"It's like your days are empty and yet there's life all around": A mixed methods, multi-site study exploring boredom during and following homelessness.

PURPOSE: To identify experiences of boredom and associations with psychosocial well-being during and following homelessness. METHODS: Using a convergent, mixed-methods explanatory design, we conducted quantitative interviews with 164 participants) (n = 102 unhoused; n = 62 housed following homelessness) using a 92-item protocol involving demographic components and seven standardized measures of psychosocial well-being. A sub-sample (n = 32) was approached to participate in qualitative interviews. Data were analyzed by group (unhoused; housed). Quantitative data were analyzed using descriptive statistics designed to generate insights into boredom, meaningful activity engagement, and their associations with psychosocial well-being during and following homelessness. Qualitative data were analyzed using thematic analysis. Quantitative and qualitative findings were integrated at the stage of discussion. RESULTS: Quantitative analyses revealed small to moderate correlations between boredom and increased hopelessness (rs = .376, p < .01), increased drug use (rs = .194, p < .05), and lowered mental well-being (rs = -.366, p < .01). There were no statistically significant differences between unhoused and housed participants on any standardized measures. Hierarchical regression analyses revealed that housing status was not a significant predictor of boredom or meaningful activity engagement (p>.05). Qualitative interviews revealed profound boredom during and following homelessness imposing negative influences on mental well-being and driving substance use. CONCLUSIONS: Boredom and meaningful activity are important outcomes that require focused attention in services designed to support individuals during and following homelessness. Attention to this construct in future research, practice, and policy has the potential to support the well-being of individuals who experience homelessness, and to contribute to efforts aimed at homelessness prevention.

The experiences of familial mental illness stigma among individuals living with mental illnesses.

Persons with mental illnesses may experience stigma from their immediate family members in addition to other forms of stigma. Using semi-structured interviews, we investigated experiences of familial mental illness stigma among 15 people diagnosed with mental illnesses in a mid-sized city in Canada. We identified five themes that speak to participants' experiences of familial mental illness stigma and ways to reduce it. The themes include the following: diagnosis as a 'double-edged sword,' potential familial isolation, familial stigma as societal stigma localized, stories of acceptance, and confronting potential familial mental illness stigma. Participants' narratives indicate that familial mental illness stigma is rooted in the broader social or public stigma, which sees its way into familial relations as well. This stigma takes various forms, including relationship bias or unfair treatment, breakdown in romantic relationships, loss of status, verbal and emotional abuse, exclusion from decision-making, and alienation within their immediate and extended families. Familial mental illness stigma experiences negatively impact participant's psychological well-being and personal empowerment. However, participants also shared ways that family members create supportive environments or actively confront or prevent stigma. Overall, this study has contributed to knowledge on mental illness stigma, particularly familial mental illness stigma from the perspective of participants living with a mental illness in a high-income country. Suggestions for future research include a focus on strategies to prevent ongoing familial mental illness stigma and large-scale studies to explore familial mental illness stigma to understand why families might perpetrate stigma.

Service restrictions from emergency shelters among people experiencing homelessness: Uncovering pathways into unsheltered homelessness and institutional circuitry.

Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mapping to examine the antecedents and consequences of service restrictions from emergency shelters among people experiencing homelessness in two cities in Ontario, Canada. A total of 49 people experiencing homelessness who had been restricted from an emergency shelter program in the past year were recruited and included in the study analysis. A pragmatic and integrative approach was used for data analysis that involved the development of meta-matrices to identify prominent and divergent perspectives and experiences with regard to service restriction antecedents and consequences. Study findings underscored that service restrictions were often the result of violence and aggression, primarily between service users. There were regional differences in other service restriction reasons, including substance use and possession. Service restrictions affected the shelter status of almost all participants, with many subsequently experiencing unsheltered homelessness, and cycling through institutional health, social, and criminal justice services (i.e., institutional circuitry). Other health and social consequences included substance use relapses and hospitalizations; cold-related injuries due to post-restriction unsheltered homelessness; suicidality; food insecurity; diminished contact with support network and connections; and intense feelings of anger, fear, and hopelessness. Overall, the study findings advance our understanding of the role of homeless services in pathways into unsheltered homelessness and institutional circuitry, which raise critical questions about how to mitigate the harms associated with service restrictions, while concurrently facilitating safety and upholding the rights of people experiencing homelessness and emergency shelter staff.

