Using appreciative inquiry to explore and enhance perceptions of empowerment for those experiencing homelessness: A pilot study

Abstract

BACKGROUND:

Individuals experiencing homelessness endure occupational injustices in the form of marginalization and deprivation at higher rates than their counterparts who are not experiencing homelessness. This population’s expressed interests, needs, and desires are frequently ignored or unsolicited by a system of care that continues to exercise power over this fragile and underserved group. Marginalization and deprivation can lead to disempowerment. Few studies have been conducted that explore the perceptions of empowerment by those experiencing homelessness. Providing a “space” for the voice of those experiencing homelessness to be heard can promote occupational justice as an outcome of occupational therapy intervention.

OBJECTIVE:

This pilot research sought to explore perceptions of empowerment by attendees of a day shelter for those experiencing homelessness.

METHODS:

Researchers used an Appreciative Inquiry approach to elicit responses to the question, “For those experiencing homelessness who attend a day shelter, what are their perceptions of how the shelter environment supports empowerment?” This qualitative approach promotes and maintains focus on positivity and inclusivity with respect to the change process from solution identification to maintenance of identified changes. Shelter attendees participated in one of three focus groups. Based upon qualitative analysis of the data, environmental enhancements were made by the researchers and post-environmental enhancement surveys collected data related to perceptions of those enhancements to promote empowerment.

RESULTS:

Six themes emerged from the data and pointed to both internal and external factors that are perceived to impact empowerment.

CONCLUSION:

Results of this study can be used by occupational therapy practitioners to support and develop inclusive and empowerment-focused approaches for those experiencing homelessness.

Keywords

Occupation justice empowerment

1 Background

Homelessness and the associated costs to society which include healthcare burden, lost wages and need for social services is a significant problem worldwide [1]. According to the United Nations, homelessness has become an international crisis [2]. It is estimated that up to one billion individuals are homeless worldwide [3]. Statistics on global homelessness are challenging to capture for a myriad of reasons which include inconsistent data collection approaches and methods and discrepancies in how homelessness is defined [4]. In addition, those experiencing homelessness are often reluctant to be interviewed and many of them remain invisible even to the most diligent of researchers [5]. Literal invisibility can make it more challenging to identify and meet their needs and figurative invisibility can reinforce their marginal status [6].

The Organisation for Economic Co-operation and Development (OECD) is an international entity consisting of 35 countries. In their latest attempt to capture information regarding the homelessness crisis, 29 of the 35 participating OECD countries provided statistics and the percentages of those experiencing homelessness in each of those countries hovered around 1% [3, 4]. While this may appear to be a relatively small percentage, the actual number of those experiencing homelessness can be staggering based on total population and many countries such as England, France and New Zealand have more recently experienced an uptick in their statistics related to homelessness. This 1% also does not account for the many countries that do not belong to the OECD. The rate of homelessness worldwide is likely much higher than the OECD has indicated secondary to challenges associated with defining and understanding the nature of homelessness as well as capturing accurate data related to a population that is transient and often elusive [7]. The United States is no less immune to this crisis despite possessing the means to end homelessness [4] which would include policy changes, coordinated systems of care, housing and employment opportunities, increased support for the most vulnerable and effective crisis response [8, 9]. The most recent Point-in-Time count conducted in January of 2017 found there to be approximately 540,000 people experiencing homelessness in the United States on any given night [10]. This US population is likely grossly under-represented as the Point-in-Time count process is inherently problematic; individuals are asked to verbally respond to a series of questionnaires and many understandably shy away from the process and hence are not counted. Additionally, while the count is conducted over several days around the country, it is highly unlikely that all persons experiencing homelessness are captured in that small window due to factors such as transiency and temporary hospitalization. Most of those experiencing homelessness are concentrated in urban areas and California, New York and Florida have the highest number. [10]. Florida has just over 32,000 individuals who identify as homeless and of those 3,200 are homeless in Broward County where this research was conducted [10].

What lies beneath these facts and figures are people with the lived experience of homelessness with often unacknowledged strengths who are struggling to survive in the face of social exclusion, marginalization, and disempowerment [11]. Occupational implications of homelessness are varied and significant [12] yet there remains a paucity of research related to understanding the experience of homelessness through the co-created lens of occupational therapy practitioners and those with lived experience; a lens which can help to identify the profession’s role in supporting these individuals to engage in needed, desired and/or expected occupations. People experiencing homelessness have significant insight about, knowledge of and ability to identify solutions to address homelessness and poverty-related issues [13]. However they are typically excluded from the process of solution identification regarding the most effective ways to deliver programs and services [11] so it is not surprising that these individuals perceive a lack of autonomy and control over their lives and environment which leads to a state of disempowerment; a trend which is reflected in the literature [14 –18].

Some of the challenges associated with experiencing homelessness include feeling invisible and distrusting others which contributes to disengagement from formal sources of aid and support [15, 16]. Perceiving that they have become invisible and feeling distrustful of systems and society at large have subsequently been linked to material deprivation, cultural marginalization and disempowerment as the system of care often overlooks the true needs of individuals experiencing homelessness and poverty-related issues [17, 18]. Due to the stigma that often accompanies homelessness which includes perceptions that this population engages in illicit behaviors and substance misuse, individuals experiencing homelessness often face many disadvantages when seeking stable employment, obtaining sufficient identification documents, accessing resources, and finding adequate social-emotional support; this stigma serves as a breeding ground for further impediments such as mental health challenges, discrimination, and lingering self-doubt [14, 15]. The disempowerment experienced by those experiencing homelessness creates an environment of decreased autonomy and control [17]. The potential exists however for counteracting negative experiences and perceptions by affording opportunities that promote self-expression, shared storytelling, and exploration of alternative activities to getting involved in illegal or dangerous situations, in order to facilitate a sense purpose and empowerment [14].

