Lived Experience Of Homelessness Research Articles

Homeless but not hopeless: overcoming the challenges of managing diabetes in people with lived experience of homelessness

Using a case vignette by way of illustration, Dr Jack Colley, Dr Mustafa Mahdi and Dr Ruth Poole here provide key practical advice on how to manage diabetes in individuals with lived experience of homelessness.

Program Evaluation and Improvement by a Homeless Community Using a Human Centered Design Approach

People experiencing homelessness are often absent from the development and implementation of new housing projects. As mounting evidence demonstrates the link between health and housing, it seems ineffective to design solutions without the participation and insight of those who are chronically unhoused. This study describes a method for program and product evaluation that people with lived experience of homelessness can use to determine the value of new offerings and then design improvements based on their evaluation. Specifically, this article reports the experience of evaluating a handbook describing the operations of a new type of housing for people experiencing homelessness. The research team, which included people with lived experience of homelessness, performed interviews to evaluate plans in the handbook, analyzed those results, and designed improvements in the operations of the housing based on the program evaluation. The team utilized participatory analysis of the interview data and then used a Human-Centered Design approach to generate ideas based on the analysis and develop concepts to improve the operational plan. The evaluation identified four high-priority problems with the operational plan and the group then designed three unique solutions to address those problems. This project demonstrates that people with lived experience of homelessness can participate as equal partners in the evaluation of a program and the subsequent program improvement design that was based on their evaluations.

Homelessness: challenges and opportunities in the “new normal”

Purpose This paper – the final paper of a series of three – aims to discuss the implications of the findings from a service user needs assessment of people experiencing homelessness in the Northwest of England. It will expand on the previous paper by offering a more detailed analysis and discussion of the identified key themes and issues. The service user needs assessment was completed as part of a review of local service provision in the Northwest of England against the backdrop of the COVID-19 pandemic. Design/methodology/approach Semi-structured questionnaires were administered and used by health-care professionals to collect data from individuals accessing the Homeless and Vulnerable Adults Service (HVAS) in Bolton. The questionnaires included a section exploring Adverse Childhood Experiences. Data from 100 completed questionnaires were analysed to better understand the needs of those accessing the HVAS. Findings Multiple deprivations including extensive health and social care needs were identified within the cohort. Meeting these complex needs was challenging for both service users and service providers. This paper will explore key themes identified by the needs assessment and draw upon further comments from those who participated in the data-gathering process. The paper discusses the practicalities of responding to the complex needs of those with lived experience of homelessness. It highlights how a coordinated partnership approach, using an integrated service delivery model can be both cost-effective and responsive to the needs of those often on the margins of our society. Research limitations/implications Data collection during the COVID-19 pandemic presented a number of challenges. The collection period had to be extended whilst patient care was prioritised. Quantitative methods were used, however, this limited the opportunity for service user involvement and feedback. Future research could use qualitative methods to address this balance and use a more inclusive approach. Practical implications This study illustrates that the needs of the homeless population are broad and varied. Although the population themselves have developed different responses to their situations, their needs can only be fully met by a co-ordinated, multi-agency, partnership response. An integrated service model can help identify, understand, and meet the needs of the whole population and individuals within it to improve healthcare for a vulnerable population. Social implications This study highlighted new and important findings around the resilience of the homeless population and the significance of building protective factors to help combat the multiplicity of social isolation with both physical and mental health problems. Originality/value The discussion provides an opportunity to reflect on established views in relation to the nature and scope of homelessness. The paper describes a contemporary approach to tackling current issues faced by those experiencing homelessness in the current context of the COVID-19 pandemic. Recommendations for service improvements will include highlighting established good practices including embedding a more inclusive/participatory approach.

On (not) being literate enough: The literacy experiences and literacy programme needs of people experiencing homelessness or who are at risk of homelessness

AbstractThis paper is focussed on literacy and the literacy experiences of people who are experiencing homelessness or are at risk of homelessness. Drawing on 23 in‐depth interviews with people who have lived experience of homelessness in Sydney, Australia, the paper examines literacy, literacy needs and interest in literacy programmes from a social practice perspective of literacy. Amartya Sen's (1999) capability approach is drawn on to examine the multidimensional barriers that impede access to literacy. Our findings show literacy needs and how literacy is understood and valued in the lives of people with lived experience of homelessness. We show the ways that spatial and temporal conditions enable and create (im)possibilities for the realisation of literacy as a capability. We also discuss how the capability is imagined to fit into existing worlds, as both an instrumental tool, as well as for personal satisfaction and broader participation in social life. Our interviewees also point to the possibilities of literacy learning and programmes supporting the realisation of other capabilities, emphasising the prospects of achieving multiple capability realisations through program design. We show how the findings bear out the principles of a social practices pedagogy in adult literacy programmes.

