The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis

Pain in People Experiencing Homelessness: A Scoping Review

BACKGROUND

Prior work suggests that people experiencing homelessness (PEH) are at heightened risk for developing pain and have a uniquely burdensome pain experience.

PURPOSE

The aim of this scoping review was to map the current peer-reviewed, published literature on the pain experience of PEH.

METHODS

In accordance with the US Annual Homeless Assessment Report, we defined homelessness as lacking shelter or a fixed address within the last year. We conceptualized the pain experience via a modified version of the Social Communication Model of Pain, which considers patient, provider, and contextual factors. Published articles were identified with CINHAL, Embase, PubMed, PsycINFO, and Web of Science databases.

RESULTS

Sixty-nine studies met inclusion criteria. Studies revealed that PEH have high rates of pain and experience high levels of pain intensity and interference. Substantially fewer studies examined other factors relevant to the pain experience, such as self-management, treatment-seeking behaviors, and pain management within healthcare settings. Nonetheless, initial evidence suggests that pain is undermanaged in PEH.

CONCLUSIONS

Future research directions to understand pain and homelessness are discussed, including factors contributing to the under-management of pain. This scoping review may inform future work to develop interventions to address the specific pain care needs of PEH.

A Network Analysis of the Relationship Between Mental and Physical Health in Unsheltered Homeless Persons in Los Angeles County

Homelessness is a public health crisis both nationally, in the United States, and internationally. Nevertheless, due to the hidden vulnerabilities of persons who are without shelter, little is known about their experiences during periods of homelessness. The present research adopts a network approach that conceptualizes how the major risk factors of homelessness interact, namely substance abuse problems, poor mental health, disability, and exposure to physical or sexual violence by an intimate partner. Our analysis draws on a large demographic survey of over 5,000 unsheltered homeless persons conducted in 2017 by the Los Angeles Homeless Services Authority. We estimated a network structure for 12 survey items tapping individual risk using the graphical least absolute shrinkage and selection operator algorithm. We then examined network centrality metrics and implemented a community detection algorithm to detect communities in the network. Our results indicated that mental illness and intimate partner violence (IPV) are central measures that connect all other mental and physical health variables together and that post-traumatic stress disorder and IPV are both highly affected by changes in any part of the network and, in turn, affect changes in other parts of the network. A community detection analysis derived four communities characterized by disability, sexual victimization and health, substance use, and mental health issues. Finally, a directed acyclic graph revealed that drug abuse and physical disability were key drivers of the overall system. We conclude with a discussion of the major implications of our findings and suggest how our results might inform programs aimed at homelessness prevention and intervention.

No one runs alone: Combining community-based program evaluation with photo elicitation interviewing among people experiencing homelessness

BACKGROUND

Homelessness is associated with poor physical and mental health, but social support may reduce negative health outcomes. A community-academic partnership with Back on My Feet (BoMF), an organization in Baltimore, MD serving people experiencing homelessness, used photo elicitation interviews (PEI) to explore how social interactions within program activities improved mental health among participants.

METHODS

Between October 2018 and June 2019, 29 BoMF participants were recruited. Participants were provided digital cameras and photographed what BoMF meant to them. Participants presented photographs in meetings that were audio recorded and transcribed. Thirty-three themes and 44 photographs were generated. Findings were presented at a public photo exhibit. The partnership used content analysis of transcripts to build upon participant-generated themes for peer-review publication.

RESULTS

Social interaction among BoMF participants and volunteers helped participants form new positive social networks, often for the first time, which made participants feel valued by their peers. This led to increased self-worth, a greater sense of social support and social connectedness, and confidence that participants could overcome future challenges.

CONCLUSIONS

Combining community-based research with PEI provided a nuanced understanding of the mechanisms through with BoMF's activities facilitated positive mental health among participants and was a feasible approach to program evaluation.