This study sought to examine perceptions of empowerment in a local day shelter in the southeast United States. Empowerment is a construct related to feeling efficacious in one’s environment and being able to voice or self-advocate for those objects, people and conditions or contexts which can support one’s sense of control [19].

Both advocacy and self-advocacy are accepted interventions in occupational therapy to promote occupational justice and participation in daily occupation at both the individual and system level [20]. In order to advocate and support skill development around self-advocacy, occupational therapy practitioners must explore and embrace the lived realities and challenges that these individuals face daily. Empowerment represents the hopes and dreams of marginalized groups for an environment free of inequalities by increasing their influence over life circumstances and in their communities and by facilitating awareness of environmental demands [19]. Thus, empowerment is the process of increasing the assets and capabilities of individuals or groups to make purposeful choices and to transform those choices into desired actions and outcomes [21].

Those experiencing homelessness make up a diverse and complex population [22]. This creates a challenge for providers in developing effective services. Although people who experience homelessness may need health and social services, they often underutilize or are unable to access these services. Such underutilization or lack of access can be due to logistical concerns such as transportation but it is often due to the fact that their true needs are not being met and they are being marginalized and excluded from the decision making and implementation processes [23]. The perceptions of the needs of this unique population are frequently misaligned with the realities experienced by those who are homeless. If those with experiences of homelessness have unique insight and knowledge to identify solutions and direct program development. However, their voices are frequently omitted or excluded during the development of systems, programs, services, and policies that impact their daily lives. If the services rendered are to be effective the system for developing services for this population must be sensitive to the needs of those who make up the population being served [11]. Identified needs that are interwoven in the physical environment and social context of this population include adequate income, affordable housing, quality healthcare, and social and community supports [24]. Service providers need to be prepared to meet this population’s unique needs with a range of health and wellness prevention and promotion strategies that take into account their unique contexts as well as systemic factors that act upon and sometimes against these individuals. Few studies have examined this population’s perceptions of service provision and delivery despite these identified discrepancies between the need for services and the lack of service utilization [23]. Their engagement and collaboration in activities such as program planning and service delivery can help create more supportive, meaningful, and realistic services [11].

The limited body of literature led researchers of this study to explore perceptions of empowerment in a shelter environment to guide thinking about future opportunities for occupational therapy and promote occupational justice for those experiencing homelessness. Both Humanism and the Model of Occupational Empowerment were used as a framework to think about and support constructs related to this research.

At the core of Humanism is the tenet that all persons have innate potential for well-being given adequate environment supports and opportunities to actualize change. Humanism invokes uniquely human constructs that concern personal meaning and value. Being, hope, self-esteem, love, and individuality are considered integral to a person’s capacity to pursue meaningful change [25] The Humanistic theory helped guide researchers’ rationale for facilitating empowerment within the shelter. This theory enabled researchers to better understand the nature of the participants’ ability to self-determine and to change or adapt within their environment to manifest optimal occupational performance. This theory was also used as a foundation for creating a more supportive environment; one that fosters the ability to support empowerment by gaining control through autonomous decision making [26].

Focusing on such human potential to look beyond the social and physical barriers that potentially stifle motivation to effect occupation-related change of those experiencing homelessness was the impetus for this study.

The Model of Occupational Empowerment (MoE) developed by Fisher is rooted in Humanism and provided researchers with a framework with which to name the experiences of those who are disempowered and to focus on the importance of the environment to support empowerment. The MoE is a conceptual guide to empower marginalized individuals by providing opportunity for self-direction and choice. This model encompasses the complicated and profound interactions between disempowering environments, occupational deprivation, learned helplessness, occupational empowerment and occupational change [27]. There is a paucity of literature applying this model directly to homelessness, however, it has been used with other marginalized populations such as mothers in recovery from substance use and underserved individuals attending community outreach centers [27 –29].

Common challenges experienced by this population are poverty, substance use and legal concerns [30 –32]. According to the MoE, these challenges can result in limited opportunities and foster learned helplessness. Model-related constructs of occupational empowerment and positive occupational change were used to guide thinking during the development of post focus group environmental enhancements. All efforts including the use of a positivity-driven focus group development and execution were intended to foster empowerment by way of occupational justice. Occupational justice refers to the right of all individuals to have equal opportunity to engage in diverse and meaningful occupations in order to meet their basic needs and reach their inherent potential [33]. Marginalization is a violation of occupational justice and refers to social and normative standards that limit individuals’ ability to integrate into society, as well as to choose and participate in occupations [33, 34]. Some implications of marginalization among those experiencing homelessness include limited involvement in meaningful occupations due to poor financial resources, inadequate housing as well as limited job and educational opportunities [27, 34]. Limited access to enjoyable and meaningful experiences is another violation of occupational justice, referred to as occupational deprivation which further disempowers marginalized populations from breaking the poverty cycle [27].

