Evaluating the role and effectiveness of co‐produced community‐based mental health interventions that aim to reduce suicide among adults: A systematic review

BackgroundSuicide is a major public health risk requiring targeted suicide prevention interventions. The principles of co‐production are compatible with tailoring suicide prevention interventions to meet an individual''s needs.AimsThis review aimed to evaluate the role and effectiveness of co‐produced community‐based suicide prevention interventions among adults.MethodsFour electronic databases (PsycInfo, CINAHL, MEDLINE and web of science) were systematically searched. A narrative synthesis was conducted.ResultsFrom 590 papers identified through searches, 14 fulfilled the inclusion criteria. Most included studies elicited the views and perspectives of stakeholders in a process of co‐design/co‐creation of community‐based suicide prevention interventions.ConclusionStakeholder involvement in the creation of community‐based suicide prevention interventions may improve engagement and give voice to those experiencing suicidal crisis. However, there is limited evaluation extending beyond the design of these interventions. Further research is needed to evaluate the long‐term outcomes of co‐produced community‐based suicide prevention interventions.Patient and Public InvolvementThis paper is a systematic review and did not directly involve patients and/or the public. However, the findings incorporate the views and perspectives of stakeholders as reported within the studies included in this review, and the findings may inform the future involvement of stakeholders in the design, development and delivery of community‐based suicide prevention interventions for adults.     

Insights into how Malaysian adults with limited health literacy self‐manage and live with asthma: A Photovoice qualitative study

BackgroundAdjusting to life with a chronic condition is challenging, especially for people with limited health literacy, which is associated with low compliance with self‐management activities and poor clinical outcomes.ObjectiveWe explored how people with limited health literacy understand asthma and undertake self‐management practices.DesignWe adapted the arts‐based qualitative methodology Photovoice.Setting and ParticipantsWe sampled ethnically diverse adults with asthma and limited health literacy from four primary healthcare clinics in Malaysia. After a semistructured in‐depth interview, a subset of participants took part in the Photovoice component in which participants undertook a 2‐week photo‐taking activity and subsequent photo‐interview. Interviews, conducted in participants'' preferred language, were audio‐recorded, transcribed verbatim, translated and analysed thematically. We used the Sorensen''s framework (Domains: access, understand, appraise, apply) to describe participants'' experience of living with asthma, what they understood about asthma and how they decided on self‐management practices.ResultsTwenty‐six participants provided interviews; eight completed the Photovoice activities. Participants with limited health literacy used various sources to access information about asthma and self‐management. Doctor–patient communication had a pivotal role in helping patients understand asthma. The lack of appraisal skills was significant and experiential knowledge influenced how they applied information. Self‐management decisions were influenced by sociocultural norms/practices, stigmatizing experiences, and available social support.ConclusionLocally tailored multilevel interventions (interpersonal, health system, community and policy) will be needed to support people with limited health literacy to live optimally with their asthma in an ethnically diverse population.Patient/Public ContributionPatients were involved in the study design, recruitment, analysis and dissemination.     

Embedding health literacy research and best practice within a socioeconomically and culturally diverse health service: A narrative case study and revised model of co‐creation

BackgroundHealth literacy interventions and research outcomes are not routinely or systematically implemented within healthcare systems. Co‐creation with stakeholders is a potential vehicle through which to accelerate and scale up the implementation of innovation from research.MethodsThis narrative case study describes an example of the application of a co‐creation approach to improve health literacy in an Australian public health system that provides hospital and community health services to one million people from socioeconomically and culturally diverse backgrounds. We provide a detailed overview of the value co‐creation stages and strategies used to build a practical and sustainable working relationship between a University‐based academic research group and the local health district focussed on improving health literacy.ResultsInsights from our experience over a 5‐year period informed the development of a revised model of co‐creation. The model incorporates a practical focus on the structural enablers of co‐creation, including the development of a Community of Practice, co‐created strategic direction and shared management systems. The model also includes a spectrum of partnership modalities (spanning relationship‐building, partnering and co‐creating), acknowledging the evolving nature of research partnerships and reinforcing the flexibility and commitment required to achieve meaningful co‐creation in research. Four key facilitators of health literacy co‐creation are identified: (i) local champions, (ii) co‐generated resources, (iii) evolving capability and understanding and (iv) increasing trust and partnership synergy.ConclusionOur case study and co‐creation model provide insights into mechanisms to create effective and collaborative ways of working in health literacy which may be transferable to other health fields in Australia and beyond.Patient and Public ContributionOur co‐creation approach brought together a community of practice of consumers, healthcare professionals and researchers as equal partners.     

