Homeless Services Research Articles

“COVID knocked me straight into the dirt”: perspectives from people experiencing homelessness on the impacts of the COVID-19 pandemic

BackgroundPeople experiencing homelessness are uniquely susceptible and disproportionately affected by the impacts of the COVID-19 pandemic. Understanding context-specific challenges, responses, and perspectives of people experiencing homelessness is essential to improving pandemic response and mitigating the long-term consequences of the pandemic on this vulnerable population.MethodsAs part of an ongoing community-based participatory research study in partnership with a homeless service organization in Indiana, semi-structured interviews were conducted with a total of 34 individuals experiencing homelessness between January and July 2021. Guided by the NIMHD Health Disparities Research Framework, which builds on the socio-ecological model, data was thematically coded using Nvivo12 qualitative coding software and themes were organized by levels of influence (individual, interpersonal, community, societal) and domains of influence (biological, behavioral, physical/built environment, sociocultural environment, health care system).ResultsNarratives revealed numerous and compounding factors affecting COVID-19 risks and health outcomes among people experiencing homelessness across all levels and domains of influence. At the individual level, people experiencing homelessness face unique challenges that heightened their susceptibility to COVID-19, including pre-existing physical and mental health conditions, substance use and behavioral health risks, socioeconomic precarity, and low health literacy and COVID-related knowledge. At the interpersonal level, poor communication between people experiencing homelessness and service providers led to limited understanding of and poor compliance with COVID safety measures. At the community level, closures and service disruptions restricted access to usual spaces and resources to meet basic needs. At a policy level, people experiencing homelessness were disregarded in ways that made pandemic relief resources largely inaccessible to them.ConclusionsOur findings reveal important and mitigable issues with ongoing pandemic response efforts in homeless populations through direct, first-hand accounts of their experiences during COVID-19. These insights offer opportunities for multilevel interventions to improve outreach, communication, and impact mitigation strategies for people experiencing homelessness. This study highlights the importance of centering the voices of vulnerable communities to inform future pandemic response for homeless and other underserved and marginalized populations.

The autistic experience of homelessness: Implications from a narrative enquiry.

Recent research suggests many autistic people experience homelessness. However, little is known about the types of homelessness autistic people experience and what barriers autistic people face when trying to exit homelessness. This study involved gathering life stories of autistic people who had experienced homelessness. Ten autistic participants talked about their pathways through homelessness and the difficulties they had in accessing support. After first becoming homeless, participants tended to experience rough sleeping and sofa surfing. When participants approached housing and homelessness services, they were often told they were not eligible for support. This could happen when support workers were not aware of autism, or when autism was not considered 'severe' enough. Overcrowding, confrontation and lack of control over routine and environment were particular issues for participants when they entered homelessness hostels. Some participants chose to sleep on the streets rather than stay in environments which increased social anxiety and sensory difficulties. This study discusses ways in which homelessness and housing services can increase accessibility and improve engagement for autistic people. It is important to increase awareness of autism while understanding that autistic people who experience homelessness may have complex needs. In addition, services need to listen to autistic people with lived experience of homelessness to decide what changes will have the most impact.

Service use and barriers to care among homeless veterans: Results from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study.

The objective of this study was to examine type of services U.S. veterans seek when they experience homelessness, characteristics associated with service use, and reasons for not using services. Data from a 2021 nationally representative survey of 1004 low-income U.S. veterans were analyzed with descriptive and multivariable analyses. One-quarter of low-income U.S. veterans with experiences of homelessness reported using homeless services while they were homeless and about 27% reported using U.S. Department of Veterans Affairs (VA) healthcare or benefits while homeless. Black and Hispanic veterans were more likely to use both homeless services and VA services while homeless than veterans of other race/ethnic groups. The most common barriers to services were: veterans felt they did not need help, they did not have information about services, there was stigma and shame, and transportation barriers were encountered. These findings suggest veterans use various VA and community-based homeless and healthcare services, but they do experience barriers that may be improved with better public information and care coordination to improve service uptake among homeless veterans.

