ArticlePDF AvailableLiterature Review

Evolving an evidence‐based model for homelessness prevention

Authors:

Abstract

While some progress has been made in addressing chronic homelessness through supportive models, a comprehensive solution for housing loss must include prevention. The purpose of this article is twofold: to conduct a review of the literature on the domains of the Framework for Homelessness Prevention; and to use literature on the concept of quaternary prevention, preventing the harms of service provision, to theorise an additional domain. The Framework for Homelessness Prevention draws upon theory from public health exploring primary, secondary and tertiary prevention, and also integrates primordial prevention. This leads to a typology of homelessness prevention that incorporates the following five domains: (a) Structural prevention; (b) Systems prevention; (c) Early intervention; (d) Eviction prevention; and (e) Housing stability. By systematically reviewing the literature we build out the evidence‐base supporting these domains. The team used research databases, internet searches and retrospective reference list reviews to identify high‐quality journal articles on prevention, which were then sorted by level of prevention. Through this process, we evolved our thinking on the Framework in considering that quaternary prevention was not initially included. Therefore, we explored the literature related to quaternary prevention in the context of homelessness and offer a sixth domain for the Framework: Empowerment. Ultimately, a comprehensive Framework for Homelessness Prevention will support communities and governments to more effectively prevent homelessness through upstream approaches.
Health Soc Care Community. 2020;00:1–10. wileyonlinelibrary.com/journal/hsc
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  1© 2020 John Wiley & Sons Ltd
1 | INTRODUCTION
Over the past two decades, new evidence-based approaches to ad-
dressing homelessness have transformed responses to housing loss
by being solutions-driven rather than strictly managing the crisis. For
example, Housing First has gained popularity within the sector with
a particular focus on supporting exits from chronic homelessness.
Housing First is intended as a shift away from traditional models
of requiring compliance with treatment services in order to receive
housing. Indeed, the terminology ‘housing first’ indicates providing
housing and suppor ts rapidly and with no preconditions, such as no
requirement to engage in other programs, supports or treatments.
For homeless sector funders, Housing First programs are appealing
due to the lower costs associated with housing with support as com-
pared to jail, hospital or emergency shelter (Goering et al., 2014).
Indeed, research to date demonstrates that Housing First supports
chronically homeless persons with high acuity mental health and ad-
dictions to find home (Goering et al., 2014).
Received: 26 August 2019 
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  Revised: 23 Ma rch 2020 
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  Accepted: 25 March 2020
DOI: 10.1111/hsc.130 00
ORIGINAL ARTICLE
Evolving an evidence-based model for homelessness
prevention
Abe Oudshoorn RN, PhD, Assistant Professor1| Erin Dej PhD, Assistant Professor2|
Colleen Parsons MSW, Research Coordinator1| Stephen Gaetz PhD, Professor3
1Arth ur Labatt Family S chool of Nursing,
Western University, London, Canada
2Depar tment of C riminology, Wilf rid Lau rier
University, Waterloo, Canada
3York University, Toronto, Canada
Correspondence
Abe Oud shoorn, Arthur Labatt Family
School of Nursing, Western University,
London, Canada.
Email: aoudshoo@gmail.com
Abstract
While some progress has been made in addressing chronic homelessness through
supportive models, a comprehensive solution for housing loss must include preven-
tion. The purpose of this ar ticle is twofold: to conduct a review of the literature on
the domains of the Framework for Homelessness Prevention; and to use literature
on the concept of quaternary prevention, preventing the harms of service provi-
sion, to theorise an additional domain. The Framework for Homelessness Prevention
draws upon theory from public health exploring primary, secondary and tertiary
prevention, and also integrates primordial prevention. This leads to a typology of
homelessness prevention that incorporates the following five domains: (a) Structural
prevention; (b) Systems prevention; (c) Early intervention; (d) Eviction prevention;
and (e) Housing stability. By systematically reviewing the literature we build out the
evidence-base supporting these domains. The team used research databases, inter-
net searches and retrospective reference list reviews to identify high-quality journal
articles on prevention, which were then sorted by level of prevention. Through this
process, we evolved our thinking on the Framework in considering that quaternary
prevention was not initially included. Therefore, we explored the literature related
to quaternary prevention in the context of homelessness and offer a sixth domain
for the Framework: Empowerment. Ultimately, a comprehensive Framework for
Homelessness Prevention will support communities and governments to more ef-
fectively prevent homelessness through upstream approaches.
KEY WORDS
empowerment, framework, homelessness, homelessness prevention, housing first, prevention
2 
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   OUDSHOORN et al .
However, in spite of these tangible successes, grounded in re-
search and evaluation evidence, Housing First as currently imple-
mented has limitations in terms of ending homelessness as a whole.
In particular, Housing First wor ks primarily at a ter tiary level, focused
on chronic homelessness, long after housing loss has occurred.
