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Abstract

Aim

This research examines the impact of the COVID-19 virus on the delivery of services to persons experiencing homelessness with concurrent disorders (PEHCD) in Greater Victoria, British Columbia, Canada.

Subject and methods

The focus on the research involves the identification of changes of service delivery to PEHCD resulting from COVID-19 isolation protocols. The research is based on mixed methods, which involved a survey and semi-structured interviews. The data were collected during the early stages of the COVID-19 pandemic using virtual technology.

Results

The results show that service provision was significantly and negatively impacted by COVID-19. However, the adaption of services and interagency cooperation allowed for rearrangement of service provision to PEHCD.

Conclusion

The results from this pilot project informed the development of an expanded project to communities across British Columbia with large PEHCD populations, which in turn will inform policy development for service delivery during pandemics and other broad scale emergencies.

Keywords

 COVID-19, homelessness, addictions, mental health, concurrent disorders, mixed

Introduction

While COVID-19 presented a significant challenge to society at large, its impact in British Columbia, Canada was exacerbated by the ongoing epidemic of opioid use in marginalized populations, including persons experiencing homelessness with concurrent disorders (PEHCD). COVID-19 stood to further increase morbidity and mortality rates in PEHCD populations. Since the declaration of the Opioid Crisis in 2016, BC has recorded more than 4,500 deaths related primarily to overdose, primarily opioids. COVID-19 was implicated in the surge of overdose-related deaths, which rose from 76 in February 2020 to 170 in May 2020, 93 percent higher than the same period a year earlier [1]. This pilot study and project expansion to communities across British Columbia with large homeless populations seeks to inform policy development for service delivery during pandemics and other broad scale emergencies.

Literature review

PEHCD: Part of Society and Community

The primary theoretical paradigm driving this research is sociology, a discipline that proposes social life is comprised of the experiences of people within a given society. Within this paradigm, sociological theory examines the relationships of organizations to PEHCD within the broader context of social structures and social processes [2]. Emerging from this paradigm are sociological perspectives that bare directly on this research, including the sociology of health and the sociology of deviance (societal reaction theory) [3,4]. In this research, these perspectives give rise to theoretical propositions that explore: (1) the generation of marginalized groups like PEHCD; (2) the identification of health needs and services; (3) responses of the justice system to the actions of PEHCD; and (4) the possibility of collaboration between service providers working with PEHCD. This last point highlights the importance of public policy analysis, which positions this research into an interdisciplinary framework [5]. As Gethmann (2014) [6] observes, interdisciplinarity can inform the developments of new relationships between service providers and the justice system by opening dialogue for collaboration and interagency cooperation related to problem-solving applied to current and future epidemics and pandemics [7].

As a marginalized group, PEHCD have social services and health care needs. Whether they live in homeless encampments like tent cities or reside in shelters or alternative housing settings, PEHCD depend on community resources for survival [8,9]. These resources include housing, food, and clothing; financial assistance and family counselling; and acute and long-term medical and mental health services [10,11]. In non-crisis times, members of this population face numerous and extreme barriers to resources which are exacerbated by other factors, such as race, gender identity, and disabilities to name a few.

At the same time, this population represents a challenge to community order maintenance. Although their crimes are not necessarily severe, members of this population are overrepresented in all levels of the criminal justice system and occupy an inordinate amount of police attention [12,13]. In addition to the services provided by social and health care workers, law enforcement occupies a unique para-care position in that they are often the first responders to PEHCD in crisis and provide referrals to social services and health care [14]. To support PEHCD, police departments can seek to understand the local context of homelessness in their city/community, develop policies and goals within police departments, provide relevant training to officers, assign a designated officer to liaise with social services, establish day centres, and help identify housing options [15]. This understanding from police departments is critical to support PEHCD during a pandemic. As asserted by the Canadian Human Rights Commission, inequality has been amplified by the COVID-19 crisis, including people in need of housing or facing food insecurity, such as PEHCD [16].

Secondary Impacts and Social Vulnerabilities during Crises

Epidemics and pandemics impact people unequally. The social determinants of health (SDOH) of people impacted by poverty, people of colour, and marginalized populations [17], such as PEHCD, need to be considered in pandemic planning and response. Research on disasters and major social crises identifies significant uptake in substance abuse in PEHCD populations [18,19]. Concurrently, service delivery is compromised in these contexts [20,21]. Since the declaration of the Opioid Crisis in 2016, BC has recorded more than 4,500 deaths related primarily to overdose, primarily opioids. COVID-19 was implicated in the surge of deaths related to overdose, which rose from 76 in February 2020 to 170 in May 2020, 93 percent higher than the same period a year earlier [1]. “Social distancing”, later renamed “physical distancing” during the pandemic, presents a significant risk to PEHCD populations. Prior to the pandemic, many PEHCD using substances would reduce the risk of overdoses through the use of a “buddy system,” not taking opioids in isolation.