Planning for and Against Vehicular Homelessness

Problem, research strategy, and findings Shelter is a necessity, yet approximately 17 out of every 10,000 people in the United States are unhoused. Public attention to homelessness has centered on individuals sitting and sleeping in public spaces. However, as many as 50% of the unsheltered live in vehicles. For people sleeping in vehicles, finding a safe place to park is an ongoing challenge, further complicated by the growing number of ordinances restricting vehicular dwelling. We drew on point-in-time count data from the Los Angeles (CA) Homeless Services Authority to examine spatial patterns of vehicular homelessness in Los Angeles from 2016 to 2020. We tested the relationship between the presence of vehicle regulations and the number of people sleeping in vehicles. Although the data likely underestimated vehicular homelessness, we found that ordinances directly reduced the number of people living in vehicles in particular census tracts. On average, cities with citywide and overnight bans had greater impacts on people sleeping in vehicles than cities with less restrictive ordinances. However, the indirect effects in neighboring tracts were stronger and demonstrate the role of these ordinances in simply shifting the vehicular homeless between areas. Takeaway for practice Given the slow pace of delivering permanent housing for people experiencing homelessness, cities should reduce the harm and precariousness of living in vehicles. Strategies to do this include the reform of punitive vehicle towing and vehicle dwelling regulations. Safe parking programs can provide individuals with a safe place to park their vehicles at night, offer ancillary services, and deter harassment from neighborhood residents and the police. Longer term, transformative change will require additional policies and programs to place people into permanently affordable housing.

Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco’s Mission District: a qualitative study

BackgroundPeople experiencing homelessness have unique health needs and barriers to medical and behavioral health care (mental health, substance use disorder, and overall well-being) compared to housed people. It remains unclear why many people experiencing homelessness do not access care when community-based homeless health care resources are available at low or no cost. This qualitative study examined perspectives of people experiencing homelessness and staff members at community-based homeless health and service organizations in San Francisco’s Mission District on unmet medical and behavioral health needs and barriers to accessing care.MethodsWe conducted 34 interviews between September and November 2020: 23 with people experiencing homelessness and 11 with staff at community-based homeless health and service organizations in the Mission District. Qualitative interviews were transcribed, coded, and analyzed using the Framework Method on NVivo Qualitative Data Analysis Software.ResultsBoth staff and homeless participants reported unmet and common health needs of mental illness, physical injury and disability, food and nutrition insecurity, and substance use disorder. Barriers to care included negative prior health care experiences, competing priorities, and provider turnover. Recommendations for improving services included building more trust with people experiencing homelessness by training clinic staff to treat patients with respect and patience and expanding clinical outreach and health education programs.ConclusionsPeople experiencing homelessness face many different health needs and barriers to care, some of which community-based organizations have the ability to address. These findings can help inform future strategies for homeless health care programs to identify and target the specific unmet health needs and barriers to care of people experiencing homelessness in their communities.

Behavioral Health Providers' Experience with Changes in Services for People Experiencing Homelessness During COVID-19, USA, August-October 2020.

The COVID-19 pandemic caused disruptions in behavioral health services (BHS), essential for people experiencing homelessness (PEH). BHS changes created barriers to care and opportunities for innovative strategies for reaching PEH. The authors conducted 50 qualitative interviews with behavioral health providers in the USA during August–October 2020 to explore their observations of BHS changes for PEH. Interviews were transcribed and entered into MAXQDA for analysis and to identify salient themes. The largest impact from COVID-19 was the closure or limited hours for BHS and homeless shelters due to mandated “stay-at-home” orders or staff working remotely leading to a disconnection in services and housing linkages. Most providers initiated telehealth services for clients, yielding positive outcomes. Implications for BHS are the need for long-term strategies, such as advances in communication technology to support BHS and homeless services and to ensure the needs of underserved populations are met during public health emergencies.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11414-022-09800-9.

