Front-Line Insights Into the Social Determinants of Health in Housing Instability: A Multi-Province Study

Abstract

Introduction:

Individuals experiencing housing instability face significant health inequities. Addressing housing instability requires an understanding of the factors that contribute to these inequities—a responsibility that has been assumed by community-based organizations. Interviewing individuals from 3 Canadian provinces, the present study aimed to examine the perspectives of individuals from front-line services of the social determinants of health (SDoH) needs of individuals experiencing housing instability.

Methods:

As part of a larger knowledge translation study, we conducted 8 semi-structured interviews with individuals from front-line services (eg, shelter workers and shelter mental health nurses) in Canada (Nova Scotia, Saskatchewan, and Alberta) and used thematic analysis to identify predominant unmet SDoH needs.

Results:

Individuals from front-line services discussed the roles of many SDoH that may perpetuate housing instability in their clients. These included: (1) limited social supports; (2) poor access to health services; (3) poor opportunities for income and employment; (4) lack of transportation; (5) gender-based discrimination; (6) race-based discrimination; and (7) limited access to education and limited literacy skills.

Conclusion:

This study reveals how front-line service providers observe SDoH factors contributing to housing instability and create barriers to accessing support services. They advocate for a multi-system approach to addressing intersecting SDoH factors to validate clients’ experiences and help them achieve stable housing. Additionally, more research and consultation with front-line providers are necessary to understand and overcome systemic barriers to stable housing.

Introduction

Insufficient access to secure housing, known as homelessness or housing instability, ¹ affects an estimated 235 000 Canadians per year. ² Health inequities are vastly overrepresented in this population, ³ and housing instability has been bi-directionally associated with poorer health outcomes.^4,5 While the concerning relationship between housing instability and worse health outcomes have been elucidated, the non-medical factors impacting negative health outcomes in this population have only recently gained attention. Further, it is not clear how workers supporting these individuals (ie, front-line workers) perceive the role of these factors in preventing their clients from achieving their housing and health-related needs.

Theis relationship between housing instability and health inequities have been consistently observed in overall health, ⁶ and more specifically with higher rates of infectious diseases (eg, COVID-19 ⁷ ), cardiovascular diseases, ⁸ as well as psychiatric and neurological conditions.^{9 -12} As a consequence of this relationship, life expectancies for individuals experiencing housing instability are dramatically reduced. An 11 year pan-Canadian study explored mortality in 15,100 individuals experiencing housing instability. They observed that 60% of deceased men and 25% of deceased women passed away before the age of 65 years old. ¹³ Further, 30% of the men who had passed away did so before the age of 45. ¹³ More recently, in Ontario, Canada, Toronto Public Health began releasing the average age of shelter residents’ deaths. In 2022, the average age of shelter residents at death was 51 years ¹⁴ ; during the same time period, the Government of Canada reported the average overall age of Canadians at death was 81.3 years. ¹⁵ At the time of writing, the most recent shelter-resident death statistics available are those of January 2024. The average age at death of homeless shelter residents was 46 years for males, 60 years for females, and 35 years for transgender/non-binary residents. ¹⁴ If we aim to reduce health and life expectancy disparities in individuals experiencing housing instability, it’s imperative to understand both the medical and non-medical factors contributing to these sobering statistics.

The social determinants of health (SDoH) are non-medical factors, such as income, education, food security, race, and housing which contribute to health, functioning, and life quality outcomes. ¹⁶ SDoH are a topic of growing interest in global efforts to reduce health inequities disproportionately faced by marginalized communities, and has spread to supporting individuals experiencing housing instability.^{3,17 -19}

Community based organizations (CBOs) have predominantly assumed the responsibility of addressing the SDoH needs of individuals experiencing housing instability. CBOs (nonprofit, non-governmental organizations that seek to address local concerns ²⁰ ) engage in advocacy, provide intervention services (eg, harm reduction, case management, mental health support ⁵ ), and often act as an intermediary for other services. Housing justice and healthcare-specific CBOs have been lauded as integral in supporting individuals experiencing housing instability throughout crises (eg, COVID-19^21,22), which often highlight social inequalities.^23,24 In Canada, over 80% of individuals experiencing housing instability reported using CBOs and did so frequently (mean of 92 visits in a 12 month span ²⁵ ). CBO service providers (ie, individuals from front-line services), evidently play an essential role in addressing the diverse SDoH needs of those experiencing housing instability.

