COVID-19 Prevention Measures Targeting Homeless People in Japan: A Cross-sectional Study

ABSTRACT

Reports worldwide have shown that COVID-19 has impacted vulnerable populations, including homeless populations. The rate of the COVID-19 infection among the homeless populations is still unknown in most countries due to these individuals being scattered inconsistently throughout urban areas; however, surveys have been conducted in some shelters and in areas outside of Japan. Further, psychological impacts associated with COVID-19 infection, such as stress and anxiety or preventive procedures to protect yourself from infection, have also not been well studied among homeless populations. This study analyzes the demographic characteristics of the homeless population, their anxieties about COVID-19, and whether the author’s weekly announcements related to COVID-19 are beneficial to them. A cross-sectional mixed methods study was conducted in a Japanese city from October 2020 to February 2021. Data regarding socio-demographic characteristics, individuals’ experiences of homelessness, and perceptions of COVID-19 were gathered via interviews and examined using quantitative and qualitative methods. 71.1% and 44.2% of the respondents expressed no history of previous diseases and having anxiety due to COVID-19 respectively. Data indicated that they associated COVID-19 with death and serious physical harm. Additionally, 78.6% found the health announcements to be helpful and took preventive measures. Homeless people do not visit doctors, except when experiencing unbearable pain. Therefore, it is necessary to continuously provide comprehensive support for Japan’s homeless population.

KEYWORDS:

• Anxiety
• public health
• Covid-19

Background

COVID-19 has now spread across the globe. Reports have shown that COVID-19 has had a particular impact on vulnerable communities, such as prisoners, nursing home residents, and low-income residents (Tackle coronavirus in vulnerable communities [Editorial], 2020, May 19). Both in Japan and abroad, researchers have addressed the need for COVID-19 prevention targeting people experiencing homelessness, as well as the need to provide support for this vulnerable population (Benavides & Nukpezah, 2020; Lewer et al., 2020).

Homeless people have been identified as a vulnerable population at increased risk for infection because many homeless people experience chronic mental illness and physical ailments (Tsai & Wilson, 2020) and face difficulties when attempting to adhere to public health directives (Ralli, Cedola, Urbano, Morrone, & Ercoli, 2020). Physical and psychological outcomes of COVID-19 among vulnerable populations are key elements of public health.

Generally speaking, the ongoing COVID-19 pandemic has had physical and psychological impacts on people from all demographics (Huang & Zhao, 2020). An example of one possible psychological effect is that the overload of COVID-19 information may induce further anxiety for some people (Jakovljevic, Bjedov, Jaksic, & Jakovljevic, 2020). Further, the economic impacts of COVID-19 have triggered a decline in household income, leading also to a decline in quality of life (Tran et al., 2020). As it stands, the physical and psychological statuses of homeless people, considered a vulnerable population, are not well studied in Japan or overseas.

In the United States and Canada, as well as European countries, homeless people live in shelters, on the street, and in train and bus stations depending on their particular circumstances. According to the Annual Homeless Assessment Report to Congress released by the United States Department of Housing and Urban Development (The US Department of Housing and Urban Development, 2020). In 2019, 567,715 people experienced homelessness on a single night in the United States. On the other hand, the survey by the Ministry of Health Labor and Welfare (MHLW) of 2021 revealed that 3824 homeless people (3510 men, 197 women, and 117 unknown) are living in parks, near rivers, on the street, in train and bus stations, and other locations in Japan (Ministry of Health, Labor and Welfare, 2021b). This number decreased from its 19,523 totally in 2006 (Ministry of Health, Labor and Welfare, 2021a). However, the homeless population may be larger than estimated. According to a survey conducted by the Tokyo Metropolitan Government between 2016 and 2017 targeting “people engaged in unstable employment while sleeping at internet cafes or manga cafes,” of the 15,300 users who stay in such establishments overnight, approximately 4,000 people were using them as permanent residences where they sleep each night (Tokyo Metropolitan Government, 2018). Domestic workers around the world have been negatively impacted by COVID-19 (International Labor Organization, 2020). Likewise, COVID-19 has led to decreased working hours and even termination for some workers in Japan. An unknown number of people may have lost their homes during the coronavirus pandemic as in Japan companies sometimes provide housing for their employees. As a result of that, they became homeless. There are very few homeless shelters in Japan. According to a list of shelters provided by the (MHLW), only two municipalities operates two shelter facilities each in Japan. Beyond this, 51 municipalities operated from 145 locations, such as hotels, instead of formal shelter facilities as of 2014 (Ministry of Health, Labor and Welfare, 2014). Therefore, the actual number of people without homes in Japan is unknown.

