Food Disparities in People

Experiencing Homelessness
UCLA School of Nursing
N249: Meeting Health-Related Needs in Underserved Populations
Brian Chen
Brittany Hartin
Ashley Kandu
Jason Ly
Irina Mkchyan
Robert Quevado
TABLE OF 01 Introduction
CONTENTS
02 Population & Disparity

03 Literature Review

04 Guideline Adaptations
 01
Introduction
 PURPOSE

Are existing practice guidelines and/or

interventions sufficient to address the food
disparities in people experiencing
homelessness?
CONCEPT DEFINITION
Population - People Disparity - Food Insecurity
Experiencing Homelessness
POPULATION: PEOPLE EXPERIENCING HOMELESSNESS

Definition: According to the US department of Housing and Urban Development (2019) an

individual who lacks a fixed, regular, and adequate nighttime residence, meaning:
● Has a primary nighttime residence that is a public or private place not meant for
human habitation;
● Is living in a publicly or privately operated shelter designated to provide temporary
living arrangements (including congregate shelters, transitional housing, and hotels
and motels paid for by charitable organizations or by federal, state and local
government programs); or
● Is exiting an institution where(s) he has resided for 90 days or less and who resided
in an emergency shelter or place not meant for human habitation immediately before
entering that institution
DISPARITY: FOOD INSECURITY

Definition - Limited or
uncertain availability of
nutritionally adequate and
safe foods, or limited or
uncertain access to food.
 DESCRIPTION OF GROUP PROCESS
● Identified vulnerable population: Non-senior adults experiencing
homelessness in Los Angeles
● Selected health disparity: Food insecurity
● Attempted to further narrow population but was unsuccessful in finding
sufficient research for single sub-group of people experiencing homelessness
○ Returned to original vulnerable population.
● As a group, conducted literature search on current guidelines and past
interventions for food disparities in people experiencing homelessness

Research Questions:
● What are the most recent and applicable interventions to decrease food
insecurity for people experiencing homelessness in the United States?
● What resources are available in Los Angeles to provide to our patients?
 02
Population &
Disparity
PEOPLE EXPERIENCING HOMELESSNESS
Definition:
● According to the US department of Housing and Urban Development (2019), homelessness is
defined as “a person who lacks a fixed, regular and adequate nighttime residence”.
● Shelters encompass emergency shelters, transitional housing facilities, rapid rehousing
programs, and permanent residences.

Statistics for 2019:

● An estimated 567,715 people were reported to experience homelessness, which was almost a
3% increase from 2018. About 19% of those experiencing homelessness are age < 18
● Less than two-thirds used shelters but it has been declining since 2014.
● California accounts for half of the people experiencing homelessness in the U.S.
● On a single night in California, 27% experienced homelessness and 72% of them remained
on the streets.
● California reported a 16.4% increase between 2018 and 2019.
DISPARITY: FOOD INSECURITY
Current Data:
● Impacted approximately 37.2 million households in 2018 and an estimated 50 million
persons in 2015.
● Related to poor health outcomes (i.e. hypertension, diabetes, depression, obesity,
malnutrition, post-traumatic stress disorder), and other mental illnesses.
● Possible correlations to poorer coping mechanisms and decreased stress tolerance.

Impact in People Experiencing Homelessness:

● Prevalence of food insecurity was six times higher in people experiencing
homelessness than the normal American household.
● For those who lacked stable shelter, 61.6% of individuals were unable to purchase the
type and amount of food they desired.
 INTERNAL FACTORS

● Feeling of exclusion and inadequate

social support system
● Alcohol, tobacco, or substance abuse
● Cognitive impairment
● Depressive symptoms
● Underlying chronic medical
comorbidities
● Lack of knowledge or failure to access
social services and/or reduced-price
food plans
EXTERNAL FACTORS
● Inability to secure stable housing,
temporary shelter, or location to cook
items from food pantries or other low-
cost grocery programs
● Unemployment or insufficient work
hours/wages
● Living with children as a single parent
● Social stigma and prejudice
● Unfavoring weather conditions
03
Literature
Review
LITERATURE SEARCH
PUBMED CINAHL