Functional health literacy and health-promoting behaviour in a national sample of British adults

OBJECTIVES: To measure the prevalence of limited functional health literacy in the UK, and examine associations with health behaviours and self-rated health. DESIGN: Psychometric testing using a British version of the Test of Functional Health Literacy in Adults (TOFHLA) in a population sample of adults. SETTING: UK-wide interview survey (excluding Northern Ireland and the Scottish Isles). PARTICIPANTS: 759 adults (439 women, 320 men) aged 18-90 years (mean age _ 47.6 years) selected using random location sampling. MAIN OUTCOME MEASURES: Functional health literacy, self-rated health, fruit and vegetable consumption, physical exercise and smoking. RESULTS: We found that 11.4% of participants had either marginal or inadequate health literacy. Multivariable logistic regression analysis indicated that the risk of having limitations in health literacy increased with age (adjusted odds ratio 1.04; 95% confidence interval 1.02 to 1.06), being male (odds ratio _ 2.04; 95% confidence interval 1.16 to 3.55), low educational attainment (odds ratio _ 7.46; 95% confidence interval 3.35 to 16.58) and low income (odds ratio _ 5.94; 95% confidence interval 1.87 to 18.89). In a second multivariable logistic regression analysis, every point higher on the health literacy scale increased the likelihood of eating at least five portions of fruit and vegetables a day (odds ratio _ 1.02; 95% confidence interval 1.003 to 1.03), being a non-smoker (odds ratio _ 1.02; 95% confidence interval 1.0003 to 1.03) and having good self-rated health (odds ratio _ 1.02; 95% confidence interval 1.01 to 1.04), independently of age, education, gender, ethnicity and income. CONCLUSIONS: The results encourage efforts to monitor health literacy in the British population and examine associations with engagement with preventative health behaviours.     

The development of a culturally sensitive educational video: How to facilitate informed decisions on cervical cancer screening among Turkish‐ and Moroccan‐Dutch women

BackgroundIn the Netherlands, all women aged 30–60 years are invited to participate in the national cervical cancer screening programme, which is aimed at early detection and treatment of precancerous lesions. One fourth of the Dutch population has a migration background, with Turkish and Moroccan immigrants being the largest immigrant populations. Turkish‐ and Moroccan‐Dutch women show lower screening participation rates and a higher incidence of cervical cancer, compared to native Dutch women. Since current information materials are not tailored to these women''s needs, we developed a short culturally sensitive educational video to facilitate informed decision‐making for cervical cancer screening among Turkish‐ and Moroccan‐Dutch women. This article describes the development process of this video and the lessons learned.MethodsUsing the Entertainment–Education communication strategy, we collaborated with an interdisciplinary team of Turkish‐ and Moroccan‐Dutch women, researchers, public health experts, and creative media professionals. We developed the video following the different stages of the Media Mapping model: Orientation, Crystallization, Design/Production, Implementation, and Dissemination. Each stage is described in the paper.ResultsThe video was developed in Moroccan‐Arabic, ‐Berber and Turkish, and emphasized three main themes: (1) more certainty about having cervical (pre)cancer and the possibility to prevent treatment, surgery, or premature death, and because of this, being there for the children, (2) according to the Islam, a woman should take good care of her health, and (3) anxiety, shame, and privacy.ConclusionsA short culturally sensitive educational video, delivered as part of a larger intervention together with the current information brochure, was developed based on theory and grounded in the needs of Turkish‐ and Moroccan‐Dutch women. The value and effectiveness of this intervention to facilitate informed cervical cancer screening decisions are evaluated in a randomised controlled trial.Patient or Public ContributionWe collaborated with Turkish‐ and Moroccan‐Dutch women during the development process of a short culturally sensitive educational video. Turkish‐ and Moroccan‐Dutch women were also invited to watch the raw footage to verify whether the content and presentation matched their needs and requirements.     