At the core of both the Humanistic theory and MoE is an individual’s right to exercise personal choice so they have greater opportunity to become agents of change in their lives. Humanistic-driven, empowerment-oriented programming or scholarly inquiry enable individuals to gain control through opportunities to make choices, as well as respecting their decisions, individuality and subjective experiences [35].

In keeping with Humanism and the MoE, an Appreciative Inquiry (AI) approach was also threaded throughout the study to support researchers and study participants in remaining positively focused and to specifically inform focus group script development. Appreciative Inquiry is a methodology originated by Cooperrider who developed the approach specifically for organizational change management [36]. Cooperrider suggests that traditional problem solving methods produce conflict and resistance as they focus more on negative aspects of an issue or organization. Appreciative Inquiry is a strengths-based approach that assesses achievements and goals of any group through a ‘5-D’ cycle: definition, discovery, dream, design, and destiny [37]. Definition involves determining which particular issues need to be addressed and developing goals around those issues. The discovery phase enables participants to appreciate what sparks imagination for what might be for the dream phase. Finally, the design phase determines what should be which leads to the destiny phase which focuses on sustaining the changes made or goals met. Taking such an approach has shown many benefits within organizational development such as increased communication, building relationships, creating mutual respect, promoting teamwork, creating an opportunity to share knowledge and experiences, improving satisfaction, and embracing diversity [37]. Since its inception, AI has gained popularity in other areas such as health care and social service organizations due to its alignment with client-centered and collaborative principles [38]. It has been used with a variety of populations and settings including adolescents in mental health prevention and adults with substance use challenges with positive results [39, 40].

This research culminated in program development in the form of environmental enhancements at the shelter.

2 Methods

2.1 Design

Researchers conducted a qualitative study for the purpose of understanding perceptions of empowerment of those experiencing homelessness who were attending a day shelter in the Southeast United States; these perceptions related to the shelter environment which, for the purposes of this study, included both the physical and social environment. Researchers built trust with the shelter attendees over the course of one year through service learning, informal interactions at the facility and opportunities via coursework embedded within a masters of occupational therapy program. While there was some turnover of attendees over the course of the year, the majority remained chronically homeless and attended the shelter on a regular basis. Three focus groups were conducted with shelter attendees to capture these perceptions. Subsequent to data analysis, environmental enhancements were designed in conjunction with research participant input to target augmentation of perceptions of empowerment by shelter attendees. Satisfaction surveys were completed following the implementation of the environmental enhancements to ascertain whether perceptions of empowerment in this sample changed as a result of the enhancements.

2.2 Setting and population

The setting for this research study was a day shelter for those experiencing homelessness in Southeast Florida. The shelter is situated on the outskirts of an urban area and the ‘tent city’ where most of the shelter attendees reside at nighttime is located just blocks away. The population selected for this study consisted of adults experiencing homelessness who voluntarily attend the day shelter.

2.3 Sampling and recruitment

Approval to conduct this study was obtained from the institutional review board (IRB) of Nova Southeastern University. All participants involved in the study signed a consent form prior to participation.

Shelter attendees were verbally recruited to form a convenience snowball sample of the homeless shelter population and represented individuals who attend on a regular basis. As an incentive for participation, attendees who completed the study were given a five-dollar gift card to a local supermarket. Researchers recruited 20 individuals currently attending the shelter who then participated in one of three focus groups offered over the course of a two-week period.

2.4 Inclusion and exclusion criteria

In order to participate in this study, participants were required to meet the following inclusion criteria: be attendees of the shelter, speak and understand the English language and be eighteen years of age or older. Additionally, attendees who demonstrated interest in the study were required to attend the shelter on a regular basis. For the purpose of this study, a ‘regular basis’ was determined to be at least one time per month for a minimum of three months. Researchers excluded individuals who were unable to comprehend the consent form and intent of the study and those who exhibited behaviors that would impede the focus group process such as verbal or physical aggression or active psychosis as evidenced by observable behaviors and/or reports from onsite unpaid or paid staff members.

2.5 Data collection

To facilitate participant focus groups, semi-structured scripts were developed by the researchers using an AI approach which includes definition, discovery, dream, design and destiny phases. Definition entails describing the issue which in this case was perceptions of empowerment which was identified as being a concern in this population as reflected in the literature review and captured anecdotally from prior encounters with these shelter attendees by way of university-related service learning opportunities and course-related activities unrelated to this research study. At the beginning of each focus group, attendees were asked to define empowerment in their own words prior to researchers offering a predetermined, literature-generated definition. The questions related to the ‘discovery phase’ were intended to help participants focus on those aspects of the shelter that were working well and those aspects that could be improved. During the ‘dream phase’ of the focus group, questions encouraged participants to consider what they would want to see at the shelter if there were no limitations related to resources. The ‘design phase’-related questions enabled participants to co-construct what could be at the shelter and finally, questions related to the ‘destiny phase’ included considerations for sustaining the ideas that grew out of the design phase. Using AI to guide the focus groups enabled researchers and participants to co-develop ideas regarding environmental enhancements by discovering values and strengths already in place, dreaming what might be at the facility, designing and co-constructing what should be, and manifesting destiny by finding a way to sustain that dream.

