Background

On any given night, more than 326,000 people in the United States experience sheltered homelessness [1]. Over 11,000 U.S. community housing and homeless shelters provide services such as transitional housing, emergency housing, and basic necessities [2]. In 2021, 157,397 people were employed in the Community Housing and Homeless Shelters sector in the United States [2], with recent annual growth of almost 3% in this sector [2]. Like other congregate settings, shelters serving people experiencing homelessness (PEH) are at a high risk for infectious disease outbreaks. Shelters have experienced outbreaks of infectious diseases like tuberculosis, severe acute respiratory syndrome (SARS), hepatitis A, and SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) [3,4,5,6]. In a meta-analysis of studies conducted in several countries between January–May 2020, researchers found that 15% of staff working in homeless shelters were infected during SARS-CoV-2 outbreaks in the shelters they worked in [6].

Water, sanitation, and hygiene (WASH) is often promoted as part of the response to infectious disease outbreaks. This includes cleaning practices and hand hygiene, which comprises washing hands with soap and water or using an alcohol-based hand sanitizer. These are important behaviors in preventing and controlling the spread of many infectious diseases [7, 8]. Previous literature has found that lack of guidance, insufficient training, and difficulty obtaining infection control supplies were barriers to implementing infection control measures in homeless shelters and other community settings [4, 5, 9]. Homeless shelter staff and health care providers have also described staffing constraints as barriers to infection prevention and control [10, 11]. However, little is known about WASH practices in shelters serving PEH in general and during infectious disease outbreaks.

In Spring 2020, CDC developed cleaning and disinfection guidance for general facilities to promote COVID-19 prevention (see Fig. 1) [12]. At the time, much was unknown about the key ways SARS-CoV-2 spread. Non-pharmaceutical interventions such as cleaning and disinfection as well as hand hygiene were promoted during this time. However, little was known about shelters experiences with these recommendations and how they were being implemented. The purpose of this project was to: 1) describe hand hygiene- and cleaning-related experiences and barriers with staff in homeless shelters during the COVID-19 pandemic, and 2) assess preferred communication strategies for shelter staff. The findings from this project can inform areas for staff and facility-level interventions. Additionally, the results of this project can inform future outbreak preparedness and pandemic planning for shelters and facilities serving PEH.

Fig. 1
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04/01/2020 CDC cleanding and disifnection guidance for facilities

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Methods

We conducted in-depth, qualitative telephone interviews with staff and administrators from six shelters in Atlanta, Georgia. Atlanta was selected as the project site due to the project team’s existing relationships with homeless service providers. We used purposive convenience sampling to identify participating shelters. At each shelter, one administrator and three to four staff were interviewed. Eligibility criteria for staff or administrators to participate were as follows: (1) ability to speak and read English, (2) 18 years of age or older, and (3) serving in a staff or administrator capacity for at least six months.

One member of the project team led the interviews using a semi-structured interview guide. Field notes were taken during the interview by a member of the project team serving as a non-participatory notetaker. The interview guide included questions about cleaning routines; barriers and facilitators to cleaning and disinfection; cleaning promotion; shelter-led hand hygiene promotion; and hand hygiene barriers and facilitators of staff. At the end of the interview, participants were shown the current CDC cleaning and disinfection guidance (Fig. 1) and were asked about preferred communication regarding hand hygiene and disinfection for shelter residents and staff. On average, interviews took 35 min, and each participant received a $25 gift card as compensation for their time. All interviews were audio recorded and the audio was transcribed verbatim for analyses.

We used inductive and deductive coding to develop a codebook for analysis. A team-based coding approach was used to code transcripts. Two researchers reviewed and coded each transcript together. One researcher shared the screen with the transcript visible to the second researcher and took turns reading the transcript aloud. All codes were discussed until 100% agreement was achieved. This activity was determined to be non-research and was conducted consistent with applicable federal law and CDC policy. 1 MAXQDA 20.0 (Verbi Software) was used for data management [13].