Identifying Predictors of Homelessness Among Adults in a Large Integrated Health System in Northern California

Introduction Homelessness contributes to worsening health and increased health care costs. There is little published research that leverages rich electronic health record (EHR) data to predict future homelessness risk and inform interventions to address it. The authors' objective was to develop a model for predicting future homelessness using individual EHR and geographic data covariates. Methods This retrospective cohort study included 2,543,504 adult members (≥ 18 years old) from Kaiser Permanente Northern California and evaluated which covariates predicted a composite outcome of homelessness status (hospital discharge documentation of a homeless patient, medical diagnosis of homelessness, approved medical financial assistance application for homelessness, and/or "homeless/shelter" in address name). The predictors were measured in 2018-2019 and included prior diagnoses and demographic and geographic data. The outcome was measured in 2020. The cohort was split (70:30) into a derivation and validation set, and logistic regression was used to model the outcome. Results Homelessness prevalence was 0.35% in the overall sample. The final logistic regression model included 26 prior diagnoses, demographic, and geographic-level predictors. The regression model using the validation set had moderate sensitivity (80.4%) and specificity (83.2%) for predicting future cases of homelessness and achieved excellent classification properties (area under the curve of 0.891 [95% confidence interval = 0.884-0.897]). Discussion This prediction model can be used as an initial triage step to enhance screening and referral tools for identifying and addressing homelessness, which can improve health and reduce health care costs. Conclusions EHR data can be used to predict chance of homelessness at a population health level.

Differences in Drug Use among Persons Experiencing Homelessness According to Gender and Nationality

The main aims of this article are to update the data related to drug and alcohol use in persons experiencing homelessness (PEH) who use shelters, and to see if there are significant differences in their drug use depending on their gender and nationality. The article presents an analysis of the interconnections between the results of drug dependence detection tools (Alcohol Use Disorders Identification Test (AUDIT), Drug Abuse Screening Test (DAST-10), Severity of Dependence Scale (SDS)) according to gender and nationality with the intention of identifying specific needs that lead to new lines of research into better approaches to homelessness. A cross-sectional, observational and analytical method was used to analyse the experiences of persons experiencing homelessness who use various shelters in the cities of Madrid, Girona, and Guadalajara (Spain). The results show that there are no gender differences in the risks of using drugs and drug addiction, but there are differences in terms of nationality for drug addiction, with Spanish nationals showing a greater tendency to develop drug addiction. These findings have significant implications, as they highlight socio-cultural and socio-educational influence as risk factors in drug addiction behaviours.

Neuropsychological functioning of homeless people in Paris: An exploratory study

Homelessness is a multifactorial issue, influenced by structural and individual factors. These factors include health status, which has been reported to be poorer among people experiencing homelessness. Although the somatic and mental health of homeless individuals has already been studied in France, to our knowledge, no research has been conducted on neuropsychological functioning in this country. Studies out with France have identified cognitive impairments as highly prevalent among homeless people, and these impairments are likely affected by local structural factors, such as healthcare access. Therefore, we conducted an exploratory study in Paris to evaluate cognition and associated factors in homeless adults. The second objective was to identify methodological specificities to consider in a future larger-scale study and for the application of the outcomes. For this exploratory phase, 14 individuals were recruited from specific services and were interviewed regarding their social, neurological, and psychiatric history, before completing a set of cognitive tests. The results showed a high diversity of profiles in terms of demographic characteristics, including being a migrant and/or illiterate. A high proportion of participants had signs of traumatic brain injury, anxiety, depressive disorders, and post-traumatic stress disorders. Most cognitive scores were in the low average of normative data. No statistical association was found between identified risk factors and cognitive performance. Future studies should consider the sociodemographic specificities of the homeless population and design appropriate measurement tools to improve the understanding of neuropsychological profiles.

The Impact of COVID-19 on Access to Resources among Individuals Experiencing Homelessness and Traumatic Brain Injury

The rates of traumatic brain injury (TBI) are higher among individuals experiencing homelessness compared with the general population. Individuals experiencing homelessness and a TBI may experience barriers to care. COVID-19 may have further impacted access to basic resources, such as food, shelter, and transportation for individuals experiencing homelessness. This study aimed to answer the following research question: What is the impact of COVID-19 on access to resources among individuals experiencing homelessness and TBI? A cross-sectional study design and purposive sampling were utilized to interview 38 English-speaking adults experiencing homelessness and who had sustained a TBI (ages 21–73) in one Colorado city. Qualitative questions related to the impact of COVID-19 were asked and qualitative analysis was used to analyze the responses. Three primary themes emerged regarding the types of resources that were restricted by COVID-19: basic/biological needs, financial needs, and a lack of connection. COVID-19 has shown the social work field the need for continued innovation and better practice standards for individuals who are not housed. For those living with a reported TBI history and experiencing homelessness, COVID-19 made it difficult to access basic services for survival.

