key: cord-0750374-lmwvczv8
authors: Guise, Andy; Burridge, Stan; Annand, P.J.; Burrows, Martin; Platt, Lucy; Rathod, Sujit D.; Hosseini, Paniz; Cornes, Michelle
title: Why were COVID-19 infections lower than expected amongst people who are homeless in London, UK in 2020? Exploring community perspectives and the multiple pathways of health inequalities in pandemics
date: 2022-01-03
journal: SSM Qual Res Health
DOI: 10.1016/j.ssmqr.2021.100038
sha: b1ddb3f266c6aec37d708e911ec2c94ff4c224b4
doc_id: 750374
cord_uid: lmwvczv8

High rates of COVID-19 infections and deaths amongst people who are homeless in London, UK were feared. Rates however stayed much lower than expected throughout 2020; an experience that compares to other settings globally. This study sought a community level perspective to explore this rate of infections, and through this explore relationships between COVID-19 and existing health inequalities. Analyses are reported from ongoing qualitative studies on COVID-19 and homeless health service evaluation in London, UK. Repeated in-depth telephone interviews were implemented with people experiencing homelessness in London (n=17; 32 interviews in total) as well as street outreach workers, nurses and hostel staff (n=10) from September 2020 to early 2021. Thematic analysis generated three themes to explore peoples' experiences of, and perspectives on, low infections: people experiencing homelessness following, creating and breaking social distancing and hygiene measures; social distancing in the form of social exclusion as a long-running feature of life; and a narrative of 'street immunity' resulting from harsh living conditions. Further study is needed to understand how these factors combine to prevent COVID-19 and how they relate to different experiences of homelessness. This community perspective can ensure that emerging narratives of COVID-19 prevention success don't ignore longer running causes of homelessness and reinforce stigmatising notions of people who are homeless as lacking agency. Our findings aid theorisation of how health inequalities shape pandemic progression: severe exclusion may substantially delay epidemics in some communities, although with considerable other non-COVID-19 impacts.

Whilst the central role for 'everyone in infections in the first wave in the UK is well demonstrated there is a need to explore what additional factors shaped COVID-19 prevention and pandemic progression in London, UK.

Such an effort can help disentangle the role of different interventions and how this relates to specific contexts (O'Carroll et al., 2021) . Study of 'everyone in' hotels in the UK suggests many housed in them found these positive, and are potentially supportive of long-term health, although there are reports of people excluded owing to drug use (Lavelle & Hattenstone, 2020; Neale, 2020 . Other experiences to those in 'everyone in' have though been less examined, resulting in limited understanding of how COVID-19 was experienced within hostels, other shared accommodation, essential services and for those who continued rough-sleeping (Parkes et al., 2021) .

Exploring these additional perspectives on how COVID-19 risk is experienced and managed is essential for how it can reveal additional sources and strategies for infection prevention that may have contributed to lower than expected infections. Crucially, there is a need to engage with individual and community level factors and interventions to understand the varying impacts of COVID-19 on people who are homeless across settings. In response, this report explores community perspectives on why COVID-19 infections remained lower than feared amongst people who are homeless in London, UK through 2020 and the first wave of the pandemic.

J o u r n a l P r e -p r o o f 5 The analysis builds on two qualitative studies. Principally, data are drawn from the [anonymised study 1], which is qualitatively exploring experiences of COVID-19 during 2020 and 2021 amongst people experiencing homelessness as well as the perspectives of community outreach and other service delivery stakeholders in London, UK. This ongoing study is grounded in long-standing community-academic partnerships in London and led by a research team including people with lived experience of homelessness.

Repeated in-depth interviews were implemented with a purposive sample of people experiencing homelessness and with people working in outreach and hostel settings. From September 2020 respondents were recruited who had experience of homelessness during 2020 and the first wave of COVID-19; understanding homelessness as rough sleeping, using hostels or within temporary accommodation. A focus was on recruiting people not involved in 'everyone in' hotels to allow exploration of perspectives not yet engaged with.