Conceptualisations of positive mental health and wellbeing among children and adolescents in low‐ and middle‐income countries: A systematic review and narrative synthesis

BackgroundMental illnesses are the leading causes of global disease burden. The impact is heightened in low‐ and middle‐income countries (LMICs) due to embryonic care systems and extant barriers to healthcare access. Understanding children and adolescents'' conceptualisations of mental health wellbeing in these settings is important to optimize health prevention and promotion initiatives.ObjectiveTo systematically review and synthesize children and adolescents'' conceptualisations and views of mental health and wellbeing in LMICs.DesignTen databases were systematically searched from inception to July 2020 and findings from included studies were synthesized.ResultsTwenty papers met eligibility criteria comprising qualitative, quantitative and mixed methods studies. Children and adolescents identified aspects of mental health and wellbeing, including positive affect and outlook and having sufficient personal resources to face daily challenges. Identified factors recognized the importance of activating both kin and lay networks in supporting and maintaining wellbeing. Conceptualisations of mental health and wellbeing were varied and influenced by culture, developmental stage and gender.Discussion and ConclusionsIrrespective of environmental and sociocultural influences on concepts of wellbeing and mental health, children and adolescents in LMICs can conceptualise these constructs and identify how they pursue positive mental health and wellbeing important for developing age and culture‐appropriate community mental health strategies. Our review highlights the need to extend inquiry to wider developmental stages and both across and within specific populations in LMICs.Patient and Public InvolvementInitial results were presented at stakeholder workshops, which included children, adolescents, parents and health professionals held in Indonesia in January 2019 to allow the opportunity for feedback.     

Trends in the psychosocial and mental health of HIV‐positive women in China from 2015 to 2020: Results from two cross‐sectional surveys

BackgroundThe human immunodeficiency virus (HIV) continues to be one of the major public health challenges in the world. Despite the advancement in medication and changes in views towards HIV in Chinese society, little is known about the changes in the psychosocial and mental health of HIV‐positive women in recent years.ObjectivesThe present study examined the change in depression, anxiety, stigma, relationship with the child, intimacy with a partner, and social support from family, friends, and health professionals, for HIV‐positive women in China from 2015 to 2020.MethodsTwo cross‐sectional surveys were conducted in 2015 and 2020, and 429 and 382 HIV‐positive women were recruited from the Women''s Health Department in Yunnan and Guangxi, China between November 2015 to May 2016, and November 2019 to January 2020, respectively.ResultsAfter controlling for significant sociodemographic variables, participants recruited in 2019–2020 had significantly lower levels of depression and anxiety and higher scores on emotional and tangible support from friends. On the other hand, they had lower scores in intimacy with partners and emotional and tangible support from family. No significant changes were found in stigma, relationship with the child, and support from health professionals.ConclusionResults provide important information on the changes in psychosocial and mental health, which offer insights into the design of interventions to promote psychosocial and mental health among HIV‐positive women in China.Patient or Public ContributionHIV‐positive women contributed to the data of this study. Health care professionals were involved in the discussion of the methods and results.     