Health literacy and its association with mental and spiritual well-being among women experiencing homelessness.

Low health literacy (HL) has been linked to low self-rated health, reduced efficacy of behaviour change, and challenges in preventing, treating, or managing health conditions. People experiencing homelessness are at risk of poor HL; however, few studies have investigated HL in relation to mental and spiritual well-being among people experiencing homelessness in general, or women experiencing homelessness specifically. This cross-sectional study of 46 women experiencing homelessness in Stockholm, Sweden, recruited during the period October 2019-December 2020, aimed to examine how HL was associated with mental and spiritual well-being among women experiencing homelessness. Participants answered questions about socio-demographic characteristics (age, length of homelessness, education) and digital technology (mobile phone/the Internet) use, in addition to Swedish language versions of three questionnaires administered through structured, face-to-face interviews: the Communicative and Critical Health Literacy Scale, the General Health Questionnaire 12 and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being. Data were analysed using linear regression, which revealed statistically significant associations between HL and mental well-being (p = .009), and between HL and spiritual well-being (p = .022). However, neither socio-demographic characteristics nor digital technology use were significantly associated with HL. In conclusion, promoting HL may improve mental and spiritual well-being in this vulnerable population. An advisory board of women with lived experiences of homelessness (n = 5) supported the interpretation of the findings and emphasised the need to consider HL in relation to basic needs such as 'housing first'. Moreover, health information and services should be accessible to people with different degrees of HL.

Involving people with lived experience of homelessness in palliative and end of life care research: key considerations from experts in the field

BackgroundCo-production of research aims to include people with lived experience of a phenomena throughout the research process. People experiencing homelessness often experience advance ill-health at a young age, yet access palliative care services at a disparately low rate to the level of palliative care need. The voices of people experiencing homelessness are infrequently heard throughout palliative care research, despite the complexities and intricacies of the area.AimTo explore the experiences of experts in the field to identify key context considerations for involving people with lived experience of homelessness in palliative and end of life care research.MethodsQualitative study comprising two data collection streams: interviews with professionals with experience of involving people experiencing homelessness in their work, and focus groups with people with lived experience (PWLE) of homelessness. Data were analysed using iterative, reflexive thematic analysis. Patient and Public Involvement contributors gave feedback on themes.ResultsA total of 27 participants took part in semi-structured interviews (N = 16; professionals) or focus groups (N = 11; PWLE homelessness). Key considerations of involving people experiencing homelessness in palliative and end of life care research were developed into four key themes: complexity of lived experience of homelessness; representation of homelessness within experts by experience; professionalising lived experience; and methods for involvement.ConclusionsInvolvement of people with lived experience of homelessness is important in developing palliative care research. This paper begins to outline some contextual considerations for promoting involvement in a complex and intricate field of research.

Who Gets a Voice in Homelessness? A Content Analysis of Quotations Used by Journalists

ABSTRACT Researchers have explored journalists’ use of sources, particularly experts; however, they have rarely considered homelessness alongside journalists’ use of sources, notably individuals with lived experience of homelessness (LEH). This content analysis considered the representation and dissemination of voices in the form of quotations from articles about homelessness in San Francisco. Researchers analyzed 7273 quotations from 820 articles published over 18 months in 109 publications; 77 of which collaborated in the SF Homeless Project to report about homelessness, its causes and solutions. Researchers classified quotations from 2759 sources by source gender/ethnicity and type (experts, nonexperts, LEH). White males were quoted in 70% of articles, making them the de facto voice of homelessness. Nonwhite females were quoted in 20% of articles and nonwhite males in 40% of articles. Underrepresentation of nonwhite females and males was most pronounced in the category of expert with over 90% of articles lacking quotes from either. Journalists quoted experts in 92% of articles and allotted experts significantly more words than any other source type. White male journalists mostly quoted other white males as experts, while female and nonwhite journalists included greater through sourcing. When journalists quoted individuals with LEH, articles were more positive and included more sources.