Recruitment also sought a purposive range of ages and genders. A target was 10 respondents participating in 'key informant' interviews designed to elicit in-depth insight into their own and also community experiences. Interviews were repeated to gain depth of insight, understand change over time and to build rapport given the challenging circumstances of interviews. Recruitment happened through a COVID-19 telephone welfare service for people experiencing homelessness run by [anonymised, linked to anon author], and through other service delivery and research networks of the team. Many respondents were then either familiar with the organisations involved or with particular individuals, which could have shaped responses in interviews. Outreach and hostel staff were also recruited through existing research networks.

Semi-structured interviews explored topics identified a priori -e.g. health care access, testing, ability to socially distance -and then integrated emerging themes. In initial interviews the question of 'why have infections been lower than expected?' emerged for how respondents had a range of explanations beyond dominant policy narratives. Through discussion this question was identified as important, and in later interviews we continued to ask about experiences of COVID-19 infection and how respondents thought this had been avoided, for themselves and for others.

Interviews were done by [anonymised -3 authors] over the telephone, owing to social distancing measures (Annand et al., 2021) ; mobile phone access is common amongst people who are homeless, albeit with limits for the most excluded, and with challenges on duration of access to a phone and the same number. Triangulation across accounts between people who are homeless and stakeholders working in services was an effort to respond to these limits. Interviews with hostel, outreach and community organisation staff therefore sought to understand the system context and experiences of rough sleeping that were harder to explore directly owing to challenges of phone access and contact with services.

Our analysis also includes data from a separate [anonymised study 2] evaluation that began before COVID-19. This study is a mixed-methods investigation including qualitative study of a [anonymised] service amongst people who are homeless, implemented by [anonymised study author]. In interviews by [anonymised] since March 2020 COVID-19 was frequently explored due to its centrality to health experiences and use of the [anonymised] service.

Where these interviews explored participants' own experiences of COVID-19 prevention or views on low infections amongst the homeless community they were integrated with this J o u r n a l P r e -p r o o f analysis. Notably, these data had less exploration of COVID-19 and so accounts had less depth, reflecting the aims of the study.

An inductive and deductive approach to thematic analysis was used (Green & Thorogood, 2014) . As data were collected, memos were written and emerging themes discussed.

Deductively, accounts were critically explored to understand the role for community agency (Friedman et al 2007) . Inductively, explanations from participants to explain low rates of infections were identified. Emerging themes were explored in repeated interviews, including reflecting with participants on the nascent analysis. Later, transcribed data were coded, with constant comparison used to refine themes. Coding of the data was led by

[anonymised] using Nvivo 12, with checks on coding by [anonymised] . Draft manuscripts were discussed by the team and shared with some interview respondents to check analysis and interpretation.

The [anonymised study 1] was approved by [anonymised] and the [anonymised study 2] evaluation by [anonymised] . All names used are pseudonyms to ensure anonymity.

This exploration of why infections were low amongst people who are homeless was framed by literatures identifying a role for community action and mobilisation in disease prevention and epidemic responses for stigmatised and marginalised populations (Cornish, Priego-Hernandez, Campbell, Mburu, & McLean, 2014; Friedman et al., 2007) J o u r n a l P r e -p r o o f such 'indigenous harm reduction' practices demonstrate the active agency that people bring to their own health, despite severe stigma and exclusion (ibid.). Relatedly, the organic emergence of models of 'secondary syringe exchange' whereby people provide needles and syringes for other people who use drugs has been found to be highly effective at reaching highly marginalised groups (Murphy, Kelley, & Lune, 2004) . Community mobilisation to harness the agency of marginalised groups is also increasingly seen as essential for designing and delivering effective interventions (Cornish et al., 2014) . An effort to explore agency amidst experiences of stigma and marginalisation was in turn framed by how these experiences are socially produced and reflect particular governing norms and balances of power (Link & Phelan, 2001; Tyler, 2020) , with those social conditions of exclusion in turn generating health risk and structural violence (Rhodes et al., 2012) .

