# A rapid review of practices to support people experiencing homelessness during COVID-19

Abe Oudshoorn (Arthur Labatt Family School of Nursing, Western University, London, Canada)
Tanya Benjamin (Dr. Sophie Lin Rydin School of Occupational Therapy, Texas Woman’s University, Houston, Texas, USA)
Tracy A. Smith-Carrier (School of Social Work, King’s University College, London, Canada)
Sarah Benbow (School of Nursing, Fanshawe College, London, Canada)
Carrie Anne Marshall (School of Occupational Therapy, Western University, London, Canada)
Riley Kennedy (Centre for Research on Health Equity and Social Inclusion, Western University, London, Canada)
Jodi Hall (School of Nursing, Fanshawe College, London, Canada)
C. Susana Caxaj (Arthur Labatt Family School of Nursing, Western University, London, Canada)
Helene Berman (Arthur Labatt Family School of Nursing, Western University, London, Canada)
Deanna Befus (Arthur Labatt Family School of Nursing, Western University, London, Canada)

ISSN: 1460-8790

Article publication date: 21 October 2021

Issue publication date: 14 December 2021

781

## Abstract

### Purpose

People experiencing homelessness are uniquely vulnerable to the impacts of a pandemic, such as COVID-19. Therefore, governments across Canada have been implementing a patchwork of responses to address the needs of those who are homeless at this time. The purpose of this study is to both compile and assess the varying responses by exploring the breadth of actions presented in print and social media.

### Design/methodology/approach

Rapid review methodology is a means of compiling a breadth of information to compare and contrast policy implementations. Herein, the authors provide a comprehensive rapid review of responses to homelessness considered through a health equity lens.

### Findings

Based on policy implementations to date, the authors offer eight recommendations of potentially promising practices among these responses. Situated within a capabilities approach, the authors call upon governments to provide a full breadth of responses to ensure that both health and housing are better protected and obtained during the COVID-19 pandemic.

### Originality/value

This paper presents the first comprehensive review of local government responses to homelessness in the context of COVID-19.

## Citation

Oudshoorn, A., Benjamin, T., Smith-Carrier, T.A., Benbow, S., Marshall, C.A., Kennedy, R., Hall, J., Caxaj, C.S., Berman, H. and Befus, D. (2021), "A rapid review of practices to support people experiencing homelessness during COVID-19", Housing, Care and Support, Vol. 24 No. 3/4, pp. 105-122. https://doi.org/10.1108/HCS-11-2020-0018

## Publisher

:

Emerald Publishing Limited

## Introduction

COVID-19 is an unfolding pandemic with all orders of government in Canada rapidly deploying crisis responses. During communicable disease outbreaks, populations who already face health vulnerabilities, including older adults and people experiencing homelessness, become even more vulnerable (Hutchins et al., 2009). Pre-pandemic, people experiencing homelessness have some of the highest morbidity rates and lowest age of mortality rates in developed nations (Frankish et al., 2005). Concerns are heightened for this already medically marginalized population in the context of a highly transmissible communicable disease. A Canadian analysis found a hazard ratio of between 1.76 and 3.66 for a positive COVID-19 test for those experiencing homelessness as compared to the rest of the population (Richard et al., 2021). Modelling from American data suggests potential hospitalization rates between 2.4 and 10.3% with a fatality estimate of 0.3 to 1.9% (Culhane et al., 2020). Whilst all orders of government in most developed nations have responsibilities around funding and/or service delivery of housing and homelessness programmes, the bulk of direct service design exists at the level of local governments. In terms of local governments, many responses have been developed in the first 1.5 years of the pandemic to address the particular needs of people experiencing homelessness as a vulnerable population. It is important to chronicle responses both for rapid dissemination during the COVID-19 crisis and for analysis following the pandemic.

The purpose of this descriptive rapid review is to catalogue and categorize government actions across Canada related to COVID-19 and homelessness. The goal herein is to explore the breadth of policy responses and provide critical analysis on the perceived potential and limitations of these responses. Cataloguing the breadth of responses means tapping into data sources outside of the literature as the pandemic is unfolding currently and because not all municipal responses will be catalogued within research writing. Ultimately, this descriptive knowledge should assist as a point to start from in planning to protect or improve the health and well-being of people experiencing homelessness during the COVID-19 or future pandemics. Whilst all orders of government are involved in responding to homelessness, this review focuses primarily on the actions of local governments who in the Canadian context implement the majority of federal and provincial programmes.