Effectiveness of Interventions for Meaningful Activity Participation in Homelessness: A Systematic Review.

Background. Meaningful activity participation has been identified as a key outcome of services designed to support individuals during and following homelessness. Little is known about the effectiveness of interventions for promoting this outcome. Purpose. To identify the range and effectiveness of interventions on promoting meaningful activity participation among persons with experiences of homelessness. Method. We conducted a systematic review using the Joanna Briggs Institute methodology following PRISMA guidelines including a critical appraisal and narrative synthesis. Findings. Of 12,343 titles and abstracts screened, we included 12 studies. The authors of the included studies primarily used standardized measures of meaningful activity engagement. Critical appraisal scores ranged from 50.0 to 77.8. The most common interventions evaluated in the included studies were psychosocial interventions (n = 6; 50.0%), followed by case management and housing support interventions (n = 4; 33.3%) and Housing First (n = 2; 16.7%). While several interventions demonstrated effectiveness in promoting meaningful activity participation including psychosocial and case management interventions, Housing First, Critical Time Intervention, and a peer support intervention were found to be ineffective for promoting engagement in meaningful activity. Conclusion. Few intervention studies have been conducted that demonstrate effectiveness for promoting participation in meaningful activity for individuals during and following homelessness. Occupational therapy researchers and practitioners can build on existing evidence by developing and evaluating novel approaches by co-designing interventions in collaboration with persons with experiences of homelessness and service providers.

Participatory Research with Persons who Experience Mental Illness in Occupational Therapy: A Scoping Review.

Background. Persons who experience mental illness also face stigma and discrimination that frequently lead to a loss of ability to exercise autonomy and agency in their lives. Purpose. The range and breadth of literature exploring participatory research with persons living with mental illness are unknown in occupational therapy and occupation science. We initiated this study to fill this gap in the existing occupational therapy and occupational science literature. Method. Using the method of Arksey and O'Malley, we have conducted a scoping review to identify the range and breadth of literature. A qualitative content analysis was performed. Findings. A total of 34 articles were included in the narrative synthesis. The content analysis led to three related themes from the included studies: (1) coming together; (2) unique potential of participatory research; and (3) challenges in conducting participatory research. Conclusions. This review highlights that participatory research is well suited to research conducted with persons living with mental illness to support meaningful engagement and minimize stigma throughout the research process. This review can guide future participatory research and practice in occupational therapy and occupational science with persons living with mental illness.

Managing high-risk behaviours and challenges to prevent housing loss in permanent supportive housing: a rapid review.

Permanent supportive housing is an effective intervention for stably housing most people experiencing homelessness and mental illness who have complex support needs. However, high-risk behaviours and challenges are prevalent among this population and have the potential to seriously harm health and threaten housing tenures. Yet, the research on the relationship between high-risk issues and housing stability in permanent supportive housing has not been previously synthesized. This rapid review aimed to identify the housing-related outcomes of high-risk behaviours and challenges in permanent supportive housing settings, as well as the approaches used by agencies and residents to address them. A range of high-risk behaviours and challenges were examined, including risks to self (overdose, suicide/suicide attempts, non-suicidal self-injury, falls/fall-related injuries), and risks to multiple parties and/or building (fire-setting/arson, hoarding, apartment takeovers, physical/sexual violence, property damage, drug selling, sex trafficking). The search strategy included four components to identify relevant academic and grey literature: (1) searches of MEDLINE, APA PsycINFO, and CINAHL Plus; (2) hand searches of three journals with aims specific to housing and homelessness; (3) website browsing/searching of seven homelessness, supportive housing, and mental health agencies and networks; and (4) Advanced Google searches. A total of 32 articles were eligible and included in the review. Six studies examined the impacts of high-risk behaviours and challenges on housing tenancies, with overdose being identified as a notable cause of death. Twenty-six studies examined approaches and barriers to managing high-risk behaviours and challenges in PSH programs. These were categorized into eight types of approaches: (1) clinical, (2) relational/educational, (3) surveillant, (4) restrictive, (5) strategic, (6) design-based, (7) legal, and (8) self-defence. Consistent across all approaches was a lack of rigorous examination of their effectiveness. Further, some approaches that are legal, restrictive, surveillant, or strategic in nature may be used to promote safety, but may conflict with other program objectives, including housing stability, or resident empowerment and choice. Research priorities were identified to address the key evidence gaps and move toward best practices for preventing and managing high-risk behaviours and challenges in permanent supportive housing.