Tinea capitis among schoolchildren in Ethiopia: A systematic review and meta analysis

BACKGROUND

Tinea capitis accounts for25 to 30% of all fungal infections, but it is often ignored because it is not life threatening in nature. It is more common among schoolchildren particularly in developing countries. Due to the presence of significant variability among the previous studies, this study was conducted to provide a pooled prevalence and associated factors of tinea capitis in Ethiopian schoolchildren.

METHOD

We conducted a systematic search in five major databases for articles similar to our topic. This review included school-based cross-sectional studies that were reported in English and conducted from 2006 through 2022. The data were extracted using Microsoft Excel and further analysis was done using StataTM Version 17.0 statistical software. Forest plots were used to assess the presence of heterogeneity with 95% confidence intervals. A random effects meta- analysis model was used to pool primary estimates. To declare the presence or absence of association, 95% confidence interval with odds ratio was used.

RESULTS

Fourteen studies with a total of 9465 schoolchildren were included. The pooled prevalence was 29.03% (95%CI: 15.37-42.71). There was observed heterogeneity, which could be explained by publication bias (P = 0.04). Family history of tinea capitis (OR: 9.18, 95%CI: 3.5-24.02), under the age of 10 years (OR: 1.65, 95%CI: 1.17-2.33) were factors increasing the development of tinea capitis among schoolchildren and schoolchildren who had hair wash at least once a week (OR: 0.31, 95%CI: 0.24-0.42) was significantly associated with reduced risk for tinea capitis.

CONCLUSION

One of the most prevalent childhood health condition in Ethiopia is tinea capitis, which affects over one in every four schoolchildren. Schoolchildren who had family history of tinea capitis and under the age of 10 years were the identified risk factors but they had hair wash at least once a week was the protective factor of tinea capitis among schoolchildren. Clinical and public engagement activities are needed to overcome the burden of the disease.

Minimal use of ICD social determinant or phenomenological codes in mental health care records

BACKGROUND

We have previously argued that psychiatric diagnosis, by focusing on pathology, minimises the role of psychosocial factors. Despite suggestions that traditional diagnosis is the only way to access treatment services, we have recommended standardised use of existing codes for possible social determinants and precise description of psychological phenomena.

AIMS

This study examines the current use of social determinant and phenomenological codes in mental health care records.

METHODS

Data provided by a local NHS Trust included 21,701 cases with a first contact date between 01 January 2015 and 01 January 2016, 4656 of whom received a primary diagnosis.

RESULTS

Overall, codes for possible social determinants were used on only 43 occasions, for 39 individuals (0.8% of the 4656 people receiving a primary diagnosis). Comparison with relevant baseline frequencies revealed a highly significant under-reporting of key social determinants. 19 cases (0.4% of 4.656) used codes for precise description of specific psychological phenomena.

CONCLUSIONS

Available ICD codes for social determinants and specific psychological phenomena are under-used in clinical practice.

Long-Term Trends in Psychiatric Emergency Services Delivered by the Boston Emergency Services Team

Rising psychiatric emergency department (ED) presentations pose significant financial and administrative burdens to hospitals. Alternative psychiatric emergency services programs have the potential to alleviate this strain by diverting non-emergent mental health issues from EDs. This study explores one such program, the Boston Emergency Services Team (BEST), a multi-channel psychiatric emergency services provider intended for the publicly insured and uninsured population. BEST provides evaluation and treatment for psychiatric crises through specialized psychiatric EDs, a 24/7 hotline, psychiatric urgent care centers, and mobile crisis units. This retrospective review examines the sociodemographic and clinical characteristics of 225,198 BEST encounters (2005-2016). Of note, the proportion of encounters taking place in ED settings decreased significantly from 70 to 58% across the study period. Findings suggest that multi-focal, psychiatric emergency programs like BEST have the potential to reduce the burden of emergency mental health presentations and improve patient diversion to appropriate psychiatric care.

Differential age-associated brain atrophy and white matter changes among homeless and precariously housed individuals compared with the general population

Background

Homeless or precariously housed individuals live with poor health and experience premature mortality compared with the general population, yet little is known about age-related brain changes among these individuals. We evaluated whether MRI measures of brain structure are differentially associated with age and selected risk factors among individuals who are homeless or precariously housed compared with a general population sample.