## The current knowledge landscape

Within the Canadian context, the pivotal starting point for adapting to the COVID-19 pandemic was the H1N1 pandemic-based review, “Pandemic Preparedness and Homelessness: Lessons from H1N1 in Canada” (Buccieri and Schiff, 2016). This review identified 9 urgent practices to be adopted by service providers and local governments in collaboration: optimize infection control procedures and hygiene practices among social service and emergency shelter staff; Share stockpiled resources among social service organizations; coordinate hours among social services to ensure available spaces to meet basic needs around the clock; rapidly create educational materials targeted to the population of people experiencing homelessness; If an existing communication network is unavailable, connect all homeless-serving organizations into a network for the purposes of information sharing and planning; Provide those experiencing homelessness with early access to vaccines if they become available, given their vulnerable population status; develop isolation spaces within shelters, such as “sick rooms”, for those infected and recovering; use temporary accommodations outside of shelters for convalescence and centralize the distribution of personal protective equipment (PPE) to maximize adequacy across organizations. The underlying assumption in this guideline is that services will continue to function and that health protection is the priority. There is a notable focus in these recommendations on information sharing/communication between organizations and a notable lack of focus on potential requirements to have physical distancing through depopulation of services. The recommendations take the principles of public health communicable disease prevention and suggest how these can be adapted to the homeless-serving sector. The recommendations have been updated during the COVID-19 pandemic by the Canadian Network for the Health and Housing of People Experiencing Homelessness (CHN3) COVID-19 pandemic (Bond, 2020). CHN3 has provided more details on criteria for testing; when to send people to hospital; sentinel surveillance; Integrated planning bodies; physical distancing; proper utilization of isolation shelters and the potential for COVID-19 specific shelters. These recommendations parallel those by Buccieri and Schiff (2016) but provide further specifics.

Those who are emergency sheltered are identified as being particularly vulnerable during a pandemic due to close proximity with others, some of whom have conditions that make it more difficult to follow public health measures. Jadidzadeh and Kneebone (2020) highlight that the challenge with shelters is not just being with a large number of unrelated people, but that there is very high turnover with the majority of shelter occupants staying for a short period of time and the highest number of new admissions being those who are new to the shelter. This means rather than being sheltered with a common cluster of individuals such as if most people were just moving around within the same shelter system, this actually shows high exposure to a constantly changing group of people. Because of this, much of the focus of local government actions or advice to local governments and service providers has been on preventing new people requiring emergency shelter (Pixley et al., 2021), depopulating shelters by moving people to more individualized temporary accommodations (Benavides and Nukpezah, 2020; Culhane et al., 2020; Koziel et al., 2020; Lewer et al., 2020; Perri et al., 2020) or exits into permanent housing (Lee, Shinn & Culhane, 2021). Whilst isolation spaces were recommended in the Buccieri and Schiff (2016) plan, the overall need for significantly more emergency accommodation to allow for distancing, isolation and treatment was under-anticipated. Culhane et al. (2020) noted that reducing shelter occupancy by 50% by providing housing alternatives in the US would require an additional 400,000 units. In the interim, local governments are leaning heavily on spaces available through hotels/motels, convention centres and student residences (Parsell et al., 2020; Shi et al., 2020).

In the Canadian context, a report by Falvo (2020) explored specific approaches to COVID-19 and homelessness in 12 Canadian cities. This report noted the concurrent efforts of both reducing shelter occupancy through the use of hotels/motels as additional spaces and the creation of new emergency shelter spaces, with simultaneous efforts to focus on rapid rehousing for those in any of the existing or newly created services. The report notes that in spite of these efforts, there are still significant challenges related to the number of people who remain unsheltered in these cities and that the temporary measures have both remained in place longer than initially budgeted whilst also still being only temporarily funded. These budgetary pressures are echoed by Deslatte et al. (2020) and Parsell et al. (2020) with significant federal-level funding required to make these supports a reality. Not mentioned in the Falvo (2020) report is that in spite of these measures taken to date, as of 14 April 2021, 2,242 outbreaks had been attributed to shelter settings in Ontario alone (Government of Ontario, 2021), defined as 1 or more residents or staff members with COVID-19. This has led to tension in the sector, particularly through the difficult and dangerous winter months, where people need a safe place indoors but congregate environments are a known danger for COVID-19 transmission (Hwang and Siegel, 2021; Oudshoorn, 2020; Xie et al., 2020).

In a literature review of responses to the rapid spread of communicable diseases for people experiencing homelessness, Babando et al. (2021) clustered responses around six themes: education and outreach, adapting the structure of services, screening and contract tracing, transmission and prevention strategies, shelter protocols and treatment, adherence and vaccination. At the governmental level, communication and collaboration were again identified, consistent with recommendations from Benavides and Nukpezah (2020), as well as restructuring services to allow for adequate physical distancing and isolation. The majority of the recommendations within the existing literature, however, offer specific guidance to service providers and parallel the approaches from the reports above. Whilst this work is being published as the pandemic is still active, the research literature shows a shifting focus from the urgency of testing, tracing and isolating cases towards considering more structural change for long-term housing outcomes (Lee et al., 2021). However, as noted by Parsell et al. (2020) there is little evidence to date that the pandemic response is leading to broader strategic housing approaches.

With a goal to refine and add to current pandemic recommendations, the research question that guided this review was: What are the practices local governments are enacting to protect or improve the health and well-being of people experiencing homelessness during the COVID-19 pandemic? In the Canadian context, there are four orders of government: Federal, Provincial/Territorial, Local and Indigenous. Each province or territory has a different design in terms of who is most responsible for delivering homelessness and housing services, however, in all cases, there is some engagement of the locality in which services are delivered. Therefore, we have focused primarily on actions taken by local governments, representing municipalities/cities/regions/counties or a variety of other terms across the country. It is worth noting that these practices may also be delivered by other orders or government or maybe enabled within local governments through funding from other orders of governments.

