Impact of COVID-19 on People Experiencing Homelessness: A Call for Critical Accountability

Improving uptake of COVID-19 testing and vaccination in a homeless population: mixed-methods evaluation of community health worker-led education in a shelter

OBJECTIVES

Access to healthcare and accurate health information is a persistent issue for people experiencing homelessness (PEH), one heightened by the COVID-19 pandemic and exacerbated by issues of health literacy and mistrust. Strategies involving community health workers (CHWs) have the potential to improve education and service delivery for PEH. The objective of this study is to assess PEH knowledge, attitudes and barriers to COVID-19 testing and vaccination, and the impact of CHW-led education within a homeless shelter in Indiana.

DESIGN/SETTING

Between November 2021 and April 2022, 15 sessions were held at a homeless shelter that combined focus group discussions with COVID-19-related education. Pre-/post-tests measured knowledge gains and attitude shifts among PEH. Guided by the socioecological model, thematic analysis of focus group transcripts identified key motivators and barriers to COVID-19 vaccination and testing.

PARTICIPANTS

78 PEH (73% male, 74% white, mean age=48).

OUTCOME MEASURES

COVID-19-related knowledge gains and willingness to receive testing and vaccination among PEH.

RESULTS

Completion of an educational session was associated with a significant increase in knowledge scores (mean pre-test score=10.76/15, SD=2.16; mean post-test score=13.58/15, SD=1.72; p<0.001), with most participants (91%) improving by up to 10 points. The proportion of unvaccinated participants (42%) willing to be vaccinated increased from 21% to 39%. Participants willing to get tested for COVID-19 after a known exposure increased from 83% to 92%. Qualitative findings from the sessions provided insights into key knowledge gaps and revealed participant preferences towards health education format and topics.

CONCLUSION

CHW-led COVID-19 education increased knowledge gains and positively influenced attitudes towards vaccination and testing among PEH. Findings highlight the importance of tailored, community-driven interventions for pandemic response and emphasise the crucial role of education in building trust and promoting health literacy to improve health outcomes for vulnerable populations.

Menstruating while homeless: navigating access to products, spaces, and services

BACKGROUND

People experiencing homelessness (PEH) in the United States face substantial challenges related to menstruation, exacerbated by the COVID-19 pandemic. Limited access to period products, heightened stigma, and gynecological challenges contribute to increased hardships for PEH, highlighting the need for improved services and policies to address period equity and overall well-being for this vulnerable population.

METHODS

We conducted semi-structured qualitative interviews with PEH (n = 12) and community healthcare and social service providers (e.g., case managers, shelter directors, community health workers, and nurses, n = 12) in Lafayette, Indiana, a city located between Indianapolis and Chicago in the United States. We used thematic analysis techniques for data analysis.

RESULTS

PEH's limited access to products, services, and safe spaces hindered effective menstruation management within restrictive community contexts. Although community healthcare and service providers offered some support, complex interactions with the healthcare system, stigma, and limited access to spaces exacerbated barriers. The COVID-19 pandemic further intensified these difficulties by closing public spaces, worsening economic conditions, and straining service provider resources.

CONCLUSIONS

Results highlight critical organizational and policy gaps in the United States for menstruation management resources and services, emphasizing the need for better integration into health and well-being programs for PEH. These insights will advance reproductive and public health research, shedding light on the disparities faced by PEH in managing menstruation in Indiana and contributing to the national discourse on addressing these barriers. Amid the complex landscape of public health, particularly during and after the pandemic, prioritizing menstrual health remains essential for all individuals' overall well-being, including those experiencing homelessness.

Purity, Danger, and Patriotism: The Struggle for a Veteran Home during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic rendered congregate shelter settings high risk, creating vulnerability for people experiencing homelessness (PEH). This study employed participant observation and interviews over 16 months in two Veteran encampments, one located on the grounds of the West Los Angeles Veteran Affairs Medical Center (WLAVA) serving as an emergency COVID-19 mitigation measure, and the other outside the WLAVA gates protesting the lack of onsite VA housing. Study participants included Veterans and VA personnel. Data were analyzed using grounded theory, accompanied by social theories of syndemics, purity, danger, and home. The study reveals that Veterans conceptualized home not merely as physical shelter but as encompassing a sense of inclusion and belonging. They sought a Veteran-run collective with a harm reduction approach to substance use, onsite healthcare, and inclusive terms (e.g., no sobriety requirements, curfews, mandatory treatment, or limited lengths of stay). The twin encampments created distinct forms of community and care that protected Veterans from COVID-19 infection and bolstered collective survival. The study concludes that PEH constitute and belong to communities that provide substantial benefits even while amplifying certain harms. Housing interventions must consider how unhoused individuals become, or fail to become, integrate into various communities, and foster therapeutic community connections.

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

BACKGROUND

People 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.

METHODS

As 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).

RESULTS

Narratives 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.

CONCLUSIONS

Our 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.