==== Front PLoS One PLoS ONE plos plosone PLoS ONE 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0231758 PONE-D-19-19733 Research Article Earth Sciences Geography Human Geography Housing Social Sciences Human Geography Housing Medicine and Health Sciences Health Care Socioeconomic Aspects of Health Medicine and Health Sciences Public and Occupational Health Socioeconomic Aspects of Health Medicine and Health Sciences Mental Health and Psychiatry Medicine and Health Sciences Public and Occupational Health Disabilities Medicine and Health Sciences Public and Occupational Health Behavioral and Social Aspects of Health Social Sciences Sociology Human Families Biology and Life Sciences Psychology Addiction Social Sciences Psychology Addiction Medicine and Health Sciences Neurology Brain Damage Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: A Delphi consensus study Priorities for homeless populations: A Delphi consensus studyShoemaker Esther S. ConceptualizationData curationFormal analysisInvestigationMethodologyWriting – original draftWriting – review & editing1234 Kendall Claire E. ConceptualizationData curationFormal analysisFunding acquisitionMethodologyWriting – review & editing12345 Mathew Christine Data curationFormal analysisWriting – original draftWriting – review & editing1 Crispo Sarah Data curationFormal analysisWriting – review & editing1 Welch Vivian Data curationFormal analysisMethodologyWriting – review & editing16 http://orcid.org/0000-0002-7734-2610Andermann Anne ConceptualizationData curationFormal analysisFunding acquisitionMethodologyWriting – review & editing789 Mott Sebastian Data curationFormal analysisWriting – review & editing7 Lalonde Christine Data curationFormal analysisWriting – review & editing1 Bloch Gary ConceptualizationData curationFormal analysisFunding acquisitionWriting – review & editing101112 http://orcid.org/0000-0003-1464-2541Mayhew Alain Data curationFormal analysisWriting – review & editing1 Aubry Tim ConceptualizationData curationFunding acquisitionWriting – review & editing13 Tugwell Peter ConceptualizationFunding acquisitionWriting – review & editing124 Stergiopoulos Vicky ConceptualizationData curationFormal analysisWriting – review & editing1114 http://orcid.org/0000-0002-1874-8346Pottie Kevin ConceptualizationFunding acquisitionMethodologySupervisionWriting – review & editing12* 1 Bruyère Research Institute, Ottawa, ON, Canada 2 Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada 3 Institute of Clinical and Evaluative Sciences, Toronto, ON, Canada 4 Ottawa Hospital Research Institute, Ottawa, ON, Canada 5 Institute du Savoir Montfort, Ottawa, ON, Canada 6 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada 7 Department of Family Medicine, McGill University, Montreal, QC, Canada 8 Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada 9 St Mary's Research Centre, St Mary's Hospital, Montreal, QC, Canada 10 Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada 11 Faculty of Medicine, University of Toronto, Toronto, ON, Canada 12 Inner City Health Associates, Toronto, ON, Canada 13 School of Psychology and Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, ON, Canada 14 Centre for Addictions and Mental Health, Toronto, ON, Canada Federici Stefano Editor Università degli Studi di Perugia, ITALY Competing Interests: The authors have declared that no competing interests exist. * E-mail: kathryn88@example.org 16 4 2020 2020 15 4 e023175815 7 2019 1 4 2020 © 2020 Shoemaker et al2020Shoemaker et alThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Background Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline. Methods We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys. Findings Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants. Interpretation The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines. Inner City Health Associateshttp://orcid.org/0000-0002-1874-8346Pottie Kevin This manuscript was funded by Inner City Health Associated (ICHA), Toronto, Canada. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Data AvailabilityAll relevant data are within the paper and its Supporting Information files.Data Availability All relevant data are within the paper and its Supporting Information files. ==== Body Introduction Homelessness is recognized as one of the most disabling and precarious conditions in high income countries [1]. Homelessness may be defined as a state in which an individual or family is without stable, permanent, or appropriate housing, and lacks the immediate prospect, means and ability of acquiring a home [2]. This definition assumes homelessness results from both a lack of affordable housing and an interplay between financial, cognitive, behavioral and physical challenges, or structural factors such as racism and discrimination. In Canada, for example, men who are chronically homeless face an estimated life expectancy of 43 years of age and women face a life expectancy of 53 years of age, compared to the average life expectancy of 80 years for men and 84 years for women in Canada. These premature and preventable deaths occur in marginalized populations and are associated with a large proportion of physical, mental health and substance use morbidity [3]. In preparing for our Delphi consensus method, we gained a new appreciation for the increasing diversity of homeless populations, including gender, age, ethnicity and types of indigenous populations. As such, we included a list of subpopulations we should address in the development of our clinical guidelines [4]. In 2014, for example, an estimated 235,000 people experienced homelessness in Canada, 27.3% of whom were women