At the same time, crowded shelters and weakened immune systems put homeless persons at risk of infection during an outbreak [22]. This was demonstrated during the early days of the pandemic when 299 shelter residents were tested for SARS-CoV-2 (a virus that causes COVID-19) in Rhode Island from April 19 to April 24, 2020, with 11.7 percent positive test results [23]. Karb, et al.  findings show “Shelters with positive cases of SARS-CoV-2 were in more densely populated areas, had more transient resident populations, and instituted fewer physical distancing practices compared to shelters with no cases” (para. 3).

Although the need for emergency response teams during crises and pandemics is recognized in research and public policy, literature on their collaboration and/or effectiveness is minimal [19]. A notable study emerged in response to the emergence of H1N1 in 2009, which involved a multi-city study to explore pandemic planning and response in the context of homeless populations in Victoria, British Columbia; Calgary, Alberta; Regina, Saskatchewan; and Toronto, Ontario. The findings from the study presented six important factors: “support for planning; infection control; system capacity; inter-sectoral collaboration; communications and training; and the heightened challenges of unpredictability faced by the homeless population” [24]. The Victoria study found that cross-sector, regional, and inter-agency collaboration was foundational to the response efforts [25]. Another notable H1N1-related study recommended:

• defining marginalized and at-risk groups as relevant to the pandemic
• increasing collaboration
• considerations for adapting pandemic plans
• supporting ease of access to digital sources for people working with marginalized populations
• addressing accessibility issues for marginalized populations
• developing adequate pipeline of support personnel before a pandemic
• improving access to vaccines
• addressing shelter, sanitation, and hygiene needs and
• improving communication [26]

This research builds on these findings to explore the impact of COVID-19 isolation practices on service delivery to PEHCD to inform policy development and future preparedness. As such, this research responds to the BC’s Office of the Human Rights Commissioner’s call for human rights oversight of government responses to the COVID-19 pandemic as it relates to isolation practices that impacted service delivery to PEHCD.

Local Context in Greater Victoria, BC, Canada

Isolation practices resulting from COVID-19 resulted in the closure of shelters and the near elimination of health and social services for PEHCD during the earlier months of the pandemic. This presented a critical challenge for Canada, where it is estimated that at least 200,000 people are homeless every year due to causes related to structural factors, system failures, and individual/relational factors [27,28]. Currently, in BC some PEHCD in urban centres have been moved to encampments while others have been relocated in single room occupancy (SRO) motels [8,29]. It also presents a unique challenge in Greater Victoria, BC, which was rated as the 16th least affordable city to live in the world, according to the 2020 Demographia International Housing Affordability [30]. Although Canada’s response to homelessness has made some progress, from simply managing the crisis (via overreliance on shelters, emergency services, law enforcement, etc.) to developing strategic, coordinated efforts, there is still much work to be done in addressing structural conditions that underpin homelessness [31]. For Greater Victoria’s 1,500+ homeless community members, this requires considering the secondary impacts [32] and social vulnerabilities [33,34] alongside immediate medical considerations during pandemic planning and response.

Methods

This research is exploratory and descriptive in nature, and because the researchers have no influence on the emergence or impact of COVID-19 on participants or the clients they serve, it was a unique quasi-experimental opportunity [33,34]. The research setting also allowed for causal inference in that the researchers can make comparisons of the impact on participants before and after the arrival of COVID-19. While confidence in the results are challenged by the lack of a true experimental model [35], the applied focus of this research allows for the generation of results that can be used by agencies participating in the project for developing policies and procedures [34-36].

Working directly alongside disadvantaged groups through their representatives or indirectly through service providers is integral to understanding lived experiences and informing future pandemic planning and response [37]. As demonstrated by Leung, et al.’s study following the severe acute respiratory syndrome (SARS) outbreak in 2003, homeless service providers and public health officials were key for understanding lessons learned, including using rapid two-way communication systems, providing staff training, accessing supplies, responding to homeless shelter closures and potential staff shortages, and having a clear plan to quarantine and treat those who become ill [38].

