Community Coalition Building and Human-Centered Design Strategies to Advance Homeless Health Systems: A Case Study from Rural North Carolina

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article provided a case study that is highly relevant for several aspects of public health. It is clearly structured and presents an innovative approach on various levels.

One thing that could be improved is the section on materials and methods. It reads more than a narrative/story about the context and progress of the overall project, which per se reads interesting, however, clarity of the implemented set of methods is a bit affected by this writing style. This could be made more clear.

Author Response

Reviewer 1:

Reviewer 1: One thing that could be improved is the section on materials and methods. It reads more than a narrative/story about the context and progress of the overall project, which per se reads interesting, however, clarity of the implemented set of methods is a bit affected by this writing style. This could be made more clear. We removed lines 121 - 130 in the original document as this was narrative writing and not supportive of the methods or materials. We renamed Methods subsection 2.2 to Stakeholder Engagement and Co-design Activities

Reworked subsection 2.2 under new title with removal of previous description and inserting updated concise information. 

Reviewer 2 Report

Comments and Suggestions for Authors

In my opinion, the article is difficult to review because it lacks scientific merit. It lacks a purpose, methods (case study method), research questions, and hypotheses. It describes a rather original social project, describing how it was constructed. This is valuable for social welfare work and local governments. 

The evaluation criteria and structure of the project report vary. However, the report lacks hard data, such as the number of people vaccinated, the number of camps visited, and the number of people who emerged from homelessness after the project's completion. It also lacks a comprehensive description of the homeless community (health insurance, employment/unemployment, adult status).

 

Author Response

Reviewer 2: In my opinion, the article is difficult to review because it lacks scientific merit. It lacks a purpose, methods (case study method), research questions, and hypotheses. It describes a rather original social project, describing how it was constructed. This is valuable for social welfare work and local governments.

The evaluation criteria and structure of the project report vary. However, the report lacks hard data, such as the number of people vaccinated, the number of camps visited, and the number of people who emerged from homelessness after the project's completion. It also lacks a comprehensive description of the homeless community (health insurance, employment/unemployment, adult status). - The article has had a major uplift in revisions, taking into consideration each reviewers comments and making adjustments accordingly. This report is based on systems change and the outcomes of implementation processes and community initiative momentum for systems change. We have made clearer language through the article to ensure audience members are understanding the project report purpose, results, and discussion.

Reviewer 3 Report

Comments and Suggestions for Authors

Comments and Suggestions for Authors
The manuscript presents and discusses an interesting case study of a pilot project implemented in a rural area to improve the local Homeless Health System. Overall, the paper is well aligned with the journal’s scope, and, in my view, it requires only minimal revisions concerning the following aspects:
1. Introduction
• The authors should carefully verify the references cited in this paragraph. Some citations
appear to be inconsistent with the statements they are meant to support. For instance, the
authors cited references [5] and [6] in the following sentence: “Burke County in western North
Carolina is a largely rural area spanning approximately 506 square miles with a population
of 88,338 [5]. Like many rural Appalachian communities, the county faces economic and
infrastructural conditions that shape access to care, including lower median household
income, limited transportation infrastructure, and a fragmented healthcare safety net. Nearly
13% of residents live below the federal poverty line. Educational and employment
opportunities lag state averages, contributing to increased vulnerability among medically
underserved populations [5,6]. However, the corresponding items in the references list do not
seem directly relevant to the claim.
• Moreover, the authors should include appropriate references for the factual statements. For
example, the authors did not cite any source for this sentence: “Housing instability and
unsheltered homelessness have become increasingly visible concerns within the country.”
4. Results
• The authors should provide a more detailed description of Table 1. This table contains
substantial information, but it is neither explained nor interpreted in the text. Currently,
sections 4.1 and 4.2 do not explicitly mention Table 1. The authors should therefore clarify
why it is included and explain which aspects the table is intended to highlight. Moreover, I
suggest that the authors revise Table 1 to improve its readability and integration into the
Results narrative.
5. Discussion
• Finally, it would be interesting to know whether similar projects (with the same aims and
methodologies) have been implemented elsewhere. If relevant examples exist, I encourage
the authors to mention them and provide useful comparisons.

Author Response

The authors should carefully verify the references cited in this paragraph. Some citations
appear to be inconsistent with the statements they are meant to support. For instance, the
authors cited references [5] and [6] in the following sentence: “Burke County in western North
Carolina is a largely rural area spanning approximately 506 square miles with a population
of 88,338 [5]. Like many rural Appalachian communities, the county faces economic and
infrastructural conditions that shape access to care, including lower median household
income, limited transportation infrastructure, and a fragmented healthcare safety net. Nearly
13% of residents live below the federal poverty line. Educational and employment
opportunities lag state averages, contributing to increased vulnerability among medically
underserved populations [5,6]. However, the corresponding items in the references list do not
seem directly relevant to the claim. - We changed the citation for this paragraph to reflect the Census Bureau data used within this paragraph. Removed previous citation #6 as it did not meet the need of the paper.

