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Published in final edited form as: Sage Open. 2026 Apr 18;16(2):10.1177/21582440261442626. doi: 10.1177/21582440261442626

COVID-19 Impact on the Lives of Youth Experiencing Homelessness: A Concurrent Mixed Methods Study

Higinio Fernandez-Sanchez 1, Marguerita Lightfoot 2, Adeline Nyamathi 3, Mary Paul 5, Yasmeen Quadri 6, Nikhil Padhye 1, Jennifer Jones 1, Huining Sun 1, Diane Santa Maria 1
PMCID: PMC13637482  NIHMSID: NIHMS2210118  PMID: 42836055

Abstract

This study examines the impact of COVID-19 on the lives of youth experiencing homelessness (YEH) using a concurrent mixed-methods approach. We recruited individuals aged 18–25 (n = 314) who were homeless and unstably housed (e.g., living in the streets with friends, hotels, or shelters). We measured COVID-19 fear and impact quantitatively and analyzed it using descriptive statistics. Concurrently, we conducted in-person or phone interviews to examine the experiences of YEH (n = 40). Thematic analysis was used to organize the findings. YEH identifying as LGBTQ+ youth within this community confronted exacerbated challenges. LGBTQ+ youth had significantly higher fear and impact scores when compared to non- LGBTQ+ youth (p = .02). Qualitative narratives illuminated the profound impact of the COVID-19 pandemic, revealing systemic inequities that disproportionately affected LGBTQ+. Distinct vulnerabilities emerged, encompassing economic strains, restricted healthcare access, and intensified social disconnections. Findings underscores the intricate layers of vulnerability within YEH populations during global health crises. The research accentuates the urgent need for systemic reforms and targeted interventions by integrating insights from a Social Determinants of Health framework. The findings offer invaluable knowledge for policymakers, service providers, and stakeholders, advocating for strategies that address disparities and promote equitable health outcomes among YEH.

Keywords: COVID-19, Gender minorities, Homelessness, LGBTQ, Youth

Introduction

Youth homelessness is a critical global public health concern that demands immediate attention. Youth experiencing homelessness (YEH) are individuals living on the street or staying with friends or in shelters, hotels, or other temporary living conditions per the McKinney-Vento Act (Stewart, 2000). YEH confronts a myriad of physical and mental health challenges, including malnutrition (Werb et al., 2010), substance use (Siconolfi et al., 2020), exposure to violence (Heerde & Pallota-Chiarolli, 2020), and limited access to healthcare services (Gallardo, et al, 2020). These complex issues often intersect, compounding the instability and trauma that homelessness inevitably brings, resulting in enduring impacts on the overall well-being of YEH (Miller et al., 2020). Furthermore, the challenges faced by YEH have been exacerbated by the ongoing COVID-19 pandemic (Gibbs et al., 2023).

The global impact of the COVID-19 pandemic is well documented, with specific attention given to its effects on communities already disadvantaged by systemic inequities (Fernandez-Sanchez et al., 2020). For instance, previous research shed light on the mental health challenges among Indigenous populations (Poitras et al., 2022) and among Latinx lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youth (Abreu et al., 2023), difficulties in accessing essential resources and services for young parents with foster care backgrounds (Shpiegel et al., 2022), and concerns about the acceptability and uptake of the COVID-19 vaccine among global migrants (Fernandez-Sanchez et al., 2023). Additionally, YEH, especially those who belong to other disproportionately affected groups, such as LGBTQ+ individuals, faced a particularly harsh and challenging experience during the COVID-19 pandemic (Abramovich et al., 2021; Noble et al., 2022). These young individuals often lack stable housing, precluding adherence to recommended hygiene and social distancing measures (Abramovich et al., 2023).

The burden of increased mental health issues on YEH existed before the COVID-19 pandemic (Hodgson et al., 2013; Narendorf et al., 2017). However, the pandemic seemed to worsen mental health and increase substance use (Gibbs et al., 2017), particularly for LGBTQ+ youth experiencing homelessness ( Noble et al., 2022). Moreover, it has been suggested that the pandemic could be interpreted as a traumatic event, resulting in post-traumatic stress disorder symptoms, which may increase fear and negatively impact mental health (Sanchez-Gomez et al., 2021).