Based on the author’s experience as a medical volunteer serving the homeless population, most homeless people in Japan are among the aging population. Some of them suffer from health problems, such as diabetes, high blood pressure, untreated wounds, and missing teeth. Indeed, many scholars overseas have discussed the health care issues of the homeless populations (Ralli et al., 2020; Zlotnick & Zerger, 2009). Youth experiencing homelessness are at high risk for experiencing psychiatric disorders (Tucker et al., 2020). Although youth homelessness is not a highly visible issue in Japan, according to a report by Nishio et al. (2015), of the 114 homeless individuals surveyed in a city in Japan, 42.1% had been diagnosed with a mental illness.

In the city the author studied, some individuals who had recently lost their house used temporary accommodations provided by the local government. However, many individuals live on the street, near rivers, or in parks. Some homeless people survive partially off of meager pensions, while others collect cans and stickers, or are engaged in irregular employment. Many homeless individuals frequent food kitchens run by nonprofit organizations.

Individuals at homeless shelters have been reported to be at a high risk of contracting COVID-19. In the United States, 36% of people living in homeless shelters in Boston tested positive for COVID-19. In addition, 67% of residents in San Francisco homeless shelters tested positive on a polymerase chain reaction (PCR) test (Imbert et al., 2020). Japanese homeless people are scattered throughout urban areas and are not clustered in shelters like in other countries, such as the United States, Canada, and some European countries. However, gathering at food kitchens and parks may increase the risk of virus transmission, similar to how restaurants act as hot spots of transmission. In the city selected for this survey, since April 2020, the majority of food kitchens have continued to provide food to the homeless on a weekly basis despite the COVID-19 outbreak. Since these food kitchens provide meals on different days of the week, homeless people are able to receive food somewhere every day. Only a few food kitchens have stopped their services. The author of this study made announcements to prevent COVID-19 infection and created an announcement board called the “Kashiko COVID-19 Fighter Board,” which was posted in an area where homeless people queue to receive food. The information of preventive measurement that were delivered to the participants at the park are as follows;

Learn the appropriate way of wearing masks.

Wash your hands diligently with water using soap.

Be careful when you touch your eyes, nose, or mouth.

The virus might be present on the door knob.

Maintain 2 meters distance when talking to people.

When talking to people, talk sideways, not face-to-face.

Do not touch the surface of the mask.

Although those who visit food kitchens wear masks, it is unknown how much anxiety they experience because of COVID-19 and the risk of being infected. There have been no studies on COVID-19 prevention targeting the homeless population in Japan. Japan has some of the lowest rates of PCR and antibody tests among all OECD countries (OECD, 2020). Moreover, the actual number of positive COVID-19 cases in Japan – among the homeless and non-homeless alike – is unknown. During the aforementioned volunteer activities, the author formulated the following research questions:

(1) What are the demographic characteristics of the homeless population? (2) What anxieties do members of the homeless population have about COVID-19? (3) Was the author’s announcement beneficial to homeless people?

Method

Study design

This is a cross-sectional mixed methods study examining both quantitative and qualitative data regarding homeless people’s perceptions of COVID-19. It was conducted between October 2020 and February 2021.

Setting and participants

The sample size was determined based on a G*Power. When the effect size was calculated with use of 0.5, the number of participants was 45. Inclusion in the study was limited to individuals who were homeless and who visited the food kitchen in Park A on Thursday in the city selected for this study. Those who were not homeless, lived in an apartment, and had access to medical assistance were excluded from being participants. Moreover, homeless individuals under the age of 18 were also excluded.

