Public Health Among People Experiencing Homelessness during COVID-19

Public Health Among People Experiencing Homelessness during COVID-19 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Public Health Among People Experiencing Homelessness during COVID-19 Michael Pearson, Carmen Monico This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3774252/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The COVID-19 pandemic magnified organizational and universal issues adversely affecting health among many including those experiencing homelessness. Among homeless populations, the high-risk nature of COVID-19 challenged access to treatment, disrupts access to housing and security, and it aggravated social disparities such as employment loss, housing access and extended homelessness. This study looks at the need to identify and implement mitigating strategies to reduce and address communicable disease within shelter environments. This study utilizes staff and client surveys through Qualtrics to document the experiences of clients and staff of a homeless shelter in Greensboro during COVID-19 and when entering service delivery. The study gauged participant perceptions regarding the shelter’s public health response, their access to health and housing resources, and access to treatment. In addition, it identified the level of impact of the pandemic on shelter services and sense of safety. The study found that multiple intersecting factors influenced disease spread, such as, living conditions, treatment adherence, and risky behavior. This research shows that to adequately provide services, to ensure safety and reduce outbreaks, mitigating strategies such as onsite screening and access to treatment and care are essential. Data collected shows that method of service delivery to populations experiencing homelessness is an essential mitigating strategy and helps address risk and barriers within homelessness. homelessness shelter services health disparities COVID-19 public health social work Introduction As of September 29, 2023, the Worldometer (43) reported 695.9 million COVID-19 cases with 6.9 million deaths and 667.9 million recoveries. As a strain of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), COVID-19 forced, unto society, undesirable social situations such as social isolation, hospitalization, and deaths [ 2 , 9 , 13 , 21 ]. The severity of the virus challenged public health responses, namely the ability to provide adequate medical treatment and manage the social aftermath: economic downturn, increased homelessness, and mental, physical, and emotional instability [ 42 , 31 , 41 ]. Among homeless populations, housing and homeless health are representative elements, resulting in homeless groups having reduced structural and system resources [ 39 ]. Additionally, for the homeless limited access perpetuates unfavorable conditions and heightens risk factors [ 36 ]. It is fact that homeless populations compared to the general population experience higher risk exposures [ 3 ]. For example, homeless have a 5–10% higher exposure risk to disease [ 26 ] and are 1–16% more likely to be impacted by disease [ 14 ]. This is influenced by the lack of secure, stable, safe, and adequate housing increasing homeless susceptibility and exposure to adverse disease life outcomes [ 35 ]. To better understand the impact of public health concerns on the homeless, it is essential to determine a few items and discuss implications. Understanding the prevalence of COVID-19 is vital. In addition to understanding the systemic concerns and risks among the homeless [ 6 ]. This will provide background into identifying essential mitigating strategies within homeless settings. Prevalence of COVID-19 in the United States and North Carolina Within the United States (U.S.), there have been 108.7 million cases of COVID-19, 1.17 million deaths, and 106.4 million recovered [ 43 ]. The pandemic has necessitated social distancing requirements which have impacted job opportunities, housing availability, access to services, and a sense of security [ 25 , 22 ]. The Centers for Disease Control and Prevention [ 10 ] report that COVID-19 had a death incidence rate of 79.7% among individuals 65–85 plus, 15.3% among 50–64, and 4.46% among those younger than 50 years old. There have been more than 1 million COVID-19 cases in North Carolina. Of the total cases, 13,533 were deaths, 27,172 were recoveries, and the additional cases were based on number of confirmed exposures with no need for hospitalization. Among the people in the state, 56% of North Carolinians are reported to have underlying health conditions, and 51.1% of adults within North Carolina are considered at high risk of illness from COVID-19 – specifically aging populations. During 2021, North Carolina experiences COVID-19 cases at a daily rate of 7 cases per 100,000 people, hospitalizations 4 per 100,000 per day and an average death rate of 5.3 per 100,000 per day [ 29 ]. Guilford County Health Department [ 19 ] reports 39,298 confirmed cases of COVID-19 as of summer 2020. Of that number, 37,509 are identified recoveries, 1,246 total hospitalizations, 518 total deaths, 65 current hospitalizations in March 2020, during which 1,270 active cases reported. As of 2023, Guilford County Health Department reports 156,543 confirmed cases of COVID-19 of that number, 155,391 are identified recoveries and 1,142 deaths. The 14-day positive rate is 4.5%- and single-day positive rate is 6.3% of those tested are positive. From 2017 to 2023, the state conducted 1,219,869 COVID tests, and the average reported age of individuals testing positive is 38.7 years old. The highest death percentage is reported for populations over 50, which is the population most vulnerable and those over 50 commonly experiencing homelessness [ 5 , 10 ]. While the exact effect on homelessness from COVID-19 is difficult to measure, recognizing the affect the pandemic can have on homeless populations in relation to the total population is essential. Generally, for every 10,000 persons, 17 experience homelessness [ 10 ], and over 3 million people can experience homelessness with 580,000 on a given night [ 11 ], with over 1.4 million persons attempting to access shelter each year [ 27 ]. As a result of COVID-19, between 2019 and 2022, the homeless population increased by five percent [ 10 , 11 ]. Moreover, among the homeless, COVID-19 exacerbated common homeless disparities (disease exposure, treatment access, increased susceptibility). The literature review confirmed that interrupting the spread of COVID-19 is difficult; however, mitigating strategies such as social distancing, isolation and access to testing are essential to preventing disease outbreak [ 31 ]. Mitigating strategies are useful to increase prevention while encouraging supportive organizational procedures, training, and education [ 5 , 24 ]. Common strategies that addressed COVID-19 concerns included organizational guidelines, prevention, and support tools, addressing crowding, supporting isolation and quarantine, as well as implementation of safety procedures, physical distancing rules, and testing [ 11 ]. Risk and Barriers COVID-19 impacts health directly and indirectly [ 21 ]. COVID-19 adversely influenced service access and resources available, placing limitations on people’s ability to address housing challenges and achieve a healthy lifestyle [ 21 ]. COVID-19 increased vulnerabilities among disadvantaged populations, increasing susceptibility for those with at-risk conditions, such as people with immunodeficiency and other underlying medical conditions [ 42 ]. COVID-19 placed constraints on society – economically, socially, and emotionally – adding to the list of equity and inequality issues people in low income and homeless populations face. The impact on individuals experiencing homelessness include indirect impacts (e.g., risk of contracting COVID-19, and limited or reduced access to health services) and direct impacts e.g., economic wellbeing, job loss and extended homelessness). Additionally, the COVID-19 pandemic revealed many operational barriers to services while working with homeless populations [ 30 ]. For example, between 2017 and 2020 considering service utilization prior to and during COVID-19; observation studies found a 46.7% decline in patient visits due to COVID-19 restrictions impacting outpatient services among mental health providers [ 2 ]. This highlights how vulnerable populations such as the homeless need proactive strategies that mitigate service barriers. Within shelter environments, poor housing conditions and the relationship between COVID-19, reveal a connection between mortality and poor living conditions. This cross-sectional analysis confirms that targeting organizational health factors such as policies, guidelines, and procedures impact living conditions and can mitigate adverse outcomes associated with COVID-19 among the homeless [ 1 ]. Likewise, through clinical observation examining how settings pose a risk to the spread of infectious disease, five homeless shelters in Boston, San Francisco, and Seattle were observed [ 27 ]. The study found that individual willingness or apprehension about testing, the ability to identify symptoms and pre-existing conditions exacerbate treatment outcomes. The factors stressed most are the need for adherence to infectious disease protocol to minimize transmission. Thus, assessing the need for treatment solutions such as education, access and vaccinations among people who are homeless is vital to mitigating the spread of a virus. Vaccine uptake is viewed positively among the homeless population, partly because of positive regard stemming from increased access to vaccination, positive campaigning, and positive impressions of vaccine efficacy [ 21 ]. Essential Mitigating Strategies COVID-19 compounds hardships for multiple individuals including homeless populations influenced by pre-existing health risks, shelter-in-place orders, and social distancing needs [ 15 ]. Access and healthcare are critical during health emergencies, however homeless groups often experience higher levels of reduced health access and care disparities [ 21 ]. Additionally, the risk of spreading communicable disease among homeless populations is influenced by living conditions, hygiene quality, sanitation practices, and overcrowding; these conditions create an environment conducive to transmission because of issues such as poor air ventilation, lack of cleanliness and lack of sanitation protocols [ 20 ]. In a longitudinal study regarding the prevalence of COVID-19 among people experiencing homelessness, there were higher rates among sheltered individuals than unsheltered individuals. This is due to shelter environments being affected by crowding, high transition rates in addition to higher levels of communicable disease. Furthermore, to interrupt COVID-19 transmission, the study indicates that knowledge about symptoms, screening, testing, and isolation are successful strategies among homeless populations [ 44 ]. Furthermore, addressing the impact of COVID19 among homeless environments requires a multi-system approach. When examining the mitigating strategies during COVID of local shelter, such as this study has done, it is possible to identify procedural and organizational challenges and to understand the rationale behind adjustments during the behavior of individuals experiencing homelessness while they enter and exit from the shelter (hereinafter referred simply as entry and exit). Furthermore, a review of shelter entry protocol will provide information about the factors and issues that impact shelter life, identifying the benefits and consequences of organizational and system-level influences on providers and clients. In this study, we examine the effect of COVID-19 on a local shelter in Greensboro, North Carolina, Greensboro Urban Ministry’s (GUM)’s Weaver House. The survey used, provides context to better understand essential mitigating strategies to engage with homeless populations. The sample is comprised of 8 Weaver House residents and 6 staff members who participated in this study. Overall, this study examines COVID-19’s influence on the sheltering process to identify the essential mitigating strategies for homeless shelters to manage through a public health crisis, homelessness barriers and risks. Methodology An ecological perspective of COVID-19 as a public health emergency is essential to understand the pandemic effects on the homeless population [ 28 ]. The national pandemic confirms that human health is intertwined with a wide range of environmental factors, including socio-economic factors, like the stock and labor markets, population density, educational level, housing, and the state of housing; as well as biological factors, such as quality of water and air and the levels of global carbon emissions [ 34 ]. Furthermore, this study will examine the shelter process and identify essential mitigating strategies to addressing public health issues, homeless barriers, and risk issues. This study will use provider and client surveys to assess for these different factors. Surveys will be structured based on a set of 27 questions. The COVID-19 intersecting factors provide opportunity to collect data on pre and post COVID-19 to understand the extent of its impact on homeless shelter life [ 17 ]. A rapid analysis will identify patterns and emerging themes in service delivery among provider and client responses [ 37 ]. The power analysis is used to identify and detect an adequate (minimal) sample size [ 12 ]. Among homeless clients, eight individuals and among staff, three individuals are an optimal sample size for qualitative research. Sample, and Design Shelter selection was determined by identifying shelter agencies through the city of Greensboro agency list and identifying the largest shelter site. Email solicitation was used to recruit agency participation. After successful email communication, the agency allowed consultation with shelter supervisors. Four supervisors agreed to assist with dissemination of information. Shelter client participants were recruited during the intake process. Residents were provided description of the study upon intake and an opportunity to voluntarily participate. Staff surveys were distributed through an internal listserv. The study time frames were between January 1, 2021 and March 1, 2021. Of the total staff, a majority (16) participated in the study and among clients (8) participated. Of both groups, participation did so voluntarily with no gift exchange. Consideration of the unique ethical concerns when conducting research with a homeless population [ 45 ], thus were included in the design of this IRB-approved study (IRB #21–029). Qualitative data was gathered from provider-client data to identify supports and mitigating strategies and impressions affecting sheltered homeless populations as related to COVID-19. Interviews and surveys lasted 30 minutes to complete. Among staff and resident participants, 25 questions were asked. Residence where asked an additional eight questions relating to organizational changes pre and post COVID-19. Questions were asked based on a Likert scale, rating response through five options ranging from strongly agree to strongly disagree. Questions for both clients and staff elicited responses about the level of impact and utilization of specific COVID-19 responses; in addition, they identified organizational, structural and systemic concerns. The series of 25 scaled staff questions were asked during the intake process and tracked through Qualtrics. The same series of questions were communicated through a Qualtrics survey to clients. Additionally, questions were asked to elicit how the shelter response to the COVID-19 public health concerns, to identify preparedness to address the pandemic, ability to keep people safe, readiness to deliver services during COVID-19, and constraints imposed by COVID-19 shelter-in-place requirements. These questions were unique to client impact and collecting information about factors influenced by organizational policy and procedural. This study engaged providers and clients to better understand assess, measure, and gauge the impact of approaches and interventions during COVID-19. Within the shelter setting, there is an organizational process, methods by which the shelter operates, and dynamic between providers, clients and services provided. Capturing a description or organizational processes, and impact of service options on clients is paramount to homelessness and understanding mitigating strategies to homeless issues. Data Analysis Rapid analysis is used to coding client and provider data. Rapid analysis