Prior to conducting focus groups at the shelter, all researchers were trained on how to conduct an effective focus group which included group management, effective interpersonal communication and providing essential probing and follow up questioning. These skills were developed via mock focus groups with faculty and peers in order to achieve competence in facilitating a focus group in order to maintain objectivity and maximize participants’ willingness to share their thoughts and experiences with researchers. Three focus groups were conducted at the shelter over a two-week period and each focus group contained different research participants. Each focus group was led by two investigators with an additional researcher present to operate the audio recorder and take field notes to capture information related to intent, facial and body gestures that could be lost in the context of a voice recording only. Prior to each attendee focus group, participants completed a brief demographic survey. Each focus group was approximately one and a half hours in length. The focus groups were conducted in a private room at the shelter. Audio recordings were transcribed verbatim and qualitatively analyzed. Field notes were used when questions arose regarding intended meaning of the transcribed audio-taped recordings.

2.6 Data analysis

Audio recordings were transcribed manually and thematically analyzed using concept coding as identified by Saldaña [38]. Concept coding as described by Saldaña is a process whereby investigators assign meso or macro levels of meaning to data that symbolize what is objectively understood to be the intended meaning of the single item, action or phrase [41]. The use of concept coding enabled researchers to initially label and index the data. Additionally, frequencies related to common perceptions about the shelter’s impact on empowerment were collected to support the notion that collective themes were being derived from the data. Each researcher coded individually to minimize potential for influence and bias that could potentially arise if coding was conducted as a group. Upon completion of individual coding, researchers compared their findings with the other members of the research team [42]. Following this process, researchers collaborated to collapse codes and subsequently identify and name themes that emerged as an outgrowth of the data. In order to improve data accuracy, researchers conducted member checking during follow up visits to the shelter to ensure that the data and subsequent themes that emerged accurately represented participants’ intended meanings.

2.7 Environmental enhancements

Upon completion of member checking and identification of themes, researchers set about the development of potential environmental enhancements that would coincide with the themes that emerged from the data. A total of nine ideas related to environmental enhancements were generated by the research team. These ideas were then presented to the study participants. The participants were asked to rank the ideas from their most desired to their least desired enhancements and three top rated enhancements were selected based upon this feedback. Prior to executing enhancements at the shelter, members were consulted to ensure their approval of the three selected environmental enhancements, to which they agreed. Following the implementation of these environmental enhancements, attendees were asked to complete post-implementation surveys regarding their satisfaction with the enhancements.

3 Results

3.1 Demographic surveys

Demographic information of the sample shelter attendee population was gathered (see Fig. 1) at the start of all focus groups using an 8 question, self-report written survey developed by the research team. A total of 20 participants completed the demographic survey. Surveys revealed the average length of attendance among shelter attendees was 1 to 3 months. The most represented age group was 45-54 years of age (35%) with the second most represented group being between the ages of 55–64 (25%). Of the 20 respondents, 75% identified as male. Race and ethnicities reported most frequently were Caucasian/White (36.8%) and African American/Black (31.6%). Fifty-five percent responded affirmatively to the question related to whether or not they had ever been diagnosed with or hospitalized because of a mental health condition (data related to other medical conditions was not captured). Fifty-five percent also reported that this was their first episode of homelessness (defined as living on the streets or in a shelter without a regular place to stay). Fifty percent indicated that this current episode of homelessness had lasted one or more years, 20% 3-4 weeks, and 15% 4–6 weeks. The survey also captured the reoccurrence of homelessness within the last 5 years and 25% of respondents reported being continuously homeless, 50% indicated they experienced one reoccurrence in that 5 years and 25% indicated that they had experienced two to three reoccurrences of homelessness within that five year time period.

Fig. 1

Demographic data.

3.2 Themes

Six themes emerged from the concept coding process during the analysis phase of the research. These themes naturally fell into two categories; themes related to external locus of control and those related to internal locus of control to support empowerment. Themes associated with external locus of control included ‘at-homeness’, ‘networking’ and ‘teach me to fish’. Internal locus of control themes that emerged included ‘voice & choice’, ‘see me’ and ‘paying it forward’. Additionally, these themes were supported and reinforced when viewed through the lens of the MoE.

3.2.1 Themes related to external locus of control to support empowerment

‘At homeness’ emerged as a sense of comfort and normalcy for the shelter attendees. Participants described feeling empowered from the comfort and security of a familiar place and discussed aspects of the shelter that provided them with comfort and normalcy that attributed to the feeling of at-homeness. For example, some attendees described the connection between normalcy and at-homeness as having pictures and posters on the wall, instead of plain, undecorated walls. Attendees also expressed wanting a phone located in a more secluded area for an increased sense of privacy and security when making personal phone calls. During the dream phase of the focus group, participants suggested ways to enhance the sense of at-homeness including: adding more color to the environment, providing them with comfortable seating and having a more private phone area. Additionally, attendees suggested that a greater sense of home could be achieved if “everyone would support one another” and “clean up after themselves”. As described by the participants, at-homeness related to the MoE elements of both a disempowering environment and occupational deprivation. The shelter environment was perceived as disempowering as it did not afford the members opportunities to access basic human needs such as the need for privacy and a sense of security. These basic human needs when not met can breed occupational deprivation as evidenced by attendees receding from previously desired and valued occupations such as social interaction and vocational exploration.