A concern with experiences of stigmatised and marginalised groups of people is essential to understanding broader dynamics of inequalities in health. A feature of the COVID-19 pandemic was the rapid emergence of inequalities across contexts in rates of infection and death linked to pre-existing inequalities structured by class, race and ethnicity (Marmot, Allen, Goldblatt, Herd, & Morrison, 2020) . Specific theoretical attention has focused on the development of COVID-19 inequalities in the USA and development of fundamental cause and stages of disease theory (Clouston, Nataleb, & Link, 2020) . These theories in combination suggest that epidemics initially impact across all socio-economic groups, and then inequalities emerge as an epidemic progresses, shaped by existing structural inequalities (ibid); the outcome is that groups with lower socio-economic status face the biggest burden of disease, whilst those with higher socio-economic status are able to deploy resources to protect themselves. Analysis here sought to understand how J o u r n a l P r e -p r o o f experiences of exclusion like homelessness relate to this developing theory of health inequalities and emerging epidemics.

Across both studies 17 people experiencing homelessness were interviewed (5 women, 12 men), a total of 32 times, and 10 people working in outreach, hostels or homeless health service delivery (see table 1 ). Respondents lived variously in large hostels, small hostels, housing of multiple occupancy with shared facilities, or temporary accommodation. Three people had been in 'everyone in' hotels briefly in early 2020 and 2 people had slept rough during 2020. All respondents from [anonymised study 1] were aged 40 or over, and 5 of 7 from [anonymised study 2], with maximum ages of 60+ (we use general age categories to ensure anonymity of participants). The sample of people homeless interviewed differs from the range of experiences included within 'core homelessness', which includes rough sleeping, where approximately 60% of people are aged under 45 (S. Fitzpatrick et al., 2021) .. However, the sample does though closely resemble experiences of people in hostels; a recent survey in a London hostel reported a mean age of 55 (Rogans-Watson et al., 2020) .

[ Respondents also reported they knew of few or no infections amongst others. Of interviewees who were homeless, one knew of someone who had died of COVID-19, and another said that "many homeless people caught it but I don't have their number" (Helen), but did not elaborate. Others though reported numbers of infections were low in their hostels, or that they did not know of anyone who had had COVID-19. There was though widespread agreement by stakeholders that infections had been lower than expected amongst people experiencing homelessness , and this went against predictions: "my team leader was quite honest with us, it's like `we should be expecting a lot of our clients to die' " and yet: "I've still not come across a client who's had Corona virus funnily enough" (S5, outreach worker). This was a 'surprise' and a question outreach and hostel staff were themselves discussing: myself and other members of my team were also, I wouldn't say shocked but not, surprised, yeah, surprised by the fact that there were low levels of numbers of our client group, the ones that we knew who were either J o u r n a l P r e -p r o o f exposed or had the virus, or who kind of succumbed to the virus and passed away, we had very low numbers. (S9, outreach worker)

Respondents had a range of experiences of COVID-19 testing: of having tested, tried and not succeeded, or not tried. Some reported or anticipated difficulties in access, owing to limits to internet access and information, or the distance to travel. Others reported few or no barriers, whether in having tested or if they needed it, linked to processes such as accessing tests alongside addressing other health issues, or how hostels had arranged testing (although not regularly): "We got tested at the beginning just to see if we had it, the whole building got swabbed and that, and everyone was alright" (Jackie).

A core part of the UK COVID-19 response was the introduction of a smart phone application, run by the National Health Service, that would enable contact tracing, by alerting people when they had been near people with COVID-19. None of our respondents reported using it, and when it was discussed people either did not know about it, did not understand it, their phone would not support the app, or they did not trust the technology. An outlier is of people collectively agreeing to not use the government endorsed 'app': 

An effort to avoid the NHS app and so quarantine could then extend to avoiding testing, as widely reported in the UK, especially for those on low incomes (Tapper, 2021) .

In summary, the experiences of COVID-19 infection reported to us conforms to the statistics described in the introduction, of infections and deaths within the community being low or lower than expected. A theme of there being potentially lower than expected infections is though complicated by potential challenges or limits in COVID-19 testing access and uptake.

Analysis of accounts to explore why infections had been lower than expected produced three themes: following, creating and breaking the rules; social distancing or social exclusion; and street immunity. (Jackie) . Such efforts by residents to support disinfection measures were also listed in widely available guidance to hostels, which could have influenced Jackie's initiative (Beale, 2020) . Other strategies included using shared kitchens late at night to avoid other residents and sourcing free facemasks from hospitals.