Indeed, many Housing First programs include homeless chronicity
and high mental health and addiction acuity scores as criteria for
intake. Other criteria might include rough sleeping, high usage of
emergency services, or pending discharge from hospital or jail to no
fixed address. Intake into Housing First for some programs includes
being ‘paper ready’, meaning that individuals have any forms that
might be needed to enter into a lease, such as identification, proof
of social assistance or rental references. Therefore, in considering
pathways into and out of homelessness, while Housing First offers
an evidence-based pathway out of homelessness for those who qual-
ify, communities also need evidence-based approaches to eliminate
pathways into homelessness. This is why while Housing First pro-
grams have re-housed thousands of people across many countries,
occupancy rates in emergency shelters remain stubbornly high.
Pathways into homelessness are diverse, with every experience
of housing loss being unique to the individual and family in some
way. The exact nature of homelessness also differs with homeless-
ness being defined as per the ‘Canadian Definition of Homelessness’
(Canadian Homelessness Research Network, 2012) as including:
being unsheltered, being emergency sheltered, being provisionally
accommodated and being at imminent risk of homelessness. This
definition is used as the authors of this review are situated in the
Canadian context . While the nature of homelessness differs, there
are some interconnected root causes identified within the liter-
ature. For example, in the context of the global North, failure of
public health and social systems to adequately support people in
crisis is a consistent theme (Nichols & Doberstein, 2016). The im-
pacts of trauma and violence, including structural violence, are also
a common concern, par ticularly in understanding the pathways to
homelessness for women (Phipps, Dalton, Maxwell, & Clear y, 2019;
Browne, 1993; Watson, 2016). Colonialism is another significant
factor, as Indigenous people across Canada are over-represented
among those experiencing housing loss (Belanger, Awosoga, &
Weasel Head, 2013; Lyons, 2011; Segaert, 2017). Involvement in the
child welfare system is common, with 57.8% of youth experiencing
homelessness having come through these systems (Gaetz, O’Grady,
Kidd, & Schwan, 2016; Nichols et al., 2017). Finally, low income is
often considered as the primar y factor leading to homelessness and
is interconnected with all of the afore-mentioned fac tors (Timmer,
Eitzen, & Talley, 2019). Therefore, there is opportunity for a clear
prevention framework to guide practices in homelessness preven-
tion as consideration can be given to key consistent health and so-
ciocultural concerns.
Public health scholars identify five levels of prevention (Kisling
& Das, 2019; Strasser, 1978) to deal with health or social concerns.
This is an expansion of the common three levels of prevention, being
primar y, secondar y and ter tiary prevention, now adding primordial
and quaternary prevention. Primordial prevention involves a focus
on system and policy level preconditions of a heath or social issue.
Primary prevention involves a focus on preconditions as well, but
more on the individual or familial level. Secondar y prevention in-
volves early detection of a concern and rapid intervention before
the issue leads to significant impacts. Tertiary prevention involves
a focus on mitigating the impacts of an already existing health or
social concern. Quaternary prevention involves a focus of mitigating
the unintended consequences of interventions across the other four
levels of prevention. The quaternary level presumes that there is risk
in how services or assistance are provided, such as risks of disem-
powering, institutionalising or silencing those who access services
or suppor ts (Pandve, 2014). The purpose of this paper is to explore
the Framework for Homelessness Prevention, which has been pro-
posed as a way to utilise the different levels of prevention to address
housing loss upstream. The Framework was developed in a Canadian
What is known about the topic:
• While supportive models are assisting people out of
homelessness into housing
• there is still an overwhelming number of new people en-
tering homelessness.
• A Framework for Homelessness Prevention has been
proposed.
• Accessing health and social services has the potential to
be a disempowering experience depending on how ser-
vices are delivered.
What this paper adds:
• Expands the Framework for Homelessness Prevention.
• Explores the research evidence supporting elements of
the Framework.
Adds the concept of quaternary prevention and empow-
erment to the Framework
FIGURE 1 Typology of Homelessness Prevention
Typology of Homelessness Prevention
1. STRUCTURAL PREVENTION
2. SYSTEMS PREVENTION
3. EARLY INTERVENTION
4. EVICTION PREVENTION
5. HOUSING STABILITY
ENDING
HOMELESSNESS
PRIMARY SECONDARY TERTIARY
  
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 3
OUDSHO ORN et al .
context and we are similarly situated in Canada. However, literature
used both to develop the original Framework and our analysis herein
is international, as are the implications of this paper. The research
literature will be reviewed in regard to the five domains within the
Framework. As this model does not currently include primordial pre-
vention, we review further literature and propose a sixth domain for
the Framework to address this level of prevention.
