Persons experiencing homelessness and vulnerable housing or those with lived experience of homelessness have worse health outcomes than individuals who are stably housed. Structural violence can dramatically affect their acceptance of interventions. We carried out a systematic review to understand the factors that influence the acceptability of social and health interventions among persons with lived experience of homelessness.
We searched through eight bibliographic databases and selected grey literature sources for articles that were published between 1994 and 2019. We selected primary studies that reported on the experiences of homeless populations interacting with practitioners and service providers working in permanent supportive housing, case management, interventions for substance use, income assistance, and women- and youth-specific interventions. Each study was independently assessed for its methodological quality. We used a framework analysis to identify key findings and used the GRADE-CERQual approach to assess confidence in the key findings.
Our search identified 11,017 citations of which 35 primary studies met our inclusion criteria. Our synthesis highlighted that individuals were marginalized, dehumanized and excluded by their lived homelessness experience. As a result, trust and personal safety were highly valued within human interactions. Lived experience of homelessness influenced attitudes toward health and social service professionals and sometimes led to reluctance to accept interventions. Physical and structural violence intersected with low self-esteem, depression and homeless-related stigma. Positive self-identity facilitated links to long-term and integrated services, peer support, and patient-centred engagement.
Individuals with lived experience of homelessness face considerable marginalization, dehumanization and structural violence. Practitioners and social service providers should consider anti-oppressive approaches and provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care. Accepting and respecting others as they are, without judgment, may help practitioners navigate barriers to inclusiveness, equitability, and effectiveness for primary care that targets this marginalized population.
Citation: Magwood O, Leki VY, Kpade V, Saad A, Alkhateeb Q, Gebremeskel A, et al. (2019) Common trust and personal safety issues: A systematic review on the acceptability of health and social interventions for persons with lived experience of homelessness. PLoS ONE 14(12): e0226306. https://doi.org/10.1371/journal.pone.0226306
Editor: Stefano Federici, Università degli Studi di Perugia, ITALY
Received: July 9, 2019; Accepted: November 22, 2019; Published: December 30, 2019
Copyright: © 2019 Magwood et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This systematic review was funded by Inner City Health Associates and Employment and Social Development Canada. EJT is funded by the Medical Research Council (MC_UU_12017/13 & MC_UU_12017/15), the Chief Scientist Office (SPHSU13 & SPHSU15), and a Chief Scientist Office Clinical Academic Fellowship (CAF/17/11). The funders of the study had no role in the study design, data collection, data analysis, data interpretation, or the writing of the report. The corresponding author had full access to all of the data in the study and had final responsibility for the decision to submit for publication.
Competing interests: Kevin Pottie, David Ponka and Claire Kendall are principal investigators in an ongoing project to develop Canadian evidence-based guidelines for providing social programs and healthcare services to people who are homeless and vulnerably housed. Terry Hannigan was paid an honorarium by the Bruyère Research Institute to provide consultations on this work. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors declare no other conflicts of interest.
Persons with lived experience of homelessness and vulnerable housing are an excluded population that is growing worldwide due to increasing costs of living, forces of urbanization, and economic crises and their associated austerity policies.[2–4] Indeed, the number of individuals experiencing vulnerable housing conditions has reached 1.8 billion worldwide. Over time, this population has struggled with mental health and addiction, profound societal stigma, and structural violence, conditions which have led to high rates of treatment recidivism and inequitably low life expectancy rates.[7,8] Inadequate housing has been universally endorsed as a violation of human rights, leading to international commitments to provide affordable and adequate housing services, within the next decade, through the 2030 Agenda for Sustainable Development.
