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Increasing Resource Awareness to Improve Quality of Life: An Evidence-Based Intervention for

People Affected by Homelessness in Spokane

Marissa McPherson and Alysha Enbom

Nursing and Health Sciences, Lewis-Clark State College

NU 442: Practicum in Population Health

Dr. Tracy Flynn, Ph.D., APRN, CNE, NP-C and Tracey A. Koch, RN, MSN, FNP

December 13, 2020

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Increasing Resource Awareness to Improve Quality of Life: An Evidence-Based Intervention for

People Affected by Homelessness in Spokane

Evidence-Based Practice is an essential piece in the nursing practice, which encourages

continuous growth and improved outcomes for both the nurse and the patient. As conveyed by

Stanhope & Lancaster (2020):

Applied to nursing, evidence-based practice includes the best available evidence from a

variety of sources, including research studies, nursing experience and expertise, and

community leaders. Culturally and financially appropriate interventions need to be

identified when working with communities. The use of evidence to determine the

appropriate use of interventions that are culturally sensitive and cost-effective is

essential. (p.214)

Within the American Journal of Nursing, through an educational series of articles

reviewing literature for evidence-based practice for nurses, Melnyk et al. (2009) describes

evidence-based practice as a multistep process that first begins with cultivating a spirit of

inquiry. This spirit allows for the continued reassessment of practice techniques to improve care

outcomes.

Identification of Community

To design an evidence-based practice intervention, we needed first to identify a

community of interest. In a nursing class at the beginning of 2020, we found an interest in the

vulnerable population dealing with homelessness. We had planned to volunteer with a

service-learning organization in North Idaho, but COVID-19 prevented this experience from

occurring. Expanding on our sparked interest developed earlier this year, we decided to work
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with another community affected by homelessness. Our focus became oriented toward the

homeless population in Spokane, Washington. The community identification portion of the

project involved immersion in the data surrounding the homeless population in Spokane.

According to the National Alliance to End Homelessness from the State of Homelessness (n.d.),

1,309 people were found to be homeless on a given night in 2019 within the Spokane City &

County Continuum of Care. They also noted that there were 25.4 homeless per 10,000 people in

the general population. Within this report, the State of Washington was reported to have 21.4

homeless per 10,000 people. This comparison implies that Spokane had a higher prevalence of

homelessness than was noted throughout Washington state in 2019, confirming the need for

interventions for this community experiencing homelessness.

With further research into the community assessment portion, we came across the

Strategic Plan to End Homelessness developed by The Spokane Continuum of Care (2015). This

publication reported that some of the primary underlying reasons for homelessness in the

Spokane area included poverty, lack of living wage jobs, and lack of affordable housing. Data

from 2008-2012 shows that both Spokane City and Spokane County exhibited a higher

percentage of the population living in poverty at 19% and 15%, respectively than in Washington

state at 13%. The Spokane Continuum of Care (2015) also reported that 22% of the homeless

population dealt with severe mental illness, and 16% dealt with chronic substance abuse during

this time frame.

Windshield Survey

After conducting an initial assessment of the community online, we conducted a

Windshield Survey to obtain more valuable information in person. This windshield survey
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consisted of observing the community of interest from a distance and occurred in the middle of

a Fall weekend day. In Spokane’s downtown area, we observed multiple people out on the

streets and sidewalks who appeared to be homeless or at risk for being homeless. Several

people had grocery carts full of blankets and bags. The people observed did not appear to have

bathed and were observed by themselves if not in front of social service facilities. They

appeared to range in age estimated between the ages of 20 and 60. Several of the people

observed were fidgeting, twitching, or talking to themselves with an appearance of possible

drug abuse, mental illness, or both. We did not observe public transportation services being

utilized by this population during the observation time frame. Visually, there were no noted

resource advertisements, bulletins, or notifications for this population within the Spokane area,

although they may have been present within buildings.

Further online research after the observation portion of the windshield survey provided

insight into resource availability within the Spokane area for this population. The Spokane

Homeless Coalition (n.d.) has an online page listing resources for the homeless community.

Resources listed included SNAP, the HFCA, and Catholic Charities, which serve as a point where

people experiencing homelessness can be assessed and provided access to resources as

needed. Although this was a great list of resources, it was not apparent whether some of the

people sleeping on the streets would have any way to access them.

