehabilitation attempts and giving them a place to stay and live. The main goal of the present study was to understand the draw of street life experiences of people experiencing homelessness through the framework of street addiction. The analytic framework of “street addiction,” developed in a previous study, parallels the criteria of behavioral addiction in DSM-5. Using an abductive-phenomenological strategy, we conducted semi-structured interviews with 12 people with chronic patterns of homelessness who had a background in substance use and with 3 support workers who worked with them. All the participants described experiences of severe street addiction and attraction to life on the streets. Their experiences matched the criteria of behavioral addiction and the theoretical model of street addiction. We recommend gaining an in-depth understanding of street addiction by conducting further studies to develop therapeutic, rehabilitative, and harm reduction responses to people experiencing homelessness.

A Co-produced International Qualitative Systematic Review on Lived Experiences of Trauma During Homelessness in Adulthood and Impacts on Mental Health.

Trauma can be both a cause and a consequence of homelessness and has lasting impacts on mental health and wellbeing. Often research focusses on trauma and adversity in childhood leading to homelessness, but understanding traumatic experiences during adulthood homelessness can be just as important for informing intervention development and policies to mitigate and eradicate homelessness. Working with people with lived experience of homelessness, this review aimed to synthesis the qualitative evidence exploring the impact of trauma during homelessness on mental health (including substance use) from the perspective of adults (18 years of age and older) experiencing homelessness. Alongside gray literature, ASSIA, CINAHL, Cochrane, EMBASE, MEDLINE, Proquest theses and dissertations, PsychInfo, Scopus and Web of Science were searched from inception until February 2024. No language, date, or geographical limits were applied. A 'best-fit' framework synthesis of 26 papers, covering the experience of over 900 people, identified three overarching themes linked with the SAMHSA three E's of trauma: 1) making sense of homelessness as a trauma, 2) dealing with the impacts of trauma and 3) responses to repeated exposure to trauma. Trauma rarely takes place in isolation and often prior experiences shape how people experiencing homelessness make sense and cope with trauma. Policy and prevention should prioritise early intervention to reduce the mental health burden of trauma and homelessness. Additionally, creating support that empowers and builds resilience will encourage more positive management strategies.

Supplemental Material for Multiple Discriminatory Threats and Well-Being Among Youth Experiencing Homelessness

Supplemental Material for Multiple Discriminatory Threats and Well-Being Among Youth Experiencing Homelessness

Development of Undergraduate Competencies in Caring for People Experiencing Homelessness.

Nurses play a critical role in reducing health inequities in people experiencing homelessness (PEH), a key social determinant of health. Health disparities specific to PEH are exacerbated by numerous factors, including bias, stigma, and a lack of nursing competency in caring for PEH. The purpose of this study was to validate registered nurse key competencies; associated knowledge, skills, and attitudes; and concepts, content, and learning activities to serve as an educational framework in providing care for PEH. Twenty-four nursing experts on the care of PEH rated draft competency and subcompetency statements for relevance and clarity, proposed revisions and missing competencies, and identified essential and useful content, concepts, and learning activities. Four key competencies, 38 subcompetencies, and associated concepts, content, and learning activities were validated by the experts. This framework can be used to guide curricular development across nursing programs to advance health equity for PEH.

A Lifeline to Fill the Silence of Homelessness: Person-Centered Analysis of Digital Coping and Links to Mental and Physical Health.

Individuals experiencing homelessness are among the most vulnerable population for mental and physical health disparities. Despite navigating numerous stressors on a day-to-day basis, they are vastly underrepresented within coping research. Using a person-centered approach, this study addresses ways in which technology is leveraged to manage ongoing stressors associated with the experience of homelessness. We employed a two-step and k-means cluster analysis within a sample of unhoused individuals (n = 66). Two distinct clusters emerged, revealing unique patterning of digital coping, stress, self-efficacy, and technology use. Resulting clusters were validated across numerous health outcomes, including mental and physical health problems, as well as digital service use and experience of homelessness. High digital engagement/low self-efficacy individuals (65% of sample) reported high levels of digital self-efficacy, yet lower levels of general self-efficacy. In contrast, low digital engagement/high self-efficacy individuals (35% of sample) engaged in relatively lower digital coping and technology use, with lower stress and higher general self-efficacy. High digital engagement/low self-efficacy individuals, in turn, reported more mental and physical health problems; whereas low digital engagement/high self-efficacy reported somewhat decreased digital access. Relatively few differences emerged between the clusters on experiences of homelessness. Due to the transient nature of unhoused people, reaching such vulnerable populations via technology to support their digital coping and subsequently enhance well-being outcomes represents a critical next step for digital equity. This population is poised to benefit from digital equity efforts, with critical implications for reduced health disparities.

What Makes a Home.Evaluating a Novel Low Support Homeless Accommodation Model Using Co-design Methods