Results

A total of 22 interviews were conducted from May through June 2020 with homeless shelter staff and administrators from six shelters. Shelters ranged in size from 20 to 450 beds and served various populations, such as men, couples, veterans, women and children, and families. Shelter types included low-barrier shelters (facilities without extensive requirements for use), emergency shelters (temporary shelter), night shelters (temporary night-by-night lodging), transitional housing (long term temporary lodging with intensive services), day shelters (where individuals can spend time during the day), or a mixture. Respondents worked in various roles such as a resident manager, vocational training coach, supervisor, director, administrator, or case manager.

Cleaning and disinfection

Respondents reported use of existing cleaning and disinfection protocols, such as those for tuberculosis (TB) prevention, that were established prior to COVID-19. Respondents described using routine cleaning schedules that included cleaning floors, wiping down high-touch surfaces, cleaning electronics, regular bathroom cleaning, doing laundry, and routine “deep-cleaning” (Table 1).

Table 1 Themes related to cleaning and disinfection practices, barriers, facilitators, and health promotion among in-depth interview respondents
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In response to the pandemic, COVID-19 specific policies were incorporated into existing protocols. For some respondents, these policies were implemented due to CDC Cleaning and Disinfection guidance (Fig. 1). Respondents who were familiar with the guidance described implementing procedures and posting parts of the guidance around the facility. Of those unfamiliar with the CDC guidance, respondents mentioned being familiar with the concepts included in the guidance and implementing many of the recommendations included in the guidance such as cleaning electronics and high-touch surfaces prior to seeing the guidance. Cleaning and disinfection activities occurred several times a day. For example, one shelter cleaned high-touch surfaces every two hours and another shelter cleaned three times a day (morning, afternoon, evening). There was a particular focus on surfaces frequently touched by multiple people, such as doorknobs and light switches. Participants reported that these surfaces had not been prioritized for frequent cleaning prior to the COVID-19 pandemic.

Respondents described using a range of cleaning and disinfection products including solutions and sprays. The products described were commercial-grade, industrial strength, or hospital-grade disinfectants and solutions. Respondents described making a bleach solution but mentioned that they did not mix any other chemicals or products together to make a cleaning solution.

Multiple individuals played a role in shelter cleaning. This included shelter residents (clients), volunteers, maintenance staff, and non-maintenance staff. In some shelters, respondents noted a decline in volunteers being able to help with cleaning practices due to COVID-19 protocols limiting personnel admitted to the shelter site and a decrease in volunteers during the pandemic. This shifted responsibility for cleaning onto staff or both staff and clients. Client roles in cleaning and disinfection varied from shelter to shelter; some clients were expected to clean as in-kind support during their stay, others received job training via their cleaning activities, and some volunteered to assist when there were insufficient staff to engage in frequent cleaning.

Strategies to promote cleaning and disinfection practices in shelters included cleaning protocols and promotional materials sent out by shelter leadership via email. Respondents noted that at the start of the pandemic, this approach was helpful, however over time they received an overload of information and expressed difficulty keeping up with the information. Other promotion strategies included posters, flyers, meetings, and webinars. Posters and flyers served as a reminder of key cleaning practices, while meetings were used to discuss cleaning approaches and issues with cleaning.

To ensure that staff and clients understood cleaning protocols and practices, respondents reported receiving in-person or virtual training on cleaning practices and protocols. Generally, staff did not say who provided trainings; however, of those that reported receiving trainings, the local health department, a Federally Qualified Health Center, maintenance leadership, or human resources led the trainings. Staff in turn trained the clients who supported cleaning activities. Client trainings were offered frequently due to high client turnover.

The main barriers to performing cleaning and disinfection included individual factors, access to supplies, and sufficient staffing capacity. Individual factors included attributes of clients or staff that made cleaning a challenge: for example, serious mental or physical health problems impacted some clients’ ability to support cleaning efforts, and perceptions of cleanliness standards and optimal cleaning techniques differed among people within a shelter. Additionally, it was difficult to relay cleaning information to clients who were unable to speak English, had low literacy, or were illiterate. Other barriers included staff and clients not following cleaning supply directions, using too little or too much cleaning product, lack of consistency with cleaning protocols, space to clean in occupied areas, or getting clients motivated to clean. An uncommon barrier was lack of access to cleaning supplies as respondents had access to cleaning supplies and utilized established cleaning routines.