Victimization, safety, and overdose in homeless shelters: A systematic review and narrative synthesis.

The objective of this prospectively registered systematic review was to identify the factors that contribute to sense of safety, victimization, and overdose risk in homeless shelters, as well as groups that are at greater risk of shelter-based victimization. Fifty-five articles were included in the review. Findings demonstrated that fears of violence and other forms of harm were prominent concerns for people experiencing homelessness when accessing shelters. Service users' perceptions of shelter dangerousness were shaped by the service model and environment, interpersonal relationships and interactions in shelter, availability of drugs, and previous living arrangements. 2SLGBTQ+ individuals were identified as being at heightened risk of victimization in shelters. No studies examined rates of shelter-based victimization or tested interventions to improve safety, with the exception of overdose risk. These knowledge gaps hinder the establishment of evidence-based practices for promoting safety and preventing violence in shelter settings.

Meaningful Activity, Psychosocial Wellbeing, and Poverty During COVID-19: A Longitudinal Study.

Background: Only a few studies have explored experiences of meaningful activity and associations with psychosocial wellbeing during COVID-19. None reflect a Canadian context or focus on persons living in poverty. Purpose: To identify experiences and associations between meaningful activity and psychosocial wellbeing for persons living in poverty during the first year of COVID-19. Method: We delivered a quantitative survey at three time points during the first year of the pandemic supplemented by qualitative interviews at Time(T) 1 and 1 year later at T3. Findings: One hundred and eight participants completed T1 surveys, and 27 participated in qualitative interviews. Several statistically significant correlations between indices of meaningful activity engagement and psychosocial wellbeing were identified across T1-T3. Meaningful activity decreased from T1-T3 [X2 (2, n = 49) = 9.110, p < .05], with a significant decline from T2-T3 (z = -3.375, p < .001). In T1 qualitative interviews, participants indicated that physical distancing exacerbated exclusion from meaningful activities early in the pandemic. At T3 (1 year later), they described how classist and ableist physical distancing policies layered additional burdens on daily life. Implications: Meaningful activity engagement and psychosocial wellbeing are closely associated and need to be accounted for in the development of pandemic policies that affect persons living in low income. Occupational therapists have a key role in pandemic recovery.

"I can't remember the last time I was comfortable about being home": lived experience perspectives on thriving following homelessness.

PURPOSE: Strategies for preventing and ending homelessness are frequently measured by their effectiveness on indices of tenancy sustainment. To shift this narrative, we conducted research to identify what is needed to "thrive" following homelessness from the perspectives of persons with lived experience in Ontario, Canada. METHODS: Conducted in the context of a community-based participatory research study aimed at informing the development of intervention strategies, we interviewed 46 persons living with mental illness and/or substance use disorder [n = 25 (54.3%) unhoused; n = 21 (45.7%) housed following homelessness] using qualitative interviews. A subsample of 14 participants agreed to engage in photovoice interviews. We analysed these data abductively using thematic analysis informed by health equity and social justice. RESULTS: Participants described experiences of "living in a state of lack" following homelessness. This essence was expressed through four themes: 1) housing as part one of the journey to home; 2) finding and keeping "my people"; 3) meaningful activity as critical for thriving following homelessness; and 4) struggling to access mental health supports in the context of challenging circumstances. CONCLUSIONS: Individuals struggle to thrive following homelessness in the context of insufficient resources. There is a need to build on existing interventions to address outcomes beyond tenancy sustainment.

Competencies for occupational therapy practice in homelessness: A Delphi study.