2 | THE FRAMEWORK
(Figure 1) Be fore reviewing the l iterature and al tering the Framewo rk,
we provide a brief summary of the Framework as it is currently pro-
posed by Gaetz and Dej (2017). The Framework is designed to at-
tend to the diverse factors involved in pathways into homelessness,
accounting for individual, relational, institutional and structural fac-
tors (Gaet z & Dej, 2017). The five categories in the Framework have
been explicitly identified as containing elements that correspond
with primary, secondary and tertiary prevention (Gaetz, Schwan,
Redman, French, & Dej, 2018). To this we would add that primordial
prevention is also attended to within several categories. The first do-
main of prevention in the Framework is Structural Prevention, which
means shifting key systems to ensure the best support is provided
for all persons. This can include poverty reduction, income support,
affordable housing supply, early childhood services, violence preven-
tion, anti-discrimination policies and landlord/tenant legislation. This
prevention domain is notably congruent with primordial prevention
in addition to primar y, secondary and ter tiar y prevention. The sec-
ond domain is Systems Prevention, which identifies failed systems as a
key cause of homelessness, as well as incorporating housing focused
support across diverse health and social systems. This can include
correcting transitions from public systems into homelessness ( jail,
child welfare, hospital), ensuring people have access to already avail-
able supports (social assistance, healthcare), and building success-
ful pathways from public systems into housing. The third domain is
Early Intervention involving crisis intervention to divert people from
homelessness or connect people to the appropriate level of service
to facilitate rapid re-housing. This can include family mediation and
reunification, shelter diversion, school-based early interventions,
support for those experiencing family violence and systems naviga-
tion support. This domain of prevention involves significant focus on
secondary prevention, although depends on other levels of preven-
tion as well. The fourth domain is Eviction Prevention, a specific form
of early intervention and housing stability. This domain includes sup-
porting the legal rights of tenants, utility or rent arrears crisis funds,
landlord mediation, and rent supplements. The fifth and final domain
is Housing Stability, which is a comprehensive consideration of how
to prevent people from becoming homeless again. Here, Housing
FIGURE 2 Literature review framework
Databases Searched: CINAHL, ProQuest,
EBSCO, and PubMed, Google Scholar.
Records idenfied through database
searching: (n = 5,091)
Screening
Included EligibilityIdenficaon
Addional records idenfied
through Framework
document (n = 99)
Duplicates (n = 413)and arcles over 20
years (n = 390) were removed
Recordsscreened
(n = 4,387)
Records excluded
(n = 4,717)
Full-text arcles assessed
for eligibility
(n = 216)
Full-text arcles excluded:
1) Not related to a Framework
domain (n = 3);
2) No evaluaonpresented (n =
71);
3) No objecve assessment of
the acvity(n = 101);
4) Assessment didn’t show
success (n = 5)
Studies included in data
synthesis
(n = 36)
Studies included in final
data synthesis
(n = 38)
Arcles added through
ancestry search
(n = 2)
4 
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   OUDSHOORN et al .
First is the most common approach, but this also includes other
wrap-around supports, individual elements of Housing First such as
rent supplements or communit y integration, as well as peer support,
life skills and cultural engagement. As noted in the introduc tion, this
domain of prevention is largely focused on tertiary prevention given
the current focus of Housing First on chronic homelessness and
those who meet criteria regarding high mental health and addiction
support needs.
3 | METHOD
Our review of the literature followed a scoping review methodology
(Arks ey & O’ Malley, 2005). The fr aming ques tions we re, ‘Do es exist-
ing research support the five domains of the Framework?’ and ‘Are
there any additional domains that could be added to the Framework
based on existing research?’ We were particularly focused on em-
pirical literature that evaluated the impact, quality or efficacy of
homelessness prevention interventions. This is because while much
literature speaks to prevention in general, and prevention proved to
be a frequently included element in recommendations, much less lit-
erature actually tests prevention interventions. (Figure 2) Therefore,
‘grey’ literature such as reports was excluded from the search. The
review included a more general search related to the terms ‘home-
less/homelessness’, ‘prevention’, ‘reduction’, then integrating each
of the five existing domains of prevention from the Framework:
‘Structural prevention’, ‘Systems prevention’, ‘Early intervention’,
‘Eviction prevention’ and ‘Housing stability’. We included articles
listed in the Framework report that were therefore used in creating
the initial Framework, as well as engaging in a manual ancestry re-
view of references from those articles already selected based on the
inclusion criteria . Screening criter ia included: (a) Do the ar ticles cover
one of the domains of the Framework; (b) Does the ar ticle present an
intervention or empirical evaluation of data on one of the domains;
(c) Is there a valid and objective assessment of the intervention or
activity; (d) Does the assessment conclude that the intervention
or activity is effective; and (e) Is the ar ticle in the English language.
Databases included CINAHL, ProQuest, EBSCO and PubMed, as
well as Google Scholar. The search returned 5,190 preliminary re-
cords, 390 of which were screened out for being over 20 years old.
Records were screened to include only original empirical research
that tested prevention, reducing the sample to 216 records for full-
text review. From these records, 36 ultimately fit all 5 criteria for
inclusion, and 2 additions were identified manually through ancestr y
reviews. In the following sections we review the five domains of the
Framework proposed by Gaetz and Dej (2017) accordingly to our
literature review.
