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.

"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.

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.

'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 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.