Public health information communication preferences among residents in six (6) King County homeless shelters between March 2020 and October 2021; Lessons from the COVID -19 pandemic

Public health information communication preferences among residents in six (6) King County homeless shelters between March 2020 and October 2021; Lessons from the COVID -19 pandemic | 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 Research Article Public health information communication preferences among residents in six (6) King County homeless shelters between March 2020 and October 2021; Lessons from the COVID -19 pandemic Nicholas Thuo, Sarah N. Cox, Julia H. Rogers, Amy C Link, Miguel Martinez, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5801586/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Introduction: An unforeseen outcome of the COVID-19 pandemic was the unprecedented proliferation of misinformation, commonly termed as an 'infodemic.' This had extensive repercussions, including a reduced ability for homeless shelters to effectively convey accurate information to their residents, who have specific needs as persons experiencing homelessness. We sought to better understand approaches used by shelters to inform residents(people experiencing homelessness) about COVID-19, how the information was perceived, and how to improve communication strategies. Methods We conducted semi-structured interviews and focus group discussions across six homeless shelters in King County, Washington between July and October 2021. We systematically selected residents and staff aged ≥ 18 years for interviews and recruited a convenience sample of residents aged ≥ 18 years who had not participated in the interviews for focus group discussions. We used a conceptual model informed by the Health Belief Model and the Confidence, Complacency, Convenience Model of Vaccine Hesitancy to understand factors influencing shelter residents’ COVID-19 information choices, perceptions, and experiences with shelter-specific communication. Thematic analysis was conducted using Dedoose. Results We conducted interviews with 25 shelter residents, six shelter staff, and eight focus groups with 43 residents. Residents reported that they received COVID-19 information from internal homeless shelter sources and external sources. Internal sources included shelter staff and residents; external sources included family, friends, healthcare providers, and other physical and online resources. Participants selected information sources based on perceived usefulness, objectivity, and trustworthiness, and if the sources were viewed as authorities on COVID-19. Shelter management was instrumental in disseminating COVID-19 information by providing staff with up-to-date COVID-19 information during meetings and sharing online and printed resources. Staff then utilized established channels to share the information with residents, including through individual and group verbal communication, posters, and flyers that were distributed to residents. While some of the shelter-provided information was perceived as well-informed, consistent, and visible, some residents reported that information was not well delivered, lacked compassion, and did not reach all residents. Shelter residents preferred communication that was simple, clear, and compassionate, and which included explanations for various recommendations. They also reported the need for tailored messages, multimodal communication, communication from trusted health professionals, and inclusion of people experiencing homelessness in message development. Conclusion Participants expressed a preference for person-centred communication approaches and underscored the importance of effective pathways for disseminating health information within homeless shelters. Utilizing clear, concise, and specific public health messaging and channels tailored to individuals experiencing homelessness can significantly improve communication between shelters and their residents. Utilizing the right channels through trusted messengers can help deliver health messaging to effectively reach people experiencing homelessness. COVID-19 Homeless Shelters Communication Strategies People Experiencing Homelessness Trust and Mistrust Figures Figure 1 Introduction COVID-19 is a significant global public health concern, affecting over 760 million people worldwide since 2019, and causing over 1.14 million deaths in the U.S. as of December 24, 2023. (1). People experiencing homelessness (PEH) have been disproportionately affected by COVID-19 due to a higher risk of severe disease from underlying health conditions, challenges accessing healthcare, and social stigma (2,3). People experiencing homelessness living in shelters were at higher risk for COVID-19 than PEH who were unsheltered, with one study reporting four times higher prevalence of COVID-19 among sheltered People experiencing homelessness (4,9). Crowded living conditions and shared facilities in shelters made it challenging to enforce physical distancing and quarantine or isolation measures (4,5). For a population experiencing overlapping social disadvantages, it is of paramount importance to clearly communicate rapidly changing information and implement public health recommendations (17–19). The COVID-19 pandemic was accompanied by widespread misinformation about topics such as the disease, transmission, vaccine safety, risk of infection, and utility of masking in what has now been termed an “infodemic” (29) of unprecedented proportions and implications. Knowledge and perception of COVID-19 severity have been shown to differ based on settings and behaviours (11, 12, 13, 15). Shelters commonly employ communication strategies to inform residents about numerous infectious disease risks, but their effectiveness in countering misinformation remains uncertain (13). A study conducted in the context of a tuberculosis outbreak found that education efforts in the shelter were minimally engaging and led to increased stress among shelter residents (14). To ensure public health prevention strategies are implemented effectively, it is important to understand the mechanisms and pathways for COVID-19 information-sharing among shelter residents and examine communication strategies that maximise utility and reach. This study used qualitative methods to explore information communication in shelter settings and explore shelters' approaches to inform their residents about COVID-19. The primary objective was to understand how shelter residents perceive shelter communication including approaches, delivery and content, and to identify what could be done to improve the flow and effectiveness of communication to residents. Methods Study design and population Between July and October 2021, we conducted qualitative semi-structured interviews ('interviews') and focus group discussions ('focus groups') in six homeless shelters that were strategically selected across Seattle-King County, WA to be socio-demographically representative of King County's sheltered People experiencing homelessness (30). The six shelters in this qualitative study included two mixed-gender adult shelters, two family shelters, one all-male older adult shelter (aged ≥ 50 years), and one young adult shelter (aged 18–25 years). Individuals aged ≥ 18 years whose primary residence or place of employment was at one of these six shelters were eligible for participation in the semi-structured interviews only. Shelter residents aged ≥ 18 years who had not previously participated in interviews were eligible for participation in focus groups. Participant recruitment Study methods, including participant recruitment, have been described in depth elsewhere (31). Participants, residents and staff, were identified for interviews through a prior quantitative survey to capture a representative sample of individuals with diverse COVID-19 vaccine attitudes and demographics (32). Convenience sampling was used to identify and recruit residents for focus group participants who had not already participated in an interview. Invitations to participate in interviews were based on efforts to ensure diversity across different racial and ethnic minority groups, gender identities, individuals with or without children, non-English speakers, and self-reported COVID-19 vaccine attitudes reported on previous shelter surveys (31) . Data sources and collection We developed interview and focus group guides in partnership with Public Health Seattle-King County and people with lived experience of homelessness. We focused on confidence in COVID-19 communication and how various factors influenced this confidence. The guides were informed by the Health Belief Model and the Confidence, Complacency, Convenience Model of Vaccine Hesitancy (23,24,25,26, 27, 28, 31). Interview guides were translated into Spanish, French, Amharic, and Tigrinya. Interviews were conducted one-on-one with an experienced interviewer and focus groups were conducted by a moderator and a notetaker. The discussions took place in private rooms in the participating homeless shelters. Two shelters conducted one focus group each and three shelters conducted two focus groups each. We were unable to conduct a focus group at one shelter given a COVID-19 outbreak. In the focus groups at family shelters, children of participants were allowed to be present and listen. All interviews and focus groups were audio-recorded and translated from the original language to English, when necessary, by a transcription service (Dynamic Language) every other week. Analysis and positionality We conducted thematic analysis using Dedoose Version 9.0.17. The analysis team developed the codebook collectively using both deductive and inductive approaches. To ensure consistent understanding and use of the codebook, the first four interview transcripts and the first two focus group transcripts were coded in pairs. Approximately one-third of additional transcripts (36%, n = 12/33) were peer-reviewed by another coder. Coders met one to two times per week to discuss coding questions and interpretations to reach a consensus with oversight and support from a qualitative Principal Investigator. To ensure our themes were true to our data, we selected multiple quotes to support each identified theme. Themes were refined by group discussion and final reflective quotes were selected by group consensus. Coding was done as transcripts were made available, allowing for quick analysis and modification of guides in real time to capture any missing elements. The study team acknowledges the role that our socioeconomic positions and experiences may have contributed to data presentation and interpretation. Among team members, there were some familial and personal lived experiences of homelessness, as well as extensive experience conducting public health practice to improve health equity in Seattle-King County that helped to minimize potential bias. The entire team was also sensitized in trauma-informed interviewing techniques and debriefed after interviews. The coding team consisted of four team members, each with a master’s degree in public health. One research team member was affiliated with the Centers for Disease Control and Prevention (CDC), and three were affiliated with the University of Washington (UW), Seattle, Washington. The researchers had prior experience in qualitative research and coding, and three researchers had previously participated in data collection at shelter sites. Ethics The Human Subjects Division of the UW Institutional Review Board approved this study (STUDY00007800) and the CDC relied upon this approval. All participants provided electronic informed consent captured through the research data capture software (REDCap). To ensure confidentiality, all data were de-identified and stored securely using participant identity (PTID) numbers. Information directly identifying shelters by name was masked. Results 1. Participant characteristics We conducted 31 interviews with 25 residents and six staff members, and eight focus groups with 43 residents [Table 1]. Interviews lasted from 10 to 90 minutes (average 44 minutes), and focus groups lasted from 52 to 111 minutes (average 68 minutes). More than half of participants (n = 40, 54%) of both interviews and focus groups were aged 18–49 years. We recruited 21 interviewees from a previous quantitative survey (32). Participants mostly identified as cisgender men (n = 43, 58%), White (n = 30, 41%) or Black/African American (n = 26, 35%). A few participants (n = 7, 9%) identified as Hispanic or Latinx, and (n = 2, 3%) spoke Spanish as their primary language. 