The impact of health‐related supports in senior housing on ambulance transfers and visits to emergency departments: The Right Care,Right Place,Right Time Project

ObjectiveTo test the impact of placing a wellness team (nurse and social worker) in senior housing on ambulance transfers and visits to emergency departments over 18 months.Data sources/study settingIntervention sites included seven Boston‐area buildings, with five buildings at comparable settings acting as controls. Data derive from building‐level ambulance data from emergency responders; building‐level Medicare claims data on emergency department utilization; and individual‐level baseline assessment data from participants in the intervention (n = 353) and control (n = 208) sites.Study designWe used a pre/postdifference in difference quasi‐experimental design applying several analytic methods. The preintervention period was January 2016‐March 2017, while the intervention period was July 2017‐December 2018.Data collection/extraction methodsEmergency responders provided aggregate transfer data on a daily basis for intervention and control buildings; the Quality Improvement Organization provided quarterly aggregate data on emergency department visit rates; and assessment data came from a modified Vitalize 360 assessment and coaching tool.Principal findingsThe study found an 18.2% statistically significant decline in ambulance transfers in intervention buildings, with greater declines in buildings that had fewer services available at baseline, compared to other intervention sites. Analysis of Medicare claims data, adjusted for the proportion of residents over 75 per building, found fewer visits to emergency departments in intervention buildings.ConclusionsHealth‐related supports in senior housing sites can be effective in reducing emergency transfers and visits to emergency departments.     

Reluctant educators and self‐advocates: Older trans adults’ experiences of health‐care services and practitioners in seeking gender‐affirming services

BackgroundTrans‐identifying individuals experience unique barriers and challenges in negotiating health‐care systems due to the cisnormative attitudes and practices which obstruct the receipt of trans‐inclusive care. To date, there has been little exploration of older trans consumers’ experiences of contemporary health‐care services when seeking to transition medically in later life.ObjectivesQualitative findings are presented from a study of trans ageing and trans‐related health and social care needs in Wales, UK (2016‐18). The objectives are to (1) examine supportive and obstructive points of interaction with health‐care professionals, and (2) identify key learning messages for improving trans‐related health care from the perspectives of trans‐identifying adults in later life.DesignTrans‐identifying participants self‐selected to take part in two interviews—a life‐history interview and a semi‐structured interview. Interview data were analysed thematically using the framework method approach.Setting and participantsThis paper focuses on the accounts of 19 participants (50‐74 years of age) who identified as trans and were seeking to transition medically in mid‐ to later life.ResultsFindings indicate how older trans patients are positioned as reluctant educators for GPs in primary care settings and illustrate the transphobic practices and cisnormative assumptions encountered across health‐care interactions and systems that impede their journey of transitioning in later life.Discussion and conclusionsMessages from this study speak to the importance of improving professionals’ knowledge of gender identity diversity across the life course and making changes at a systemic level in redressing cisnormative assumptions and systems that reinforce inequities on the basis of gender identity.     

COVID‐19: The Time for Collaboration Between Long‐Term Services and Supports,Health Care Systems,and Public Health Is Now

Policy Points

• To address systemic problems amplified by COVID‐19, we need to restructure US long‐term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near‐term and long‐term policy solutions.
• Seven near‐term policy recommendations include requiring the uniform public reporting of COVID‐19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations.
• Long‐term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age‐friendly public health system.

ContextThe heavy toll of COVID‐19 brings the failings of the long‐term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID‐19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long‐term disinvestment and neglect of state‐ and local‐level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.MethodsWe analyze several impacts of the COVID‐19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states’ fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.FindingsWe propose seven near‐term actions that US policymakers could take: implementing a uniform public reporting of COVID‐19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age‐friendly public health system.ConclusionsCOVID‐19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.     