and 18.7% were youth, with a growing number of seniors [4,5]. Over-represented homeless populations included Indigenous Peoples (First Nations, Métis, and Inuit), people with disabilities, veterans, newly arrived refugees and other migrants, and gender diverse people [4]; while over one fifth of people with psychological or learning disabilities experience hidden homelessness [6]. As a consequence, we decided to include persons with lived experience of homelessness in our working group and as participants in the Delphi method [7]. Primary healthcare practitioners may benefit from structured training, support, and clinical guidelines to address the multimorbidity, advocacy and social needs of this population [8,9]. Engaging stakeholders, including people with lived experience, to prioritize needs and populations that will then be scientifically assessed using systematic reviews, may improve real-world trustworthiness and ultimately uptake of the final guidelines [10]. This approach has been implemented by the National Institute for Health and Care Excellence in the United Kingdom, which engages Citizen Panels to include the voices of lay members into clinical care guidelines [11]. Our approach is informed by the methods outlined by the MuSE (Multi-Stakeholder Engagement Consortium) [12]. and the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) group to develop health guidelines [13]. The objective of our Delphi consensus study was therefore to engage expert health professionals and people with lived experience in a priority setting consensus process for needs and populations and to ultimately guide the development of evidence-based clinical guidelines. Methods Study design We used a modified Delphi approach using three phases, which are outlined below [8,14]. This method has been successfully used for priority setting for other marginalized populations [15–17]. Five members of the research team, which included two health professionals, family physicians and two persons with lived experience of homelessness, all with expertise in homeless health care, and a scientist with expertise in evaluating change, met in person in July 2017. The group reviewed literature and reports outlining the prevalence of disease and impact of homelessness as described in the introduction, as well as current approaches to delivering care for at risk populations. We pilot tested the survey with four expert health professionals and four lived experience participants. The working group modified questions to ensure multi-stakeholder clarity and acceptability. They developed an initial list of needs and at risk homeless health populations for experts to consider in recommending priorities for homeless health guidelines (see Delphi Round 1 in S1 Appendix). Ethics approval We obtained ethics review and approval from the Bruyère Research Ethics Board (Ottawa, Ontario) (M16-17-012). Survey participants We invited expert health professionals and persons with lived experience of homelessness from across Canada to participate in our Delphi. We used purposeful snowball sampling approaches among our homeless health networks. We purposefully selected participants to ensure the inclusion of a variety of local perspectives, including indigenous perspectives. Canadian health professionals from family medicine, internal medicine, psychiatry and nursing were purposely identified using the following inclusion criteria: a) homeless health expertise and/or b) provincial or territorial diversity province and/or c) research in the area of homeless health. Every health professional was ultimately selected for their knowledge in homelessness. In addition, we decided to include people with lived experience of homelessness. E-mail invitations were sent to each expert to determine interest and to explain the time commitment involved in participating in the Delphi process. Certain people were selected directly from our network, but the majority of participants were selected from 10 sites across Canada, shelters, food banks, and other community organizations. In these scenarios, one of our community outreach workers collaborated with local staff to select, invite and verbally deliver the survey to participants. Survey administration and analysis The Delphi Consensus process included three surveys rounds. We administered three rounds of surveys using Survey Monkey from May 15, 2017 to November 15, 2017. Each survey was live for 3–4 weeks and two reminders were sent. For people with lived experience, a research staff person interviewed the accepting participant and sent paper survey results by fax. The definition of the consensus was determined before the analysis of the round by the Delphi working group and in consultation with an epidemiologist. Investigators were blinded to the results during the data analysis. Follow-up was done through email and phone call or using local contacts with community partners. If a participant did not reply after three follow-up attempts over several weeks, they were removed from the next round. Round one In Delphi round 1 (See S2 Appendix and S3 Appendix), we collected participants' characteristics such as practitioner specialty, age range and gender. We provided participants with a list of seven potential priority needs as well as a list of seven at-risk populations. The objective for all participants was to rank the highest priority needs considering value added (opportunity for a unique and relevant contribution), level of inequity (reduction of unfair and preventable health inequities) and burden of condition (number of people that may suffer from a disease or condition) [18]. They also ranked