3.1 | Structural prevention
Evidence on s tructural pr evention as effec tive is reasonabl y available
throughout international research. In particular, work has been done
to unpack the relationship between pover ty and homelessness, and
related poverty reduction or income support strategies. Parsell and
Marston (2012), for example, highlight that policy focusing on pov-
erty reduction achieves sustainable homelessness prevention. While
research continues to be more readily available for the global North,
evidence of the efficacy of poverty reduction in preventing home-
lessness has been found in both the global North and global South,
with Shinn (2007) noting that policies supporting more equal income
distribution relate to reduced rates of homelessness. Therefore,
policies supporting sufficient income, such as basic income set to
a liveable wage, are policies that prevent homelessness. Shinn
et al. (2008) fur ther state that focusing policy approaches to end-
ing homelessness on service strategies may actually be detrimental
if we do not consider the broader policy domains in which home-
lessness is precipitated. While income adequac y is a well-supported
form of structural prevention (Evans, Sullivan, & Wallskog, 2016), af-
fordable housing development receives more mixed support in the
literature. Minnery and Greenhalgh (2007) note that while housing
must of course be affordable to prevent housing loss, this cannot
be the sole policy approach to preventing homelessness due to the
complex social experiences and support needs that are often at play
in housing loss. These suppor t needs may often be related to ment al
health and addiction challenges (Chamberlain & Johnson, 2013). To
this we would also highlight that in most countries, new affordable/
social housing development is far from keeping pace with commu-
nity need (Suttor, 2016). Finland is a stand-out in this area as they
have maintained investments in new social housing, which is linked
to overall lower rates of homelessness (Housing Europe, 2017).
Policies regarding responses to intimate partner violence have
also been evaluated. Netto, Pawson, and Sharp (2009) in the UK
explored a change in policy approach from having people experi-
encing domestic violence leaving their home to access suppor t, to
a ‘Sanctuary Scheme’. The concept of a Sanctuary Scheme involves
shifting the expectation away from victims of violence leaving the
home and accessing crisis services to being able to remain in the
home and being protec ted from their abusive partner. They note
how this policy successfully prevents homelessness and fundamen-
tally reorients the structural approach to violence; however, they
also warn that this approach may not be suitable for all persons. That
is, if it involves taking resources away from crisis centres, and the
individual or family experiencing violence wants to leave the home,
this can actually decrease the options available and potentially in-
crease risk of violence. Rather, they recommend both a shift to a
Sanctuary Scheme as well as maintaining some crisis violence shel-
ters or centres.
Overall, there is good evidence to support structural prevention
as a relevant domain of prevention for the Framework. However,
whereas hundreds of articles make recommendations regarding
structural approaches, far fewer have actually tested these ap-
proaches. The research is currently dominated by conceptual ver-
sus instrumental work. There is significant room for comprehensive
research across the elements of structural prevention to highlight
the most promising policy approaches. In particular, we note that
  
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OUDSHO ORN et al .
we were unable to identif y any empirical studies on shifting struc-
tural elements of colonialism as an effective form of structural pre-
vention. Given that historical and contemporary settler colonial
practices continue to harm and even kill Indigenous people and
communities (National Inquiry into Missing & Murdered Indigenous
Women & Girls, 2019), at this point it is impossible to evaluate the ef-
ficienc y and effectiveness of structural prevention policies regard-
ing colonialism on reducing Indigenous homelessness. This reflects a
concerning ongoing gap suggesting that insufficient shifts have been
made away from colonialism for research to exist in this area.
3.2 | Systems prevention
A significant body of literature exists supporting systems preven-
tion as an evidence-based component of homelessness prevention.
Much of this literature focuses on ‘Critical Time Interventions’ (CTI),
which are intensive, time-limited, case-based supports for vulner-
able people experiencing transitions. This might include hospital
discharge for individuals who present with mental health challenges
(Tomita, Lukens, & Herman, 2014) or women who have experienced
abuse and enter an emergency shelter (Lako et al., 2013). CTI’s ef-
fectiveness has been proven across various settings and with various
populations who may be at risk of entering homelessness (Herman,
2014; Herman et al., 2011). We are cautious, however, that some
of this research focuses on system outcomes such as cost effec-
tiveness rather than homelessness prevention. This is evidenced in
intervention evaluations that only measure short-term service utili-
sation rates versus long-term housing stability. Because CTI can be
service intensive, a common concern is that it is only intended for
those most likely to have high service costs, leading to the use of
service prioritisation tools. Service prioritisation tools themselves
have mixed outcomes including both limited reliability of predicting
homelessness (Brown, Cummings, Lyons, C arrión, & Watson, 2018)
and falsely prioritising people who would not otherwise become
homeless (Shinn, Baumohl, & Hopper, 2001).
Whether labelled as a critical time intervention or not, discharge
from psychiatric care into shelter, no fixed address or the street is
one of the more comprehensively explored elements of systems
prevention. Forchuk et al. (2008) are at the forefront of this work,
developing and evaluating an intervention that is proven effective
as participants who are discharged into housing with suppor ts re-
mained housed. The authors conclude that, ‘policies related to hous-
ing and community start-up costs’ are inter-connected with reducing
homeless among patients who are discharged from psychiatric care
(Forchuk et al., 2008, p. 574).