Methods

We compared T1-weighted and diffusion tensor imaging measures of brain macrostructure and white matter microstructure in a well-characterised sample of 312 precariously housed participants with a publicly available dataset of 382 participants recruited from the general population. We used piecewise and multiple linear regression to examine differential associations between MRI measures and between the samples, and to explore associations with risk factors in the precariously housed sample.

Results

Compared with the general population sample, older age in the precariously housed sample was associated with more whole-brain atrophy (β=-0.20, p=0.0029), lower whole-brain fractional anisotropy (β=-0.32, p<0.0001) and higher whole-brain mean diffusivity (β=0.69, p<0.0001). Several MRI measures had non-linear associations with age, with further adverse changes after age 35-40 in the precariously housed sample. History of traumatic brain injury, stimulant dependence and heroin dependence was associated with more atrophy or alterations in white matter diffusivity in the precariously housed sample.

Conclusions

Older age is associated with adverse MRI measures of brain structure among homeless and precariously housed individuals compared with the general population. Education, improvements in care provision and policy may help to reduce the health disparities experienced by these individuals.

A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States

BACKGROUND

Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement.

METHODS

Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates.

RESULTS

There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates.

CONCLUSIONS

Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

Association of physician financial incentives with primary care enrolment of adults with serious mental illnesses in Ontario: a retrospective observational population-based study

BACKGROUND

Financial incentives may improve primary care access for adults with schizophrenia or bipolar disorder (serious mental illness [SMI]). We studied the association between receipt of the SMI financial premium paid to primary care physicians and rostering of adults with SMI in different patient enrolment models (PEMs), including enhanced fee-for-service and capitation-based models with and without interdisciplinary team-based care.

METHODS

We conducted a retrospective cohort study involving Ontario adults (≥18 yr) with SMI in PEM practices, in fiscal years 2016/17 and 2017/18. Using negative binomial models, we examined relations between rostering and the primary care model and the contribution of the incentive. Similar models were developed for adults with type 1 or 2 diabetes mellitus and the general population.

RESULTS

Among 9730 physicians in PEM practices, 4866 (50.0%) received a premium and 448 319 (88.4%) people with SMI in PEMs were rostered. Compared with enhanced fee for service, the likelihood of rostering people with SMI was 3.0% higher for patients in capitation with team-based care (adjusted relative risk [RR] 1.03, 95% confidence interval [CI] 1.02-1.04), with similar results for capitation without team-based care (adjusted RR 1.00 95% CI 0.99-1.01). Rostering for people with diabetes was similar in team-based care (adjusted RR 1.02, 95% CI 1.02-1.03) but higher in capitation without team-based care (adjusted RR 1.03, 95% CI 1.02-1.03) and slightly higher for the Ontario population (team-based care 1.04, 95% CI 1.04-1.05, capitation without team-based care 1.03, 95% CI 1.03-1.04).

INTERPRETATION

Rostering of people with SMI was lower than for the general population. Additional policy measures are needed to address persisting inequities and to promote rostering of this underserved population with complex needs.

Risk of psychiatric readmission in the homeless population: A 10-year follow-up study

Homelessness continues to be a major social and clinical problem. The homeless population has a higher burden of disease that includes psychiatric disorders. In addition, they have a lower use of ambulatory health services and a higher use of acute care. Few investigations analyze the use of services of this population group in the long term. We analyzed the risk of psychiatric readmission of homeless individuals through survival analysis. All admissions to a mental health hospitalization unit in the city of Malaga, Spain, from 1999 to 2005, have been analyzed. Three analyses were carried out: two intermediate analyses at 30 days and 1 year after starting follow-up; and one final analysis at 10 years. In all cases, the event was readmission to the hospitalization unit. The adjusted Hazard Ratio at 30 days, 1-year, and 10-year follow-ups were 1.387 (p = 0.027), 1.015 (p = 0.890), and 0.826 (p = 0.043), respectively. We have found an increased risk of readmission for the homeless population at 30 days and a decreased risk of readmission at 10 years. We hypothesize that this lower risk of long-term readmission may be due to the high mobility of the homeless population, its low degree of adherence to long-term mental health services, and its high mortality rate. We suggest that time-critical intervention programs in the short term could decrease the high rate of early readmission of the homeless population, and long-term interventions could link them with services and avoid its dispersion and abandonment.

