“…as a system whole, especially with what is happening in the world right now, we need to re-construct, re-work and re-structure how we deliver services. Client identities are missing entirely. Health equity needs to be at the forefront of the change, especially when Black and Indigenous individuals are disproportionately affected by this pandemic. My specific recommendation is a complete flip of how we deliver care.”
~ Survey Respondent
This post is the third in a blog series highlighting the findings from our Canadian Institutes of Health Research-funded study focused on promising mental health and substance use practice adaptations used by front-line providers during the COVID-19 pandemic with young people who are experiencing or have experienced homelessness.
Our findings are based on answers to questions from a 26-item electronic survey completed in June 2020 by 188 Canadian front-line providers who work with youth (16 – 24 years) who are experiencing or have experienced homelessness. The survey was divided into three main sections: 1) youth mental health and substance use utilization patterns; 2) provider practice adaptations; and 3) promising and transformative approaches to service delivery. In our previous two posts, we summarized findings from the first two sections of the survey. In this post, we highlight findings from the final section.
As we noted in our last post on provider practice adaptations, the majority of survey respondents said they had pivoted to providing mental health and substance use supports over the phone or virtually. This final section of the survey gave providers the opportunity – mostly through free text responses (as opposed to selecting from a pre-determined set of responses) – to expand on which adaptations might hold post-pandemic promise. Notably, for the most part, rather than expanding on the practice adaptations themselves (e.g., promising virtual app), providers commented on the way these services should be delivered. In other words, the medium (phone/virtual supports) seemed to be less important than the message (ensuring youth felt supported). Additionally, the theme of addressing inequity was prominent in this section as it had been in the previous section on practice adaptations.
Effective Mental Health Practice Adaptations
- Proactive outreach – the majority of providers shared youth need more frequent and consistent check-ins compared to pre-pandemic given their more intense experiences of social isolation and economic uncertainty. Connecting more frequently but for shorter periods of time was found to be effective – especially given phone/virtual supports seem to require more demanding engagement.
Holistic approach – some providers have enhanced their mobile outreach and combine in-person mental health supports with the delivery of food, personal care items, and art supplies. Offering of this form of support is driven by the belief that young people struggling the most with their mental health are less likely to reach out for help.
Virtual care – promising adaptations noted by providers (with the caveat that accessing these forms of support requires resources) included:
- Youth-focused webinars
- Drop-in video/social media chats (e.g., Instagram live sessions on creating structure and routine)
- “Self-serve” applications like Woebot
- Creating social media platforms with up-to-date resources
Effective Substance Use Practice Adaptations
- Pushing back: people first – several providers who work with young people who use substances commented on purposely not adapting; rather, they felt it was important to maintain (in a safe way) the same level of substance use and harm reduction supports available pre-pandemic.
Enhanced outreach – this links to the theme of pushing back and is similar to the comments on the need for a proactive/holistic approach. The difference specific to substance use adaptations was the sense of urgency given the perception that substance use is increasing (along with the risk of overdose). Several providers mentioned using similar virtual supports to the ones previously mentioned (e.g., Zoom group therapy and Instagram live sessions); however, many highlighted the importance of in-person connection.
Effective collaboration – some providers noted the importance of collaborating with other agencies, especially given pandemic-related barriers to accessing appropriate supports for substance use. One provider commented on the effectiveness of increasing their in-person engagement (to combat COVID-related closures) along with telemedicine support from a physician as needed.
Post-Pandemic Potential and Challenges
When asked whether their practice adaptations hold post-pandemic promise, the majority (72%) of providers responded their mental health adaptations definitely or probably hold promise, while just over half (51%) responded their substance use adaptations definitely or probably hold promise. The uncertainty specific to substance use adaptations aligns with the reported general uncertainty around what is happening during the pandemic with youth who use substances (see previous blog posts).
We asked providers about their concerns or challenges related to service adaptations specific to mental health and substance use (providers could select more than one option). Their top three concerns link to our emerging overarching theme of health equity:
Reach – providers were very or somewhat concerned about reaching everyone who needs mental health (83%) or substance use (68%) supports.
Awareness – providers were very or somewhat concerned about youth being aware of the adaptations in mental health (76%) or substance use (62%) supports.
Access – providers were very or somewhat concerned about youth being able to access the technology required to participate in adapted mental health (75%) or substance use (67%) supports.
Recommendations for Service Adaptations: System Overhaul
Our final survey question offered a free text response and centered around provider recommendations on services adaptations to better respond to the mental health/substance use needs of youth post-pandemic or in the event of a future pandemic. Again, rather than elaborating on innovative practice adaptations such as promising virtual supports, providers overwhelmingly cited inequitable structural factors as the things that need changing. Also, the importance of continuing some form of in-person supports – especially for the most marginalized/underserved young people – was clearly emphasized.
“We need mental health and substance use street outreach workers. Hit the streets. Get to the people who are not being seen. Get to the people who need the help the most. Waiting behind a desk for a referral does nothing for the person on the street in agony.”
“We have had to recognize that our most resilient youth are the ones who participate in virtual supports. The most entrenched have become more vulnerable and have disengaged from service.”
Providers shared articulate and emphatic calls for post-pandemic system-level reform. There were appeals to defund the police force and invest more in housing and communities, provide free access – including the provision of tablet computers and cell phones – to virtual and telephone supports, amend privacy policies to allow providers to communicate using common platforms such as FaceTime and WhatsApp, and ensure appropriate infrastructure, staffing and training are in place in anticipation of a second pandemic wave.
“Join the movement to defund the police and invest in housing and other important life-affirming infrastructure. Decriminalize substance use. Implore bureaucracies to be more responsive and let youth lead the process.”
We went into this study to understand what provider practice adaptations might hold post-pandemic potential – a better way of serving young people who are experiencing or have experienced homelessness. We are learning that, for providers working on the front lines of this pandemic, “promising and transformative” practice adaptations are less about downstream individual-level interventions and more about addressing upstream, system-level structural inequities – a reimagining of the entire system. Providers spoke about the link between social inequities (e.g., public policy around COVID-related closures, racism, discrimination related to gender identity and sexual orientation, and inadequate income) and the ability to achieve equity in health and well-being – the social determinants of health.
As we continue doing a “deeper dive” into the survey data and incorporate responses from focus groups with providers and young people, two important questions come to mind: 1) What does the youth-serving homelessness sector consider an essential service? (the type/number of ongoing service reductions/closures speaks volumes) and 2) What is essential about the way these services are delivered? (the importance of human connection comes to mind) We look forward to unpacking these questions in our upcoming posts.