Regular activities of homeless individuals since the outbreak of COVID-19

Every Thursday, the SK organization has been providing food for homeless people and other people in need at Park A in the selected city. Meanwhile, a Life and Health Consultation Team, which belongs to the SS organization, has established an information center in Park A where those in need can receive life and health consultation. The team consisted of volunteer medical workers, including doctors and nurses, as well as other or volunteers without a medical background. Generally, visitors to food kitchens first eat the provided food and then visit the life and health consultation booth to receive consultation or pick up daily necessitiesThe author of this study developed an announcement board called the “Kashiko COVID-19 Fighter Board” based on the graphics depicting infection control and prevention measures developed for Japan (Japanese’s Society for Infection Prevention and Control, 2020) and information released by the Centers for Disease Control and Prevention (Center for Disease Control and Prevention. (n.d.), 2019)). Information included how to put on and take off a face mask, the importance of oral hygiene, hand washing, how to prevent the spread of the virus when coughing, and social distancing guidelines. The author asked the illustrator to create new illustrations or use freely available pictures from the internet. The author printed out these graphics and information on pieces of A4 paper and posted them to the board.

On a separate board, information about not touching one’s eyes and massaging one’s face muscles to promote blood flow was posted. Every Thursday starting from the end of April 2020 up until March 2021, the author made 10-minute announcements based on recent COVID-19 news and information at Park A. She addressed homeless individuals queuing in line to receive free food. The author wore a Pink Ranger costume to get the attention of people standing in line (Figure 1). The costume also protected the author from being exposed to COVID-19 via aerosol particles. On certain occasions, a dental assistant would provide information on oral care as a method for preventing infection. The author also informed listeners that free masks were available. Beginning in the summer of 2020, the author and other volunteers distributed toothbrushes for infection prevention. Some homeless people asked that the text on the letter board be made larger, and that less Kanji characters be used; therefore, the announcement board was revised four times in order to address such requests.

Figure 1. The costume performance when providing announcement to participants of soup kitchen The costume performance allows participants of soup kitchen to pay attention on the announcement (Fumiko Noda drew the pictures on the board).

Procedure

Semi-structured, open-ended interviews that lasted approximately 10 minutes were conducted with 45 homeless people who visited the food kitchen every week between October 2020 and February 2021. People who use the food kitchen include homeless people, people living off meager pensions in apartments, and people with serious medical needs. Therefore, before starting each interview, the author randomly picked up a person who was waiting in the food kitchen area and asked whether or not he or she is homeless. The author randomly picked two to three homeless people to interview each week, and asked them questions based on the interview script. The interview questions focused on anxiety and prevention of COVID-19 infection. Other questions included the respondent’s age, sex, duration of homelessness, the number of visits they make to food kitchens each month, and their history of illness. The interviewer also asked respondents which types of social services provided at the park they felt were most beneficial. Interviewees were also asked about their perception of the announcements given every week by the author, and if there were any other methods that could be used to improve COVID-19 prevention. Finally, the author asked about their quality of life, such as the quality of their meals and sleep.

Data analysis

For quantitative analysis, data were analyzed using R studio and SPSS 27. Demographic data and data on perceptions of COVID-19 anxiety and prevention were analyzed using descriptive statistics. For qualitative analysis, the author gathered statements from participants related to COVID-19 and examined text data using KH Coder software, which is a software used for content analysis and text mining. It was developed by Kouichi Higuchi. The network figure captured the frequency of certain statements (Figure 2). Based on the results of the network figure, the author used theoretical thematic analysis procedures developed by Virginia Braun and Victoria Clarke (Braun & Clarke, 2006). They developed those procedures to find and analyze the pattern in the qualitative data (Braun & Clarke, 2006; The University of Auckland New Zealand, (n.d.)). The author extracted codes and generated themes.

Figure 2. Network Figures from Qualitative data Network Figure depicted frequently used words regarding perception of COVID-19 Bigger circle means higher frequent words from interviewers.