Ethical approval for this research was provided by the Research Ethics Board at Royal Roads University. The research design involved mixed methods, utilizing quantitative and qualitative approaches [36]. Participants were invited to partake in the research by reaching out to organizations providing services to PEHCD in Greater Victoria, BC. Once an agency was contacted and service providers were interested in the research, a snowball approach [39] was used to identify other participants and organizations. As an interdisciplinary study [6], three different kinds of organizations were targeted: social, health, and criminal justice. A quantitative instrument with 30 questions was developed for this research to capture participants’ experiences regarding service delivery before and after the advent of COVID-19. Participants were also invited to participate in an interview containing four semi-structured questions. The data was collected through virtual/none face-to-face digital technology between March and May 2021.

Results and discussion

A total of 31 service providers from seven organizations participated in the research. Of those, eight volunteered to be interviewed. Although some participants opted out of certain questions, responses are sufficient for their intended purpose. All participants were white, and the majority were female. Age ranged from 20 to 70 plus, with the most frequently recorded group being 50 to 70. All participants were located in Victoria, with 21 providing social services and 3 providing health or justice-related services. Most participants, 29, provided services relating to persons experiencing both homelessness and concurrent disorders. Significantly, 19 of the organizations involved serviced more than 200 people a day.

Roughly one half of the participants (16) indicated that they had received pre-pandemic training, and 26 noted that they had adapted their services to the pandemic. Regarding impact, only four participants indicated that the pandemic had not limited services. Many organizations (21) received information related to COVID-19 and 16 received information pertaining to PEHCD. Most organizations (26) had adapted their services in response to COVID-19. Many (19) had been invited to participate in meetings or to collaborate with other organizations serving PEHCD. Finally, 19 participants provided examples of challenges where solutions were developed in response to COVID-19. Figure 1 provides a distribution of the challenges noted by participants.

Figure 1. Participants responding to challenges

A preliminary review of quantitative results revealed several challenges experienced by participants including: (1) existing facility design/space; (2) staff shortages due to COVID-19 exposure/illness; (3) understanding COVID-19 information; (4) access to supplies (e.g., masks and hand sanitizer); and (5) increased risk of overdoses due to isolation.

The qualitative data analysis shows the effects of agency adaptations to challenges. For example, a health care worker noted that bureaucracy was rearranged to provide a designated coordinator mental health service. In addition, “pop-up” clinics were provided in areas frequented by PEHCD. Social service agencies rededicated open spaces for program delivery, provided personal safety equipment, and constructed “safe areas” using plexi-glass structures. A mobile shower system was also developed, as were toilet facilities.

Conclusions

This research shows that several gaps emerged in services to PEHCD with the isolation practices associated with COVID-19. Yet organizations have been effective in adapting service delivery to meet newly formulated safety protocols. Despite challenges, service providers successfully continue to meet their clients’ needs. However, PEHCD went several weeks before services could be reopened. Social isolation practices, transformation of service delivery, and the gaps in services resulting from the virus have further marginalized a disadvantage population1. Therefore, further exploration of this issue in other cities in BC is underway by the researchers. Policy implications and recommendations will follow from this expanded research.

Declarations

• Funding was provided by an internal research grant from Royal Roads University.
• There are no conflicts of interest between the authors and other agencies or persons.
• Ethical approval was obtained by the research Ethics Office of Royal Roads University and is available upon request.
• Consent to participate is attached at the end of this manuscript.
• Consent for publication (N/A).
• Availability of data (N/A).
• Code availability (N/A).
• Author’s contributions: M. Young 75% (research design, literature review, data retrieval and analysis, supervision of second author/research assistant; R. Van Tuyl 25% (survey development, literature review, editing).

Note

Britten (2020) and Clow (2020) highlight the needs experienced by PEHCD which are not easily met outside of existing service agencies. As well, the Homeless Hub (nd) identifies the persistent barriers faced by PEHCD which are exacerbated by pandemics and other large-scale emergencies. Canavan, et al. (2012) and Stergiopoulos (2014) identify the breadth and scope of service required, including health care. Boustead and LaTourrette (2014) and SAMSA (2020) show the negative effect on service delivery during large-scale emergencies and crises. Public Safety Canada (2007) and Reichert and Mayer (2018) provide information on the involvement of PEHCD in the criminal justice system. Finally, the uptake of substance abuse during pandemics and emergencies among PEHCD is also documented (Settembrino, 2016; SUDD).