the most at risk populations from a list of seven previously identified populations. Microsoft Excel 2010 was used to run descriptive statistical analyses, including mean and standard deviation. Participants were also asked to list additional priority needs and at risk populations that were missing from the review generated lists. These were subsequently added to the list for round two (see Delphi Round 1 Survey, S1 Appendix). Round two Round two of the Delphi consisted of two sections. Section one included the priority needs that ranked in the top 60% of participant ranking, including experts and people with lived experience. We would later report the experts and lived experience results separately but for our Delphi process we included both groups together. A mean rank (and standard deviation) was calculated for each need [19]. In section two, participants were asked to select their four highest priorities from a list of nine needs including those from the first round and an additional two based on participants' comments from round one. They were asked to consider the following criteria: added value, equity, and burden of disease. Round three Round three of the Delphi survey included priority needs and at risk populations identified in the previous round. No free-text option was provided and no qualitative data was gathered during this round. People with lived experience had the option to answer step one and two surveys consecutively, and significant effort was made to follow up with them to include them in the third and final round of the survey. The third and final round built consensus on the need and population ranking. We finalized rankings at a team meeting of experts working in the field of evidence-based homeless health. Electronic survey participants had the option to complete the survey using Survey Monkey or to request paper copies to facilitate completion. We analyzed the data using Microsoft Excel 2010. Results We reached a 73% response rate among health professionals (114 invited and 84 completed the first round of the survey). It was difficult to estimate the response rate of people with lived experience of homelessness given the majority were approached by community volunteers from the organization partners. Reasons why participants chose not to participate in all steps included leave of absence or sabbatical leave, clinical workload, or reasons not described. Please refer to Fig 1 for the number of participants in each round of the Delphi consensus process. 10.1371/journal.pone.0231758.g001Fig 1 Delphi survey participants sampling and response rate. Table 1 outlines the demographic characteristics of all Delphi survey participants. In total, six Canadian provinces and ten urban centres were represented. The majority of participants came from Ontario (61.90% health professionals; 53.95% people with lived experience). Participants in both groups were well balanced in terms of gender and although all age groups were included in the survey, very few participants were younger than 25 years old whereas people with lived experience were on average slightly older than the health professional group. Approximately 80% of participants in both groups listed English as their first language. The sex, age, and first language distribution among people with lived experience and health professionals remained very similar across the three rounds. Among people with lived experience, 39 people experienced homelessness or being vulnerably housed for less than two years (51.32%) and eight participants reported 11+ years as their length of experiencing homelessness or being vulnerably housed (10.53%). Compared to the first round, people with lived experience who answered the third round of the Delphi were less likely to experience long term homelessness. Six people with lived experience also identified as health professionals. 10.1371/journal.pone.0231758.t001Table 1 Demographic characteristics of Delphi survey participants for rounds 1, 2, and 3. Characteristic Health Professionals People with Lived Experience n (%) Delphi Round 1 Delphi Round 2 Delphi Round 3 Delphi Round 1 Delphi Round 2 Delphi Round 3 N = 84 N = 66 N = 58 N = 76 N = 76 N = 29 Age < 30 8 (9.53) 8 (12.12) 7 (12.07) 7 (9.21) 6 (7.89) 3 (10.34) 31–40 23 (27.38) 23 (34.85) 18 (31.03) 12 (15.79) 13 (17.11) 8 (27.59) 41–50 27 (32.14) 17 (25.76) 17 (29.31) 21 (27.63) 21 (27.63) 10 (34.48) 51–60 15 (17.86) 12 (18.18) 12 (20.69) 31 (40.79) 30 (39.47) 6 (20.69) 61+ 11 (13.10) 6 (9.09) 4 (6.9) 5 (6.58) 6 (7.89) 2 (6.90) Gender Male 36 (42.86) 29 (43.94) 23 (39.66) 43 (56.58) 43 (56.58) 17 (58.62) Female 47 (55.96) 36 (54.55) 34 (58.62) 33 (43.42) 33 (43.42) 12 (41.38) Other 1 (1.19) 1 (1.52) 1 (1.72) - - - Province British Columbia 3 (3.57) 2 (3.03) 1 (1.72) 12 (15.79) 12 (15.79) - Alberta 5 (5.95) 4 (6.06) 4 (6.90) 13 (17.11) 11 (14.47) 5 (17.24) Manitoba 1 (1.19) - - - 1 (1.32) - Ontario 52 (61.90) 46 (69.70) 42 (72.42) 41 (53.95) 41 (53.95) 10 (34.48) Quebec 16 (19.05) 10 (15.15) 8 (13.79) 9 (11.84) 10 (13.16) 14 (48.28) Nova Scotia 3 (3.57) 2 (3.03) 2 (3.45) - - - Newfoundland and Labrador 4 (4.76) 2 (3.03) 1 (1.72) - - - Missing - - - 1 (2.78) 1 (1.32) - First language English 67 (79.76) 56 (84.85) 50 (86.21) 61 (80.26) 58 (76.32) 15 (51.72) French 13 (15.48) 7 (10.61) 5 (8.62) 4 (5.26) 7 (9.21) 1 (3.45) Other+ 4 (4.76) 3 (4.55) 3 (5.17) 3 (3.95) 11 (14.47) 13 (44.83) Not reported - - 8 (10.53) - - Profession Primary care provider 36 (42.86) 33 (50.00) 28 (48.28) - 1 (1.32) 1 (3.57) Specialist physician 10 (11.90) 8 (12.12) 9 (15.52) - 1 (1.32) - Registered nurse 5 (5.95) 2 (3.03) 3 (5.17) 2 (2.63) 2 (2.63) 1 (3.57) Public health expert 5 (5.95) 4 (6.06) 4 (6.90) 1 (2.78) 1 (1.32) 1 (3.57) Social worker 5 (5.95) 2 (3.03) 1 (1.72) 3 (3.95) 3 (3.95) 1 (3.57) Homelessness researcher 16 (19.05) 12 (18.18) 10 (17.24) 1 (2.78) 1 (1.32) 1 (3.57) Community health advocate 6 (7.14) - 1 (1.72) 10 (13.16) 2 (2.63) - Not applicable/missing 11 (13.10) 2 (3.03) 2 (3.45) 59 (77.63) 8 (10.53) - Length of homelessness experience* < 2 years - - - 39 (51.32) 40 (52.63) 16 (55.16) 2–5 years - - - 17 (22.37) 19 (25.00) 10 (34.48) 6–10 years - - - 12 (15.79) 8 (10.53) 2 (6.8.8) 11+ years - - - 8 (10.53) 9 (11.84) 1 (3.48) Length of involvement in homelessness research or programs < 2 years 15 (17.86) 14 (21.21) 14 (24.14) 27 (35.53) 27 (28.95) 13 (44.83) 2–5 years 17 (20.24) 8 (12.12) 7 (12.07) 13 (17.11) 11 (14.47) 9 909-248-8862 years 18 (21.43) 19 (28.79) 15 (25.86) 4 (5.26) 6 (7.89) 6 (20.69) 11+ years 24 (28.57) 17 (25.76) 17 (29.31) 3 (3.95) 4 (5.26) - Not applicable/missing 10 (11.90) 6 (9.09) 5 (8.62) 29 (38.16) 28 (36.84) 1 (3.45) Among health professionals, most worked as primary care providers, specialist physicians and registered nurses (n = 51, 60.71%), and others were researchers, public health experts, social workers, or community health advocates. Health professionals with different lengths of experience working with homeless populations participated in the Delphi survey; 24 (28.57%) of participants indicated 11+ years of experience in the field and 15 (17.86%) reported less than two years of experience. Table 2 lists the prioritized and ranked needs from the Delphi consensus process by people with lived experience of homelessness and health professionals. Both groups prioritized, in the order of importance: facilitating access to housing, mental health and addiction care, care coordination/case management, and facilitating access to adequate income. There were few important differences in ranking between the two groups of participants. One difference was that health professionals ranked chronic disease management as the fifth priority while people with lived experience ranked nutrition and dietary support as their fifth priority. In terms of populations, both groups prioritized women, families, and children, Indigenous Peoples (First Nations, Métis, and Inuit), persons with acquired brain injury, intellectual, or physical disabilities, youth, and refugees and other migrants (see Table 909-248-8862/journal.pone.0231758.t002Table 2 Priority needs ranking. Priority People with Lived Experience Health Professionals 1 Facilitating access to Housing Facilitating access to Housing 2 Mental Health and Addiction Care/Trauma Mental Health and Addiction Care/Trauma 3 Care coordination/Case management Care coordination/Case management 4 Facilitating access to adequate income Facilitating access to adequate income 5 Nutrition and dietary support Chronic disease management 6 Chronic disease management (e.g. diabetes, smoking related lung disease) HIV, Hepatitis B/C, TB, other infectious diseases 7 HIV, Hepatitis B/C, TB, other infectious diseases Nutrition and Dietary support 8 Exposure related illnesses End-of-life care 9 End-of-life care Exposure related illness 10.1371/journal.pone.0231758.t003Table 3 Priority populations ranking. Priority People with Lived Experience Health Professionals 1 Women, families and children Indigenous (First Nations, Métis, Inuit) 2 People with acquired brain injury, intellectual, or physical disabilities Women, families and children 3 Indigenous (First Nations, Métis, Inuit) People with chronic homelessness 4 Refugees and migrants Youth 5 Youth Elderly 6 People with language barriers People with acquired brain injury, intellectual, or physical disabilities 7 Elderly Refugees and migrants 8 Victims of intimate partner violence / domestic abuse People with diverse sexual orientations and/or gender diversity (LGBTQ) 9 People with diverse sexual orientations and/or gender diversity (LGBTQ) Visible minorities 10 Visible minorities People with language barriers 11 Veterans Veterans Table 4 outlines the relevance and importance of the needs and populations that were selected and that will be used to develop systematic reviews and then trustworthy clinical guidelines for practitioners to improve the health of people experiencing homelessness or who are vulnerably housed 10.1371/journal.pone.0231758.t004Table 4 Relevance and importance of high priority topics and populations. Topic Importance 1 Facilitating access to housing It is important to situate housing as a basic human right [20], irrespective of health and social service uptake [21]. Initiatives that prioritize access to housing have demonstrated success among those with substance use disorders, veterans [22–24], and PLE from rural settings [25]. 2 Providing mental health and addiction care A number of interventions have been developed for PLEs with mental illness and addictions [26] in Canada and internationally, including intensive case management [27], assertive community treatment [28], supportive and supported housing [29], housing first [30], critical time interventions [31], and harm reduction services such as managed alcohol programs [32], supervised injection sites and wet shelters [33]. Such interventions are either not widely available or implemented with various degrees of fidelity to the evidence-based models [34]. Screening for mental health, addictions, and associated neurocognitive impairment and other disabilities among PLEs and building greater awareness of the range of supports available is essential to supporting PLEs in finding and keeping housing, addressing their mental health and substance use needs, and achieving community integration [35]. 