Increased oversight of cleaning activities, adequate access to supplies, and established routines made it easier to complete cleaning activities. Oversight involved staff doing walk-throughs of the facility and checking product supply levels and how different areas were being cleaned.

Hand hygiene

Staff respondents reported washing hands with soap and water, using hand sanitizer, and using gloves (Table 2). As a result of the COVID-19 pandemic, staff reported increasing the frequency of hand hygiene behaviors. Common times for handwashing included before and after handling food or after using the restroom. Respondents typically used hand sanitizer when walking into or out of the shelter, before eating, and periodically while working at their desk or office. Several respondents mentioned preferring to wash their hands compared to using hand sanitizer, but because of time constraints and restroom location, respondents described relying on hand sanitizer more.

Table 2 Themes related to hand hygiene practices, barriers, facilitators, and health promotion among in-depth interview respondents
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Strategies to promote hand hygiene behavior among staff and clients included sharing or posting posters or flyers of when hands should be washed and placing hand sanitizer dispensers in several locations to serve as physical reminders to frequently clean hands. Other promotional methods included videos, trainings, and reviewing proper hand hygiene methods and importance of hand hygiene during staff meetings. Respondents mentioned that washing your hands for at least 20 s, keeping hands away from the mouth and eyes, and how to use hand sanitizer were emphasized during staff meetings/trainings. A few respondents desired signs encouraging hand hygiene to post at their shelters.

Staff generally did not perceive barriers to implementing hand hygiene behaviors. Among staff who expressed having barriers, primary barriers included difficulty remembering to practice hand hygiene, insufficient time, limited access to hand hygiene products, bathroom location, or inadequate hand hygiene facilities. One respondent also noted it was not possible to leave alcohol-based hand sanitizer out in shelters due to concerns for clients with alcohol use disorders.

Staff’s facilitators to frequent hand hygiene included access to products, positively encouraging hand hygiene behaviors among each other, and established routines. The availability of hand sanitizer dispensers and bathrooms being stocked with soap and paper towels facilitated hand hygiene behaviors. Since the start of the pandemic, respondents described an increased awareness to practice hand hygiene throughout the day, making it a routine behavior.

Guidance communication preferences

Respondents reported a desire for more guidance on the recommended frequency of cleaning and disinfection; how to clean and disinfect specific objects (e.g., leather furniture, toys, electronics); how to clean donated food, furniture, or clothes; and a more concise list of recommended cleaning and disinfection supplies (Table 3). Additionally, respondents wanted guidance on using gloves safely, the disposal process of personal protective equipment, and how often to clean soft surfaces.

Table 3 Guidance Communication Preferences
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Since clients were often involved in cleaning and have various levels of reading proficiency, respondents suggested that guidance include pictures. Respondents described a preference for having a web-based training and tools to train staff and clients such as Q&A sessions with experts to ask for clarifications. Respondents suggested that future guidance be communicated through partnerships and systems already in place, such as with shelter leaders, local health departments, organizations that work with PEH (e.g., faith-based organizations), hotels and motels that PEH may use, and Federally Qualified Health Centers.

Discussion

This project examined cleaning and hand hygiene practices and barriers among staff in homeless shelters and preferred communication strategies. Overall results revealed that shelters engaged in frequent hand hygiene and cleaning, with a specific focus on frequently touched surfaces due to the COVID-19 pandemic. Staff reported insufficient staffing capacity as a barrier to engaging in cleaning and disinfection practices, reinforcing a key challenge reported by other shelters serving PEH prior to and during the pandemic [14, 15]. To maintain cleaning practices in shelters, there was an increased reliance on persons who were not employed in roles that included cleaning duties; in addition to non-maintenance staff and volunteers, clients played a key role in cleaning and disinfection activities. However, frequent client turnover and individual barriers along with access to cleaning supplies presented a challenge to ensuring cleaning was done correctly. Insufficient or ineffective cleaning practices due to these barriers resulted in added burden to staff.