Results

Table 1 documents characteristics concerning the eating and sleeping habits of the 45 homeless people who were interviewed. All of the homeless people interviewed were men. Among the 45 respondents, 30 (68.8%) were over 60 years old and 14 (31.2%) were under 60 years old. In addition, 32 out of 45 respondents (71.1%) answered that they had no history of disease and 84.4% felt that they benefited from food services.

Table 1. Demographic characteristics

Item	n	Category	Frequency		Percentage (%)
Sex	45	Male	45		100.0
		Female	0		0
Age		20–30	1		2.2
		30–40	1		2.2
		40–50	4		8.9
		50–60	8		17.8
		60–70	15		33.3
		70–80	14		31.1
		Over 80 years	2		4.4
Diseases (Participants’ answers)	45	High blood pressure	5		11.1
		Diabetes	2		4.4
		Brain-related disease	1		2.2
		No history of disease	32		71.1
		Other	5		11.1
		History of brain surgery (1), lung cancer (1), back pain (1), history of knee surgery (1), I stopped drinking alcohol (1), I go to the doctor only if I feel sick (1), history of tuberculosis (1), mental illness (1), cancer (no name stated) (1), retinopathy (1), emphysema (1), I became healthy after I was homeless
Kinds of services that are beneficial for you when you attend food service (multiple answers)	45	Food service		38	84.4
		Daily life consultation		3	6.7
		Health consultation		1	2.2
		Apartment move-in consultation		6	13.3
		Medical assistance application consultation		1	2.2
		Obtaining essentials for daily life		26	57.8
		Referral to a medical institution		6	13.3
		Other items that are beneficial to you
		The kindness of the staff (1), to meet friends (1), it is healthy to walk to come here (1), to get medicines or masks (1), the barber comes regularly (1)

Table 2 shows the situation of homeless people surveyed at Park A. The average number of months spent homeless was 78 months. On average, homeless people over 60 had spent a longer time homeless. The average number of times receiving food from a food kitchen was 18 times per month. Younger respondents visited food kitchens more often. In addition, 18 out of 42 respondents (42.9%) felt that their quality of sleep was poor. 19 out of 39 respondents (49%) felt that they were able to eat a sufficient amount of food. Table 3 represents the perception of COVID-19. A total of 44.2% of participants expressed that they were worried about COVID-19, while 44.2% did not think it became difficult to receive support, and 55.8% did not think COVID-19 caused any trouble. Moreover, 53.3% of respondents answered that they felt no need to receive daily living essentials in order to prevent COVID-19, while others expressed the need for blankets and sleeping bags. A chi-square test revealed that there was no significant association between the ages of participants and their reported levels of anxiety or inconvenience experienced as a result of COVID-19 (Table 4).

Table 2. Street life experience, number visits to the food kitchen, and sleep and food conditions

Street life experience	n	Average months of homelessness
Age
20–30	43	1
30–40		4
40–50		57.5
50–60		72
60–70		106
70–80		55.8
Over 80 years		168
Total average and SD		78 ± 93
Number of visits per month to the food kitchen	45
Age		Average months of visit
20–30		28
30–40		20
40–50		20
50–60		17
60–70		19
70–80		15
Over 80 years		16
Total average and SD		18 ± 8
Do you think you are getting enough sleep?	42	Number
I think so.		18
Maybe		7
I do not think so.		17
Other comment		Sleeping time: 2–3 hours (4), 3 hours (6), 4 hours (2), 5–6 hours (13), 7 hours (3), 8 hours (1), 10 hours (2), I try to sleep during the day (4), I cannot sleep well at night (2), I collect cans at midnight or in the morning (2), I feel cold at night (2), It is difficult to sleep in summer (1)
Do you think you are eating enough during each meal?	39
I think so.		19
Maybe		13
I do not think so.		7
		Number of meals: 1 time (12), 2 times (9), I do my best to have a meal that is balanced and includes protein and carbohydrates. I eat natto (Japanese beans).