How important is integration to the successful ‘roll out’ of specialist hospital discharge schemes for people who are homeless?

In 2021, we published research funded by the UK National Institute for Health Research that demonstrated the effectiveness and cost effectiveness of specialist hospital discharge schemes for people who are homeless. A key finding of the research was that areas that had a specialist homeless hospital discharge scheme had fewer delayed discharges and could reduce their emergency readmissions among homeless patients by 14%. This positive outcome attracted the attention of national health policy makers who allocated £16 million funding to 17 local authority areas to “roll out” new schemes. This paper reports the preliminary findings of an implementation evaluation. We assess how important integration was in those areas that successfully translated the evidence about “what works’ into practice. This presentation is targeted at academics and commissioners of integrated care.
 The evaluation employed a positive deviance (appreciative enquiry) methodology. This approach seeks out exceptionally performing sites, investigates the underlying factors contributing to the successful behaviours and strategies, and plans an appropriate means to replicate these with the aim to effect a change. The rationale behind appreciative inquiry is that solutions to common problems mostly exist within clinical/practice communities rather than externally with policy makers or managers.
 The first step of the evaluation was to collect audit (performance) data from the 17 local authorities taking part in the programme. Audit data was then used to select three case studies sites that demonstrated high performance against key metrics such as having a shorter length of stay in ‘step-down’ services (longer stays being indicative of housing shortages and difficulties maintaining flow through the system). In the case study sites, reflective interviews and focus groups then sought to establish what factors underpinned this successful implementation. This included interviews with a range of key stakeholders including people with lived experience of homelessness and transitions out-of-hospital (over sixty stakeholders in total).
 Integration was found to be a key factor in understanding successful implementation at many different levels - from building the initial strategic vision to delivering quality in frontline service delivery. Often this was ‘relational’ integration where building social networks in strategic places was the main factor in determining routinization and sustainability. Often boundary spanning was key where ‘homeless commissioners’ needed to cross the divide into the unfamiliar world of health service commissioning. Relational working required a dedicated project manager with highly developed skills in business planning, evaluation and policy literacy to negotiate the many hurdles that stood in the way of the routinization of specialist care. Successful sites also involved people with lived experience of homeless in meaningful rather than tokenistic activities, integrating their knowledge of services and practice to ensure compassion was at the forefront of practice. Taking an in-depth qualitative perspective on successful implementation is important as very few of the 17 test sites managed to sustain their new services once the initial programme funding had run out.

International evidence on lived experiences of trauma during homelessness and effects on mental health including substance use: a co-produced qualitative systematic review

BackgroundTrauma is an experience (physical or emotional) that is life-threatening, harmful, or out of the ordinary and has lasting effects on mental health and wellbeing. Much of the information about trauma within homeless populations focuses on events in childhood. Using coproduction principles, we aimed to synthesise qualitative evidence exploring the impact of trauma during adulthood homelessness on mental health, including substance use. MethodsIn this qualitative systematic review, we searched ASSIA, CINAHL, Cochrane, EMBASE, MEDLINE, Proquest theses and dissertations, PsychInfo, Scopus, and Web of Science for studies published from inception until Sept 6, 2022, alongside grey literature from relevant websites. Search terms were developed based on the PICO framework. No language, date, or geographical limits were applied. Any qualitative research reporting experiences of trauma and its impact on mental health during homelessness in adults was eligible. We extracted relevant data (eg, methodology, sample characteristics, homelessness, and findings). People with lived experience of homelessness were provided with bespoke training by the lead researcher. They contributed to refining the review aims, screening, coding, and theme development. Quality was assessed using the CASP Qualitative Studies Checklist. FindingsWe included 26 qualitative papers, including 876 adults experiencing homelessness between ages 18 and 70 years (448 [51%] women and 428 [49%] men). All papers focused on urban settings. Eight papers were from the USA, five from Canada, four from the UK and Australia, three from Brazil, and one from Ethiopia and Iran. A framework synthesis of these 26 papers identified three preliminary themes. People experiencing homelessness make sense of trauma in three ways: internalised understanding, relationality to others, and with a survival lens. Coping strategies for managing feelings of fear, anxiety, and depression included substance use, self-rationalisation, and strategies to feel safe. Finally, when people experienced repeated trauma, they became either dissociated, and accepted their situation, or resilient, wishing to change their circumstances. InterpretationFurther evidence is needed in rural or coastal regions, where people experiencing homelessness may face greater isolation. Trauma rarely takes place in isolation, and often previous experiences of trauma shape how people experiencing homelessness make sense of trauma and cope with it. Support to address coping with the effects of trauma should focus on ensuring people do not become desensitised and prevent deterioration of mental health and substance use. The strength of this review is its coproduction with people with lived experience. Single person data extraction with secondary checks was a limitation. FundingNational Institute for Health and Care Research (NIHR) School for Primary Care Research as part of the Three NIHR Research Schools Mental Health Programme.