By working with individuals experiencing housing instability, individuals from front-line services (eg, shelter workers, shelter mental health nurses) gain a unique perspective of SDoH barriers. Through supporting many individuals, they amass a wealth of observations rather than relying on the experiences of only 1 person. Further, given the vulnerability of individuals experiencing housing instability, collaborating with individuals from front-line services avoids overburdening the unhoused population while still gaining lived experiences. As such, insights of SDoH needs of individuals experiencing housing instability can be elucidated from individuals from front-line services.

To date, the authors are aware of only 2 studies that have collaborated with individuals from front-line services to understand the SDoH needs of individuals experiencing housing instability in Canada.^26,27 Completed over a decade ago, McNeil et al ²⁶ specifically explored the perspectives of nurses, doctors, and other medical clinicians in their knowledge of SDoH and in their preparedness for the treatment of individuals experiencing housing instability. Healthcare providers described the challenging nature of translating their clinical education/assumptions when providing care to individuals experiencing housing instability. For instance, practitioners understand that SDoH factors adversely impacted their clients experiencing housing instability, but their knowledge was insufficient to integrate this information into treatment planning (eg, understanding the barriers to refilling prescriptions or attending follow-up appointments). More recently, D’Souza and Mirza ²⁷ sought to identify SDoH barriers to accessing health services for foot conditions. Their interviews revealed how the inaccessibility of healthcare, low socioeconomic status, and limited social support negatively impacted service users experiencing housing instability. In turn, this resulted in a decreased trust in the healthcare system from individuals experiencing housing instability, and an increase in disability due to the progression of their conditions. ²⁷ Though both studies offer valuable insight into the SDoH needs of individuals experiencing housing instability in Canada, our research team advocates for an updated and more comprehensive view of mechanisms through which to support the unhoused members of our community. An updated view is necessary to encompass the dynamic social conditions influencing SDoH barriers in Canada, such as the increased cost of living ²⁸ (eg, food prices and rising rent) and the impacts of the COVID-19 pandemic ²⁹ (eg, increased prevalence of mental illnesses and decreased funding). By interviewing individuals from front-line services, their direct insights can identify widely experienced SDoH barriers preventing individuals experiencing housing instability from meeting their housing and health-related needs. We believe that such a perspective is uniquely positioned to enhance health outcomes in this population.

The research team set out to share the valuable observations of individuals from front-line services in understanding SDoH barriers faced by individuals experiencing housing instability. As part of a larger ³⁰ participatory action research project ³¹ pertaining to the neuroscience of housing instability, we conducted semi-structured interviews with individuals from front-line services in 3 Canadian provinces. In this work, we aimed to integrate information about conditions overrepresented in individuals experiencing housing instability with the stories of individuals from front-line services. These observations informed the collaborative creation of a knowledge translation activity.

Using these interviews, we now explore their observations of disparities in access to SDoH faced by their clients. These perspectives present a valuable way to ensure accessible housing support can be provided to the Canadian population.

Methods

All participants interviewed have experience in housing support organizations in various roles. Individuals from front-line services included housing outreach/support workers, mental health nurses/support workers, social workers, shelter coordinators of housing organizations and/or CBOs, and executive directors or presidents of housing organizations and/or CBOs.

The participants (mean age = 40.6 years) were associated with organizations across Canada, including Nova Scotia (6), Alberta (1), and Saskatchewan (1). In total, 8 individuals (n = 8) participated in the interviews, 4 self-identifying as women, 1 self-identifying as a man, and 3 self-identifying as non-binary. Participants were recruited via word of mouth and were included based on their experience working or volunteering with housing organizations and/or CBOs. There were no other criteria restricting participation in the present study. This allowed a breadth of positions and experiences to be included. Our participants included: 2 individuals serving in leadership roles of housing organizations, 1 mental health support worker for a housing and social service organization, 1 mental health nurse working with a housing and social service organization, 1 case manager/team lead for a housing and social service organization, 1 support worker for a women and family violence support organization, 1 housing mutual aid volunteer, and 1 social worker serving individuals involved with the judicial system.