‘Networking’ was described as the ability to connect with outside resources and have access to and knowledge about other programs. Attendees expressed that networking was a way to empower themselves by having opportunities to access services and resources. Attendees indicated that they wanted more and better communication between staff and attendees and that lack of information regarding programs and resources left them feeling disempowered. Attendees expressed a desire to broaden their network of human resources and support beyond the shelter and one participant stated that he wanted to be “provided more opportunities to get out in the community to interact with people that can guide us.” This theme supports the MoE element of occupational empowerment by providing the resources including connections to people and systems of support that enable attendees develop self-direction and determine what is needed for themselves to move toward greater health and wellness.

‘Teach me to fish” is described as the external opportunities provided for self-improvement to support empowerment. This theme is derived from feelings conveyed by the attendees that reflect the Chinese proverb “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.” The attendees referred to this as “being provided the right tools” so that they could then “put in the hard work to gain knowledge” to promote a sense of self-efficacy and empowerment. Tools and resources that shelter attendees identified as empowering included educational and motivational videos, life skill workshops and classes and additional computers to encourage self-directed learning. Teach me to fish relates to the MoE elements of both occupational empowerment as well as change. Having the tools to engage in meaningful occupation are critical for people to enact occupational change. For example, while many of the attendees expressed a desire for more knowledge of available resources, they were not provided with the tools to independently access that information and thus relied on the willingness and availability of staff members to provide that information.

3.2.2 Themes related to internal locus of control to support empowerment

The ‘voice and choice’ theme emerged as having the ability to make choices and have control over one’s life course. Participants explored the idea of being empowered when having the ability to make choices and exert control in their environment. This theme was consistent in attendee focus groups. Shelter attendees discussed needing/wanting more structure and routine, improved shelter management, more individualized help and the ability to petition the staff and express their concerns and ideas. The antithesis of voice and choice as relates to the MoE is the idea of learned helplessness. When environments are perceived as disempowering, that perception can be internalized, blend seamlessly with the cognitive schema and create a state of learned helplessness.

‘Paying it forward’ emerged as a theme due to a collective desire of the attendees to apply their inherent capabilities and learned skills to help others, especially newcomers to the shelter. This theme emerged as an exchange of knowledge and experience between attendees related to skills, resources, and life choices. Several attendees stated that the opportunity to assume a role or take on a job at the shelter would give them a sense of purpose, community and empowerment to increase personal growth. One attendee spoke of his way of paying it forward which was to volunteer his time to provide haircuts to fellow attendees at the shelter. According to Fisher and Hotchkiss, occupational empowerment is “the process of supporting others in the development of self-initiative and independence” (p.65) [24]. Paying it forward expresses the participants’ strong desire to support one another by sharing their experiences, strength, hope and knowledge to promote community and occupational engagement and develop personal meaning and purpose.

Finally, the theme ‘see me’ reflects sentiments that emerged from the focus groups about being heard, feeling valued and respected by others, and having others see them as a unique human spirit. In the discovery phase, shelter attendees explored aspects of the shelter that make them feel ‘seen’. Examples related to ‘being seen’ included volunteers coming to the shelter, calling attendees by their name, having outside activities and engaging with volunteers during these activities. In the dream phase of the focus groups, participants explored ideas regarding what it would be like if the shelter environment was perceived as more compassionate, empathetic and if there were mutual trust between all members of the shelter community. “Feeling” invisible relates to the MoE as it can create a state of learned helplessness and lead to occupational deprivation. Learned helplessness is a by-product of feeling ineffectual or invisible in one’s environment. I am not seen either literally or figuratively ergo, I do not exist and can effect no control in and over my environment. If I have no control then my occupational opportunities shrink and consequently, I don’t do, therefore, I am not.

3.3 Post focus group environmental enhancements

Based upon the results of the qualitative analysis of the data, the three environmental enhancements that were prioritized by the study participants included: creation of a suggestion box for attendees, creation of an ‘empowerment zone’ or place where attendees could visit to get or give supportive messages and a series of electronic (CDs) talks and videos regarding empowerment and motivation.

Nineteen post-modification surveys were completed regarding satisfaction with the environmental enhancements. The post-modification survey included an open response to encourage reflection regarding the enhancements and participant feedback included comments such as “the atmosphere you have provided has changed my outlook on everything”, “[I like the] open environment atmosphere. [I] like positive notes hanging around.” and “To have a safe and enjoyable environment has made a big difference and we need to get more one on one therapy.” The data collected from the post-modification attendee survey is presented in Fig. 2.

Fig. 2

Post-modification survey results.

4 Discussion

Driven by the lack of literature, this study sought to explore perceptions of environmental empowerment among attendees at a day shelter for the homeless. Gaining a greater understanding of the perceived needs of this marginalized and underserved population can better inform the provision of services including occupational therapy whether those services are delivered at the individual, community or population level. The holistic nature of occupational therapy practice puts practitioners in a unique position to target the environment for intervention in homeless shelters. Occupational therapists recognize the human potential to overcome challenging situations given a supportive context and environment.