“Structural violence” describes the social arrangements that put individuals and populations in harm's way through systematic exclusion over time. These arrangements are considered structural because they are embedded in the political and economic organization of our social world; they are violent because they cause harm to people. Structural violence manifests as unequal access to social systems of support like housing, health care, education and employment. For example, the inability for individuals with “no fixed address” to receive coverage for healthcare or social services demonstrates how structural violence could stand in the way of addressing fundamental human needs.[13,14] Despite the impact of these structures on some of the most underserved patients, with few exceptions, primary care practitioners are not trained to influence such social forces nor do they consistently have the capacity to adequately address their related social determinants of health . To reduce structural violence and achieve health equity, practitioners and health systems must address the needs of underserved populations. Primary care providers have an opportunity to identify and act on social issues at the point of care by connecting patients with various support resources within and beyond the health system, such as local support groups, housing advocacy organizations or employment agencies. Clinical practice guidelines represent an evidence-based tool designed to support providers’ decisions when delivering primary health care to persons with lived experience of homelessness. Such guidelines should consider the acceptability of the recommended community resources and interventions.
Interventions must emerge from local contexts and meet the essential needs and preferences of persons with lived experience of homelessness.[17–20] The content, scale and intensity of interventions should be proportionate to the level of social, economic or environmental disadvantage someone faces and the support they need. Such interventions are complex in nature,[22–24] resulting in challenges to optimizing their design and delivery so as to guarantee the best health and social outcomes. There is wide agreement that a broad range of evidence is needed to inform decisions on the implementation of complex interventions, especially those that have impacts across the health or social care system. Data from qualitative research contributes critical information to help decision-makers effectively address this need. The views of people experiencing social exclusion, such as homelessness, should be used to guide programs and practitioners so as to ensure that health and social services are inclusive, equitable, and effective. As an example, many existing effective interventions have the potential to help the homeless and vulnerably housed forge routes out of homelessness.[17,26–28] However, the acceptability of these interventions is necessary for effectiveness, without this participants may fail to adhere to recommendations or benefit from improved outcomes.
This review is one of a series of reviews to inform national clinical practice guidelines for the care of homeless or vulnerably housed persons. We conducted a Delphi consensus process that included 84 practitioners and 76 persons with lived experience of homelessness to prioritize relevant interventions which could be referred to by primary care providers, including permanent supportive housing, case management, income assistance, interventions for substance use, and women- and youth-focused interventions. Our research team conducted parallel systematic reviews which evaluated the effectiveness of these interventions.[27,28,31–33] Given that health and structural interventions are affected by multiple intersecting factors that might not be captured in a quantitative review, the objective of this systematic review of qualitative studies is to understand the factors that influence the acceptability of these health and structural interventions from the perspective of persons who are homeless or vulnerably housed.
Search strategy and selection criteria
We conducted a systematic review according to a published protocol. We included persons with lived experience of homelessness through all stages of this review so as to improve the relevance and applicability of the findings. Specifically, these individuals participated in the prioritization of selected interventions and populations of interest and in the interpretation of the qualitative key findings. We used the PRISMA guidelines to report our findings (See S1 File). Ethical approval was not required for this study.
Studies were eligible for inclusion in our systematic review if they utilized a qualitative design, involved data collection and analysis, and included at least one of the interventions specified in our protocol (S2 File). These reports could be published in any language. Mixed-method and quantitative studies were not eligible for inclusion as they are less likely to provide rich data compared with standalone qualitative studies. We focused on studies whose participants were homeless or vulnerably housed, defined as individuals who are unsheltered, emergency sheltered, provisionally accommodated, or at risk of homelessness. The subpopulations of interest included women, youth, and people with acquired brain injury or intellectual or physical disabilities, which were identified as priority groups in our Delphi consensus. We excluded studies that focused exclusively on indigenous-specific interventions, as an examination of these interventions is being conducted by an indigenous-specific research team. The geographic setting was restricted to high-income countries  that have acknowledged affordable housing as a human right. We excluded low-quality studies. (See S3 File for the full inclusion criteria).
We developed a systematic search for qualitative literature, using relevant keywords and MeSH terms (S4 File). We searched MEDLINE, EMBASE, PsycINFO, and ERIC via Ovid; and ProQuest Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts and Sociology Database for qualitative studies published from January 1st, 1994 to September 4th, 2019. We also searched grey literature for relevant studies and reports (S5 File). We did not hand-search for additional studies.