Perspectives of homeless service providers on their work, their clients, and the healthcare system.

PurposeTo describe the perspectives of homeless service providers who work for Chicago organizations that primarily serve persons experiencing homelessness.MethodsA qualitative, cross-sectional study of Chicago homeless service providers (n = 17) consisting of a semi-structured interview and the Attitudes Toward the Homeless Inventory (ATHI). Interviews were analyzed for themes and patterns using inductive approach.ResultsFour categories of 16 themes describing homeless service providers’ perspectives and perceptions: 1) perspectives on work, 2) perspectives on the general population of those experiencing homelessness at large, 3) perceptions of the population of those experiencing homelessness based on client interactions, and 4) perceptions of hospitals and healthcare.ConclusionsA richer understanding of the perspectives of homeless service may provide guidance in recruitment and training of workers in this area and offer insight into caring for persons experiencing homelessness in hospital settings.

De-Implementation: Lessons to be Learned when Abandoning Inappropriate Homelessness Interventions

Evidence on what works to end homelessness is growing. Evidence also highlights that some forms of help are harmful and should be de-implemented. The ability to abandon low-functioning interventions is considered essential to improve conditions for homeless people. It is common for challenges to be encountered when evidence exists claiming that alternative approaches are more effective and/or cost-effective. This is particularly true in the context of the problematic staircase model and the highly effective Housing First. In this study, the aim was to collect published articles on the process of abandoning established methods with low scientific support. This scoping review explores evidence on de-implementation that may clarify why it can be difficult to introduce interventions like Housing First despite having strong scientific evidence. The call for a shift toward greater provision of Housing First in Sweden underlines the timeliness of this problem. Forty-one articles published between 2014 and 2020 were included. The review found no articles focusing on the de-implementation of homelessness services. Findings from other fields show that the important first step is to identify what needs to be phased out. Together with organized demands from users and favorable financial effects, scientific evidence can constitute driving mechanisms for de-implementation. We found a lack of practical frameworks and theoretical explanations that could support successful phasing out of unnecessary interventions in the homelessness field. It is suggested that to support the implementation of new ways of working that better benefit homeless people, we must pay attention to established ways of working. This requires a developed theory of de-implementation of homelessness interventions and calls for more robust research.

A cross-sectional survey of smoking and cessation support policies in a sample of homeless services in the United Kingdom

BackgroundSmoking is extremely common amongst adults experiencing homelessness. To date, there is no nationally representative data on how tobacco dependence is treated and if and how smoking cessation is supported across the homeless sector. The aim of this study was to document smoking and e-cigarette policies of UK homeless services and identify areas of good practice and where improvements could be made.MethodsA cross-sectional survey with homeless centre staff was conducted between June 2020-December 2020 totalling 99 homeless centres. Quotas were stratified based on population and service type across Scotland, Northern Ireland, Wales, and England. Interviews were conducted over the phone or online in a minority of cases. Survey questions were themed to assess, i) onsite smoking and e-cigarette (vaping) policies ii) screening and recording of smoking status, iii) cessation training and resources available to staff, iv) cessation support for service users.Results92% accounted for smoking within their policies in some form (stand-alone policy (56%) or embedded within another health and safety policy (36%)). 84% allowed smoking in at least some (indoor and outdoor) areas. In areas where smoking was not allowed, vaping was also disallowed in 96% of cases. Staff smoking rates were 23% and 62% of centres reported staff smoked with service users. Just over half (52%) reported screening and recording smoking status and 58% made referrals to Stop Smoking Services (SSS), although established links with SSS were low (12%) and most centres did not provide staff training on supporting smoking cessation. Areas of good practice included regular offers of smoking cessation support embedded in routine health reviews or visits from SSS and offering tangible harm reduction support. Areas for improvement include staff training, staff smoking with service users and skipping routine screening questions around smoking.ConclusionsSmoking is accounted for across different policy types and restricted in some areas within most settings. Smoking cessation support is not routinely offered across the sector and there is little involvement with the SSS.