The other are of significant coverage in this domain is youth in
transition, usually in the context of transition from justice systems or
child welfare systems. Britton and Pilnik (2018) created a list of rec-
ommendations and policy changes to reduce child welfare policies
and program designs that may create barriers to housing for youth in
transition. This includes recognising that all systems that serve youth
have a role to play in making cer tain that youth are not criminalised
for a lack of housing and that ‘child welfare services must provide
housing an d assist with record s ealing or expungem ent, enrollment i n
public benefits, and employment ’ (Britton & Pilnik, 2018). Adopting
transition and re-entry planning and practices within existing ser-
vices that support youth involved in the criminal justice systems and
homelessness, such as education, employment, housing etc., lead to
better housing outcomes. Similarly, programs that are designed spe-
cifically for youth who are ageing out of foster care lead to higher
rates of housing stability (Brown & Wilderson, 2010).
Overall, in our review we found good evidence to support sys-
tems prevention as an accurate domain of homelessness prevention.
Various inter ventions and evaluations demonstrate that that public
systems, such as health, child welfare and justice, are crucial institu-
tions for preventing homelessness. Much of this research points to
the need to translate this knowledge into practice; it is often a lack of
political will and resources that hinders systems prevention.
3.3 | Early intervention
Early intervention is another domain that proves to be well sup-
ported within the existing literature. Early intervention for youth
can include such models as reconnection with family or other natu-
ral supports or school-based support. Research on family reconnec-
tion demonstrates multiple positive outcomes including reconciled
relationships with family members, a positive return to residing with
family, and improved socioeconomic conditions (Winland, Gaetz, &
Patton, 2011). The Geelong Project (2014) in Australia provides evi-
dence on early intervention by offering youth services in school set-
tings to allow rapid support to youth who are at risk of disengaging
with school and have become or are at risk of becoming homeless.
By providing tiered monitoring and case management , the program
has both successfully diverted youth from entering emergency shel-
ter and supported homeless youth into accommodation through
a host home program ( The Geelong Project, 2014), meaning care-
fully screened community members provide youth with temporary
accommodation.
For broad ba sed early inter ventions, resea rch on cash suppor ts as
both eviction prevention and early inter vention is notably prevalent.
This evidence is notable because the practice of cash support can be
philosophically or politically controversial in some jurisdictions. The
controversy comes when this is perceived as too much of a ‘hand
out’ in more conser vative jurisdictions where cash transfers from
governments to individuals are frowned upon. People in these juris-
dictions often argue that providing cash suppor t disincentivises re-
cipients from solving their own housing crisis. However, the research
is quite clear that rent supplements, rent al arrears payments, secu-
rity deposits and utility arrears payment s all lead to homelessness
prevention. For example, an analysis of the Homeless Prevention
Call Centre in Chicago which processes approximately 75,000 calls
annually revealed that providing temporary financial assistance
does indeed prevent individuals from entering shelters (Evans et al.,
2016). Additionally, Crane, Warnes, and Fu (20 06) demonstrate that
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rental arrears are indeed a pathway into homelessness, particularly
among older adults facing the death of a loved one. This is supported
by research on the Home Base program in New York (Greer, Shinn,
Kwon, & Zuider veen, 2016), which also demonstrates that financial
interventions are a successful model of early inter vention.
With financial support being an effective form of early inter-
vention, detecting financial need/crisis is key to upstream support.
For example, in 2012, the U.S Department of Veterans Affairs de-
veloped a brief screening instrument for veterans measuring their
risk of imminent homelessness. This created statistically valid results
as the screening revealed that early detec tion of poor credit and/or
poor rental histor y, a change in income, unpaid housing expenses, or
temporality of housing can further prevent the risk of homelessness
(Byrne, Treglaia, Culhane, Kuhn, & Kane, 2016; Montgomer y, Fargo,
Bryne, Kane, & Culhane, 2013). Therefore, while crisis financial sup-
ports can be a form of secondary prevention, intelligent systems can
also be designed to make this primar y prevention. This is congruent
with the Framework design that speaks to the levels of prevention
crossing the different elements in the typology. While research ex-
ists demonstrating early intervention as an effective domain, studies
are largely American, meaning that the particularities of various ju-
risdictions internationally have yet to be published in the literature.
There is room for more research across the diverse interventions
described in this domain.
3.4 | Eviction prevention
The homeless service sector identifies eviction prevention as an
area of increased ser vice need internationally (van Laere, Wit, &
Klazinga, 2009). However, this was the domain of the Framework
for which we identified the least empirical intervention research.
Within Germany, Busch-Geertsma and Fitzpatrick (200 8) found
that diverse eviction prevention services delivered at the munici-
pal level do successfully prevent eviction and housing loss. Similarly,
Montgomery, Dichter, Thomasson, and Roberts (2016) found that
connecting veterans with health professionals or social work ser-
vices and housing services was a determining factor in prevent-
ing eviction. In an evaluation of an eviction prevention program
in Toronto, Canada, Ecker, Holden, and Schwan (2018) found that
98% of evictions were prevented with a strong focus on address-
ing rental arrears supported by case management and connecting
with landlords. Noting the limited intervention research in this do-
main, the Prevention Framework itself provides some hypotheses
for further research to build out evidence on eviction prevention.
