Article Text

Protocol
Understanding discrimination towards persons experiencing homelessness: A scoping review protocol
  1. Sarah L Canham1,2,3,
  2. Jeffrey N Rose4,
  3. Rachel Weldrick2,
  4. Elizabeth Siantz1,
  5. Tallie Casucci5,
  6. Mary M McFarland6
  1. 1College of Social Work, University of Utah, Salt Lake City, Utah, USA
  2. 2Department of Gerontology, Simon Fraser University, Vancouver, British Columbia, Canada
  3. 3Department of City and Metropolitan Planning, The University of Utah, Salt Lake City, Utah, USA
  4. 4Department of Parks, Recreation, and Tourism, College of Health, University of Utah, Salt Lake City, Utah, USA
  5. 5J. Willard Marriott Library, University of Utah, Salt Lake City, Utah, USA
  6. 6Eccles Health Sciences Library, University of Utah, Salt Lake City, Utah, USA
  1. Correspondence to Dr Sarah L Canham; sarah.canham{at}utah.edu

Abstract

Introduction Given the increasing rates of homelessness in recent years, there is an urgent need to address the ongoing discrimination and societal disinterest in preventing, reducing and ending homelessness. There is no systematic review of experiences of stigma and discrimination among persons experiencing homelessness or interventions to combat this discrimination. The objective for the proposed study is to identify ways in which persons experiencing homelessness have been stigmatised and discriminated against, the results of these experiences, and interventions to reduce stigma and discrimination towards persons experiencing homelessness.

Methods and analysis We are conducting a scoping review with guidance from the JBI Manual for Evidence Synthesis and Arksey and O’Malley’s framework. From 15 to 19 July 2022, we searched the following databases from our institutional licensed years of coverage: Medline, Embase, CINAHL Complete, Academic Search Ultimate, APA PsycINFO, Science Citation Index Expanded, Social Sciences Citation Index, Arts & Humanities Citation Index, Emerging Sources Citation Index, Left, PAIS International, PILOTS, Psychology & Behavioral Sciences Collection, Sociological Abstracts, and Dissertations and Theses Global. Two independent reviewers are screening study titles/abstracts and will independently screen the full texts. Study inclusion criteria include any study type reporting primary findings of English-language research on non-refugee persons experiencing homelessness in any type of setting or service worldwide. Three reviewers will then chart data of our included studies. Data will be extracted and organised into categories and subthemes in tabular form. To understand the validity of the scoping review findings in the local context and to gather additional perspectives on the topic, we will conduct an ‘expert consultation’ workshop.

Ethics and dissemination This study has ethics approval from the University of Utah Institutional Review Board. Review findings will be disseminated through a peer-reviewed journal and at conferences. We plan to preregister this protocol with Open Science Framework.

  • PUBLIC HEALTH
  • SOCIAL MEDICINE
  • HEALTH SERVICES ADMINISTRATION & MANAGEMENT
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Strengths and limitations of this study

  • First scoping review on this topic identifying ways in which persons experiencing homelessness has been stigmatised and discriminated against and interventions used to reduce this stigma and discrimination.

  • Likelihood of bias (reporting biases, Hawthorne effect, publication bias) in reporting and publishing studies concerning homeless discrimination.

  • Potential for stigma or discrimination towards persons experiencing homelessness to be described in the discussion as an incidental finding but not mentioned in an abstract or title.

  • Likelihood of language and publication bias due to the research team being unable to review non-English literature.

  • Representativeness of consultation workshop participants cannot be guaranteed; there is a likelihood of some selection bias.