is used to inscribe and categorize information to address research objectives [ 37 ]. Characteristics used to code data is through a repetitive cycle of sorting, sifting, and shift [ 33 ], identifying themes to reduce overlap of information and provide an accurate interpretation of information, and in formulating perspectives about mitigating techniques used with homeless populations [ 32 ]. Additionally. Rapid analysis is an efficient method of compiling and summarizing data after collection [ 40 ]. To assist with data collection a matrix will assist in summarizing participant responses and organizing within domains to analyze and interpret data and better understand the relationships of the data [ 8 ]. In this research, it is essential to draw a connection between provider-client impressions of mitigating strategies to understand essential approaches to engage homeless populations. Results Resident and Staff participants were asked a series of similar questions. The number of questions asked is based on the ability to identify the level of impact and application of specific COVID-19 responses. Questions can be identified in two categories: structural and systemic issues of concern. Each question relates to client or staff experience at entry, thoughts about mitigating strategies, and sense of safety during COVID-19. Procedures to COVID-19 During intake, client participants 100% strongly agree that they were informed about COVID-19, felt COVID-19 issues were being addressed within the shelter, and had access to being treated for COVID-19. Among clients, 83.33% strongly agree that agency policies and procedures addressed COVID-19 infectious disease and identify with feeling agency protocol changed to protect from COVID-19, impacting how service is delivered. Among surveys conducted by staff, responses are split where 50% strongly agree or somewhat agree, and 50% strongly disagree or somewhat disagree that their agency had a communicable disease response to COVID-19. Also, 81.25% of staff respondents strongly agree or somewhat agree that their agency adjusted its policies and procedures to address the COVID-19 infectious disease. There is a mixed perception among staff regarding if agency protocol changed to protect from COVID-19 (50% strongly agree or somewhat agree, and 43.7 5% somewhat disagree or strongly disagree, and 6.25% neither agree nor disagree). According to resident responses, reactions are split (50% neither agree nor disagree, 33.3% strongly agree, and 16.7% strongly disagree) that before COVID-19, the agency had some communicable disease response protocol. Among clients, views are mixed (16.67% strongly agree or somewhat disagree and 33.33% somewhat agree or strongly disagree) with getting COVID-19 from a shelter environment. Of client responses, 40% strongly agree that contact tracing impacts disease spread, Among staff, they feel strongly about getting COVID-19 from a shelter environment; 43.75% strongly agree, 37.50% somewhat agree, and 12.50% neither agree nor disagree, and 6.25% somewhat disagree. Staff expresses mixed thoughts 37.5% strongly agree, 25% somewhat agree, 18.75% somewhat disagree, 12.50% neither agree nor disagree, and 6.25% strongly disagree regarding contracting COVID-19. An overwhelming majority, 87.50%, strongly agree with being aware of the safety procedures to avoid contracting COVID-19. COVID-19 Impact Based on resident responses, 50% strongly disagree with experiencing evictions due to COVID-19, whereas 50% do. Among responses to experiencing job loss or reduced hours due to COVID-19, client responses are mixed (50% strongly disagree, 33.3% strongly agree, and 16.7% somewhat agree). Among treatment options for substance use, respondents identify 66.67% somewhat agree, while 16.67% strongly agree and express issues or experience limitations due to COVID-19. Likewise, 66.67% also identify housing option limitations due to COVID-19 and experiencing mental health service limitations. Among clients, 66.7% identified risk concerns with contacting COVID-19 and 83% strongly agreed that COVID-19 affected living conditions. Among staff, (68.75% strongly or somewhat agree versus 31.25% strongly disagree or agree) about feeling informed about how COVID-19 impacts employment. Many staff, 43.75%, strongly agree that COVID-19 impacts evictions, while 18.75% disagree. As far as job loss in the last year or reduction of hours because of COVID-19, 81.25% strongly agree. Among staff, 56.25% strongly agree, 12.50% somewhat agree, 18.75% neither agree nor disagree, and 12.50% somewhat agree housing options are limited due to COVID-19. Among treatment for mental health, 81.25% strongly agree and somewhat agree and regarding treatment options for substance use during COVID-19. Additionally, among staff, 50% expressed concern about contracting COVID-19 and 68% strongly agreed COVID-19 affected the environment they work in. Of shelter clients, 83.33% identified how to respond to COVID-19 and identify that living conditions impact spread. However, a mixed view is expressed about encountering COVID-19 from a shelter client (33.33% strongly agree, somewhat disagree, and strongly agree). Whereas 50% of the clients feel ventilation impacts COVID-19 spread, and the rest express mixed views (16.67% agree, neither agree nor disagree, or strongly disagree). However, 100% of respondents identify that crowded living conditions impact the spread of COVID-19. Amongst staff responses to the impact of living conditions and spread, 56.25% strongly agree, and 25% somewhat agree that living conditions impact spread. Additionally, 43.75% of staff somewhat agree, and 37.50% strongly agree, while 18.75% neither agree nor disagree that COIVD-19 spread is impacted by adequate air ventilation. Likewise, 68.75% strongly agree, 18.75% somewhat agree, and 12.50% neither agree nor disagree that crowded living conditions or crowded public space impact spread. Mitigating Strategies Based on client reports, 66.67% of clients identify homeless populations as at-risk for contacting COVID, lacking access to testing, being treated, and vaccinated from COVID-19. Of clients, 66.67% of the population express concern with contacting COVID-19 and feel social distancing has been an issue. Of respondents, at least 50% strongly agree with contracting COVID-19 within the community they live. Split views express getting COVID-19 at work (16.67% equally strongly agree, agree, somewhat agree, and disagree and strongly disagree). Between staff, 100% strongly agree and express concern about contracting COVID-19 at work. Staff identifies that 75% somewhat agree and strongly agree that social distancing is difficult with COVID-19. Ability to contract trace, staff, identifies some difficulty (62.50% strongly agree and 25% somewhat agree). In general, 56.25% strongly agree with having concerns with getting sick from COVID19. Moreover, for those concerned with contracting COVID-19 from someone outside the shelter, 50% somewhat agree, and 43.75% strongly agree. Amongst clients, views are split about getting sick from COVID, 33.33% (strongly agree or somewhat agree). Of clients, 83.33% feel confident in the vaccine distribution process, and a majority, 66.67%, strongly agree and identify with having equal access to the vaccine. Based on the treatment protocol, 75% of clients strongly agree, while 12.50% either somewhat agree and somewhat disagree in the confidence of being tested, quarantined, and vaccinated. Based on staff perspective, generally, 62.50% of staff strongly agree that homeless individuals lack access to be tested, quarantined, and vaccinated. According to staff response, while homeless individuals will have access to the vaccine, there is some confidence that 62.50% of participants strongly agree and somewhat agree. A minor level of confidence 18.75% equally identifying somewhat disagree and strongly disagree. Homeless individuals are at a higher risk for contacting COVID-19, most participants, 56.25%, strongly agree with the statement, and 18.75% somewhat agree with this statement. A mixed perception with those neither agreeing nor disagreeing and somewhat disagreeing was reported at 12.50%. Furthermore, hand washing, cleaning, sanitizing and other healthy behavior were identified among homeless populations, by 66.67%, where clients agree that awareness of safety procedures is essential to avoiding contracting COVID-19. Among staff, 87.50% strongly agree with this statement. Additionally, based on client response, there is a mixed perception in satisfaction in the vaccine administration process, where 44.16% somewhat agree and 44.16% strongly disagree, where are 16.67% neither agree nor disagree with the vaccine process. Among staff, there is a mixed perception in satisfaction in the vaccine administration process, where 37.50% neither agreeing nor disagreeing with effectiveness and 25% strongly disagreeing, and 18.75% equally strongly agreeing and somewhat agree with the vaccine administration outcome. Summary of Resident and Staff Surveys Identifying if a shelter is a safe living situation is essential to disease management. Among staff and residents, they share a shared space that reflects a work environment and living situation. Furthermore, shelter conditions are impacted by safety protocol, crowding, and managing contact tracing issues. Social isolation orders and the need for social distance have impacted the way many shelter services are delivered. Shelter staff and clients are required to maintain social distancing to ensure overall safety. Social isolation has impacted services related to the personal capacity, job access, level of employment, access to help, and reason for homelessness. COVID-19 is impacting society in multiple ways. It impacts the level of social confidence to maintain safety, a sense of security, and a level of interaction with others. As a result, data shows that fears of contracting COVID-19 are high. Interventions to addressing COVID-19 are not just impacted by the disease but also by organizational and individual behavior, protocol, and sense of individual and collective responsibility. Similarly, COVID-19 is identified as having an impact on service. That impact relates to employment access, access to service, and the ability to address essential needs. The impact of the social distancing effect on individuals may vary based on personal circumstances. However, the impact of COVID-19 on services is influenced by multiple factors, level of access, opportunity, and deviation from the established norm. Likewise, multiple environmental influences impact a communicable disease. Living conditions are impacted and affect all parties within the environment. Among staff and residents, both play a role in shelter conditions, additionally, the actual space and conditions of the shelter space impact spread. Furthermore, COVID-19 is impacting society in multiple ways. It impacts the level of social confidence to maintain safety, a sense of security, and a level of interaction with others. As a result, data shows that fears of contracting COVID-19 are high. Interventions to addressing COVID-19 are not just impacted by the disease but also by organizational and individual behavior, protocol, and sense of responsibility. Discussion We analyzed data collected through resident interviews and staff surveys to determine the COVID-19 impact on shelter services at GUM. Table 1 summarizes the surveys assessing client experiences during COVID-19. Table 2 summarizes staff surveys reviewing common concerns about COVID-19. Table 1 Clients 1. Prior to COVID 19, did your agency have a communicable disease response protocol? Views are split where 50% neither agree nor disagree, 33.33% strongly agree, and 16.67% strongly disagree 2. As a result of COVID 19, did your agency adjust its policies and procedures to address the COVID 19 infectious Disease? A majority 83.33% strongly agree. 3. Do you think your agencies protocol changes protected from COVID 19? A majority 83.33 strongly agree with this statement and 16.67 somewhat agree. 4. Do you feel informed about the impact of COVID 19 as time progressed? An overwhelming 100% of participants strongly agree with this statement 5. Do you feel informed about how COVID 19 impacts your employment? A majority of 83.33% agree with this statement and 16 .67 neither agree nor disagree. 6. Your concern with COVID19 is getting sick? Responses are split we are 33.33% strongly agree an 33.33 somewhat agree, an 16.67 somewhat agree, an 6.67 strongly disagree 7. Your concern with COVID 19 is contacting from someone else? a majority 666.67 strongly agree and 33.33 neither agree nor disagree 8. Your concern with COVID 19 is getting it at work? responses are split we're majority of participants equally agree 16.67% with strongly agreeing, somewhat agreeing neither agreeing or disagreeing and somewhat disagreeing with this statement. There is a majority 33.33% that strongly disagree with this statement 9. Your Concern with COVID 19 is contracting it within the community you live? responses are split regarding this category however 50% strongly agree whereas and other categories individuals are split between 16.77% (somewhat agree, somewhat disagree, strongly disagree ) 10. You feel strongly about getting COVID 19 from a shelter environment? Responses are split we're 16.67% either strongly agree or somewhat disagree, or 33.33% either somewhat agree or strongly disagree. 11. You have come in contact with someone who has had COVID 19? Responses are split where 33.33% identified as strongly agreeing, somewhat disagreeing, and strongly disagree 12. You are aware of the safety procedures to implement to avoid contracting COVID 19? a majority of individuals strongly agree 66.67% whereas there's a split between neither agreeing nor disagreeing an strongly disagreeing of 16.67% 13. You feel satisfied in the vaccine administration process. a majority of participants 88.33% somewhat agree and strongly disagree whereas 16.67% neither agree nor disagree 14. Homeless individuals will have equal access to the vaccine. a majority 66.67% strongly agree our son would agree 15. Homeless individuals are at a risk for contacting COVID 19 and majority 66.67% strongly agree where 16.67% is split between neither agreeing nor disagreeing or somewhat disagree 16. Homeless individuals lack access to be tested, treated and vaccine for COVID 19? A majority 66.67% strongly agree an are split 16.67 between somewhat disagreeing and strongly disagree 17. COVID 19 issues are being address within the shelter? 100% of participants agree with this statement 18. Q19 - Do you feel informed about how to respond to COVID 19 majority of participants agree with this statement 83.33 strongly agreeing and 16.67 19. Do you feel you have access to being treated for COVID 19? 100% of participants agreed with this date 20. Do you feel housing options are limited due to COVID 19? a majority 66.67% strongly agree and 16.67 someone agree whereas 16.67% neither agree nor disagree 21. Has treatment for mental Health been limited due to COVID 19? Views are mixed however 66.66% strongly agree and strongly have somewhat agree and 16.67% either neither agree or disagree or strongly disagree 22. Have treatment options for substance use issues been limited due to COVID 19? A majority of individuals somewhat agree with this statement an the rest are mixed between 16.67% of strongly agreeing and neither green nor disagreeing . 23. Are you experiencing evictions being a direct impact of COVID 19? 50% of the population strongly disagree with this statement whereas 30 three point 3% strongly agree and 16.67% somewhat agree 24. Have you experience anyone losing a job or reducing hours due to COVID 19 50% of the population strongly disagree with this statement whereas 30 three point 3% strongly agree and 16.67 somewhat agree 25. Has Social distancing been an issues through COVID 19? 66.67% of the population strongly disagree with this statement whereas 16.67% is split between strongly agreeing and somewhat agree. 26. Do you feel contract tracing impacts disease spread? There's mixed perception regarding this question where 40% strongly agree Anne 20% is mixed between somewhat agreeing neither agree nor disagree or strongly agree 27. Do you feel living conditions impact COVID 19 spread? 83.33% of the population strongly agree Table 2 Staff 1. Prior to COVID 19, did your agency have a communicable disease response protocol? Responses are split where have were 50% strongly agree or somewhat agree and 50% strongly disagree or somewhat agree. 2. As a result of COVID 19, did your agency adjust its policies and procedures to address the COVID 19 infectious Disease? Where 81.25% of respondents strongly agree or some would agree . 