Table 3. Perception of COVID-19

Items	n	No of participants who answered (multiple answer)	%	95% Confidence interval
After COVID-19 spreads, do you think it is difficult to receive support?	43
I think so.		13	30.2	17.2–46.1
Maybe		11	25.6	13.5–41.2
I do not think so.		19	44.2	29.1–60.1
Are you worried about the spread of COVID-19?	43
I think so.		19	44.2	29.1–60.1
Maybe		8	18.6	8.4–33.4
I do not think so.		16	37.2	23–53.3
Do you have troubles due to the spread of COVID-19	43
I think so.		10	23.3	11.8–38.6
Maybe		9	20.9	10–36
I do not think so.		24	55.8	39.9–70.9
Is an announcement for the prevention of COVID-19 beneficial for you?	42
It is helpful.		33	78.6	63.2–89.7
Maybe		9	21.4	10.3–36.8
It was not helpful.		0	0
I can obtain information (6), I learned something I did not know (2), I obtained information about brushing teeth (2), I felt safe when I listened to the information because I had not obtained enough information (1), Please do this type of interview more often (1)
Prevention of COVID-19 spread	45
Hand washing		22	48.9
Wearing a mask		40	88.9
Cough etiquette		4	8.9
Sufficient meals		2	4.4
Keeping distance		4	8.9
Brushing teeth		11	24.4
Rinsing one’s mouth		6	13.3
Pearson’s chi-square test ()
Which are you more worried about: flu or COVID-19?	43
COVID-19		22	48.9
Influenza		4	8.9
Both		9	20.0
Neither		8	17.8
What are some missing essential items for infection prevention?	45
I do not need any essentials at the moment.		24	53.3
Meal		3	6.7
Mask		5	11.1
Soap		4	8.9
Toothbrush		3	6.7
Towel		3	6.7
Other		16	35.6
I need blankets for sleeping (6), a sleeping bag (1), shaving tools (2), underwear (2), clothes or gloves or warm winter clothes (1), alcohol gel (1)

Table 4. Chi-squared for perception of COVID-19

Age and level of worry regarding COVID-19	Chi-squared = 14.484, df = 12, p-value = 0.2709
Age and the feeling of trouble due to COVID-19	Chi-square = 15.84, df = 12, p-value = 0.1987
	Chi-squared of association between announcement and oral hygiene
Announcement and mouth wash	Chi-squared = 0.57273, df = 1, p-value = 0.4492
Announcement and mouth rinsing	Chi-squared = 0.58923, df = 1, p-value = 0.4427

The qualitative data reveals more details concerning the opinions of respondents (Table 5). Figure 2 shows that the frequency of words is depicted by the size of the circle. They were anxiety, prevention, infection, death, human beings, and food service. The content of the interviews of the 45 participants on COVID-19 were categorized into the following main topics: infection, concern for daily life, and prevention. COVID-19 infection was further divided into transmission, death, perception of COVID-19, and uncertain future. The category of “concern for one’s daily livelihood due to COVID-19” was divided into food service support, job, and a place to go. The category of “Prevention against COVID-19” included wearing a mask and maintaining social distance. The qualitative data indicates that they were concerned with preventing themselves from contracting the disease and transmitting it to others. According to the perception of COVID-19, respondents felt that being infected with COVID-19 could lead to serious health consequences or death. In total, 33 out of 42 respondents (78.6%) answered that the author’s announcements were helpful. Table 4 shows that 88.9% wore masks and some of those wore masks to receive food. However, there was no significant association between the benefit of the announcements and the ratio of mask wearing or oral hygiene practice (Table 4).