BACKGROUND: Homelessness is growing internationally, and resources to guide occupational therapy practice in this area are needed. OBJECTIVES: To identify competencies needed for occupational therapists to support individuals during and following homelessness. MATERIAL AND METHODS: We conducted a three-round Delphi study with occupational therapy practitioners and researchers with expertise in homelessness. RESULTS: Of 35 potential participants, n = 16 participated in Round I, n = 20 participated in Round II, and n = 18 participated in Round III. Participants included occupational therapists and researchers in Canada, United States, Brazil, UK, Ireland and New Zealand. Consensus was achieved on a total of 93 competencies in 10 categories after 15 were eliminated in Rounds II and III. The categories with the greatest number of competencies included occupational knowledge (n = 18), followed by psychosocial competencies (n = 16). CONCLUSIONS AND SIGNIFICANCE: This study represents the first to identify the competencies needed for occupational therapists working in the area of homelessness. Practitioners and educators are encouraged to view the identified competencies as a guide for the professional development of occupational therapists in this context. Stakeholders consulted for this study were able to communicate in English and situated in middle to high-income countries. As such, the competencies identified in this study only apply to these sociocultural contexts.

Bridging the transition from homelessness: Developing an occupational therapy framework.

BACKGROUND: Occupational therapists support individuals experiencing homelessness in traditional roles, and occupational therapy positions focussed specifically on homelessness appear to be growing. OBJECTIVES: To develop and refine a framework to guide occupational therapy practice and research in homelessness. METHOD: We developed a framework and refined it through a stakeholder consultation process conducted with 17 international occupational therapy experts using an online survey. In this survey, we presented an initial framework and requested qualitative feedback. We analyzed this qualitative data using content analysis. RESULTS: Stakeholder feedback was categorized into eight recommendations: (1) Revision to the 'four processes'; (2) Emphasizing social justice and systems-level advocacy; (3) Reflecting intersectionality; (4) Emphasizing meaningful activity; (5) Emphasizing peer support; (6) Incorporating a focus on independent living skills; (7) Increasing a focus on an activity for addressing substance misuse; and (8) Acknowledging cognitive and physical health. Each of these recommendations was incorporated into a refined version of this framework. These recommendations and a refined version of the framework are presented in this paper. CONCLUSIONS: We have developed and refined a framework aimed at guiding practice and research in occupational therapy in homelessness that will be evaluated in future research. SIGNIFICANCE: Though a range of frameworks exists for guiding the practice of occupational therapists more generally, this framework represents the first that is focussed specifically on guiding occupational therapy practice and research with individuals who experience homelessness. Research and practice implications are discussed.

Humor in rehabilitation professions: a scoping review.

PURPOSE: Studying humor in the rehabilitation professions is important given its positive effects on health and well-being. We conducted a scoping review to understand how the use of humor has been explored in the existing literature in four rehabilitation professions. The rehabilitation professions included audiology, speech-language pathology, physical therapy, and occupational therapy. MATERIALS AND METHODS: The five-stage method identified by Arksey and O'Malley was used to conduct this review. Six databases were searched. We included 57 articles in our final review, summarized in a narrative synthesis. RESULTS: We generated seven themes in our analysis: (1) humour as a management strategy in therapy; (2) humour as a power establisher vs. equalizer; (3) humour as a coping mechanism in rehabilitation; (4) conceptualizations of non-verbal humor cues in therapy; (5) Is humour trainable? (6) Humor used to foster group cohesion; and (7) Attitudes and beliefs surrounding humor practice. CONCLUSIONS: Our findings emphasize the importance of using humor in the rehabilitation professions, and the ways in which humor is conceptualized in a multitude of ways for both clinician and client. Future work is needed to further understand the presence and use of humor in rehabilitation professions.IMPLICATIONS FOR REHABILITATIONIn a scoping review of the literature, this study showed that humor was used mainly positively in rehabilitation by the included professions of audiology, speech-language pathology, physical therapy, and occupational therapy and contributed to a sense of belonging.Humor may be an effective way to improve management of client/clinician relations as well as improving group cohesion in rehabilitation settings.In the rehabilitation professions of audiology, speech-language pathology, physical therapy, and occupational therapy, non-verbal humor cues were used in instances where communication was difficult or impaired for clients.

Effectiveness of Suicide Safety Planning Interventions: A Systematic Review Informing Occupational Therapy.