2. Mapping shelter COVID-19 communication flow We developed a communication flow diagram from resident and staff responses to COVID-19 information (i.e., how they received information from external and internal sources, and how it was filtered) [ Figure 1 ]. Through data analysis, we identified three key elements that described content, delivery, channels, and partnerships and present them as: 1) COVID-19 information sources, 2) trust and mistrust of sources, and 3) communication preferences. Participants described how information flowed from external and internal sources through technology, print materials, and interpersonal communication, and was assessed by receivers based on trustworthiness, objectivity and honesty, consistency, and compassion. These themes are presented in more detail in the following section, with illustrative quotes in Tables 2, 3 and 4. Figure 1: Intra and Extra Shelter information sources and perceptions (figure attached) 3. COVID-19 information sources Interviews about COVID-19 information sources used by residents and staff of homeless shelters identified both shelter-specific internal information sources and external information sources ( Table 2: Internal and External Sources of information among shelter residents and staff) . 3.1. External shelter sources: External sources were reported as those not managed or controlled by the shelter staff or management. These sources were classified as either physical or electronic sources. The interaction with these sources was unstructured and relied on the individual’s ability to access or interact with these information sources. Examples of external sources included external healthcare providers, government agencies, public media networks and print materials. 3.2. Internal shelter sources: Internal sources were reported as those tailored to provide information to residents through the shelter staff using various channels (e.g., in-person meetings, posters, announcements). The sources were selected by the management of the shelters and shared with the staff for onward communication to residents. 3.2.1. Shelter management to staff: Shelter managers established specific communication channels to educate and orient staff on COVID-19 and prevention measures, including community meetings, distributing flyers and brochures, holding one-on-one meetings with staff, and putting up posters on walls. 3.2.2. Shelter staff to residents: Shelter staff used community meetings, posters, one-on-one sessions between shelter staff and residents, and third-party health providers in the shelter to provide information and updates on policies to residents. 4.0 Reasons for trust: Perceptions of COVID-19 information sources and content 4.1 Factors influencing trustworthiness of sources The following factors were found to influence how trustworthy participants deemed COVID-19 information sources based on resident views and staff perceptions with quotes available in Appendix ( Table 3 : Factors influencing trustworthiness of sources of information ) . 4.1.1 Proxy trust (trusted because others trust them) : Participants reported having trust in individuals as a source, such as family and friends, who were held in high esteem by other people with whom they already had a trust relationship, and were considered to be informed or trained. 4.1.2 Provides useful information : Participants reported having trust in sources of information viewed as practical, relatable, and implementable. Such information was further reported as easy to understand and execute within the shelter setting. 4.1.3 Proven : Participants reported having trust in a source that had provided helpful and accurate health information in the past, or any information source that had been shared in the past that turned out to be true. 4.1.4 Objective : Participants reported having trust in sources that were perceived to be objective, including individuals presenting information anchored in verifiable data. Determination of objectivity was rooted in professional qualifications and the provision of evidence to support the information. Evidence was critical whether provided by an individual or accessed electronically in supporting this perception. 4.1.5 Honest : Participants reported that previous healthcare interactions marked by honest communication improved trust. If a healthcare provider had provided information that was confirmed to be true and helped an individual, the trust was established and carried into the reception of COVID-19 information. 4.1.6 Has training, experience, and authority in the topic : Participants reported having trust in individuals as sources of information if they perceived the individual as having enough experience and practical knowledge on the topic, particularly healthcare providers. Healthcare providers with known training or titles perceived as prestigious (such as “doctor”) that conveyed the person’s training were perceived as more trustworthy as they had the necessary education. This was also highlighted in instances where individuals independently accessed information in other forms that were attributed to professionals with these attributes. 4.2 Factors influencing trustworthiness of content Communicated content with the following attributes were reported to be trusted and “embraced” by shelter residents: 4.2.1 Well thought out : Information that was perceived as well-reasoned or anchored in logic and resonating with the recipients’ beliefs and understanding was more likely to be trusted. Many resources that had very little information, or very surface level information, were deemed not well thought out, and people were unable to determine the rationale of why the information was being recommended or provided. Materials with background information and opportunities to learn more were well-received. 4.2.2 Consistent : Information that was uniform in content and meaning and was shared regularly was considered trustworthy. With new information being reported almost daily, maintaining a consistent storyline was seen as a sign of being trustworthy. 4.2.3 Clear : Presentations in written form that were easy to understand and clear were trusted. Open, simple communication without misleading wording was trusted. 5.0. Reasons for mistrust: Perceptions of COVID-19 information sources and content Participants reported that sources were assessed based on whether the information they provided was clear and candid. The following perceptions affected how a source was perceived: 5.1 Perceptions on the credibility of the information source 5.1.1 Has contradictory, changing, or ‘fake’ information : participants reported that being provided inconsistent information was considered a sign of being untrustworthy. Sources were expected to provide information that matched earlier information or could be logically linked to past information. 5.1.2 Withholds information : participants reported that if a source was perceived to not provide all the information available, the legitimacy of the information was questioned. The frequently changing recommendations and information led people to believe that certain pieces of information were being withheld, making it difficult to trust the information. 5.1.3 Deception : participants reported that when they felt that the information provided was not anchored in what they perceived as truth, they concluded that they were intentionally being deceived. Participants described how perceptions of deception were driven by interpersonal relationships and political views. Sources deemed as “deceptive” were considered untrustworthy. 5.1.4 In it for the money : information presented to participants when viewed as being shared with the intention of making a profit was not trusted. Products specifically marketed and sold as tools to prevent the spread of COVID-19 were questioned for not having peoples’ actual needs in mind, only seeking to make money. 5.2 Shelter communication presentation and approach. The following situations and attributes contributed to perceptions of untrustworthiness based on how it was communicated: 5.2.1 Unseen or unnoticed : some residents reported that information was sometimes shared in their absence and they did not directly receive the information. This led to concerns about information received through third parties, including other residents or friends in the shelter. This was attributed to poor timing on the part of the shelter. 5.2.2 Lacked compassion : residents did not trust any information that lacked empathy and showed either a disregard for their issues or prioritised the issue of COVID-19 above their personal needs. 5.2.3 Contradictory guidance : when different shelter staff gave updates that contradicted updates shared previously by other staff members, residents felt that they could not trust shelter staff because they provided contradictory guidance. This challenge was partly due to the rapidly changing information that was difficult to keep up with. 6.0 Preferences regarding information and communication of information among People experiencing homelessness When asked about preferences for receiving information and communications about COVID-19, PEH provided details of preferred channels, reporter characteristics, and manner of delivery ( Table 4: Preferred channels, reporter characteristics, and manner of delivery: People Experiencing Homelessness preferences in illustrative quotes. ). These included: 6.1. COVID-19 Content attributes Information that was to be shared with People experiencing homelessness needed to be in a form that could be understood and verified. PEH reported that the content should be: 6.1.1 Consistent and reliable : information that would remain unchanged and shared regularly was considered trustworthy and more acceptable and useful. 6.1.2 Objective : the content should not appear to be biased in any way that appears to favour one political, social, or religious leaning. Instead, information should be anchored in verifiable data that people can directly explore themselves. 6.1.3 Simple : information should be synthesized into accessible language that is easy to understand and not requiring further interpretation. This would include the use of non-scientific language and translation of print products to other commonly spoken languages. 6.2. Delivery of information People experiencing homelessness expressed that information should be communicated to them in a manner that is acceptable, in a form that reflects their dignity and be delivered by persons to whom they can relate. This includes delivering information with the following traits: 6.2.1 Compassionate : Delivery of information needs to be in an empathetic manner that appeals not only to the intellect but to the hearts and minds of People experiencing homelessness 6.2.2 Person-centred (Centered on the individual's well-being and requirements): In the context of a shelter, the information shared and how it is shared should be in a form that takes into consideration the unique issues surrounding People experiencing homelessness. This would also include providing possible connections to other needs people have. For example, asking shelter residents to receive COVID-19 testing or vaccination, but not providing them with food or connecting them to other social or medical care indicated that peoples’ daily life needs were not considered or accounted for. 6.2.3 Inclusive team : Teams delivering information need to have representation rom People experiencing homelessness who can understand and articulate their issues. Receiving information from a person who had experienced or was currently experiencing homelessness was viewed as part of the community and more likely to be trusted. 