● Search terms ● Search terms

○ “(homeless) AND “food ○ “Food security” OR
insecurity” “food insecurity” OR
○ = Yield: 102 hunger OR food AND
● Modifications homeless”
○ Clinical trials ● Modifications
○ 5 years ○ English
○ = Yield: 4 ○ Full Text
○ January 2015 - May 2020
○ = Yield: 122
 INTERVENTION #1: SCREENING
● Purpose
○ To implement a food insecurity screening performed for veterans currently or previously experiencing
homelessness, from six different Veterans Affairs (VA) primary care clinics
● Procedures
○ A social worker, physician, registered nurse, or nutritionist initiates the topic with a single question regarding
food insecurity in the last 3 months, and if the answer is yes from the patient, then six additional more specific
questions are asked to determine who the patient should see next in follow-up
● Results
○ Common factors in food insecurity included depression, psychosis, alcohol abuse, and diabetes
○ Screening with questions allowed health care providers to build rapport with patients
○ Accepted by patients and endorsed by health care clinicians because survey was brief (3-5 minutes) and
addressed food insecurity from various facets
● Limitations
○ Limited to veterans, who were predominantly men
○ Additional research needed in follow-up survey and the influence of the screener’s role on the patient’s
responses
● Applicability
○ Although the study was primarily males, the study was performed on adults experiencing homelessness with the
last five years in the United States
 INTERVENTION #2: DIET PROGRAM
● Purpose
○ To evaluate the feasibility and effectiveness of a diet and physical activity program for adults experiencing
homelessness
● Procedures
○ Participants were randomly assigned to the diet/physical activity group (intervention) or the group that received
all the intervention components (i.e. diet/physical activity/newsletter) after the study completion (control).
● Results
○ Self reported fruit and vegetable consumption (baseline to end-of-treatment) was not significantly different
between the 2 groups
● Limitations
○ Study specific to people experiencing homelessness living in shelters, but does not take into account those
outside the facility or without permanent housing
○ Program focused mainly on healthy eating and engaging in exercise within the study, but post-intervention
follow-up was lacking
● Applicability
○ Generalizability may be limited due to being done primarily on males, but can still be relatable due to study
being done in the U.S. and within the last 5 years
 INTERVENTION #3: HPACT PROGRAM
● Purpose
○ To analyze the effectiveness of the Homeless Patient Aligned Care Team (H-PACT) program for veterans
experiencing homelessness by combining health care with social services.
● Procedures
○ Enrolled for minimum of 1 year at H-PACT clinics that offered primary care, mental health services, and resources
for transportation, food, shelter, hygiene and clothing. Additional resources included legal and employment
assistance.
○ Sites were evaluated yearly and categorized into low-, medium-, and high-performing clinics based on utilization
of services and number of ED or hospital admissions.
● Results
○ High-performing clinics provided more food services (i.e. food pantry, vouchers, food stamp applications) than
low-performing locations (64.7% vs 14.3%, P = .02).
○ Inclusion of community resources and outreach for transportation, clothing and food improved performance of
the clinic.
● Limitations
○ Possible experimenter bias for expectancies of the clinics and their capabilities for veterans experiencing
homelessness
○ Restricted to veterans experiencing homelessness
○ Cost of program maintenance was significantly high and required funding from community leaders.
● Applicability
○ Though further research is needed to evaluate program for other populations, it can be applied to general
population as an option to address food disparity in the communities experiencing homeless.
 INTERVENTION #4a: HOUSING PROGRAMS
Pankratz et al. (2017):
● Purpose
○ To determine if rent assistance for those frequently experiencing homelessness will report improved housing
stability and psychosocial experiences, including quality of life, social support, community contribution, and
food security.
● Procedures
○ Two groups of populations experiencing chronic homelessness and receiving intensive case management were
followed over six months. One group also received rent assistance through the Housing Assistance with Support
(HAWS) program. Individuals were interviewed prior at baseline before receiving rent assistance, and after six
months.
● Results
○ HAWS reported a 2.5 improvement in the FS Scale (P .008), while non-HAWS only indicated ..75 improvement (P
= .411).
○ Rent assistance and intensive case management offered markedly better housing stability that continued after
six months.
● Limitations
○ Small sample size that was formed by outside evaluators to reduce experimenter bias.
○ Drop out rate = 15% due to lack of follow-up, incarceration, re-location, or unwillingness to participate
● Applicability
○ Though the study was conducted in Canada, the sample population was similar to the target population.
 INTERVENTION #4b: HOUSING PROGRAMS
Shinn et al. (2016):
● Purpose
○ To analyze 3 different housing and social programs to each other and to 12 different sites in the US as an potential end to
homelessness.
● Procedures
○ Sample families were invited from the emergency shelters to participate in the study. They were placed into programs
based on their eligibility. A control group who received usual care with no additive services were also followed. Families
chose to accept the offers into the programs. Interviewed adults in families at emergency shelters and at 20 months.
○ Housing programs available were permanent housing subsidies, community-based rapid re-housing subsidies and project-
based transitional housing.
● Results
○ Permanent and rapid re-housing improved food security from 66% to 75% in families. Transition housing did not show an
influence on food security.
○ Food security for permanent housing subsidies is higher reported than usual care (P < .01).
○ Food security in rapid housing is higher than usual care (P < .05).
○ Permanent housing subsidies provided a more significant impact on homelessness and food disparities than the two other
housing programs.
● Limitations
○ Many families lost eligibility for housing programs for various researson
○ Limited to adults in families.
● Applicability
○ Though study focused on families, self-reports were provided by adults of the families. Can be applied to general population
experiencing homelessness.
○ Further research is needed to assess other groups.
 COMMON GAPS IN LITERATURE
● Insufficient data on addressing only food disparity as
intervention. Most studies provided a multi-faceted approach
including food security to combat the challenges in caring for
individuals experiencing homelessness.
○ Food security was often a secondary outcome from research