Table 5. Terms from qualitative data about perceptions of COVID-19

Theme and definition	Category and definition	Quote	No of quotes
COVID-19 infection: COVID-19 infection is caused by the novel coronavirus.	Transmission: Homeless people avoid getting infected and infecting others.	Avoid transmitting infection to others.	6
		I do not spread my own droplets.	1
		I try to do my best not to spread infection.	1
		I don’t want to be infected.	8
		I can get infected.	1
		I am afraid of getting infected.	4
		I would like to avoid getting infected because I might have to visit crowded places.	1
	Thoughts on death: Death is associated with COVID-19 infection.	When you die, you die.	1
		I am not worried so much because all human beings will eventually die.	2
		Humans live as they are.	1
		I will wear a mask; otherwise, I might die of COVID-19.	1
		I might die if I get infected with COVID-19.	1
	Perception of COVID-19: How are the physical and mental impacts of COVID-19 perceived?	I am afraid to suffer from COVID-19 complications.	1
		I am afraid to suffer from serious illness.	1
		The virus spreads just through coughing.	1
		I am worried about my age.	1
		COVID-19 spreads with human spit.	1
		I am worried because I am getting older and weaker.	1
		If you catch a cold, you are more likely to get infected with COVID-19.	1
		COVID-19 affects the lungs.	1
		There is no cure for COVID-19.	1
		I am worried that my respiratory system will be damaged because my respiratory system is weak.	1
		Tuberculosis and COVID-19 are the same. You do not have to worry if you pay attention to your diet.	0
		It is easy to get infected when you are weak, such as while having a cold.	1
		Fever rises when a person is infected with COVID-19.	1
		COVID-19 has something to do with taste. So far, I have a sense of taste.	1
		The third wave of COVID-19 is coming. I feel I am likely to get infected.	1
		I am worried about losing strength.	1
		I heard that there are no symptoms even if I get infected with COVID-19.	1
		I hear that contact with people is not a good thing because it increases the risk of getting COVID-19.	1
		COVID-19 is dangerous for the human body.	1
		The relationships among people are changing amidst the pandemic.	1
	Unpredicted future: There are no treatments for COVID-19 as yet, and the trend of the outbreak is unknown.	I do not know because it is said that the treatment is ineffective worldwide.	1
		I cannot see the future.	1
		I do not know if I can get a vaccine.	1
		The COVID-19 issue should not be considered difficult.	1
		PCR tests are not prevalent in Japan.	1
		I hear the story, but I do not know who is infected.	1
Concern for daily life due to COVID-19: Something that you worry about in this situation due to uncertainty or unpredictability	Food service support: Homeless people go to different places and get served food.	Some organizations do not provide food service routinely.	1
		Food service support is running out.	3
		No soup was provided at food service support; food service support became inconvenient.	1
	Job: Homeless/I get some money by collecting cans or other such jobs.	I lost my job, or the number of jobs available declined.	2
	Places to go: Homeless people have various places to go to.	The library is closed.	1
		The bicycle race track is closed.	1
		It becomes difficult to go to the local government office.	1
Prevention of COVID-19: Homeless people are taking preventive measures against COVID-19.	Mask: The rationale for which homeless people wear masks	I do not like to bother other people because I regularly go to food service.	1
		The staff of food kitchen workers told us to wear a mask.	3
		Without wearing a mask, I am not able to attend food service.	1
		Wearing a mask is a habit.	1
		Everybody wears a mask.	4
		I am wearing a mask to prevent the spread of COVID-19.	1
		Wearing a mask has become common sense.	1
		Masks play a great role in preventing the spread of COVID-19.	1
		Wearing masks leads to the prevention of infection to some degree.	2
		Wearing a mask is good manners.	1
		If I do not wear a mask, everybody looks at me. I am worried about how other people will look at me.	1
	The place that people gather: homeless people tend to avoid places where people gather.	I do not go to places where people gather.	3
		COVID-19 is transmitted in places with many people.	1

Discussion

The mixed methods employed in this study seem to have been effective at identifying the cultural understanding of psychological features (Groleau, Pluye, & Nadeau, 2007). By supplementing the qualitative data with quantitative data, this study bolsters the overall validity and credibility of the findings as a whole. These various analysis methods were used to investigate the data related to COVID-19 in the previous literature. Radanliev, De Roure, and Walton (2020) analyzed three topics – mortality, immunity, and vaccination – based on bibliographic data from Web of Science Core Collection with Biliometrix’package. The conceptual map rendered in visual form using R studio clarifies the key elements of these topics. Likewise, the KH coder software used in this study was able to extract the elements of thought of participants, although the data management capacity in KH coder is lower than in R studio.