6.2.4 Ensure everyone is reached : Communication should take into consideration the availability of residents and how it can reach them in an appropriate and timely manner. This would include the timing of community sessions and the use of media that most people had access to. Offering multiple information sessions at different days and times on the same topic would help ensure everyone can receive the same information from the same source, not relying on hearing things from others or “through the grapevine.” 6.2.5 Incentives appreciated : Provision of incentives in the form of gift cards were helpful to residents as they allowed them to fulfil other needs, while receiving a service (information, vaccination) they needed. Discussion In this qualitative study, we gained valuable insight into how homeless shelter residents in Seattle, Washington used a variety of sources internal and external to their shelter to receive information about COVID-19 within an environment that was reportedly higher risk. Implementing public health messages that are both clear and concise, specifically tailored to the unique circumstances of people experiencing homelessness, emerged as a potent strategy to enhance communication effectiveness between shelters and their residents. We identified sources of information that People experiencing homelessness utilized, factors associated with perceived trustworthiness of information, and drivers of successful communication delivery. While residents utilized multiple sources for their information, not all sources were equally trusted. Residents valued information that came from family members who were knowledgeable and respected. They also looked for information that was practical, reliable, objective, honest, and easy to implement. Information that was perceived as inconsistent or contradictory to previous recommendations led to doubt and mistrust of the information. Additionally, residents thought that some information sources had hidden agendas, primarily seen as using the COVID-19 pandemic to make money. Residents appreciated information and communication that was simple, reliable, person-centred, and accessible to everyone in the shelter. During the COVID-19 pandemic, the CDC provided recommendations on how to make COVID-19 prevention content inclusive for People experiencing homelessness, including using a variety of communication channels and ensuring that recommendation language was not stigmatizing (19). Preferences reported by People experiencing homelessness in our study support these recommendations. Additionally, National Health Care for the Homeless Council's (2009) guidance on disaster preparedness noted the challenge of using written material for communication and recommended a more personal approach to providing information (20). Utilizing more person-centered communication strategies would allow interaction, discussion, and clarification of issues raised. Reaching shelter residents when they were most available was also an important tool for delivering information. Stennett et al. found that communicating information during group functions like mealtimes was more likely to reach more people (16). Elsewhere, the use of technology such as mobile phones and computers showed an opportunity to address community health-related issues among People experiencing homelessness and other marginalized groups (21). In addition to being first, being right, and being credible in communications during public health emergencies, additional considerations should be made when communicating with people in homeless shelters (12,16). Local public health teams should work with local homeless service providers to ensure that communication during public health emergencies is accessible and appropriate for People experiencing homelessness. Credibility and providing correct information were key factors in our study. The infodemic during COVID-19 affected the interpretation of what was true and credible. This meant that all information was filtered based on trusted sources and other credibility parameters highlighted in our results to only retain correct information. One previous study found a lack of bidirectional communication as a gap in the linkage of primary health care among People experiencing homelessness (22). While our results did not illuminate unidirectional communication as a barrier to trustworthiness, it warrants consideration in practice. However, we did identify gaps in the communication strategies used in the shelters and highlighted the preferences of the shelter residents and staff. These included addressing and defining who the most effective communicator would be; known medical staff, persons who had experienced homelessness, and known and trusted state or public health officials were all trusted sources identified by shelter residents in our study. Content specific or tailored to People experiencing homelessness was also seen as important, considering that they were already experiencing other challenges and had competing needs. This means that while creating and communicating COVID-19 prevention messages, one needs to weave them into other challenges people face and acknowledge that there are many competing life priorities for People experiencing homelessness beyond COVID-19 vaccines alone and use content that speaks through their current situations. Finally, communication in homeless shelters must be compassionate and non-stigmatizing. People experiencing homelessness still wanted specific and technical information about COVID-19. Stigma about the literacy and mental capacity of People experiencing homelessness meant that many of the communication materials designed for them were not adequate for their questions or needs. Our study had important strengths and limitations. First, the qualitative nature of our data allowed us to hear directly from People experiencing homelessness and work with a variety of shelters representing different age groups, gender identities, and other demographic composition, which likely provides an appropriate representation of the broader population of People experiencing homelessness in Seattle. The primary limitation is the potential for social desirability bias based on COVID-19 vaccination mandates, where participants may have felt the social pressure to report conformity and agreement to public health guidelines and policies. Other limitations included lack of generalizability across different settings dissimilar to Seattle and cross-sectional data collection which may have captured only the current challenges as opposed to the fluid situations and perceptions that the COVID-19 pandemic presented. To mitigate this, we used trauma-informed approaches with experienced interviewers to encourage open engagement. Future research, particularly research involving the health and well-being of People experiencing homelessness or other marginalized populations, should consider a multi-dimensional approach by going beyond individual factors and leveraging social networks. Social networks may have more credibility and influence than outsiders when it comes to information sharing. A community participatory research approach would also enhance collective, reflective, and systematic inquiry of the information to increase acceptance. In practice, communities should proactively include people with lived expertise of homelessness in the development of communication plans and materials to ensure that information and communication is tailored to the needs of People experiencing homelessness, provided through trusted sources, and available and accessible for all. Conclusion Communication in homeless shelters during COVID-19 highlighted multiple challenges with public health information dissemination among marginalized populations. The elements of communication, including the source and recipient, the medium, contextual factors, the message, and feedback, need to take a shape and form that considers the preferences of residents of homeless shelters. Our study highlighted that communication through multiple modalities (print, interpersonal, television/other media), that is consistent in language, describes why information changes, and is reinforced by shelter environments would be preferred and support effective public health messaging that is acceptable and impactful. Declarations Author Contributions HYC wrote the proposal and secured funding for this research, Study design was conducted by HYC, SNC, JHR, NKL, BM, MAF, EJC,EM, NT, ACL, and MAA. NT, SN, JH, ACL, MM and MA conducted data acquisition, read transcripts to ensure completeness. NT, SNC, JH, MM, and AAM coded the transcript and analyzed the data. NT wrote the first draft with input from SNC, MA and AMA. All authors reviewed and edited the manuscript and contributed to the interpretation of results. Ethics Approval The University of Washington Institutional Review Board (STUDY00007800) approved this study. Participants provided informed consent to take part in SSIs and FGDs, with their permission obtained for audio recordings. All data, including field notes, transcripts, and documents linking participants, were securely stored on a restricted-access server at the University of Washington. Gift cards were given to participants as a token of appreciation for their involvement. Consent for publication All Authors provided consent for publication Availability of data and materials Data is provided within the manuscript as tables, figures and quotes Competing interests Helen Y Chu has disclosed consulting engagements with Ellume, AbbVie, Pfizer, and The Bill and Melinda Gates Foundation. Additionally, she has received research funding from Gates Ventures and Sanofi Pasteur, as well as support and reagents from Ellume and Cepheid, unrelated to the submitted work. No other conflicts of interest have been reported. Funding Source: This work was funded by the Centers for Disease Control and Prevention (CDC) through an agreement with the University of Washington. Acknowledgements We extend our gratitude to all residents and staff who participated in the study and to the research assistants who supported data collection. We also thank the shelter program managers for their collaboration in participant recruitment and Public Health Seattle King County for their input on survey design and recruitment. References World Health Organization. Coronavirus (COVID-19) dashboard. https://covid19.who.int/. Accessed January 02, 2024. Lima, N. N. R., de Souza, R. I., Feitosa, P. W. G., de Sousa Moreira, J. L., da Silva, C. G. L., & Neto, M. L. R. (2020). People experiencing homelessness: Their potential exposure to COVID-19. Psychiatry research, 288, 112945. Rodriguez, N. M., Lahey, A. M., MacNeill, J. J., Martinez, R. G., Teo, N. E., & Ruiz, Y. (2021). Homelessness during COVID-19: challenges, responses, and lessons learned from homeless service providers in Tippecanoe County, Indiana. BMC Public Health, 21(1), 1-10. Yoon, J. C., Montgomery, M. P., Buff, A. M., Boyd, A. T., Jamison, C., Hernandez, A., ... & Morris, S. B. (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: an official publication of the Infectious Diseases Society of America. Perri, M., Dosani, N., & Hwang, S. W. (2020). COVID-19 and people experiencing homelessness: challenges and mitigation strategies. Cmaj, 192(26), E716-E719. Khan M, Adil SF, Alkhathlan HZ, Tahir MN, Saif S, Khan M, et al. COVID-19: A Global Challenge with Old History, Epidemiology and Progress So Far. Mol Basel Switz. 