● Difficulty to follow-up with patients due to housing and financial

instability.
● Limited generalizability as most subjects were predominantly
male.
● Studies on meal programs conducted in 1980-1990s.
 04
Guideline
Adaptations
CURRENT GUIDELINES
Healthy People 2020 Recommendations:
● Food assistance programs address barriers to accessing healthy foods.
Evidence supports these programs may reduce food insecurity.
● Non-senior, Adult Programs:
○ Supplemental Nutrition Assistance Program (SNAP)
○ Women, Infants, and Children Program (WIC)
○ CalFresh
● Programs for Seniors:
○ Senior Farmers Market Nutrition Program
○ Commodity Supplemental Food Program
● Programs for Children:
○ National School Lunch Program
○ School Breakfast Program
CURRENT GUIDELINES

AARP Foundation Recommendations:

● Screen and referral strategy for primary care care
providers
○ Administer brief screening questionnaire
■ 2 item screening tool
○ Refer positive patients to assistance programs
and community resources
■ Assistance programs
● SNAP, Calfresh
■ Community resources
● Food banks, food pantries
CURRENT GUIDELINES
American Academy of Pediatrics Recommendations:
● Screening for food insecurity at health maintenance visits and refer
positive patients to food assistance and community resources
● 2-question validated screening tool
● Referral to food assistance programs and community specific resources
○ WIC, National School Lunch
○ Food banks, food pantries
BRIEF SCREENING FOR FOOD INSECURITY
 SUPPORTING EVIDENCE
● Screening
○ Brief assessment using two-item screening tool
■ Sensitivity across high-risk population subgroups of ≥97 % and a
specificity of ≥74% for food insecurity (Gundersen et. al., 2016)

● Referral to food assistance programs

○ Recipients of SNAP benefits experienced 30% reduction in being food
insecure (Ratcliffe et al., 2011)
○ Inconsistent evidence supporting role of food banks and food pantries in
reducing food insecurity
■ Food banks do not reduce long term food insecurity but may be useful
in providing emergency food access (Bazerghi et. al., 2016; Loopstra,
2018)
 MODIFICATION OF GUIDELINES
Current Guidelines: Modification:
● AARP: Screening and referral ● Include non-senior adults experiencing
for senior patients homelessness in the screening for
● American Academy of food insecurity and referral for eligible
Pediatrics: Screening and food relief programs at every health
referral for pediatric patients visit

Why is it important to include screening and referral for food insecurity in non-
senior adults experiencing homelessness?
● Homelessness is correlated with increased food insecurity (Hernandez et. al.,
2019)
● Food insecurity is associated with negative outcomes including increased risk
for impaired mental health and chronic diseases such as DM, HTN and
hyperlipidemia (Gundersen et. al., 2015; Parpouchi et al., 2016)
CYCLE OF FOOD INSECURITY AND CHRONIC DISEASE
GUIDELINE ADAPTATION: SCREENING & REFERRAL
Benefits: Drawbacks:
● Low-cost ● May be viewed as an additional
● Screening is quick and easy clinician burden in already resource
poor clinical settings
● Applicable to non-senior adult
populations experiencing Anticipated Problems with
homelessness Implementation:
● High acceptability to clinicians ● Encouraging providers to adopt
and patients change in practice
● Referral utilizes ● Provider attitudes
multidisciplinary team ○ Fear of reducing patient
satisfaction
● Patients have indicated
● Clinician confidence in managing
preference for inclusion of positive screenings
screening and referral for food
insecurity at clinic visits (Kopparapu et al., 2020)
 OUTCOME MEASURES
Outcome Measures Method of Evaluation
Decreased food insecurity Screening completed at every visit
Hunger Vital Sign (HVS) Two-Question Screening Tool
Household Food Security Survey