In the current study, the exploration of strengths and barriers to empowerment enabled informed decision-making and collaborative consultation regarding environmental enhancements that would benefit primary stakeholders. In approaching change within an organization such as a homeless day shelter, an AI approach holds promise. Consistent with the literature, the use of AI in this current study served to create space for meaningful dialogue between researchers and shelter attendees to empower, foster exploration of meaning, and build a more positive environment for all stakeholders. The approach involved focus groups that followed the 5-D cycle of define, discover, dream, design, and destiny [37]. The define phase served to gather information about the stakeholders’ definition of empowerment. Attendees described empowerment as “I have a choice. I control my own destiny” and “we wouldn’t be hungry, broke, [and] dirty.” The discovery phase of the focus groups centered on appreciating the positive features of the shelter. Attendees mentioned access to basic needs such as food, clothing, showers, bus passes and healthcare as positive aspects of the shelter. Individuals attending the shelter also appreciated the presence of some positive relationships and support from other attendees. The phases of dream and design involved imagining what might be and then determining what should be. During these phases, attendees expanded their ideas regarding what they believed would empower them in their current circumstances; ideas which often differed from the common notion that empowerment stems from meeting basic needs for survival and included development of life skills and relationships, feeling seen and heard, and having a more home-like and inspiring physical environment. The post-environmental modification surveys yielded positive responses and attendees reported that the environment felt more “positive”, “enjoyable,” and “open”. Such responses may reflect that an AI approach was utilized to empower stakeholders in a day shelter and may have supported or even created the “just right” conditions to breed a sense of belonging.

The environmental enhancements were a direct outgrowth of the study themes that emerged. The suggestion box was intended to provide members with opportunities to share their concerns and make suggestions to staff. This intervention related to the theme of ‘see me’ by demonstrating to the members that they are valued and respected within the shelter community. The suggestion box also reflected the theme of ‘voice and choice’ by giving members an avenue to express their thoughts and take a more active role in facilitating change in the day to day shelter operations. The ‘empowerment zone’ specifically included the addition of fresh paint, a chalkboard mural where members could take or leave inspirational messages and an inspirational quote to an area in the shelter that was underutilized and devoid of anything particularly ‘homelike’. This ‘empowerment zone’ related to the theme of ‘at-homeness’ and ‘see me’ by fostering a more comfortable and positive environment that added a sense of normalcy. The ‘zone” also related to the ‘pay it forward’ theme by providing a way for members to connect with each other and potentially engage in altruistic behaviors, and ‘voice and choice’ by creating a platform for self-expression. The CDs containing the educational and motivational videos related to the theme of ‘teach me to fish’ by supporting self-efficacy, confidence to face challenges and skill acquisition. In addition, information from the videos could potentially be used when pursuing opportunities for employment by providing attendees with tools necessary to connect with other resources which addressed the theme of ‘networking’.

As one’s sense of empowerment is impacted by both internal and external factors, occupational therapists have a role in being able to address negative environmental factors, foster more empowering contexts, and create opportunities for increased occupational engagement. Consistent with the literature, this study demonstrated that environmental factors can be a significant barrier to occupational engagement for those experiencing homelessness.

5 Limitations and future directions

Individuals experiencing homelessness in Southeast Florida may have different experiences than those in other parts of the United States or globally. These differences may be due to variability in climate, funding, federal, state and local government approaches, laws and regulations related to homelessness and societal perceptions of homelessness and these individuals. Additionally, individuals for this study were recruited by convenience sampling which does not enable an accurate representation of the general population. Another limitation lies in the potential reluctance of those experiencing homelessness to be transparent with their true thoughts and feeling for fear of systemic backlash that might impact access to resources and services [43, 44]. Finally, attendee surveys were collected just one week post-environmental modification and reflected neither satisfaction with the changes over time nor enhanced perceptions of empowerment over time. Further research should be conducted with other shelters to add to the limited body of research in this area, clarify findings and improve understanding of the occupation-related needs of this population. In addition, future studies should ensure a sufficient time-period to adequately evaluate effects of interventions which could be accomplished by using a participatory action approach. Understanding the nature and impact of the environment to support of hinder occupational engagement including but not limited to social participation and work among those experiencing homelessness is crucial to the effectiveness of occupational therapy intervention.

Conflict of interest

None to report.

Footnotes

Acknowledgments

The authors would also like to acknowledge Julia Roncesvalles, MSOT, OTR/L and Angela West, MSOT, OTR/L for their contributions to this project.

References

Wong

, Park

, Nemon

. Homeless service delivery in the context of continuum of care. Administration in Social Work. 2006;30(1):67–94. http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=106245885&site=ehost-live&scope=site. Accessed April 22, 2019.

United Nations. [Internet]. Switzerland: Homelessness and the right to housing. 2017 [cited 2018 December 14]. Available from: https://www.ohchr.org/en/issues/housing/pages/homelessnessandhumanrights.aspx

Global Homelessness Statistics. homelessworldcup.org. https://homelessworldcup.org/homelessness-statistics/. Accessed April 14, 2019.

Organisation for Economic Co-operation and Development [Internet]. France: Homeless population. 2017 [cited 2018 December 14]. Available from https://www.oecd.org/els/family/HC3-1-Homeless-population.pdf

The Methodology of Counting the Homeless. ncbi. nlm.nih.gov. https://www.ncbi.nlm.nih.gov/books/NBK218229/. Published 1988. Accessed April 20, 2019.