2020 Dec 23;26(1):E39. Tobolowsky FA, Gonzales E, Self JL, Rao CY, Keating R, Marx GE, et al. COVID-19 Outbreak Among Three Affiliated Homeless Service Sites - King County, Washington, 2020. MMWR Morb Mortal Wkly Rep. 2020 May 1;69(17):523–6. Ghinai I, Davis ES, Mayer S, Toews KA, Huggett TD, Snow-Hill N, et al. Risk Factors for Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Homeless Shelters in Chicago, Illinois-March-May, 2020. Open Forum Infect Dis. 2020 Nov;7(11):aa477. Baggett TP, Keyes H, Sporn N, Gaeta JM. COVID-19 outbreak at a large homeless shelter in Boston: Implications for universal testing [Internet]. Public and Global Health; 2020 Apr [cited 2022 Aug 24]. Available from: http://medrxiv.org/lookup/doi/10.1101/2020.04.12.20059618 Rogers JH, Link AC, McCulloch D, Brandstetter E, Newman KL, Jackson ML, et al. Characteristics of COVID-19 in Homeless Shelters : A Community-Based Surveillance Study. Ann Intern Med. 2021 Jan;174(1):42–9. Kuhn R, Henwood B, Lawton A, Kleva M, Murali K, King C, et al. COVID-19 vaccine access and attitudes among people experiencing homelessness from a pilot mobile phone survey in Los Angeles, CA. PloS One. 2021;16(7):e0255246. Islam MS, Rahman KM, Sun Y, Qureshi MO, Abdi I, Chughtai AA, et al. Current knowledge of COVID-19 and infection prevention and control strategies in healthcare settings: A global analysis. Infect Control Hosp Epidemiol. 2020 Oct;41(10):1196–206. Chen E, Lerman K, Ferrara E. Tracking Social Media Discourse About the COVID-19 Pandemic: Development of a Public Coronavirus Twitter Data Set. JMIR Public Health Surveill. 2020 May 29;6(2):e19273. Connors WJ, Hussen SA, Holland DP, Mohamed O, Andes KL, Goswami ND. Homeless shelter context and tuberculosis illness experiences during a large outbreak in Atlanta, Georgia. Public Health Action. 2017 Sep 21;7(3):224–30. Klintman M. Knowledge resistance: how we avoid insight from others. Manchester: Manchester University Press; 2021. Mosites E, Harrison B, Montgomery MP, Meehan AA, Leopold J, Barranco L, et al. Public Health Lessons Learned in Responding to COVID-19 Among People Experiencing Homelessness in the United States. Public Health Rep Wash DC 1974. 2022 Aug;137(4):625–9. Swick KJ, Bailey LB. Communicating Effectively with Parents and Families Who Are Homeless. Early Child Educ J. 2004 Dec;32(3):211–5. Mesa Vieira C, Franco OH, Gómez Restrepo C, Abel T. COVID-19: The forgotten priorities of the pandemic. Maturitas. 2020 Jun;136:38–41. C.R. Stennett. Identifying an effective way to communicate with the homeless population. Cox SN, Rogers JH, NB, et al. Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021. Dr R.B. McFee. COVID-19 Laboratory Testing/CDC Guidelines. 2020 Aug 6; Villa S, Jaramillo E, Mangioni D, Bandera A, Gori A, Raviglione MC. Stigma at the time of the COVID-19 pandemic. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2020 Nov;26(11):1450–2. Sabrina Edgington. Disaster planning for people experiencing homelessness Nashville; National health care for the homeless council; 200 Mar. McInnes DK, Li AE, Hogan TP. Opportunities for Engaging Low-Income, Vulnerable Populations in Health Care: A Systematic Review of Homeless Persons’ Access to and Use of Information Technologies. Am J Public Health. 2013 Dec;103(S2):e11–24. Yu ACM, Gadermann A, Palepu A. Strengths, challenges, and gaps in linkage to primary care among hospitalized individuals who are homeless in Vancouver, British Columbia. J Soc Distress Homelessness. 2020 Jul 2;29(2):84–94. Rosenstock IM. The Health Belief Model and Preventive Health Behavior. Health Education Monographs. 1974;2(4):354-386. doi:10.1177/109019817400200405 The Health Belief Model: A Decade Later - Nancy K. Janz, Marshall H. Becker, 1984. Accessed May 3, 2022. https://journals.sagepub.com/doi/10.1177/109019818401100101 MacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036 https://www.who.int/health-topics/infodemic Meehan AA, Cox SN, Thuo NB, et al. Previous Health Care Experiences’ Influence on Current Health Care Perceptions among Residents in Six Homeless Shelters in Seattle, Washington, July-October 2021. Journal of Patient-Centered Research and Reviews, [in press]. July 2023. Cox, S. N., Thuo, N. B., Rogers, J. H., Meehan, A. A., Link, A. C., Martinez, M., ... & Chu, H. Y. (2023). A qualitative analysis of COVID-19 vaccination intent, decision-making, and recommendations to increase uptake among residents and staff in six homeless shelters in Seattle, WA, USA. Journal of Social Distress and Homelessness, 1-13. Cox, S. N., Rogers, J. H., Thuo, N. B., Meehan, A., Link, A. C., Lo, N. K., Manns, B. J., Chow, E. J., Al Achkar, M., Hughes, J. P., Rolfes, M. A., Mosites, E., & Chu, H. Y. (2022). Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021. Vaccine: X, 12, 100232. https://doi.org/10.1016/j.jvacx.2022.100232 Additional Declarations Competing interest reported. Helen Y Chu has disclosed consulting engagements with Ellume, AbbVie, Pfizer, and The Bill and Melinda Gates Foundation. Additionally, she has received research funding from Gates Ventures and Sanofi Pasteur, as well as support and reagents from Ellume and Cepheid, unrelated to the submitted work. No other conflicts of interest have been reported. Funding Source: This work was funded by the Centers for Disease Control and Prevention (CDC) through an agreement with the University of Washington. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 01 May, 2026 Reviews received at journal 20 Apr, 2026 Reviews received at journal 18 Apr, 2026 Reviewers agreed at journal 13 Apr, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviewers agreed at journal 10 Apr, 2026 Reviewers agreed at journal 10 Apr, 2026 Reviews received at journal 23 Mar, 2025 Reviewers agreed at journal 18 Mar, 2025 Reviewers agreed at journal 13 Mar, 2025 Reviewers agreed at journal 10 Mar, 2025 Reviewers invited by journal 02 Mar, 2025 Editor invited by journal 15 Jan, 2025 Editor assigned by journal 14 Jan, 2025 Submission checks completed at journal 14 Jan, 2025 First submitted to journal 10 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-5801586","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401906854,"identity":"444746b2-138f-4378-85c0-bfc605f17a15","order_by":0,"name":"Nicholas Thuo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArklEQVRIiWNgGAWjYDACCQY2IGkDxIyNB4jUwgzSkgbS0kCSlsNgNnFazKX7jz3mqThvt7b9MNCWGptoglos5xxmN+Y5czt525lEoJZjabkNhLQY3Ehmk+Ztu51sdgCohbHhMNFaziWbnX9ImpYDdmY3iLblzmEzyTlnkhPMbgBtSSDKL7cbn0m8qbCzNzuf/vDBhxobwlpgIBGsMoFY5SBgT4riUTAKRsEoGGEAAGV4RPnY8wYfAAAAAElFTkSuQmCC","orcid":"","institution":"University of Washington","correspondingAuthor":true,"prefix":"","firstName":"Nicholas","middleName":"","lastName":"Thuo","suffix":""},{"id":401906855,"identity":"0ae2d509-9a66-43bf-87e4-cf6e3abc8ab4","order_by":1,"name":"Sarah N. Cox","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"N.","lastName":"Cox","suffix":""},{"id":401906856,"identity":"3ccda1d7-fed6-4cb6-b4cf-10a80f48b830","order_by":2,"name":"Julia H. Rogers","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"H.","lastName":"Rogers","suffix":""},{"id":401906857,"identity":"a15a015e-692f-4134-ae88-69f227e2ffa6","order_by":3,"name":"Amy C Link","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Amy","middleName":"C","lastName":"Link","suffix":""},{"id":401906858,"identity":"3a9f58cf-987e-4963-9732-4b0b2cdcc0e0","order_by":4,"name":"Miguel Martinez","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Miguel","middleName":"","lastName":"Martinez","suffix":""},{"id":401906859,"identity":"701c9016-3568-41f3-9979-8dc72630f06a","order_by":5,"name":"Eric J. Chow","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"J.","lastName":"Chow","suffix":""},{"id":401906860,"identity":"8ef668e1-1cf8-425a-9ca4-dfec4ba6cdef","order_by":6,"name":"Ashley A. Meehan","email":"","orcid":"","institution":"Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"A.","lastName":"Meehan","suffix":""},{"id":401906861,"identity":"930e20c0-408d-4071-9ba3-3fa0e85657a3","order_by":7,"name":"Emily Mosites","email":"","orcid":"","institution":"Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Emily","middleName":"","lastName":"Mosites","suffix":""},{"id":401906862,"identity":"bfa0c5d1-561c-4cb9-85c7-3165461f2970","order_by":8,"name":"Brian J Manns","email":"","orcid":"","institution":"Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Brian","middleName":"J","lastName":"Manns","suffix":""},{"id":401906863,"identity":"867ac21e-6e78-4ac8-973a-96bfd01259f0","order_by":9,"name":"Melissa A. Rolfes","email":"","orcid":"","institution":"Centers for Disease Control and Prevention","correspondingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"A.","lastName":"Rolfes","suffix":""},{"id":401906864,"identity":"6c2c9667-62d4-4096-ad73-d522022d689b","order_by":10,"name":"Morhaf Al Achkar","email":"","orcid":"","institution":"Wayne State University","correspondingAuthor":false,"prefix":"","firstName":"Morhaf","middleName":"Al","lastName":"Achkar","suffix":""},{"id":401906865,"identity":"e45cc5b7-eca3-4143-9cc6-5d63d66fa899","order_by":11,"name":"Helen Y Chu","email":"","orcid":"","institution":"University of Washington","correspondingAuthor":false,"prefix":"","firstName":"Helen","middleName":"Y","lastName":"Chu","suffix":""}],"badges":[],"createdAt":"2025-01-10 07:53:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5801586/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5801586/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73899516,"identity":"c107f61b-bb8b-404f-a81e-2db6c70ca912","added_by":"auto","created_at":"2025-01-15 17:08:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":154265,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntra and Extra Shelter information sources and perceptions\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1Publichealthinformationcommunicationpreferencesamongresidentsinsix6KingCountyhomelesssheltersbetweenMarch2020andOctober2021lessonsfromCOVID19pandemic.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5801586/v1/f6b7d62010e5a1374088177d.jpg"},{"id":73900366,"identity":"2e2f2d56-caff-4269-8bda-54c1e2e638bc","added_by":"auto","created_at":"2025-01-15 17:16:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1209941,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5801586/v1/3d19e00a-7e95-4f0c-8f73-5766a4d08d69.pdf"},{"id":73899514,"identity":"05b8ffdb-b2f7-4bbd-b9c0-4793066bc3f2","added_by":"auto","created_at":"2025-01-15 17:08:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":69511,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-5801586/v1/418669d5c3e64fcfce4ba22f.docx"}],"financialInterests":"Competing interest reported. Helen Y Chu has disclosed consulting engagements with Ellume, AbbVie, Pfizer, and The Bill and Melinda Gates Foundation. Additionally, she has received research funding from Gates Ventures and Sanofi Pasteur, as well as support and reagents from Ellume and Cepheid, unrelated to the submitted work. No other conflicts of interest have been reported.\n\nFunding Source: This work was funded by the Centers for Disease Control and Prevention (CDC) through an agreement with the University of Washington.","formattedTitle":"Public health information communication preferences among residents in six (6) King County homeless shelters between March 2020 and October 2021; Lessons from the COVID -19 pandemic","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCOVID-19 is a significant global public health concern, affecting over 760\u0026nbsp;million people worldwide since 2019, and causing over 1.14\u0026nbsp;million deaths in the U.S. as of December 24, 2023. (1). People experiencing homelessness (PEH) have been disproportionately affected by COVID-19 due to a higher risk of severe disease from underlying health conditions, challenges accessing healthcare, and social stigma (2,3). People experiencing homelessness living in shelters were at higher risk for COVID-19 than PEH who were unsheltered, with one study reporting four times higher prevalence of COVID-19 among sheltered People experiencing homelessness (4,9). Crowded living conditions and shared facilities in shelters made it challenging to enforce physical distancing and quarantine or isolation measures (4,5). For a population experiencing overlapping social disadvantages, it is of paramount importance to clearly communicate rapidly changing information and implement public health recommendations (17\u0026ndash;19).