## Theoretical perspective

This rapid review was conducted as a collaboration among researchers affiliated with the Centre for Research on Health Equity and Social Inclusion (CRHESI). CRHESI exists to enhance the mobilization and utilization of research related to health equity and social inclusion for evidence-based decision-making in health and public policy, as well as service delivery. Key elements of equity research include: acknowledging the power inherent in varying social structures and locations; appraising how they intersect to shape health and social inequities; and keeping a critical eye towards historical, structural and systemic violence and oppression that influence research findings and their interpretation. This critical theoretical lens on health inequities motivates our focus on actions to support people experiencing homelessness. The goals are to highlight gaps in local government responses and to widely disseminate promising practices, in the hope that more local governments and other orders or governments will consider how such practices might be locally adopted and yield positive outcomes for this otherwise marginalized population.

## The capabilities approach and its relevance to this review

One significant potential challenge in rapid reviews is the ability to critically analyse findings as congruent with the case for this paper, insufficient time has been available to longitudinally assess the merits of different approaches. Where evaluation and research data are not available to assess outcomes, theoretical perspectives can help in making assessments. For this study, the capabilities approach (CA) introduced by Sen (2001) and extended by Nussbaum (2011) is used to reflect on the limitations of current approaches and to highlight promising practices. This allows for some critical analysis in our discussion beyond a simple description of current approaches. We have drawn on the CA as applied to the case of global mental health throughout this paper (White et al., 2016). This theoretical framework is fitting for this study as it allowed us to ground our assessments of what is valuable or concerning in current approaches in congruence with the principles of equity and social justice. The CA reflects Giddens’ sociology of “structuration” (Giddens, 1991), specifically how the macro and microstructures and personal agency are in constant interaction. As a social justice approach, the CA postulates poverty as not solely financial deprivation but also a deprivation of opportunity based on inequities and systemic injustices. Whilst the 10 central capabilities include core elements of meeting basic necessities, such as “Life”, “Bodily Health” and “Bodily Integrity”, they also include “Affiliation”, consisting in part of social interaction and self-respect, as well as “Control Over One’s Environment” (Nussbaum, 2011). Therefore, effective approaches to homelessness in the context of a pandemic must meet basic needs, as well as create a context in which people can maintain autonomy and experience empowerment. Nussbaum (2011) highlights in particular how government policy in the form of laws can be used as a means to protect key capabilities. In the context of homelessness, Evangelista (2010) highlights the multiple key capabilities situated within having a home and loss of home as a loss of the ability to achieve a state of well-being. This is captured in Batterham’s (2019) definition of homelessness as “experiencing capability deprivation (forced lack)”. Finally, the CA acknowledges the importance of understanding the differential experiences of and barriers to, well-being in equity across population groups. Equity will be another grounding concept in the analysis of approaches.

## Methodology and methods

Rapid review is a methodology that evolved out of health technology assessment (Harker and Kleijnen, 2012) and is based on the inherent challenge of technologies evolving faster than traditional knowledge synthesis processes. If health-care organizations were to wait for sufficient knowledge to be published and synthesized into systematic reviews prior to purchasing or implementing new technology, they would perpetually be using outdated technologies. Rapid reviews are a form of evidence synthesis conducted in the context of an urgent and immediate need (Khangura et al., 2012). In this study, the urgency of the unfolding COVID-19 pandemic is the justification for using a rapid review approach. Rapid review requires a clear research question, a systematic approach to accessing and summarizing the evidence and logic regarding the “quality” of the evidence that will be deemed acceptable (Khangura et al., 2012). These methodological considerations are included in our methods.

The goal of the review is to identify any local government actions being taken to support people experiencing homelessness in Canada. Depending on the region, these may also overlap with provincial/territorial, federal or Indigenous government responses. Ensuring detection of all local government actions whilst the pandemic is unfolding in real-time creates a significant challenge for data collection. Whilst our literature review has covered a variety of analyses of government responses to homelessness during the COVID-19 pandemic, not all government responses will necessarily be reviewed in academic publications nor will these necessarily be published already. Rather, public data sources provide broader and more timely access to policy and programme responses as they unfold. Local and national media present real-time data sources as to how communities are adapting services. Additionally, social media provides a platform to disseminate these stories internationally. Therefore, rather than a scoping or systematic review of the researcher literature, which may be appropriate post-pandemic, a review of media sources was the method chosen to achieve the two goals of this review: breadth of data, i.e. ensuring we captured all possible local government responses and timeliness of data, i.e. ensuring that responses occurring as close to our writing as possible were all captured.

Data were retrieved from both social media and published media sources over two time periods. For social media, the Twitter scraper TAGS was used. The search period was set to the past 7 days as the longest backward searching option available, between 2 April 2020 and 9 April 2020, accounts with 50 or more followers to enhance the likelihood of accessing data from formal sources and to a maximum of 5,000 tweets. This was repeated in April 2021. These tweets were reviewed by a research coordinator to identify those that pertained to local government interventions in Canada and any embedded links were followed. Data obtained from outside of the Canadian context was used to guide a secondary search to ensure we did not miss any similar Canadian approaches. For published media, a Factiva search was conducted on 16 April 2020, using the string [(homeless or homelessness) and (covid or covid19 or covid-19 or coronavirus or pandemic)]. The sources were limited to publications and web news, with a time range of the preceding 4 weeks from 17 March to 16 April 2020 and again from 15 March to 14 April 2021 and the region set to Canada, the location of the researchers. The titles of published articles were screened by a research coordinator to remove irrelevant articles.