Ethics

This study was approved by the institutional research board at St Francis Xavier University (approval #26221) on 2023/01/05.

Interview Structure

The interviews were semi-structured, allowing participants to elaborate on their answers and take as long as needed to describe their observations. ³² Following warm up questions to build rapport, ³³ all interviews began with the question: “How did you become involved supporting individuals experiencing housing instability?” Participants were asked about their work with their clients and their training. Further, they were asked about the barriers their clients face in accessing support (eg, housing justice and/or healthcare CBOs), how they overcome these challenges, and the existing supports available that are accessible and accommodating. Participants were asked to self-identify the barriers they observed their clients to face in accessing resources and services, and were not explicitly asked about individual SDoH barriers. Demographic questions were saved until the end of the interview, and the research team aimed to keep all interviews less than 1 h long to prevent fatigue from the interviewee and interviewer. ³⁴ All participants provided written informed consent prior to conducting the interviews, and were compensated for their time in accordance with the minimum living wage at the time of study from the province of the research team (Nova Scotia). Compensation was made possible through a Change Lab for Action Research Initiative (CLARI) grant. Questions guiding the interviews have been provided in Appendix A.

Interviews were conducted using the online platform Microsoft Teams by the primary author. To avoid missing important information or inaccuracies in handwritten notes, ³⁵ interviews were recorded and then professionally transcribed and verified by the primary author.

Acknowledging the power dynamic inherent to interview situations, ³³ the research team aimed to reduce this by providing all participants the opportunity to review and correct their transcripts prior to analysis. Providing interviewees the opportunity to revise their transcripts allows factual details to be corrected, new insights to be shared, and for participants to remove information they may feel is inappropriate, confidential, or sensitive. ³⁶ We hoped this collaborative experience would empower our interviewees and improve trust between the interview parties. ³⁷ Some participants (3/8) provided changes from their original submission. These were predominantly minor clarifications (eg, specification of “health clients” when the audio was indiscernible), with 1 participant removing some story sharing and identifying details. All participants were given the option to be acknowledged by name for their contributions or to participate confidentially.

Theoretical Framework

Lave and Wenger ³⁸ propose situated learning: a theory that suggests that learning best occurs through participating in complex social interactions rather than from abstract instruction.^38,39 The “legitimate peripheral participation,” as described by Lave and Wenger ³⁸ suggests that individuals from front-line services gain valuable knowledge throughout their work/volunteer activities. This enables them to transition throughout their careers to key individuals in communities of practice (CoP ³⁸ ), and posits our participants as key knowledge-users concerning the SDoH barriers faced by their clients. Recognizing the learning that emerges from front-line experiences, the research team sought to record insights from participants on SDoH needs and barriers as they relate to housing instability. Further, we asked our participants to identify collective barriers their clients face instead of asking about specific barriers reported in extant literature. This further served to recognize their role as knowledge-users and the expertise that comes from their lived experiences.

Interview Analysis

The research team reviewed the transcripts to familiarize ourselves with the content of the interviews. After this review, we developed 3 first-cycle codes (based on similar content ³³ ) informed by the most pertinent World Health Organization’s (WHO) categorization of SDoH ⁴⁰ : (1) system barriers to accessing healthcare and other services (eg, emergency shelters); (2) social and community vulnerabilities; and (3) economic/education security barriers. We iteratively reviewed these first-cycle codes, and from them developed second-cycle specific SDoH and barriers themes during qualitative description. ⁴¹ These themes were specific mechanisms through which our participants’ clients experienced reduced ability to have their housing/SDoH needs met, thus all second-cycle themes were exclusively developed from the data, unrelated to a priori sources (ie, WHO report). Second-cycle themes were added to a codebook if they were identified by 2 or more respondents. These included: (1) system barriers to accessing healthcare and other services: limited social and professional supports; poor access to health services; and lack of transportation; (2) social and community vulnerabilities: gender-based discrimination; and race-based discrimination; and (3) economic/education security barriers: poor opportunities for income and employment; and limited access to education and limited literacy skills. However, the themes identified under social and community vulnerabilities (gender-based discrimination; and race-based discrimination) were described by only 2 participants. Thus, we reclassified these themes as “Further Insights” to share these under-discussed comments while distinguishing them from the broader identified themes.