The identified studies were uploaded to Rayyan reference manager software to facilitate study selection. Two reviewers independently screened titles/abstracts and full texts; disagreements were resolved through discussion or by consulting a third reviewer. We assessed the methodological quality of remaining studies by using the Critical Appraisal Skills Programme (CASP) checklist for qualitative studies. CASP checklists are widely used in the health care domain and offer guidance for the critical appraisal with respect to trustworthiness, results and relevance of research studies. Criteria for the quality assessment of qualitative studies include the appraisal of a clearly stated aim, an appropriate qualitative methodology, and the consideration of ethical issues. We used the scoring system developed by Butler and colleagues (2016) to rate studies as high-, moderate-, or low-quality and report individual study assessments in the S6 File . As done in other recent systematic reviews of qualitative studies [42–44] and in line with guidance available from the Cochrane Handbook, we excluded low-quality studies from the synthesis of our systematic review based on the outcome of our critical appraisal.
We used a standardized data extraction sheet that included the study methodology, population, intervention, findings, study limitations, and funding details. Data were extracted by two reviewers independently. Disagreements were resolved through discussion.
We used the ‘best fit’ framework method as a systematic and flexible approach to analyzing the qualitative data.[46–48] Framework-based synthesis using the 'best fit' strategy is a highly pragmatic and useful approach for a range of policy urgent questions  whose use is supported in the development of clinical practice guidelines. Framework synthesis is currently the most commonly used approach in a guideline process and is recommended when a question requires an understanding of complexity (see  for examples). Framework analysis is a five-stage process that includes familiarization with the data, identifying a thematic framework, indexing (applying the framework), charting and mapping, and interpretation. Based on extensive team discussions, we selected the Risk and Vulnerability framework  due to its unique emphasis on structural factors, alongside biomedical and behavioural factors, that contribute to vulnerability and its stigma-informed approach. The Risk and Vulnerability framework identifies factors (causes of risk and vulnerability) and patient preferences that influence intervention accessibility, uptake, and acceptability. This framework additionally identifies biomedical, behavioural, and structural factors that act as enabling factors and influence corresponding causes of risk of and vulnerability to homelessness. A reviewer coded the data into the three domains of the Risk and Vulnerability framework, using a matrix spreadsheet to facilitate analysis; this was verified by a second reviewer (see Table 1). Mapping involved examining the concordant findings, disconformity data, and associations between themes. Interpretations were guided by our review objectives as well as the emerging themes. Mapping and interpretation were done through discussion with the entire review team.
We used the Confidence in the Evidence from Reviews of Qualitative research (CERQual) tool [25,53] to assess the confidence of the key findings of this review. We defined a key finding as the analytic output (e.g., theme or factor) from our qualitative evidence synthesis that, based on data from primary studies, described the experiences of persons engaging with health and structural interventions that target homeless populations. CERQual bases the evaluation on four criteria: the methodological limitations of the included studies that support a review finding, the relevance of the included studies to the review question, the coherence of the review findings, and the adequacy of the data that contributes to a review finding (See Table 2).
Our systematic search identified 11,017 citations. After deduplication, we screened 10,247 articles by title and abstract, excluded 10,074 articles and considered 173 studies for a full-text review, based on the relevance of the subject. The full-text review excluded a further 113 studies, leaving 60 studies for review, which were then assessed for methodological quality. Low-quality studies were excluded, leaving 35 studies that met our inclusion criteria and quality standards. (See Figs 1 and 2: PRISMA and S7 File).
Table 3 shows the characteristics of the included studies that are heterogeneous in terms of sample size, intervention, setting, and target populations. These studies represent the views of over 900 service users. Of the 35 included studies, 14 were conducted in Canada, 14 in the USA, 6 in the UK and 1 in Australia. Interventions included women-specific education and peer support, case management, place-based interventions for youth, non-abstinence-contingent supportive housing programs (e.g., Housing First), income assistance, needle-exchange services, and peer administration of naloxone. Target populations included youth, women, the elderly, men, mothers and families, and generalized populations who experienced homelessness and vulnerable housing. Table 3 presents the CASP summary of the methodological assessment (see also Appendix S6).