For example, services provided as early intervention, such as crisis
financial suppor t, could perceivably also work for eviction preven-
tion, and should be analysed accordingly. Likewise, effective sys-
tems prevention strategies that support positive transitions from
care systems into housing are perceivably another form of eviction
prevention, illustrating the need to address all categories of the
Prevention Framework simultaneously. That said, more interven-
tion research is needed to understand the nuances of the variety
of supports suggested in this domain, such as what makes for the
most effective landlord intervention, or how to identify those who
are service disconnected and at imminent risk of evic tion. An area
where this research might be more easily conducted is within social
housing, as social housing providers tend to have more access to
resident data than private landlords, and often have eviction reduc-
tion as a strategic goal in their services.
3.5 | Housing stability
The largest quantity of literature identified through the scoping
review was in support of housing stabilit y as a tertiary mode of
homelessness prevention, provided to those who have previously
experienced homelessness. This can be almost wholly credited to
the wide uptake of Housing First as a program model, which includes
housing stabilit y as a core principle. The evaluation of these pro-
grams provides a large base of empirical intervention research that
demonstrates that those provided with housing stabilit y services are
more likely to remain housed despite past experiences of chronic
homelessness. For example, Pearson, Montgomery, and Locke
(2009) compared three Housing First programs and found that sup-
port for housing stabilit y is effective even among those considered
‘hardest-to-serve’. We use quotes here around hardest-to-serve as
this phrase can be problematic in terms of situating the challenges
of positive housing outcomes with the individual rather than with
structural barriers and system limitations. The supports within
the realm of housing stability can be diverse, including integrated
substance use and mental health interventions, risk-management
strategies and trauma-oriented ser vices (Roy et al., 2016). Housing
stability is also connected with eviction prevention, as demon-
strated by Brisson and Covert (2015) who found that stability sup-
ports in the context of an identified lease violation prevent housing
loss. Through the At Home/Chez Soi trials, this stability has proven
cost effective among those who use the highest quantity of pub-
lic services (Goering et al., 2014). This project was the largest ran-
domised controlled trial on Housing first in the world, spanning five
cities with 2000 participants over 2 years.
Housing stabilit y as tertiary prevention interconnects the four
other domains of prevention from the Framework. For example,
Dasinger and Speiglman’s (2007) evaluation of Project Independence
(PI) identified rent subsidies as a form of housing stability, demon-
strating the interconnectedness between eviction prevention and
housing stability, for example. Similarly, program participants from
Waterloo Region's Housing Services and STEP Home who were pro-
vided with rental assistance showed significantly greater improve-
ments over time in housing stability and quality of life as compared
to the control group (Pankratz, Nelson, & Morrison, 2017), again
connecting eviction prevention to housing stability. Another exam-
ple of the interconnectedness of the domains is how Farrell, Dibble,
Randall, and Britner (2017) align systems prevention with housing
stability in identifying how in-home suppor ts provided by the child
welfare system can assist in supporting housing stability.
  
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OUDSHO ORN et al .
Ongoing support s, as identified by the individual receiving sup-
port, are key to housing stability in the context of those with a his-
tory of homelessness (Brown, Vaclavik, Watson, & Wilka, 2017).
However, the nature of these supports varies considerably. This
might include elements built into the housing selec tion process, such
as housing families in a familiar neighbourhood, near the children's
schools, with easy access to transportation, and close to family and
friends (Fisher, Mayberr y, Shinn, & Khadduri, 2014). It can include
health support s such as referral and systems navigation (Fargo et al.,
2017) or ongoing counselling and psychological support (Fichter &
Quadflieg, 2006). For some it might mean creating access to social
support where others are best served by a broader focus on general
life satisfaction (Broner, Lang, & Behler, 2009). The mode of deliver y
can also vary, from case management, to assertive community treat-
ment (Vet et al., 2013), to moderate case management for those with
lower support needs. Regardless of the design, housing stability is a
well-established domain of tertiary homelessness prevention. Again
illustrating the interconnectedness of modes of prevention, hous-
ing stability also becomes a form of primary prevention as cycles of
housing loss are effectively interrupted.
4 | DISCUSSION
As presented in detail below, throughout the scoping review the
concept of empowerment was repeatedly mentioned as an aspect
of homelessness prevention and we therefore propose this as an ad-
ditional domain to include in the Framework. Returning to the con-
cept of quaternary prevention introduced in the outset of this paper,
there is risk within the provision of health and social services that
these services themselves might unintentionally facilitate the disem-
powerment of individuals who make use of them. While this might
not be the case for all programs and services, due to the multiple
marginalities inhabited by those experiencing homelessness, there
is a significant power differential between service providers and the
institutions and structures they work within and those experiencing
homelessness that makes this risk ever-present. For example, where
choice is removed, voice is silenced or opportunities are constrained,
and so while basic needs might be met, there is still a loss of power
experienced by the individual. Consider then quaternary prevention
as a way to proac tively address this risk rather than a general indict-
ment of health and social services. To be clear, quaternary preven-
tion is not a critique of public access to health and welfare systems in
general, but a warning that how these systems operate is impor tant
to the psychological and social well-being of those who access these
services. In the context of homelessness, we propose that quater-
nary prevention involves building space for service recipients to em-
power themselves throughout service provision.