3. Do you think your agencies protocol changes protected from COVID 19? Participants are mixed where 50% strongly agree or somewhat agree, and 43.7 5% somewhat disagree or strongly disagree and 6.25% neither agree nor disagree. 4. Do you feel informed about how COVID 19 impacts employment? Where more participants strongly or somewhat agree then those that strongly disagree or agree (68 .75% versus 31.25% ). 5. You are concerned with getting sick from COVID19? A majority of individuals strongly agree with this statement 56.25% or as a marginal percentage 37.50%. 6. Your are concerned with contracting COVID 19 from someone else? A more majority of individuals overall agree with this statement however, 50% somewhat agree and 43.75 strongly agree. ( SD) 7. Your are concern with getting COVID 19 at work? A majority of participants strongly agree with this statement 68.75 Anne somewhat agree with this statement 31.25% (OCLC). 8. Your are Concern with contracting COVID 19 while in the community you live? Mixed response is given with regard to this question 31.25% equally somewhat agree and somewhat disagree whereas 18.75% strongly agree, 12.50 percent strongly disagree and 6.25% neither agree nor disagree. 9. You feel strongly about getting COVID 19 from a shelter environment? A majority of participants 43.75% strongly agree with this statement whereas 37.50% some would agree and 12.50 neither agree nor disagree an 6.25% somewhat disagree (LCC). 10. You have come in contact with someone who has had COVID 19? Participant response is mixed however 37.5% strongly agree 25% somewhat agree 18.75% somewhat disagree 12.50% neither agree nor disagree and 6.25% strongly disagree. 11. You are aware of the safety procedures to avoid contracting COVID 19? An overwhelming majority 87.50 strongly agree. 12. You feel satisfied in the vaccine administration process. There is a mixed impression with 37.50 neither agreeing nor disagreeing, 25% strongly disagreeing and 18.75% equally strongly agreeing and somewhat agree. 13. Homeless individuals will have equal access to the vaccine. There is some confidence 62.50% of participants strongly agree and somewhat agree and a minor level of confidence 18.75 percent equally identifying somewhat disagree and strongly disagree. 14. Homeless individuals are at a higher risk for contacting COVID 19. A majority of participants 56.25 strongly agree with the statement and 18 point 75 somewhat agree with this statement there is also a mixed perception with those neither agreeing nor disagreeing and somewhat disagreeing at 12.50%. (VC) 15. Homeless individuals lack access to be tested, quarantined and vaccine for COVID 19? In general 62.50% of participants strongly agree and somewhat disagree with this question Anne 18.75% equally somewhat agree or disagree. 16. You feel confident that you can be tested, quarantined and vaccinated for COVID 19? A majority of participants 75% strongly agree with this statement and 12.5 0 percent equally somewhat agree and somewhat disagree. 17. Housing options are limited due to COVID 19? A small majority 56.25% strongly agree with this statement 12.50 somewhat agree 18.75 neither agree nor disagree an 12.50 somewhat agree 18. Treatment for mental Health been limited due to COVID 19? An overwhelming majority of 81.25 strongly agree and somewhat agree with this statement . 19. Treatment options for substance use has been limited due to COVID 19? An overwhelming majority of 81.25 strongly agree with this statement. COVID-19 affected society through pending evictions, job loss, reduction of working hours, and interrupted options to seek treatment. Among, clients and staff participating in our study reported mixed views about the COVID-19 impact on the overall livelihood and ability to access services and other coping mechanisms. Key themes inferred from resident surveys and staff surveys were existing and adapted health protocols, operational challenges, entry and exit concerns, responses to COVID-19, impact on services, impact on sheltering, living conditions, risk factors, treatment protocol, behavior protocol, and access to care. These themes were clustered into categories, which we used to report results: (1) structural and systemic impacts of COVID-19; (2) concerns about entry and exit to shelters; and (3) risk concerns and protective factors to public health emergencies. COVID-19 has required a change in structural approaches to managing infectious disease within shelters. Factors such as personal belief and sense of safety affect the reasoning and feelings of residents and staff regarding the social limitations the pandemic imposed on the shelter. Both residents and staff recognized that specific guidelines in response to COVID-19 are essential. Residents and staff report that changing policies and agency protocol impacted service delivery. Client and resident confidence level regarding any organizational changes was influenced by the clarity and communication of guidelines. Participants had different perceptions regarding the impact of infectious diseases based on their level(s) of exposure; nonetheless, they considered that having a protocol to manage COVID-19 was key. Shelters are considered a high-risk environment due to several social, economic, and behavioral factors making the homeless populations at-risk for contacting COVID-19, such as the lack of access to testing, treatment, and control over ability to socially distance. Based on client and staff responses, feelings of powerlessness (e.g., ability to control, monitor, and prevent COVID-19) affect perceptions about being able to reduce exposure and weakens senses of security. To ensure overall safety and security from COVID-19, shelter staff must be knowledgeable about communicable diseases, be responsive to infectious control, grant access to treatment, and support treatments. Perceptions about safety and security among staff and residents are influenced by opinions and beliefs about access to treatment and testing. Lacking access to tests, quarantine and vaccinations diminishes residents’ confidence in the ability of staff to create a safe shelter environment and minimize the risk of contracting COVID-19 while receiving services. The impact of COVID-19 in shelter settings is directly related to the staff responses. As discussed, next, preventative behavior is needed to reduce or eliminate the contraction of COVID-19 among residents, such as hand washing, and sanitizing shelter facilities. Likewise, to reduce negative perceptions about satisfaction with vaccine administration or interventions to reduce COVID-19 spread, confidence in equity and equality of services is needed. Furthermore, our study suggests that the impact is related to the inequalities this population experiences regarding their social, economic and demographic characteristics The need for social distance disrupts the level of access, and deviates from the established norm for many within shelter settings. Within the GUM shelter, COVID-19 directly affected the ability of people experiencing homelessness to enter the shelter, secure, and attain housing when exiting the shelter. COVID-19 also indirectly impacts entry-exit dynamics in terms of length of stay and perceived level of safety. The COVID-19 pandemic influenced the level of resident and staff confidence to maintain safety, their senses of security, and their interactions with others. Although both resident and staff perceptions included concerns in all the areas we measured, there were some differences. For instance, staff were more concerned with getting infected than were residents. The interventions needed to address COVID-19 relate to the agency following safety protocols, CDC guidelines and individual behaviors such as a sense of responsibility to prevent disease spread. The concerns about COVID-19 in shelters are influenced by a variety of issues, such as feelings about exposure and ability to maintain safety. People experiencing homelessness are vulnerable to multiple health inequalities, such as limited access to healthcare services, medication, and treatment for diseases. Among shelter organizations, there is limited ability to address pandemics by ensuring proper ventilation, managing shelter capacity, improving shelter conditions, increasing senses of safety, and adhering to organizational health and safety protocols. Research shows that COVID-19 in shelter settings is a risk factor due to concerns related to shared living space (20). Any facility providing housing for homeless populations must account for direct (e.g., overcrowding) and indirect (e.g., transient lifestyles) influences. Establishing protocols that address direct and indirect influences helps contain pandemic-related concerns during a public health crisis (24). Shelter environments contain multiple aggravators to communicable disease spread, such as living conditions that create an environment that influences exposure rate among staff and residents. Furthermore, the ability to quarantine and maintain social distance affects the level and quality of service delivery (2). Implications COVID-19 has required many changes to structural approaches to managing infectious disease within shelters. The response has influenced how clients are served and how staff engage residents. The shelter changes relate to understanding and identifying guidelines to address COVID-19. Data revealed that the impact of an infectious disease can have a different impression based on the level of exposure and awareness of agency intervention responses. Data showed that opinions and feelings about perceived agency influence depend on the level of impact on the group affected, served, or engaging the intervention. Whether a service provider or client serviced, data identifies, having a protocol to manage a communicable disease is key. Within shelter environments, COVID-19 poses a risk. That risk is influenced by how that environment is managed. Based on data, there is a concern for COVID-19 among shelters. However, the reason for concern varies based on perspective, feelings about exposure, and ability to maintain safety protocol. COVID-19 as a communicable disease is a risk factor for everyone that shares space. As a result, direct and indirect influences impact spread. Ventilation and shelter capacity are identified as essential components to disease spread. An adequate response to addressing COVID-19 is addressing systemic risk factors within shelter environments. COVID-19 has multiple direct and indirect impacts, presenting several risks among homeless populations. Risk factors are based on individual and collective behavior, the impact of living conditions, and organizational decision-making. Additionally, ensuring overall safety and security from COVID-19 is dependent on several factors, knowledge of the communicable disease, response to infectious control, access to treatment, and prescribing to treatment behavior. Several influencing factors govern the treatment protocol, and among the homeless, their treatment options are limited due to their social situation. Homeless populations are vulnerable to environmental disparities due to their lack of access and options to treatment. Moreover, addressing treatment issues is helping ensure and strengthening access, response, and behavior protocol. Addressing the impact of communicable disease and its impact is influenced by the responses to the infectious disease. Essential behavior is needed to reduce or eliminate the contraction of COVID-19. With limited resources, transportation, income, and access, it is essential to know how to combat infectious diseases. Conclusion Homeless shelters are a complex environment impacted by compounding factors in society, organizations, and among individuals. Because of COVID-19, some of the structural and systemic factors that affect homeless populations in direct and indirect ways were uncovered and aggravated. The ability to impact service outcomes effectively and efficiently for the homeless population is dependent on the availability of and access to resources, sound prevention plans, and quality community collaboration. Imperative is the utilization of multi-systemic and organizational interventions when assisting homeless populations. To help address public health issues within shelter settings in the context of a health emergency such as the COVID-19 pandemic, it is vital to examine the living conditions of homeless populations, particularly their risk factors and protective factors, to address the prevalence of influencing conditions, mitigating protocols, and the impact of service delivery. Declarations Funding and/or Competing Interests We (the authors) did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support was received. We have no relevant financial or non-financial interests to disclose. The authors have no competing interests to declare that are relevant to the content of this article. We certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. We have no financial or proprietary interests in any material discussed in this article. Ethical Approval We confirm all relevant ethical guidelines have been followed, and any necessary Cayuse Human Ethics IRB and/or ethics committee approvals have been obtained. Informed Consent Informed consent was obtained from all participants. We confirm that all necessary participant consent has been obtained and the appropriate institutional forms have been archived. Any participant/sample identifiers included were not known to anyone (e.g., agencies or participants themselves) outside the research group so cannot be used to identify individuals. Data & Materials We have followed all appropriate research reporting guidelines and research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Author Contribution Statement Michael Pearson conceived of the research idea, developed the theory, and performed the computations. MP also contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript. Dr. Carmen Monico was involved in the study design, and supervised and reviewed the research study, providing guidance and advice throughout the research project development. Data Availability Statement The author confirms that all data generated or analyzed during this study are included in this published article. Acknowledgement We (the authors) are grateful to the Authorization of Greensboro Urban Ministry’s Administrations and participants and residents of the Weaver House for engaging in this study and providing very valuable information. We are also appreciative of Dr. Mathieu Despard, Professor in the A&T and UNCG Joint Social Work Programs, as well as Dontae Robert, joint PhD student, for their contributions to the research design. A special thanks to Dr. Brien Ashdown for his professional editing of the manuscript. References Ahmad, K., Erqou, S., Shah, N., Nazir, U., Morrison, A. R., Choudhary, G., & Wu, W-C. (2020). Association of poor housing conditions with COVID-19 incidence and mortality across US counties. PLoS ONE, 15 (11), e0241327. https://doi.org/10.1371/journal.pone.0241327 Aragona, M., Barbato, A., Cavani, A., Costanzo, G., & Mirisola, C. (2020). Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties. Public Health, 186 , 52–56. https://doi.org/10.1016/j.puhe.2020.06.055 Amiri, F. B., Doosti-Irani, A., Sedaghat, A., Fahimfar, N., & Mostafavi, E. (2018). Knowledge, attitude, and practices regarding HIV and TB among homeless people in Tehran, Iran. International journal of health policy and management, 7 (6), 549. Baggett, T., Racine, M., Lewis, E., De Las Nueces, D., O' Connell, J., Bock, B., & Gaeta, J. (2020). Addressing COVID-19 among people experiencing homelessness: Description, adaptation, and early findings of a multiagency response in Boston. Public Health Reports, 135 (4), 435–441. https://doi.org/10.1177/0033354920936227 Banerjee, D., & Bhattacharya, P. (2020). The hidden vulnerability of homelessness in the COVID-19 pandemic: Perspectives from India. International Journal of Social Psychiatry, 67 (1), 3–6. https://doi.org/10.1177/0020764020922890 Balut, M.D., Gin, J.L., Alenkin, N.R. et al. Vaccinating Veterans Experiencing Homelessness for COVID-19: Healthcare and Housing Service Providers’ Perspectives. J Community Health 47, 727–736 (2022). https://doi.org/10.1007/s10900-022-01097-1 Brown, M., Cummings, C., Lyons, J., Carrión A., & Watson, D. P. (2018). Reliability and validity of the vulnerability index-service prioritization decision assistance tool (VI-SPDAT) in real-world implementation. Journal of Social Distress and the Homeless, 27 (2), 110–117. https://doi.org/10.1080/10530789.2018.1482991 Bucher, C. E. C. (2008). Toward a needs-based typology of homeless youth. Journal of Adolescent Health, 42 (6), 549–554. Capelouto, J. D. (2020, June 21). Housing: Many fear looming homelessness 'crisis': Atlantans living in poverty were already on the financial brink, and the coronavirus pandemic threatens to push them over the edge. The Atlanta Journal-Constitution . https://www.ajc.com/news/local/many-fear-looming-housing-homelessness-crisis-amid-hold-evictions/VySs1aszfZXvOTdi0GFOtO/ Center for Disease Control and Prevention. (2021a). COVID data tracker - Demographic trends. Retrieved from https://covid.cdc.gov/covid-data-tracker/#demographics . Center for Disease Control and Prevention. (2021b). Interim guidance for homeless service providers to plan and respond to coronavirus disease. Retrieved from https://www.google.com/url?q=https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html& sa=D&source=editors&ust=1627945738843000&usg=AOvVaw2EviIgpdBOfqly4GCTTq6M. Cohen, J. (2013). Statistical power analysis for the behavioral sciences. Elsevier Science . Diaz, A.