Abstract Background Homelessness is a global challenge, with a prevalence of 4%; the problem is underestimated due to limitations in data collection. In Ireland, 1% of the population, including children, adults, and families, experience homelessness due to housing shortages and systemic complexities. Homeless accommodation is defined as emergency and temporary; the wording is used interchangeably. The ETHOS typology of homelessness comprises two dimensions - housing-focused and support-focused. Supports range from high to low levels. This study evaluated an emergency housing accommodation with low support to assess its feasibility and impact. Methods Previous residents of an urban residential area with low support [introduced in August 2021] and key stakeholders, including policymakers and health and social care professionals, were invited to collaborate in a half-day co-design workshop [February 2024]. The workshop modified Stanford D’s five-stage design thinking processes to consider ‘How might we harness strengths and abilities to create a home and beyond’. Qualitative data were captured on flip charts, post-its, and via photographs over three rounds of activities following initial reflection regarding 1) identifying emerging challenges, 2) exploring potential solutions, and 3) considering resources for advocacy and success. Results Data analyses from 16 participants highlight 1)Personal insights: silence, freedom in decision-making, feeling overwhelmed, valuing independence and understanding accommodation transitions; 2)Organisational insights: developing and promoting independent skills, managing resident preferences and personalities, balancing regulations within emergency accommodation, and staff training. Space was critical in fostering therapeutic well-being and a sense of home environment. Conclusions Effective organisational structures are required to facilitate coherent transfers and transitions. Using co-design methods enabled real-world partnerships and engagement. Key messages • Homelessness is a significant public health challenge, and a model of low support emergency accommodation has value in supporting transition through and out of services. • Engaging with people with lived experience of homelessness is essential for developing supported accommodation models.

Empowering People Experiencing Homelessness for cancer prevention using the Health Navigator Model

Abstract Cancer poses a significant public health concern. Reports highlight that cancer-related mortality rates are double among people experiencing homelessness (PEH). CANCERLESS project delivered an innovative solution based on the Health Navigator Model (HNM). The HNM is an evidence-based patient-centred intervention that develops patient empowerment through health education and social support, promoting timely access to cancer prevention services. A pre-post design study conducted across four pilot sites in Europe (Austria, Greece, Spain, UK) involved 652 PEHs. Pilot interventions based on the HNM were implemented, with effectiveness evaluated at baseline and post-intervention. The study assessed the impact of the HNM on various factors including risk behaviors, lifestyles, quality of life, empowerment, health literacy, psychological distress and utilization of health and care services. Preliminary findings from CANCERLESS HNM intervention showed significant improvements (p= .000) in participants’ quality of life (55.82 (27.65) vs. 66.18 (22.27)) and sense of empowerment (25.58 (19.95) vs. 59.94 (43.10)). However, there were no observable impacts in health literacy (p= .509) or psychological distress (p= .140), which remained within acceptable ranges both pre- and post-intervention. Similarly, there were no significant changes observed in lifestyle or risk behaviours among PEHs. Nonetheless, the evaluation of effectiveness suggested that the HNM increase in the uptake of cancer prevention care, such as cancer screening (p= .000). The CANCERLESS HNM intervention significantly improved the quality of life and empowerment of PEHs. Additionally, it successfully promoted their involvement in cancer prevention efforts, addressing disparities in access to preventive healthcare services. Increased engagement in such initiatives can lead to early detection and treatment, ultimately reducing cancer morbidity and mortality rates, thereby positively impacting public health. Key messages • By promoting health equity and social justice, interventions like CANCERLESS HNM contribute to building healthier and more resilient public health systems. • CANCERLESS boosts cancer prevention awareness, tackles healthcare disparities, enhances cancer early detection, benefiting public health.

Understanding the Population of People Experiencing Homelessness in Cape Town and their Service Use

Cape Town, South Africa, has an estimated 14,357 people living on the street or in temporary shelters. Current responses to homelessness are either punitive—focusing on law enforcement and displacement—or compassionate, offering basic relief like food or handouts. Neither approach is effectively addressing the root causes of homelessness, and the number of homeless individuals continues to rise. This paper advocates for a developmental approach that provides structured support to help people exit homelessness. There is limited knowledge about the causes of homelessness in South Africa, the services utilized by those affected, and the kind of support needed for sustainable solutions. To address this gap, a survey of 350 homeless individuals in Cape Town was conducted, gathering data on demographics, service use, income sources, health, substance use, and interactions with legal systems. The results reveal that the average duration of homelessness is 8.6 years, with over 70% of respondents experiencing homelessness for more than a year. The main causes of homelessness were identified as structural issues such as lack of income, housing access, and loss of family support. Only 11% of participants were in temporary shelters, and their average daily income was around R78 (about $4 USD). Substance use disorders were prevalent, affecting 63% of respondents, while 54% reported being arrested at least once during their experiencing homelessness. Most had not accessed developmental services, highlighting a critical gap in support. If the current approach persists, homelessness will worsen, with more individuals becoming entrenched in chronic homelessness. A shift towards a developmental approach is urgently needed, focusing on personalized support, affordable housing, rehabilitation, psychosocial services, and employment programs to facilitate a meaningful exit from homelessness.

The Role of Companionship in Volunteer Homelessness Support Services: A Qualitative Study

Drawing on developments in the application of occupational science to issues of homelessness and tenancy sustainability, this paper will argue for the recognition of authentic, everyday relationships as a core part of tenancy support. Data from a small-scale evaluation of a volunteer-led homelessness support service will be explored through a framework of social support to show the importance of companionship in enabling individuals to exit homelessness. The data show that individuals valued the provision of social support from volunteers in everyday locations, as it replicated authentic relationships which individuals had sometimes lost through their experiences of homelessness. This paper argues that the facilitation of authentic, everyday relationships should be considered an important part of homelessness support.

Centring lived experience of homelessness in law and policy reform

This reflective work considers homelessness and provides a model of participation for improving homelessness responses through StreetCare, a NSW-based advisory committee of people with diverse lived experiences of homelessness. StreetCare provides unique, essential and pertinent advice to relevant stakeholders in the housing and homelessness sector at the local, state and national level. Through the example of StreetCare, this piece explains how the participation of those with lived experience in reform contributes to better outcomes, to the empowerment of lived experience advocates, and to more equitable laws.

The Hope and Goals of Youth Experiencing Homelessness

The Hope and Goals of Youth Experiencing Homelessness