Despite these valuable insights, our understanding of the impact and fear of the COVID-19 pandemic among YEH remains limited. This knowledge gap underscores the need for research on the unique experiences and challenges faced by YEH during the COVID-19 crisis. In response to this gap, we investigated the knowledge and experiences of YEH aged 18–25 during the COVID-19 pandemic. While LGBTQ+ youth represent a disproportionately impacted subgroup and are a key population of concern, we included youth of all sexual orientations. We employed a mixed-methods approach, combining quantitative and qualitative data to reveal nuanced insights and perspectives.

To gain a comprehensive understanding, this research was guided by the Social Determinants of Health (SDoH) framework, which acknowledges that health outcomes are shaped not only by individual factors but also by the broader social, political, economic, and environmental conditions in which individuals live (Braveman & Gottlieb, 2014; Marmot, 2005). In the context of homelessness, some determinants can include socioeconomic status, access to health care and education, housing stability, food insecurity, and systemic inequalities. Recognizing the multiple challenges faced by YEH, we sought to highlight the web of SDoH influencing their experiences during the COVID-19 pandemic. By employing this framework, we aimed to provide a broader understanding of the unique challenges faced by YEH and contribute to the development of targeted interventions while addressing the broader social context.

Specifically, we aimed to 1) assess the fear levels and severity of impact experienced by YEH during the COVID-19 pandemic, 2) investigate variations in fear levels and severity of impact among members of the LGBTQ+ youth, and 3) examine the lived experiences of YEH during the COVID-19 pandemic.

Methods

Design

This concurrent mixed methods study spanned from April 2020 to December 2022. This strategic approach was chosen to harness the strengths of each method and to effectively compare the data, ensuring alignment between quantitative and qualitative findings (Bell et al., 2023). By comparing and combining both data types, we gained a holistic perspective on how YEH experienced the COVID-19 pandemic.

Sample

This study involved a cohort of individuals 18–25 years old who were experiencing homelessness and unstable housing. Quantitative data were gathered from 314 participants, and 40 youth participated in qualitative individual semi-structured interviews. To capture a more comprehensive understanding of experiences, we extended data collection beyond discontinuing the U.S. government-issued lockdown measures.

Participants were selected from a cohort of YEH enrolled in a randomized trial. In the parent study, youth were eligible to participate if they were 16–25 years old, proficient in English, experiencing homelessness and unstable housing at the time of study enrollment, and intended to stay within the metropolitan area during the study. Youth who were noticeably under the influence of drugs or alcohol or experiencing acute mental distress were offered a referral for services and encouraged to return for screening and enrollment later.

Setting

Participants in the current study were recruited and interviewed at various shelters and drop-in centers in one large metropolitan area in the South.

Recruitment

YEH enrolled in the parent study were approached to participate in this study between April 2020 and December 2022. The opportunity to join this study was presented to potential participants at various study visits, including during their initial enrollment in the parent study, intervention sessions, and follow-up assessments—those who expressed their willingness to participate provided written informed consent.

Data Collection for All Phases

Data collection was conducted via phone and video calls by trained research staff, including research assistants and nurses. Participants received an overview of the study, provided verbal informed consent, and completed sociodemographic and survey data collection using the REDCap platform. Semi-structured interviews, lasting around 20 minutes, were audio-recorded. Participants received a $20 USD gift card for each completed survey and interview.

Phase I: Quantitative Component

Data Collection.

The survey items were, in part, adapted from the Gwadz Qualitative Interview Guide (Center for Drug Use and HIV/HCV Research, 2020; Gwadz 2021), which includes COVID-19 interview items for populations that experience systemic disadvantages, and additional items were accessed from the PhenX (Hamilton et al., 2011) toolkit to facilitate data harmonization whenever possible as many measures were not yet developed early in the pandemic.

Sexual orientation.