3 Delivering care coordination and case management Effective care coordination can bridge various care settings (i.e. inpatient or long-term care), potential participants (i.e. informal caregivers, health specialists), and other resources (i.e. education, community services) to create a unique care pathway tailored for the patient. Facilitating care coordination makes navigating complex health systems manageable for PLEs. 4 Facilitating access to adequate income Case management programs for PLEs have included the need for obtaining adequate income at the centre of their support plans [36]. It is assumed that adequate income is a prerequisite for improving the health and increasing the likelihood of obtaining housing for PLEs. The role of health providers in addressing income insecurity is increasingly recognized. Both the Canadian Medical Association and the College of Family Physicians of Canada have produced guidance documents for physicians on addressing income and other social determinants of health [37,38]. Income intervention programs have been co-located with health care programs in the United Kingdom [39] and the United States [40] Population Importance 1 Indigenous people Indigenous people experience multiple risk factors for becoming homeless or vulnerably housed, such as low education level, insecure employment, and poor health [41]. Their distinct experience of being indigenous within a colonized country puts them at a structural and systematic disadvantage and at a significantly higher risk of homelessness or vulnerable housing [42]. 2 Youth Youth who are PLEs have unique health needs as they experience high rates of substance use [43,44], frequent histories of exposure to domestic violence [45], and often resort to sex work to meet their basic needs once removed from the family setting [46]. 3 Women, families, children Women, families, and children tend to be underrepresented among official homeless counts as they are more likely to be experiencing hidden homelessness and precarious housing compared to single men [47]. Women also have different paths into homelessness or vulnerable housing and suffer different sequelae than men [48]. 4 People with acquired brain injury, intellectual, or physical disabilities Disability can lead to homelessness or vulnerable housing, as it is often accompanied by loss of income, social supports, and adequate housing [49]. Discussion Using a Delphi consensus method, guided by three criteria: value added, inequity, and burden of illness, we were able to identify and rank priority needs for people who are homeless or vulnerably housed in Canada. Early working group lists were more disease specific but health professionals and persons with lived experience of homelessness rankings rapidly shifted to more upstream social determinant of health needs such as income support and a shared consensus emerged between health professionals and people with lived experience. The top four priority needs selected were: facilitating access to housing; providing mental health and addiction care; delivering care coordination and case management; and facilitating access to adequate income. Access to housing, considered a basic human right [50], is a critical first step in implementing health and social care interventions for people experiencing homelessness and the prioritization of this need reflects the published research [51]. Prioritizing access to early housing have improved outcomes among people with serious mental illness [52,53], substance use disorders, veterans [26–28], and people experiencing homelessness in rural regions [54]. The provision of mental health and addiction care, selected by both groups of Delphi participants, reflect the high prevalence of mental health conditions, and alcohol and substance use among people experiencing homelessness or who are vulnerably housed. Increasing our awareness of mental health difficulties and addictions among people experiencing homelessness or who are vulnerably housed is key to sustaining housing and community integration [55], and can prompt and inform research priorities. Case management provides intentional person-centered support, assessment and planning in order to facilitate the delivery and uptake of health and social care services in a timely manner [56]. Effective case management can bridge care settings (i.e. inpatient or long-term care), care providers (i.e. informal caregivers, health specialists), and other resources (i.e. education, community services) to tailor an individualized care pathway, and has been shown to help individuals achieve housing stability [23]. The majority of people experiencing homelessness or who are vulnerably housed experience income insecurity [57]. Having identified access to income support as a priority by both Delphi groups participants supports evidence suggesting income as a critical determinant of health and well-being [58] and potential roles of care providers in mitigating consequences of income insecurity [37,59]. Delphi participants further identified specific populations that could benefit from targeted research to focus the guidelines specifically to their needs in addition to that of the population of people experiencing homelessness. Participants prioritized: Indigenous Peoples (First Nation, Métis, and Inuit); youth; women, families, and children; and people with acquired brain injury, intellectual, or physical disabilities. Indigenous Peoples in Canada include First Nations, Métis and Inuit populations. In urban settings, this population is over represented in Canada's homeless population. Although the