Perspectives on registration to primary care from inclusion health groups in England: a mixed-method study

BackgroundAlthough everyone living in the UK is entitled to access free primary care within the National Health Service (NHS), evidence shows that people in need of health care are wrongly being refused access. This study aimed to explore the perspectives of individuals from inclusion health groups on primary care registration and accessibility. MethodsThis was a mixed-methods study. From Oct 5, 2022, to Feb 20, 2023, we surveyed 49 people (36 [73%] men; 12 [24%] women) and interviewed 25 other (14 [56%] men; 11 [44%] women) who were service users of the University College London Hospital Find & Treat mobile service. This service included people with lived experience of homelessness, asylum seeking, addiction, selling sex, and irregular immigration. We recruited these participants through hostels for people with ongoing addiction and complex needs, initial asylum accommodation centres, and day shelters. Our research team included two peer researchers. FindingsOf those surveyed, 25 (51%) perceived their access to primary health-care services as good, and 17 (35%) reported obstacles to going to the general practitioner (GP). Participants described multiple barriers to registering for GP surgeries, including a lack of understanding and poor communication with NHS services, a fear of discrimination, and a lack of digital access that prevents information seeking and access to services. Respondents also reported using emergency services instead of primary care because they were more immediately accessible without previous registration. Facilitators to GP registration included one-on-one support and outreach work that helps people navigate into services and know their rights, and the use of specialist GP services, which are perceived as more accepting, especially for people experiencing homelessness. InterpretationThe barriers to registration identified are related to both individual and group level characteristics and produce both similar and divergent needs between different inclusion health groups. The need for additional support during registration was clear, and our work highlights the requirement for interventions to improve access to primary care for underserved groups, as well as coordinated policy action. One-on-one support in particular, either outreach or provided in services where inclusion health groups spend time, appears to be a key facilitator to ensuring comprehensive and fast access to GP services. FundingNational Institute for Health and Care Research (NIHR).

Barriers and facilitators to health care access for people experiencing homelessness in four European countries: an exploratory qualitative study

BackgroundPeople experiencing homelessness (PEH) are known to be at higher risk of adverse health outcomes and premature mortality when compared to the housed population and often face significant barriers when attempting to access health services. This study aimed to better understand the specific health care needs of PEH and the barriers and facilitators associated with their timely and equitable access to health services in the European context.MethodsWe conducted an exploratory cross-national qualitative study involving people with lived experience of homelessness and health and social care professionals in Austria, Greece, Spain, and the UK. A total of 69 semi-structured interviews comprising 15 social care professionals, 19 health care professionals, and 35 PEH were completed, transcribed, and analysed thematically.ResultsFindings were organised into three overarching themes relating to the research question: (a) Health care needs of PEH, (b) Barriers to health care access, and (c) Facilitators to health care access. Overall, the general health of PEH was depicted as extremely poor, and mainstream health services were portrayed as ill-equipped to respond to the needs of this population. Adopting tailored approaches to care, especially involving trusted professionals in the delivery of care, was identified as a key strategy for overcoming existing barriers.ConclusionsThe results of this study indicate there to be a high degree of consistency in the health care needs of PEH and the barriers and facilitators associated with their access to health care across the various European settings. Homelessness in itself is recognized to represent an essential social determinant of health, with PEH at risk of unequal access to health services. Changes are thus required to facilitate PEH’s access to mainstream primary care. This can also be further complemented by investment in ‘in-reach’ services and other tailored and person-centred forms of health care.Trial registrationThis study was registered retrospectively on June 6, 2022, in the registry of ClinicalTrials.gov under the number NCT05406687.

Group Versus Individual Diabetes Education for Persons With Experience of Homelessness in Canada.