Sexual orientation was assessed using a single item (Which of the following best represents how you think of yourself?) and responses were grouped into two categories: LGBTQ+ (including those who reported gay, lesbian, bisexual, pansexual, or something else) and straight/heterosexual.

Coronavirus Impact Scale.

We selected the Coronavirus Impact Scale (Stoddard et al., 2021) as a self-report instrument for evaluating the impact of the COVID-19 pandemic. The scale yields a single score, ranging from 7 to 28, with higher scores signifying a more substantial perceived impact associated with COVID-19 and its related restrictions. In the present study, the calculated Cronbach’s alpha for this scale was 0.92.

The measure was then dichotomized, defining a severe pandemic impact as a score exceeding one standard deviation above the study population mean. Next, a sensitivity analysis was conducted on the highest tertile of impact. Participants were also asked to use a Likert scale ranging from 1 (no change) to 4 (severe) to rate how much the Coronavirus pandemic had changed their lives in the following aspects: routines, family income, employment, food access, medical/healthcare access, mental health treatment access, access to extended family and non-family social supports, and experiences of stress.

Fear of COVID-19.

To assess the level of fear associated with COVID-19, we employed the “Fear of the Coronavirus Questionnaire” (Ahorsu et al., 2022). This assessment tool consists of 7 items, on which respondents rate their degree of agreement using a 5-point Likert scale (1=strongly disagree and 5=strongly agree). The items include statements such as, “My hands become clammy when I think about COVID-19” and “I am afraid of losing my life because of COVID-19.”

The level of fear experienced by each respondent was determined by summing their responses across these items; a score above the average of the sums indicated a greater level of fear. Scores ranged from 7 to 35, with higher scores indicating a greater level of fear concerning COVID-19 and severe fear defined as above the entire sample mean. In the present study, this scale’s internal consistency and reliability were assessed using Cronbach’s α, with a result of 0.95.

Data Analysis.

A primary analytic goal was to investigate variations in fear levels and severity of impact. Scores of both scales were summed for each participant, and sample mean scores were calculated for both scales. One comparison was conducted with YEH, which identifies as LGBTQ+ versus those that do not. Given the violation of normality, the Wilcoxon rank-sum test (Mann–Whitney U test) was used to compare the central values of distributions of scores. Analyses were conducted using the “psych” package in R statistical software (v. 4.3.1).

Phase II: Qualitative Component

Data Collection.

The research team developed a semi-structured interview guide, adapted from the Gwadz Qualitative Interview Guide, to explore COVID-19 knowledge and experiences among YEH. Topics included sources and credibility of information, COVID-19 symptoms, testing, diagnosis, adherence to preventive measures, and the impact on daily life, mental health, relationships, and access to resources. Interviews also addressed participants’ perceived vulnerability to COVID-19, healthcare access during the pandemic, social and economic challenges, and their experiences with public health measures. Probes explored how past experiences of homelessness and trauma influenced their responses to the pandemic.

Data Analysis.

A skilled HIPAA-compliant transcription service transcribed all recorded interviews. A thematic analysis framework outlined by Braun & Clarke (2006) was applied and involved six stages: familiarization with the data, initial code generation, identification of themes, theme review, theme definition, naming, and final reporting of findings. Initially, the data collectors—a registered nurse, a research assistant, a research coordinator, and two doctorally prepared nurse scientists experienced in qualitative research—independently reviewed and coded the first five interviews. Throughout the research process, regular team meetings were held to establish consensus on the coding. Subsequently, patterns of significance were identified and organized into categories that aligned with emerging themes. The research team then identified the meanings associated with the experiences of YEH concerning their knowledge of the COVID-19 pandemic. Five distinct themes were synthesized and conceptually framed within the participants’ experiences. These analyses were conducted iteratively and interactively.

Trustworthiness and Rigor

To ensure trustworthiness and rigor, strategies addressing credibility, transferability, dependability, and confirmability were implemented. Credibility was enhanced through peer debriefing with qualitative research experts, providing diverse perspectives. Transferability was ensured using thick descriptions and purposeful sampling to capture diverse perspectives and contexts. Dependability was maintained by adhering to standardized data collection protocols, guaranteeing participant consistency. Confirmability was achieved through reflexivity, acknowledging and addressing researcher biases.