Increased nutritional intake Mini Nutrition Assessment

Malnutrition Screening Tool

Reduced risk of obesity and diabetes BMI, Hemoglobin A1c, fingerstick or plasma glucose
mellitus

Improved chronic disease management Blood pressure, lipid panel, decreased hospitalizations
(i.e. hypertension, hypercholesterolemia) and ER visits

Lessened depressive symptoms PHQ-9 at each visit

Utilization of coping strategies, such as, meditation,
mindfulness, and breathing exercises.
FOOD RELIEF PROGRAMS IN L.A.
● Afterschool Meal Program ● Head Start
● CalFresh (Supplemental ● Home-Delivered Nutrition
Nutrition Assistance Program Program
or SNAP) ● Market Match
● Congregate Nutrition ● Meals on Wheels
Program (Congregate or ● School Breakfast Program
Senior Meals) and National School Lunch
● Child and Adult Care Food Program (School Meals)
Program (CACFP) ● Summer Meals Program
● Food Gleaning and ● Women, Infants, and Children
Redistribution (WIC)
● Food Pantries (Feeding ● WIC + CalFresh, Better
America, Mazon, LA Regional Together!
Food Bank, Westside Food
From LA County Department of Public Health
Bank) http://publichealth.lacounty.gov/nut/food_assistance_pro
grams.htm
 FUTURE RECOMMENDATIONS
For Research:
● Recruit individuals experiencing homelessness from multiple shelters or
communities to better diversify sample groups and improve generalizability
● Maintain contact through post-study interventional care to ensure adequate follow-
up and more accurate data
○ Consider incentives for participants, if possible
● More rigorous evaluation of interventions in reducing food insecurity and negative
health outcomes associated with food insecurity

For APRNs:
● Connect patients to community resources and referrals, such as, public health
agencies and social workers at the time of visit
● Recognize housing and food disparities as important social determinants of health
by implementing Shuler’s Model when planning care
● Advocate for public policy initiatives aimed at reducing food insecurity
 SUMMARY
● Negative health outcomes associated with food insecurity include
depression, obesity and chronic diseases such as HTN, DM,
hypercholesterolemia
● Primary care visits provide opportunity for identifying and
addressing food insecurity in those experiencing homelessness
● Strategies for addressing food insecurity in people experiencing
homelessness include screening, education, and referral to
comprehensive social support and assistance programs
 REFERENCES
AARP® Official Site - Join & Explore the Benefits. (n.d.). Retrieved from
https://www.aarp.org/content/dam/aarp/aarp_foundation/2016-pdfs/FoodSecurityScreening
AHAR Reports. (n.d.). Retrieved from https://www.hudexchange.info/2019/homelessness-assistance/ahar
Bazerghi, C., McKay, F. H., & Dunn, M. (2016). The role of food banks in addressing food insecurity: A systematic review. Journal of
Community Health, 41(4), 732–740. https://doi.org/10.1007/s10900-015-0147-5
Gundersen, C., Engelhard, E. E., Crumbaugh, A. S., & Seligman, H. K. (2017). Brief assessment of food insecurity accurately identifies high-risk US adults.
Public Health Nutrition, 20(8), 1367–1371. doi: 10.1017/s1368980017000180
Eicher-Miller, H. A., Mason, A. C., Abbott, A. R., Mccabe, G. P., & Boushey, C. J. (2009). The Effect of Food Stamp Nutrition Education on the Food
Insecurity of Low-income Women Participants. Journal of Nutrition Education and Behavior, 41(3), 161–168. doi: 10.1016/j.jneb.2008.06.004
Food Insecurity. (n.d.). Retrieved from
https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/food-insecurity
Hernandez, D. C., Daundasekara, S. S., Arlinghaus, K. R., Tobar, N., Reitzel, L. R., Kendzor, D. E., & Businelle, M. S. (2019). Cumulative risk factors
associated with food insecurity among adults who experience homelessness. Health Behavior Research, 2(1).
https://doi.org/10.4148/2572-1836.1033
Gundersen, C., Engelhard, E. E., Crumbaugh, A. S., & Seligman, H. K. (2017). Brief assessment of food insecurity accurately identifies high-risk US adults.
Public Health Nutrition, 20(8), 1367–1371. doi: 10.1017/s1368980017000180
Gundersen, C., & Ziliak, J. P. (2015). Food Insecurity And Health Outcomes. Health Affairs, 34(11), 1830–1839. doi: 10.1377/hlthaff.2015.0645
Kendzor, D. E., Allicock, M., Businelle, M. S., Sandon, L. F., Gabriel, K. P., & Frank, S. G. (2017). Evaluation of a Shelter-Based Diet and Physical Activity
Intervention for Homeless Adults. Journal of Physical Activity and Health, 14(2), 88–97. doi: 10.1123/jpah.2016-0343
 REFERENCES
Kopparapu, A., Sketas, G., & Swindle, T. (2020). Food insecurity in primary care: Patient perception and preferences. Family Medicine, 52(3), 202–205.
https://doi.org/10.22454/fammed.2020.964431
Leung, C. W., Epel, E. S., Willett, W. C., Rimm, E. B., & Laraia, B. A. (2014). Household Food Insecurity Is Positively Associated with Depression among
Low-Income Supplemental Nutrition Assistance Program Participants and Income-Eligible Nonparticipants. The Journal of Nutrition, 145(3), 622–
627. doi: 10.3945/jn.114.199414
Loopstra, R. (2018). Interventions to address household food insecurity in high-income countries. Proceedings of the Nutrition
Society, 77(3), 270–281. https://doi.org/10.1017/s002966511800006x
Makelarski, J. A., Abramsohn, E., Benjamin, J. H., Du, S., & Lindau, S. T. (2017). Diagnostic Accuracy of Two Food Insecurity Screeners
Recommended for Use in Health Care Settings. American journal of public health, 107(11), 1812–1817. https://doi.org/10.2105/AJPH.2017.304033
Nagata, J. M., Palar, K., Gooding, H. C., Garber, A. K., Bibbins-Domingo, K., & Weiser, S. D. (2019). Food Insecurity and Chronic Disease in US
Young Adults: Findings from the National Longitudinal Study of Adolescent to Adult Health. Journal of General Internal Medicine, 34(12), 2756–
2762. Doi:10.1007/s11606-019-05317-8