PICOT Question

Following the community’s general assessment, we determined the primary intervention

we wanted to implement into the community by defining our PICOT clinical question. As

described by (Melnyk et al., 2009), this PICOT question breaks down into “patient population
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(P), intervention or issue of interest (I), comparison intervention or issue of interest (C),

outcome(s) of interest (O), and time it takes for the intervention to achieve the outcome(s) (T).”

Our PICOT question involved (P) as the homeless population in Spokane, WA. (I) for intervention

included providing education and knowledge about resources currently available to this target

population and community. We did not feel that (C) for comparison was an incredibly pertinent

portion. We aim to compare our intervention’s application to a lack thereof to improve this

community’s quality of life. It would be difficult to ascertain what that person’s quality of life

might be like without the resources provided. It would be unethical to deny resource

information to anyone within this population. (O) for outcome involved increasing the quality of

life for this population while creating awareness of the community’s available resources. One

tool we found that may assist in measuring this outcome was The Flanagan Qualify of Life Scale.

This qualitative research instrument breaks quality of life into categories: material and physical

well-being, relationships with other people, social, community and civic activities, personal

development and fulfillment, and recreation (Burckhard & Anderson, 2003). Another tool we

found we could incorporate with the quality of life scale involved creating an infographic, flyer,

or another informative tool depicting the community’s available resources. (T) for the time was

discussed regarding our population, but we did not find there to be an appropriate time frame.

If even one patient utilizes the resources presented to them, our intervention will have been

successful. As discussed within the featured educational article series aimed at advancing

evidence-based nursing practice in the American Journal of Nursing, Stillwell et al. (2010)

expand on this idea:

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Note that a comparison may not be pertinent in some PICOT questions, such as in

"meaning questions," which are designed to uncover the meaning of a particular

experience. Time is also not always required. But population, intervention or issue of

interest, and outcome are essential to developing any PICOT question. (para. 11)

Literature Review

Using the PICOT question as a reference, we moved toward reviewing the literature. We

decided to focus our literature review on evaluating which resources were the most vital for

those experiencing homelessness. Throughout the literature, overwhelming evidence presented

a prevalence of other vulnerabilities among those who are homeless. This evidence indicated

that people experiencing homelessness could be vulnerable due to being homeless and

increasingly vulnerable due to other underlying conditions or circumstances. Some of these

vulnerabilities included suffering from mental and physical illness and comorbidity, and dealing

with homelessness in youth.

As described earlier, 22% of homeless people within Spokane were dealing with severe

mental illness and 16% with chronic substance abuse (The Spokane Continuum of Care, 2015).

We found these statistics to be integral in identifying mental health care resource needs within

this population. In a quantitative systemic review and meta-analysis, Ayano et al. (2019) found

that schizophrenia and other psychotic disorders had a significantly higher rate of prevalence in

the homeless population when compared to the general population, with rates noted up to 92%

for those who were homeless and living on the streets. They describe information from four

studies that associated a higher risk of “disability and mortality from suicide and general

medical, as well as alcohol and drug-related causes” regarding people dealing with mental
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illness and homelessness (Ayano et al., 2019). According to the World Health Organization

(n.d.), people with mental disabilities are a vulnerable group. They further discuss the issue,

stating that the homeless population’s mental health needs are often neglected even though

rates of prevalence of mental disability within this population can exceed 50%. Data presented

shows a high prevalence of mental illness among the homeless population and a need for

intervention to increase life quality.

Physical disabilities and illness were critical points within the literature review for this

community. To determine the prevalence of physical ailments, geriatric conditions, and

co-morbidity in the homeless population, Brown et al. (2016) conducted a qualitative,

population-based study. The evidence showed that geriatric condition prevalence rates among

homeless participants with a median age of 58 were comparable to the general population’s

geriatric condition prevalence rate for more of a median age of 80 years old. Interventions for

this population for geriatric conditions are necessary at an earlier age than would be considered

for the general population. Another systematic review involving physical conditions prevalent

within the homeless population by To et al. (2016) touched on foot-related conditions. They

found that foot problems were more prevalent in homeless people than in those who were not

homeless, although they were often overlooked. To et al. (2016) also provide the insight that

“Foot problems can also be a manifestation of chronic disease as evidenced by high rates of

diabetes, peripheral vascular disease, and hypertension found across studies.” They stressed the

need for more interventions for preventative foot hygiene and footwear and ongoing screening,

assessment, and interventions for treatments of foot-related problems in the homeless

population. Another study discovered within our literature review involved the compounding
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vulnerability demographics of being a Veteran having HIV, HCV, or HBV infections and being

homeless. In their retrospective study, Noska et al. (2017) discovered that the prevalence of

these three infections was higher in the VA population than the general population and higher

still for the VA population experiencing homelessness. With the noted higher prevalence of

physical disability and illness within the homeless population within these presented data sets,

the need for an intervention to implement resources and increase knowledge of available

resources is evident.