 

Reviewer 3:

Moreover, the authors should include appropriate references for the factual - We have updated the references for the entire manuscript, including attention to the Introduction paragraph. New and removed references from previous versions are seen in the reference list. With accurate data and citations to support statements.

 

Reviewer 3:

Reviewer 3: The authors should provide a more detailed description of Table 1. This table contains
substantial information, but it is neither explained nor interpreted in the text. Currently,
sections 4.1 and 4.2 do not explicitly mention Table 1. The authors should therefore clarify
why it is included and explain which aspects the table is intended to highlight. Moreover, I
suggest that the authors revise Table 1 to improve its readability and integration into the
Results narrative. - We were able to enhance section 4.3 to include a reference to Table 1 and to uplift the findings mentioned within the table to be more explanatory.

 

Reviewer 3:

Finally, it would be interesting to know whether similar projects (with the same aims andmethodologies) have been implemented elsewhere. If relevant examples exist, I encourage
the authors to mention them and provide useful comparisons - This is completed within the discussion section where 3 new examples were compared.  

 

Reviewer 4 Report

Comments and Suggestions for Authors

Overall assessment and recommendation

The manuscript presents a relevant and timely contribution to the field of public health and healthcare for people experiencing homelessness, especially in rural contexts, where the available evidence remains limited. The case analyzed has applied relevance and potential for transferability due to its cross-sectoral approach, the use of community outreach strategies, and the incorporation of co-design processes. However, before publication, the manuscript requires revisions aimed at strengthening the theoretical integration, clarifying the methodological approach, and presenting the results in a more analytical way, better supported by empirical evidence. Therefore, my recommendation is to accept the manuscript subject to revisions.

 

1. Theoretical consistency and updating of the literature

The general framework of the manuscript, systems thinking, community coalition building, and human-centered design, is relevant and consistent with the object of study. However, its analytical integration remains insufficient. Systems thinking is mentioned as a guiding principle, but it is not clearly translated into the analysis of system dynamics, interdependencies, bottlenecks, feedback loops, or mechanisms of change. Similarly, Community Coalition Action Theory is presented mainly descriptively, without showing with sufficient precision how its dimensions structure the analysis or help interpret the results.

It would also be advisable to problematize the use of human-centered design further. The manuscript notes the participation of stakeholders with lived experience, but it does not sufficiently specify their actual degree of influence in decision-making, the feedback mechanisms, or the safeguards against merely consultative participation. This point is important because co-design should not be presented only as a participatory technique, but as a process that redistributes decision-making capacity in the design of the intervention.

Likewise, the manuscript should engage more deeply with recent literature on health and homelessness. Although mobile and street medicine interventions can improve access, trust, and linkage to services, their structural impact is limited if they are not integrated into broader systems of care, social protection, and housing policies. In this regard, the article would gain solidity if it situated its contribution within the evidence on healthcare access, social determinants of health, service integration, and participation of people with lived experience.

The authors are not necessarily expected to incorporate all of the following references. They are suggested as illustrative examples of relevant literature that could help strengthen the theoretical and empirical framing of the manuscript:

Aubry, T., Bloch, G., Brcic, V., Saad, A., Magwood, O., Abdalla, T., … & Tugwell, P. (2020). Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: A systematic review. The Lancet Public Health, 5(6), e342–e360. https://doi.org/10.1016/S2468-2667(20)30055-4

Baggett, T. P., O’Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet health care needs of homeless adults: A national study. American Journal of Public Health, 100(7), 1326–1333. https://doi.org/10.2105/AJPH.2009.180109

Baxter, A. J., Tweed, E. J., Katikireddi, S. V., & Thomson, H. (2019). Effects of housing first approaches on health and well-being of adults who are homeless or at risk of homelessness: Systematic review and meta-analysis. Journal of Epidemiology & Community Health, 73(5), 379–387. https://doi.org/10.1136/jech-2018-210981

Hwang, S. W., & Burns, T. (2014). Health interventions for people who are homeless. The Lancet, 384(9953), 1541–1547. https://doi.org/10.1016/S0140-6736(14)61133-8

Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12, 18. https://doi.org/10.1186/1475-9276-12-18

Magwood, O., Salvalaggio, G., Beder, M., Kendall, C., Kpade, V., Daghmach, W., … & Tugwell, P. (2020). The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews. PLoS ONE, 15(1), e0227298. https://doi.org/10.1371/journal.pone.0227298

U.S. Department of Housing and Urban Development. (2024). The 2024 Annual Homeless Assessment Report (AHAR) to Congress. https://www.huduser.gov/portal/sites/default/files/pdf/2024-AHAR-Part-1.pdf

2. Methodology

The methodological design is appropriate for a project report or practice-based report, but it requires greater precision in order to assess the credibility and traceability of the analysis. The manuscript mentions internal documentation, meeting records, planning materials, co-design artifacts, and implementation reports, but it does not sufficiently specify the volume, typology, or selection criteria for these materials. It would be advisable to indicate, at minimum, the approximate number of meetings, documents reviewed, time period covered, and inclusion criteria.