Previous studies have identified homeless adults as a population at risk of developing chronic health conditions (Aggarwal, Lippi, & Michael, 2020). Particularly, cardiovascular diseases have been identified as a high risk disease associated with COVID-19 (Chen et al., 2020; Tsai & Wilson, 2020). In this study, 71.1% of respondents stated that they had no history of disease. However, 68.8% of respondents were over 60 years old. This finding differs from previous studies. It is assumed that respondents avoided seeing the doctor except when experiencing unbearable pain.

The results of this study did not reveal a statistically significant association between age and anxiety in the context of COVID-19 or feelings of being inconvenienced by COVID-19. This may be because the sample size was too small. However, qualitative data captured the concerns and feelings of inconvenience of respondents. Anxiety may be spurred by various causes. Existing literature from around the world discusses the mental and physical health outcomes associated with COVID-19. Exposure to excessive, conflicting, inaccurate, and/or uncertain health information (Lee et al., 2021; Wang et al., 2021) may be included as a factor in negative mental health outcomes. For example, in the initial stages of the pandemic, the use of face masks was controversial worldwide. The study conducted by Wang et al. (2020) compared the psychological effects of mask recommendations in two countries with differing recommendations. The respondents in the country where masks were not frequently used revealed high rates of anxiety, depression, and stress. In this study, 17 people presented the rationale of wearing masks as a preventive measure. The use of face masks during COVID-19 helps relieve negative psychological effects, which can help both volunteers and homeless individuals feel more comfortable with participating at food kitchens. Masks help reduce physical and mental risks associated with obtaining food and other basic resources or information, although the process of gathering these supplies remains a concern for infection risk.

Anxiety has also been associated with the government response to the COVID-19 pandemic. A meta-analysis and systematic review focused on 33 countries (Lee et al., 2021) revealed that prompt government measures benefited the mental and physical health of people. This study also revealed that Japan has the lowest level of approval of government response to the pandemic among G7 countries (Vardavas et al., 2021). Japan’s suicide rate had decreased since 1979 and suddenly rose in 1998 and then slightly decreased (Dhungel, Sugai, & Gilmour, 2019); however, the rate remained high among women from July to September 2020 (Nomura et al., 2021). In 2020, a government policy was implemented granting 100,000 yen to all residents in the basic resident register of local government offices in Japan. The number of homeless individuals not registered as residents who did not receive these benefits is unknown. However, some local governments have worked to encourage homeless people to receive their benefits by registering as new residents. Further, the number of homeless people in Japan who have received a COVID-19 vaccine is unknown. MHLW has delivered a notice encouraging vaccination to local government offices (Ministry of Health, Labor and Welfare, 2021c), and some nonprofit organizations (NPOs) who assist homeless populations encourage homeless individuals to get vaccinated by delivering accurate, up-to-date information. The role of NPOs in managing public health should be recognized by government agencies and subsidies should be considered to protect the services they provide.

The fact that 53.3% of respondents stated that there was nothing more that could be done to prevent the spread of COVID-19 indicates that the free food provided to the homeless by several organizations has helped support the livelihoods of the homeless population in Japan. However, some expressed that they need underwear, blankets, and sleeping bags. It is necessary to understand the needs of the homeless regardless of the COVID-19 situation.

The interviews revealed that homeless people possessed basic information of COVID-19 despite not owning a smartphone or TV. Some respondents reported receiving information from acquaintances or the radio. Statements made during interviews also indicated that the announcements made by the author in combination with the announcement board provided homeless people with helpful information that they had not known previously. One respondent stated, “I feel safe when listening to the announcement.” Various alternative therapies exist alongside conventional healthcare. For instance, existing studies have presented alternative therapies with digital humanities tools to deal with the effects of the prolonged COVID-19 lockdown (Radanliev, De Roure, & Walton, 2021). Hospital clowns have been known to provide laughter and healing to medical patients worldwide (Adams, 2002). A 2016 intervention study supported the association between hospital clowns and positive emotional effects for patients (Auerbach, Ruch, & Fehling, 2016). Wearing a costume to deliver COVID-19 information may provide a sense of intimacy and emotional ease to homeless individuals at food kitchens. Further, promoting health while wearing a costume might alleviate the tense atmosphere of gathering during the pandemic.