Using the Risk and Vulnerability framework (See Table 4), we did not identify any key findings that highlight biomedical factors that influence the acceptability of health and structural interventions. We identified 11 key findings at the behavioural and structural levels of the Risk and Vulnerability framework that influence the acceptability of services; these findings are described below. The GRADE-CERQual confidence in findings ranged from very low to moderate (see Table 5). Confidence levels were downgraded due to methodological limitations, heterogeneity in populations and interventions, and the coherence of the data.
We identified three key findings that influence intervention acceptability at the behavioural level:
Studies found that one’s sense of self may be challenged as they adapt to a life off the streets. Individuals with a history of homelessness found it challenging to give up the homeless identity/community. Many individuals who experienced homelessness had difficulty adapting to new environments and underwent an adjustment period to become accustomed to new structured communities and lifestyles,[68,72,77,79] for example, requiring several months to feel worthy of “walking on the sidewalks instead of in the back alleys.” Youth, in particular, felt that shelter environments did not foster the development of young adults and found it particularly challenging to assimilate to the shelters’ institutional nature. Others recognized the importance of rules and structure as essential elements for personal development.
Participants felt that having a sense of autonomy while participating in programs improved their motivation to “do what it takes” to maintain positive outcomes. However, some participants felt a loss of autonomy when involved in programs due to their perception of providers’ patronizing attitudes.[65,72,79] For example, participants reported being “treated like kids” and being “told what to do”.
Mothers expressed feelings of pride when they observed positive changes in their children’s health and social outcomes after participating in maternal programs. They felt that family-oriented interventions allowed them to become effective mothers [54,66,71,82]: “It’s awesome because it makes me feel like I’m doing the right thing you know, that I’m being a good parent”.
We identified eight key findings that influence intervention acceptability and accessibility at the structural level:
Stable housing and service programs created a sense of safety, security and stability for individuals with lived experience of homelessness, who often faced hardships in securing safe places for personal belongings and activities [26,56,63,67,68,72,73,76,79,85], “where you don’t have to watch your back all the time” . Women, in particular, found that women-specific programs created safe spaces to engage with one another in an environment free from violence and trauma. Such programs promoted feelings of empowerment, self-efficacy, and enhanced self-esteem.[74,75]
People who experienced homelessness or vulnerable housing often felt that the limited housing options did not address their personal needs and preferences, such as preferred neighbourhoods or housing with sufficient privacy, or were unattainable due to restrictive eligibility criteria.[55,56,58,60,72,80,86] Youth expressed interest in congregate housing models, as these promoted companionship and a sense of community and surrogate family with others in similar circumstances.[67,86] Women prioritized the safety of their children and expressed concerns regarding the safety of the neighbourhoods in which they lived.[72,82] Many women communicated a preference for integrated services within housing programs.
Men and women of all ages with lived experience of homelessness valued being able to trust their service providers and others around them. They felt that once trust was established, a strong relationship could develop, and could facilitate relationship-building for others: “[…] as soon as a couple of them start to trust you, you start to get everyone else in the hostel to know you”. However, male youth had more difficulty trusting providers and accessing services than other groups. [26,57,58,61,64,68,72,79–82,84–86]
Once trust was established, persons who experienced homelessness or vulnerable housing appreciated the pivotal role caseworkers played in providing them with tools to promote their empowerment and independence.[58,62,63,67,68,70,75,82,86] Quick connections to appropriate services may lead to rapid results, which some service users needed to see to sustain motivation to remain engaged.