prevalence varies by region, approximately 20–50% of those vulnerably housed or homeless are Indigenous [60]. Indigenous people experience multiple risk factors for becoming homeless or vulnerably housed, such as low education level, insecure employment and poor health [41], which are further exacerbated by structural and systematic barriers [42]. This finding sparked the development of an Indigenous researcher led approach for Indigenous people who are homeless or vulnerably housed [61]. Youth who are homeless or vulnerably housed are often difficult to identify and support due to their social situation and challenges relating to youth protection [62]. Precariously housed youth experience high rates of substance use [44,63], exposure to domestic violence [45], and often resort to sex work to meet their basic needs once removed from the family setting [46]. Women, families, and children are often underrepresented among official homeless counts [64] as they are more likely to be experiencing hidden homelessness compared to single men [6]. Women have different paths into various forms of homelessness, suffer different sequelae than men [48], and experience significant negative health consequences [65]. Disability is a significant feature among those who experience different forms of homelessness, particularly in terms of having acquired brain injuries [66], developmental disabilities, neurocognitive impairment, and musculo-skeletal injuries [67]. Disability, often accompanied by decrease or loss of income, social supports, and safe and secure housing [49] can become a precursor to homelessness. Strengths and limitations The main strength of our study stems from the inclusion of people with lived experience of homelessness from across Canada. Our team collaborated with a diverse range of community organizations and sought need prioritization. Our study has a number of limitations. Repeatedly reaching persons with lived experience, most with no fixed address or contact numbers, was a significant challenge and meant accepting lower response rates over time. We did not include a substantive qualitative phase to the study and are unable to describe in detail the rationale for how participants prioritized the needs and populations. Finally, we are unable to conduct subgroup analysis of the needs ranking (e.g. for Indigenous Peoples) as the sample size of individual groups is too small. Conclusion Our Delphi consensus method, with people with lived experience of homelessness and expert health professionals, uncovered priority needs for homeless populations. These needs sparked a series of systematic reviews and two distinct homeless health guidelines. Including people with lived experience provided a unique real world perspective on needs and marginalization. While medical conditions appeared on the initial list of needs, the voices of both health professionals and people with lived experience shifted the consensus to social determinants of health reflecting existing structural barriers. Providing mental health and addiction care was identified as the most important issue among both groups of respondents. Supporting information S1 Appendix Results of ranking of needs and populations after Delphi rounds 1 and 2. (DOCX) Click here for additional data file. S2 Appendix Multi stakeholder Delphi consensus to Identify priorities for Canadian evidence-based guidelines to improve the health of homeless and vulnerably housed people. (PDF) Click here for additional data file. S3 Appendix Consensus de Delphi multipartite visant à déterminer les priorités des lignes directrices canadiennes fondées sur des données probantes pour améliorer la santé des sans-abri et des personnes vulnérables. (PDF) Click here for additional data file. 10.1371/journal.pone.0231758.r001 Author response to previous submission Submission Version0 15 Jul 2019 Attachment Submitted filename: Response letter PONE-D-19-19733.docx Click here for additional data file. 10.1371/journal.pone.0231758.r002 Decision Letter 0 Federici Stefano Academic Editor © 2020 Stefano Federici2020Stefano FedericiThis is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Submission Version0 28 Jan 2020 PONE-D-19-19733 Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: a Delphi consensus study PLOS ONE Dear Dr. Pottie, Thank you for submitting your manuscript to PLOS ONE. 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The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly ********** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: I Don't Know ********** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No ********** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ********** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The Delphi technique is a tried-and-tested way for groups to build a consensus. Yet to date the method has seldom been used in homelessness. The value for Delphi panels in the context of evidence-use is that they can create an agreed view between researcher, professional and patient on what might work best, not a top-down 'we know what research is best for you' approach. I was therefore delighted to see the technique used in this context to develop new policy and practice guidelines. The National Institute for Health and Care Excellence (NICE) in the UK uses Citizen Councils. While these are not strictly Delphi panels, they have a similar ethos: creating advice and guidelines that reflect a real-world consensus, not just rigidly following the scientific evidence from the lab. The authors of the article took great care to ensure the inclusion of a diverse national group of people with lived homelessness