The purpose of the study was to explore various forms of diabetes self-management education (DSME), including group and individual sessions, for persons with lived experiences of homelessness (PWLEH) in Canada. A qualitative descriptive study using open-ended interviews with health care and homeless sector service providers was utilized to serve those experiencing homelessness in 5 cities across Canada. NVivo qualitative data analysis software was used to facilitate thematic analysis, focusing on variations in DSME for PWLEH. We conducted interviews with 96 unique health and social care providers. Four themes were identified through focused coding of interviews. First, the use of a harm reduction approach during diabetes education tailored to PWLEH considered patients' access to food, medications, and supplies and other comorbidities, including mental health and substance use disorders. The second theme related to the unsuitability of the curriculum in mainstream diabetes education in a group setting for PWLEH. Third, the role of group education in community building is to create supportive relationships among members. The final theme was the importance of trust and confidentiality in DSME, which were most easily maintained during individual education, compared to group formats. Overall, PWLEH experience unique challenges in managing diabetes. DSME adapted to these individuals' unique needs may be more successful and could be delivered in both individual and group settings.

Communicating effectively with inclusion health populations: 2022 ICCH symposium

ObjectiveTo describe communication strategies for clinical practice that allow practitioners to work more effectively with marginalised population groups and to discuss how to incorporate these into medical practice. MethodsActive practitioners working in inclusion health and people with lived experience of homelessness and the asylum-seeking process shared their perspectives in the symposium at the 2022 International Conference on Communication in Healthcare (ICCH) and a subsequent conference on empathy in healthcare. The views of attendees were sought. Symposium DiscussionWe describe the perspectives shared at the symposia under two main themes: communication needs in people experiencing homelessness and migrant populations, and trauma-informed practice. ConclusionsPeople experiencing homelessness have more communication challenges compared to the general adult population. Migrant, refugee, and asylum-seeking populations also face the complexity of negotiating unfamiliar healthcare, legal and social systems with the added burden of language barriers. Trauma-informed practice provides a useful framework that can improve communication with these groups.

Staying safe, feeling welcome, being seen: How spatio-temporal configurations affect relations of care at an inclusive health and wellness centre.

People experiencing homelessness also experience poorer health and frequently attend acute care settings when primary health care would be better equipped to meet their needs. Existing scholarship identifies a complex mix of individual and structural-level factors affecting primary health care engagement driving this pattern of health services utilisation. We build on this existing knowledge, by bringing the spatio-temporal configurations of primary health care into focus. Specifically, we interrogate how space and time inflect situated practices and relations of care. This study took an ethnographic approach and was conducted 2021-2022 at an inclusive health and wellness centre ("the Centre") in Southeast Queensland, Australia. The data consists of 46 interviews with 48 people with lived experience of homelessness, including participants who use the services offered at the Centre (n = 26) and participants who do not (n = 19). We also interviewed 20 clinical and non-clinical service providers affiliated with the Centre and observed how service delivery took place. Interviews and observations were complemented by visual data, including participant-produced photography. All data were analysed employing a narrative framework. We present three interrelated themes demonstrating how space and time affect care, that is 'staying safe', 'feeling welcome' and 'being seen'. 'Staying safe' captures the perceptions and practices around safety, which sit in tension with making service users feel welcome. 'Feeling welcome' attends to the sense of being invited to use services free of judgment. 'Being seen' depicts capacities to see a health care provider as well as being understood in one's lived experience. Spatio-temporal configurations, such as attendance policies, consultation modalities and time allocated to care encounters afford differential opportunities to nurture reciprocal relations. We conclude that flexible service configurations can leverage a relational model of care. Service providers were consulted during the design stage of the project and had opportunities to inform data collection instruments. Two service providers contributed to the manuscript as co-authors. People with lived experience of homelessness who use the services at the inclusive health centre contributed as research participants and provided input into the dissemination of findings. The photography they produced has been featured in an in-person exhibition, to which some have contributed as consultants or curators. It is hoped that their insights into experiences of welcomeness, safety and being seen will inform flexible and relational primary health care design, delivery, and evaluation to better cater for people experiencing housing instability and poverty.