The primary limitation of this approach is that it requires reporting on a municipal adaptation to have occurred. Whilst there are no other alternative comprehensive data sources, as localities are not required to publicly report on all adaptations, it does mean that approaches may be missed if they were done with no reporting. Whilst having two time periods of data collection assists in comprehensiveness, further data collection across the duration of the pandemic may uncover new and novel approaches not found herein.

## Analysis

The two Twitter scrapes yielded 1,781 unique tweets and the published media searches yielded 13,363 combined articles of which 4,140 were auto removed as duplicates, leaving 9,223 articles. A database was developed to list the various approaches. These were categorized as those directly addressing homelessness/housing issues and those addressing the other relevant social determinants of health (i.e. income, social supports, health services, transportation and safety). Duplicates in the database were removed as they were entered. Once completed, the database was circulated to the full research team for review, consisting of experts in health equity, homelessness and health and social services. Data from the 2021 searches were compared against preliminary findings from 2020 to supplement the expanding data table. Using the CA to facilitate analysis, the team reviewed and discussed which of these practices were perceived as most promising and where particular gaps were noted.

## Findings

High-level strategies: Addressing homelessness during COVID-19

Strategies

• Increasing shelter capacity.

• Increasing housing capacity.

• Disease prevention

• Food security and basic needs.

• Homelessness prevention.

• Relocation of people who are unsheltered (people sleeping rough).

• Increasing system capacity.

• Transportation.

• Communication and coordination.

• Knowledge mobilization

The following represents the breadth of activities that we found through our rapid review representing how local governments are supporting those experiencing homelessness during the COVID-19 pandemic. These have been organized by the over-arching strategy, such as increasing shelter capacity or preventing disease, sub-strategies enacted to achieve this end and the specific approach(es), if available or applicable. We note that example cities may not be comprehensive as not all approaches are reported in the media. What is of note is that practices were included if they were implemented by a single local government or more and our discussion below speaks to the breadth and rapidity of implementation of some strategies. Additional findings from the second data collection period are indicated in italics. This table provides the full scope of approaches without indication of whether they are promising, problematic, both or otherwise. In the discussion, we unpack these nuances (Table 1).

## Discussion

Congruent with the CA that positions social justice around the social determinants of health, a particularly promising practice was opening hotel/motel space to provide people options to depopulate shelters and leave encampments. This approach has been consistently identified across literature published on the COVID-19 pandemic to date (Benavides and Nukpezah, 2020; Culhane et al., 2020; Koziel et al., 2020; Lewer et al., 2020; Perri et al., 2020). Given that hotel/motel spaces became quickly available in the context of travel and tourism declines in the global pandemic, this allowed for greater housing capacity in an otherwise strained global housing system. At the same time, both encampments and emergency shelters were noted as high-risk spaces for disease transmission, making better housing alternatives an urgent priority. Therefore, our second recommendation is that local governments use local, provincial/territorial, federal and/or Indigenous government funds to open hotel/motel spaces for people experiencing homelessness. This is particularly urgent as various strategies can play at odds with each other. For example, depopulating shelters to reduce viral spread without providing a housing alternative simply shifts risk from the shelter facility to other places and spaces in the community. That said, hotels/motels do not completely reduce the risk of transmission as outbreaks have occurred in these settings as well. Per Koziel et al. (2020), there are complications in delivering this form of temporary accommodations including proper staffing and aligning service provider and hotel/motel policies. Proper PPE and distancing need to be supported in these spaces similar to other homeless-serving organizations and social services in general. As well, there need to be clear and transparent processes regarding access to these rooms and these processes should again be guided by front-line providers and advocates. It is also worth noting the tensions in this approach. Whilst hotel alternatives were used as a welcome option to those leaving congested emergency shelters, they were also positioned in some of our data as the justification for continuing to enforce by-laws to clear encampments. This is both incongruent with a CA in which autonomy and choice are central and incongruent with the CDC (2020) guidelines on not clearing encampments during the pandemic. This serves as an example of how these various approaches are interactive at the community level and can actually run counter to each other.

Following on the preceding point, our third recommendation is that any shelter depopulation is enacted simultaneously with an equivalent or greater replacement of housing options, preferably more permanent housing options. Media articles on shelter depopulation often quoted anxieties of service providers and those experiencing homelessness related to the lack of alternatives within a strained housing system. This is congruent with Culhane et al.’s (2020) finding that in the US a 50% shelter density reduction would require an additional 400,000 units of housing. Whilst municipalities were under pressure to ease congestion, several indicated that they were creating new spaces to do so rather than just depopulating existing spaces. Disease prevention should not lead to decreased system capacity or vulnerable persons being pushed into more vulnerable situations. Again, this creates a tension between approaches, for example, in some communities where increased emergency shelter spaces were being offered to give people an opportunity to come in over the winter and exit encampments, yet these new spaces were also subject to COVID-19 outbreaks. This led to examples in communities where advocates were both calling for more emergency shelter spaces and an end to creating more emergency shelter spaces. We noted in some news stories that people were being forcibly removed from campsites with an offer of a hotel/motel or shelter space, yet the articles expressed concern about the feasibility of the alternatives being offered. In this manner, there is an infringement on personal autonomy in the process of relocating individuals experiencing homelessness. Perri et al. (2020) highlight the importance of using a trauma-informed approach when supporting those who may be recommended to relocate during the pandemic such as moving into isolation spaces. Therefore, our fourth recommendation is that to be congruent with the CA, no movements to rehouse individuals should occur without respecting individuals’ right to autonomy and without full and prior consent.