experience. This is no small feat given the transient nature of the population. Perhaps a little reframing in the introduction could have made it even clearer that the purpose of the work was to create rigorous and relevant guidelines to improve the care of people experiencing homelessness in Canada, building on a series of excellent systematic reviews. Applying this methodology will ensure the guidelines are as useful as possible in real life. It is very positive that the authors are committed to continuing engagement efforts with an ever wider range of participants. Indeed, the fact that mental health and addiction care was identified as the most important issue among respondents suggests this will be important to highlight even further the structural causes of homelessness. Reviewer #2: I have been asked to review "Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: a Delphi consensus study" for potential publication in PLoS One. This manuscript provides useful prioritization information in an important area of public health. I offer the following comments in order as they appear in the manuscript for the authors to consider: - Abstract: Methods is difficult to follow grammatically. Could it be revised to "Initial needs were drafted from a literature review. To ensure accuracy and relevancy, we recruited 84 practitioners and 76 people with lived homelessness experience to participate in a 3-step Delphi consensus survey identifying and rating health and social priorities for homeless populations." - Abstract: Methods would benefit from one line summarizing the criteria used to identifying individual needs and sub-populations as "high priority" or "most important". - Abstract Findings would benefit from explicitly identifying the number of needs and sub-populations identified as "high priority". - Introduction Lines 56-59: Could the authors also provide the life-expectancy figures for men and women who are not chronically homeless? - Introduction Lines 59-61 make an unexpected jump to first-person language and discussion of the systematic reviews/Delphi conducted by this team. It reads as very out of place to me and could be removed, or at least moved elsewhere (e.g., to an appropriate place in the last paragraph of the introduction). - Methods Lines 102-104 are difficult to follow grammatically. - The Methods section would be easier to follow if sub-headers were used throughout. Per most reporting guidelines for empirical research, I recommend separate subsections for (1) participants (eligibility criteria and recruitment strategy), (2) data collection instruments (questionnaire items), (3) procedures (drafting of items, piloting, and running the process), and (4) analysis (how the authors analyzed the data from the Delphi). At the moment, the information in the methods section presents this information that seems "out of order" to me. For example, the authors discuss the Delphi survey, then they note the rankings were finalized during a meeting subsequent to the survey, and then they go back to information about conducting the Delphi survey (i.e., Survey Monkey or paper). - The Methods section should include information on how many needs and populations were on the "initial list of needs and populations" (Line 122) and whether needs/populations were added or dropped in subsequent rounds. - The Methods section should provide more information on the actual ranking task: were all needs and populations listed on one page? Did participants do a Q-sort task? Did they pick their top 10 (and then rank within it)? Please describe to the degree needed for the reader to replicate the ranking task. To this end, copies of the Delphi protocol and the survey for each round should be provided as an online supplement or included in an online repository (e.g., the Open Science Framework). - In conjunction with more information on the ranking task, the Methods section also should provide more specific information on the analytic procedure used to analyze the ranking data for each round. For example, were rankings averaged across participants and then sorted? Please describe to the degree needed for the reader to replicate the analytic procedure. - Methods Lines 140-141: The authors need to provide more details about the following: "We finalized rankings at a team meeting of experts working in the field of evidence-based homeless health." Who were the experts? How many were there at the meeting, and how were they chosen? When and for how long did the meeting take place? What information from the Delphi did they use at the meeting, and what was the specific procedure and analysis process for "finalizing" the rankings? - Results Line 155: Figure 1 should include the response percentages as well as the N's. - Results Lines 160-161 states "all age groups were included in the survey", though this is an artifact of the age categories created by the authors. The "<30" group particularly strikes me as one that should be split into more groups, given the growing public health concern about youth homelessness (including the statistics provided by the authors on youth homelessness). - Results Lines 177-186: These findings are difficult to interpret without the methodological context asked for above (i.e., the actual ranking task and the analytic procedure). The authors should provide more detail on how many items were considered in each round and provide a table with the actual ranking data on these items, including which and the number of items that do (and do not) meet their criteria for "most important" or "high priority". It is also not clear why only the needs are listed in a table: could similar