O’Toole, T. P., Roberts, C. B., & Johnson, E. E. (2017). Screening for Food Insecurity in Six Veterans Administration Clinics for the
Homeless, June–December 2015. Preventing Chronic Disease, 14. doi: 10.5888/pcd14.160375
Pankratz, C., Nelson, G., & Morrison, M. (2017). A quasi-experimental evaluation of rent assistance for individuals experiencing chronic
homelessness. Journal of Community Psychology, 45, 1065-1079. https://doi.org/10.1002/jcp.21911
Parpouchi, M., Moniruzzaman, A., Russolillo, A., & Somers, J. M. (2016). Food insecurity among homeless adults with mental illness. PLOS
ONE, 11(7), e0159334. https://doi.org/10.1371/journal.pone.0159334
 REFERENCES
Pediatrics, C. O. C., & Nutrition, C. O. (2015, October 1). Promoting Food Security for All Children. Retrieved from
https://pediatrics.aappublications.org/content/pediatrics/early/2015/10/20/peds.2015-3301
Pooler, J., Levin, M., Hoffman, V., Karva, F., & Levin-Zwerdling, A. (2016). Implementing food security screening and referral for older
patients in primary care: A resource guide and toolkit. American Association of Retired Persons. Retrieved from
https://www.aarp.org/content/dam/aarp/aarp_foundation/2016-pdfs/FoodSecurityScreening.pdf
Ratcliffe, C., Mckernan, S.-M., & Zhang, S. (2011). How Much Does the Supplemental Nutrition Assistance Program Reduce Food
Insecurity? American Journal of Agricultural Economics, 93(4), 1082–1098. doi: 10.1093/ajae/aar026
Reber, E., Gomes, F., Vasiloglou, M.F., Schuetz, P., & Stanga, Z. (2019). Nutritional risk screening and assessment. Journal of Clinical
Medicine, 8(7), 1065. https://doi.org/10.3390/jcm8071065
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United States: An experimental evaluation.European Journal of Homelessness, 10(1), 13-30.
 TABLE OF EVIDENCE - #1
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications
O’Toole, T.P., Roberts, To evaluate a food 1.Sample 1.Methods 1.Statistical Analysis 1.Interpretation
C.B., & Johnson, E.E. insecurity screening Total: 270 Qualitative, evaluative study No statistical analysis Accepted by patients and
(2017). Screening for performed for Males: 93.1% mentioned by authors. endorsed by health care
food insecurity in six veterans, people Average age: 53 years 2. Procedures clinicians
Veterans Administration currently or previously Reported food Screening was performed by a 2. Results Questionnaire addressed
clinics for the people experiencing insecurity: 48.5% registered nurse, primary care Among those who noted potential causes of food
experiencing homelessness, from provider, nutritionist or social food insecure: insecurity
homelessness, June – different Veterans 2. Setting worker with the start of one 87% cooked their own Brief 3 to 5 minute tool to
December 2015. Affairs primary care Homeless Patient question. meals encourage convenience and
Preventing Chronic clinics. Aligned Care Teams In the past 3 months, were there 54.2% purchased pre- application in assessments.
Disease, 14(4), 1-4. (H-PACTs) from six times when the food for you just made food Adequate sample size
https://doi.org/10.5888/ different VA did not last and there was no accumulated through multiple
pcd14.160375. locations: East Coast, more money to buy more (If yes, Had depression, sites.
Midwest, West Coast, ask the questions below) psychoses, alcohol abuse, Weak sampling design through
rural and urban. ● Where did you get your food or diabetes: convenience.
from? Approximately 20%
● The number meals eaten each 2. Limitations
day Screening with questions Current and past veterans
● Do you cook their own meals? allowed health care experiencing homelessness
● Do you receive food stamps? providers build rapport were evaluated.
● Do you have diabetes? with the patient. Additional research required to
● Have you felt any symptoms address impact of the
of hypoglycemia (sweating, screener’s position on patient’s
chest pain, lightheaded)? responses.
TABLE OF EVIDENCE - #1
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications
The last six questions determined
if follow-up was needed from the
multidisciplinary team.