Background. Suicide safety planning (SSP) is a suicide prevention approach that involves developing a collaborative plan between a service provider such as an occupational therapist and a person who is at risk of suicide. Purpose. To synthesize effectiveness studies on SSP. Method. Using the Joanna Briggs Institute methodology, we conducted a systematic review of effectiveness studies including a: (1) title and abstract screening; (2) full-text review; (3) critical appraisal; and (4) narrative synthesis. Findings. We included 22 studies. Critical appraisal scores ranged from 38.5 to 92.3 (m = 63.7). The types of interventions included were: standard and enhanced SSP (n = 11); electronically delivered SSP (n = 5); and SSP integrated with other approaches (n = 6). Only three studies identified meaningful activity as a component of SSP. Evidence across a range of studies indicates that SSP is effective for reducing suicide behavior (SB) and ideation (SI). While some studies have demonstrated effectiveness for reducing symptoms of mental illness, promoting resilience and service use, the number of studies exploring these outcomes is currently limited. Implications. Occupational therapists support individuals expressing SI, and SSP is a necessary skill for practice.

Experiences of familial stigma among individuals living with mental illnesses: A meta-synthesis of qualitative literature from high-income countries.

WHAT IS KNOWN ON THE SUBJECT?: Mental illness stigma has been long acknowledged as a social problem that continues to persist and contribute to social exclusion of affected persons globally. Researchers have explored mental illness stigma in the general public and among health professionals, with little focus on stigma from family members and close relatives of persons with mental illnesses. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study appears to be the first meta-synthesis of familial mental illness stigma in high-income countries. Family members or close relatives of persons with mental illnesses may be perpetrators of stigma. That is, the family may enact stigma of mental illness against their relative to "save face" or by avoiding or narrowing their social contacts. Familial stigma is harmful due to the likely disaffection it brings within one's home environment. Familial mental stigma from the existing literature seems to be a by-product of public stigma and stigma by association WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further research is necessary to look at the existence of familial mental illness stigma as well as available policies to reduce its impact on affected individuals in high-income countries. Researchers in high-income countries should endeavour to examine the relationship between familial, public and associative stigma to establish baseline metrics to inform future anti-stigma programs seeking to reduce familial mental illness stigma. ABSTRACT: INTRODUCTION: Familial mental illness stigma is a pervasive issue but very subtle in high-income countries. Familial mental illness stigma implies persons living with mental illnesses are discriminated against by their family members or close relatives. AIM/QUESTION: This meta-synthesis explored the experiences of familial stigma among individuals living with mental illnesses in high-income countries, focusing on empirical literature, to understand the breadth of current literature and ways to reduce this form of stigma. METHOD: We conducted a meta-synthesis through a structured search of qualitative data from six electronic databases (Sociological Abstract, CINAHL, Medline, PsycINFO, Google Scholar and Embase). Inclusion criteria comprised: empirical primary research, primary technique for data collection is qualitative, studies published in a peer-reviewed journal in the English language between 2000 and 2020, studies reported on experiences of familial mental illness stigma, and studies conducted in high-income countries. The exclusion criteria were as follows: all grey literature, studies not written in English and non-peer-reviewed, studies not focused on familial mental illness stigma, quantitative peer-reviewed articles on the related concept and peer-reviewed articles on the related topic before the year 2000. RESULTS: The study identified only 28 peer-reviewed articles on the topic within two decades. Concealment of familial stigma was found to be detrimental due to the potential for alienation within one's home environment. Disclosure and social contact within the family system were considered as critical interventions to provide some safety nets for individuals with mental illnesses. DISCUSSION AND IMPLICATIONS FOR PRACTICE: The paucity of studies over the review period highlights the need for further attention to support optimal environments for persons living with mental illnesses. Families' understanding of the difficulties of mental illness stigma is vital to supporting the development of policies and interventions towards the avoidance of social exclusion within societies. Families should make concerted efforts to reduce stigma, and this includes within the family system. Education and training approaches around mental illness-related stigma should involve individuals with lived experience and their families, as well as service providers and the general public.

'We stick people in a house and say okay, you're housed. The problem is solved': A qualitative study of service provider and organisational leader perspectives on thriving following homelessness.