Narratives of determined efforts to manage COVID-19 risk could reflect a desirability bias, whether owing to past contact with the research team, or through knowledge of the public health and medical school grounding of some of the research team. Some accounts displayed both public and more private accounts. Dave, as above, first says "I've always kept me distance, I've always wore me mask and stuff like that and I've always washed me hands", but later "it's very hard as well because you just slip out of that cycle…fist bump whatever, hug whatever, but you didn't realise until after you've done it"; an initial assurance giving way to a more complex account shaped by context. Bias may also be displayed when complaining of others who did not follow rules, and so demonstrating one's own separation from these behaviours: "the guy next door to me, the guy above me and all that cause they're just like .. well they basically lost the plot, they're not getting the message" (Jim). An alternative interpretation of such complaints is of different understandings of what is appropriate social distancing. Others directly described breaking J o u r n a l P r e -p r o o f rules, and so indicating any desirability bias was not universal. "I know some close, some friends who are not infected, I feel they're not infected and then I stay close to them" (Raj).

There were accounts from within hostels of people not wearing masks or bringing in visitors despite bans. Not following rules -self-reported, and by others -was often linked to drug and alcohol use: "the majority of people in here [hostel] don't wear them [masks] , as I said, they drink you know." (Peter). Here breaking the rules is described as coming from necessity: "if they have an addiction to alcohol they can't just say `well I'm just not going to drink anymore' it doesn't work like that" (S7, hostel worker) and "I mean if there's three or four of you and you're sharing a bottle of cider you're not going to be sat two metres apart."

(Leon). Leon, who had lived in an 'everyone in' hotel briefly, continued to meet-up and drink with his friends daily, an experience described by an outreach worker: "this [COVID] is the least of their worries" and "a lot of drugs are there … and it's easy for them to beg with you know a high foot traffic from commuters to get the drugs, so we see encampments of clients who you know, I wouldn't say are socially distancing, they're sharing needles, they're sharing tents you know so there's no social distancing there." (S5, outreach worker). Whilst data here principally focused on breaking the rules from necessity and that mainly linked to drugs and alcohol, there were also reports of breaking the rules grounded in other logics, of either misunderstanding guidance or of considering it not applying to them: "some people or my friends like wouldn't see me for a long time they come and hug me and they said they don't care about virus" (Raj).

Following, creating and breaking rules came in the context of various efforts to change hostel environments to aid social distancing: "no visitors allowed in this building for the last six months, and from September it was when we go out just wear a mask, and you can't make any contact even in the corridor, and you just get the food and go straight up to your room and eat in your room" (Henry). Hostel staff also described efforts to source face masks for residents, and change staff rotas and work routines to minimise social contact (Story & Hayward, 2020) .

Social distancing for some was also described as a long-running feature of their lives in terms of having little social contact, pre-dating COVID-19, and so helping them to prevent COVID-19. As Jim describes: "I'm pretty good at keeping my own company. Well you see I've had osteoporosis for the last…years so .. but a lot of the time I was bed ridden anyway so that's been going on for years, so I'm pretty much used to self-isolating anyway". For Jane mental ill-health has generated her long-standing isolation: "I tend to just keep in my room and actually that's mainly to do with my OCD rather than the COVID itself"; generally Jane described themselves as a 'loner', even if they would go to day centres to be around people before the pandemic. Such direct descriptions of COVID-19 prevention borne of social exclusion were rare from our respondents who were homeless, but it was more common for long-running limits on social networks to figure in peoples' accounts and so hint at how this social exclusion may be a factor. Of the 12 respondents who described their social networks, half indicated they were in contact with some friends and/or family, and the other half described social isolation: being a 'solo person', not having any good friends, and losing friends from being homeless, and these experiences originating before the COVID-19 pandemic.