Results

8 individuals from front-line services were interviewed about their involvement in supporting individuals experiencing housing instability. Responses were coded based on the SDoH needs and barriers faced by individuals experiencing housing instability. Some quotes have been edited for length and clarity.

The research team sought to understand the barriers to accessing SDoH needs faced by individuals experiencing housing instability. In the following section, we will describe the SDoH content and some associated stories provided by participants. These were coded across 6 major themes and 2 further insights that we developed during our analysis of emerged through the interviews: (1) limited social supports; (2) poor access to health services; (3) poor opportunities for income and employment; (4) lack of transportation; and (5) limited access to education and limited literacy skills. Further insights from participants indicated the persistence of (1) gender-based discrimination, and (2) race-based discrimination.

The collective insights from our interviews are underscored in 1 quote describing the intersection of the above mentioned SDoH with housing:

For many determinants, housing is a fundamental determinant that makes all those other determinants possible. You’re not going to be able to focus on your relationships or education or employment if you don’t have housing.

Social and Professional Supports

Seven participants described how social support (from family, friends, romantic partners, and/or professional support from front-line service workers) may influence housing access. These were described in different contexts as potentially positive and negative. Negatively, a lack of social support may increase an individual’s risk of experiencing housing instability:

The clients that come to us for housing instability are generally there because there’s been some sort of breakdown in the family. That’s a large portion. Whether it’s they’re coming from foster care or they’re coming from an abusive household or whatever.

In geographically isolated and underfunded rural communities, individuals are sometimes removed from social supports to access services:

Not having familial support in the area and not knowing anybody can be a huge barrier. Or not even knowing what services are offered in the area that they’re in as well.

Positively, social support served as a potential protective factor. Having social supports was observed to greatly improve the housing situation of some clients:

Largely, improving their housing situation came down to the fact that they felt supported. They reconnected with things like education or helpful family members. There was this reintegration within the family unit, with whatever that looks like, so that they were in a healthier spot in getting their basic needs met.

Social support from front-line service providers (sometimes described as professional support) was also reported as being beneficial for clients. Positive relationships where clients felt supported by individuals from front-line services may play an integral role in achieving housing stability:

In that case, it really was [service providers] being there for them. That was really what helped them avoid the severity of their crisis, being even more severe, is that [service providers] were there for them and they weren’t left alone.

However, clients trusting service providers was described as extremely important:

Trust is a barrier. Somebody who hasn’t worked in this field may say, “Well, it’s simple. They just need to go and do that.” Well, it’s not simple when you don’t have trust. You don’t understand how to navigate the system, and you don’t trust the people that are trying to help you. That’s a barrier, right?

Access to Health Services

Four participants described their clients’ experiences with, and access to, healthcare services (physical and mental). From a quantity perspective, individuals from front-line services reported that there are currently an insufficient number of services available for those in need:

We know that with the way that all the provinces are right now, there’s not enough services for folks. When they’re not well, it’s next to impossible to find services.

The lack of family doctors across Canada has also put a strain on walk-in services that are not designed for longer-term care:

There’s 100,000 people on the list for a family doctor [in this province]. You can’t expect a walk-in to make a diagnosis when this is someone that they’ve seen for the first time. They don’t know their baseline. You need a doctor to be around for a while in order to make the important decisions. “This person seems like they’re very far away from their baseline. Should we put medication in place? Should we follow up to see if the medication is working?”