Research aimed at identifying and evaluating approaches to homelessness has predominately focused on strategies for supporting tenancy sustainment. Fewer studies focus on strategies for enabling thriving following homelessness, and the perspectives of service providers and organisational leaders (SPOL) on this topic are rare. We conducted this study in the context of a community-based participatory research project in two cities in Ontario, Canada. This research was aimed at identifying the strengths and challenges of existing supports in enabling thriving following homelessness, followed by co-designing a novel intervention alongside persons with lived experience of homelessness (PWLEH) and SPOL. The current study presents the findings of interviews conducted in 2020-2021 with SPOL in organisations serving PWLEH. We interviewed 60 individuals including service providers (n = 38; 63.3%) and organisational leaders (n = 22; 36.7%) using semi-structured qualitative interviews. Interviews were conducted and recorded on Zoom to align with physical distancing protocols associated with the COVID-19 pandemic. Recordings were transcribed verbatim and analysed abductively informed by the lenses of social justice and health equity. The essence of our findings is represented by a quote from a research participant: 'We stick people in a house and say okay, you're housed. The problem is solved'. This essence was expressed through five themes: (1) stuck in a system that prevents thriving, (2) substance use as an important coping strategy that prevents tenancy sustainment and thriving, (3) the critical importance of targeting community integration following homelessness, (4) incorporating peer expertise as imperative and (5) people need to be afforded options in selecting housing and services following homelessness. Our findings indicate that SPOL envision possibilities of thriving following homelessness yet are embedded within a system that often prevents them from supporting individuals who are leaving homelessness to do so. Research, practice and policy implications are discussed.

'The Big Island Model': Resident experiences of a novel permanent supportive housing model for responding to rural homelessness.

Research on rural homelessness focuses primarily on describing the experiences and prevalence of homelessness in rural contexts, with little focus on intervention strategies. We conducted a case study of the 'Big Island Model' (BIM), a novel approach to providing housing and support to individuals experiencing homelessness that has been developed for, and reflects, a rural context. We interviewed 13 participants (n = 10 men; n = 3 women) supported by the BIM using mixed interviews including qualitative and quantitative components exploring experiences of living within this model and aspects of psychosocial well-being. Descriptive statistics were calculated to represent demographic data and participants' scores on standardised measures. Wilcoxon signed-rank tests were conducted with threshold scores and population norms derived from existing literature to identify any differences between residents' median scores on each standardised scale and scores derived from published literature. Qualitative data were analysed using thematic analysis. On measures of meaningful activity, residents reported significantly lower levels of boredom (p < 0.01) and a greater degree of engagement in productivity (p < 0.01) compared with participants in other studies. Mental well-being was reported to be higher (p < 0.05) and drug use was significantly lower than a low-moderate range (p < 0.01). Community integration scores revealed significantly lower physical integration (p < 0.05) and significantly higher psychological integration than individuals who had transitioned to housing in another study (p < 0.001). Our analysis of qualitative interviews resulted in the identification of a central essence characterising residents' experiences: 'Becoming Through Belonging'. This essence was represented by four distinct themes: (1) the healing qualities of nature; (2) being meaningfully occupied; (3) living in a mutually supportive environment; and (4) this place is here to help.

Psychotherapy Within Occupational Therapy Literature: A Scoping Review.

Background. Recent changes in the Canadian regulatory landscape have prompted reflections on the role and scope of occupational therapy in the provision of psychotherapy. Purpose. To document how psychotherapy has been explored in occupational therapy literature. Method. We conducted a scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review (PRISMA-ScR) guidelines by searching eight databases (e.g., Medline, AMED, CINAHL, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews, Sociological Abstracts, and ProQuest Dissertations & Theses). Articles included at the full-text stage were subjected to a narrative synthesis. Findings. A total of 207 articles met the criteria for inclusion, spanning 93 years. 47.3% of these articles represented non-empirical literature, with only 14% representing effectiveness studies, suggesting that this body of literature remains in an early stage of development. Implications. Occupational therapists have been writing about and practicing psychotherapy for nearly a century, yet there remains an important opportunity to develop and evaluate occupation-based psychotherapy approaches. Effectiveness studies are needed.

The experience of food insecurity during and following homelessness in high-income countries: A systematic review and meta-aggregation.