Introduction

Discrimination towards persons experiencing homelessness is not a new trend, yet remains an under-researched topic. While a wealth of scholarship examines racism, sexism and ageism, there is a dearth of work in the field of discrimination based on an individual’s housed or unhoused status. Canham et al1 conducted a secondary qualitative data analysis of interviews with persons with no fixed address who were being discharged from the hospital, resulting in a conceptual model of the experience of ‘homeism’—a term for the discrimination towards persons experiencing homelessness.1

While homeism is described as distinct from other forms of stigmatisation and discrimination, it intersects with stigmas based on age, race, gender, physical ability, mental health and more.2 Prior research3–5 has described people experiencing homeism when they are seeking healthcare or housing.1 Canham et al1 found homeism to be related to negative stereotypes about persons experiencing homelessness as well as negative perceptions and false presumptions that society has assigned to persons who use substances. These stereotypes persist across various groups and subcategories of persons experiencing homelessness, even as homelessness is increasingly heterogeneous, filled with diverse experiences, circumstances and identities.6 Homeism was also found to result from expectations that people need to be clean and groomed if they want to be respected and treated well.1 Despite challenges for persons who are living unsheltered or staying in congregate homeless shelters to shower, clean clothes, or maintain hygiene,7 society offers minimal exception to these expectations.

Canham et al1 described ways in which homeism contributes to poor health outcomes that result from treatment disparities and patient disengagement. Furthermore, being treated poorly, not listened to, and labelled as unworthy of care contribute to treatment disparities.8 Given inadequate care and treatment, some patients who are experiencing homelessness are hesitant to engage with the healthcare system, choose to avoid certain healthcare locations and become frustrated with how they are treated and leave against medical advice.1 3

Rationale

Given the increasing rates of homelessness in recent years,9 there is an urgent need to address the ongoing discrimination and societal disinterest in preventing, reducing and ending homelessness. If one path forward is to build political will to implement policies that will increase supportive and affordable housing, we need increased interest and recognition of homeism as an experience distinct from other forms of discrimination. Thus, there is a need to identify the existing evidence and knowledge gaps and set a research agenda for understanding and reducing homeism. While systematic reviews have examined interventions used to reduce discrimination,10 how stigma and discrimination influence the care towards persons with mental illness11 and interventions to combat this form of discrimination,12 there is no systematic review of experiences of discrimination among persons experiencing homelessness or interventions to combat this discrimination.

Scoping review objectives

The overall objective for the proposed study is to identify the ways in which persons experiencing homelessness have been stigmatised and discriminated against, the results of these experiences, and interventions that have been used to reduce stigma and discrimination (ie, reduce homeism). To attain this objective, the following research question and subquestions will be pursued:

Research question

What is the evidence concerning stigma and discrimination towards persons experiencing homelessness?

Subquestions

  1. What does the existing literature report on experiences of stigma and discrimination among persons experiencing homelessness?

  2. What does the existing literature report on outcomes of stigma and discrimination among persons experiencing homelessness?

  3. What does the existing literature report on interventions to reduce stigma and discrimination towards persons experiencing homelessness?

  4. What do persons experiencing homelessness and homeless service providers think about the existing literature? (via expert consultation, described below)

Our research question is organised to JBI’s mnemonic, PCC13:

  • Participants: persons experiencing homelessness.

  • Concept: discrimination, stigmatisation, stigma.

  • Context: worldwide health and social care settings.

A search for existing evidence reviews or protocols on the topic was conducted (TC) in PROSPERO, MEDLINE (PubMed), Open Science Framework, Epistemonikos, Cochrane Library, Campbell Systematic Reviews, JBI Evidence Synthesis on 29 April 2022. No reviews or protocols on topic were identified.

Methods and analysis

We will conduct our scoping review with guidance from the latest version of the JBI Manual for Evidence Synthesis.13 Using the framework as outlined by Arksey and O'Malley,14 we will organise our scoping review in six stages: (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, (5) collating, summarising and reporting the results and (6) expert consultation. For transparency and reproducibility, we will adhere to the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) reporting guidelines in reporting results.15

Patient and public involvement

No patient involved.