\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic was accompanied by widespread misinformation about topics such as the disease, transmission, vaccine safety, risk of infection, and utility of masking in what has now been termed an \u0026ldquo;infodemic\u0026rdquo; (29) of unprecedented proportions and implications. Knowledge and perception of COVID-19 severity have been shown to differ based on settings and behaviours (11, 12, 13, 15). Shelters commonly employ communication strategies to inform residents about numerous infectious disease risks, but their effectiveness in countering misinformation remains uncertain (13). A study conducted in the context of a tuberculosis outbreak found that education efforts in the shelter were minimally engaging and led to increased stress among shelter residents (14).\u003c/p\u003e \u003cp\u003eTo ensure public health prevention strategies are implemented effectively, it is important to understand the mechanisms and pathways for COVID-19 information-sharing among shelter residents and examine communication strategies that maximise utility and reach. This study used qualitative methods to explore information communication in shelter settings and explore shelters' approaches to inform their residents about COVID-19. The primary objective was to understand how shelter residents perceive shelter communication including approaches, delivery and content, and to identify what could be done to improve the flow and effectiveness of communication to residents.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eBetween July and October 2021, we conducted qualitative semi-structured interviews ('interviews') and focus group discussions ('focus groups') in six homeless shelters that were strategically selected across Seattle-King County, WA to be socio-demographically representative of King County's sheltered People experiencing homelessness (30). The six shelters in this qualitative study included two mixed-gender adult shelters, two family shelters, one all-male older adult shelter (aged\u0026thinsp;\u0026ge;\u0026thinsp;50 years), and one young adult shelter (aged 18\u0026ndash;25 years). Individuals aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years whose primary residence or place of employment was at one of these six shelters were eligible for participation in the semi-structured interviews only. Shelter residents aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years who had not previously participated in interviews were eligible for participation in focus groups.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003eStudy methods, including participant recruitment, have been described in depth elsewhere (31). Participants, residents and staff, were identified for interviews through a prior quantitative survey to capture a representative sample of individuals with diverse COVID-19 vaccine attitudes and demographics (32). Convenience sampling was used to identify and recruit residents for focus group participants who had not already participated in an interview. Invitations to participate in interviews were based on efforts to ensure diversity across different racial and ethnic minority groups, gender identities, individuals with or without children, non-English speakers, and self-reported COVID-19 vaccine attitudes reported on previous shelter surveys (31) .\u003c/p\u003e\n\u003ch3\u003eData sources and collection\u003c/h3\u003e\n\u003cp\u003eWe developed interview and focus group guides in partnership with Public Health Seattle-King County and people with lived experience of homelessness. We focused on confidence in COVID-19 communication and how various factors influenced this confidence. The guides were informed by the Health Belief Model and the Confidence, Complacency, Convenience Model of Vaccine Hesitancy (23,24,25,26, 27, 28, 31). Interview guides were translated into Spanish, French, Amharic, and Tigrinya. Interviews were conducted one-on-one with an experienced interviewer and focus groups were conducted by a moderator and a notetaker. The discussions took place in private rooms in the participating homeless shelters. Two shelters conducted one focus group each and three shelters conducted two focus groups each. We were unable to conduct a focus group at one shelter given a COVID-19 outbreak. In the focus groups at family shelters, children of participants were allowed to be present and listen. All interviews and focus groups were audio-recorded and translated from the original language to English, when necessary, by a transcription service (Dynamic Language) every other week.\u003c/p\u003e\n\u003ch3\u003eAnalysis and positionality\u003c/h3\u003e\n\u003cp\u003eWe conducted thematic analysis using Dedoose Version 9.0.17. The analysis team developed the codebook collectively using both deductive and inductive approaches. To ensure consistent understanding and use of the codebook, the first four interview transcripts and the first two focus group transcripts were coded in pairs. Approximately one-third of additional transcripts (36%, n\u0026thinsp;=\u0026thinsp;12/33) were peer-reviewed by another coder. Coders met one to two times per week to discuss coding questions and interpretations to reach a consensus with oversight and support from a qualitative Principal Investigator. To ensure our themes were true to our data, we selected multiple quotes to support each identified theme. Themes were refined by group discussion and final reflective quotes were selected by group consensus. Coding was done as transcripts were made available, allowing for quick analysis and modification of guides in real time to capture any missing elements.\u003c/p\u003e \u003cp\u003eThe study team acknowledges the role that our socioeconomic positions and experiences may have contributed to data presentation and interpretation. Among team members, there were some familial and personal lived experiences of homelessness, as well as extensive experience conducting public health practice to improve health equity in Seattle-King County that helped to minimize potential bias. The entire team was also sensitized in trauma-informed interviewing techniques and debriefed after interviews. The coding team consisted of four team members, each with a master\u0026rsquo;s degree in public health. One research team member was affiliated with the Centers for Disease Control and Prevention (CDC), and three were affiliated with the University of Washington (UW), Seattle, Washington. The researchers had prior experience in qualitative research and coding, and three researchers had previously participated in data collection at shelter sites.\u003c/p\u003e\n\u003ch3\u003eEthics\u003c/h3\u003e\n\u003cp\u003e The Human Subjects Division of the UW Institutional Review Board approved this study (STUDY00007800) and the CDC relied upon this approval. All participants provided electronic informed consent captured through the research data capture software (REDCap). To ensure confidentiality, all data were de-identified and stored securely using participant identity (PTID) numbers. Information directly identifying shelters by name was masked.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003e1. Participant characteristics\u003c/h2\u003e\n \u003cp\u003eWe conducted 31 interviews with 25 residents and six staff members, and eight focus groups with 43 residents [Table\u0026nbsp;1]. Interviews lasted from 10 to 90 minutes (average 44 minutes), and focus groups lasted from 52 to 111 minutes (average 68 minutes). More than half of participants (n\u0026thinsp;=\u0026thinsp;40, 54%) of both interviews and focus groups were aged 18\u0026ndash;49 years. We recruited 21 interviewees from a previous quantitative survey (32). Participants mostly identified as cisgender men (n\u0026thinsp;=\u0026thinsp;43, 58%), White (n\u0026thinsp;=\u0026thinsp;30, 41%) or Black/African American (n\u0026thinsp;=\u0026thinsp;26, 35%). A few participants (n\u0026thinsp;=\u0026thinsp;7, 9%) identified as Hispanic or Latinx, and (n\u0026thinsp;=\u0026thinsp;2, 3%) spoke Spanish as their primary language.\u003c/p\u003e\n \u003cdiv\u003e\u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003e2. Mapping shelter COVID-19 communication flow\u003c/h3\u003e\n\u003cp\u003eWe developed a communication flow diagram from resident and staff responses to COVID-19 information (i.e., how they received information from external and internal sources, and how it was filtered) [\u003cstrong\u003eFigure 1\u003c/strong\u003e]. Through data analysis, we identified three key elements that described content, delivery, channels, and partnerships and present them as: 1) COVID-19 information sources, 2) trust and mistrust of sources, and 3) communication preferences. Participants described how information flowed from external and internal sources through technology, print materials, and interpersonal communication, and was assessed by receivers based on trustworthiness, objectivity and honesty, consistency, and compassion. These themes are presented in more detail in the following section, with illustrative quotes in Tables\u0026nbsp;2, 3 and 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1: Intra and Extra Shelter information sources and perceptions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(figure attached)\u003c/p\u003e\n\u003cdiv id=\"Sec11\"\u003e\n \u003ch2\u003e3. COVID-19 information sources\u003c/h2\u003e\n \u003cp\u003eInterviews about COVID-19 information sources used by residents and staff of homeless shelters identified both shelter-specific internal information sources and external information sources (\u003cstrong\u003eTable\u0026nbsp;2: Internal and External Sources of information among shelter residents and staff)\u003c/strong\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\"\u003e\n \u003ch2\u003e3.1. External shelter sources:\u003c/h2\u003e\n \u003cp\u003eExternal sources were reported as those not managed or controlled by the shelter staff or management. These sources were classified as either physical or electronic sources. The interaction with these sources was unstructured and relied on the individual\u0026rsquo;s ability to access or interact with these information sources. Examples of external sources included external healthcare providers, government agencies, public media networks and print materials.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\"\u003e\n \u003ch2\u003e3.2. Internal shelter sources:\u003c/h2\u003e\n \u003cp\u003eInternal sources were reported as those tailored to provide information to residents through the shelter staff using various channels (e.g., in-person meetings, posters, announcements). The sources were selected by the management of the shelters and shared with the staff for onward communication to residents.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\"\u003e\n \u003ch2\u003e3.2.1. Shelter management to staff:\u003c/h2\u003e\n \u003cp\u003eShelter managers established specific communication channels to educate and orient staff on COVID-19 and prevention measures, including community meetings, distributing flyers and brochures, holding one-on-one meetings with staff, and putting up posters on walls.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\"\u003e\n \u003ch2\u003e3.2.2. Shelter staff to residents:\u003c/h2\u003e\n \u003cp\u003eShelter staff used community meetings, posters, one-on-one sessions between shelter staff and residents, and third-party health providers in the shelter to provide information and updates on policies to residents.