Several stakeholders offered the same theory as that described by Jim and Jane: "I think there's that natural social isolation that being homeless has given this client group" (S2, outreach worker), with people having "social bubbles" that "are really, really tiny" and "that's kind of what we've related it to [low infections] , the kind of social exclusion side of things" (S10, hostel worker). Others elaborated on this theory:

they're quite a socially isolated group anyway, and they're probably just not in situations where they're being exposed to COVID-19, potentially, would be more my theory. You know, they're not, they weren't getting on trains to commute to work, or sitting in an office, or going to big family parties around at someone's house (S8, outreach nurse)

Further, people who are homeless are "probably mixing with themselves" and not in other areas of public life. These limited social networks were related to situations of drug and alcohol use: "you know people share needles, they will share their drugs, they will share their alcohol, but I think that people stick within the same circles from what I understand, like people know each other but you'd usually quite often find the same group of people together" and from this limiting of social contact to other people with the same experience we might explain lower than expected infections (S1, outreach worker). Social, economic and spatial isolation then potentially act to reduce COVID-19 risk through enabling a particular form and experience of social distancing.

Another explanation offered for low infections, overlapping with the above, was of COVID-those rough sleeping. As Leon says: "for some reason it's not affecting us and I don't know whether it's .. if we just naturally have antibodies against it"). A specific mechanism was suggested by Jackie:

I was actually quite surprised nobody in here got it , but then I think, the thing is, we've been exposed to so many elements and so like living on the streets and stuff, maybe our immune system is a little bit stronger.

This idea was echoed by stakeholders with views such as this: "one sort of lay person's view is that you know these guys have been exposed to so much shit in their life they're probably quite robust, they find it .. they've probably got immune systems that have seen it all you know" (S2, outreach worker). Whilst strengthened immune systems resulting from longrunning exposure to pathogens figured in some accounts -and such co-infection has been hypothesised to protect against COVID-19 amongst people experiencing homelessness (Maguire, 2020) and similar explanations offered for children (Ng et al., 2020 ) -for others it was a mechanism of 'resilience' from being 'in the open air' (S3, outreach worker). Here then an overlap to the theme above of social isolation, with time in the open air itself potentially protective (S1, outreach worker), and so exclusion from settings where there might be risk of air borne transmission (Greenhalgh et al., 2021) .

A direct reading of these accounts indicating immunity or protection from rough sleeping needs caution, partly for the plausibility of any biological mechanism, and also for how a potential 'street immunity' allows for a desirable identity of vitality -a resource not commonly available to people experiencing homelessness. Notions of people as 'immune', 'robust' and 'resilient' could instead account for a normalisation of pain given contexts of J o u r n a l P r e -p r o o f stigma and limited health care access (Harris, 2020) . Such an interpretation arose from an interview with a hostel worker after we speculated on an emerging theory of 'street immunity' resulting from exposure to pathogens. After their initial response -"It is something I've considered" -they segued in to a related line of argument:

S7 -you see some of the people that are coming in and you know when they end up going to get health checks and you're like `how has this person not ended up in hospital before they came here, how were they not found on the streets dead?' and it turns out that they've had an illness going on for years … and they're isolated and they're not accessing these services and they're carrying on and it's always amazed me … and you just don't understand how they've managed to survive that long, and I do wonder if perhaps that has had an impact on their immune systems and their ability to you know be able to fight these things as it were in a way and .. you know.

might be immunity or it might just be people just basically can ... are used to withstanding an enormous amount of pain.

Rather than an active immune system, it might instead be an experience of being 'numb' (S7, hostel worker) given so much suffering and limited access to health care. The suffering from mild to moderate COVID-19 may for some be indistinguishable from other ongoing pain, and not form part of processes of care access, and so further echo an overarching theme of social exclusion as shaping experiences of COVID-19.

This exploration of community experiences and perspectives has identified three themes to describe processes that may explain the lower than expected rates of COVID-19 amongst people who are homeless: following, creating and breaking rules, as well as social exclusion and street immunity. The analysis suggests a range of sometimes contradictory themes that point to factors that could both help explain lower than expected COVID-19 infections in terms of limited testing access and uptake, but also in how COVID-19 infections were prevented. We discuss these themes and raise questions for future exploration.

The potentially important role for people experiencing homelessness in following and initiating COVID-19 restrictions follows insights from past pandemics where affected and marginalised communities have initiated locally relevant responses (Friedman et al., 2007) .

This theme in the data is reminder of the agency of communities facing severe stigma and marginalisation. In distinction from the theory that framed our exploration of this topic (Friedman et al., 2007) , we heard reports of expression of agency amongst those we interviewed, but not indications of community or network organisation; i.e. data did not indicate coordinated efforts to involve others in particular preventative actions or spread certain messages such as with the early stages of the HIV epidemic and drug use messaging.