3. Measures
Health care team members
surveyed and interviewed with
open-ended questions after end
of screening process, about the
questions to the patient and their
understanding of the subject.

4. Reliability & Validity

Reliability and validity not
established.

5. Generalizability
Although the study was primarily
males, the study was performed
within the last 5 years in various
clinics across the United States
(US).
 TABLE OF EVIDENCE - #2
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications
Kendzor, D.E., Allicock, To evaluate the efficacy 1.Sample 1.Methods 1.Statistical Analysis 1.Interpretation
M., Businelle, M.S., and effectiveness of a Total: 32 Quantitative, RCT Analyses of covariances Weak sampling plan with
Sandon, L.F., Gabriel, diet and physical Males: 75.0% (ANCOVAs) utilized when convenience sampling
K.P. & Frank, S.G. (2017). activity program for Average age: 48 years 2. Procedures comparing parametric Small sample size
Evaluation of a shelter- adults experiencing Reported food Participants were randomly data in the 24-hour recall Participants did report that the
based diet and physical homelessness. insecurity: 93.8% assigned to the diet/physical interviews, such as diet and physical program was
activity intervention for activity group (intervention) or changes in weight, waist helpful in improving eating
adults experiencing 2. Setting the group that received all the circumference, and habits and engaging in physical
homelessness. Journal Adults experiencing intervention components (i.e. fruit/vegetable activity
of Physical Activity and homelessness were diet/physical activity/newsletter) consumption Although limited results
Health, 14, 88-97. recruited from a after the study completion regarding healthy eating and
https://doi.org/10.1123/ transitional homeless (control). 2. Results food security, larger scaled
jpah.2016-0343 shelter in Dallas, TX No statistical significance studies may be implicated for
Newsletter consisted of healthy found comparing the future
eating, physical activity, and fruit/vegetable
weight management. Diet consumption between
consisted of being offered 1 intervention and control
serving a fresh fruit and vegetable (P=0.18)
daily.
33.3% of participants had
a positive change in
motivation to increase
fruit/vegetable comparing
baseline to 4-weeks
TABLE OF EVIDENCE - #2
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications
3. Measures 2. Limitations
Food security measured at Study specific to people
baseline through the 6-item USDA experiencing homelessness
Food Security Survey. The living in shelters, but does not
Automated Self-Administered 24- take into account those
Hour Recall (ASA24) and single- outside the facility or without
item measure of stage-of-change permanent housing
was utilized at baseline and at the Program focused mainly on
end of treatment (post 4- weeks) healthy eating and engaging in
exercise within the study, but
4. Reliability & Validity post-intervention follow-up
Validity established, but reliability was lacking
not established