Consider Housing First as an example of a ser vice provided to
those experiencing homelessness. One of the principles of Housing
First is participant choice (Tsemberis, Gulcur, & Nakae, 2004), such
as choice to en gage in a program in gen eral, as well as spec ific choices
around housing type and location. Where choice is offered, program
participants can empower themselves by exercising this choice ver-
sus experiencing the disempowerment of being told to where they
have to move. In a qualitative evaluation of Housing First, Voronka
et al. (2014) heard from participants that it was important that help
offered is truly aligned with the needs and interests of par ticipants.
Spaces for empowerment can include adopting principles of client/
patient-centred care from the healthcare sector. Housing workers
within shelters or Housing First programs should be developing
housing plans collaboratively with participants rather than being
driven by top-down metrics. For example, within a Housing First
program this might involve facilit ating a participant to move to a new
apartment if they are no longer satisfied with their current location.
Rather than being counted against measures within the program
of ‘housing permanence’, these types of supported, desired moves
should be considered a success if driven by the participant. Finally,
the sector should reflect on the language they use, encouraging the
move towards person-first language (i.e. people experiencing home-
lessness) and language that centres on responsibility on the system
(i.e. de-housed versus becoming homeless). In this paper we have
tried to consistently refer to housing loss, which is a process, in lieu
of homelessness, which is often perceived as a static or permanent
state.
As a new domain of prevention in general, and an opportunity to
enhance the Framework for Homelessness Prevention specifically,
quaternary prevention and the issue of empowerment is relatively
novel. However, there is some existing literature that points to how
empowerment can improve outcomes in the context of housing loss.
For example, as mentioned above, choice has been an element in-
tegrated in various ways into a number of Housing First programs
(Tsemberis et al., 200 4). So, where choice is already integrated,
achieving quaternary prevention is simply a matter of fidelit y to the
principles of the program. In this context, barriers to fidelity need to
be acknowledged, such as how other system issues can negatively
impact u pon choice, which ex ist outside of th e realm of control of any
one program. For example, where vacancies are low, rents are high,
or housing supplements are unavailable, choice in type and location
of housing can be very limited. Another example is the inclusion of
police into Housing First ACT teams in Vancouver, creating an ele-
ment of coercion that is incongruent with the principle of consumer
choice (Van Veen, Ibrahim, & Morrow, 2018). This highlights the link
between primordial and quaternary prevention, in that policies to in-
crease the availability of adequate income or affordable housing also
allow for more choice for those experiencing housing loss. Where
empowerment is not already integrated into program design, there
are a number of increasingly proven methods to do so. For example,
the inclusion of ‘first voice’ has become an expanded approach to
creating spaces for empowerment (Bernard, 2012). First voice refers
to those with lived experience having the first say in activities or
issues related to their experiences (Young Man, 1992). This builds
upon a growing focus on integration of lived experience in general
within the sector (Le Dantec, Poole, & Wyche, 2009). Consistent
with the principle of ‘nothing about us without us’, centring those
with lived experience in planning processes is a tangible way to
8 
|
   OUDSHOORN et al .
move from disempowerment to empowerment (Lived Experience
Advisor y Council, 2016). However, this comes with the warning that
speaking to inclusion of lived experience without ac tually doing so in
a meaning ful way, referred to as ‘tokenism’ (Gonzalez & Bull, 2012),
can itself be an incredibly disempowering process.
A helpful concept on which to ground ef forts for quaternary
prevention is ‘social integration’. Designing services to facilitate
true social integration means that systems should be designed to
move beyond the basic provision of housing to deep, long-term out-
comes. If services provide housing but disconnect participants from
choice, voice, control and integration, then short-term outcomes are
achieved at the cost of long-term losses. Tsai, Mares, and Rosenheck
(2012) highlight social integration as the key goal of delivering
re-housing programs and housing stability. Of course, true to the
concept of empowerment, clients should be able to self-define their
social integration goals, as integration is an individualised concept.
Choice is a thread that runs through any services that are going to
address homelessness while creating spaces for people to empower
themselves.
Including Empowerment as a sixth domain of homelessness pre-
vention as we propose herein would lead to the following revised
Framework: (Figure 3) As described above, the various levels of
prevention cut across the domains, and the same holds true for the
domain ‘Empowerment’ as it touches upon various levels of preven-
tion. Empowerment is primary prevention as integrating control and
choice throughout services such as income assistance could pre-
vent homelessness before it occurs. Similarly, empowerment could
be included in tertiary prevention such as optimising choice within
Housing First programs. Ideally, empowerment would be a thread
through all levels of prevention when addressing homelessness.