Additional portions of our literature study surrounded the availability and efficacy of

interventions aimed at reducing homelessness. One systematic review and meta-analysis

conducted by Munthe-Kass et al. (2018) provided an overview of the effectiveness of specific

interventions developed to decrease and prevent homelessness and assist with housing stability

for those experiencing homelessness or who are at risk for homelessness. The review’s purpose

involved guiding the future planning, development, and improvement of these interventions to

promote better outcomes. Some of the interventions studied included case management,

housing first, critical time intervention, abstinence-contingent housing,

non-abstinence-contingent housing with high-intensity case management, housing vouchers,

and residential treatment. Munthe-Kass et al. (2018) discovered that implementing these

interventions improved clients’ outcomes compared to a lack of intervention implementation.

Furthering the review of related yet differing intervention evaluations involves

addressing interventions focused on the population of youth experiencing homelessness.

Within their review of systemic reviews and randomized controlled trials, Wang et al. (2019)

evaluated the efficacy and impact of specific interventions aimed toward youth who are
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homeless. They emphasized the difference between an adult and a youth experiencing

homelessness. They reported that the reasoning for homelessness and the daily experiences

and risks involved with being homeless were significantly different between the adult and youth

population. The research displayed that youth experiencing homelessness benefited from

cognitive behavior therapy in treating depression, family-based therapy in addressing substance

abuse issues, and housing programs in improving housing stability (Wang et al., 2019).

Community Health Needs Assessment

Following our literature review of the general homeless population, we narrowed in on

the smaller community of interest. We researched Community Health Needs Assessments

focused around Spokane County. We reviewed one Community Health Needs Assessment from

the Spokane Regional Health District (2018). They decided the top three health priorities that

needed focus and improvement in Spokane County involved reducing family violence and

trauma, increasing access to mental health and substance abuse treatment, and increasing

access to affordable housing. This information was pertinent to ensuring our designed

intervention incorporated the community’s most essential needs.

Healthy People 2020 Topic and Objective

After compiling and evaluating data from our initial community assessment, windshield

survey, literature review, and CHNA analysis, we concluded that the Spokane population

experiencing homelessness needed assistance with access to health services. This conclusion

closely matched with The Healthy People 2020 topic of “access to health services” with the

objective aimed to “reduce the proportion of persons who are unable to obtain or delay in

obtaining necessary medical care, dental care, or prescription medicines.” (Healthy People,
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2020.) We utilized this objective to design an idea for an intervention involving providing

education to the population experiencing homelessness or those at-risk of becoming homeless.

We felt this education needed to involve healthcare and housing resources available. It is

evident that there are resources listed and available for the Spokane area, but there is also a

lack of advertisement and knowledge of these resources within the community. The research

discussed previously shows that interventions are effective when implemented.

Design of Intervention

The intervention itself includes developing an informative program that will provide

resource availability and options to those who are experiencing or who are at-risk for

experiencing homelessness. These resources will be based primarily on healthcare, which will

also include mental health and preventative health. We plan to initiate discussions and partner

with resource groups, hospitals, and clinics within the community to reach more people. We will

need to provide ongoing resource information to the homeless population, including those who

are at-risk. Education would come standard as an electronic copy in a slideshow presentation

with multiple uses such as electronic viewing and translation into different languages. The most

crucial form of the intervention involves printing copies to provide to those in need. Having

electronic accessibility provides an increased ability to reach more people. We encourage

implementing this slideshow into the onboard training for health care workers within the clinics

and hospitals within the community. It is also essential to distribute this to food banks and

shelters as the research implies these organizations are likely to contact this population more

frequently. The underlying aim is to provide information to improve the lives of this population.
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Following the process of outlining the intervention, we researched the logistics behind

actually developing and implementing the intervention. We found that The U.S. Department of

Health & Human Services (n.d.) provides information regarding multiple grants available for

assisting the homeless population. We aim to apply for grants through the Health Resources

and Services Administration, including The Health Care for the Homeless program and The

Projects for Assistance in Transition from Homelessness.