To address staffing challenges, frequent client turnover, and individual barriers, staff identified a need for a range of health education modalities such as trainings, health communication materials, and detailed guidance. High staff turnover in homeless shelters as a reported barrier to adequate training is consistent with a previous study [14]. In another study, researchers found that 57% of homeless shelter staff reported cleaning was part of their regular duties, however of these staff, 43% reported not receiving training on cleaning surfaces for SARS-CoV-2 [11]. Although this project found that most staff reported receiving training, staff turnover was a key barrier to the capacity to train new staff. Additionally, staff were unable to easily use the same training materials they received to train their clients due to formats not being suitable for client training, materials only being offered in English, and not in an accessible literacy level. Shelters need detailed, tailored training materials that can easily be used to train new staff and clients in order to increase knowledge and adherence to recommended guidance.

Respondents also revealed that shelters needed cleaning and disinfection guidance with more specific details such as when and how to clean specific items. Standard guidance from public health partners on hand hygiene and cleaning and disinfection that provides more specificity on supplies, cleaning techniques and best practices, similar to guidance developed specifically for early childhood care and education centers, would be helpful for shelters serving PEH [16]. During outbreaks where specific cleaning activities are needed, guidance could be adapted. Future guidance may also consider how to address potential shortages of cleaning supplies and staff. Since clients play an important role in cleaning and disinfection practices in shelters, guidance should be easily understandable for both staff and clients.

Materials such as trainings or guidance should be developed using best practices for health communication, such as tailoring materials to specific groups served by different shelter types, ensuring materials are linguistically and culturally appropriate, and developing materials that accommodate low literacy levels. During H1N1, it was found that access to many sources of information could be confusing for people in general [17]. However, a best practice from H1N1 response efforts was communication from public health officials to service providers, and availability of information in formats that accommodated low literacy levels, and this should be a standard public health communication practice going forward [17, 18]. When developing materials, it is important that information is presented in an easily digestible manner and can easily be related to clients. For example, respondents suggested the use of visual educational tools such as short, applied videos to help overcome literacy and language barriers; these types of materials could be used routinely to train new clients. In a literature review of the use of visual aids in health education materials, researchers found that people with low literacy had statistically significant improvements in health literacy outcomes when visual aids were developed; the most effective types were pictograms and videos [19]. Using these best communication practices, hand hygiene should continue to be promoted to ensure new clients/staff know the key times to clean hands and the best way to do so. Finally, as some PEH may have physical or mental health problems that would make engaging in cleaning activities difficult, materials can include strategies for how to adapt cleaning practices and protocols to accommodate disabilities or other limitations.

Shelters in this project were able to scale up their hand hygiene and cleaning practices during the COVID-19 pandemic by increasing cleaning frequency and focusing efforts on frequently touched surfaces. Although baseline practices are needed to support general infectious disease prevention efforts, shelters should be prepared to scale up efforts and have sufficient resources to respond to future pandemics or outbreaks. For example, since this project’s completion, the American Rescue Plan Act provided $80,000,000 to health departments to support COVID-19 testing and prevention in homeless service sites, encampments, and other congregate living facilities [20, 21]. Recipients could use the money to support activities such as addressing shelter staff shortages and buying additional supplies [20, 21]. In a study examining the impacts of COVID-19 on PEH and homeless service providers, researchers found that homeless service providers experienced financial challenges such as unexpected expenses related to purchasing PPE and supplies for staff and clients and had to rely on local, non-federal sources of funding at the time of the study [15]. Federal support to help with fiscal and human resources can help to address barriers, develop baseline practices, and plans for scale up. Findings from this project demonstrated the importance of public health and academic partners collaborating with shelter staff to develop educational tools to engage in recommended cleaning and hand hygiene practices.

This assessment has at least two limitations. First, this qualitative assessment was conducted in Atlanta, Georgia, and the perspectives and experiences of the respondents may not be generalizable to other geographic areas. Second, this assessment relied on self-report and did not include an in-person environmental assessment or observational component. As a result, assessment findings could be impacted by response bias.

Conclusion

This project highlighted that adequate staffing, supplies, and tailored, accessible training materials and guidance are needed to implement cleaning, disinfection, and hygiene interventions; these are critical for preventing and controlling infectious diseases in shelters. Adoption of these strategies at baseline would enhance routine infectious disease prevention, as well as improve public health emergency preparedness for infectious disease outbreaks or pandemics.