Homelessness is a pervasive challenge caused by poverty which continues to grow in economically developed countries, posing significant health impacts (Fazel et al., Lancet, 384: 1529-1540, 2014). While food security related to poverty and low income has been investigated, this review specifically explores the experience of food security during and following homelessness. Given the fact that the health of individuals who experience homelessness is known to be poor and the importance of nutrition, this is a necessary contribution. Informed by a health equity lens, this review synthesises the findings and quality of the literature regarding experiences of food security during and following homelessness in high-income countries. We used the Joanna Briggs Institute methodology, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Qualitative studies published to date were obtained from six databases. We conducted a meta-aggregation of existing qualitative findings. Twenty-four studies on 462 participants were included in the review. Through meta-aggregation four themes were created: (1) imposed food options as a determinant of health out of my control; (2) obtaining food for survival despite stigma or other consequences; (3) situated within a system that maintains food insecurity; and (4) surviving hardships. Persons during and following homelessness in high-income countries face multiple challenges when securing food while situated in an oppressive system that lacks choice. Despite this, persons who have experienced homelessness demonstrate resilience by finding ways to meet their basic needs in the face of imposed barriers. Implications for research, policy and practice are offered.

Effectiveness of employment-based interventions for persons experiencing homelessness: A systematic review.

Employment is frequently desired by persons who experience homelessness yet is often elusive. Little is known about the range and effectiveness of employment-based interventions evaluated in existing literature on key psychosocial outcomes including employment participation, mental well-being, housing tenure, community integration and substance use. To identify and synthesise existing studies, we conducted a systematic review of effectiveness using the methodology proposed by the Joanna Briggs Institute (JBI) following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Following the removal of duplicates, we screened 13,398 titles and abstracts, and reviewed 79 studies at the full-text review stage using two independent raters. A total of 16 studies met criteria for inclusion in a narrative synthesis and were subjected to critical appraisal. The majority of studies were conducted in the US (n = 14; 87.5%) with other studies published in Canada (n = 1; 6.3%) and Australia (n = 1; 6.3%). Interventions evaluated in existing studies included combined substance use and vocational skills interventions (n = 7; 43.8%), supported employment (n = 6; 37.5%), and integrated supports including an employment component (n = 3; 18.8%). The effectiveness of these interventions on employment, mental well-being, housing tenure, community integration, and substance use is presented. Findings suggest that research evaluating employment interventions for persons who experience homelessness is in an early stage of development. Researchers and practitioners may consider collaborating with persons with lived experiences of homelessness and practitioners in co-designing and modifying existing approaches to target key outcomes more effectively. Policymakers may consider allocating resources to such initiatives to further the development of practice and research aimed at supporting persons who experience homelessness to secure and sustain employment during and following homelessness.

Violence and victimisation in the lives of persons experiencing homelessness who use methamphetamine: A scoping review.

Methamphetamine (MA) use among individuals who experience homelessness has tripled in recent years. This is a problematic trend given the harmful impacts of this substance on health and social well-being. While there is a large body of literature on the relationship between substance use and trauma, little is known about the scope of existing empirical literature exploring this topic related to MA use. Anecdotally, MA is frequently associated with violence and victimisation, which may be related to stigma associated with using MA. However, little is known about the scope of empirical literature exploring violence and victimisation in the lives of individuals who experience homelessness and use MA. We conducted a scoping review to fill this gap in existing literature using Arksey and O'Malley's methodological framework. Our search was conducted between January 2021 and March 2021 and was deployed in seven databases: Medline, Embase, CINAHL, PsycINFO, Sociological Abstracts, Nursing and Allied Health and AMED. Two independent raters screened 700 titles and abstracts after the removal of duplicates. A total of 54 articles were subjected to a full-text review and 20 articles met the inclusion criteria. We generated two themes: methamphetamine and victimisation and challenging behaviours. Six (30%) of the included articles explored MA use in relation to violence, while 18 (90%) explored experiences of victimisation among persons experiencing homelessness. Our findings highlight that individual who experience homelessness and use MA are particularly vulnerable to experiences of trauma. Though existing literature does acknowledge the challenging behaviour associated with MA use, only three existing studies demonstrated a relationship between MA use and physical violence. Research exploring the impacts of MA use on victimisation among persons who experience homelessness, and the development of interventions for managing challenging behaviours associated with MA use are needed.