Reflexivity.

The research team, experienced in nursing, public health, social work, adolescent health, sexual health, and social justice, comprised individuals from diverse backgrounds, including people of color, LGBTQ+ individuals, and migrants. These shared backgrounds and experiences, closely aligned with those of the research participants, informed the team’s approach and understanding of the study’s context, particularly regarding trust in healthcare guidelines and COVID-19-related issues.

Phase III: Integration of Qualitative and Quantitative Data

After findings from both the qualitative and quantitative components were obtained separately, these distinct datasets were synthesized through triangulation, involving the comparison and contrasting of qualitative and quantitative findings to unveil convergent or divergent patterns. This systematic analysis of the interplay of the data led to a deeper and more comprehensive grasp of the research question, thus enriching the overall findings and bolstering the interpretation of research outcomes. This data integration process enabled us to establish a more holistic and nuanced perspective, ultimately enhancing the study’s validity and depth (See Figure 1).

Figure 1.

Figure 1.

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Illustration of steps taken in the concurrent mixed methods comparison study.

Ethical Considerations

This research was reviewed and approved by the Institutional Review Board at The University of Texas Health Science Center at Houston (UTHealth Houston) (Protocol #: HSC-SN-18-0993). Before engaging in this study, every participant provided written consent, ensuring their complete willingness to participate. To reduce the risk of COVID-19 transmission and ensure the safety of participants and research staff, trained research staff reviewed consent over the phone prior to the interview and acquired a signature electronically. Staff were trained in trauma-informed approaches, ethical human subjects research, and study protocols. The research team emphasized consistently throughout the study that their involvement remained entirely voluntary, and at any point, they could withdraw from the study without any penalty. To protect the privacy and anonymity of our participants, all names in this manuscript have been substituted with pseudonyms. The data collected throughout this investigation is safeguarded within highly secured data center servers hosted and managed by UTHealth Houston. The potential benefits of this research substantially outweighs the study’s minimal risks, as the data generated can inform policy and essential service delivery for this vulnerable population.

Results

Demographic Characteristics

The study included a diverse sample of participants across both quantitative (n=314) and qualitative (n=40) components, with a majority being young adults in their early twenties and predominantly male. The sample reflected a wide range of racial and ethnic backgrounds, with a significant proportion identifying as Black or African American. A notable percentage of participants identified as LGBTQ+ (35% in the quantitative sample and 30% in the qualitative sample), and most were not currently employed or enrolled in higher education. Details on the demographic characteristics and housing status of the participants in both quantitative and qualitative samples are summarized in Table 1.

Table 1.

Youth Experiencing Homelessness, Houston, Texas, USA 2023

Characteristics Quantitative Sample (%; n=314) Qualitative Sample (%; n=40)
Gender
Male 54 57.5
Female/Other 46 42.5
Sexual Orientation
LGBTQ+ 35 30
Straight/Heterosexual 65 70
Race/Ethnicity
Black or African American 59 57.5
Multiracial 19 12.5
White 12 12.5
Hispanic or Latino 10 10
Educational Attainment
Completed High School 70 70
Currently Enrolled in Higher Ed. 13 7.5
Employment Status
Employed 28 25
Not Employed 72 75
Housing Status (Previous Night)
Staying in a shelter 58 25
Staying with friend or sexual partner 15 23
Living in own apartment 11 25
Staying with a family member 7 15
Outside or abandoned building 5 5
Other 4 8
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Integration of Qualitative and Quantitative Components

COVID-19 Impact.

The mean score on the Coronavirus Impact Scale was 10.6 for the full sample, indicating a generally low impact of the pandemic on their lives. Approximately 21% of the sample experienced severe implications from the COVID-19 pandemic, as defined by scoring one standard deviation above the sample mean. Individuals in the LGBTQ+ group reported a significantly higher effect of the pandemic on their lives in comparison to others (p=.02).