5. Generalizability
Generalizability may be limited
due to being done primarily on
males, but can still be relatable
due to study being done in the
U.S. and within the last 5 years
 TABLE OF EVIDENCE - #3
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications

O’Toole, T.P., Johnson, To analyze the 1. Sample 1. Methods 1. Statistical Analysis 1. Discussion
E.E., Aiello, R., Kane, V., effectiveness of the Total veterans: 3,543 Correlational, comparative statistical significance was Integrating social services and
& Pape, V. (2016). Homeless Patient # of sites: 33 research design. set at P < .05. health care provided high-
Tailoring to vulnerable Aligned Care Team (H- Served in military quality, comprehensive care
populations by PACT) program over 4 after September 11, 2. Procedures 2. Results for the veterans experiencing
incorporating social years for veterans 2001: 8.8% Veterans enrolled for a minimum Only 42% of programs homelessness.
determinants of health: experiencing Women: 4.0% of 1 year. They were offered a offered meals or Treating underlying problems
the veterans health homelessness by 65+ years: 11.0% variety of care and services. Use resources for low-price of housing, food and other
administration’s combining health care All veterans enrolled of resources were compared food. social support programs
“homeless patient with social services. in program from 2011 between veterans experiencing improved health outcomes by
aligned care team” to August 1, 2014. homelessness enrolled and not High-performing site addressing common obstacles
program. Preventing Only those who enrolled in H-PACT. Yearly surveys provided assistance in that were prioritized by those
Chronic Disease, 13(44), participated in follow- evaluated how and which foods more than low- experiencing homelessness.
1-4. up appointments of services were being used, performing clinics (64.7% However, an efficient and
https://doi.org/10.588/ services were efficiency of staffing, community vs 14.3%, P = .02). success H-PACT program
pcd13.150567 included. outreach, and effectiveness of required significant funding
electronic medical records to Inclusion of community from community leaders to
2. Setting incorporate social determinants resources and outreach maintain all services for
At multiple H-PACT of health. Care teams labeled as for transportation, veterans experiencing
sites across the as high-, medium- and low- clothing, and food homelessness.
United States. performing based on number of improved performance of
ED or inpatient admissions. the clinic. 2. LImitations
Adequate sample size.
TABLE OF EVIDENCE - #3
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications
3. Intervention Monitored over course of 4 years
H-PACT offered flexible access to in multiple center, but current
care through walk-in clinics, data evaluated veterans
community outreach, multiple experiencing homelessness.
services available at each site, Did not have a control group.
multidisciplinary healthcare Possible bias to report on
teams, and continued education program that improved patient
of staff on caring for people outcome and managed social
experiencing homelessness. In a determinants of health.
single visit, veterans are offered
mental health services, food 3. Implications
and/or transportation vouchers, Additional research is needed to
clothing, and sometimes housing. evaluate patient satisfaction
Additional services included legal chronic disease management.
and employment assistance. Patient engagement increased
with integrated social and health
4. Generalizability services in veterans experiencing
Conducted on veterans homelessness and could be
experiencing homelessness across applied in future studies on a
the US; could be applied to other general population experiencing
non-veterans who are homelessness. Additional
experiencing homelessness research is needed to evaluate
patient satisfaction chronic
disease management. ion.
 TABLE OF EVIDENCE - #4a
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications

Pankratz, C., Nelson, G., To determine if rent 1. Sample 1. Methods 1. Statistical analysis 1. Discussion
& Morrison, M. (2017). assistance for those Tota: 51 Quasi-experimental research Sample characteristics Rent assistance and intensive case
A quasi-experimental frequently Number in each design. Participants were were incongruent in that management offered markedly
evaluation of rent experiencing group: chosen based on qualifications HAWS had significantly better housing stability that
assistance for homelessness will Control group: 25 determined by individuals who less housing stability continued after six months.
individuals experiencing report improved Experimental group were not the researchers. that non-HAWS Food insecurity was not a problem in
chronic homelessness. housing stability and with rent assistance: participants. Effect sizes the three cities Those who received
Journal of Community psychosocial 26 2. Procedures were computed using rent assistance still utilized soup
Psychology, 45, 1065- experiences, People were divided into two Cohen’s d to test kitchens.
1079. including quality of Male: 67% groups: one group with the differences between Housing stability allowed the people
https://doi.org/10.1002/ life, social support, Born in Canada: 93% Support to End Persistent groups. Alpha set at P < experiencing homelessness
jcp.21911 community Unemployed or Homeless (STEP Home) .05 for significance. increased control of their
contribution, and retired: 90% program, and the other group environment and plan for the future.
food security. Years of education: received assistance from STEP 2. Results
11 years Home and another rent relief HAWS reported greater 2. Limitations
program. Patients were improvements than non- Small sample size that was formed
Inclusion criteria: 16 interviewed at baseline prior to HAWS. by outside evaluators to reduce
years or older, receiving rent assistance and six experimenter bias.
represent high months after first interview. Though statistically Drop out rate was 15% due to lack of
vulnerability as insignificant. HZWS follow-up, missing contact
evident with a score reported a 2.5 information, incarceration, re-
of 8 or more on the improvement in the FS location, unwilling to participate and
Vulnerability Index- Scale (P .008), while non- unstable medical problems.
Service HAWS only
TABLE OF EVIDENCE - #4a
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications
Prioritization Decision indicated 0.75 Participants were awarded with
Assistance Pre-screen improvement (P = .411). financial incentives (gift cards) to come
Tool (VI-SPDAT), have to each visit.
a STEP Home 60% of the HAWS Interviewers gave ample opportunities
manager, and living in reported higher scores for participants to come to follow-up
one of the 3 cities in above the average but several were unreachable.
Ontario. scores of those who did Weak research and sampling design
not receive rent (convenience).
2. Setting assistance.
Conducted in three 3. Implications
cities in Ontario, Providing housing stability empowered
Canada. individuals to better their quality of
life, social support, community
functioning and food security.
 TABLE OF EVIDENCE - #4b
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications

Shinn, M. Brown, S.R., To analyze 3 1. Sample 1. Methods 1. Statistical analysis 1. Discussion

Wood, M., & Gubits, D. different housing Total: 2,282 families Cross-sectional study. No statistical analyses Priority offers through the study for
(2016). Housing and and social programs Average age of Randomization of families into was provided. housing subsidies reduced
service interventions for to each other and to females: 29, usually eligible programs. homelessness as evidenced by
families experiencing 12 different sites in with 1 or 2 children 2. Results reduced shelter stays.
homelessness in the the US as an Had spouse in 2. Procedures Permanent and rapid re- Permanent housing subsidies
United States: An potential end to shelter with them:: Sample families were invited housing improved food provided a more significant impact
experimental homelessness. 27.4% from the emergency shelters to security from 66% to on homelessness and food
evaluation.European Average housing participate in the study, and 75% in families. disparities than the two other
Journal of income: $7,400 placed into programs based on Transitional housing did housing programs.
Homelessness, 10(1), 13- Chronic eligibility. A control group not show an influence on
30. homelessness: 63% received usual care with no food security. 2. Limitations
additive services. Families chose Housing subsidies usually entailed a
Inclusion criteria: to accept the offers into the Food security for long waiting list, and there were less
Utilized emergency programs. Interviewed adults in permanent housing subsidies than households.
shelters for at least a families at emergency shelters subsidies is higher Many families lost intervention in
week, low annual and at 20 months. reported than usual care programs due to ineligibility
household income. (P < .01). Subsides did not always guarantee
3. Interventions to provide sufficient relief for lower
2. Setting 1st group = permanent housing Food security in rapid income families.
Emergency shelters subsidies offered with vouchers housing is higher than Limited to adults in families.
in the United States that covered up to 70% of the usual care (P < .05).
rent.
TABLE OF EVIDENCE - #4b
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications

2nd group = community-based 3. Implications

rapid re-housing that was given Further research is needed to under
for up to 18 months .Subsidies in the impact of these subsides in other
this group required re- sub-groups of populations
certification of the family every 3 experiencing homelessness.
months and participation in low- Permanent housing subsidies
intensity case management. offered the most beneficial results in
Helps provided immediate housing and food security.
assistance.

3rd group = project-based

transitional housing which was
temporary shelter in a supervised
location with other families
experiencing homelessness.
Participants were required to
undergo intensive case
management.

4. Measures
Housing stability, family
preservation, adult well-being,
and self-sufficiency were
measured based on self-report.
TABLE OF EVIDENCE - #4b
Author, Year Purpose Sample & Setting Methods, Design, Results Discussion, Interpretation,
Interventions & Measures Limitations, & Implications

Self-sufficiency was evaluated

with food insecurity survey from
the US Department of Agriculture.

5. Reliability & Validity

Food insecurity was validated
with proper citation.

6. Generalizability
Though study focused on families,
self-reports were provided by
adults of the families. Can be
applied to general population
experiencing homelessness.