Continuity of care
Many persons who experienced homelessness identified challenges in accessing care and maintaining adequate health when there were high turnover rates of service providers, thus resulting in a discontinuity of care. The transient nature of providers was detrimental to the ability of persons experiencing homelessness to seek out and utilize services. One participant said “Sometimes you need something solid in your life. Not knowing, especially for an addict… the unknown brings fear. It ends after three years. […]. it worries me a lot, the ‘after’ here”. Youth, in particular, highlighted the need for stability, continuity and commitment by support workers. [55,56,58,62,64,66,70,77,79,80,82,86]
Individuals participating in housing programs initially felt socially isolated but found that support from peers and staff with shared lived experience of marginalization allowed them to develop strong connections with and eventual feelings of altruism toward their peers.[58,60,62,67,68,72,76,84] The key relationships identified were with staff,[62,66,72,73,86] peers, [56,64,67,69,84] friends, family,[54,66,69] people from their cultural community,[60,72] and the broader community.[67,72] These individuals also found that the peer support in youth- and women-specific programs was especially beneficial to the development of relationships and in enhancing one’s commitment to seek treatment and participate in programs.[26,54,56,64,67,69,73,84,87]
Socially constructed gender roles (assigned to men and women, based on cultural beliefs, values, employment, and family role) were found to result in restricted access to programs.[65,66,74,75,84] For example, men faced difficulties in showing their vulnerability and in building trust, which inhibited their openness to accessing support services. Women reported restrictive relationships with men and family members, which limited their ability to take on roles other than as the mother/caretaker. However, in one study, women felt that their family role facilitated positive program outcomes.
Finally, studies highlighted that the intergenerational cycle of violence and poverty experienced by individuals who are vulnerably housed exacerbated their mental health problems and related stigma.[66,67,70] This was particularly prominent among women [54,75,82] and their children. Youth, in particular, felt stigmatized for admitting to having mental health issues; this led to feelings of low self-worth and expectations of failure.[59,69,72,77,81,84] As participants gained insights into their mental illness, they acquired a sense of control over their own lives.[56,61,67,72,85,86]
We found several behavioural and structural factors that influenced the acceptability of health and structural interventions, including permanent supportive housing, case management, income, interventions for substance use, and women- and youth-focused interventions, for persons who are homeless or vulnerably housed. We found that several behavioural and structural factors influenced the acceptability of these interventions. The included studies reported, with moderate confidence, that persons with lived experience of homelessness described recurrent experiences of marginalization, dehumanization, and exclusion, and that they highly valued trust and safety within human interactions. Other key findings with moderate confidence included the need for autonomy and support in relationships and that gender should be considered in intervention delivery. Trust and safety and the negative impacts of structural violence resonated across the studies. As the paradigm of safety expands to all settings within the healthcare continuum, there is a need for anti-oppressive approaches (critically reflecting on the power structures such as systemic racism, sexism, homophobia, transphobia, ableism that impact patients’ lives) [89,90] that address structural violence. Primary care providers are uniquely positioned to provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care 
Trauma-informed care involves the following five principles: trauma awareness and acknowledgment; safety and trustworthiness; choice, control, and collaboration; strengths-based and skills-building care; and cultural, historical, and gender issues. The establishment of trust allows for the development of self-identity and small daily interactions that contribute to broader social connections.[92–94] Furthermore, trust in healthcare practitioners improves the likelihood of persons experiencing homelessness or vulnerable housing seeking assistance and adhering to treatment. Individuals who experienced homelessness and vulnerable housing preferred a continuity of services and a consistent/stable group of service providers/practitioners.[55,71] Additionally, supporting empowerment,  resilience and a sense of safety develops over time, suggesting an important function for longitudinal strengths-based or skill-building roles, such as case management and peer support. Peers were a preferred avenue for support, given that persons with a shared lived experience of homelessness may understand each other and the challenges they face in navigating fragmented health and social systems. Persons with lived experience of homelessness valued a physically and emotionally safe setting for interventions. For example, mothers emphasized personal safety when securing adequate housing and services for themselves and for their children. Results from this review also showed that persons with lived experience valued having integrated services or a “one-stop shop” situation where various needs could be met and services could be coordinated.