Issues related to urban camping, rough sleeping or being unsheltered were prevalent in stories of how local governments were responding to COVID-19. We note that this is a contentious issue given that urban encampments can be seen as both safer than an emergency shelter depending on community practices or more dangerous than other housing or shelter options. Both narratives were present in our review: To leave people living in urban encampments due to the view that they would be safer there or to remove tents in these encampments in the interest of human safety. Notably, the choice of individuals residing in these encampments was often unacknowledged in these discussions. Journalists made efforts to include the voices of those impacted by policies yet decision-makers quoted often focused on pragmatic concerns rather than personal rights. Our fifth recommendation is to respect individuals’ autonomy and “allow people who are living unsheltered or in encampments to remain where they are” [Centres for Disease Control and Prevention (CDC), 2020]. This recommendation is in keeping with the (CDC) guideline, “Interim Guidance on Unsheltered Homelessness and Coronavirus Disease 2019 (COVID-19) for Homeless Service Providers and Local Officials”, which explicitly notes that best practice is to allow individuals to choose to remain unsheltered if they chose to do so (CDC, 2020). This is both congruent with honouring personal autonomy and preventing disease transmission among sub-groups of people experiencing homelessness and is supported by academic experts on homelessness (Culhane et al., 2020). This would also prevent the need to move individuals who are homeless into higher-risk settings. Whilst the Government of Canada (2020) has distributed guidelines for shelter service providers [“Guidance for providers of services for people experiencing homelessness (in the context of COVID-19)”] it does not have any specific considerations for individuals who are unsheltered or who are living in encampments.

It should also be noted that several media articles identified that where people who are unsheltered have traditionally received the least amount of supports, they continue to do so in the context of COVID-19. Congruent with the CA, an equity consideration must be given to particular populations who are structurally disadvantaged. This has previously been highlighted by Parsell, Clarke and Kuskoff who note that people experiencing homelessness faced high risks and marginalities prior to the pandemic without necessarily sufficient structural supports and need those supports now and in the future. Therefore, our sixth recommendation is that cities/regions use active outreach to provide both basic necessities and harm reduction support to sheltered and unsheltered individuals. Several municipalities were noted to be providing outreach-based food support in addition to COVID-19 screening. This increased by the second data pull as Food Banks of Ontario and other similar providers nationally took a very proactive approach to food and other basic necessity delivery. The harm reduction focus was in the context of several news articles noting that the use of overdose prevention sites had declined during COVID-19 whereas the number of overdose deaths had increased. This is in the context of an opioid poisoning crisis in Canada (Kolla et al., 2020) exasperated by the pandemic (Bonn et al., 2020) and disproportionately affecting those experiencing homelessness (Collins et al., 2020).