Romeo

. Down and out in New York City: A Participant-Observation Study of the Poor and Marginalized. Journal of Cultural Diversity. 2005;12(4):152–160. http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=snh&AN=21216515&site=ehost-live&scope=site. Accessed July 9, 2019.

Busch-Geertsema

, Culhane

, Fitzpatrick

. Developing a global framework for conceptualising and measuring homelessness. Habitat International [Internet]. 2016 Jul [cited 2018 Dec 14];55:124–32. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=eih&AN=114628965&site=ehost-live&scope=site

Fowler

, Hovmand

, Marcal

, Das

. Solving Homelessness from a Complex Systems Perspective: Insights for Prevention Responses. Annual Review Of Public Health. 2019;40:465–86. doi: 10.1146/annurev-publhealth-040617-013553

National Alliance to End homelessness [Internet]. District of Columbia: Solutions. 2019 [cited 2019 July 9]. Available from: https://endhomelessness.org/ending-homelessness/solutions/

10.

National Alliance to End Homelessness [Internet]. District of Columbia: State of homelessness. 2017 [cited 2018 December 15]. Available from: https://endhomelessness.org/homelessness-in-america/homelessness-statistics/state-of-homelessness-report/

11.

Sakamoto

, Khandor

, Chapra

, Hendrickson

, Maher

, Roche

, & Chin

. Toronto, ON: Factor Inwentash Faculty of Social Work, University of Toronto. 2008: Homelessness-diverse experiences, common issues, shared solutions: The need for inclusion and accountability. Available from: http://www.streethealth.ca/downloads/homelessness-diverse-experiences-common-issues-shared-solutions-the-need-for-inclusion-and-accountability-march-2009.pdf

12.

Marshall

, Lysaght

, Krupa

. Occupational transition in the process of becoming housed following chronic homelessness. Canadian Journal of Occupational Therapy [Internet]. 2018 Feb [cited 2018 Dec 17];85(1):33–45. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=128350512&site=ehost-live&scope=site

13.

Hammell

KRW

. Empowerment and occupation: A new perspective. Canadian Journal of Occupational Therapy [Internet]. 2016 Dec [cited 2018 Dec 17];83(5):281–7. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=120612897&site=ehost-live&scope=site

14.

Bender

, Begun

, Dunn

, Mackay

, Dechants

. Homeless Youths’ Interests in Social Action via Photovoice. Journal of Community Practice. 2018;26(1):107–120.

15.

Farrugia

. The symbolic burden of homelessness: Towards a theory of youth homelessness as embodied subjectivity. Journal of Sociology. 2011;47(1):71–87. doi:10.1177/1440783310380989

16.

Kubota

, Kohlen

, Clandinin

, Caine

. Recognizing the Body as Being Political: Considering Arendt’s Concepts in the Context of Homelessness in Japan. Journal of Contemporary Ethnography. 2019;48(2):287–305. doi:10.1177/0891241618783840

17.

Cunningham

, Slade

. Exploring the lived experience of homelessness from an occupational perspective. Scandinavian Journal of Occupational Therapy. 2019;26(1):19–32. doi:10.1080/11038128.2017.1304572

18.

Addo

. Homeless Individuals’ Social Construction of a Park: A Symbolic Interactionist Perspective. Qualitative Report. 2018;23(9):2063–2074. http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=a9h&AN=131713398&site=ehost-live&scope=site. Accessed April 23, 2019.

19.

Kaplan

, Skolnik

, Turnbull

. Enhancing the empowerment of youth in foster care: Supportive services. Child Welfare [Internet]. 2009Jan [cited 2018 Dec 17];88(1):133–61. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=105360330&site=ehost-live&scope=site

20.

Occupational Therapy Practice Framework: Domain & Process, 3rd Edition. American Journal of Occupational Therapy [Internet]. 2014 Mar 2 [cited 2018 Dec 17];S1-48. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=104051937&site=ehost-live&scope=site

21.

Akpotor

, Johnson

. Client Empowerment: A concept Analysis. International Journal of Caring Sciences [Internet]. 2018 May [cited 2018 Dec 17];11(2):743–50. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=131851614&site=ehost-live&scope=site

22.

National Alliance to End Homelessness [Internet]. District of Columbia: Who experiences homelessness? 2018 [cited 2018 December 17]. Available from: https://endhomelessness.org/homelessness-in-america/who-experiences-homelessness/

23.

Thompson

, McManus

, Lantry

, Windsor

, Flynn

. Insights from the street: Perceptions of services and providers by homeless young adults. Evaluation and Program Planning [Internet]. 2006 Feb [cited 2018 Dec 17];29(1):34–43. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=psyh&AN=2006-03651-002&site=ehost-live&scope=site

24.

Baggett

, O’Connell

, Singer

, Rigotti

. The unmet health care needs of homeless adults: A national study. American Journal of Public Health. 2010;100(7):1326–1333. doi:10.2105/AJPH.2009.180109

25.

Schneider

, Krug

. Existential-humanistic Therapy, 2nd Ed. Washington, DC: American Psychological Association; 2017. doi:10.1037/0000042-000

26.

Nelson

. Why the Profession of Occupational Therapy Will Flourish in the 21st Century. American Journal of Occupational Therapy [Internet]. 1997 Jan [cited 2018 Dec 17];51(1):11–24. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=108016143&site=ehost-live&scope=site

27.