Actionable research for understanding and addressing homelessness.

Homelessness results from an interaction of structural determinants and individual vulnerabilities, creating various pathways into homelessness and having multilevel impacts. Understanding and addressing homelessness requires research that not only takes an ecological perspective but also can be translated into action. Despite research demonstrating differing needs and experience among various subpopulations, particularly marginalized groups, homeless service systems often take a one-size-fits-all approach. Additionally, homeless service systems' prioritization of the most vulnerable and chronically homeless for permanent housing programs results in a service system that operates in a state of triage, with minimal attention to prevention efforts. This special issue highlights actionable research focused on preventing homelessness and addressing disparities among marginalized groups. Included articles target homelessness at multiple levels using a combination of qualitative, quantitative, and mixed-methods approaches. Embedded in community psychology values, this study focuses on prevention, leverages participatory methods, relies on diverse lived experiences, and explores community-based solutions.

Homeless youth shelters and services for transgender and gender non-conforming (TGNC) clients: Results from a nationwide survey

This study explored results from a nationwide survey conducted with homeless youth shelter directors. The research sought to further the understanding of how policy and societal changes about gender affirming access to services have affected service delivery and accommodations at homeless youth shelters for transgender and gender non-conforming (TGNC) youth. Results from (n = 117) youth shelters indicate the majority of those surveyed are current in implementing many of the Housing and Urban Development (HUD) gender affirming policies. Among others, recommendations include a need for shelters to incorporate TGNC safety accommodations, and to update dress code policies from a universal design perspective.

Does local community effort relate to neighbors' homelessness?

Interjurisdictional spillovers can compromise the effectiveness of homeless assistance policy and service provision, as individuals that become homeless in service deserts are forced to move to nearby communities that provide services they require. The resulting migration causes difficulties in accurately measuring the effectiveness of homeless assistance policies and hinders the establishment of measures aimed at ending homelessness at a regional level. The present investigation addresses these challenges by exploring how local community effort aided by government and nonprofit organizations relates to interjurisdictional outcomes. Our findings indicate that an increase in homeless services offered by nonprofit organizations in a community relates with fewer services (i.e., reduction in total beds per homeless person) and more homelessness in neighboring communities. Further, simultaneously increasing the number of both government and nonprofit organizations mitigates some of the negative spillovers. These findings augment the results yielded by previous research in this field, as they indicate that cross-sector collaboration can benefit the broader community and is more effective in reaching vulnerable populations and reducing homelessness than investing in government and nonprofit-led efforts executed independently.

Magnet mobility myths: exploring geographical mobility amongst people experiencing, or at-risk of, homelessness in Australia

It is often assumed that people experiencing homelessness gravitate to large cities and central city areas because of the concentration of homelessness services — a so-called magnet or honeypot effect. Yet little is actually known about how people experiencing homelessness move across space over time. This article explores this geography by comparing the mobility of those experiencing homelessness, those ‘at-risk’, and those renting privately in Australia, between waves in two Australian panel surveys: Journeys Home and the Household, Income and Labour Dynamics in Australia (HILDA). Results suggest that while people experiencing homelessness are more likely to move than the other two groups, they more similarly short distances and appear more likely to move for reasons such as relationship breakdown, eviction and to escape violence. While some evidence of movement to areas with particular characteristics (sorting) was detected amongst those at-risk and those renting privately, this was not the case for those experiencing homelessness. Results do not support the contention that people experiencing homelessness gravitate to central urban areas well-resourced with homelessness services over time. The findings challenge assumptions about magnet effects and homelessness and have important implications for the provision and delivery of homelessness services in Australia and beyond.

The application of GIS in homelessness research and service delivery: A qualitative systematic review.