Supporting individuals choosing to remain in urban campsites has implications related to the by-law and by-law enforcement. In the articles, it was identified that some local governments placed an informal hold on enacting certain by-laws, whilst a few formally paused by-laws related to ticketing of persons in public spaces. A noted concern both in news articles and from a CA was how new public health-related by-laws can unjustly and inequitably target those experiencing homelessness, with a few examples in the media of police or by-law officers ticketing people for congregating, being in public parks that were restricted as part of emergency measures or using substances in public spaces. Therefore, our seventh recommendation is that by-laws affecting individuals residing in encampments or who are unsheltered not be enacted during an emergency declaration and similarly, that any by-laws related to the public health emergency have explicit exemptions for individuals experiencing homelessness. This recommendation was not noted in our review of existing literature around municipal responses and is, therefore, unique herein. Strategies such as providing outreach-based education on physical distancing make sense; giving two people experiencing homelessness $800 tickets each for sharing a sleeping space in a park does not serve to support this population or to offer pandemic-related guidance, but instead, such tactics serve to police and punish people for situations beyond their control. Heightening police practices with individuals experiencing homelessness under the rhetoric of public safety is incongruent with a CA that guides us to actively work towards eliminating structural violence. Furthermore, criminalization of survival has a direct impact on individuals’ ability to secure safe housing in the future, exacerbating conditions that lead to homelessness, to begin with. Finally, we consider how the CA requires us to consider the unique experiences of certain marginalized populations. It is noted that several local governments have created responses to address the specific risks faced by women and girls (cis and trans). Due to domestic violence and the increased risk of social isolation, strategies have been developed both to provide safety in place and to provide safe places of exit such as enhanced shelter capacity. Our eighth recommendation is that local governments include in their responses an intersectional analysis of risk related to key populations. As the homeless-serving sector has become increasingly attuned to the need for specialized services, these must continue to be available during a pandemic. For example, does the city/region maintain safe, trans-affirming spaces despite the closures of many in-person services? How does enhanced surveillance of public spaces, formally (e.g. policing) and informally (e.g. public reporting/snitch lines), further endanger street-level sex workers? How do we work with Indigenous communities and community organizations to address the needs of Indigenous people experiencing homelessness? Whilst this conversation appeared in a few articles, it was notably limited, which we raise as a concern. A particular area of concern was the lack of discussion around Indigenous, Black and People of Colour experiencing homelessness and their unique historical and social context. Further, seeking community feedback and questioning, which populations may be excluded from current formalized local government responses would promote discussion of unique needs, resources and best practices that meet the needs of all individuals experiencing homelessness. Systemic barriers are experienced differently within and across subgroups and result in differing needs. For example, the pandemic-related needs of single youth may look different than the needs of newcomer families, which again may vary from individuals with severe and persistent mental illness. Ultimately, from our rapid review of traditional and social media, we have found an encouraging breadth of responses that support individuals experiencing homelessness during the COVID-19 pandemic. That said, these approaches can at times run counter to each other. This is most notable in the overall tension of where people can reside. With inadequate supports to make permanent housing for all an immediate reality, local governments found themselves juggling the trifecta of hotels/motels, emergency shelters and urban encampments. Whilst the first offered the best option, with privacy and space, both shelters and urban encampments face challenges related to COVID-19 transmission and encampments particularly safety challenges through the Canadian winter. This led to several situations where municipalities/regions tried to create systems to coerced people into a particular form of occupancy, most usually trying to coerce people into new or expanded emergency shelter spaces. This ultimately lends strength to an ongoing, non-pandemic-specific approach to ensuring housing for all. Congregate living environments and rough sleeping will never have the same health outcomes of having a home, inside or outside a pandemic. Whilst issues related to shelter capacity and use of motels/hotels, access to PPE and cleaning of shelter spaces have been more prevalent across communities by the second data pull, many of the other activities noted in Table 1 were not widely adopted on our first data pull in April 2020. There was a notably slower adoption of services, such as free public transit, the hotel/motel approach, basic needs distribution and portable housing benefits. Indeed, articles had some communities removing these supports (such as free transit and a non-enforcement of by-laws) at the same time as other communities were adopting them. We would encourage local governments and the agencies they fund to review this list to consider if there is more that can still be done in their area to more effectively support homeless and precariously housed individuals at this time. Secondly, we recommend using a range of strategies identified as a starting point for planning for future pandemics or future waves of COVID-19. Moving forward, we plan to evaluate the available data on the effectiveness of such responses to further extend our current recommendations. ## Table 1 Local government responses to homelessness during COVID-19 High-level strategy Sub-strategy Specific approach Definition Examples: Descriptions of actions Example locations Increasing shelter capacity Repurposing of public spaces Increasing shelter capacity by locating shelter beds in buildings, such as community centres, convention centres or arenas, particularly buildings already publicly owned The transformation of Kenora Memorial Arena into a COVID-19 isolation space Hamilton, ON transformed its largest hockey arena into a pandemic homeless shelter Edmonton, AB transformed a convention centre into a temporary shelter Kenora, ON Hamilton, ON Victoria, BC Ottawa, ON Edmonton, ON Repurposing of private spaces For-profit Increasing shelter capacity by renting, purchasing or borrowing private buildings to repurpose, including hotels or motels A Calgary hotel was transformed into a COVID-19 isolation site for people with no fixed address Toronto’s shelter department stated that the city moved 1,000 homeless people out of shelters and into hotel rooms Calgary, AB Toronto, ON London, ON Edmonton, AB Lethbridge, AB Saskatoon, SK