Such differences could reflect the rapid emergence of the pandemic, the limits on social mobility undermining capacities for social organisation, as well as long-running limits on the resources and capacities by which groups of people who are homeless may take selfdirected action. The actions described to us do though emphasise the role for community engagement (Kinsman & Funk, 2020) in coproducing pandemic responses. Investigation is needed to understand how this agency can be best enabled, and in particular how community action can enable structural interventions (Sweat & O'Reilly, 2013) . Specific exploration is needed of the role of community agency in realising the potential of structural level hostel and hotel level measures, and then what the effects are of any fatigue over time in diminishing adherence to necessary measures. Further study, and recognition of the role for this agency, is important to counter discourses of people experiencing homelessness as 'risk' to the rest of society (Selsky, 2020) and further highlight the agency and active role for people experiencing homelessness in protecting their own health and that of others.

The themes of social exclusion and street immunity could be interpreted as suggesting that longer-running exclusion from care could limit testing uptake, and so explain lower than expected infections as a consequence of them not being detected. The experience of structural violence, and the widely reported exclusion from health care that many face (Elwell-Sutton, Fok, Albanese, Mathie, & Holland, 2017), has been previously described as leading to a normalisation of pain and corresponding absence of care-seeking (Harris, 2020) . This phenomena -narrated as 'street immunity' -could help explain experiences from France where of people who were homeless surveyed and who tested seropositive for COVID-19, two thirds did not report symptoms (2021) . Social exclusion and a corresponding absence of caring social support networks could also undermine capacities for accessing COVID-19 testing and treatment, given the increasing recognition of the role of social capital in pandemic responses (Oronce & Tsugawa, 2021) .

The themes of social exclusion and 'street immunity' could also though suggest long-running exclusion and structural violence (Rhodes et al., 2012) may have, perversely, contributed to preventing infections. The patterns of economic, social and spatial isolation in the UK that can result from particular experiences of prevailing stigma; limited, punitive or underfunded J o u r n a l P r e -p r o o f 21 services; criminalised drug use, and a distorted housing system (Gallent, 2019; Harris, 2020; Johnsen, Cloke, & May, 2005; Loopstra et al., 2016; Moran & Atheron, 2019; Thompson, Guise, Edgar, Solley, & Burrows, 2020) . In combination, these processes may have generated living conditions and experiences that limited exposure to COVID-19.

Additionally, the narrative of 'street immunity' would reflect how these conditions may have challenged immune systems to generate a response to COVID-19. Caution is needed in hypothesising specific immunological effect. However, the mechanisms described could help explain lower rates of infection amongst those homeless and unsheltered, as reported by Yoon et al (2020) , whether through enhanced immunity in response to exposure to pathogens, or the role of being in the open air.

Identifying a potential role for social exclusion in COVID-19 prevention or in undermining testing access needs further scrutiny. If social exclusion is found to generate COVID-19 this would pose challenging questions for public health. Not least for how any prevention effect being grounded in such harsh experiences comes at significant risk for other health challenges (Yoon et al., 2020) and severe indirect effects of COVID-19 are then more likely (Bambra, Riordan, Ford, & Matthews, 2020) . Future analysis should explore these different experiences of homelessness, structural violence and COVID-19 and relate them further to their specific contexts and histories, such as particular long-running dynamics of housing in Ireland (O'Sullivan, 2020) or income generating strategies amidst specific drug markets in the USA (Bourgois, 1998) . Variation in COVID-19 epidemiology across settings internationally should also include comparative analyses of the structural conditions and histories involved in creating particular experiences of exclusion (Hopper, 2003; Wacquant, 2008) . Recognising the potential role for long-running social exclusion in preventing COVID-J o u r n a l P r e -p r o o f housed and included in society.