Our review also shows that persons with lived experience of homelessness undergo a shift in self-identity. Primary care providers should remain open to personal and social identity and marginalization. Many individuals who had experienced homelessness underwent an adjustment period to become accustomed to new structured communities and lifestyles.[68,72] A new living environment and community allowed for the reconfiguring of one’s identity. In general, participants who maintained positive self-identities while homeless related more strongly to street culture and related peers. The process of acculturation may have an impact on both their social and psychological well-being and can also promote health by creating access to previously inaccessible health and social services. As persons with lived experience undergo a shift in their cultural values and beliefs, their self-perception, such as having competent parenting abilities, contributes to a positive self-identity; as a caregiver for example. Mothers who experienced homelessness and vulnerable housing expressed pride when they observed their children's’ positive changes in health and social outcomes, due to their participation in maternal programs.[54,66,71,82] Throughout our findings, pride was identified as an emotional attribute that was linked to pro-social behaviour.
Our results underscore the necessity of there being an intersectional approach that considers age and gender when developing interventions and services for people who experience homelessness.[97,98] Men and women have different experiences of homelessness,[99–101] and these should be reflected in service provision and evaluation.[102,103] For instance, previous research has shown that homelessness or unstable housing among women can be harder to detect due to hesitancy in self-identifying as such due to the associated stigma. Furthermore, trauma or severed social ties upon separation from an abusive partner can increase the risk of social isolation and emotional distress. Including equity-related considerations around sex, gender and diversity can increase the reach and impact of interventions; thus, enabling these interventions to better meet the diverse needs of homeless women and their families.
Similarly, age should also be considered when developing and delivering interventions for persons with lived experience of homelessness. For example, older adults who experience homelessness face challenges in terms of the continuity of case management and care, while youth face the challenge of breaking the cycle of generational poverty and homelessness. Key challenges faced by youth include social isolation, alienation, low self-worth, lack of resources, and substance abuse. Young people are drawn to providers who convey openness and acceptance, emphasize establishing trust, and instill hope. The physical environment of shelters and housing services represents a structural barrier for youth, as they find it difficult to assimilate to the institutional nature of the shelter environment. Furthermore, youth expressed a need for life-skills services, such as education, managing finances and obtaining housing, which would allow them to establish autonomy and meet their personal goals.
This systematic review offers a pragmatic response to time-critical projects  and the GRADE-CERQual approach assesses the confidence levels of the key findings. However, using secondary data is limited by the information provided in published primary studies. Furthermore, employing the ‘best-fit’ variant of framework analyses requires assurance that data is not forced into the a priori framework; rather new themes are created as needed. Using secondary data and ‘best fit’ strategies may be very helpful when policymakers, practitioners or other decision makers need answers quickly, and are able to tolerate some ambiguity about whether the answer is the very best that could be given . The literature included in this qualitative analysis was restricted to seven intervention groups that were identified through a modified Delphi consensus process by both persons with lived experience of homelessness and recognized experts in the field; however, this approach may have missed relevant findings from studies examining other interventions. We also recognize the possibility that valuable insights may have been excluded from the synthesis through the exclusion of low-quality studies, an assessment process which is itself subjective and relies on varying levels of reporting standards. Finally, the exclusion of indigenous-specific interventions limits the applicability of these findings to this population.
The experiences among individuals who are homeless varies greatly; therefore, including persons with lived experience of homelessness in the development and implementation of interventions may help ensure that the needs of the community are met and will facilitate their sense of choice and control over their care. Incorporating their values and preferences is necessary to create appropriate and effective programs and interventions with greater chances of success in serving this population and in reducing health inequities. Key factors to be considered in the development of new programs include the behavioural and structural influences that dictate service acquisition and adherence. Current and future primary care and public health interventions should be developed and implemented with particular attention paid to the factors relevant to transitions in care identified in this review, such as trust, personal safety, and the continuity of care. However, it should be noted that there exists challenges in commissioning services, instituting changes in service provision, and the development of specific care pathways for persons experiencing homelessness when public services are subject to austerity measures. This review’s findings contribute to biomedical and healthcare strategies (e.g., harm-reduction strategies); educational and behavioural strategies (e.g., counselling and referral services); environmental strategies that support and facilitate behaviour change; and policy and legislative strategies (e.g., related to poverty, social housing, law enforcement) . Establishing a trusting relationship at first contact with service providers and primary care practitioners is the foundation for positive outcomes.
The authors would like to thank Ayesha Ratnayake (University of Ottawa) for her contributions and expertise.
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