-P., & Paynich, V. (2020). Homelessness and the global pandemic: The role of Los Angeles’s city parks and open spaces during COVID-19. National Recreation and Park Association (NRPA) Parks & Recreation, 55 (6), 36. Retrieved from https://www.nrpa.org/parks-recreation-magazine/2020/june/homelessness-and-the-global-pandemic/ Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet (London, England), 384 (9953), 1529–1540. https://doi.org/10.1016/S0140-6736(14)61132-6 Finnigan, R. (2021). Self-reported impacts of the COVID-29 pandemic for people experiencing homelessness in Sacramento, California. Journal of Social Distress and Homelessness, Online first publication. https://doi.org/10.1080/10530789.2021.1879618 Fitch, D. (2010). Homeless management information system customization intervention. Journal of Human Behavior in the Social Environment, 20 (2), 255–255. https://doi.org/10.1080/10911350903269922 Fraser, M. W., Richman, J. M., Galinsky, M. J., & Day, S. H. (2009). Intervention research: Developing social programs. Oxford Press . Greensboro Urban Ministry. (2021). Weaver House Shelter . Retrieved from www.greensborourbanministry.org Guilford County Division of Public Health. (n.d.). COVID-19 Data . Retrieved from https://www.guilfordcountync.gov/our-county/human-services/health-department/coronavirus-covid-19-info/covid-19-data Hammer, C., Brainard, J. & Hunter, P. (2017). Risk factors and risk factor cascades for communicable disease outbreak in complex humanitarian emergencies: A qualitative systematic review. BMJ Global Health, 3 , Article e000647. https://doi.org/10.1136/bmjgh-2017-000647 Hsu, H. E., Ashe, E. M., Silverstein, M., Hofman, M., Lange, S. J., Razzaghi, H., Mishuris, R. G., Davidoff, R., Parker, E. M., Penman-Aguilar, A., Clarke, K. E. N., Goldman, A., James, T. L., Jacobson, K., Lasser, K. E., Xuan, Z., Peacock, G., Dowling, N. F., & Goodman, A. B. (2020). Race/ethnicity, underlying medical conditions, homelessness, and hospitalization status of adult patients with COVID-19 at an urban safety-net medical center – Boston, Massachusetts, 2020. Morbidity and Mortality Weekly Report, 69 (27), 864–869. https://doi.org/10.15585/mmwr.mm6927a3 Johns Hopkins University. (2021). COVID-19 dashboard by the Center for Systems Science and Engineering at John Hopkins University . Retrieved June 24, 2021 from http://www.covidtracker.com Khan, S. Akter, S., Khan, T., Hariar, G., & Awai Miah, M. A. (2021). Psychological distress among Bangladeshi physicians: roles or perceived stigma, fear or infection and resilience in the context of covid-19. Journal of Social Distress and Homelessness, Online first publication. https://doi.org/10.1080/10530789.2021.1892932 Leung, C. S., Ho, M. M., Kiss, A., Gundlapalli, A. V., & Hwang, S. W. (2008). Homelessness and the response to emerging infectious disease outbreaks: lessons from SARS. Journal of Urban Health, 85 (3), 402–410. https://doi.org/10.1007/s11524-008-9270-2 Marcus, T., Hesse, J. Scheibe, A. Shelly, S., Lalla, S., Hugo, J. (2020). Harm reduction in an emergency response to Homelessness touring South African's COVID-19 lockdown. Harm reduction Journal Mendenhall, E., Kohrt, B. A., Norris, S. A., Ndetei, D., & Prabhakaran, D. (2017). Non communicable disease syndemics: poverty, depression, and diabetes among low-income populations. The Lancet, 389 (10072), 951–963. Mosites E., Parker, E.M., Clarke, K. E. N., Gaeta, J. M., Baggett, T. P., Imbert, E., Sankaran, M., Scarborough, A., Huster, K., Hanson, M., Gonzales, E., Rauch, J., Page, L., McMichael, T. M., Keating, R., Marx, G. E., Andrews, T., Schmit, K., Morris, S. B., Dowling, N. F., Peacock, G., & COVID-19 Homelessness Team. (2020). Assessment of SARS-COVID-19 infection prevalence in homeless shelters—four U.S. cities, March 27-April 15, 2020.. Morbidity and Mortality Weekly Report, 69 (17), 521–522. https://doi.org/10.15585/mmwr.mm6917e1 Nooe, R. M. & Patterson, D.A. (2010). The ecology of homelessness. Journal of Huma Behavior in the Social Environment, 20 (2), 105–152. North Carolina Department of Health and Human Services (NCDHHS), (2021). COVID-19 North Carolina Dashboard. COVID-19 North Carolina Dashboard | NC COVID-19 (ncdhhs.gov) Okonkwo, N. E., Aguwa, U. T., Jang, M., Barré, I. A., Page, K. R., Sullivan, P. S., Beyrer, C., & Baral, S. (2020). COVID-19 and the U.S. response: Accelerating health inequities. BMJ Evidence-Based Medicine, 26 , 176–179. https://doi.org/10.1136/bmjebm-2020-111426 Perri, M., Dosani, N., & Hwang, S. W. (2020). Covid-19 and people experiencing homelessness: Challenges and mitigation strategies. Canadian Medical Association. Journal, 192 (26), 716–719. https://doi.org/10.1503/cmaj.200834 Ramírez, I. J., & Lee, J. (2020). COVID-19 emergence and social and health determinants in Colorado: a rapid spatial analysis. International journal of environmental research and public health, 17 (11), 3856. Renfro, C. P., Rome, Z., Gatwood, J., & Hohmeier, K. C. (2022). Use of Rapid Assessment Procedures when analyzing qualitative data in pharmacy research. Research in Social and Administrative Pharmacy, 18 (1), 2249–2253. Saadat, S., Rawtani, D., & Hussain, C. M. (2020). Environmental perspective of COVID-19. The Science of the total environment , 728 , Online first publication. https://doi.org/10.1016/j.scitotenv.2020.138870 Sharam, A., & Hulse, K. (2014). Understanding the nexus between poverty and homelessness: relational poverty analysis of families experiencing homelessness in Australia. Housing, Theory and Society, 31 (3), 294–309. Somerville, P. (2013). Understanding homelessness. Housing, theory, and society, 30 (4), 384–415. Taylor, B., Henshall, C., Kenyon, S., Litchfield, I., & Greenfield, S. (2018). Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis. BMJ open, 8 (10), e019993. Tobolowsky, F. A., Gonzales, E., Self, J. L., Rao, C. Y., Keating, R., Marx, G. E., McMichael, T. M., Lukoff, M. D., Duchin, J. S., Huster, K., Rauch, J., McLendon, H., Hanson, M., Nichols, D., Pogosjans, S., Fagalde, M., Lenahan, J., Maier, E., Whitney, H., Sugg, N., Chu, H., Rogers, J., Mosites, E, & Kay, M. (2020). COVID-19 Outbreak Among Three Affiliated Homeless Service Sites - King County, Washington, 2020. Morbidity and Mortality Weekly Report, 69 (17), 523–526. https://doi.org/10.15585/mmwr.mm6917e2 Toro, P. A., & McDonnell, D. M. (1992). Beliefs, attitudes, and knowledge about homelessness: a survey of the general public. American journal of community psychology, 20 (1), 53–80. https://doi.org/10.1007/BF00942181 Trotter, R. T., Needle, R. H., Goosby, E., Bates, C., & Singer, M. (2001). A methodological model for rapid assessment, response, and evaluation: the RARE program in public health. Field methods, 13 (2), 137–159. Tsai, J., Grace, A. & Vazquez, M. Experiences with Eviction, House Foreclosure, and Homelessness Among COVID-19 Infected Adults and Their Relation to Mental Health in a Large U.S. City. J Community Health (2022). https://doi.org/10.1007/s10900-022-01166-5 World Health Organization (2020, May 22). Operational planning guidance to support country preparedness and response: COVID–19 strategic preparedness and response. https://www.who.int/publications/i/item/draft-operational-planning-guidance-for-un-country-teams Worldometer (2023). COVID-19 coronavirus pandemic. https://www.worldometers.info/coronavirus/ Yoon, J.C., Montgomery, M.P., Buff, A., Boyd, A.T., Jamison, C., Hernández, A., Schmit, K., Shah, S., Ajoku, S., Holland, D., Prieto, J., Smith, S., Swancutt, M., Turner, K., Andrews, T., Flowers, K., Wells, A., Marchman, C., Laney, E.B., Bixler, D., Cavanaugh, S., Flowers, N., Gaffga, N., Ko, J.Y., Paulin, H., Weng, M., Mosites, E., & Morris, S. (2020). COVID-19 prevalence among people experiencing homelessness and homelessness service staff during early community transmission in Atlanta, Georgia, April–May 2020. Clinical Infectious Diseases , Article ciaa1340. https://doi.org/10.1093/cid/ciaa1340 Valado, T., & Amster, R. (2012). Professional lives, personal struggles: Ethics and advocacy in research on homelessness. Lexington Books . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3774252","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":271537922,"identity":"20a8782a-01a3-4ef8-ab58-d6240972e52e","order_by":0,"name":"Michael Pearson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYBADOX4og7GBWC3Gkg2kaknccIBYLbrtZw8++LmnjnHzjdyDH78w2MjC9OIEZmfykg17nh1mNruRlywtw5BmTFjLDR4zCZ4DB9jMbuSYMUswHE4kRov5zz8H6niMZ4C1/CdKixkzzwFmCQOJHDPGDwwHiNByBuSFA4cNJM68MZZmMEg2nklQy/GzBz++OVBX39+eY/jxR4WdbB8hLQwMPAgmM48BQeVoWhh/EKVjFIyCUTAKRhoAAL8GRHlpdrv+AAAAAElFTkSuQmCC","orcid":"","institution":"North Carolina Agricultural and Technology (NCAT) \u0026 University of North Carolina Greensboro (UNCG). 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As a strain of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), COVID-19 forced, unto society, undesirable social situations such as social isolation, hospitalization, and deaths [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The severity of the virus challenged public health responses, namely the ability to provide adequate medical treatment and manage the social aftermath: economic downturn, increased homelessness, and mental, physical, and emotional instability [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong homeless populations, housing and homeless health are representative elements, resulting in homeless groups having reduced structural and system resources [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Additionally, for the homeless limited access perpetuates unfavorable conditions and heightens risk factors [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. It is fact that homeless populations compared to the general population experience higher risk exposures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. For example, homeless have a 5\u0026ndash;10% higher exposure risk to disease [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and are 1\u0026ndash;16% more likely to be impacted by disease [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This is influenced by the lack of secure, stable, safe, and adequate housing increasing homeless susceptibility and exposure to adverse disease life outcomes [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo better understand the impact of public health concerns on the homeless, it is essential to determine a few items and discuss implications. Understanding the prevalence of COVID-19 is vital. In addition to understanding the systemic concerns and risks among the homeless [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This will provide background into identifying essential mitigating strategies within homeless settings.\u003c/p\u003e\n\u003ch3\u003ePrevalence of COVID-19 in the United States and North Carolina\u003c/h3\u003e\n\u003cp\u003eWithin the United States (U.S.), there have been 108.7\u0026nbsp;million cases of COVID-19, 1.17\u0026nbsp;million deaths, and 106.4\u0026nbsp;million recovered [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The pandemic has necessitated social distancing requirements which have impacted job opportunities, housing availability, access to services, and a sense of security [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The Centers for Disease Control and Prevention [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] report that COVID-19 had a death incidence rate of 79.7% among individuals 65\u0026ndash;85 plus, 15.3% among 50\u0026ndash;64, and 4.46% among those younger than 50 years old. There have been more than 1\u0026nbsp;million COVID-19 cases in North Carolina. Of the total cases, 13,533 were deaths, 27,172 were recoveries, and the additional cases were based on number of confirmed exposures with no need for hospitalization. Among the people in the state, 56% of North Carolinians are reported to have underlying health conditions, and 51.1% of adults within North Carolina are considered at high risk of illness from COVID-19 \u0026ndash; specifically aging populations.\u003c/p\u003e \u003cp\u003eDuring 2021, North Carolina experiences COVID-19 cases at a daily rate of 7 cases per 100,000 people, hospitalizations 4 per 100,000 per day and an average death rate of 5.3 per 100,000 per day [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Guilford County Health Department [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reports 39,298 confirmed cases of COVID-19 as of summer 2020. Of that number, 37,509 are identified recoveries, 1,246 total hospitalizations, 518 total deaths, 65 current hospitalizations in March 2020, during which 1,270 active cases reported. As of 2023, Guilford County Health Department reports 156,543 confirmed cases of COVID-19 of that number, 155,391 are identified recoveries and 1,142 deaths. The 14-day positive rate is 4.5%- and single-day positive rate is 6.3% of those tested are positive. From 2017 to 2023, the state conducted 1,219,869 COVID tests, and the average reported age of individuals testing positive is 38.7 years old. The highest death percentage is reported for populations over 50, which is the population most vulnerable and those over 50 commonly experiencing homelessness [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile the exact effect on homelessness from COVID-19 is difficult to measure, recognizing the affect the pandemic can have on homeless populations in relation to the total population is essential. Generally, for every 10,000 persons, 17 experience homelessness [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and over 3\u0026nbsp;million people can experience homelessness with 580,000 on a given night [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], with over 1.4\u0026nbsp;million persons attempting to access shelter each year [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. As a result of COVID-19, between 2019 and 2022, the homeless population increased by five percent [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, among the homeless, COVID-19 exacerbated common homeless disparities (disease exposure, treatment access, increased susceptibility).\u003c/p\u003e \u003cp\u003eThe literature review confirmed that interrupting the spread of COVID-19 is difficult; however, mitigating strategies such as social distancing, isolation and access to testing are essential to preventing disease outbreak [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Mitigating strategies are useful to increase prevention while encouraging supportive organizational procedures, training, and education [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Common strategies that addressed COVID-19 concerns included organizational guidelines, prevention, and support tools, addressing crowding, supporting isolation and quarantine, as well as implementation of safety procedures, physical distancing rules, and testing [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eRisk and Barriers\u003c/h3\u003e\n\u003cp\u003eCOVID-19 impacts health directly and indirectly [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. COVID-19 adversely influenced service access and resources available, placing limitations on people\u0026rsquo;s ability to address housing challenges and achieve a healthy lifestyle [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. COVID-19 increased vulnerabilities among disadvantaged populations, increasing susceptibility for those with at-risk conditions, such as people with immunodeficiency and other underlying medical conditions [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. COVID-19 placed constraints on society \u0026ndash; economically, socially, and emotionally \u0026ndash; adding to the list of equity and inequality issues people in low income and homeless populations face. The impact on individuals experiencing homelessness include indirect impacts (e.g., risk of contracting COVID-19, and limited or reduced access to health services) and direct impacts e.g., economic wellbeing, job loss and extended homelessness).