Health‐care professionals’ assessment of a person‐centred intervention to empower self‐management and health across chronic illness: Qualitative findings from a process evaluation study

BackgroundPerson‐centred care (PCC) empowers patients to manage their chronic illness and promote their health in accordance with their own beliefs, values and preferences. Drawing on health‐care professional''s (HCP’s) experiences implementing an empowerment‐focused, person‐centred intervention called the Bodyknowledging Program (BKP), we undertook a process evaluation that aimed to assess the impact on patient health and well‐being.MethodsWe used individual in‐depth interviews and semi‐structured focus groups comprising n = 8 interprofessional HCP who facilitated intervention sessions with n = 58 patients situated in Norwegian specialist care sites. Content analysis was used to analyse the data and summarize major themes.ResultsHealth‐care professional interviews revealed four main ways in which the intervention operated in support of health‐related patient outcomes: (i) addressing the whole person; (ii) hope and affirmation; (iii) expanding recovery; and (iv) social support and revitalized relationships. The intervention provided new tools for patients to understand the social, emotional and physical impact of their illness. Health‐care professional reported new insights to facilitate patient engagement and to promote patients’ health.ConclusionsThe Bodyknowledging Program facilitated patient engagement through the promotion of patient‐centred care while developing the patients’ ability to exploit their own resources for effectively managing their health within illness. The process evaluation supported the underlying theoretical basis of the intervention and was suggestive of its potential transferability elsewhere.     

Living with Chronic Illness Scale: International validation through the classic test theory and Rasch analysis among Spanish‐speaking populations with long‐term conditions

BackgroundThe Living with Chronic Illness (LW‐CI) Scale is a comprehensive patient‐reported outcome measure that evaluates the complex process of living with long‐term conditions.ObjectiveThis study aimed to analyse the psychometric properties of the LW‐CI scale according to the classic test theory and the Rasch model among individuals living with different long‐term conditions.DesignThis was an observational, international and cross‐sectional study.MethodsA total of 2753 people from six Spanish‐speaking countries living with type 2 diabetes mellitus, chronic obstructive pulmonary disease, chronic heart failure, Parkinson''s disease, hypertension and osteoarthritis were included. The acceptability, internal consistency and validity of the LW‐CI scale were analysed using the classical test theory, and fit to the model, unidimensionality, person separation index, item local independency and differential item functioning were analysed using the Rasch model.ResultsCronbach''s α for the LW‐CI scale was .91, and correlation values for all domains of the LW‐CI scale ranged from .62 to .68, except for Domain 1, which showed correlation coefficients less than .30. The LW‐CI domains showed a good fit to the Rasch model, with unidimensionality, item local independency and moderate reliability providing scores in a true interval scale. Except for two items, the LW‐CI scale was free from bias by long‐term condition type.DiscussionAfter some adjustments, the LW‐CI scale is a reliable and valid measure showing a good fit to the Rasch model and is ready for use in research and clinical practice. Future implementation studies are suggested.Patient and Public ContributionPatient and public involvement was conducted before this validation study ‐ in the pilot study phase.     

Children's perspectives and experiences of the COVID‐19 pandemic and UK public health measures

BackgroundThe COVID‐19 pandemic has had profound impacts on how we live our lives; yet, the implications for children and the effects on children''s everyday lives have been relatively underacknowledged. Understanding children''s views on COVID‐19 and related restrictions on their lives provides an important opportunity to understand how children have responded to the pandemic, including the impacts on their social and emotional well‐being.ObjectiveThis study explored the experiences and perspectives of children in relation to the COVID‐19 pandemic and related restrictions on everyday life.MethodA qualitative study using semistructured online interviews with participatory drawings was undertaken between May and July 2020. Eighteen children from England and Wales, aged 7–11 years, participated in interviews.FindingsThemes included children''s reflections on (1) COVID‐19 as a deadly contagion; (2) fears and sadness and (3) social responsibility and opportunities to respond positively.ConclusionsYoung children offer insightful reflections on their experiences during the first wave of the COVID‐19 pandemic in the United Kingdom. Children and young people''s perspectives must be considered in future public health discourse.Patient or Public ContributionThis work was informed by conversations with my own three primary school‐aged children and the children of friends. A formal Patient and Public Involvement (PPI) group was not established due to the speed with which the project was undertaken. Any future research in this area would benefit from formal PPI in the design, methods and questions.     

