How Does Living in Temporary Accommodation and the COVID-19 Pandemic Impact under 5s' Healthcare Access and Health Outcomes? A Qualitative Study of Key Professionals in a Socially and Ethnically Diverse and Deprived Area of London.

Background: Children < 5 years living in temporary accommodation (U5TA) are vulnerable to poor health outcomes. Few qualitative studies have examined service provider perspectives in family homelessness; none have focused on U5TA with a cross-sector approach. This study explored professionals' perspectives of the barriers and facilitators, including pandemic-related challenges, experienced by U5TA in accessing healthcare and optimising health outcomes, and their experiences in delivering services. Methods: Sixteen semi-structured online interviews were conducted. Professionals working in Newham (London) with U5TA families were recruited from non-profit organisations, the health sector, and Local Authority. A thematic analysis was conducted. Findings: Professionals described barriers including poor parental mental health; unsuitable housing; no social support; mistrust of services; immigration administration; and financial insecurity. Digital poverty, language discordance, and the inability to register and track U5TA made them even less visible to services. Professionals tried to mitigate barriers with improved communication, and through community facilitators. Adverse pandemic effects on U5TA health included delay and regression in developmental milestones and behaviours. In-person services were reduced, exacerbating pre-existing barriers. Interpretation: COVID-19 further reduced the ability of professionals to deliver care to U5TA and significantly impacted the lives of U5TA with potential life-long risks. Innovative and tailored cross-sector strategies are needed, including co-production of public health services and policies focusing on early development, mental health support, employment training, and opportunities for parents/carers.

How did living in temporary accommodation during the COVID-19 pandemic affect children younger than 5 years' access to health care and health outcomes? A qualitative study of key professionals in a socially and ethnically diverse and deprived area of London.

BACKGROUND: Children younger than 5 years living in temporary accommodation due to homelessness (U5TA) are extremely vulnerable to the effects of the COVID-19 pandemic. Few qualitative studies have examined provider perspectives in family homelessness, but none focused on U5TA specifically. We aimed to qualitatively explore professionals' perspectives of pandemic-related challenges and barriers experienced by U5TA in accessing health care and optimising health outcomes, and their experiences of delivering U5TA services. METHODS: 16 semi-structured interviews were done online. Professionals working in the London Borough of Newham with U5TA families were purposively sampled and recruited from non-profit organisations, the health sector, and local authority. A thematic codebook approach was used to analyse the data combining inductive and deductive codes using an adapted socioecological model as a guiding theoretical framework. FINDINGS: Two non-profit organisation professionals, seven health visitors, one GP, therapist, dietician, nurse, public health consultant, and two social workers from the local authority's No Recourse to Public Funds team described adverse pandemic effects on U5TA health: delay and regression in developmental milestones and behaviours-eg, toileting, feeding skills, emotional regulation, and social-communication skills. Pre-existing systemic barriers were exacerbated during the pandemic when the reduction of in-person services with professionals necessitated remote delivery of health and social care services. Differential effects of digital poverty, language discordance, and inability to register and track U5TA rendered this population invisible to services. Professionals highly agreed that barriers to optimal health outcomes and service access included poor mental health, unsuitable housing, no social support, mistrust of mainstream services, immigration administration, financial insecurity, and loss of informal jobs among U5TA families. Professionals sometimes mitigated these barriers with good communication skills, developing trusting relations, and through community facilitators. INTERPRETATION: COVID-19 widened health inequalities and inequities, substantially affecting the lives of U5TA and ability of professionals to deliver quality care to U5TA. Innovative and tailored cross-sector strategies, including co-production of public health services, are required. Policies and services urgently need to focus on early development, mental health support, employment training, and opportunities for parents and carers, plus unambiguous definitions of what is deemed suitable accommodation and actionable planned steps to ensure enforcement. FUNDING: None.

Exploring the Interactions between Housing and Neighbourhood Environments for Enhanced Child Wellbeing: The Lived Experience of Parents Living in Areas of High Child Poverty in England, UK.