For those able to receive care, some individuals may struggle to understand the unspoken social rules of healthcare services. For example, in an ideal world, medical appointments would always begin at the scheduled time; in reality, this is infrequently the case due to the unpredictability of the healthcare system. One participant shared stories about a service user who, following a stroke, had difficulty understanding these unspoken norms, and who experienced personality changes that impacted his ability to use services (eg, decreased patience). When he attempted to receive further healthcare:

He was asked to leave the ER because he questioned why the wait was long. He’s been asked to leave walk-ins because he walks in for an appointment and he believes that his appointment should start on time, which we know is never going to happen.

While it is reasonable to expect punctuality for appointments, difficulties in understanding the discrepancy between ideal and reality scenarios of the healthcare system may impede access to services, as evidenced by the client leaving before having their needs addressed.

For those unable to receive traditional care, popular alternatives (such as telecare) are often still inaccessible:

Even looking at the COVID thing, how many of our clients have tablets or computers at home [? O]r internet? When the library shut down, that shut down the communication station for a pile of the folks in the community. Even right now, they’re saying, “if you are on the doctor’s list and you need a doctor, you can always call 211 and then go online to talk to a doctor on Maple” [a virtual care platform in Canada]. That would take me about an hour to try to sit down and explain to someone [experiencing housing instability] how they’re going to access that service. We’d have to lend them a tablet, we’d have to set it all up for them, they’d have to go to the library or somewhere else with reliable WiFi, and it wouldn’t be a confidential call.

While some libraries in Canada allow room bookings for private calls, this is not yet a streamlined or easily accessible service for many. However, these calls, and medical care more broadly, was described as being incredibly important to the clients of individuals from front-line services. Specifically, access to formal diagnoses of disorders is often required for treatment:

With access to diagnoses does come pharmaceutical interventions, comes psychiatric support, clinical interventions, all of that if you have that diagnosis.

Diagnoses, however, may inadvertently harm individuals experiencing housing instability and prevent them from receiving other care. For example:

As more than one young woman told me in response to, for example, a borderline personality diagnosis, is that “Once you’re diagnosed with BPD, nobody ever believes another thing you ever say,” because everybody thinks it’s the disorder speaking. I think that it was very helpful to sit with people and to consult with them about what they think of the diagnosis. Are there parts of it that make sense? Are there other parts of it that don’t?

Income and Employment

Five participants discussed the importance of income and employment in achieving stable housing, as well as barriers to gaining employment without stable housing. One participant who works with youth stressed the importance of this:

Being able to either get their [General Education Diploma] or finish high school so that they can go on to find work and become vocationally successful. Huge, huge benefit. A lot of issues are helped by [finding work]. Get your basic needs met and then your other needs start to fall into place.

Financial insecurity may result in individuals staying in unsafe relationships to secure housing. This was described by 1 participant:

They can’t leave a relationship because they don’t have the finances to leave that relationship because they’re solely relying on their partner. Sometimes if they’re eligible for any disability or income assistance support, the partner’s not allowing them to reach out to those services to get that as well.

One participant also suggested that individuals may turn to illegal or unsafe practices to earn an income. When describing an individual battling addiction:

We know that they were getting involved in [sex] work, which is– my understanding is they weren’t being trafficked, they were doing the work themselves because that can be a way to make money. That’s survival. In general, I’m not against sex work, but they seem to have disappeared, so I’m worried.

Transportation

Three participants discussed how insufficient access to transportation, particularly in rural communities, impacted accessing health and housing services. One participant described:

If they miss the bus, they’re depressed, they’re supposed to go see their counselor, they’re just going to turn around and go home.

The participant then highlighted the importance of holistic funding that makes overcoming these challenges possible.

Having the ability to be able to give them a taxi chit or bus tickets on short notice, that’s really important. You don’t want to have to apply to your boss’s boss’s boss for a $15 taxi chit. We have to have responsive money that’s allocated for those situations where we need it right away.