Advancing understanding of influences on cervical screening (non)‐participation among younger and older women: A qualitative study using the theoretical domains framework and the COM‐B model

BackgroundEffective screening can prevent cervical cancer, but many women choose not to attend their screening tests.ObjectiveThis study aimed to investigate behavioural influences on cervical screening participation using the Theoretical Domains Framework (TDF) and COM‐B models of behaviour change.DesignA qualitative study and semistructured phone interviews were conducted with women invited for routine screening tests within the national cervical screening programme in Ireland.Setting and ParticipantsForty‐eight women aged 25–65 years were recruited from the national screening register.ResultsSeven core themes were identified that mapped to three COM‐B components and 11 TDF domains: (1) knowledge of cervical cancer and screening, (2) coping with smear tests, (3) competing motivational processes—automatic and reflective, (4) cognitive resources, (5) role of social support, (6) environmental influences and (7) perceputal and practical influences. A range of knowledge about screening, perceived risk of cervical cancer and human papillomavirus infection was evident. Factors that influenced screening behaviours may be hierarchical—some were assigned greater importance than others. Positive screening behaviours were linked to autonomous motivation. Deficits in physical and psychological capability (inadequate coping skills) were barriers to screening, while physical and social opportunity (e.g. healthcare professional ‘champions’) could facilitate participation. Older women raised age‐related issues (e.g. screening no longer necessary) and had more negative attitudes to screening, while younger women identified practical barriers.ConclusionsThis study provides insight into screening participation and will aid development of theoretically informed interventions to increase uptake.Patient or Public ContributionWomen invited for screening tests through the national screening programme were interviewed. A Public & Patient Involvement (PPI) Panel, established to provide input into all CERVIVA research projects, advised the research team on recruitment materials and were given the opportunity to review and comment on the interview topic guide. This panel is made up of six women with various cervical screening histories and experiences.     

The one‐year impact of accountable care networks among Washington State employees

ObjectiveTo estimate the impact of a new, two‐sided risk model accountable care network (ACN) on Washington State employees and their families.Data Sources/Study SettingAdministrative data (January 2013‐December 2016) on Washington State employees.Study DesignWe compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0‐5, 6‐18, 19‐26, 18‐64).Data Collection/Extraction MethodsWe used difference‐in‐difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children.Principal FindingsWe estimate a 1‐2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: −1.8, P < .01; age 0‐5: −1.2, P = .07; age 6‐18: −1.2, P = .06; age 19‐26; −1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19‐26 were also responsive with inpatient admissions declines (−0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures.ConclusionsWashington''s state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.     

Perceptions,needs and preferences of chronic disease self‐management support among men experiencing homelessness in Montreal

ObjectiveThis study explored the perceptions, needs and preferences for chronic disease self‐ management (SM) and SM support among men experiencing homelessness.DesignA qualitative interpretive approach was used. Eighteen semi‐structured interviews were conducted with 18 homeless men with a chronic disease at an emergency overnight shelter of Welcome Hall Mission (WHM) in Montreal, Quebec. Interviews were audio‐recorded, transcribed verbatim and thematically analysed.ResultsThe majority of participants perceived SM as important, described confidence to perform medical SM behaviours, and creatively adapted their SM behaviours to homelessness. Emotional SM was described as most challenging, as it was intertwined with the experience of homelessness. Three vulnerable groups were identified: (a) those with no social networks, (b) severe physical symptoms and/or (c) co‐morbid mental illness. The preferred mode of delivery for SM support was through consistent contacts with health‐care providers (HCPs) and peer‐support initiatives.Discussion and ConclusionsDespite competing demands to fulfill basic needs, participants valued chronic disease SM and SM support. However, SM support must address complex challenges relating to homelessness including emotional SM, multiple vulnerabilities and barriers to forming relationships with HCPs.