Community groups and partnerships will need to be incorporated to ensure efficacy and

to assist in outcome evaluation. We plan to follow through with patient’s charts electronically to

follow their care over time. If even one patient utilizes the resources presented to them, the

intervention will prove successful. We would recruit volunteers who are homeless or at-risk of

being homeless to provide feedback on the resources we have educated them on. Feedback

will be quantified utilizing a questionnaire. The Flanagan Quality of Life Scale Tool (Burckhard &

Anderson, 2003) discussed previously would be utilized with these volunteers. The feedback

questionnaire and the quality of life scales will be incorporated into the presented informative

program.

Presentation to Community

After developing the intervention’s planned design, we looked for a service agency

involved with those within the Spokane community dealing with homelessness. We found that

the Salvation Army based in the Spokane area had the most well-rounded approach and an

extensive connection to resources (The Salvation Army, n.d.). The name association alone may

provide increased resource knowledge and networking abilities to hospitals and clinics as well.

We felt that the volunteers would be beneficial in distributing the intervention and therefore
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sought out the Volunteer and Event Coordinator for the Spokane area. After putting together a

summary of our proposal with an associated cover letter, we submitted the proposal to the

Volunteer and Event Coordinator. We hope to have sparked an interest in implementing our

designed intervention to improve the quality of life of the community of people dealing with

homelessness in the Spokane area.

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References:

Ayano, G., Tesfaw, G., & Shumet, S. (2019). The Prevalence of Schizophrenia and Other Psychotic

Disorders Among Homeless People: A Systematic Review and Meta-analysis.

https://doi.org/10.1186/s12888-019-2361-7

Brown, R. T., Hemati, K., Riley, E. D., Lee, C. T., Ponath, C., Tieu, L., Guzman, D., & Kushel, M. B.

(2016). Geriatric Conditions in a Population-Based Sample of Older Homeless Adults.

https://doi.org/10.1093/geront/gnw011

Burckhardt, C. S., & Anderson, K. L. (2003). The Quality of Life Scale (QOLS): reliability, validity,

and utilization. Health and quality of life outcomes, 1, 60.

https://doi.org/10.1186/1477-7525-1-60

Healthy People 2020. (2020). Access to Health Services

https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2009). Evidence-Based

Practice: Step by Step: Igniting a Spirit of Inquiry. AJN The American Journal of Nursing,

109(11), 49–52.

https://doi.org/10.1097/01.NAJ.0000363354.53883.58

Munthe‐Kaas, H. M., Berg, R. C., & Blaasvær, N. (2018). Effectiveness of Interventions to Reduce

Homelessness: A Systematic Review and Meta-analysis.

https://doi.org/10.4073/csr.2018.3

National Alliance to End Homelessness. (n.d.) SOH: State and CoC Dashboards.

https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of

-homelessness-dashboards/?State=Washington
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Noska, A. J., Belperio, P. S., Loomis, T. P., O’Toole, T. P., & Backus, L. I. (2017). Prevalence of

Human Immunodeficiency Virus, Hepatitis C Virus, and Hepatitis B Virus Among

Homeless and Nonhomeless United States Veterans.

https://doi.org/10.1093/cid/cix295

The Salvation Army. (n.d.). Spokane Citadel Corps.

https://www.spokane.salvationarmy.org/spokane_citadel/

The Spokane Continuum of Care. (2015). Strategic Plan to End Homelessness.

https://static.spokanecity.org/documents/chhs/plans-reports/planning/2015-2020-strat

egic-plan-to-end-homelessness.pdf

Spokane Homeless Coalition. (n.d.). Finding Help.

http://www.spokanehc.com/finding-help.html

Stanhope, M., & Lancaster, J. (2020). Public health nursing: Population-centered health care in

the community.

To, M. J., Brothers, T. D., & Van Zoost, C. (2016). Foot Conditions among Homeless Persons: A

Systematic Review.

https://doi.org/10.1371/journal.pone.0167463

U.S. Department of Health & Human Services (n.d.) Grants.

https://www.hhs.gov/programs/social-services/homelessness/grants/index.html

Wang, J. Z., Mott, S., Magwood, O., Mathew, C., Mclellan, A., Kpade, V., Gaba, P., Kozloff, N.,

Pottie, K., & Andermann, A. (2019). The Impact of Interventions for Youth Experiencing

Homelessness on Housing, Hental Health, Substance Use, and Family Cohesion: A

Systematic Review.
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https://doi.org/10.1186/s12889-019-7856-0

WHO | Mental health, poverty and development. (n.d.). WHO; World Health Organization.

https://www.who.int/mental_health/policy/development/en/