Using novel methodology to estimate the prevalence of mental disorders in British Columbia, Canada

PURPOSE

A needs-based model of health systems planning uses a systematic estimate of service needs for a given population. Our objective was to derive annual prevalence estimates of specific mental disorders in the adult population of British Columbia, Canada and use a novel triangulation approach encompassing multiple data sources and stratifying these estimates by age, sex, and severity to inform Ministry partners, who commissioned this work.

METHODS

We performed systematic literature reviews and subsequent meta-analyses to derive an annual prevalence estimate for each mental disorder. We then generated age- and sex-specific estimates by triangulating published epidemiological studies, routinely collected province-wide health administrative data, and nationally representative health survey data sources. The age- and sex-specific estimates were further stratified by severity using the Global Burden of Disease severity distributions and published literature.

RESULTS

Anxiety disorders had the highest annual prevalence estimates (6.93%), followed by depressive disorders (6.42%). All other mental disorders had an annual prevalence of less than 1%. Prevalence estimates were consistently higher in younger age groups. Depressive disorders, anxiety disorders, and eating disorders were higher in women, while estimates for bipolar disorders, schizophrenia, and ADHD were slightly higher in men in younger age groups.

CONCLUSION

We generated robust annual prevalence estimates stratified by age, sex, and severity using a triangulation approach. Variation by age, sex, and severity implies that these factors need to be considered when planning for mental health services. Our approach is replicable and can be used as a model for needs-based planning in other jurisdictions.

Current insights of community mental healthcare for people with severe mental illness: A scoping review

Background

For the last four decades, there has been a shift in mental healthcare toward more rehabilitation and following a more humanistic and comprehensive vision on recovery for persons with severe mental illness (SMI). Consequently, many community-based mental healthcare programs and services have been developed internationally. Currently, community mental healthcare is still under development, with a focus on further inclusion of persons with enduring mental health problems. In this review, we aim to provide a comprehensive overview of existing and upcoming community mental healthcare approaches to discover the current vision on the ingredients of community mental healthcare.

Methods

We conducted a scoping review by systematically searching four databases, supplemented with the results of Research Rabbit, a hand-search in reference lists and 10 volumes of two leading journals. We included studies on adults with SMI focusing on stimulating independent living, integrated care, recovery, and social inclusion published in English between January 2011 and December 2022 in peer-reviewed journals.

Results

The search resulted in 56 papers that met the inclusion criteria. Thematic analysis revealed ingredients in 12 areas: multidisciplinary teams; collaboration within and outside the organization; attention to several aspects of health; supporting full citizenship; attention to the recovery of daily life; collaboration with the social network; tailored support; well-trained staff; using digital technologies; housing and living environment; sustainable policies and funding; and reciprocity in relationships.

Conclusion

We found 12 areas of ingredients, including some innovative topics about reciprocity and sustainable policies and funding. There is much attention to individual ingredients for good community-based mental healthcare, but very little is known about their integration and implementation in contemporary, fragmented mental healthcare services. For future studies, we recommend more empirical research on community mental healthcare, as well as further investigation(s) from the social service perspective, and solid research on general terminology about SMI and outpatient support.

Understanding the primary health care experiences of individuals who are homeless in non-traditional clinic settings

BACKGROUND

Despite the widespread implementation of Health Care for the Homeless programs that focus on comprehensive, integrated delivery systems of health care for people experiencing homelessness, engaging and retaining people experiencing homelessness in primary care remains a challenge. Few studies have looked at the primary care delivery model in non-traditional health care settings to understand the facilitators and barriers to engagement in care. The objective of our study was to explore the clinic encounters of individuals experiencing homelessness receiving care at two different sites served under a single Health Care for the Homeless program.

METHODS

Semi-structured interviews were conducted with people experiencing homelessness for an explorative qualitative study. We used convenience sampling to recruit participants who were engaged in primary care at one of two sites: a shelter clinic, n = 16, and a mobile clinic located in a church, n = 15. We then used an iterative, thematic approach to identify emergent themes and further mapped these onto the Capability-Opportunity-Motivation model.

RESULTS

Care accessibility, quality and integration were themes that were often identified by participants as being important facilitators to care. Psychological capability and capacity became important barriers to care in instances when patients had issues with memory or difficulty with perceiving psychological safety in healthcare settings. Motivation for engaging and continuing in care often came from a team of health care providers using shared decision-making with the patient to facilitate change.