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\"\u003e\n \u003ch2\u003e4.0 Reasons for trust: Perceptions of COVID-19 information sources and content\u003c/h2\u003e\n \u003cdiv id=\"Sec17\"\u003e\n \u003ch2\u003e4.1 Factors influencing trustworthiness of sources\u003c/h2\u003e\n \u003cp\u003eThe following factors were found to influence how trustworthy participants deemed COVID-19 information sources based on resident views and staff perceptions with quotes available in Appendix (\u003cstrong\u003eTable\u0026nbsp;3\u003c/strong\u003e: \u003cstrong\u003eFactors influencing trustworthiness of sources of information )\u003c/strong\u003e .\u003c/p\u003e\n \u003cp\u003e4.1.1\u0026nbsp;\u003cem\u003eProxy trust (trusted because others trust them)\u003c/em\u003e: Participants reported having trust in individuals as a source, such as family and friends, who were held in high esteem by other people with whom they already had a trust relationship, and were considered to be informed or trained.\u003cbr\u003e4.1.2\u0026nbsp;\u003cem\u003eProvides useful information\u003c/em\u003e: Participants reported having trust in sources of information viewed as practical, relatable, and implementable. Such information was further reported as easy to understand and execute within the shelter setting.\u003cbr\u003e4.1.3\u0026nbsp;\u003cem\u003eProven\u003c/em\u003e: Participants reported having trust in a source that had provided helpful and accurate health information in the past, or any information source that had been shared in the past that turned out to be true.\u003cbr\u003e4.1.4\u0026nbsp;\u003cem\u003eObjective\u003c/em\u003e: Participants reported having trust in sources that were perceived to be objective, including individuals presenting information anchored in verifiable data. Determination of objectivity was rooted in professional qualifications and the provision of evidence to support the information. Evidence was critical whether provided by an individual or accessed electronically in supporting this perception.\u003cbr\u003e4.1.5\u0026nbsp;\u003cem\u003eHonest\u003c/em\u003e: Participants reported that previous healthcare interactions marked by honest communication improved trust. If a healthcare provider had provided information that was confirmed to be true and helped an individual, the trust was established and carried into the reception of COVID-19 information.\u003cbr\u003e4.1.6\u0026nbsp;\u003cem\u003eHas training, experience, and authority in the topic\u003c/em\u003e: Participants reported having trust in individuals as sources of information if they perceived the individual as having enough experience and practical knowledge on the topic, particularly healthcare providers. Healthcare providers with known training or titles perceived as prestigious (such as \u0026ldquo;doctor\u0026rdquo;) that conveyed the person\u0026rsquo;s training were perceived as more trustworthy as they had the necessary education. This was also highlighted in instances where individuals independently accessed information in other forms that were attributed to professionals with these attributes.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\"\u003e\n \u003ch2\u003e4.2 Factors influencing trustworthiness of content\u003c/h2\u003e\n \u003cp\u003eCommunicated content with the following attributes were reported to be trusted and \u0026ldquo;embraced\u0026rdquo; by shelter residents:\u003c/p\u003e\n \u003cp\u003e4.2.1\u0026nbsp;\u003cem\u003eWell thought out\u003c/em\u003e: Information that was perceived as well-reasoned or anchored in logic and resonating with the recipients\u0026rsquo; beliefs and understanding was more likely to be trusted. Many resources that had very little information, or very surface level information, were deemed not well thought out, and people were unable to determine the rationale of why the information was being recommended or provided. Materials with background information and opportunities to learn more were well-received.\u003cbr\u003e4.2.2\u0026nbsp;\u003cem\u003eConsistent\u003c/em\u003e: Information that was uniform in content and meaning and was shared regularly was considered trustworthy. With new information being reported almost daily, maintaining a consistent storyline was seen as a sign of being trustworthy.\u003cbr\u003e4.2.3\u0026nbsp;\u003cem\u003eClear\u003c/em\u003e: Presentations in written form that were easy to understand and clear were trusted. Open, simple communication without misleading wording was trusted.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\"\u003e\n \u003ch2\u003e5.0. Reasons for mistrust: Perceptions of COVID-19 information sources and content\u003c/h2\u003e\n \u003cp\u003eParticipants reported that sources were assessed based on whether the information they provided was clear and candid. The following perceptions affected how a source was perceived:\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\"\u003e\n \u003ch2\u003e5.1 Perceptions on the credibility of the information source\u003c/h2\u003e\n \u003cp\u003e5.1.1\u0026nbsp;\u003cem\u003eHas contradictory, changing, or \u0026lsquo;fake\u0026rsquo; information\u003c/em\u003e: participants reported that being provided inconsistent information was considered a sign of being untrustworthy. Sources were expected to provide information that matched earlier information or could be logically linked to past information.\u003cbr\u003e5.1.2\u0026nbsp;\u003cem\u003eWithholds information\u003c/em\u003e: participants reported that if a source was perceived to not provide all the information available, the legitimacy of the information was questioned. The frequently changing recommendations and information led people to believe that certain pieces of information were being withheld, making it difficult to trust the information.\u003cbr\u003e5.1.3\u0026nbsp;\u003cem\u003eDeception\u003c/em\u003e: participants reported that when they felt that the information provided was not anchored in what they perceived as truth, they concluded that they were intentionally being deceived. Participants described how perceptions of deception were driven by interpersonal relationships and political views. Sources deemed as \u0026ldquo;deceptive\u0026rdquo; were considered untrustworthy.\u003cbr\u003e5.1.4\u0026nbsp;\u003cem\u003eIn it for the money\u003c/em\u003e: information presented to participants when viewed as being shared with the intention of making a profit was not trusted. Products specifically marketed and sold as tools to prevent the spread of COVID-19 were questioned for not having peoples\u0026rsquo; actual needs in mind, only seeking to make money.\u003cbr\u003e\u003cstrong\u003e5.2 Shelter communication presentation and approach.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eThe following situations and attributes contributed to perceptions of untrustworthiness based on how it was communicated:\u003c/p\u003e\n \u003cp\u003e5.2.1\u0026nbsp;\u003cem\u003eUnseen or unnoticed\u003c/em\u003e: some residents reported that information was sometimes shared in their absence and they did not directly receive the information. This led to concerns about information received through third parties, including other residents or friends in the shelter. This was attributed to poor timing on the part of the shelter.\u003cbr\u003e5.2.2\u0026nbsp;\u003cem\u003eLacked compassion\u003c/em\u003e: residents did not trust any information that lacked empathy and showed either a disregard for their issues or prioritised the issue of COVID-19 above their personal needs.\u003cbr\u003e5.2.3\u0026nbsp;\u003cem\u003eContradictory guidance\u003c/em\u003e: when different shelter staff gave updates that contradicted updates shared previously by other staff members, residents felt that they could not trust shelter staff because they provided contradictory guidance. This challenge was partly due to the rapidly changing information that was difficult to keep up with.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\"\u003e\n \u003ch2\u003e6.0 Preferences regarding information and communication of information among People experiencing homelessness\u003c/h2\u003e\n \u003cp\u003eWhen asked about preferences for receiving information and communications about COVID-19, PEH provided details of preferred channels, reporter characteristics, and manner of delivery (\u003cstrong\u003eTable\u0026nbsp;4: Preferred channels, reporter characteristics, and manner of delivery: People Experiencing Homelessness preferences in illustrative quotes.\u003c/strong\u003e).\u003c/p\u003e\n \u003cp\u003eThese included:\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\"\u003e\n \u003ch2\u003e6.1. COVID-19 Content attributes\u003c/h2\u003e\n \u003cp\u003eInformation that was to be shared with People experiencing homelessness needed to be in a form that could be understood and verified. PEH reported that the content should be:\u003c/p\u003e\n \u003cp\u003e6.1.1\u0026nbsp;\u003cem\u003eConsistent and reliable\u003c/em\u003e: information that would remain unchanged and shared regularly was considered trustworthy and more acceptable and useful.\u003cbr\u003e6.1.2\u0026nbsp;\u003cem\u003eObjective\u003c/em\u003e: the content should not appear to be biased in any way that appears to favour one political, social, or religious leaning. Instead, information should be anchored in verifiable data that people can directly explore themselves.\u003cbr\u003e6.1.3\u0026nbsp;\u003cem\u003eSimple\u003c/em\u003e: information should be synthesized into accessible language that is easy to understand and not requiring further interpretation. This would include the use of non-scientific language and translation of print products to other commonly spoken languages.\u003c/p\u003e\n \u003cdiv id=\"Sec23\"\u003e\n \u003ch2\u003e6.2. Delivery of information\u003c/h2\u003e\n \u003cp\u003ePeople experiencing homelessness expressed that information should be communicated to them in a manner that is acceptable, in a form that reflects their dignity and be delivered by persons to whom they can relate. This includes delivering information with the following traits:\u003c/p\u003e\n \u003cp\u003e6.2.1 \u003cem\u003eCompassionate\u003c/em\u003e: Delivery of information needs to be in an empathetic manner that appeals not only to the intellect but to the hearts and minds of People experiencing homelessness 6.2.2\u0026nbsp;\u003cem\u003ePerson-centred\u003c/em\u003e (Centered on the individual\u0026apos;s well-being and requirements): In the context of a shelter, the information shared and how it is shared should be in a form that takes into consideration the unique issues surrounding People experiencing homelessness. This would also include providing possible connections to other needs people have. For example, asking shelter residents to receive COVID-19 testing or vaccination, but not providing them with food or connecting them to other social or medical care indicated that peoples\u0026rsquo; daily life needs were not considered or accounted for.\u003cbr\u003e6.2.3\u0026nbsp;\u003cem\u003eInclusive team\u003c/em\u003e: Teams delivering information need to have representation rom People experiencing homelessness who can understand and articulate their issues. Receiving information from a person who had experienced or was currently experiencing homelessness was viewed as part of the community and more likely to be trusted.\u003cbr\u003e6.2.4\u0026nbsp;\u003cem\u003eEnsure everyone is reached\u003c/em\u003e: Communication should take into consideration the availability of residents and how it can reach them in an appropriate and timely manner. This would include the timing of community sessions and the use of media that most people had access to. Offering multiple information sessions at different days and times on the same topic would help ensure everyone can receive the same information from the same source, not relying on hearing things from others or \u0026ldquo;through the grapevine.