This analysis has some limitations related to the method uti-
lised. For one, negative findings receive far more limited publica-
tion, therefore research contradicting the relevance of the domains
would be much less likely to be present with the literature. Second,
we limited our search to English language articles and restricted the
time period to the last 20 years. Third, where articles were unclear
in regard to their process for assessing approaches they were ex-
cluded. This means that we erred on the side of excluding ar ticles
were there was insufficient information to make a decision for in-
clusion. Good evidence may be been excluded through this cautious
approach. Fourth, the analysis was conducted by a single researcher
rather than the recommended method of double screening. Fifth,
the review was limited to English language publications thus exclud-
ing a significant body of literature. Lastly, in terms of adding a do-
main to the Framework, the literature review was based on the five
existing domains, therefore studies that were particularly novel and
might lead to another domain would be excluded.
In conclusion, the Framework for Homelessness Prevention
offers an evidence-based and practical approach to prevention of
housing loss. In a contex t of multiple pathways and interconnected
systems, it can be daunting to consider the right areas to focus pre-
vention activities. The Framework provides direction in narrowing
the focus according to evidence on what works in the context of
homelessness. In addition to the five proposed domains, we offer
empowerment as a potential sixth domain in the light of quater-
nary prevention. More research is needed to understand points of
disempowerment, how empowerment is already being enacted in
the sector, and new opportunities to expand empowerment. While
first voice and lived experience are increasingly valued in the sector
(Norman & Pauly, 2013), more intentional work should be done to
reduce the potential negative impacts of service utilisation.
ORCID
Abe Oudshoorn https://orcid.org/0000-0003-0277-8724
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Gaetz S. Evolving an evidence-based model for homelessness
prevention. Health Soc Care Community. 2020;00:1–10.
https ://doi.or g/10.1111/ hsc.13 0 00
... Effective systems of ending homelessness must also include the prevention of homelessness (Oudshoorn, Dej, Parsons and Gaetz, 2020). In this paper we explore what homelessness prevention might look like, focusing on refugee families in two cities in Canada. ...
... These acuity measures shift Housing First from primary or secondary prevention to tertiary prevention as they screen for long-term emergency shelter users. By putting a priority on rehousing those who have already been in shelter for extended periods there is a gap for early intervention with those who score lower on the acuity scales (Oudshoorn, Dej, Parsons & Gaetz, 2020). Therefore, Housing First as a programme is only one tool within a broader homelessness prevention framework (Gaetz and Dej, 2017). ...
... Therefore, Housing First as a programme is only one tool within a broader homelessness prevention framework (Gaetz and Dej, 2017). Homelessness prevention includes a diversity of approaches including structural prevention, systems prevention, early intervention, eviction prevention, housing stability, and empowerment (Oudshoorn, Dej, Parsons & Gaetz, 2020). ...
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_ Ending homelessness also includes effective prevention of home-lessness. For families experiencing homelessness, one potential opportunity is diversion, based on the unique pathways into homelessness they experience. With growing concern regarding the increase of refugees in family shelters, this research sought to understand pathways of refugee families to shelter with a consideration of the potential for diversion, or other interventions. Using an interpretive description approach, 15 participants were interviewed from two family shelters as an opportunity to understand in detail complex journeys of migration and homelessness. Three themes are proposed from the interviews: 1) Starting with nothing; 2) Shelter as a refuge; and 3) Wading through the bureaucratic mire. It was notable for our participants that rather than diversion, best experiences came from early access into family shelters, particularly where there was expertise in working with refugee claimants. In noting the difference between our sample and those families experiencing homelessness who have citizenship, diversion does not appear to be as promising a practice for this sub-population. Rather, we recommend building knowledge of the refugee claimant process and resources within the homeless serving system and allowing family shelters to be a site of intervention.
... Like many countries, Canada emphasizes prevention as a key component of its efforts to end homelessness (Employment and Social Development Canada, 2020a). While other models exist (Gaetz & Dej, 2017;Mackie, 2015;Oudshoorn et al., 2020), most homelessness prevention frameworks are based on the public health conceptualizing of primary, secondary and tertiary prevention (Shinn et al., 2001). Primary prevention initiatives include proactive measures to prevent new cases of homelessness and stop people from becoming homeless in the first place. ...
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Primary and secondary prevention initiatives stop people from becoming homeless and help them exit quickly when they do. This study uses administrative data from emergency shelters in Canada from 2010–2016 to compare homelessness pathways and housing outcomes between first-time and recurrent shelter users. It uses a multinomial logit model to identify factors that influence the likelihood of exiting into housing following a shelter stay. The findings demonstrate that first-time users are over two times more likely to exit into newly acquired housing than recurrent users, and that the pathways into and out of homelessness vary significantly between the two groups. The findings suggest that the composition of existing prevention strategies do not sufficiently meet the needs of first-time users experiencing financial and substance use challenges. For recurrent users, federal policies that promote Housing First initiatives increase exits into housing. However, duration of previous homelessness negatively influences housing outcomes, reinforcing the need for early intervention prevention initiatives.
... Using a homelessness prevention framework Oudshoorn et al., 2020), UBI would constitute structural prevention through its alteration of legislation and policy that promotes primordial stabilization and tertiary intervention. The former focuses on policy-level preconditions of social issues, such as financial security, whereas the latter involves mitigation of the harmful effects of existing problems, or homelessness in this case . ...
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