COVID-19 Fear.

The mean score on the COVID-19 Fear Scale was 12.51 for the full sample, indicating an average degree of fear experienced by the participants, with 52% of the individuals reporting severe levels of anxiety (i.e., score exceeding the sample mean). LGBTQ+ youth had significantly higher fear scores (p=0.02) when compared to non-LGBTQ+ youth.

While our quantitative findings showed that YEH belonging to the LGBTQ+ community were more significantly impacted by the COVID-19 pandemic, qualitative data shed light on the various ways in which this impact was experienced. By using the SDoH framework, we discovered three overarching themes: a. structural inequities and economics, b. access to healthcare and strained social connections, and c. navigating COVID-19 information with ambiguity, misinformation, and fear. The SDoH framework facilitated a critical examination of these themes and provided a broader understanding of the impact of SDoH on the experiences of YEH during the ongoing health crisis.

Structural Inequities and Economics.

Our qualitative findings largely corroborated the quantitative results. The experiences of YEH during the COVID-19 pandemic underscored the structural inequities and economic vulnerabilities they faced, with a particular emphasis on those identifying as part of the LGBTQ+ community. Experiences shared by YEH reflect the impact of the pandemic on employment opportunities, as numerous businesses were forced to shut down, limiting their ability to access reliable work opportunities and secure needed financial resources.

These shared experiences also revealed the economic strain faced by YEH, making tasks such as obtaining adequate food more challenging. However, other YEH reflected on the protective role of existing support structures, such as homeless shelters providing meals and a place to sleep, highlighting how systemic issues exacerbate the disparities faced by those without such resources. The following interview excerpts collectively highlight how structural inequalities compounded the economic hardships experienced by marginalized youth during the COVID-19 pandemic, particularly members of the LGBTQ+ community.

I really can’t go out and find a job. Some of the places are shutting down, so I really can’t go to job fairs or find work to support myself and do regular day activities, like go to the grocery store, to the bank, or do things that a normal person would do.

(Black, bisexual, female, staying with someone)

To be honest, it’s been quite difficult, but I’ve been managing so far. It’s been like one meal a day, one drink a day, but I’ve been going to places where I could find water fountain and refill an old water bottle, even though I can’t eat three meals a day.

(Multiracial, bisexual, transgender female, unsheltered)

Others, staying in a shelter expressed that there was limited impact on daily life.

Since they provide us with free food and water here [shelter], it has not had a big impact on me. I mean, it has not been a big problem for me. But if I hadn’t been here, maybe it would have been a little complicated. But I’ve been great so far.

(Black, gay, transgender male, staying in a shelter)

Access to Healthcare and Strained Social Connections.

The shared experiences of YEH highlight the vulnerabilities, access to healthcare, and the profound impact on social connections and family relationships due to COVID-19. YEH reported a range of experiences accessing healthcare, from being unable to get an appointment to having no challenges meeting with a healthcare provider. For many, there was no change because they reported not accessing healthcare prior to the pandemic owing to a lack of need or desire. YEH, who reported difficulty accessing healthcare, cited a lack of options as their primary concern. These experiences show the multiple vulnerabilities faced by YEH in securing essential healthcare, emphasizing the imperative for systemic reforms.

It’s just hard for me to get an appointment scheduled. But I think it will be harder if I change doctors.

(Black, heterosexual, male, staying in a shelter)

Before the coronavirus, I wasn’t going to doctors. I don’t really use doctors or go to doctors.

(Black, heterosexual, male, staying in their own apartment)

I’ve been talking with my doctor over the phone and receiving medications through the mail.

(Other race, bisexual, male, staying in their own apartment)

Simultaneously, the impact of the pandemic on social connections and family relationships exacerbated participants’ vulnerability. The qualitative data highlight the intensified challenges YEH faces, particularly people within the LGBTQ+ community. Strains on family bonds manifested through physical and emotional distance, disrupting traditional means of familial support. Expressions of fear and concern when reaching out to family demonstrate the emotional toll on these vital connections. The following interview excerpts underscore the consequences of the pandemic on familial reunions and the need to reconnect with family members.