Although this study was not an intervention study, the announcement was considered effective, as it induced respondents to undertake certain preventive measures, such as wearing a mask, improving their dental hygiene, and carrying disinfectant gel. In particular, respondents were required to wear a mask at the food kitchen, which in turn improved the overall safety at those events.

Although initial data was not obtained before the announcements were commenced, some volunteers indicated that more participants are receiving toothbrushes. Repeated announcements about oral hygiene for the prevention of infection may lead to more homeless people brushing their teeth (n = 11) and using mouthwash (n = 6). Based on my observations as a medical volunteer, it appears that many homeless people do not use toothbrushes and are missing teeth; however, there is no data on this in Japan. Previous studies indicate that oral hygiene has an effect on rates of pneumonia and influenza (Abe et al., 2006; Yoneyama et al., 2002). Improved awareness of oral hygiene among homeless people may lead to improved infection prevention. The author and supporters requested that participants spray disinfectant gel on their hands while waiting in line, and everyone was cooperative except one or two. Although homeless people live on the street or in parks, they still desire to live, and therefore, they readily accept information and guidance about COVID-19.

Previous studies have examined the impact of outreach on HIV prevention among the homeless and street youth (Gleghorn et al., 1997) as well as the effectiveness of interventions by social workers and local governments via screenings and PCR tests for COVID-19 (Benavides & Nukpezah, 2020; Wu & Karabanow, 2020). However, no studies related to general COVID-19 health education targeting the homeless have been conducted.

Homeless people eat one or two meals per day and often visit food kitchens at night. Food kitchens are run by different organizations and open on different days. The majority of respondents reported getting a poor quality of sleep that lasted no longer than five hours. Studies outside of Japan have shown that COVID-19 can impact mental health, decreasing the quality of sleep and increasing levels of anxiety and depression (Gualano, Lo Moro, Voglino, Bert, & Siliquini, 2020; Huang & Zhao, 2020; Khan, Mamun, Griffiths, & Ullah, 2020). The low quality of sleep reported by homeless people may not be associated with COVID-19. Rather, poor quality of sleep among the homeless may be a result of noisy environment when sleeping outside.

Conclusion

This study prevents quantitative findings complemented by qualitative data. A conceptual map of qualitative data was presented with basic categorization.

The results of this study show that homeless people perceive COVID-19 to be related to death and serious physical harm. They have made efforts to prevent contracting COVID-19. Specifically, wearing masks is required at food kitchens, which are vital to the survival of those who are homeless. The study also revealed that some respondents did not have enough information regarding medical assistance; therefore, continuous support is essential in order to maintain and improve the health of homeless individuals. This can be achieved through the delivery of social services, such as providing free meals and places to sleep. This, in turn, can improve their quality of life and improve prevention of infectious diseases, including COVID-19. This study concludes that the homeless population in Japan must be continually provided with beneficial information about COVID-19.

List of abbreviations

AHAR Annual Homeless Assessment Report

PCR Polymerase chain reaction

COVID-19 Coronavirus disease

Declarations

Ethics approval and consent to participate:

The Nagoya University Ethics Committee approved this research protocol on Oct 7, 2020 (Approval No. 20,269). All participants provided written informed consent. The informed consent form was written using large, easily legible font.

Consent for publication

Not applicable

Availability of Data and Materials

The datasets used during the current study are included in this published article and are available from the corresponding author on reasonable request. Numeric data are also available from Esumi Corporation in Japan.

Author contribution

The author designed the study and interpreted the data by consulting specialists in statistics and data analysis. The author wrote the entire manuscript.

Acknowledgments

I would like to thank all of the study participants and volunteer staff at the Sasashima Support Center. I would also like to extend my gratitude to Mr. R. Fukushima for his expertise in statistics and MR. S. Okazaki for his expertise in data analysis.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work is completed.