\u003c/p\u003e \u003cp\u003eAdditionally, the COVID-19 pandemic revealed many operational barriers to services while working with homeless populations [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. For example, between 2017 and 2020 considering service utilization prior to and during COVID-19; observation studies found a 46.7% decline in patient visits due to COVID-19 restrictions impacting outpatient services among mental health providers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This highlights how vulnerable populations such as the homeless need proactive strategies that mitigate service barriers.\u003c/p\u003e \u003cp\u003eWithin shelter environments, poor housing conditions and the relationship between COVID-19, reveal a connection between mortality and poor living conditions. This cross-sectional analysis confirms that targeting organizational health factors such as policies, guidelines, and procedures impact living conditions and can mitigate adverse outcomes associated with COVID-19 among the homeless [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLikewise, through clinical observation examining how settings pose a risk to the spread of infectious disease, five homeless shelters in Boston, San Francisco, and Seattle were observed [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The study found that individual willingness or apprehension about testing, the ability to identify symptoms and pre-existing conditions exacerbate treatment outcomes. The factors stressed most are the need for adherence to infectious disease protocol to minimize transmission. Thus, assessing the need for treatment solutions such as education, access and vaccinations among people who are homeless is vital to mitigating the spread of a virus. Vaccine uptake is viewed positively among the homeless population, partly because of positive regard stemming from increased access to vaccination, positive campaigning, and positive impressions of vaccine efficacy [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eEssential Mitigating Strategies\u003c/h3\u003e\n\u003cp\u003eCOVID-19 compounds hardships for multiple individuals including homeless populations influenced by pre-existing health risks, shelter-in-place orders, and social distancing needs [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Access and healthcare are critical during health emergencies, however homeless groups often experience higher levels of reduced health access and care disparities [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Additionally, the risk of spreading communicable disease among homeless populations is influenced by living conditions, hygiene quality, sanitation practices, and overcrowding; these conditions create an environment conducive to transmission because of issues such as poor air ventilation, lack of cleanliness and lack of sanitation protocols [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn a longitudinal study regarding the prevalence of COVID-19 among people experiencing homelessness, there were higher rates among sheltered individuals than unsheltered individuals. This is due to shelter environments being affected by crowding, high transition rates in addition to higher levels of communicable disease. Furthermore, to interrupt COVID-19 transmission, the study indicates that knowledge about symptoms, screening, testing, and isolation are successful strategies among homeless populations [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, addressing the impact of COVID19 among homeless environments requires a multi-system approach. When examining the mitigating strategies during COVID of local shelter, such as this study has done, it is possible to identify procedural and organizational challenges and to understand the rationale behind adjustments during the behavior of individuals experiencing homelessness while they enter and exit from the shelter (hereinafter referred simply as entry and exit). Furthermore, a review of shelter entry protocol will provide information about the factors and issues that impact shelter life, identifying the benefits and consequences of organizational and system-level influences on providers and clients.\u003c/p\u003e \u003cp\u003eIn this study, we examine the effect of COVID-19 on a local shelter in Greensboro, North Carolina, Greensboro Urban Ministry\u0026rsquo;s (GUM)\u0026rsquo;s Weaver House. The survey used, provides context to better understand essential mitigating strategies to engage with homeless populations. The sample is comprised of 8 Weaver House residents and 6 staff members who participated in this study. Overall, this study examines COVID-19\u0026rsquo;s influence on the sheltering process to identify the essential mitigating strategies for homeless shelters to manage through a public health crisis, homelessness barriers and risks.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eAn ecological perspective of COVID-19 as a public health emergency is essential to understand the pandemic effects on the homeless population [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The national pandemic confirms that human health is intertwined with a wide range of environmental factors, including socio-economic factors, like the stock and labor markets, population density, educational level, housing, and the state of housing; as well as biological factors, such as quality of water and air and the levels of global carbon emissions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Furthermore, this study will examine the shelter process and identify essential mitigating strategies to addressing public health issues, homeless barriers, and risk issues. This study will use provider and client surveys to assess for these different factors. Surveys will be structured based on a set of 27 questions. The COVID-19 intersecting factors provide opportunity to collect data on pre and post COVID-19 to understand the extent of its impact on homeless shelter life [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. A rapid analysis will identify patterns and emerging themes in service delivery among provider and client responses [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The power analysis is used to identify and detect an adequate (minimal) sample size [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Among homeless clients, eight individuals and among staff, three individuals are an optimal sample size for qualitative research.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSample, and Design\u003c/h2\u003e \u003cp\u003eShelter selection was determined by identifying shelter agencies through the city of Greensboro agency list and identifying the largest shelter site. Email solicitation was used to recruit agency participation. After successful email communication, the agency allowed consultation with shelter supervisors. Four supervisors agreed to assist with dissemination of information. Shelter client participants were recruited during the intake process. Residents were provided description of the study upon intake and an opportunity to voluntarily participate. Staff surveys were distributed through an internal listserv. The study time frames were between January 1, 2021 and March 1, 2021.\u003c/p\u003e \u003cp\u003eOf the total staff, a majority (16) participated in the study and among clients (8) participated. Of both groups, participation did so voluntarily with no gift exchange. Consideration of the unique ethical concerns when conducting research with a homeless population [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], thus were included in the design of this IRB-approved study (IRB #21\u0026ndash;029).\u003c/p\u003e \u003cp\u003eQualitative data was gathered from provider-client data to identify supports and mitigating strategies and impressions affecting sheltered homeless populations as related to COVID-19. Interviews and surveys lasted 30 minutes to complete. Among staff and resident participants, 25 questions were asked. Residence where asked an additional eight questions relating to organizational changes pre and post COVID-19. Questions were asked based on a Likert scale, rating response through five options ranging from strongly agree to strongly disagree. Questions for both clients and staff elicited responses about the level of impact and utilization of specific COVID-19 responses; in addition, they identified organizational, structural and systemic concerns. The series of 25 scaled staff questions were asked during the intake process and tracked through Qualtrics. The same series of questions were communicated through a Qualtrics survey to clients. Additionally, questions were asked to elicit how the shelter response to the COVID-19 public health concerns, to identify preparedness to address the pandemic, ability to keep people safe, readiness to deliver services during COVID-19, and constraints imposed by COVID-19 shelter-in-place requirements. These questions were unique to client impact and collecting information about factors influenced by organizational policy and procedural.\u003c/p\u003e \u003cp\u003eThis study engaged providers and clients to better understand assess, measure, and gauge the impact of approaches and interventions during COVID-19. Within the shelter setting, there is an organizational process, methods by which the shelter operates, and dynamic between providers, clients and services provided. Capturing a description or organizational processes, and impact of service options on clients is paramount to homelessness and understanding mitigating strategies to homeless issues.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eRapid analysis is used to coding client and provider data. Rapid analysis is used to inscribe and categorize information to address research objectives [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Characteristics used to code data is through a repetitive cycle of sorting, sifting, and shift [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], identifying themes to reduce overlap of information and provide an accurate interpretation of information, and in formulating perspectives about mitigating techniques used with homeless populations [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Additionally. Rapid analysis is an efficient method of compiling and summarizing data after collection [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. To assist with data collection a matrix will assist in summarizing participant responses and organizing within domains to analyze and interpret data and better understand the relationships of the data [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this research, it is essential to draw a connection between provider-client impressions of mitigating strategies to understand essential approaches to engage homeless populations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e Resident and Staff participants were asked a series of similar questions. The number of questions asked is based on the ability to identify the level of impact and application of specific COVID-19 responses. Questions can be identified in two categories: structural and systemic issues of concern. Each question relates to client or staff experience at entry, thoughts about mitigating strategies, and sense of safety during COVID-19.\u003c/p\u003e\n\u003ch3\u003eProcedures to COVID-19\u003c/h3\u003e\n\u003cp\u003eDuring intake, client participants 100% strongly agree that they were informed about COVID-19, felt COVID-19 issues were being addressed within the shelter, and had access to being treated for COVID-19. Among clients, 83.33% strongly agree that agency policies and procedures addressed COVID-19 infectious disease and identify with feeling agency protocol changed to protect from COVID-19, impacting how service is delivered.\u003c/p\u003e \u003cp\u003eAmong surveys conducted by staff, responses are split where 50% strongly agree or somewhat agree, and 50% strongly disagree or somewhat disagree that their agency had a communicable disease response to COVID-19. Also, 81.25% of staff respondents strongly agree or somewhat agree that their agency adjusted its policies and procedures to address the COVID-19 infectious disease. There is a mixed perception among staff regarding if agency protocol changed to protect from COVID-19 (50% strongly agree or somewhat agree, and 43.7 5% somewhat disagree or strongly disagree, and 6.25% neither agree nor disagree).\u003c/p\u003e \u003cp\u003eAccording to resident responses, reactions are split (50% neither agree nor disagree, 33.3% strongly agree, and 16.7% strongly disagree) that before COVID-19, the agency had some communicable disease response protocol. Among clients, views are mixed (16.67% strongly agree or somewhat disagree and 33.33% somewhat agree or strongly disagree) with getting COVID-19 from a shelter environment. Of client responses, 40% strongly agree that contact tracing impacts disease spread,\u003c/p\u003e \u003cp\u003eAmong staff, they feel strongly about getting COVID-19 from a shelter environment; 43.75% strongly agree, 37.50% somewhat agree, and 12.50% neither agree nor disagree, and 6.25% somewhat disagree. Staff expresses mixed thoughts 37.5% strongly agree, 25% somewhat agree, 18.75% somewhat disagree, 12.50% neither agree nor disagree, and 6.25% strongly disagree regarding contracting COVID-19. An overwhelming majority, 87.50%, strongly agree with being aware of the safety procedures to avoid contracting COVID-19.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCOVID-19 Impact\u003c/h2\u003e \u003cp\u003eBased on resident responses, 50% strongly disagree with experiencing evictions due to COVID-19, whereas 50% do. Among responses to experiencing job loss or reduced hours due to COVID-19, client responses are mixed (50% strongly disagree, 33.3% strongly agree, and 16.7% somewhat agree). Among treatment options for substance use, respondents identify 66.67% somewhat agree, while 16.67% strongly agree and express issues or experience limitations due to COVID-19. Likewise, 66.67% also identify housing option limitations due to COVID-19 and experiencing mental health service limitations. Among clients, 66.7% identified risk concerns with contacting COVID-19 and 83% strongly agreed that COVID-19 affected living conditions.\u003c/p\u003e \u003cp\u003eAmong staff, (68.75% strongly or somewhat agree versus 31.25% strongly disagree or agree) about feeling informed about how COVID-19 impacts employment. Many staff, 43.75%, strongly agree that COVID-19 impacts evictions, while 18.75% disagree. As far as job loss in the last year or reduction of hours because of COVID-19, 81.25% strongly agree. Among staff, 56.25% strongly agree, 12.50% somewhat agree, 18.75% neither agree nor disagree, and 12.50% somewhat agree housing options are limited due to COVID-19. Among treatment for mental health, 81.25% strongly agree and somewhat agree and regarding treatment options for substance use during COVID-19. Additionally, among staff, 50% expressed concern about contracting COVID-19 and 68% strongly agreed COVID-19 affected the environment they work in.\u003c/p\u003e \u003cp\u003eOf shelter clients, 83.33% identified how to respond to COVID-19 and identify that living conditions impact spread. However, a mixed view is expressed about encountering COVID-19 from a shelter client (33.33% strongly agree, somewhat disagree, and strongly agree). Whereas 50% of the clients feel ventilation impacts COVID-19 spread, and the rest express mixed views (16.67% agree, neither agree nor disagree, or strongly disagree). However, 100% of respondents identify that crowded living conditions impact the spread of COVID-19.\u003c/p\u003e \u003cp\u003eAmongst staff responses to the impact of living conditions and spread, 56.25% strongly agree, and 25% somewhat agree that living conditions impact spread. Additionally, 43.75% of staff somewhat agree, and 37.50% strongly agree, while 18.75% neither agree nor disagree that COIVD-19 spread is impacted by adequate air ventilation. Likewise, 68.75% strongly agree, 18.75% somewhat agree, and 12.50% neither agree nor disagree that crowded living conditions or crowded public space impact spread.