Fisher

, Hotchkiss

. A Model of Occupational Empowerment for Marginalized Populations in Community Environments. Occupational Therapy in Health Care [Internet]. 2008 Mar [cited 2018 Dec 17];22(1):55–71. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=s3h&AN=30003204&site=ehost-live&scope=site

28.

Cardinale

, Malacari

, Broggi

, Savignano

, Fisher

. Model of Occupational Empowerment and Gunnarsson’s Tree Theme: Intervention for Mothers in Recovery. Occupational Therapy in Mental Health [Internet]. 2014 Jan [cited 2018 Dec 17];30(1):43–68. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=104043901&site=ehost-live&scope=site

29.

Marval

, Townsend

. Homelessness: Enabling solutions in primary health-care occupational therapy. Occup Ther Now [Internet]. 2014 Oct 1 [cited 2018 Dec 17];15(5):17–9. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=amed&AN=0177160&site=ehost-live&lscope=site

30.

Rothwell

, Sussman

, Grenier

, Mott

, Bourgeois-Guérin

. Patterns of Shelter Use Among Men New to Homelessness in Later Life: Duration of Stay and Psychosocial Factors Related to Departure. Journal Of Applied Gerontology: The Official Journal Of The Southern Gerontological Society. 2017;36(1):71–93. http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=cmedm&AN=26769822&site=ehost-live&scope=site. Accessed April 23, 2019.

31.

Crosby

, Hsu

H-T

, Jones

, Rice

. Factors that contribute to help-seeking among homeless, trauma-exposed youth: A social-ecological perspective. Children and Youth Services Review. 2018;93:126–134. doi: 10.1016/j.childyouth.2018.07.015

32.

Rew

, Slesnick

, Johnson

, Aguilar

, Cengiz

. Positive attributes and life satisfaction in homeless youth. Children and Youth Services Review . 2019;100:1–8. doi: 10.1016/j.childyouth.2019.02.021

33.

Durocher

, Gibson

, Rappolt

. Occupational justice: A conceptual review. Journal of Occupational Science [Internet]. 2014 Oct [cited 2018 Dec 17];21(4):418–30. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=psyh&AN=2014-33156-005&site=ehostlive&scope=site

34.

VanLeit

, Starrett

, Crowe

. Occupational concerns of women who are homeless and have children: An occupational justice critique. Occupational Therapy in Health Care [Internet]. 2006 Sep [cited 2018 Dec 17];20(3/4):47–62. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=106122605&site=ehost-live&scope=site

35.

Fransen

, Pollard

, Kantartzis

, Viana-Moldes

. Participatory citizenship: Critical perspectives on client-centred occupational therapy. Scandinavian Journal of Occupational Therapy [Internet]. 2015 Jul [cited 2018 Dec 17];22(4):260–6. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=109797040&site=ehost-live&scope=site

36.

Cooperrider

, Srivastva

. Appreciative inquiry in organizational life. In: Woodman RW, Pasmore WA, editors. Research in organizational change and development: An annual series featuring advances in theory, methodology and research, Vol 1 [Internet]. Elsevier Science/JAI Press; 1987 [cited 2018 Dec 17]. p. 129-69. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=psyh&AN=1987-98155-004&site=ehost-live&scope=site

37.

Van Wyk

. Change management: Making use of appreciative inquiry. Professional Nursing Today [Internet]. 2015 Dec [cited 2018 Dec 17];19(4):20–3. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=ccm&AN=111492118&site=ehost-live&scope=site

38.

Clossey

, Mehnert

, Silva

. Using Appreciative Inquiry to Facilitate Implementation of the Recovery Model in Mental Health Agencies. Health & SocialWork [Internet]. 2011 Nov 1 [cited 2018 Dec 17];36(4):259–66. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=eric&AN=EJ954916&site=ehost-live&scope=site

39.

Lind

. The Power of Adolescent Voices: Co-Researchers in Mental Health Promotion. Educational Action Research [Internet]. 2007 Sep 1 [cited 2018 Dec 17];15(3):371–83. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=eric&AN=EJ828239&site=ehost-live&scope=site

40.

McAdama

, Mirza

KAH

. Drugs, hopes and dreams: Appreciative inquiry with marginalized young people using drugs and alcohol. Journal of Family Therapy [Internet]. 2009 May [cited 2018 Dec 17];31(2):175–93. Available from: http://search.ebscohost.com.une.idm.oclc.org/login.aspx?direct=true&db=psyh&AN=2009-05695-005&site=ehost-live&scope=site

41.

Saldaña

. The Coding Manual for Qualitative researchers. Los Angeles, CA: Sage; 2016.

42.

Krueger

, Casey

. Focus groups: A practical guide for applied research. Los Angeles: Sage; 2009.

43.

Campbell

, O’Neill

, Gibson

, Thurston

. Primary healthcare needs and barriers to care among Calgary’s homeless populations. BMC Fam Pract. 2015;16:139. Published 2015 Oct 13. doi:10.1186/s12875-015-0361-3

44.

Poremski

, Woodhall-Melnik

, Lemieux

, Stergiopoulos

. Persisting Barriers to Employment for Recently Housed Adults with Mental Illness Who Were Homeless. J Urban Health. 2015;93(1):96–108. doi:10.1007/s11524-015-0012-y