Children's health can be affected by the interrelated characteristics of the physical and social environment where they live, including housing quality, neighbourhood characteristics and the local community. Following a systems-based approach, this exploratory project sought to understand how the needs and aspirations associated with the home environment can work in synergy with, or be exacerbated by, other aspects of the local area. The study recruited parents of children aged 2-12 years old from two local authorities in England with high levels of child poverty: Tower Hamlets in East London, and Bradford District in West Yorkshire. Thematic analysis of participant interviews highlighted ten themes and opportunities for improvements. The evidence presented in this research emphasises how environmental quality issues within and outside the home, compounded further by delays in repairs and reduction in service standards, as well as affordability issues, are likely to deeply affect the wellbeing of an entire generation of disadvantaged children whose parents can feel disempowered, neglected and often isolated when attempting to tackle various dimensions of inequalities. Interventions which can improve the quality of housing, and access to space and services, are urgently needed, including initiatives to support and empower families and local communities, especially those prioritising opportunities for action.

Parental mental health and associations between living in temporary accommodation and socio-political determinants during the COVID-19 pandemic

576 Figure 1Is the adjusted odds ratio (OR) plot showing the odds of an increased rank of depression severity with living in Temporary Accommodation as the main exposure and each predictior variable given all the other variables were held constant in the model[Figure omitted. See PDF] 576 Figure 2Is the adjusted odds ratio (OR) plot showing the odds of an increased rank of anxiety severity with living in temporary accommodation as the main exposure and each predictior variable given all the other variables were held constant in the model[Figure omitted. See PDF]22.9% and 20.0% of TA parents/caregivers had severe anxiety and moderate anxiety compared to 4.0% and 25.0% of non-TA parents/caregivers, respectively. For parents/caregivers living in TA, the odds of a more severe anxiety rank were 2.46 times higher (95%CI:1.27–4.75). Other significant factors for anxiety were: Very Low Food Security (OR 4.45, 95%CI:3.26–6.08);families ‘finding it very difficult’ financially (OR 1.62, 95%CI:0.96–2.73). [Figure 2]ConclusionFamilies living in TA had a greater odds of poor parental mental health outcomes, which was further compounded by factors including NRPF status, financial insecurity, food insecurity and poor housing environments. Poor parental mental health is an adverse childhood experience (ACE) directly impacting both the health and wellbeing of the parent and child throughout the life course. Targeted policies and tailored community-based mental health strategies, including the co-location of mental health and housing support within settings already accessed by TA families with under 5s, are vitally needed, since this vulnerable group is at higher risk of poorer parental mental health and a higher ACE count, which is exacerbated by the unsuit ble and unsafe TA environment.

Socio-political determinants of health inequalities during the COVID-19 pandemic: Under 5s and their families living in temporary accommodation in a socially diverse and deprived population—Newham, East London

605 Figure 1Comparisons Between TA and Non-TA Families: Socio-political Determinants[Figure omitted. See PDF] 605 Table 1Health care access: comparison of non-TA and TA families n (%)ConclusionTA children were increasingly disadvantaged among multiple domains: socio-demographics, food insecurity, inadequate/poor housing, health service access. Therefore, the need is urgent to minimise the potential lifelong health impacts of these socio-political determinants of health experienced by this vulnerable group in addition to tackling the immediate risks arising from issues such as digital exclusion and poor housing conditions, which were likely exacerbated during the pandemic. The future of the pandemic is uncertain and future lockdowns are possible, so all families must have digital access now that many vital health services and schooling are online, even some exclusively. The time families spend in TA must be reduced, and the co-production of interim solutions and future policies to ensure a minimum set of housing standards for TA should be made a priority to address these inequalities and inequities.

Mitigating the severity of child homelessness in the UK: a global mixed-methods systematic review