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eMitigating Strategies\u003c/h2\u003e \u003cp\u003eBased on client reports, 66.67% of clients identify homeless populations as at-risk for contacting COVID, lacking access to testing, being treated, and vaccinated from COVID-19. Of clients, 66.67% of the population express concern with contacting COVID-19 and feel social distancing has been an issue. Of respondents, at least 50% strongly agree with contracting COVID-19 within the community they live. Split views express getting COVID-19 at work (16.67% equally strongly agree, agree, somewhat agree, and disagree and strongly disagree).\u003c/p\u003e \u003cp\u003eBetween staff, 100% strongly agree and express concern about contracting COVID-19 at work. Staff identifies that 75% somewhat agree and strongly agree that social distancing is difficult with COVID-19. Ability to contract trace, staff, identifies some difficulty (62.50% strongly agree and 25% somewhat agree). In general, 56.25% strongly agree with having concerns with getting sick from COVID19. Moreover, for those concerned with contracting COVID-19 from someone outside the shelter, 50% somewhat agree, and 43.75% strongly agree.\u003c/p\u003e \u003cp\u003eAmongst clients, views are split about getting sick from COVID, 33.33% (strongly agree or somewhat agree). Of clients, 83.33% feel confident in the vaccine distribution process, and a majority, 66.67%, strongly agree and identify with having equal access to the vaccine. Based on the treatment protocol, 75% of clients strongly agree, while 12.50% either somewhat agree and somewhat disagree in the confidence of being tested, quarantined, and vaccinated.\u003c/p\u003e \u003cp\u003eBased on staff perspective, generally, 62.50% of staff strongly agree that homeless individuals lack access to be tested, quarantined, and vaccinated. According to staff response, while homeless individuals will have access to the vaccine, there is some confidence that 62.50% of participants strongly agree and somewhat agree. A minor level of confidence 18.75% equally identifying somewhat disagree and strongly disagree. Homeless individuals are at a higher risk for contacting COVID-19, most participants, 56.25%, strongly agree with the statement, and 18.75% somewhat agree with this statement. A mixed perception with those neither agreeing nor disagreeing and somewhat disagreeing was reported at 12.50%.\u003c/p\u003e \u003cp\u003eFurthermore, hand washing, cleaning, sanitizing and other healthy behavior were identified among homeless populations, by 66.67%, where clients agree that awareness of safety procedures is essential to avoiding contracting COVID-19. Among staff, 87.50% strongly agree with this statement. Additionally, based on client response, there is a mixed perception in satisfaction in the vaccine administration process, where 44.16% somewhat agree and 44.16% strongly disagree, where are 16.67% neither agree nor disagree with the vaccine process. Among staff, there is a mixed perception in satisfaction in the vaccine administration process, where 37.50% neither agreeing nor disagreeing with effectiveness and 25% strongly disagreeing, and 18.75% equally strongly agreeing and somewhat agree with the vaccine administration outcome.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSummary of Resident and Staff Surveys\u003c/h2\u003e \u003cp\u003eIdentifying if a shelter is a safe living situation is essential to disease management. Among staff and residents, they share a shared space that reflects a work environment and living situation. Furthermore, shelter conditions are impacted by safety protocol, crowding, and managing contact tracing issues.\u003c/p\u003e \u003cp\u003eSocial isolation orders and the need for social distance have impacted the way many shelter services are delivered. Shelter staff and clients are required to maintain social distancing to ensure overall safety. Social isolation has impacted services related to the personal capacity, job access, level of employment, access to help, and reason for homelessness.\u003c/p\u003e \u003cp\u003eCOVID-19 is impacting society in multiple ways. It impacts the level of social confidence to maintain safety, a sense of security, and a level of interaction with others. As a result, data shows that fears of contracting COVID-19 are high. Interventions to addressing COVID-19 are not just impacted by the disease but also by organizational and individual behavior, protocol, and sense of individual and collective responsibility.\u003c/p\u003e \u003cp\u003eSimilarly, COVID-19 is identified as having an impact on service. That impact relates to employment access, access to service, and the ability to address essential needs. The impact of the social distancing effect on individuals may vary based on personal circumstances. However, the impact of COVID-19 on services is influenced by multiple factors, level of access, opportunity, and deviation from the established norm.\u003c/p\u003e \u003cp\u003eLikewise, multiple environmental influences impact a communicable disease. Living conditions are impacted and affect all parties within the environment. Among staff and residents, both play a role in shelter conditions, additionally, the actual space and conditions of the shelter space impact spread.\u003c/p\u003e \u003cp\u003eFurthermore, COVID-19 is impacting society in multiple ways. It impacts the level of social confidence to maintain safety, a sense of security, and a level of interaction with others. As a result, data shows that fears of contracting COVID-19 are high. Interventions to addressing COVID-19 are not just impacted by the disease but also by organizational and individual behavior, protocol, and sense of responsibility.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe analyzed data collected through resident interviews and staff surveys to determine the COVID-19 impact on shelter services at GUM. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the surveys assessing client experiences during COVID-19. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes staff surveys reviewing common concerns about COVID-19.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. \u003cb\u003ePrior to COVID 19, did your agency have a communicable disease response protocol?\u003c/b\u003e Views are split where 50% neither agree nor disagree, 33.33% strongly agree, and 16.67% strongly disagree\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eAs a result of COVID 19, did your agency adjust its policies and procedures to address the COVID 19 infectious Disease?\u003c/b\u003e A majority 83.33% strongly agree.\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eDo you think your agencies protocol changes protected from COVID 19?\u003c/b\u003eA majority 83.33 strongly agree with this statement and 16.67 somewhat agree.\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eDo you feel informed about the impact of COVID 19 as time progressed?\u003c/b\u003e An overwhelming 100% of participants strongly agree with this statement\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eDo you feel informed about how COVID 19 impacts your employment?\u003c/b\u003eA majority of 83.33% agree with this statement and 16 .67 neither agree nor disagree.\u003c/p\u003e \u003cp\u003e6. \u003cb\u003eYour concern with COVID19 is getting sick?\u003c/b\u003e Responses are split we are 33.33% strongly agree an 33.33 somewhat agree, an 16.67 somewhat agree, an 6.67 strongly disagree\u003c/p\u003e \u003cp\u003e7. \u003cb\u003eYour concern with COVID 19 is contacting from someone else?\u003c/b\u003ea majority 666.67 strongly agree and 33.33 neither agree nor disagree\u003c/p\u003e \u003cp\u003e8. \u003cb\u003eYour concern with COVID 19 is getting it at work?\u003c/b\u003eresponses are split we're majority of participants equally agree 16.67% with strongly agreeing, somewhat agreeing neither agreeing or disagreeing and somewhat disagreeing with this statement. There is a majority 33.33% that strongly disagree with this statement\u003c/p\u003e \u003cp\u003e9. \u003cb\u003eYour Concern with COVID 19 is contracting it within the community you live?\u003c/b\u003e responses are split regarding this category however 50% strongly agree whereas and other categories individuals are split between 16.77% (somewhat agree, somewhat disagree, strongly disagree )\u003c/p\u003e \u003cp\u003e10. \u003cb\u003eYou feel strongly about getting COVID 19 from a shelter environment?\u003c/b\u003e Responses are split we're 16.67% either strongly agree or somewhat disagree, or 33.33% either somewhat agree or strongly disagree.\u003c/p\u003e \u003cp\u003e11. \u003cb\u003eYou have come in contact with someone who has had COVID 19?\u003c/b\u003eResponses are split where 33.33% identified as strongly agreeing, somewhat disagreeing, and strongly disagree\u003c/p\u003e \u003cp\u003e12. \u003cb\u003eYou are aware of the safety procedures to implement to avoid contracting COVID 19?\u003c/b\u003ea majority of individuals strongly agree 66.67% whereas there's a split between neither agreeing nor disagreeing an strongly disagreeing of 16.67%\u003c/p\u003e \u003cp\u003e13. \u003cb\u003eYou feel satisfied in the vaccine administration process.\u003c/b\u003e a majority of participants 88.33% somewhat agree and strongly disagree whereas 16.67% neither agree nor disagree\u003c/p\u003e \u003cp\u003e14. \u003cb\u003eHomeless individuals will have equal access to the vaccine.\u003c/b\u003e a majority 66.67% strongly agree our son would agree\u003c/p\u003e \u003cp\u003e15. \u003cb\u003eHomeless individuals are at a risk for contacting COVID 19\u003c/b\u003eand majority 66.67% strongly agree where 16.67% is split between neither agreeing nor disagreeing or somewhat disagree\u003c/p\u003e \u003cp\u003e16. \u003cb\u003eHomeless individuals lack access to be tested, treated and vaccine for COVID 19?\u003c/b\u003e A majority 66.67% strongly agree an are split 16.67 between somewhat disagreeing and strongly disagree\u003c/p\u003e \u003cp\u003e17. \u003cb\u003eCOVID 19 issues are being address within the shelter?\u003c/b\u003e 100% of participants agree with this statement\u003c/p\u003e \u003cp\u003e18. \u003cb\u003eQ19 - Do you feel informed about how to respond to COVID 19\u003c/b\u003e majority of participants agree with this statement 83.33 strongly agreeing and 16.67\u003c/p\u003e \u003cp\u003e19. \u003cb\u003eDo you feel you have access to being treated for COVID 19?\u003c/b\u003e100% of participants agreed with this date\u003c/p\u003e \u003cp\u003e20. \u003cb\u003eDo you feel housing options are limited due to COVID 19?\u003c/b\u003ea majority 66.67% strongly agree and 16.67 someone agree whereas 16.67% neither agree nor disagree\u003c/p\u003e \u003cp\u003e21. \u003cb\u003eHas treatment for mental Health been limited due to COVID 19?\u003c/b\u003e Views are mixed however 66.66% strongly agree and strongly have somewhat agree and 16.67% either neither agree or disagree or strongly disagree\u003c/p\u003e \u003cp\u003e22. \u003cb\u003eHave treatment options for substance use issues been limited due to COVID 19?\u003c/b\u003eA majority of individuals somewhat agree with this statement an the rest are mixed between 16.67% of strongly agreeing and neither green nor disagreeing .\u003c/p\u003e \u003cp\u003e23. \u003cb\u003eAre you experiencing evictions being a direct impact of COVID 19?\u003c/b\u003e50% of the population strongly disagree with this statement whereas 30 three point 3% strongly agree and 16.67% somewhat agree\u003c/p\u003e \u003cp\u003e24. \u003cb\u003eHave you experience anyone losing a job or reducing hours due to COVID 19\u003c/b\u003e 50% of the population strongly disagree with this statement whereas 30 three point 3% strongly agree and 16.67 somewhat agree\u003c/p\u003e \u003cp\u003e25. \u003cb\u003eHas Social distancing been an issues through COVID 19?\u003c/b\u003e 66.67% of the population strongly disagree with this statement whereas 16.67% is split between strongly agreeing and somewhat agree.\u003c/p\u003e \u003cp\u003e26. \u003cb\u003eDo you feel contract tracing impacts disease spread?\u003c/b\u003e There's mixed perception regarding this question where 40% strongly agree Anne 20% is mixed between somewhat agreeing neither agree nor disagree or strongly agree\u003c/p\u003e \u003cp\u003e27. \u003cb\u003eDo you feel living conditions impact COVID 19 spread?\u003c/b\u003e83.33% of the population strongly agree\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. \u003cb\u003ePrior to COVID 19, did your agency have a communicable disease response protocol?\u003c/b\u003e Responses are split where have were 50% strongly agree or somewhat agree and 50% strongly disagree or somewhat agree.\u003c/p\u003e \u003cp\u003e2. \u003cb\u003eAs a result of COVID 19, did your agency adjust its policies and procedures to address the COVID 19 infectious Disease?\u003c/b\u003e Where 81.25% of respondents strongly agree or some would agree .\u003c/p\u003e \u003cp\u003e3. \u003cb\u003eDo you think your agencies protocol changes protected from COVID 19?\u003c/b\u003e Participants are mixed where 50% strongly agree or somewhat agree, and 43.7 5% somewhat disagree or strongly disagree and 6.25% neither agree nor disagree.\u003c/p\u003e \u003cp\u003e4. \u003cb\u003eDo you feel informed about how COVID 19 impacts employment?\u003c/b\u003eWhere more participants strongly or somewhat agree then those that strongly disagree or agree (68 .75% versus 31.25% ).\u003c/p\u003e \u003cp\u003e5. \u003cb\u003eYou are concerned with getting sick from COVID19?\u003c/b\u003eA majority of individuals strongly agree with this statement 56.25% or as a marginal percentage 37.50%.\u003c/p\u003e \u003cp\u003e6. \u003cb\u003eYour are concerned with contracting COVID 19 from someone else?\u003c/b\u003e A more majority of individuals overall agree with this statement however, 50% somewhat agree and 43.75 strongly agree. ( SD)\u003c/p\u003e \u003cp\u003e7. \u003cb\u003eYour are concern with getting COVID 19 at work?\u003c/b\u003eA majority of participants strongly agree with this statement 68.75 Anne somewhat agree with this statement 31.25% (OCLC).\u003c/p\u003e \u003cp\u003e8. \u003cb\u003eYour are Concern with contracting COVID 19 while in the community you live?\u003c/b\u003e Mixed response is given with regard to this question 31.25% equally somewhat agree and somewhat disagree whereas 18.75% strongly agree, 12.50 percent strongly disagree and 6.25% neither agree nor disagree.\u003c/p\u003e \u003cp\u003e9. \u003cb\u003eYou feel strongly about getting COVID 19 from a shelter environment?\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA majority of participants 43.75% strongly agree with this statement whereas 37.50% some would agree and 12.50 neither agree nor disagree an 6.25% somewhat disagree (LCC).\u003c/p\u003e \u003cp\u003e10. \u003cb\u003eYou have come in contact with someone who has had COVID 19?\u003c/b\u003eParticipant response is mixed however 37.5% strongly agree 25% somewhat agree 18.75% somewhat disagree 12.50% neither agree nor disagree and 6.25% strongly disagree.\u003c/p\u003e \u003cp\u003e11. \u003cb\u003eYou are aware of the safety procedures to avoid contracting COVID 19?\u003c/b\u003e An overwhelming majority 87.50 strongly agree.\u003c/p\u003e \u003cp\u003e12. \u003cb\u003eYou feel satisfied in the vaccine administration process.\u003c/b\u003e There is a mixed impression with 37.50 neither agreeing nor disagreeing, 25% strongly disagreeing and 18.75% equally strongly agreeing and somewhat agree.\u003c/p\u003e \u003cp\u003e13. \u003cb\u003eHomeless individuals will have equal access to the vaccine.\u003c/b\u003e There is some confidence 62.50% of participants strongly agree and somewhat agree and a minor level of confidence 18.75 percent equally identifying somewhat disagree and strongly disagree.\u003c/p\u003e \u003cp\u003e14. \u003cb\u003eHomeless individuals are at a higher risk for contacting COVID 19.\u003c/b\u003e A majority of participants 56.25 strongly agree with the statement and 18 point 75 somewhat agree with this statement there is also a mixed perception with those neither agreeing nor disagreeing and somewhat disagreeing at 12.50%. (VC)\u003c/p\u003e \u003cp\u003e15. \u003cb\u003eHomeless individuals lack access to be tested, quarantined and vaccine for COVID 19?\u003c/b\u003eIn general 62.50% of participants strongly agree and somewhat disagree with this question Anne 18.75% equally somewhat agree or disagree.\u003c/p\u003e \u003cp\u003e16. \u003cb\u003eYou feel confident that you can be tested, quarantined and vaccinated for COVID 19?\u003c/b\u003eA majority of participants 75% strongly agree with this statement and 12.5 0 percent equally somewhat agree and somewhat disagree.