Brantford, ON Montreal, QC Niagara, ON and most other mid-to-large communities in Canada Non-profit Increasing shelter capacity by renting, purchasing or borrowing building space from non-profits, such as churches or social service organizations The largest church in Calgary’s southeast quadrant was transformed into a homeless shelter B.C. Housing has also arranged for 367 shelter spaces in six communities Calgary, AB Vancouver, BC Toronto, ON Kitchener, ON Penticton, BC Winnipeg, MB Increasing shelter hours For those that are normally part of the day, such as overnight only, allowing people to remain all day in the shelter The hours at the seven emergency shelter sites in the Waterloo region were extended to keep the spaces open at all times Hours have been extended at some shelters, such as allowing people to remain at the shelter during daytime hours Waterloo, ON Toronto, ON Calgary, AB Creating new shelters Building Rapid development of new emergency shelter buildings, such as using prefab designs Montreal opened 5 new emergency shelters within the first few months of the pandemic Vancouver opened a new “surge” shelter Montreal, QC Vancouver, BC Windsor, ON Hamilton, ON London, ON Tents Creation of tent-based temporary emergency shelters, such as large emergency tents or using many small tents in an organized camp In Topaz Park, 200 tents were set up in army camp fashion on former soccer fields 8–10 people were relocated from downtown to a temporary camp on the outskirts of Smithers Victoria, BC Smithers, BC Increasing violence against women (VAW) shelter opportunities Specific supports for women, girls and families leaving violence during the pandemic, most primarily shelter focused, including use of hotels or motels An organization that otherwise closed services continued to operate their emergency shelter for women and kids impacted by domestic abuse and homelessness The federal government committed$200m to help shelters for homeless people and women and children fleeing domestic violence
Woodstock, ON
Lethbridge, AB
Grand Prairie, AB
Miramichi, NB
Halifax, NS
Whitehorse, YT
Increasing housing capacity Private initiatives for new housing options Landlord, property owners, businesses using current land or buildings to bring new affordable units on the market and prioritizing them to those experiencing homelessness Toronto extended its Housing Now programme in which the city provides land to developers in exchange for some affordable housing Toronto, ON
London, ON
Communities across Canada because of the Canadian-provincial housing benefit although this was planned prior to the COVID-19 pandemic
Public initiatives Purchase of mobile homes Governments increasing their publicly managed affordable stock, such as through purchase or head lease of mobile homes The City of London created a temporary shelter in partnership with non-profits through the use of construction trailers London, ON
Disease prevention Change in shelter protocols De-populate Reducing the number of people sleeping or congregating in close proximity within shelters. For some, this reduced shelter capacity if alternative shelter options were not found, some went so far as closing shelters entirely The men’s night shelter in Chatham-Kent stopped providing overnight accommodations.
A shelter in Toronto decreased capacity by 40 beds to eliminate the use of bunk beds and increase social distancing
Chatham-Kent, ON
Toronto, ON
Data from the second collection indicated that it appears that all communities across Canada have focused on some degree of reduced shelter occupancy to support physical distancing
Enhanced cleaning Cleaning and sterilizing of both surfaces and materials within shelters. Best practices are provided by public health agencies and provincial and federal public health organizations Seasons House is conducting enhanced cleaning throughout the shelter using approved cleaning supplies that have been rated effective against coronavirus
Homes First in Toronto has been screening residents for symptoms and increasing its cleaning, as recommended by Toronto Public Health
Quesnel, BC
Toronto, ON
By second data collection, it appears all shelters across Canada have enhanced cleaning procedures
PPE access Masks for staff and/or residents, a mix of N95, surgical and non-medical masks, are often prioritized around residents who are symptomatic In Montreal, the health ministry is assisting to replenish shelters’ stocks of masks and other protective equipment Montreal, QC
By second data collection, it appears all shelters across Canada have enhanced PPE access
No eviction from the shelter Change in policies around evictions or bans to ensure that people are not forced to leave the shelter during the pandemic due to behaviours or substance use Articles referenced efforts to reduce forced evictions from shelters versus a policy change London, ON
Peel Region, ON
Calgary, AB
Policies (new/adapted) addressing health Loosening prescription guidelines National pharmacy guidelines changed to allow for easier renewals and dispensing of long-term doses. Included specific shifts around methadone maintenance treatment to reduce those on daily prescriptions and allow for more “carries” The B.C. government changed policy to allow drug users to take home and have delivered prescribed medications that replace street drugs
The federal government has been moving to consider authorizing all medical providers to prescribe buprenorphine without a federal waiver to do so
Vancouver, BC
These included both federal drug guideline changes and provincial support around prescribing and were reported across the country
Increased health service access Enhancing harm reduction practices Broader distribution of safe use supplies, expanding or creating managed alcohol programmes, enhancing peer engagement for safe injection happening outside of supervised consumption sites, enhancing SCS hours or staffing
Introduction of safe supply programmes
Keeping six outreach teams, a harm-reduction advocacy group is now handing out clean needles to homeless residents
Those urban camping in the Victoria region is receiving outreach support from public health nurses
Safe supply received federal government support including guidelines
Hamilton, ON
Victoria, BC
London, ON
Vancouver, BC
Toronto, ON
York Region, ON
Winnipeg, MB
Prince George, BC
Point of care testing Having COVID-19 testing taking place in partnership with outreach services or shelter services The InterCommunity Health Centre has teamed up with public health to administer COVID-19 tests to people living on the street
Sanguen Health Centre’s mobile clinic is conducting COVID-19 assessments
London, ON
Waterloo, ON
By the second data pull, “sentinel” and asymptomatic testing was being conducted mostly at shelters across the country
Food security and basic needs Food distribution Leveraging private-sector donations, use of excess food at the start of the crisis, maintaining existing food security networks, distribution through outreach teams and more The downtown YMCA in Montreal has set up a mobile canteen in the Sud-Ouest borough to provide meals to the homeless
A shelter in Collingwood is preparing hot meals for those temporarily housed in hotel rooms
Montreal, QC
Collingwood, ON
Basic needs distribution Basic needs kits are provided through street outreach, as part of food distribution locations or through shelters A group of volunteers in Saskatoon is making hygiene kits for those experiencing homelessness Saskatoon, SK
