Behavioral Health Service Use and Housing Insecurity: Qualitative Findings and Considerations for Conducting Research with People Experiencing Homelessness during the COVID-19 Pandemic

Background and purpose: People experiencing housing insecurity and homelessness are more likely than their stably housed counterparts to experience mental health or substance use-related conditions. However, behavioral health service use among housing insecure individuals remains low; for some, pandemic-era policies and changes impacted the way they could access behavioral health and housing-related services.

This study aimed to understand how people experiencing housing insecurity and homelessness access behavioral health services including mental health and substance use-related services and to examine the role social supports and previous treatment experiences in accessing or utilizing these services, and considerations on the impact of the pandemic on these services. It will also highlight methodological and systemic considerations taken to ethically conduct in-person research with marginally housed people and people experiencing homelessness during a pandemic.

Methods: Thirty in-depth semi-structured interviews were conducted in fall 2021 with 22 adults experiencing housing insecurity or homelessness who self-reported an interest or use of behavioral health services and the emergency department in the last year. Interviews focused on domains including current and previous housing situation, service use, social supports, and barriers to accessing services. Participants were recruited and interviews were primarily conducted in-person at safety net food programs (one food pantry and one mobile soup kitchen). Interviews were transcribed verbatim and analyzed using a Framework approach to qualitative analysis.

Results: Participants were, on average, 48.5 years old (range 28-60 years), predominantly Black/African American (n=13, 58%), and male (n=17, 77%). Most (n=18, 86%) were enrolled in a public health insurance plan such as Medicaid or Medicare. Interview findings fell into five primary themes: 1) personal networks as a conduit for behavioral health service use; 2) housing situations as directly related to use of services; 3) siloed systems; 4) policies and procedures create barriers; 5) using services when there was a need. Participants described ways in which they interacted with both behavioral health and homelessness response systems, the impact of these systems on their wellbeing, and remaining barriers to care.

Pandemic-era data collection learning and findings include: 1) balancing participant comfort and safety; 2) navigating programmatic shifts; 3) considerations for outdoors and phone-based interviewing.

Conclusion and implications: Findings highlight the experiences of housing insecure individuals when seeking services related to behavioral health, as well as researcher learnings of conducting qualitative research in the pandemic-era. Programs and policies – and social workers engaged in this work – can be aware of the ways in which service users experiences individual-level engagement and policies and should be critical and reflective of these in order to shift programs and policies to increase access to behavioral health services among people experiencing housing insecurity. Social work researchers should also consider how their research methods safeguard the health, safety, and autonomy of participants.