\u0026rdquo;\u003cbr\u003e6.2.5\u0026nbsp;\u003cem\u003eIncentives appreciated\u003c/em\u003e: Provision of incentives in the form of gift cards were helpful to residents as they allowed them to fulfil other needs, while receiving a service (information, vaccination) they needed.\u003c/p\u003e\u003cbr\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this qualitative study, we gained valuable insight into how homeless shelter residents in Seattle, Washington used a variety of sources internal and external to their shelter to receive information about COVID-19 within an environment that was reportedly higher risk. Implementing public health messages that are both clear and concise, specifically tailored to the unique circumstances of people experiencing homelessness, emerged as a potent strategy to enhance communication effectiveness between shelters and their residents. We identified sources of information that People experiencing homelessness utilized, factors associated with perceived trustworthiness of information, and drivers of successful communication delivery. While residents utilized multiple sources for their information, not all sources were equally trusted. Residents valued information that came from family members who were knowledgeable and respected. They also looked for information that was practical, reliable, objective, honest, and easy to implement. Information that was perceived as inconsistent or contradictory to previous recommendations led to doubt and mistrust of the information. Additionally, residents thought that some information sources had hidden agendas, primarily seen as using the COVID-19 pandemic to make money. Residents appreciated information and communication that was simple, reliable, person-centred, and accessible to everyone in the shelter.\u003c/p\u003e \u003cp\u003eDuring the COVID-19 pandemic, the CDC provided recommendations on how to make COVID-19 prevention content inclusive for People experiencing homelessness, including using a variety of communication channels and ensuring that recommendation language was not stigmatizing (19). Preferences reported by People experiencing homelessness in our study support these recommendations. Additionally, National Health Care for the Homeless Council's (2009) guidance on disaster preparedness noted the challenge of using written material for communication and recommended a more personal approach to providing information (20). Utilizing more person-centered communication strategies would allow interaction, discussion, and clarification of issues raised.\u003c/p\u003e \u003cp\u003eReaching shelter residents when they were most available was also an important tool for delivering information. Stennett et al. found that communicating information during group functions like mealtimes was more likely to reach more people (16). Elsewhere, the use of technology such as mobile phones and computers showed an opportunity to address community health-related issues among People experiencing homelessness and other marginalized groups (21). In addition to being first, being right, and being credible in communications during public health emergencies, additional considerations should be made when communicating with people in homeless shelters (12,16). Local public health teams should work with local homeless service providers to ensure that communication during public health emergencies is accessible and appropriate for People experiencing homelessness.\u003c/p\u003e \u003cp\u003eCredibility and providing correct information were key factors in our study. The infodemic during COVID-19 affected the interpretation of what was true and credible. This meant that all information was filtered based on trusted sources and other credibility parameters highlighted in our results to only retain correct information. One previous study found a lack of bidirectional communication as a gap in the linkage of primary health care among People experiencing homelessness (22). While our results did not illuminate unidirectional communication as a barrier to trustworthiness, it warrants consideration in practice. However, we did identify gaps in the communication strategies used in the shelters and highlighted the preferences of the shelter residents and staff. These included addressing and defining who the most effective communicator would be; known medical staff, persons who had experienced homelessness, and known and trusted state or public health officials were all trusted sources identified by shelter residents in our study. Content specific or tailored to People experiencing homelessness was also seen as important, considering that they were already experiencing other challenges and had competing needs. This means that while creating and communicating COVID-19 prevention messages, one needs to weave them into other challenges people face and acknowledge that there are many competing life priorities for People experiencing homelessness beyond COVID-19 vaccines alone and use content that speaks through their current situations.\u003c/p\u003e \u003cp\u003eFinally, communication in homeless shelters must be compassionate and non-stigmatizing. People experiencing homelessness still wanted specific and technical information about COVID-19. Stigma about the literacy and mental capacity of People experiencing homelessness meant that many of the communication materials designed for them were not adequate for their questions or needs.\u003c/p\u003e \u003cp\u003eOur study had important strengths and limitations. First, the qualitative nature of our data allowed us to hear directly from People experiencing homelessness and work with a variety of shelters representing different age groups, gender identities, and other demographic composition, which likely provides an appropriate representation of the broader population of People experiencing homelessness in Seattle. The primary limitation is the potential for social desirability bias based on COVID-19 vaccination mandates, where participants may have felt the social pressure to report conformity and agreement to public health guidelines and policies. Other limitations included lack of generalizability across different settings dissimilar to Seattle and cross-sectional data collection which may have captured only the current challenges as opposed to the fluid situations and perceptions that the COVID-19 pandemic presented. To mitigate this, we used trauma-informed approaches with experienced interviewers to encourage open engagement. Future research, particularly research involving the health and well-being of People experiencing homelessness or other marginalized populations, should consider a multi-dimensional approach by going beyond individual factors and leveraging social networks. Social networks may have more credibility and influence than outsiders when it comes to information sharing. A community participatory research approach would also enhance collective, reflective, and systematic inquiry of the information to increase acceptance. In practice, communities should proactively include people with lived expertise of homelessness in the development of communication plans and materials to ensure that information and communication is tailored to the needs of People experiencing homelessness, provided through trusted sources, and available and accessible for all.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCommunication in homeless shelters during COVID-19 highlighted multiple challenges with public health information dissemination among marginalized populations. The elements of communication, including the source and recipient, the medium, contextual factors, the message, and feedback, need to take a shape and form that considers the preferences of residents of homeless shelters. Our study highlighted that communication through multiple modalities (print, interpersonal, television/other media), that is consistent in language, describes why information changes, and is reinforced by shelter environments would be preferred and support effective public health messaging that is acceptable and impactful.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHYC wrote the proposal and secured funding for this research, Study design was conducted by HYC, SNC, JHR, NKL, BM, MAF, EJC,EM, NT, ACL, \u0026nbsp;and MAA. \u0026nbsp;NT, SN, JH, ACL, MM and MA conducted data acquisition, read transcripts to ensure completeness. NT, SNC, JH, MM, and \u0026nbsp;AAM coded the transcript and analyzed the data. \u0026nbsp;NT wrote the first draft with input from SNC, MA and AMA. All authors reviewed and edited the manuscript and contributed to the interpretation of results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of Washington Institutional Review Board (STUDY00007800) approved this study. Participants provided informed consent to take part in SSIs and FGDs, with their permission obtained for audio recordings. All data, including field notes, transcripts, and documents linking participants, were securely stored on a restricted-access server at the University of Washington. Gift cards were given to participants as a token of appreciation for their involvement.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eAll \u0026nbsp;Authors provided consent \u0026nbsp;for publication\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript as tables, figures and quotes\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eHelen Y Chu has disclosed consulting engagements with Ellume, AbbVie, Pfizer, and The Bill and Melinda Gates Foundation. Additionally, she has received research funding from Gates Ventures and Sanofi Pasteur, as well as support and reagents from Ellume and Cepheid, unrelated to the submitted work. No other conflicts of interest have been reported.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Source:\u003c/strong\u003e This work was funded by the Centers for Disease Control and Prevention (CDC) through an agreement with the University of Washington.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our gratitude to all residents and staff who participated in the study and to the research assistants who supported data collection. We also thank the shelter program managers for their collaboration in participant recruitment and Public Health Seattle King County for their input on survey design and recruitment.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Coronavirus (COVID-19) dashboard. https://covid19.who.int/. Accessed January 02, 2024.\u003c/li\u003e\n\u003cli\u003eLima, N. N. R., de Souza, R. I., Feitosa, P. W. G., de Sousa Moreira, J. L., da Silva, C. G. L., \u0026amp; Neto, M. L. R. (2020). People experiencing homelessness: Their potential exposure to COVID-19. Psychiatry research, 288, 112945.\u003c/li\u003e\n\u003cli\u003eRodriguez, N. M., Lahey, A. M., MacNeill, J. J., Martinez, R. G., Teo, N. E., \u0026amp; Ruiz, Y. (2021). Homelessness during COVID-19: challenges, responses, and lessons learned from homeless service providers in Tippecanoe County, Indiana. BMC Public Health, 21(1), 1-10.\u003c/li\u003e\n\u003cli\u003eYoon, J. C., Montgomery, M. P., Buff, A. M., Boyd, A. T., Jamison, C., Hernandez, A., ... \u0026amp; Morris, S. B. (2020). COVID-19 prevalence among people experiencing homelessness and homelessness service staff during early community transmission in Atlanta, Georgia, April\u0026ndash;May 2020. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America.\u003c/li\u003e\n\u003cli\u003ePerri, M., Dosani, N., \u0026amp; Hwang, S. W. (2020). COVID-19 and people experiencing homelessness: challenges and mitigation strategies. Cmaj, 192(26), E716-E719.\u003c/li\u003e\n\u003cli\u003eKhan M, Adil SF, Alkhathlan HZ, Tahir MN, Saif S, Khan M, et al. COVID-19: A Global Challenge with Old History, Epidemiology and Progress So Far. Mol Basel Switz. 