Literature searching

A librarian (TC) developed the search strategies (online supplemental appendix) using a combination of keywords and database subject headings for the primary databases from sentinel studies and team feedback, then translated the strategy to the other selected databases. An information specialist (MMM) peer-reviewed the strategy to PRESS guidelines.16

Between 15 July and 19 July 2022, we searched the following years within these databases: Medline (Ovid) 1946–2022, Embase (embase.com) 1974–2022, CINAHL Complete (Ebscohost) 1937–2022, Academic Search Ultimate (Ebscohost) 1965–2022, APA PsycINFO (Ebscohost) 1872–2022, Web of Science Core Collection (Clarivate Analytics), which includes Science Citation Index Expanded (1900–2022), Social Sciences Citation Index (1900–2022), Arts & Humanities Citation Index (1975–2022), and Emerging Sources Citation Index (2015–2022), Left Index (ProQuest) 1982–2022, PAIS International (ProQuest) 1972–2022, PILOTS: Published International Literature on Traumatic Stress (ProQuest) 1871–2022, Psychology & Behavioral Sciences Collection (Ebscohost) dates vary by title, Sociological Abstracts (ProQuest) 1952–2022 and Dissertations and Theses Global (ProQuest) 1861–2022. Neither language nor date limits were applied to the database strategies. However, we excluded conference abstracts in Embase, limited to academic journals or reviews in Academic Search Ultimate, and limited to academic journals in Psychology & Behavioral Sciences Collection. Citation management and duplicate detection and removal were accomplished with EndNote (Clarivate Analytics). Searches will be updated before submission of the review manuscript for publication.

Grey literature that will be searched for white papers and technical reports include Homeless Hub (https://www.homelesshub.ca); National Alliance to End Homelessness (https://endhomelessness.org/), Institute of Global Homelessness (https://www.ighomelessness.org/), Homelessness Link (https://www.homeless.org.uk/). Inclusion criteria for grey literature are the same as for the database results.

For studies meeting inclusion criteria, references will also be evaluated for relevancy and potential inclusion.

Study selection (eligibility criteria)

Inclusion criteria

  • Participants: persons experiencing homelessness in non-refugee situations. There is an extensive literature on refugee status individuals, but such studies will not be included unless there is specific information about homelessness and stigma and/or discrimination. In cases where there are intersecting discrimination experiences (ie, sources that describe both homeism and discrimination/stigma based on another marginalised or minoritised identity or status), the source will be included, so that the full range of evidence is identified.

  • Concept: discrimination, stigmatisation, stigma, prejudice, marginalisation.

  • Context: any type of setting or service need (eg, healthcare, employment, education) worldwide.

  • Study type: any study type reporting primary findings.

Screening

We will use Covidence (Veritas Health Innovation), an online systematic reviewing platform, to screen and select studies.

Two reviewers (JNR/ES/RW/SLC) are independently screening titles and abstracts and then will independently review full text for inclusion. Using the Covidence platform, reviewers indicate either ‘yes’ or ‘no’ to determine whether a given abstract or full-text meets inclusion criteria. When two reviewers enter conflicting votes (eg, one reviewer indicates ‘yes’ and a second reviewer indicates ‘no’), the Covidence system flags this discrepancy. When this occurs, the research team discusses the item and reaches a consensus via majority vote during a weekly meeting. On reaching consensus, SC/RW input the final decision into Covidence. Two reviewers (JNR/ES/RW/SLC) will also independently conduct the full-text screening. Any discrepancy in whether to include or exclude a study will be resolved by team discussion until consensus is reached. If reviewers cannot reach agreement, SLC/RW will make the final decision.

Data extraction

We will use Excel (Microsoft) to extract and chart our data. Two reviewers (SLC and RW) piloted our data charting form using sentinel articles. Three reviewers will then chart data of our included studies. One reviewer will extract the data, and a second reviewer will verify the data. Relevant data will be extracted from the Methods and Results/Findings sections of included studies. Our extraction data will include:

  • Author(s), year of publication, source title.

  • Origin/country of origin (where the source was published or conducted).

  • Publication type and name (eg, manuscript, thesis/dissertation, report).

  • Aims/purpose.