Education and Literacy

Two participants described the relationship between literacy and housing access, specifically, forms and paperwork for accessing support services:

The way in which government forms are presented are kind of ableist. You have to have a certain cognitive capacity to understand how a form is laid out. You have to be literate. If there’s functional literacy issues that have gone undiagnosed through the school system, that’s another barrier. Maybe there’s other factors, like ADHD or substance abuse, impacting their attention and ability to fill out those government forms.

Further, 2 more participants described the value of education and literacy, particularly as factors relevant for securing and maintaining income and by extension stable housing. Limited education and literacy may be particularly notable when combined with other factors:

Literacy and education can be a huge part of being a barrier as to why they’re not being able to find housing. Sometimes it’s food insecurity, so you are not paying your rent because you know that you need to go buy groceries for yourself or your kids. . . All those compounded together could be a huge barrier for anybody.

Further Insights: Gender

While not widely discussed by our sample, 2 participants described how being of a gender minority negatively impacted housing support access. One participant referenced their lived experiences of housing instability, and their avoidance of emergency shelters due to safety concerns being a transgender non-binary woman. They also reported observing similar behaviors in their clients:

That individual was of a gender minority, also, they had addiction. That makes it difficult to go into shelters. Also, as a gender minority, certain circumstances were dangerous. It’s why I avoided them as a trans woman. That was definitely a barrier to access to support.

More broadly, another participant suggested it is necessary to consider the impact of being a gender minority on service use. They shared that to effectively support gender minority individuals experiencing housing instability (eg, transgender, nonbinary, 2-spirit), it is necessary to have gender-minority-specific services (eg, safe spaces for individuals of gender minorities):

We have to make sure that we’re really thinking through how [service delivery] impacts people across diverse experiences, but also with different lived experiences, different social locations. Things have to be gender-[minority]-specific. I think it’s important to be gender inclusive and really think through how [our service delivery] impacts folks [of gender minorities].

Further Insights: Race

Another perspective that was not well-described but present in our data was the role of race-based discrimination. However, 2 participants did describe how racism impacts housing and mental healthcare access. One participant emphasized this in the context of racism and mental illness perpetuating the overrepresentation of Black people experiencing incarceration:

If I’m working with an African [PROVINCE] man, who’s really rageful and screaming and yelling, it’s really easy for people to just discount him as an angry Black man, when really he’s actively unwell and experiencing psychosis. Like he is psychotic currently and needs some intervention, but the way that it presents under the lens of racism is that he is just an angry Black man, who’s very, very violent and volatile and needs to go to jail.

Conclusions

It is important to explore the extent to which a lack of access to SDoH needs may prevent individuals from achieving stable housing and meeting their health needs. Consulting individuals from front-line services presented an opportunity to learn further about this issue. Throughout the 8 interviews conducted, 7 participants discussed the role of social and professional supports, 5 described the importance of income and employment, 4 reported poor access to health services, 4 described the value of education and literacy, 3 described inaccessibility of transportation, 2 described gender-based discrimination, and 2 described race-based discrimination.

Our interview results provide an overview of the perspectives of individuals from front-line services, indicating that associations exist between SDoH and housing access in Canada.

Participants frequently reported social and professional support as a factor that influences housing stability. They described the breakdown of social supports leading to housing instability, the important role of social and professional supports when experiencing housing instability, and how re-establishing social supports was beneficial to securing and maintaining housing. Several participants further expressed that there are an insufficient number of healthcare services available to their clients, and that the services available are a poor fit or are not prepared to deal with the level of acuity presented by their clients. However, individuals from front-line services also shared that access to treatment for medical (especially psychiatric) conditions may considerably improve housing outcomes. Income and employment also serve as important considerations for housing stability. Without employment, participants described individuals staying in unsafe relationships to maintain housing they otherwise could not afford, as well as engaging in illegal and unsafe activities for income. Some participants emphasized that having employment was a protective factor and improved housing outcomes. Gender, race, and education and literacy were minimally discussed in the interviews. Literacy was predominantly discussed in the context of understanding government forms, and education was discussed as 1 facilitator to employment. Gender and race were not frequently identified as key barriers to housing or SDoH, though interviewees acknowledged they may play some role in diagnosis and service use.