2020 Dec 23;26(1):E39.\u003c/li\u003e\n\u003cli\u003eTobolowsky FA, Gonzales E, Self JL, Rao CY, Keating R, Marx GE, et al. COVID-19 Outbreak Among Three Affiliated Homeless Service Sites - King County, Washington, 2020. MMWR Morb Mortal Wkly Rep. 2020 May 1;69(17):523\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGhinai I, Davis ES, Mayer S, Toews KA, Huggett TD, Snow-Hill N, et al. Risk Factors for Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Homeless Shelters in Chicago, Illinois-March-May, 2020. Open Forum Infect Dis. 2020 Nov;7(11):aa477.\u003c/li\u003e\n\u003cli\u003eBaggett TP, Keyes H, Sporn N, Gaeta JM. COVID-19 outbreak at a large homeless shelter in Boston: Implications for universal testing [Internet]. Public and Global Health; 2020 Apr [cited 2022 Aug 24]. Available from: http://medrxiv.org/lookup/doi/10.1101/2020.04.12.20059618\u003c/li\u003e\n\u003cli\u003eRogers JH, Link AC, McCulloch D, Brandstetter E, Newman KL, Jackson ML, et al. Characteristics of COVID-19 in Homeless Shelters : A Community-Based Surveillance Study. Ann Intern Med. 2021 Jan;174(1):42\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKuhn R, Henwood B, Lawton A, Kleva M, Murali K, King C, et al. COVID-19 vaccine access and attitudes among people experiencing homelessness from a pilot mobile phone survey in Los Angeles, CA. PloS One. 2021;16(7):e0255246.\u003c/li\u003e\n\u003cli\u003eIslam MS, Rahman KM, Sun Y, Qureshi MO, Abdi I, Chughtai AA, et al. Current knowledge of COVID-19 and infection prevention and control strategies in healthcare settings: A global analysis. Infect Control Hosp Epidemiol. 2020 Oct;41(10):1196\u0026ndash;206.\u003c/li\u003e\n\u003cli\u003eChen E, Lerman K, Ferrara E. Tracking Social Media Discourse About the COVID-19 Pandemic: Development of a Public Coronavirus Twitter Data Set. JMIR Public Health Surveill. 2020 May 29;6(2):e19273.\u003c/li\u003e\n\u003cli\u003eConnors WJ, Hussen SA, Holland DP, Mohamed O, Andes KL, Goswami ND. Homeless shelter context and tuberculosis illness experiences during a large outbreak in Atlanta, Georgia. Public Health Action. 2017 Sep 21;7(3):224\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eKlintman M. Knowledge resistance: how we avoid insight from others. Manchester: Manchester University Press; 2021.\u003c/li\u003e\n\u003cli\u003eMosites E, Harrison B, Montgomery MP, Meehan AA, Leopold J, Barranco L, et al. Public Health Lessons Learned in Responding to COVID-19 Among People Experiencing Homelessness in the United States. Public Health Rep Wash DC 1974. 2022 Aug;137(4):625\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSwick KJ, Bailey LB. Communicating Effectively with Parents and Families Who Are Homeless. Early Child Educ J. 2004 Dec;32(3):211\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eMesa Vieira C, Franco OH, G\u0026oacute;mez Restrepo C, Abel T. COVID-19: The forgotten priorities of the pandemic. Maturitas. 2020 Jun;136:38\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eC.R. Stennett. Identifying an effective way to communicate with the homeless population.\u003c/li\u003e\n\u003cli\u003eCox SN, Rogers JH, NB, et al. Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021.\u003c/li\u003e\n\u003cli\u003eDr R.B. McFee. COVID-19 Laboratory Testing/CDC Guidelines. 2020 Aug 6;\u003c/li\u003e\n\u003cli\u003eVilla S, Jaramillo E, Mangioni D, Bandera A, Gori A, Raviglione MC. Stigma at the time of the COVID-19 pandemic. Clin Microbiol Infect Off Publ Eur Soc Clin Microbiol Infect Dis. 2020 Nov;26(11):1450\u0026ndash;2.\u003c/li\u003e\n\u003cli\u003eSabrina Edgington. Disaster planning for people experiencing homelessness Nashville; National health care for the homeless council; 200 Mar.\u003c/li\u003e\n\u003cli\u003eMcInnes DK, Li AE, Hogan TP. Opportunities for Engaging Low-Income, Vulnerable Populations in Health Care: A Systematic Review of Homeless Persons\u0026rsquo; Access to and Use of Information Technologies. Am J Public Health. 2013 Dec;103(S2):e11\u0026ndash;24.\u003c/li\u003e\n\u003cli\u003eYu ACM, Gadermann A, Palepu A. Strengths, challenges, and gaps in linkage to primary care among hospitalized individuals who are homeless in Vancouver, British Columbia. J Soc Distress Homelessness. 2020 Jul 2;29(2):84\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003eRosenstock IM. The Health Belief Model and Preventive Health Behavior. Health Education Monographs. 1974;2(4):354-386. doi:10.1177/109019817400200405\u003c/li\u003e\n\u003cli\u003eThe Health Belief Model: A Decade Later - Nancy K. Janz, Marshall H. Becker, 1984. Accessed May 3, 2022. https://journals.sagepub.com/doi/10.1177/109019818401100101\u003c/li\u003e\n\u003cli\u003eMacDonald NE. Vaccine hesitancy: Definition, scope and determinants. Vaccine. 2015;33(34):4161-4164. doi:10.1016/j.vaccine.2015.04.036\u003c/li\u003e\n\u003cli\u003ehttps://www.who.int/health-topics/infodemic\u003c/li\u003e\n\u003cli\u003eMeehan AA, Cox SN, Thuo NB, et al. Previous Health Care Experiences\u0026rsquo; Influence on Current Health Care Perceptions among Residents in Six Homeless Shelters in Seattle, Washington, July-October 2021. Journal of Patient-Centered Research and Reviews, [in press]. July 2023.\u003c/li\u003e\n\u003cli\u003eCox, S. N., Thuo, N. B., Rogers, J. H., Meehan, A. A., Link, A. C., Martinez, M., ... \u0026amp; Chu, H. Y. (2023). A qualitative analysis of COVID-19 vaccination intent, decision-making, and recommendations to increase uptake among residents and staff in six homeless shelters in Seattle, WA, USA. Journal of Social Distress and Homelessness, 1-13.\u003c/li\u003e\n\u003cli\u003eCox, S. N., Rogers, J. H., Thuo, N. B., Meehan, A., Link, A. C., Lo, N. K., Manns, B. J., Chow, E. J., Al Achkar, M., Hughes, J. P., Rolfes, M. A., Mosites, E., \u0026amp; Chu, H. Y. (2022). Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021. Vaccine: X, 12, 100232. https://doi.org/10.1016/j.jvacx.2022.100232\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, Homeless Shelters, Communication Strategies, People Experiencing Homelessness, Trust and Mistrust","lastPublishedDoi":"10.21203/rs.3.rs-5801586/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5801586/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e \u003cp\u003eAn unforeseen outcome of the COVID-19 pandemic was the unprecedented proliferation of misinformation, commonly termed as an 'infodemic.' This had extensive repercussions, including a reduced ability for homeless shelters to effectively convey accurate information to their residents, who have specific needs as persons experiencing homelessness. We sought to better understand approaches used by shelters to inform residents(people experiencing homelessness) about COVID-19, how the information was perceived, and how to improve communication strategies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted semi-structured interviews and focus group discussions across six homeless shelters in King County, Washington between July and October 2021. We systematically selected residents and staff aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years for interviews and recruited a convenience sample of residents aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years who had not participated in the interviews for focus group discussions. We used a conceptual model informed by the Health Belief Model and the Confidence, Complacency, Convenience Model of Vaccine Hesitancy to understand factors influencing shelter residents\u0026rsquo; COVID-19 information choices, perceptions, and experiences with shelter-specific communication. Thematic analysis was conducted using Dedoose.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe conducted interviews with 25 shelter residents, six shelter staff, and eight focus groups with 43 residents. Residents reported that they received COVID-19 information from internal homeless shelter sources and external sources. Internal sources included shelter staff and residents; external sources included family, friends, healthcare providers, and other physical and online resources. Participants selected information sources based on perceived usefulness, objectivity, and trustworthiness, and if the sources were viewed as authorities on COVID-19. Shelter management was instrumental in disseminating COVID-19 information by providing staff with up-to-date COVID-19 information during meetings and sharing online and printed resources. Staff then utilized established channels to share the information with residents, including through individual and group verbal communication, posters, and flyers that were distributed to residents. While some of the shelter-provided information was perceived as well-informed, consistent, and visible, some residents reported that information was not well delivered, lacked compassion, and did not reach all residents. Shelter residents preferred communication that was simple, clear, and compassionate, and which included explanations for various recommendations. They also reported the need for tailored messages, multimodal communication, communication from trusted health professionals, and inclusion of people experiencing homelessness in message development.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e Participants expressed a preference for person-centred communication approaches and underscored the importance of effective pathways for disseminating health information within homeless shelters. Utilizing clear, concise, and specific public health messaging and channels tailored to individuals experiencing homelessness can significantly improve communication between shelters and their residents. Utilizing the right channels through trusted messengers can help deliver health messaging to effectively reach people experiencing homelessness.\u003c/p\u003e","manuscriptTitle":"Public health information communication preferences among residents in six (6) King County homeless shelters between March 2020 and October 2021; Lessons from the COVID -19 pandemic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 17:07:59","doi":"10.21203/rs.3.rs-5801586/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-01T17:45:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T15:44:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T21:28:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46024618563105847820498768653406563552","date":"2026-04-13T13:19:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156386012037506122440991776498189694475","date":"2026-04-12T17:57:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285221979332688661094000265041327923269","date":"2026-04-10T21:03:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264464287629070703580712904868437369237","date":"2026-04-10T14:27:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-23T16:07:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"212977543536512546923754603180926517889","date":"2025-03-18T16:08:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208393958189769545150700672785223598224","date":"2025-03-14T00:32:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317957903210299978829544208745866559100","date":"2025-03-10T21:46:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-02T16:41:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-01-15T09:27:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-14T08:47:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-14T08:44:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-01-10T07:38:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4eed7559-dad6-4fb8-9f2b-5680f53933ad","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-01-15T17:07:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 17:07:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5801586","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5801586","identity":"rs-5801586","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}