The human-centered design process also requires greater detail. Although the participation of more than 40 community stakeholders and 10 people with lived experience of homelessness or housing instability is reported, the recruitment mechanisms, the number and duration of sessions, the specific role of each group, and the way in which their contributions influenced final decisions are not clearly described.

Likewise, the thematic analysis should be presented with greater transparency. It would be important to specify the coding procedures, the number of researchers involved, the phases of analysis, the development of categories, the resolution of discrepancies, and possible validation strategies. Given that much of the data comes from internal documentation generated by the project partners themselves, the manuscript should explain how potential confirmation biases were addressed.

Finally, although the study is presented as a practice improvement activity rather than human subjects research, it would be advisable to specify the ethical procedures applied in the co-design process, especially regarding consent, confidentiality, compensation, and a trauma-informed approach.

3. Results

The results section clearly describes the evolution of the initiative and the main changes produced in cross-sectoral collaboration, service design, piloting of a mobile women’s health unit, and organizational learning. However, the results are at times presented more as an implementation narrative than as an analytical presentation of findings.

In particular, the manuscript states that the initiative produced “measurable changes,” but it does not specify which indicators support that statement or what documentary evidence supports each result. It would be advisable to qualify the more conclusive statements or accompany them with specific indicators, empirical examples, or evidence drawn from the materials analyzed.

It would also be advisable to show more clearly how the voice of people with lived experience was incorporated. The manuscript notes that they emphasized the importance of trust, continuity, and relationships in care, but it does not include brief quotations, examples from empathy maps, emerging categories, or excerpts from co-design materials that would allow readers to directly assess that contribution.

Table 1 contains useful information, but it needs reorganization. It combines questions, indicators, sources, and findings in a somewhat heterogeneous way, and some results appear as general observations rather than systematized data. In addition, certain critical findings, modest demand, limited community awareness, scheduling and transportation problems, lack of laboratory services, and the need to improve communication among partners, should receive greater analytical attention, as they directly affect the feasibility of the model.

Finally, it would be advisable to distinguish more precisely between process outcomes, implementation outcomes, and health outcomes. The manuscript offers valuable findings on coalition development, co-design, and initial feasibility, but it does not present clinical, longitudinal, or population-level impact outcomes. This distinction should be made explicit in order to avoid overinterpretation.

 

Overall, the manuscript addresses a relevant applied experience with high practical value, but it requires revision aimed at strengthening its theoretical density, methodological transparency, and analytical precision. With these improvements, the article could constitute a valuable contribution to the study of and intervention in public health with people experiencing homelessness in rural contexts.

Author Response

In order to address the reviewer's point on the decision making of the residents we added a paragraph on page four that addressed our initial intentions and the experience and training provided to help ensure that the engagements with residents were conducted as true co-creators and not just consultants. On Page 5 we included more detail on how the second gender specific focus groups resulted in insights that directly impacted the development of the pilot

 

Reviewer 4:

Reviewer 4: The general framework of the manuscript, systems thinking, community coalition building, and human-centered design, is relevant and consistent with the object of study. However, its analytical integration remains insufficient. Systems thinking is mentioned as a guiding principle, but it is not clearly translated into the analysis of system dynamics, interdependencies, bottlenecks, feedback loops, or mechanisms of change. Similarly, Community Coalition Action Theory is presented mainly descriptively, without showing with sufficient precision how its dimensions structure the analysis or help interpret the results. - We have updated this section entirely with incorporation of reviewer 4 and Reviewer 1’s comments regarding methods and material section. Subsection 2.3 was rewritten with new resources to help elaborate on the translation of frameworks to help guide analysis.

 

Reviewer 4:

Reviewer 4: although the study is presented as a practice improvement activity rather than human subjects research, it would be advisable to specify the ethical procedures applied in the co-design process, especially regarding consent, confidentiality, compensation, and a trauma-informed approach - We expanded on this section to include additional details.