\u003c/p\u003e \u003cp\u003e17. \u003cb\u003eHousing options are limited due to COVID 19?\u003c/b\u003e A small majority 56.25% strongly agree with this statement 12.50 somewhat agree 18.75 neither agree nor disagree an 12.50 somewhat agree\u003c/p\u003e \u003cp\u003e18. \u003cb\u003eTreatment for mental Health been limited due to COVID 19?\u003c/b\u003eAn overwhelming majority of 81.25 strongly agree and somewhat agree with this statement .\u003c/p\u003e \u003cp\u003e19. \u003cb\u003eTreatment options for substance use has been limited due to COVID 19?\u003c/b\u003e An overwhelming majority of 81.25 strongly agree with this statement.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCOVID-19 affected society through pending evictions, job loss, reduction of working hours, and interrupted options to seek treatment. Among, clients and staff participating in our study reported mixed views about the COVID-19 impact on the overall livelihood and ability to access services and other coping mechanisms. Key themes inferred from resident surveys and staff surveys were existing and adapted health protocols, operational challenges, entry and exit concerns, responses to COVID-19, impact on services, impact on sheltering, living conditions, risk factors, treatment protocol, behavior protocol, and access to care. These themes were clustered into categories, which we used to report results: (1) structural and systemic impacts of COVID-19; (2) concerns about entry and exit to shelters; and (3) risk concerns and protective factors to public health emergencies.\u003c/p\u003e \u003cp\u003eCOVID-19 has required a change in structural approaches to managing infectious disease within shelters. Factors such as personal belief and sense of safety affect the reasoning and feelings of residents and staff regarding the social limitations the pandemic imposed on the shelter. Both residents and staff recognized that specific guidelines in response to COVID-19 are essential. Residents and staff report that changing policies and agency protocol impacted service delivery. Client and resident confidence level regarding any organizational changes was influenced by the clarity and communication of guidelines. Participants had different perceptions regarding the impact of infectious diseases based on their level(s) of exposure; nonetheless, they considered that having a protocol to manage COVID-19 was key.\u003c/p\u003e \u003cp\u003eShelters are considered a high-risk environment due to several social, economic, and behavioral factors making the homeless populations at-risk for contacting COVID-19, such as the lack of access to testing, treatment, and control over ability to socially distance. Based on client and staff responses, feelings of powerlessness (e.g., ability to control, monitor, and prevent COVID-19) affect perceptions about being able to reduce exposure and weakens senses of security.\u003c/p\u003e \u003cp\u003eTo ensure overall safety and security from COVID-19, shelter staff must be knowledgeable about communicable diseases, be responsive to infectious control, grant access to treatment, and support treatments. Perceptions about safety and security among staff and residents are influenced by opinions and beliefs about access to treatment and testing. Lacking access to tests, quarantine and vaccinations diminishes residents\u0026rsquo; confidence in the ability of staff to create a safe shelter environment and minimize the risk of contracting COVID-19 while receiving services.\u003c/p\u003e \u003cp\u003eThe impact of COVID-19 in shelter settings is directly related to the staff responses. As discussed, next, preventative behavior is needed to reduce or eliminate the contraction of COVID-19 among residents, such as hand washing, and sanitizing shelter facilities. Likewise, to reduce negative perceptions about satisfaction with vaccine administration or interventions to reduce COVID-19 spread, confidence in equity and equality of services is needed.\u003c/p\u003e \u003cp\u003eFurthermore, our study suggests that the impact is related to the inequalities this population experiences regarding their social, economic and demographic characteristics The need for social distance disrupts the level of access, and deviates from the established norm for many within shelter settings. Within the GUM shelter, COVID-19 directly affected the ability of people experiencing homelessness to enter the shelter, secure, and attain housing when exiting the shelter. COVID-19 also indirectly impacts entry-exit dynamics in terms of length of stay and perceived level of safety. The COVID-19 pandemic influenced the level of resident and staff confidence to maintain safety, their senses of security, and their interactions with others. Although both resident and staff perceptions included concerns in all the areas we measured, there were some differences. For instance, staff were more concerned with getting infected than were residents.\u003c/p\u003e \u003cp\u003e The interventions needed to address COVID-19 relate to the agency following safety protocols, CDC guidelines and individual behaviors such as a sense of responsibility to prevent disease spread. The concerns about COVID-19 in shelters are influenced by a variety of issues, such as feelings about exposure and ability to maintain safety. People experiencing homelessness are vulnerable to multiple health inequalities, such as limited access to healthcare services, medication, and treatment for diseases. Among shelter organizations, there is limited ability to address pandemics by ensuring proper ventilation, managing shelter capacity, improving shelter conditions, increasing senses of safety, and adhering to organizational health and safety protocols.\u003c/p\u003e \u003cp\u003eResearch shows that COVID-19 in shelter settings is a risk factor due to concerns related to shared living space (20). Any facility providing housing for homeless populations must account for direct (e.g., overcrowding) and indirect (e.g., transient lifestyles) influences. Establishing protocols that address direct and indirect influences helps contain pandemic-related concerns during a public health crisis (24). Shelter environments contain multiple aggravators to communicable disease spread, such as living conditions that create an environment that influences exposure rate among staff and residents. Furthermore, the ability to quarantine and maintain social distance affects the level and quality of service delivery (2).\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eCOVID-19 has required many changes to structural approaches to managing infectious disease within shelters. The response has influenced how clients are served and how staff engage residents. The shelter changes relate to understanding and identifying guidelines to address COVID-19.\u003c/p\u003e \u003cp\u003eData revealed that the impact of an infectious disease can have a different impression based on the level of exposure and awareness of agency intervention responses. Data showed that opinions and feelings about perceived agency influence depend on the level of impact on the group affected, served, or engaging the intervention. Whether a service provider or client serviced, data identifies, having a protocol to manage a communicable disease is key.\u003c/p\u003e \u003cp\u003eWithin shelter environments, COVID-19 poses a risk. That risk is influenced by how that environment is managed. Based on data, there is a concern for COVID-19 among shelters. However, the reason for concern varies based on perspective, feelings about exposure, and ability to maintain safety protocol.\u003c/p\u003e \u003cp\u003eCOVID-19 as a communicable disease is a risk factor for everyone that shares space. As a result, direct and indirect influences impact spread. Ventilation and shelter capacity are identified as essential components to disease spread. An adequate response to addressing COVID-19 is addressing systemic risk factors within shelter environments.\u003c/p\u003e \u003cp\u003eCOVID-19 has multiple direct and indirect impacts, presenting several risks among homeless populations. Risk factors are based on individual and collective behavior, the impact of living conditions, and organizational decision-making. Additionally, ensuring overall safety and security from COVID-19 is dependent on several factors, knowledge of the communicable disease, response to infectious control, access to treatment, and prescribing to treatment behavior. Several influencing factors govern the treatment protocol, and among the homeless, their treatment options are limited due to their social situation. Homeless populations are vulnerable to environmental disparities due to their lack of access and options to treatment. Moreover, addressing treatment issues is helping ensure and strengthening access, response, and behavior protocol.\u003c/p\u003e \u003cp\u003eAddressing the impact of communicable disease and its impact is influenced by the responses to the infectious disease. Essential behavior is needed to reduce or eliminate the contraction of COVID-19. With limited resources, transportation, income, and access, it is essential to know how to combat infectious diseases.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHomeless shelters are a complex environment impacted by compounding factors in society, organizations, and among individuals. Because of COVID-19, some of the structural and systemic factors that affect homeless populations in direct and indirect ways were uncovered and aggravated. The ability to impact service outcomes effectively and efficiently for the homeless population is dependent on the availability of and access to resources, sound prevention plans, and quality community collaboration. Imperative is the utilization of multi-systemic and organizational interventions when assisting homeless populations. To help address public health issues within shelter settings in the context of a health emergency such as the COVID-19 pandemic, it is vital to examine the living conditions of homeless populations, particularly their risk factors and protective factors, to address the prevalence of influencing conditions, mitigating protocols, and the impact of service delivery.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding and/or Competing Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe (the authors) did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support was received. We have no relevant financial or non-financial interests to disclose. The authors have no competing interests to declare that are relevant to the content of this article. We certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. We have no financial or proprietary interests in any material discussed in this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe confirm all relevant ethical guidelines have been followed, and any necessary Cayuse Human Ethics IRB and/or ethics committee approvals have been obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants. We confirm that all necessary participant consent has been obtained and the appropriate institutional forms have been archived. Any participant/sample identifiers included were not known to anyone (e.g., agencies or participants themselves) outside the research group so cannot be used to identify individuals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData \u0026amp; Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe have followed all appropriate research reporting guidelines and research reporting checklist(s) and other pertinent material as supplementary files, if applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMichael Pearson conceived of the research idea, developed the theory, and performed the computations. MP also contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript. Dr. Carmen Monico was involved in the study design, and supervised and reviewed the research study, providing guidance and advice throughout the research project development.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author confirms that all data generated or analyzed during this study are included in this published article. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe (the authors) are grateful to the Authorization of Greensboro Urban Ministry\u0026rsquo;s Administrations and participants and residents of the Weaver House for engaging in this study and providing very valuable information. We are also appreciative of Dr. Mathieu Despard, Professor in the A\u0026amp;T and UNCG Joint Social Work Programs, as well as Dontae Robert, joint PhD student, for their contributions to the research design. A special thanks to Dr. Brien Ashdown for his professional editing of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAhmad, K., Erqou, S., Shah, N., Nazir, U., Morrison, A. R., Choudhary, G., \u0026amp; Wu, W-C. (2020). Association of poor housing conditions with COVID-19 incidence and mortality across US counties. PLoS ONE, \u003cem\u003e15\u003c/em\u003e(11), e0241327. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0241327\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0241327\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAragona, M., Barbato, A., Cavani, A., Costanzo, G., \u0026amp; Mirisola, C. (2020). Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties. Public Health, \u003cem\u003e186\u003c/em\u003e, 52\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.puhe.2020.06.055\u003c/span\u003e\u003cspan address=\"10.1016/j.puhe.2020.06.055\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmiri, F. B., Doosti-Irani, A., Sedaghat, A., Fahimfar, N., \u0026amp; Mostafavi, E. (2018). Knowledge, attitude, and practices regarding HIV and TB among homeless people in Tehran, Iran. International journal of health policy and management, \u003cem\u003e7\u003c/em\u003e(6), 549.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaggett, T., Racine, M., Lewis, E., De Las Nueces, D., O' Connell, J., Bock, B., \u0026amp; Gaeta, J. (2020). Addressing COVID-19 among people experiencing homelessness: Description, adaptation, and early findings of a multiagency response in Boston. Public Health Reports, \u003cem\u003e135\u003c/em\u003e(4), 435\u0026ndash;441. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0033354920936227\u003c/span\u003e\u003cspan address=\"10.1177/0033354920936227\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanerjee, D., \u0026amp; Bhattacharya, P. (2020). The hidden vulnerability of homelessness in the COVID-19 pandemic: Perspectives from India. International Journal of Social Psychiatry, \u003cem\u003e67\u003c/em\u003e(1), 3\u0026ndash;6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0020764020922890\u003c/span\u003e\u003cspan address=\"10.1177/0020764020922890\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalut, M.D., Gin, J.L., Alenkin, N.R. \u003cem\u003eet al.\u003c/em\u003e Vaccinating Veterans Experiencing Homelessness for COVID-19: Healthcare and Housing Service Providers\u0026rsquo; Perspectives. J Community Health 47, 727\u0026ndash;736 (2022). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10900-022-01097-1\u003c/span\u003e\u003cspan address=\"10.1007/s10900-022-01097-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown, M., Cummings, C., Lyons, J., Carri\u0026oacute;n A., \u0026amp; Watson, D. P. (2018). Reliability and validity of the vulnerability index-service prioritization decision assistance tool (VI-SPDAT) in real-world implementation. Journal of Social Distress and the Homeless, \u003cem\u003e27\u003c/em\u003e(2), 110\u0026ndash;117. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10530789.2018.1482991\u003c/span\u003e\u003cspan address=\"10.1080/10530789.2018.1482991\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBucher, C. E. C. (2008). Toward a needs-based typology of homeless youth. Journal of Adolescent Health, \u003cem\u003e42\u003c/em\u003e(6), 549\u0026ndash;554.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCapelouto, J. D. (2020, June 21). Housing: Many fear looming homelessness 'crisis': Atlantans living in poverty were already on the financial brink, and the coronavirus pandemic threatens to push them over the edge. \u003cem\u003eThe Atlanta Journal-Constitution\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ajc.com/news/local/many-fear-looming-housing-homelessness-crisis-amid-hold-evictions/VySs1aszfZXvOTdi0GFOtO/\u003c/span\u003e\u003cspan address=\"https://www.ajc.com/news/local/many-fear-looming-housing-homelessness-crisis-amid-hold-evictions/VySs1aszfZXvOTdi0GFOtO/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenter for Disease Control and Prevention. (2021a). \u003cem\u003eCOVID data tracker - Demographic trends.