GIS is increasingly popular in the study of complex social issues, such as homelessness. This study aims to assess how GIS has been leveraged and applied to homelessness research and service delivery. Systematic searching of sixteen databases was completed between January and March of 2021 using the terms "homeless" and "Geospatial Information Systems (GIS)." A final sample of 19 sources were identified from a total of 1719 identified sources. Through quantitative and qualitative methods, the included sources examined 1) static location characteristics associated with homelessness, and 2) mobility of homeless persons.

Housing First is Not Enough

This policy brief critically examines the Housing First turn in U.S. homeless policy. Housing First is a popular model of homeless services that rehouses people experiencing chronic homelessness without preconditions like sobriety, treatment, or employment. The Department of Housing and Urban Development promotes Housing First as an evidence-based practice that grantees should adopt. While I laud this as a step in the right direction, this paper identifies three shortcomings of Housing First that limit its ability to end chronic homelessness. I then discuss two supply-side interventions (i.e., tax credit expansion and integrated public housing) that can compensate for these shortcomings.

Shifting social worker attitudes toward homelessness: an MSW training program evaluation

ABSTRACT Homeless agencies rely on social workers to fulfill a critical role in housing first service delivery yet social worker recruitment and retention for high-demand fields are challenging. A consortium of five Masters of Social Work (MSW) programs located in Southern California participated in a student training program to enhance field placements in the homeless sector. The Homeless Social Work Education Program (“the Program”) provides a homeless sector-specific curriculum designed to reverse misunderstood causes of homelessness and improve comfort affiliating with homeless. This article presents the Program’s evaluation findings at the end of Year 2. Over the two-year period, 28 students completed a pre- and post-evaluation which included the Attitudes Toward Homelessness Inventory (ATHI). The results showed a significant student improvement in the outlook towards the homeless population. The Homeless Social Work Education Program may offer a model that will address workforce deficits in the homeless social service sector by improving attitudes towards working with this population.

Clinic- and Community-Based SARS-CoV-2 Testing Among People Experiencing Homelessness in the United States, March-November 2020.

Objective:SARS-CoV-2 testing is a critical component of preventing the spread of COVID-19. In the United States, people experiencing homelessness (PEH) have accessed testing at health clinics, such as those provided through Health Care for the Homeless (HCH) clinics or through community-based testing events at homeless service sites or encampments. We describe data on SARS-CoV-2 testing among PEH in US clinic- and community-based settings from March through November 2020.Methods:We conducted a descriptive analysis of data from HCH clinics and community testing events. We used a standardized survey to request data from HCH clinics. We developed and made publicly available an online data entry portal to collect data from community-based organizations that provided testing for PEH. We assessed positivity rates across clinics and community service sites serving PEH and used generalized linear mixed models to account for clustering.Results:Thirty-seven HCH clinics reported providing 280 410 tests; 3.2% (n = 8880) had positive results (range, 1.6%-4.9%). By race, positivity rates were highest among people who identified as >1 race (11.6%; P < .001). During the reporting period, 22 states reported 287 community testing events and 14 116 tests; 7.1% (n = 1004) had positive results. Among facility types, day shelters (380 of 2697; 14.1%) and inpatient drug/alcohol rehabilitation facilities (32 of 251; 12.7%) reported the highest positivity rates.Conclusions:While HCH clinic data provided results for a larger number of patients, community-based testing data showed higher positivity rates. Clinic data demonstrated racial disparities in positivity. Community-based testing data provided information about SARS-CoV-2 transmission settings. Although these data provide information about testing, standard surveillance systems are needed to better understand the incidence of disease among PEH.