Predictors and consequences of homelessness in whole-population observational studies that used administrative data: a systematic review

BackgroundHomelessness is a complex societal and public health challenge. Limited information exists about the population-level health and social care-related predictors and consequences of persons with lived experience of homelessness (PEH). Studies that focus on population subgroups or ad hoc questionnaires to gather data are of relatively limited generalisability to whole-population health surveillance and planning. The aim of this study was to find and synthesise information about the risk factors for, and consequences of, experiencing homelessness in whole-population studies that used routine administrative data.MethodWe performed a systematic search using EMBASE, MEDLINE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO research databases for English-language studies published from inception until February 2023 that reported analyses of administrative data about homelessness and health and social care-related predictors and consequences. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.ResultsOf the 1224 articles reviewed, 30 publications met the inclusion criteria. The included studies examined a wide range of topic areas, and the homelessness definitions used in each varied considerably. Studies were categorised into several topic areas: Mortality, morbidity and COVID-19; health care usage and hospital re-admission; care home admission and shelter stay; and other (e.g. employment, crime victimisation). The studies reported that that the physical and mental health of people who experience homelessness was worse than that of the general population. Homeless individuals were more likely to have higher risk of hospitalisation, more likely to use emergency departments, have higher mortality rates and were at greater risk of needing intensive care or of dying from COVID-19 compared with general population. Additionally, homeless individuals were more likely to be incarcerated or unemployed. The effects were strongest for those who experienced being homeless as a child compared to those who experienced being homeless later on in life.ConclusionsThis is the first systematic review of whole-population observational studies that used administrative data to identify causes and consequences associated with individuals who are experiencing homelessness. While the scientific literature provides evidence on some of the possible risk factors associated with being homeless, research into this research topic has been limited and gaps still remain. There is a need for more standardised best practice approaches to understand better the causes and consequences associated with being homeless.

Evaluation of the implementation of a medical respite program for persons with lived experience of homelessness

ABSTRACT Medical respite programs (MRPs) constitute a potential strategy to improve the continuum of care for persons who have lived experiences of homeless (PWLEH). A MRP was developed in Alberta, Canada, through a partnership between the provincial health authority (Alberta Health Services) and the province’s largest homeless shelter (Calgary Drop-In Centre). We conducted a qualitative study of 25 stakeholders who held an operational, administrative and/or healthcare provider role in the MRP’s design and implementation to evaluate the barriers and facilitators to its implementation using Proctor’s implementation framework. While stakeholders had a common motivation of addressing health inequity, the program’s acceptability and fidelity were hampered by a lack of clear common objectives and expectations. Program adoption was difficult due to differences in organizational policies and priorities. Program staff and leadership were dedicated to the patient population, enhancing feasibility, but the limited training and experience of frontline providers specifically in addictions and mental health resulted in important needs not being met (affecting intervention appropriateness). The lack of integration with community resources, despite being intended as a program to transition patients from hospital to community, affected program penetration. Our findings are relevant for other jurisdictions and organizations aiming to develop and implement similar interventions.

760 Building Cold Injury Prevention and Control Strategies with People Who are Experiencing Homelessness

Abstract Introduction The incidence of hypothermia and frostbite is increasing given larger numbers of people experiencing homelessness (PEH) across the country. Cold injuries create functional deficits that compound comorbidities of people who already experience disproportionate disability burdens. We collaborated with PEH to identify modifiable cold injury hazards, understand prevention knowledge and first aid techniques, and develop prevention strategies. Methods We conducted 12 interviews with PEH with and without lived experience of cold injury. Interviews covered domains of risk factors/hazards, utility of existing educational materials, novel strategies, and acceptable stakeholders for dissemination. Interviews were transcribed and coded by two analysts using both deductive and inductive approaches. Results Participants varied in the type (e.g., street, encampment, shelter) and chronicity of homelessness. Six themes emerged: i) PEH are engaged in prevention, ii) there is a need for improved awareness around synergistic risks (e.g., rain, nicotine or amphetamine use, diabetes), iii) existing materials are not sufficiently contextually specific, iv) a narrowly focused prevention and dissemination strategy will not suffice, v) prevention strategies need to be framed within the realities of living homeless, and vi) respect and kindness are integral to successful uptake (Table 1). Conclusions Insightful perspectives shared by PEH provided key strategies for cold injury prevention. Prevention strategies must fit into the reality of homelessness, be respectfully delivered, and need to be a collective community effort where voices of PEH are valued. Applicability of Research to Practice Themes and specific perspectives uncovered by this study can help clinicians, community service providers, and public health practitioners develop cold injury prevention strategies alongside people with lived experience of homelessness.