 

Reviewer 4:

Reviewer 4: The human-centered design process also requires greater detail. Although the participation of more than 40 community stakeholders and 10 people with lived experience of homelessness or housing instability is reported, the recruitment mechanisms, the number and duration of sessions, the specific role of each group, and the way in which their contributions influenced final decisions are not clearly described. - This is addressed further in the Methods section 2.2

 

Reviewer 4:

Reviewer 4: It would also be advisable to problematize the use of human-centered design further. The manuscript notes the participation of stakeholders with lived experience, but it does not sufficiently specify their actual degree of influence in decision-making, the feedback mechanisms, or the safeguards against merely consultative participation. This point is important because co-design should not be presented only as a participatory technique, but as a process that redistributes decision-making capacity in the design of the intervention. - This is addressed further in Methods section 2.2, 2.3, 2.5, and Implementation phase 4.

 

Reviewer 4:

Reviewer 4: the results are at times presented more as an implementation narrative than as an analytical presentation of findings. - The results section has been rewritten based on the reviewers feedback. The style has changed to less storytelling and more outcomes based.

 

Reviewer 4:

Reviewer 4: Finally, it would be advisable to distinguish more precisely between process outcomes, implementation outcomes, and health outcomes. The manuscript offers valuable findings on coalition development, co-design, and initial feasibility, but it does not present clinical, longitudinal, or population-level impact outcomes. This distinction should be made explicit in order to avoid overinterpretation. - We added a clear entry passage to the results section to ensure audience members understand the results section. This is not a clinical outcomes discussion, rather a case study to explain collective impact for building systems for a common goal rather than silos.  

 

Reviewer 4:

Reviewer 4: the manuscript states that the initiative produced “measurable changes,” but it does not specify which indicators support that statement or what documentary evidence supports each result. It would be advisable to qualify the more conclusive statements or accompany them with specific indicators, empirical examples, or evidence drawn from the materials analyzed. - We shifted away from “Measurable changes” to “process and implementation outcomes as this terminology reflects more of the qualitative, community shift each activity is built on.

 

Reviewer 4:

Reviewer 4: Table 1 contains useful information, but it needs reorganization. It combines questions, indicators, sources, and findings in a somewhat heterogeneous way, and some results appear as general observations rather than systematized data. In addition, certain critical findings, modest demand, limited community awareness, scheduling and transportation problems, lack of laboratory services, and the need to improve communication among partners, should receive greater analytical attention, as they directly affect the feasibility of the model. - We want to acknowledge the reviewers comments and appreciate the feedback. Under this set of revision, we were not able to address this review. We would like to carry forward this revision to the secondary round of peer review to allow further critical appraisal of the table.

 

Reviewer 4:

Reviewer 4: Likewise, the manuscript should engage more deeply with recent literature on health and homelessness. Although mobile and street medicine interventions can improve access, trust, and linkage to services, their structural impact is limited if they are not integrated into broader systems of care, social protection, and housing policies. In this regard, the article would gain solidity if it situated its contribution within the evidence on healthcare access, social determinants of health, service integration, and participation of people with lived experience.

The authors are not necessarily expected to incorporate all of the following references. They are suggested as illustrative examples of relevant literature that could help strengthen the theoretical and empirical framing of the manuscript: - We reviewed every reference and compared to its use within the article. A complete revision and use of sources was completed.

Aubry, T., Bloch, G., Brcic, V., Saad, A., Magwood, O., Abdalla, T., … & Tugwell, P. (2020). Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: A systematic review. The Lancet Public Health, 5(6), e342–e360. https://doi.org/10.1016/S2468-2667(20)30055-4

 

Baggett, T. P., O’Connell, J. J., Singer, D. E., & Rigotti, N. A. (2010). The unmet health care needs of homeless adults: A national study. American Journal of Public Health, 100(7), 1326–1333. https://doi.org/10.2105/AJPH.2009.180109

 

Baxter, A. J., Tweed, E. J., Katikireddi, S. V., & Thomson, H. (2019). Effects of housing first approaches on health and well-being of adults who are homeless or at risk of homelessness: Systematic review and meta-analysis. Journal of Epidemiology & Community Health, 73(5), 379–387. https://doi.org/10.1136/jech-2018-210981

 

Hwang, S. W., & Burns, T. (2014). Health interventions for people who are homeless. The Lancet, 384(9953), 1541–1547. https://doi.org/10.1016/S0140-6736(14)61133-8

 

Levesque, J. F., Harris, M. F., & Russell, G. (2013). Patient-centred access to health care: Conceptualising access at the interface of health systems and populations. International Journal for Equity in Health, 12, 18. https://doi.org/10.1186/1475-9276-12-18

 

Magwood, O., Salvalaggio, G., Beder, M., Kendall, C., Kpade, V., Daghmach, W., … & Tugwell, P. (2020). The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews. PLoS ONE, 15(1), e0227298. https://doi.org/10.1371/journal.pone.0227298

 

U.S. Department of Housing and Urban Development. (2024). The 2024 Annual Homeless Assessment Report (AHAR) to Congress. https://www.huduser.gov/portal/sites/default/files/pdf/2024-AHAR-Part-1.pdf