Recognising the potential role for agency, social exclusion and street immunity in limiting COVID-19 amongst people who are homeless provides novel insights for international debates seeking to understand the contributions of different interventions for people experiencing exclusion (O'Carroll et al., 2021) . As above, the 'everyone in' housing interventions along with the hostel level interventions in the UK have been prominent in explanations of low infections (GLA, 2021; NAO, 2021) ; the importance of 'everyone in' underlined by how this scheme was not given more funding in early 2021 whilst the UK experienced a severe second wave of the pandemic, including with reported rises in infections amongst people experiencing homelessness . The analysis here is an important adjunct to recognition of 'everyone in' and the hostel level measures, through showing how this must be considered alongside other factors, and how they may combine. Such combined effects could include 'everyone in' being partially enabled through processes described here; that hotels reduced numbers of those most vulnerable in some hostels, with community agency and social exclusion then acting to reinforce prevention in hostels; and -for people continuing to sleep rough -that their own agency, social exclusion and possible 'street immunity' may have been more influential. As above, ongoing analysis needs to explore more the variation according to different experiences of homelessness (O'Sullivan, 2020; Yoon et al., 2020) .

Studying the complexity of causality of COVID-19 prevention in the UK, as elsewhere, is essential to respond to a particular danger of a narrative of COVID-19 prevention success J o u r n a l P r e -p r o o f overly focused on single interventions to the neglect of long-running structural dynamics.

Whilst 'everyone in' and hostel level measures were radical and remarkable and with large impact, a narrow focus on provision of hotel rooms risks depoliticising homelessness (Elwood & Lawson, 2017) by ignoring the long-running factors in the UK homelessness crisis (Suzanne Fitzpatrick, Bramley, & Johnsen, 2012; Gallent, 2019) that an exploration of social exclusion and 'street immunity' bring to the fore. Indeed, any congratulations offered to the current UK government for 'everyone in' comes in the context of recent and rapid rises in homelessness that can be linked to specific government policy changes (BMA, 2019; Loopstra et al., 2016) , and continuing inaction on the fundamental causes of the UK housing crisis (Gallent, 2019) . Such depoliticization of homelessness is evident in similar debates, where housing first -an intervention approach centred on provision of housing with support and without conditions -is increasingly being promoted across the policy sector, but in ways that ignore the complexities of this intervention and that also serve interests seeking to forestall action on the housing supply and costs (Pleace, 2021) . Uncritical reflection on low COVID-19 infections and the role of emergency interventions -as we are arguably now seeing with housing first -could then distract from action on the long-term challenges of housing, health and welfare policies and their role in inequalities.

Findings of social exclusion potentially limiting COVID-19 suggest further dynamics through which COVID-19 and socio-economic status combine .As described in the introduction, the theory of fundamental causes and stages of disease theory suggests lower socio-economic status is linked to the emergence of COVID-19 inequalities after an initial period of higher infections amongst those of higher socio-economic status, as people of lower socioeconomic status are unable to access or deploy resources or protective strategies, and these J o u r n a l P r e -p r o o f experiences building on long-running ill-health (Clouston et al., 2020) . The findings here can help develop this theory. Whilst emergency housing interventions have shaped the pandemic dynamics for some groups in the UK, for others extreme social exclusion, as well as 'street immunity' and contexts for it, may be more dominant. Extremes of low socioeconomic status -being unhoused and impoverished, as well as marginalised by drug usecould provide various routes of protection, and so may prevent or create further delays, perhaps lengthy, in the emergence of COVID-19 inequalities. However, whilst inequalities in COVID-19 infections and deaths may not emerge at the start of the pandemic, it is likely that inequalities in the indirect effects of COVID-19, and in particular the effects of lock-down policies could be far higher for these especially excluded groups. Further analysis is needed to disaggregate different experiences of low socio-economic status, and how these relate to direct and indirect inequalities relating to COVID-19. Recognising these multiple dynamics of health inequalities and COVID-19, and other infectious disease pandemics, could help in planning the timing and sequencing of interventions. Specifically, if extremes of socioeconomic exclusion do lead to delays in COVID-19 inequalities it suggests the need for COVID-19 support to be sustained well beyond an initial emergency period and any wave of infections amongst the general population; further, any support measures should also priorities protecting against indirect effects of COVID-19, through for example ensuring access to money and income.