information be provided for the sub-populations as well? - Results Lines 187-189 are not results but rather are methods (see Lines 140-141). The authors here should report how many items came to this group, and the results of their discussions (e.g., how many items made the final list) according to the methodological details asked for above about the meeting. - Discussion Line 193: I do not see a "Table 3" anywhere in the manuscript file. - Discussion Lines 253-255: Please provide citations to support this claim. - Discussion Lines 273-275: The authors refer to "the guideline development process", but have not provided the reader with any details about this. What guideline is being developed? Who is developing it? Who is involved? Who will use it once done? ********** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose "no", your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Ligia Teixeira Reviewer #2: Yes: Sean Grant [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at kathryn88@example.org. Please note that Supporting Information files do not need this step. 10.1371/journal.pone.0231758.r003 Author response to Decision Letter 0 Submission Version1 26 Feb 2020 PONE-D-19-19733 Title: Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: a Delphi consensus study Editor Comments: The Reviewers appreciated the study, though, both noted that the manuscript requires careful revision of the writing, especially in terms of clarity and fluency. I therefore suggest the Author to proceed with the reviewers' suggestions and, if necessary, to use a professional English language proofreading service. Response: Thank you for this comment. We have thoroughly proofread and revised the manuscript and edited it for relevancy, clarity and fluency. Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Response: Thank you, we have amended and used PLOS style requirements. 2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Response: We have included the English and French version of the survey questionnaire as appendices. This questionnaire was developed based on a literature review and feedback from our Delphi team of researchers and persons with lived experience of homelessness. Reviewer #1: 1. The Delphi technique is a tried-and-tested way for groups to build a consensus. Yet to date the method has seldom been used in homelessness. The value for Delphi panels in the context of evidence-use is that they can create an agreed view between researcher, professional and patient on what might work best, not a top-down 'we know what research is best for you' approach. Response: Thank you. Yes, we sought a real world perspective that could lead to trustworthy guidelines. 2. I was therefore delighted to see the technique used in this context to develop new policy and practice guidelines. The National Institute for Health and Care Excellence (NICE) in the UK uses Citizen Councils. While these are not strictly Delphi panels, they have a similar ethos: creating advice and guidelines that reflect a real-world consensus, not just rigidly following the scientific evidence from the lab. Response: Thank you, this is a good point. Our patient and other stakeholder approach was guidelines by concepts from the MuSE project. (Petkovic D, MuSE Systematic Reviews BioMed Central 2020). The inclusion of homeless and vulnerably housed participants provided a real world perspective and consensus and provided leverage to build a network of users for the evidence. We agree with the reviewer that the mentioning of the NICE Citizen Councils would be useful and we have added a sentence into the last paragraph of our introduction: "This approach has been implemented by National Institute for Health and Care Excellence in the United Kingdom, which engages Citizen Panels to include the voices of lay members into clinical care guidelines. Our approach is informed by the methods outlined by the MuSE (Multi-Stakeholder Engagement Consortium) and the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) group to develop health guidelines." 3. The authors of the article took great care to ensure the inclusion of a diverse national group of people with lived homelessness experience. This is no small feat given the transient nature of the population. Response: Thank you 4. Perhaps a little reframing in the introduction could have made it even clearer that the purpose of the work was to create rigorous and relevant guidelines to improve the care of people experiencing homelessness in Canada, building on a series of excellent systematic reviews. Applying this methodology will ensure the guidelines are as useful as possible in real life. Response: Thank you for this suggestion. We have reframed the introduction to stress the purpose of this study. The Delphi sought to inform systematic reviews and primary care focused evidence-based clinical guidelines. 5. It is very positive that the authors are committed to continuing engagement efforts with an ever wider range of participants. Indeed, the fact that mental health and addiction care was identified as the most important issue among respondents suggests this will be important to highlight even further the structural causes of homelessness. Response: Thank you, we agree. We have highlighted this in the results and discussion section. Reviewer #2: 1. I have been asked to review "Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: a Delphi consensus study" for potential publication in PLoS One. This manuscript provides useful prioritization information in an important area of public health. I offer the following comments
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