How homelessness poses a barrier to infection prevention

© iStock/Петр Ткаченко

Drs Martha Montgomery and Monique Carry of the CDC discuss hand hygiene accessibility for people experiencing homelessness.

Particularly in the early stages of the COVID-19 pandemic, an array of messaging campaigns emphasised the critical importance of basic infection prevention and control measures such as social distancing and hand hygiene. However, access to basic hand hygiene facilities is by no means universal. In 2020, a research team from the US Centers for Disease Control and Prevention (CDC) spoke with a cohort of people experiencing both sheltered (living in emergency shelters or transitional housing facilities) and unsheltered (living in spaces not meant for human habitation) homelessness in Atlanta, Georgia, to establish the key barriers that they faced in terms of hand hygiene access and communication. The study, titled ‘Hand hygiene during the COVID‐19 pandemic among people experiencing homelessness—Atlanta, Georgia, 2020’, was published in April 2021 in the Journal of Community Psychology. Health Europa Quarterly (HEQ) speaks with co-authors Drs Martha Montgomery and Monique Carry about the findings of their study and the need to shore up hand hygiene accessibility.

What role does hand hygiene play in the prevention and control of infection, particularly during a global pandemic? What is the optimum hand hygiene routine?

During the COVID-19 pandemic, hand hygiene has been a very important measure to help prevent the virus from spreading. It is one of the key infection prevention measures that the CDC recommends, along with wearing a mask that covers your mouth and nose, staying six feet away from other people, and more recently, getting a COVID-19 vaccine when it is available. We recommend that people make sure to wash their hands often with soap and water for at least 20 seconds – there are some specific times when it is particularly important to wash your hands, such as before eating or preparing food; before touching your face; after using the bathroom; after leaving a public place; after blowing your nose, coughing, sneezing, or touching your mask; after changing a diaper; caring for someone who is sick; or taking care of animals or pets.

Your study, ‘Hand hygiene during the COVID‐19 pandemic among people experiencing homelessness—Atlanta, Georgia, 2020’ examined the barriers faced by people experiencing homelessness (PEH) in establishing and maintaining hand hygiene routines. What were the most pressing issues reported by the study’s respondents?

The biggest issue that people reported was in accessing handwashing facilities and supplies. This is often a barrier for people experiencing homelessness, but our respondents reported that it was particularly challenging during the COVID-19 pandemic, because especially early on – we first started conducting the interviews around May – a lot of places where they had been able to access hand hygiene amenities like public facilities, restaurants and businesses were still closed because of the pandemic; so that made it especially hard to access facilities and supplies.

In cases where people did have access to supplies like soap or hand sanitiser, was there an issue of being able to continue to carry those around?

This was especially an issue for people experiencing unsheltered homelessness: they have limited space to store their belongings and they have to carry everything with them. Because of this, one of the key recommendations that came out from the study was that, if you are providing supplies for people experiencing homelessness, it is important consider providing those supplies in small quantities that can be easily carried around.

Were there significant differences between the responses of sheltered and unsheltered respondents?

The locations where people were able to find a clean water source differed: people who were living in a shelter would often report using the shelter as a location to wash their hands, whereas people living unsheltered had to rely more on the public facilities or businesses. We conducted the surveys in Atlanta, Georgia; and some people there had noticed that handwashing stations had been set up throughout the city – but the locations of the stations were sometimes unreliable, and sometimes respondents were not sure exactly where they could find these stations or when they were going to be available. We also found that people who were living unsheltered were more likely to rely on hand hygiene solutions that were portable in small sizes: hand sanitiser, bottled water or even disinfectant wipes.

How could hand hygiene messaging campaigns be adapted in areas with high populations of PEH to take into account their specific needs?

One of the things that we learned about communication and messaging for people experiencing homelessness was that people reported using a wide variety of media sources, so there was not really one consistent channel to reach people experiencing homelessness. Some people reported seeing billboards or signs; some had seen TV advertisements. Some people reported that they received information via text messages. We noted that it is helpful to use a wide variety of channels in trying to reach this population, but then even more important than that – and we have seen some creative examples of this – is pairing that messaging with actual facilities and supplies that can boost people’s access to handwashing, where possible. There was an example in Philadelphia where they painted murals with key hand hygiene messages, such as making sure to wash hands for 20 seconds; and combined those murals with handwashing stations. That combination of messaging with actual access to facilities and supplies was a particularly useful example, because more than education, people were looking for accessible handwashing facilities and supplies.

What should be done at the policy level to broaden uptake of hand hygiene routines among homeless populations?

It can be helpful to take a close look at any local policies that might have an impact on the closure of public parks or buildings, and to think about how those might be accessed by people experiencing homelessness for hand hygiene: places like public libraries and public parks were frequently closed at the beginning of the pandemic. Because of this, one thing that we did on our end, after we had conducted the interviews and analysed the results, was to take a look at the CDC’s policies and recommendations on public parks and to build a strong message that restroom facilities in public parks should be able to stay open, so that people – not even just people experiencing homelessness, but the population in general – have access to handwashing stations or facilities.

Dr Martha Montgomery
Dr Monique Carry
COVID-19 Emergency Response
Centers for Disease Control and Prevention

This article is from issue 18 of Health Europa. Click here to get your free subscription today.


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