London, ON
Kamloops, BC
Kelowna, BC
Kitchener, ON
This was broadly adopted by foodbanks nationally, particularly highlighted by Food Banks of Ontario
Access to sanitation Sanitation stations Location of portable washrooms, handwash stations and/or showers throughout communities to replace or enhance closed washroom facilities and community centres A hygiene centre for the homeless has opened up at Kelowna’s Metro Community Church
In Toronto, portable toilets and handwashing stations have been set up downtown
Kelowna, BC
Toronto, ON
London, ON
Ottawa, ON
Vancouver, BC
Edmonton, AB
Prince George, BC
Building access Continuing or creating new access to buildings with toilets and/or showers, such as community centres, churches and gyms A church in Hamilton opened for daytime respite
Sidney has purposely kept its washrooms and shower facility open in Tulista Park and in Iroquois Park. City staff clean and sanitize these facilities multiple times daily
Hamilton, ON
Sidney, BC
Homelessness prevention Eviction prevention Policy preventing eviction All provinces implementing temporary moratoriums on evictions Funding for housing supports through BC Housing has been increased to ensure people can maintain their housing
As of March 17, ON placed a moratorium on eviction hearings and enforcement
BC
ON
By second data pull eviction moratoriums and come, gone and in some cases returned in provinces and territories across Canada
Rent supplements/utility support Creating or enhancing “rent banks” or utility relief programmes BC banned evictions until the crisis has passed and offered $500 a month in rental support to be paid directly to landlords starting on 1 April The City of Brantford used provincial dollars to provide emergency loans for tenants who cannot pay their rent BC Brantford, ON By second data pull, strategies had been implemented broadly to support rent arrears, for example in Alberta and Yukon Territories. Some are provincial and some are municipal/regional approaches Safety Virtual support for women, girls and families experiencing violence Attempts to mitigate increased risks related to isolation A women’s shelter in Chatham is offering 24-h crisis and support lines Chatham-Kent, ON The federal programme to increase VAW funding was used for virtual supports by providers across the country Decreased ticketing of persons in public places Put on hold enforcement of by-laws related to those who are street-involved or rough sleeping Members of Hamilton’s legal, medical and street outreach community are demanding that police stop ticketing homeless people for not observing distancing rules amid the COVID-19 pandemic Articles noted both hold on enforcing municipal by-laws as well as returns to enforcing by-laws Hamilton, ON Toronto, ON Saskatoon, SK Relocation of people who are unsheltered (people sleeping rough) To shelter Supporting (or coercing) people who are unsheltered into the shelter as a more sanitary and controlled environment. Some communities are more choice-based, whilst others enact significant pressure, such as threats of ticketing or of removal of tents. Depends on shelter capacity The health authority in Victoria is working with BC Housing to relocate people out of parks Articles noted both situations of forced relocation and invited relocation Victoria, BC Toronto, ON Vancouver, BC London, ON To day spaces Supporting (or coercing) people who are unsheltered into day spaces where they have better access to basic needs support Montreal opened five-day centres for the homeless Montreal, QC Increasing system capacity Redeploying public sector staff Local government staff redeployed to support the shelter sector or other related services District staff in Mission, BC were redeployed to supporting front-line service provision This became very prevalent in the media in Ontario due to an early order provincially allowing for the redeployment of unionized staff Mission, BC London, ON Hamilton, ON Toronto, ON Windsor, ON St Catherines, ON Grants and funding Mostly flow-through federal, then flow-through provincial; private donations and foundations; several local governments now releasing new funds The government making an immediate investment of$207.5m to support those experiencing homelessness and women fleeing gender-based violence during the COVID-19 pandemic. This was distributed through the provinces/territories and municipalities Federal Government of Canada
On the second data pull, more provincial/territorial funding was noted that was not just flow-through federal funding
Transportation Shuttles Supporting transportation to and from shelters, to other basic needs services and between shelters to balance capacity The City of Greater Sudbury created a nightly shuttle bus to transport individuals from homeless services to temporary hotel accommodations Greater Sudbury, ON
Free public transit All transit fees are waived This became a very popular approach across the country hitting the media shortly after our first data pull London, ON
Vancouver, BC
Victoria, BC
Nanaimo, BC
Brandon, MB
Kingston, ON
Peterborough, ON
Timmins, ON
St. John’s, NS
Halifax, NS
Hamilton, ON
Kingston, ON
Mississauga, ON
Guelph, ON
Montreal, QC
Communication and coordination Information provided on shifting sector policies, accessing new or changed services (e.g. how people qualify for hotels) and public health best practices, such as PPE or cleaning. Communications also include sector data, such as real-time shelter occupancy and the number of people turned away, as well as information on changed programmes, such as meal services Stratford’s homelessness emergency operations group is meeting twice weekly to report on the status of individuals experiencing homelessness throughout the region Stratford, ON
Toronto, ON
Calgary, AB
Edmonton, AB
Winnipeg, MB
Regina, SK
Knowledge mobilization This is about organizations serving the homeless community either sharing sector information with the broader public or crisis-related information with the people they support Siloam in Winnipeg focused efforts on getting information to those in the community who do not have access to technology or wifi Winnipeg, MB

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## Corresponding author

Abe Oudshoorn can be contacted at: aoudshoo@gmail.com

Abe Oudshoorn is based at the Arthur Labatt Family School of Nursing, Western University, London, Canada.

Tanya Benjamin is based at the Dr. Sophie Lin Rydin School of Occupational Therapy, Texas Woman’s University, Houston, USA.

Tracy A. Smith-Carrier is based at the School of Social Work, King’s University College, London, Canada.

Sarah Benbow is based at the School of Nursing, Fanshawe College, London, Canada.

Carrie Anne Marshall is based at the School of Occupational Therapy, Western University, London, Canada.

Riley Kennedy is based at the Centre for Research on Health Equity and Social Inclusion, Western University, London, Canada.

Jodi Hall is based at the School of Nursing, Fanshawe College, London, Canada.

C. Susana Caxaj is based at the Arthur Labatt Family School of Nursing, Western University, London, Canada.

Helene Berman is based at the Arthur Labatt Family School of Nursing, Western University, London, Canada.

Deanna Befus is based at the Arthur Labatt Family School of Nursing, Western University, London, Canada.