I don’t really go see my family as much because they’re scared of the coronavirus. We’re not seeing anybody right now. We didn’t do anything for Thanksgiving.

(Black, heterosexual, male, staying with someone)

I am highly concerned because I really want to get back to Houston to meet my girl and my kid, and also meet the rest of my family back in Houston.

(Multiracial, bisexual, transgender female, unsheltered)

I was pretty scared. I’m not going to lie. When I called my dad, I shed a few tears because I was a little scared. It was pretty concerning because of the stories I heard about the death toll. It was crazy.

(Black, heterosexual, male, staying with someone)

They were navigating COVID-19 Information with Ambiguity, Misinformation, and Fear.

Participants stayed up to date regarding COVID-19 policies (e.g., staying at home, wearing a mask in public) with multiple sources of information, particularly watching and reading the news (51%) and searching social media (54%). The youth took various precautions during COVID-19; the majority said they regularly washed their hands (80%), wore a mask (78%), and socially distanced (70%). A small percentage of youth (15%) met with a provider to talk about their mental health, and approximately 50% of those youth used telehealth to meet with that provider online vs. in person.

Fear was influenced by access to information and perceived susceptibility among the interview respondents. All respondents cited sources of information, but many still expressed uncertainties due to the volume, conflict, and evolution of information related to COVID-19. For some, this uncertainty was accompanied by a lack of fear; for others, it resulted in more fear. The quotes below reflect a broad spectrum of responses, from resilient self-perception in the face of uncertainty to trauma and confusion induced by the rapid changes brought about by uncertainty during the pandemic. Ultimately, youth experienced a lack of clear guidance and trusted sources of information, which contributed to a sense of vulnerability, fear, and concern.

To be honest, I’m not going to get sick. I’m strong… I don’t take it extremely seriously, but I do consider my health just in case. But as far as sources, I wouldn’t say there’s a source to go to. I mean, the CDC has their rules, regulations, and stuff like that, but I don’t know so much.

(Black, heterosexual, male, staying in a rehab facility)

When it happened [pandemic], that’s when I got in the program [shelter], and I’m lucky I got in the program beforehand. It was very traumatizing because I was like, oh, shoot—what things do we need, and should we not go outside at all? It wasn’t very clear at first. There was a lot that was said so that people would go wild. Other things about how to catch it are that people are saying, ‘Oh, you get it.’ Some people say if you have HIV, you can get it [COVID-19] faster. It was very confusing and very terrifying to the point where it was just like I didn’t want to hear it anymore.

(Black, gay, transgender male, staying in a shelter)

At first, I was a little paranoid. It took a big toll on me because I gained 20 or 30 pounds, and I was not happy with myself. I feel like I was losing a sense of identity because of everything happening, which messed with me.

(Latino, heterosexual, male, staying with someone)

The critical analysis of the data reflected that members of the LGBTQ+ community were impacted disproportionately by the COVID-19 pandemic. This finding was further evidenced by the experiences described by YEH during the interviews. Interviews illustrated how SDoH, such as access to healthcare, housing, and social and community context, shaped the experiences of YEH during the COVID-19 pandemic.

Discussion

In this study, we aimed to provide a nuanced understanding of the practical impacts of the COVID-19 pandemic on youth experiencing homelessness (YEH). The SDoH framework facilitated a critical analysis and integration of the qualitative and quantitative data. Among the full sample, COVID-19 impact was low, and fear was average, illustrating the diverse experience of the pandemic among YEH across race, gender, sexual orientation, and housing situations. YEH who belonged to the LGBTQ+ community, however, were disproportionately affected by the COVID-19 pandemic, as evidenced by quantitative findings and the three qualitative themes: structural inequities and economics, access to healthcare and strained social connections, and navigating COVID-19 information with ambiguity, misinformation, and fear.