Descriptions of the importance of social support were consistent with several studies of individuals experiencing housing instability, and serious mental illnesses/substance use disorders.^{42 -44} In 1 study, semi-structured qualitative interviews were conducted in Greater Los Angeles, and all individuals (n = 19) interviewed described social and professional support as important for securing and maintaining housing. ⁴⁴ Differences in formal (eg, front-line worker) and informal (eg, family) support was highlighted by Gabrielian et al, ⁴⁴ however, differences in sources of support were not discussed in the present interviews. Both results from Gabrielian et al ⁴⁴ as well as the present study suggested that positive social support serves as a protective factor against housing instability, whereas a breakdown in these connections can negatively influence housing outcomes. Our results expand upon the extant literature by alluding to the difficult decisions service-users may need to make: individuals from rural communities may need to relocate to access support services, but as a consequence they may lack family support in the area. This paradox has not been described in previous interviews with front-line workers in Canada^26,27; thus, our research presents an important perspective in a country with such diverse urbanization patterns. This further underscores the integral role of the front-line worker in providing personalized and empathetic care. The social support provided by front-line workers, and its benefit of increasing service-user confidence, supports the downstream value of the humanizing and patient-centered care that motivates CBOs, positioning them as integral mechanisms through which housing instability can be addressed.

Despite Canada’s universal healthcare system, 50% (4/8) of the participants reported issues their clients face with accessing health services. They discussed how their clients are often refused, mistreated, and/or asked to leave medical facilities and thus receive poor medical care (if they receive medical care at all). They also emphasized how transportation issues and difficulties in finding a primary caregiver served as significant barriers to healthcare access. This aligns closely with the healthcare barriers identified by individuals experiencing housing instability in Ontario, Canada. ⁴⁵ A study in Calgary, Alberta further reported that difficulties with self-advocacy, navigating the complexities of the medical system, and a lack of identification documents also serve as barriers to accessing medical care. ⁴⁶ Educating medical care providers about these barriers may serve as a pathway to empower more knowledgeable and empathetic workers, consequently, improving the quality of care they deliver.

D’Souza and Mirza ²⁷ highlighted similar healthcare issues: disrespect from medical practitioners, reliance on emergency services, and transportation barriers prevent healthcare service access. However, this exclusively reflects the concerns of those seen by medical practitioners; our study offers a more complete perspective by describing those who are turned away from medical centers. We illustrate the critical gaps in the reality of the homeless sector: those with the highest level of acuity receive the least care. This implores a fundamental shift in healthcare delivery, advocating for those currently unreflected in the healthcare system, instead of exclusively considering those already accessing it.

Income and employment were mentioned by several participants but were not highlighted as a major SDoH of importance to their clients. This was surprising, given that a pan-Canadian study of 5 housing-first sites (ie, sites where housing is provided prior to other services), reported that 93% to 98% of individuals were unemployed, and 61% to 83% wanted to work. ⁴⁷ This discrepancy may be the result of the focus of our broader study ³⁰ being on the neurological and psychiatric conditions overrepresented in individuals experiencing housing instability. Though not identified as a major theme, this still offers new insights into the SDoH barriers in Canada, highlighting the impact of income and employment on meeting SDoH needs—an aspect not reported by D’Souza and Mirza. ²⁷

Transportation concerns were highlighted by several participants. Of the individuals who reported barriers posed by unreliable transportation or who highlighted the necessity of transportation for their clients, ⅔ were in rural communities and ⅓ was working in a city but in a position involving a provincial scope. The importance of this variable has been discussed in a recent systematic review which describes transportation modes, destinations, and distances traveled by individuals experiencing housing instability. ⁴⁸ This systematic review summarized that accessing medical services, visiting family, going to foodbanks, shelters, job interviews and attending church were the most important destinations for individuals experiencing housing instability. ⁴⁸ Similarly, D’Souza and Mirza, ²⁷ describe the reliance on transportation to address medical needs. This is consistent with the description from our participants that transportation is imperative for their clients to access essential health and social services. As such, advocating for accessible public transportation near medical and housing facilities may serve as a new avenue to reduce healthcare access disparity in individuals experiencing housing instability.