Investigating the Comparative Effectiveness of Place-Based and Scatter-Site Permanent Supportive Housing for People Experiencing Homelessness During the COVID-19 Pandemic: Protocols for a Mixed Methods, Prospective Longitudinal Study.

Permanent supportive housing (PSH) is an evidence-based practice to address homelessness that is implemented using 2 distinct approaches. The first approach is place-based PSH (PB-PSH), or single-site housing placement, in which an entire building with on-site services is designated for people experiencing homelessness. The second approach is scatter-site PSH (SS-PSH), which uses apartments rented from a private landlord while providing mobile case management services. This paper describes the protocols for a mixed methods comparative effectiveness study of 2 distinct approaches to implementing PSH and the patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk. People experiencing homelessness who are placed in either PB-PSH or SS-PSH completed 6 monthly surveys after move-in using smartphones provided by the study team. A subsample of participants completed 3 qualitative interviews at baseline, 3 months, and 6 months that included photo elicitation interviewing. Two stakeholder advisory groups, including one featuring people with lived experience of homelessness, helped guide study decisions and interpretations of findings. Study recruitment was supposed to occur over 6 months starting in January 2021 but was extended due to delays in recruitment. These delays included COVID-19 delays (eg, recruitment sites shut down due to outbreaks and study team members testing positive) and delays that may have been indirectly related to the COVID-19 pandemic, including high staff turnover or recruitment sites having competing priorities. In end-July 2022, in total, 641 people experiencing homelessness had been referred from 26 partnering recruitment sites, and 563 people experiencing homelessness had enrolled in the study and completed a baseline demographic survey. Of the 563 participants in the study, 452 had recently moved into the housing when they enrolled, with 272 placed in PB-PSH and 180 placed in SS-PSH. Another 111 participants were approved but are still waiting for housing placement. To date, 49 participants have been lost to follow-up, and 12% of phones (70 of the initial 563 distributed) were reported lost by participants. Recruitment during the pandemic, while successful, was challenging given that in-person contact was not permitted at times either by program sites or the research institutions during COVID-19 surges and high community transmission, which particularly affected homelessness programs in Los Angeles County. To overcome recruitment challenges, flexible strategies were used, which included extending the recruitment period and the distribution of cell phones with paid data plans. Given current recruitment numbers and retention rates that are over 90%, the study will be able to address a gap in the literature by considering the comparative effectiveness of PB-PSH versus SS-PSH on patient-centered quality of life, health care use, and health behaviors that reduce COVID-19 risk, which can influence future public health approaches to homelessness and infectious diseases. ClinicalTrials.gov NCT04769349; https://clinicaltrials.gov/ct2/show/NCT04769349. DERR1-10.2196/46782.

Homeless youth‐led activism and direct action: Lessons from a participatory research project in Tio'tia:ke/Montréal

AbstractThis article explores the involvement of youth with lived experience (LE) in activism and research aimed at addressing youth homelessness in Canada. Based within a youth‐participatory action research project in Tio'tiá:ke/Montréal, Canada, we reflect on how young people described their own activist organising, as well as the practical ways we may harness actions that homelessness youth are already doing to create communities and solidarity. The authors are members of Youth Action Research Revolution (YARR), a research team primarily made up of youth with LE of homelessness. We position the analysis at an intersection of our own experiences and 63 interviews with youth aged 16–29 conducted by YARR from 2018 to 2021. Conceiving of participatory, youth‐led research as a form of direct action we outline lessons learned from our own research and LE. Young people within our team and participants in YARR's research shared critiques of State systems while outlining the work that they undertook with their peers to act on issues of housing precarity, often eschewing activism aimed at State processes or institutional reform in favour of direct action. This article proposes a mode of fostering youth‐led, socially just change around homelessness—one that shifts conversations from inclusion to solidarity, and recognises the radical potential of research by‐and‐for young people. The authors conclude that research and advocacy on homelessness is always inherently political for young people with LE, and that harnessing the direct action that youth already do to survive is not only a socially just form of mobilising, but can contribute to broader activism towards housing justice.

Integrated approach to cardiovascular disease in people experiencing homelessness: a qualitative study

BackgroundHomelessness is associated with an increased risk of cardiovascular disease (CVD), beyond impact of socioeconomic status. CVD is preventable and treatable, though barriers to interventions exist for people experiencing homelessness....