The qualitative design and social distancing for data collection necessitate caution in interpreting and generalising findings. The sample is also not representative of all experiences of homelessness. However, the repeated interviews and triangulation from J o u r n a l P r e -p r o o f 25 different sources allowed insight into a little explored set of experiences. Further study to establish the role of the factors suggested is essential.

In conclusion, this analysis provides theories that should be tested further for their contribution to COVID-19 epidemiological understanding and the role of pre-existing health inequalities. Lower than feared COVID-19 infections amongst people who are homeless could be explained by how community agency, social exclusion and processes of 'street immunity' interacted with emergency housing interventions. While social exclusion and 'street immunity' may have given some protection against COVID-19, the entrenched health and social inequalities involved should still be addressed. Understanding how these factors, in combination with emergency housing, contributed to the reduced transmission of COVID-19 will increase our understanding of the epidemiology of the virus to inform public health interventions.

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Pathways into Multiple Exclusion Homelessness in Seven UK Cities

The homelessness Monitor: England 2021

Harm reduction theory: Users' culture, micro-social indigenous harm reduction, and the self-organization and outside-organizing of users' groups

Whose housing crisis? Assets and homes in a changing economy

COVID-19 response for people sleeping rough

Qualitative methods for health research

Ten scientific reasons in support of airborne transmission of SARS-CoV-2. The Lancet

Covid-19-are we rationing who we care about?

Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care

Comparing the initial Everyone In COVID-19 London response to the resurgence of

Reckoning with homelessness

Coronavirus Disease 2019 Outbreak in a San Francisco Homeless Shelter

Day centres for homeless people: spaces of care or fear?

Good practices during the COVID-19 pandemic for organisations supporting people experiencing homelessness: findings from an EU-wide survey. Homeless in Europe

Efforts escalate to protect homeless people from COVID-19 in UK. The Lancet Respiratory Medicine

The government hasn't 'ended homelessness', no matter what it says. The Guardian

The homeless migrants left in the lurch in Denmark. Homeless in Europe

Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and

COVID-19 among people experiencing homelessness in England: a modelling J o u r n a l P r e -p r o o f study

Conceptualising stigma

The impact of economic downturns and budget cuts on homelessness claim rates across 323 local authorities in England

Comment on blog

Build back fairer: the COVID-19 Marmot Review. The pandemic, socioeconomic and health inequalities in England

The philosophy of homelessness

The Health Benefits of Secondary Syringe Exchange

Investigation into the housing of rough sleepers during the COVID-19 pandemic

Experiences of being housed in a London Hotel as part of the 'everyone in' initiative; part 1: life in the hotel

Experiences of being housed in a London Hotel as part of the 'everyone in' initiative

Preexisting and de novo humoral immunity to SARS-CoV-2 in humans

Harm reduction in the time of COVID-19: Case study of homelessness and drug use in Dublin, Ireland

Reimagining Homelessness for policy and practice Bristol

Bonding and linking social capital are key determinants for successful pandemic policy

They already operated like it was a crisis, because it always has been a crisis': a qualitative exploration of the response of one homeless service in Scotland to the COVID-19 pandemic

Neoreaction and Housing First: a review essay

Structural violence and structural vulnerability within the risk environment: theoretical and methodological perspectives for a social epidemiology of HIV risk among injection drug users and sex workers

Seroprevalence and risk factors of exposure to COVID-19 in homeless people

Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Housing, Care and Support

Homeless at 'double risk' of getting, spreading coronavirus

COVID-19 Homeless Sector Plan: triage-assess-cohort-care. Retrieved from www.pathway.org.uk [accessed 26th

Ideological barriers to structural interventions: towards a model of values-based interventions

Low-paid shun Covid tests because the cost of self-isolating is too high

Tackling homelessness in the age of COVID-19

Universal Credit: the health impacts for people who are experiencing homelessness

COVID-19: a potential public health problem for homeless populations

Stigma, the machinery of inequality

Urban outcasts

How has the coronavirus outbreak affected the homeless shelter system in Poland? Homeless in Europe

Coronavirus Disease 2019 (COVID-19) Prevalences Among People Experiencing Homelessness and Homelessness Service Staff During Early Community Transmission

Thank you to Mat Amp and Jo Brown for help with recruitment. Thank you especially to Darren, for his passion and impact in peer research.