  • Population and sample size (gender identity, race/ethnicity and age, if applicable).

  • Methodology/methods.

  • Key findings on the experiences of homeism.

  • Key findings on the outcomes of homeism.

  • Intervention type, comparator and details of these (eg, duration of the intervention) (if applicable).

  • Outcomes and details of these (eg, how measured) (if applicable).

  • Definitions (types) of stigma/discrimination (quality) (if applicable).

  • Pervasiveness of stigma/discrimination (quantity) (if applicable).

  • Narratives, stories, lived experience of stigma/discrimination (if applicable).

Missing data

In cases where there is missing data, we will contact the corresponding author (two times over a 3-week period) to supplement information missing from the primary source.

Quality assessment

In compliance with scoping review methodology, no quality assessment of included studies will be conducted, as our goal is to rapidly map the literature.

Data analysis

We will use NVivo to support our descriptive analysis of the extracted data and thematic analysis of studies’ findings.17 Two researchers (SC and RW) will organise study findingsinto categories (eg, experiences, outcomes, interventions) and sub-themes based on inductive analysis. The researchers will begin by developing low‐level, descriptive codes from units of text being coded as themes and labelled with a word or phrase closely related to the research findings. Through an iterative process of rereading the sources, thematic codes will be subjected to constant comparative analysis to refine the organisation and construction of codes until the patterns and relationships across codes are agreed on by the research team.17

Expert consultation

The sixth step in Arksey and O’Malley’s framework is ‘expert consultation.’ Following the charting of data and development of draft summaries of findings, we will conduct an approximately 3-hour World Café workshop with up to 20 service providers and 20 persons with experiences of homelessness (past or present) during which time we will present our preliminary findings and elicit feedback from participants. The primary goal of this expert consultation will be to understand the validity of the scoping review findings in the local context and to gather additional perspectives on the topic, as done in prior scoping reviews conducted by members of the research team18 and others.19

Participants will be recruited through written advertisements (eg, flyers, e-newsletters) from Salt Lake County, Utah community from housing, homelessness, health and social service agencies that support persons experiencing homelessness. Flyers will be posted at area agencies to inform potential participants about the workshop. Prior to the initiation of any data collection at the workshop, all potential participants will be informed about the purpose and voluntary nature of the study and the potential benefits and risks. After this information has been explained to potential participants, each participant will be asked if they wish to participate and provide informed consent. If any potential participant decides they would not like to participate, they will be free to leave without any repercussion. There will also be time for potential participants to ask questions about the study prior to providing consent.

Participants will be divided into groups of 5–8 people, each with one research facilitator and one notetaker. Each small group will concurrently engage in discussions about review findings, research and intervention opportunities and actions; key points of discussion from each small group will be shared out to the large group. The workshop will provide an opportunity to ground the analysis in the local community, incorporate feedback, validate review findings and allow participants networking opportunities. Conversations will be audio-recorded and anonymous field notes will be taken; no participant names will be recorded. Following the workshop, audio files will be transcribed verbatim and checked for accuracy before being destroyed. Data from facilitated conversations at the workshop will be analysed following the same analytical process as our data extraction phase (ie, thematic analysis) and integrated with findings from the scoping review.

Presentation of results

We will organise results from included studies into categories and subthemes in tabular form. Feedback from the consultation workshop will be incorporated into narrative descriptions and (tabular or graphical) representations.

Ethics and dissemination

This study has received ethics approval from the University of Utah Institutional Review Board (IRB_00153402). Results will be submitted to a peer-reviewed journal for publication and disseminated at conference presentations. Any changes from the scoping protocol methodology will be acknowledged and defined in the manuscript. We plan to preregister this protocol with Open Science Framework.

Ethics statements

Patient consent for publication

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @rachelweldrick

  • Contributors SLC led the conceptualisation and design of this work, and the first draft of this protocol. TC and MMM designed the search strategy methods. JNR, RW, ES, TC and MMM each made substantial contributions to the drafting and critical revision of the work. All authors approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.