A strength of this study compared to D’Souza and Mirza ²⁷ is its inclusion of perspectives from participants in multiple areas of Canada (3 provinces). Having multiple participants based in rural communities allowed us to share observations that are underrepresented in urban research. Our virtual interview approach enabled the research team to discuss challenges encountered by organizations from across the country, generalizing our findings. Additionally, the diverse group of participants spanned various different professional groups, educational backgrounds, and career stages. Of the front-line individuals interviewed, 35% (3/8) identified as a member of the 2SLGBTQIA+ community, and 50% (4/8) identified as having a mental or physical disability. This diversity allowed for a broad range of perspectives on the challenges faced by individuals from front-line services and their clients, which can increase the potential transferability of the recommendations.

Nevertheless, our study has some limitations that should be considered. First, we were not able to recruit participants from every province and territory. In future work, more assertive outreach is necessary to create a comprehensive pan-Canadian perspective, particularly in the territories and in major Canadian cities, such as Toronto (Ontario), Montreal (Quebec), and Vancouver (British Columbia). Additionally, there were no participants who self-reported as Indigenous or any other ethnic or racial minority. This may further explain why race was not commonly discussed in the interviews. Alternatively, this may also be a result of the broader study’s focus on neurological and psychiatric conditions overrepresented in their clients, and that barriers were identified by participants during the interview. If participants had been explicitly asked about barriers commonly reported in the extant literature, there may have been greater emphasis on barriers not predominantly discussed (eg, race-based discrimination). Given the racial disparities in housing instability, ⁴⁹ additional research should ensure perspectives from front-line workers and front-line leaders of diverse ethnic backgrounds are included. Their insights may offer a more nuanced understanding of organizational challenges (eg, racism in shelters) related to these issues. This may be, in part, a consequence of our word of mouth sampling method, which has important limitations in reach and diversity. Consequently, our findings will be biased toward the experiences of these individuals (predominantly in 1 province), and more diverse recruitment may offer broader insights into SDoH.

This study was also limited in its cross-sectional nature. It is possible that the perspectives of individuals from front-line services may change throughout the duration of their involvement in this field and as social situations change (eg, the COVID-19 pandemic, international affairs resulting in an increased number of refugees, etc.). Therefore, ongoing dialogue with individuals from front-line services is necessary to create dynamic and contemporary programs.

Finally, outside the scope of this study were the perspectives of individuals experiencing housing instability. While individuals from front-line services will work with numerous individuals and thus have a broader perspective, further research should additionally include individuals experiencing housing instability to ensure their voices are being heard,^50,51 as they are the experts on the challenges they are currently facing. ⁵² Additionally, this would help to determine the proficiency of individuals from front-line services in identifying the needs of their clients, and identifying potential discrepancies between the perspectives of clients and service providers.^53,54

Another audience who may benefit from hearing these insights are policy-makers and similar government stakeholders. As such, further work should determine the best way to disseminate the perspectives of individuals from front-line services to stakeholders (eg, via knowledge translation activities) to improve the quality of housing support programs. Sharing these perspectives to various stakeholders initiates the discussion of opportunities to create holistic and evidence-based interventions to support individuals experiencing housing instability.

For instance, sharing barriers to accessing healthcare services with healthcare professionals may prompt the development of partnerships with individuals from front-line services to better serve this population. Similarly, discussing the role of transportation with transit planners and representatives from a local Department of Transportation may create the opportunity to increase the frequency of specific routes and thus the accessibility of services.

This study elucidates the manners in which individuals from front-line services believe SDoH factors perpetuate housing instability and create barriers for accessing housing support/health services. Individuals from front-line services described that an SDoH-informed approach is necessary to both validate the experiences of clients, and help them achieve their housing and health needs. More research is needed to understand the systemic barriers that prevent individuals from achieving these goals. Finally, more consultation with individuals from front-line services, who play such a pivotal role in helping individuals exit housing instability, is warranted to effectively address this important social issue.