Structural Inequities and Economics

Members of the LGBTQ+ community in this study incurred a disproportionate impact from the COVID-19 pandemic, as evidenced by more pronounced, statistically significant severe consequences and higher fear, alongside the shared experiences of YEH. These findings are consistent with global literature on LGBTQ+ individuals, highlighting the considerable negative impact of the COVID-19 pandemic on their mental health. (Kidd et al., 2021; Souleymanov et al., 2023). Discrimination and structural health disparities can contribute to an increased vulnerability among LGBTQ+ individuals, potentially leading to adverse health outcomes (Becares, 2021; Drabble & Eliason, 2021). Similarly, other disproportionality-affected groups like racial and ethnic minorities, including Black, Latinx, and Indigenous populations, have faced higher rates of hospitalization and mortality compared to their White counterparts (Katikireddi et al., 2021; Tai et al., 2022; Vasquez-Reyes, 2020). Disparities in wealth, employment, and housing underscore the multiple and complex challenges confronted by these communities. Collectively, our findings, coupled with existing evidence, highlight the importance of addressing SDoH to advance health equity and foster a more just healthcare system, both in the present and in preparation for future health crises.

At the onset of the pandemic, shelters implemented restrictions to curb the transmission of COVID-19 among residents, limiting their ability to leave shelter grounds except for medical appointments. While implemented to safeguard residents, these restrictions evoked distress among the YEH in this study. They felt compelled to decide between securing or maintaining employment and having a place to live. Previous COVID-19-focused research has primarily concentrated on financial and housing instability resulting from factors such as reduced work hours, layoffs, employment challenges (Noble et al., 2022; Rew et al., 2021), and issues related to transportation or identification cards due to interruptions in these services (Gibbs et al., 2023).

Access to Healthcare and Strained Social Connections

YEH, in this study, reported using technology to navigate the healthcare system and social connections. This included telehealth for follow-up appointments and video calls through mobile phones or social media to connect with family members. However, beyond individual stories, these experiences collectively underline the urgent need for systemic reforms to ensure equitable access to healthcare services and address the strains on familial bonds during times of crisis. YEH’s challenges in accessing healthcare and social services were illustrated across diverse social contexts, revealing systemic difficulties ranging from scheduling appointments to mistrust or underutilization of healthcare services.

Even before the pandemic, a persistent pattern of limited engagement with healthcare systems emerged and is consistent with another study reporting that only about one-third of YEH have a regular healthcare provider (Chelvakumar et al., 2017; Klein et al., 2000), likely due to lack of awareness, lack of trauma-informed care, lack of inclusivity, complex healthcare systems, cost, and lack of care coordinator across facilities (Gallardo et al., 2020). Some YEH, however, demonstrated adaptability in navigating these challenges by relying on remote healthcare interactions during the pandemic.

Navigating COVID-19 Information with Ambiguity, Misinformation, and Fear

YEH reported an evolution of feelings through the pandemic, partially due to the information shared via news, social media, and their day-to-day context. Some did not perceive themselves to be susceptible to COVID-19, while others expressed feelings of extreme fear. YEH often received conflicting information from family, service providers, peers, and media. The experience of fear, ambiguity, and information overload is consistent with other studies reporting historical harms, mistrust of systems, and access to reliable health information to be factors in shaping attitudes toward the COVID-19 vaccine (Balma et al., 2023; Osman et al.,2023), particularly among racial and ethnic minorities.

Mistrust and perceived racism have been recognized as factors influencing access to and satisfaction with healthcare (Benkert et al., 2006), and when these factors are combined with the changing recommendations, conflicting information, and unknown nature of the COVID-19 virus, making health-related decisions may be especially difficult for this population.

Implications for Practice, Policy, and Research

The findings of this study have several implications for practice, policy, and future research. There is an urgent need for policy interventions that address the structural and systemic inequities and economic vulnerabilities faced by YEH, particularly those with multiple intersecting identities, such as LGBTQ+ individuals. Policies should focus on supporting employment opportunities, financial resources, and food security for YEH during global health crises. In this regard, we advocate for policies that emphasize the active participation of community members in decision-making, intervention, and policy development. This method has proven effective in enhancing the prevention of diseases, promoting a fairer allocation of services, and enhancing the quality of care services (Iton et al., 2022).