\u003c/em\u003e Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://covid.cdc.gov/covid-data-tracker/#demographics\u003c/span\u003e\u003cspan address=\"https://covid.cdc.gov/covid-data-tracker/#demographics\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCenter for Disease Control and Prevention. (2021b). \u003cem\u003eInterim guidance for homeless service providers to plan and respond to coronavirus disease.\u003c/em\u003e Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.google.com/url?q=https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html\u0026amp;\u003c/span\u003e\u003cspan address=\"https://www.google.com/url?q=https://www.cdc.gov/coronavirus/2019-ncov/community/homeless-shelters/plan-prepare-respond.html\u0026amp;\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003esa=D\u0026amp;source=editors\u0026amp;ust=1627945738843000\u0026amp;usg=AOvVaw2EviIgpdBOfqly4GCTTq6M.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCohen, J. (2013). Statistical power analysis for the behavioral sciences. \u003cem\u003eElsevier Science\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiaz, A.-P., \u0026amp; Paynich, V. (2020). Homelessness and the global pandemic: The role of Los Angeles\u0026rsquo;s city parks and open spaces during COVID-19. \u003cem\u003eNational Recreation and Park\u003c/em\u003e Association \u003cem\u003e(NRPA) Parks \u0026amp; Recreation, 55\u003c/em\u003e(6), 36. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nrpa.org/parks-recreation-magazine/2020/june/homelessness-and-the-global-pandemic/\u003c/span\u003e\u003cspan address=\"https://www.nrpa.org/parks-recreation-magazine/2020/june/homelessness-and-the-global-pandemic/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFazel, S., Geddes, J. R., \u0026amp; Kushel, M. (2014). The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet (London, England), \u003cem\u003e384\u003c/em\u003e(9953), 1529\u0026ndash;1540. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S0140-6736(14)61132-6\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(14)61132-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFinnigan, R. (2021). Self-reported impacts of the COVID-29 pandemic for people experiencing homelessness in Sacramento, California. Journal of Social Distress and Homelessness, Online first publication. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10530789.2021.1879618\u003c/span\u003e\u003cspan address=\"10.1080/10530789.2021.1879618\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFitch, D. (2010). Homeless management information system customization intervention. Journal of Human Behavior in the Social Environment, \u003cem\u003e20\u003c/em\u003e(2), 255\u0026ndash;255. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10911350903269922\u003c/span\u003e\u003cspan address=\"10.1080/10911350903269922\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFraser, M. W., Richman, J. M., Galinsky, M. J., \u0026amp; Day, S. H. (2009). Intervention research: Developing social programs. \u003cem\u003eOxford Press\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreensboro Urban Ministry. (2021). \u003cem\u003eWeaver House Shelter\u003c/em\u003e. Retrieved from www.greensborourbanministry.org\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuilford County Division of Public Health. (n.d.). \u003cem\u003eCOVID-19 Data\u003c/em\u003e. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.guilfordcountync.gov/our-county/human-services/health-department/coronavirus-covid-19-info/covid-19-data\u003c/span\u003e\u003cspan address=\"https://www.guilfordcountync.gov/our-county/human-services/health-department/coronavirus-covid-19-info/covid-19-data\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHammer, C., Brainard, J. \u0026amp; Hunter, P. (2017). Risk factors and risk factor cascades for communicable disease outbreak in complex humanitarian emergencies: A qualitative systematic review. BMJ Global Health, \u003cem\u003e3\u003c/em\u003e, Article e000647. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjgh-2017-000647\u003c/span\u003e\u003cspan address=\"10.1136/bmjgh-2017-000647\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsu, H. E., Ashe, E. M., Silverstein, M., Hofman, M., Lange, S. J., Razzaghi, H., Mishuris, R. G., Davidoff, R., Parker, E. M., Penman-Aguilar, A., Clarke, K. E. N., Goldman, A., James, T. L., Jacobson, K., Lasser, K. E., Xuan, Z., Peacock, G., Dowling, N. F., \u0026amp; Goodman, A. B. (2020). Race/ethnicity, underlying medical conditions, homelessness, and hospitalization status of adult patients with COVID-19 at an urban safety-net medical center \u0026ndash; Boston, Massachusetts, 2020. Morbidity and Mortality Weekly Report, \u003cem\u003e69\u003c/em\u003e(27), 864\u0026ndash;869. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15585/mmwr.mm6927a3\u003c/span\u003e\u003cspan address=\"10.15585/mmwr.mm6927a3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohns Hopkins University. (2021). \u003cem\u003eCOVID-19 dashboard by the Center for Systems Science and Engineering at John Hopkins University\u003c/em\u003e. Retrieved June 24, 2021 from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.covidtracker.com\u003c/span\u003e\u003cspan address=\"http://www.covidtracker.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan, S. Akter, S., Khan, T., Hariar, G., \u0026amp; Awai Miah, M. A. (2021). Psychological distress among Bangladeshi physicians: roles or perceived stigma, fear or infection and resilience in the context of covid-19. Journal of Social Distress and Homelessness, Online first publication. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10530789.2021.1892932\u003c/span\u003e\u003cspan address=\"10.1080/10530789.2021.1892932\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeung, C. S., Ho, M. M., Kiss, A., Gundlapalli, A. V., \u0026amp; Hwang, S. W. (2008). Homelessness and the response to emerging infectious disease outbreaks: lessons from SARS. Journal of Urban Health, \u003cem\u003e85\u003c/em\u003e(3), 402\u0026ndash;410. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11524-008-9270-2\u003c/span\u003e\u003cspan address=\"10.1007/s11524-008-9270-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarcus, T., Hesse, J. Scheibe, A. Shelly, S., Lalla, S., Hugo, J. (2020). Harm reduction in an emergency response to Homelessness touring South African's COVID-19 lockdown. Harm reduction Journal\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendenhall, E., Kohrt, B. A., Norris, S. A., Ndetei, D., \u0026amp; Prabhakaran, D. (2017). Non communicable disease syndemics: poverty, depression, and diabetes among low-income populations. The Lancet, \u003cem\u003e389\u003c/em\u003e(10072), 951\u0026ndash;963.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosites E., Parker, E.M., Clarke, K. E. N., Gaeta, J. M., Baggett, T. P., Imbert, E., Sankaran, M., Scarborough, A., Huster, K., Hanson, M., Gonzales, E., Rauch, J., Page, L., McMichael, T. M., Keating, R., Marx, G. E., Andrews, T., Schmit, K., Morris, S. B., Dowling, N. F., Peacock, G., \u0026amp; COVID-19 Homelessness Team. (2020). Assessment of SARS-COVID-19 infection prevalence in homeless shelters\u0026mdash;four U.S. cities, March 27-April 15, 2020.. Morbidity and Mortality Weekly Report, \u003cem\u003e69\u003c/em\u003e(17), 521\u0026ndash;522. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15585/mmwr.mm6917e1\u003c/span\u003e\u003cspan address=\"10.15585/mmwr.mm6917e1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNooe, R. M. \u0026amp; Patterson, D.A. (2010). The ecology of homelessness. Journal of Huma Behavior in the Social Environment, 20 (2), 105\u0026ndash;152.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorth Carolina Department of Health and Human Services (NCDHHS), (2021). COVID-19 North Carolina Dashboard. COVID-19 North Carolina Dashboard | NC COVID-19 (ncdhhs.gov)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOkonkwo, N. E., Aguwa, U. T., Jang, M., Barr\u0026eacute;, I. A., Page, K. R., Sullivan, P. S., Beyrer, C., \u0026amp; Baral, S. (2020). COVID-19 and the U.S. response: Accelerating health inequities. BMJ Evidence-Based Medicine, \u003cem\u003e26\u003c/em\u003e, 176\u0026ndash;179. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmjebm-2020-111426\u003c/span\u003e\u003cspan address=\"10.1136/bmjebm-2020-111426\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerri, M., Dosani, N., \u0026amp; Hwang, S. W. (2020). Covid-19 and people experiencing homelessness: Challenges and mitigation strategies. Canadian Medical Association. Journal, \u003cem\u003e192\u003c/em\u003e(26), 716\u0026ndash;719. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1503/cmaj.200834\u003c/span\u003e\u003cspan address=\"10.1503/cmaj.200834\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRam\u0026iacute;rez, I. J., \u0026amp; Lee, J. (2020). COVID-19 emergence and social and health determinants in Colorado: a rapid spatial analysis. International journal of environmental research and public health, \u003cem\u003e17\u003c/em\u003e(11), 3856.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRenfro, C. P., Rome, Z., Gatwood, J., \u0026amp; Hohmeier, K. C. (2022). Use of Rapid Assessment Procedures when analyzing qualitative data in pharmacy research. Research in Social and Administrative Pharmacy, \u003cem\u003e18\u003c/em\u003e(1), 2249\u0026ndash;2253.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaadat, S., Rawtani, D., \u0026amp; Hussain, C. M. (2020). Environmental perspective of COVID-19. \u003cem\u003eThe Science of the total environment\u003c/em\u003e, \u003cem\u003e728\u003c/em\u003e, Online first publication. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.scitotenv.2020.138870\u003c/span\u003e\u003cspan address=\"10.1016/j.scitotenv.2020.138870\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharam, A., \u0026amp; Hulse, K. (2014). Understanding the nexus between poverty and homelessness: relational poverty analysis of families experiencing homelessness in Australia. Housing, Theory and Society, \u003cem\u003e31\u003c/em\u003e(3), 294\u0026ndash;309.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSomerville, P. (2013). Understanding homelessness. Housing, theory, and society, \u003cem\u003e30\u003c/em\u003e(4), 384\u0026ndash;415.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTaylor, B., Henshall, C., Kenyon, S., Litchfield, I., \u0026amp; Greenfield, S. (2018). Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis. BMJ open, \u003cem\u003e8\u003c/em\u003e(10), e019993.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTobolowsky, F. A., Gonzales, E., Self, J. L., Rao, C. Y., Keating, R., Marx, G. E., McMichael, T. M., Lukoff, M. D., Duchin, J. S., Huster, K., Rauch, J., McLendon, H., Hanson, M., Nichols, D., Pogosjans, S., Fagalde, M., Lenahan, J., Maier, E., Whitney, H., Sugg, N., Chu, H., Rogers, J., Mosites, E, \u0026amp; Kay, M. (2020). COVID-19 Outbreak Among Three Affiliated Homeless Service Sites - King County, Washington, 2020. \u003cem\u003eMorbidity and Mortality Weekly Report, 69\u003c/em\u003e(17), 523\u0026ndash;526. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15585/mmwr.mm6917e2\u003c/span\u003e\u003cspan address=\"10.15585/mmwr.mm6917e2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToro, P. A., \u0026amp; McDonnell, D. M. (1992). Beliefs, attitudes, and knowledge about homelessness: a survey of the general public. American journal of community psychology, \u003cem\u003e20\u003c/em\u003e(1), 53\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/BF00942181\u003c/span\u003e\u003cspan address=\"10.1007/BF00942181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrotter, R. T., Needle, R. H., Goosby, E., Bates, C., \u0026amp; Singer, M. (2001). A methodological model for rapid assessment, response, and evaluation: the RARE program in public health. Field methods, \u003cem\u003e13\u003c/em\u003e(2), 137\u0026ndash;159.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsai, J., Grace, A. \u0026amp; Vazquez, M. Experiences with Eviction, House Foreclosure, and Homelessness Among COVID-19 Infected Adults and Their Relation to Mental Health in a Large U.S. City. J Community Health (2022). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s10900-022-01166-5\u003c/span\u003e\u003cspan address=\"10.1007/s10900-022-01166-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization (2020, May 22). \u003cem\u003eOperational planning guidance to support country preparedness and response: COVID\u0026ndash;19 strategic preparedness and response.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/draft-operational-planning-guidance-for-un-country-teams\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/draft-operational-planning-guidance-for-un-country-teams\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorldometer (2023). COVID-19 coronavirus pandemic. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.worldometers.info/coronavirus/\u003c/span\u003e\u003cspan address=\"https://www.worldometers.info/coronavirus/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoon, J.C., Montgomery, M.P., Buff, A., Boyd, A.T., Jamison, C., Hern\u0026aacute;ndez, A., Schmit, K., Shah, S., Ajoku, S., Holland, D., Prieto, J., Smith, S., Swancutt, M., Turner, K., Andrews, T., Flowers, K., Wells, A., Marchman, C., Laney, E.B., Bixler, D., Cavanaugh, S., Flowers, N., Gaffga, N., Ko, J.Y., Paulin, H., Weng, M., Mosites, E., \u0026amp; Morris, S. (2020). COVID-19 prevalence among people experiencing homelessness and homelessness service staff during early community transmission in Atlanta, Georgia, April\u0026ndash;May 2020. \u003cem\u003eClinical Infectious Diseases\u003c/em\u003e, Article ciaa1340. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/cid/ciaa1340\u003c/span\u003e\u003cspan address=\"10.1093/cid/ciaa1340\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eValado, T., \u0026amp; Amster, R. (2012). Professional lives, personal struggles: Ethics and advocacy in research on homelessness. \u003cem\u003eLexington Books\u003c/em\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"homelessness, shelter services, health disparities, COVID-19, public health, social work","lastPublishedDoi":"10.21203/rs.3.rs-3774252/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3774252/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe COVID-19 pandemic magnified organizational and universal issues adversely affecting health among many including those experiencing homelessness. Among homeless populations, the high-risk nature of COVID-19 challenged access to treatment, disrupts access to housing and security, and it aggravated social disparities such as employment loss, housing access and extended homelessness. This study looks at the need to identify and implement mitigating strategies to reduce and address communicable disease within shelter environments. This study utilizes staff and client surveys through Qualtrics to document the experiences of clients and staff of a homeless shelter in Greensboro during COVID-19 and when entering service delivery. The study gauged participant perceptions regarding the shelter\u0026rsquo;s public health response, their access to health and housing resources, and access to treatment. In addition, it identified the level of impact of the pandemic on shelter services and sense of safety. The study found that multiple intersecting factors influenced disease spread, such as, living conditions, treatment adherence, and risky behavior. This research shows that to adequately provide services, to ensure safety and reduce outbreaks, mitigating strategies such as onsite screening and access to treatment and care are essential. Data collected shows that method of service delivery to populations experiencing homelessness is an essential mitigating strategy and helps address risk and barriers within homelessness.\u003c/p\u003e","manuscriptTitle":"Public Health Among People Experiencing Homelessness during COVID-19","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-09 05:19:04","doi":"10.21203/rs.3.rs-3774252/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7d47c12-df53-4af4-922c-62d34fd0aa02","owner":[],"postedDate":"February 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-25T09:15:05+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-09 05:19:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3774252","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3774252","identity":"rs-3774252","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}