A Multi-Dimensional View of Stigma Experienced by Lone Parents in Irish Homeless and Employment Services

This critical and empirical article explores contemporary reproduction, experience, and responses to stigma in welfare delivery in Ireland. Combining qualitative data about lone parents (n22) gathered through two different research projects in 2017 and 2018 allows us to interrogate stigma in a multi-dimensional way and as an overarching experience as an ongoing project of neo liberalism. We analyse our findings using Baumberg’s (2016) typology of stigma which differentiates claim making stigma from personal and societal stigma, applying the framework to empirical data concerning lone parents’ recent experiences of Irish labour activation and homeless support services. We find that while behavioural conditionality necessarily frames this experience and constrains claimants, it is not totalising. We conclude by using Tyler’s concept of stigmacraft to situate the context of stigma as part of the political economy of welfare.

Effect of an Emergency Department Closure on Homeless Patients and Adjacent Hospitals.

IntroductionHomeless and housed patients differ on several emergency department (ED) metrics (emergency medical services [EMS] use, chief complaints, admission rates, etc.). On January 1, 2018, Memorial Hospital (MH), a safety-net hospital in Pawtucket, Rhode Island, closed. We studied the impact of this closure by analyzing homeless patient utilization of the two closest EDs before and after MH closed.MethodsA retrospective chart review compared the ED records of The Miriam Hospital (TMH), (1.8 miles from MH) and Rhode Island Hospital (RIH), (4.3 miles from MH). We analyzed visits between January 1, 2017–December 30, 2018. (MH closed on 1/1/2018). Patients were identified as homeless if their address listed was either “homeless” or a shelter/homeless service provider. All other patients were assumed to be housed. We removed from the analysis visits without an address listed or visits missing other key study variables (1.6% of the total).ResultsA total of 113,925 unique patients visited the RIH and TMH EDs in 2017, as well as 117,167 in 2018. Homeless patients accounted for 1.18% of patients seen in 2017 and 1.32% in 2018. Between 2017 and 2018, this represents an increase of individual homeless patients of 15.46% (1553-1345), while the number of unique housed patients increased by 2.69% (115,614-112,580). The closer hospital, TMH, saw a 43.72% increase in homeless visits, while RIH saw an 8% increase. Homeless patients were discharged significantly more often than housed patients (74% vs 65%) and had significantly longer time to admission (466.0 vs 304.0 minutes) and discharge (397.9 vs 263.7 minutes) compared to housed patients. Homeless patients presented with suicidality (8.61% of visits) and alcohol-related concerns (29.88% of visits) significantly more than housed patients (1.43% and 2.94%, respectively).ConclusionWhen a local ED closes, other EDs are impacted. We found visits made by homeless patients increased more than those made by housed patients and skewed significantly toward the closer hospital. We also found that homeless patients spend significantly more time in the ED and presented with behavioral health complaints more frequently. This impact of hospital closure on patterns of ED utilization by homeless patients has implications for ED management and homeless services both in the ED and the community.

‘It’s Not Just About a Rainbow Lanyard’: How Structural Cisnormativity Undermines the Enactment of Anti-Discrimination Legislation in the Welsh Homelessness Service

AbstractTrans people1 – those whose gender identity does not match that assigned to them at birth – are at considerably elevated risk of homelessness, reflecting their marginalized legal, bureaucratic and socio-economic status2. Recent substantial international expansion to the medico-legal rights afforded them operates in tension with cisnormative welfare structures. Based upon a Critical Discourse Analysis of interviews with 35 trans people with experience of homeless in Wales, UK, alongside 12 workers in the system, I argue that anti-discrimination legislation is insufficient in its current form to prevent discrimination against trans people. I suggest that, without addressing deeper structural cisnormativity, service provision for trans people experiencing homelessness and other forms of social marginalisation will remain inadequate. This argument rests upon the following findings. (1) Failing to consider exclusion at a structural level leads to system-gaps and misunderstandings, producing poor service experiences. (2) The specific needs of trans applicants are under considered in system planning, reducing scope for meaningful homelessness interventions. (3) An equalities approach can produce a reductive and potentially pathologizing focus upon trans identity, diverting from specific individual needs. I conclude that provision of inclusive services necessitates consideration of the impact of deep cisnormative assumptions in service design and delivery, and their resultant exclusion of trans people.