Service providers should adopt a comprehensive approach to address the diverse needs of YEH, with specific attention to LGBTQ+ individuals. Practices can include targeted support for employment opportunities, mental health, and access to healthcare consistent with a proposed framework for healthcare access among YEH, such as approachability, acceptability, accommodation, affordability, and adequacy (Gallardo et al., 2020). Service providers emphasize the desire to be better equipped to serve the unique needs of LGTQ+ youth and enhance care coordination across other youth-serving organizations (Damian et al., 2023). Additionally, homeless shelters and support structures must be strengthened to provide consistent aid to YEH. In this regard, rapid housing programs should be made available for YEH. One successful initiative is LifeWorks’ Rapid Rehousing, a housing-first program based in apartments that aims to link YEH with housing without prerequisites or artificial obstacles (Farnish & Schoenfeld, 2022). The program provides personalized rental support and case management, ultimately empowering youth to sustain independent housing.

Further research is needed to explore the long-term impacts of the COVID-19 pandemic on YEH, with a specific focus on their intersectionality. Tailored intervention studies are necessary to address YEH’s economic hardships, healthcare access, and social connections during and after the pandemic. This research can provide valuable insights for evidence-based practices and policy recommendations to support this population better. Future research adopts a community-based participatory action research approach involving stakeholders’ voices and active participation. This approach, recommended elsewhere, helps to address structural racism and SDoH to advance health equity (Fernandez-Sanchez, 2023; Shelton et al., 2021).

While the study focuses on LGBTQ+ YEH, the findings have broader implications for other groups facing similar vulnerabilities, such as people of color and migrants. Addressing systemic inequities, improving healthcare access, and fostering economic stability can benefit many populations beyond the LGBTQ+ community, promoting overall social and health equity.

Limitations.

There are several limitations to this study. Due to the rapid onset of the COVID-19 pandemic and the urgency to begin data collection, we could not use validated measures or elicit feedback from YEH on the interview guide. Improved measures likely became available. However, we continued to use the same measures for standardization.

Additionally, all interviews were conducted via phone, which may have impacted responses and prevented interviewers from making observations and recording non-verbal notes. Also, results may not be generalizable as the sample was already engaged in a study; thus, they may not represent all YEH. Finally, it is essential to note that there was a two-year recruiting time frame. While prolonged data collection was intended to capture experiences during several stages of the pandemic, the experiences of youth at the beginning of the pandemic likely differed from those in the middle and toward the end.

Conclusion

This study reinforces the significant disadvantages endured by Youth Experiencing Homelessness (YEH) during the COVID-19 pandemic, emphasizing the urgency for targeted interventions and systemic reforms. The integration of qualitative and quantitative data through the Social Determinants of Health (SDoH) framework highlighted the disproportionate challenges faced by YEH, particularly those belonging to the LGBTQ+ community, in areas such as structural inequities, economic vulnerabilities, healthcare access, and strained social connections.

The implications and recommendations derived from this study extend beyond the context of the COVID-19 pandemic, remaining relevant during any pandemics, natural disasters, or global crises. It underscores the imperative of continuous support for the health and well-being of YEH, advocating for policies and practices that address disparities and promote equitable health outcomes. This research provides invaluable knowledge for policymakers, service providers, and stakeholders, emphasizing the need for strategies that empower YEH communities and ensure their resilience in the face of diverse challenges beyond the scope of the immediate health crisis.

Acknowledgments:

We would like to thank all the youth for participating in this research, and our community partners.

Funding:

This work was supported by the National Institutes of Health [grant number R01NR017837, 2023].

Footnotes

Declaration of Interest Statement: We have no conflict of interest.

Ethical statement: Our study was approved by the Institutional Review Board at The University of Texas Health Science Center at Houston (Protocol #: HSC-SN-20-1081). All participants provided written informed consent prior to enrollment in the study.

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