Title: VOICES OF WOMEN IN HOMELESSNESS DURING THE OUTBREAK OF THE
COVID-19 PANDEMIC: A CO-CREATED QUALITATIVE STUDY
Version: 2 Date: 14 Nov 2022
Reviewer:  Danilo Falzon
Reviewer's report:
Thank you for the opportunity to review this paper. This is a strong and ethical study which
makes contributions to literature on homelessness, covid-19 and co-produced/health inclusion
research approaches. Of particular strength, and to be commended, was the inclusive methods
used to shape the research design, data collection and analysis - which I agree increases the
trustworthiness of the findings and produces research which is meaningful to the population in
question. The findings are strong and well written and highlight several important points points
about intersections between gender and homelessness during the pandemic.
The comments below outline some very minor points to be addressed (largely small points in
relation to grammar). As stated below, the introduction could include some more information
(see details below). I suggest that this paper is suitable for publication with very few, minor
revisions.
BACKGROUND
Lines 81-83: ‘Furthermore, there are differences between men and women, that must be
understood and responded to appropriately in clinical practice.’ The authors could provide some
examples the gendered aspects of homelessness here.
Lines 83-85: ‘Women’s experiences of homelessness encompass forms of extreme deprivation
(11), and it adds important intergenerational dimensions, as the effect of homelessness
significantly impacts generations to come (12)’ – The meaning of this sentence isnt clear to me
and it should be rephrased so that the meaning is clearer.
Lines 87-88: ‘The theoretical framework regarding intersectionality considers social factors such
as age, class, disability, ethnicity…’ – This could be rephrased: ‘Intersectionality provides a
theoretical lens to consider the interactions between social factors such as….’
Lines 96-97: ‘Hence, it could be postulated that women in homelessness are even more
vulnerable during pandemics.’ – Could the authors provide some example of how gender makes
women more vulnerable during the pandemic – e.g. domestic abuse/control, economic and
financial factors? Whilst I don’t doubt that this is the case it would be good to provide the reader
with some examples of how gender shapes experiences of the pandemic. What examples were
provided in the UN policy brief for example?
Line 99: ‘It has been concluded’…Change to ‘there is evidence that’
Line 99-101: ‘It has been concluded that involvement with people who have experienced social
exclusion can provide evidence and insights, during the research process, that can be used to
improve access and uptake of healthcare services among vulnerable groups in society’ – This
could be reworded and also the authors could provide some examples of how inclusion in the
research process can improve access and uptake of healthcare services.
Consider something like: ‘There is evidence that the involvement of those with lived experience
in the research process can provide evidence and insights which would otherwise remain
underexplored or hidden in traditional approaches to the research process (approaches which
often marginalise the voices of the community being researched). Enabling those with lived
experience to shape research design, topics for consideration, and the data collection and analysis
process can lead to better understanding of the experiences, needs, resources and challenges
facing the group in question. This can lead to the design of more appropriate policy and services
– potentially improving access and uptake of healthcare services amongst the populations in
question.’ – This is only an example but I think a bit more detail along these lines would be
helpful.
Lines 113-115: ‘However, public involvement rarely extends to the meaningful involvement of
groups outside mainstream society (16), such as women in homelessness’ – I agree but could
the authors outline why this might be the case and in what ways seemingly ‘co-produced’
research might be tokenistic and not meeting the guidelines they set out (i.e. why it falls short
of meaningful engagement). What kind of barriers to meaningfully co-produced research are
there (pressure to publish, lack of lived experience networks, tokenism, lack of such goals being
embedded in funding structures for research)?
Line 115: Consider starting a new paragraph where the sentence starts – ‘The COVID-19
pandemic has changed the world dramatically’.
Lines 115-118: ‘If we are to build a fairer and healthier society as we emerge from the pandemic,
we need a radical shift in public involvement in research practice to enable the reciprocal
involvement of inclusion health target populations (2, 16).’ – I agree with this point but I think
the authors paint a simplistic portrait of a huge systemic shift without reflecting on the challenges
of this, what work is underway in this area, why it might fall short etc. I would consider a)
toning the language down a bit b) Exploring further how such shifts might be achieved and the
scope of this task c) Reflecting that many researchers do meaningfully involve community as
best they can, and that there may be reasons why they can’t do this to the extent to which they
would like to.
METHODS:
Lines 134: ‘The present study aligned with a constructionist, qualitative paradigm’…. Can the
authors explain a bit what constructionism is. Additionally, qualitative research isn’t a research
paradigm, it is a method/approach.
Line 278: ‘The de-contextualization was discussed (31)’ – could the authors outline what this
means?
RESULTS:
Line 348: ‘shrinking circumstances’ The authors should consider rewording as it isn’t entirely
clear what is meant by this… Reduced opportunities for social and societal support?
Line 465 (quote): ‘I don’t have any poser to stop them’ – typo, change to ‘power’.
Line 481: ‘In a lonely life without a shelter of a home’ –  consider changing to ‘without the
physical and psychological shelter provided by a home’
Line 518: ‘Thus, the women described not being afraid of catching a slight virus’ – I appreciate
the point being made here (that the participants faced much more pressing challenges in relation
to daily survival and that they were unafraid of the virus as they had experienced worse).
However, I think you should change the wording to reflect that the women perceived COVID-19
to be a ‘slight virus’…People experiencing compromised immune systems and with health
conditions were at significant risk of death and harm from the virus so its not fair to characterise
it as ‘slight’ (I understand that this is being reported from the women’s perspective, but I just
think you should make clear that this is the case).
DISCUSSION
Lines 554-556: ‘In practice, however, the groups furthest behind were even left more behind
during the COVID-19 pandemic’…Consider rewording slightly to – ‘in practice, however, the
groups furthest behind were left even further behind during the COVID-19 pandemic’.
Lines 574-576: ‘People in homelessness are at increased risk of COVID-19 infection and
related hospitalizations and mortality (3), in part due to high transmission rates in overcrowded
homelessness shelters (37).’ And due to underlying health conditions which make the changes
of severe infection/complications higher.
Line 593: ‘The pandemic was described to have a devastated impact on the women with
substance use’ – change to ‘as having a devastating impact on the women who used substances’.
Lines 670-672: ). ‘If the women had taken their own photos and brought them to the interview,
most likely we had more clearly attended to each woman’s individual life, experiences, and
well-being at unique intersections’ – consider ‘we would have been able to more clearly attend
to each women’s…’