Background In 2019, 585 000 children in England were homeless or at risk of becoming homeless. The pressure of the COVID-19 pandemic on the health-care delivery system has amplified the inequalities faced by marginalised children. Although the UK has had a series of successful health sector reforms, few have designed or implemented strategies that target reach, access, and use of public health services for marginalised children. This project aims to identify such strategies by exploring solutions used in low-income and middle-income countries (LMICs), through reverse-innovation. Methods We undertook a systematic review of the literature published in English from PubMed, MEDLINE, and SCOPUS between Jan 1, 2010, and March 31, 2021. We explored the literature focusing on policy, strategy, intervention, and services, using keywords and Medical Subject Headings corresponding to the target population, and medical, health, and nutrition services including preventive and immunisation services, and outcomes. Our target population included homeless and marginalised children. We defined marginality in terms of social distances following Braun and Gatzweiler (2013). We included in our search homelessness, temporary accommodation (eg, makeshift accommodation, emergency shelter, and feral), the conditions that put a child at risk of homelessness (eg, war, battle, conflict, refugee, displaced, and migrant), and the general conditions of social distances (eg, poverty, and financial catastrophe) that do not belong to discrimination. We used the Arksey O'Malley framework with Levene's extension in the aforementioned databases and Google Scholar to improve inclusivity. The primary outcomes included access, coverage, and utilisation of child health and nutrition services. The impact measurements included morbidity, mortality, and economic outcomes (return on investment, cost, and efficiency). We applied natural language processing for thematic analysis of qualitative evidence. The analysis was assisted by Python (v3.7.12). Findings We found 53 final articles (47 quantitative and six qualitative) from LMICs. Community-focused and financial interventions were successful in different settings. Financial interventions such as user-fee removal increased health care and service use between 15–309%. Cash transfers increased immunisation coverage, financial security, and nutrition. Mobile health services and the individualised tactics of community midwives and volunteers improved the coverage and use of child health and nutrition services. Community-based savings groups, user-fee removal, and cash transfer policies improved access and utilisation. mHealth applications and capacity building of health workforce increased coverage and quality of these services and improved clinic attendance. Interpretation UK policy makers could adapt and adopt targeted and conditional cash transfer policies to provide greater financial security to homeless families and make child health care more affordable and inclusive. Volunteer and mobile-clinic-based community services would increase access and use of these services in the COVID-19 recovery phase. Our review may have missed matured strategies published before 2010. We were unable to estimate a pooled effect. Funding ESRC, UK Research and Innovation rapid response COVID 19.

Identifying housing-level barriers to optimal health for Under5s experiencing homelessness: a citizen science approach

BackgroundThe first five years of life are critical for optimal growth, health and cognitive development during which ~90% of brain development occurs. However, many children experience poverty and/or homelessness. Data from 2019 suggested there could be more than 210,000 homeless children in temporary accommodation (TA) or sofa surfing, and ~585,000 who are either homeless or at risk of becoming homeless in England.ObjectivesTo explore the housing environmental barriers to optimal health for children under the age of five (U5s) experiencing homelessness and living in TA.MethodsThe study employed a mixed-methods, participatory design integrating citizen science to identify housing-level barriers to achieving optimal health. Participants were mothers of U5s living in TA, and conveniently sampled at a local charity providing support to U5s experiencing homelessness in Newham, London. Newham has the highest number of children in TA in England (1 in 12 children are homeless) and 1 in 2 children live in poverty. The study had two parts(i) Housing Survey and (ii) House Visits.A housing survey utilised citizen science methodology to collect data including mobile phone images and free text captions to describe the TA housing conditions including those which participants considered as barriers to their child’s health. The survey was first piloted over two weeks on five participants, following refinement based on collaborative feedback and dialogue between the doctoral researcher and study participants. To compliment the housing survey, the doctoral researcher visited the participants’ TA and took observational notes with an audio-recorder and digital photos.A thematic analysis was conducted to triangulate themes across the data. Kingfisher’s Unfit Housing UK Research Report guided the categories for the results. Specific factors explored within these data included ease of access to the property, safety risks, disrepairs, visible structural problems, poor ventilation, temperature control, space (e.g., for a baby to crawl).ResultsIn the Housing Survey, fifteen participants collected data over a period of one month at the end of 2019. In 2019–2020, four House Visits were completed (Pre-COVID), but further visits were cancelled due to the pandemic.Several themes were prominent and overlapped across the Housing Surveys and House Visits, which were noted as risks to child health and development. Thematic categories included (i) overcrowding, (ii) dampness/mould growth, (iii) poor/inadequate kitchen/toilet facilities, (iv) infestations/vermin, (v) structural problems/disrepair, (vi) unsafe electrics, (vii) excessively cold/warm due to inadequate temperature regulation and (viii) unsafe surfaces that risk causing trips or falls.ConclusionsThe Early Years is a short, yet vital period to ensure to the next generation have the best start in life, however U5s in TA face numerous barriers in the housing environment which have significant short- and long-term health impacts. Despite a small sample size, findings are consistent with the Children’s Commissioner ‘Bleak houses’ report and likely to be generalisable across other similar families experiencing homelessness in England.Policy should be enacted to regulate the conditions of TA across England with greater monitoring of and accountability for the safety and regulations to ensure that these environments promote optimal growth and development for U5s.