CONCLUSION

To optimize health care for people experiencing homelessness, clinical interventions should: (1) utilize shared-decision making during the visit, (2) foster a sense of trust, compassion, and acceptance, (3) emphasize continuity of care, including consistent providers and staff, and (4) integrate social services into Health Care for the Homeless sites.

Prevalence of eviction, home foreclosure, and homelessness among low-income US veterans: the National Veteran Homeless and Other Poverty Experiences study

OBJECTIVES

Housing stability is essential for health and social well-being, and the United States is focused on preventing homelessness among veterans, so this study examined the prevalence of different events related to housing instability among low-income US veterans.

STUDY DESIGN

This was a nationally representative survey.

METHODS

Using a sample of 1004 low-income veterans in 2021, this study examined the lifetime prevalence and characteristics associated with eviction, home foreclosure, and homelessness among low-income US veterans.

RESULTS

In the total sample, 10.9% reported a lifetime history of eviction, 8.0% reported a lifetime history of home foreclosure, and 19.9% reported a lifetime history of homelessness. Among those with a history of homelessness, 39.2% also reported a history of eviction, and 13.9% reported a history of home foreclosure. Hierarchical logistic regression analyses found that for eviction, sociodemographic characteristics (e.g. being Hispanic, having private insurance, and being from the Northeast was associated with lower risk of eviction) together explained 26% of the variance, and clinical characteristics explained an incremental 12% additional variance. For homelessness, sociodemographic characteristics explained 18% of the variance, and clinical characteristics explained an incremental 20% (e.g. diagnosis of schizophrenia or bipolar disorder, any history of suicide attempt, and lower physical health scores were associated with higher risk of homelessness). For home foreclosure, sociodemographic, clinical, and psychosocial variables together only explained 14% of the variance.

CONCLUSION

Evictions, home foreclosures, and homelessness are discrete events and occur at relatively high rates among low-income veterans. In addition, homelessness was more associated with biosocial dysfunction, whereas eviction was more closely associated with socio-economic vulnerability, which may inform intervention efforts for both events.

Mental illness among 500 people living homeless and referred for psychiatric evaluation in Lisbon, Portugal

BACKGROUND

Our goal was to identify the demographic profile of the people living homeless with mental illness in Lisboa, Portugal, and their relationship with the national healthcare system. We also tried to understand which factors contribute to the number and duration of psychiatric admissions among these homeless people.

METHODS

We used a cross-sectional design, collecting data for 4 years among homeless people, in Lisboa, Portugal, that were referred as possible psychiatric patients to Centro Hospitalar Psiquiátrico de Lisboa (CHPL). In total, we collected data from 500 homeless people, then cross-checked these people in our CHPL hospital electronic database and obtained 467 patient matches.

RESULTS

The most common psychiatric diagnosis in our sample was drug abuse (34%), followed by alcohol abuse (33%), personality disorder (24%), and acute stress reaction (23%). Sixty-two percent of our patients had multiple diagnoses, a subgroup with longer follow-ups, more psychiatric hospitalizations, and longer psychiatric hospitalizations. The prevalence of psychotic disorders was high: organic psychosis (17%), schizophrenia (15%), psychosis not otherwise specified (14%), and schizoaffective disorder (11%), that combined altogether were present in more than half (57%) of our homeless patients.

CONCLUSION

The people living homeless with multiple diagnoses have higher mental health needs and worse determinants of general health. An ongoing effort is needed to identify and address this subgroup of homeless people with mental illness to improve their treatment and outcomes.

Diet Quality, Health, and Wellbeing within the Irish Homeless Sector: A Qualitative Exploration

Financial barriers and limited cooking facilities are major obstacles to healthy dietary practices among the homeless population. Homelessness is currently at crisis point and up-to-date evidence from multiple stakeholders is needed to address dietary inequalities. The aim of this study was to understand dietary practices, barriers to healthy eating within homeless services from multiple perspectives. Twelve service users and five healthcare and social service providers participated in semi-structured interviews. Data were analysed thematically. Four themes were identified which included: lack of control over diet and food supply; sources of food for the homeless population; practical barriers to good nutrition; and the impact of diet on emotional and physical wellbeing. Frequent consumption of energy-dense, nutrient-poor foods was reported. Food insecurity resulted in perceived depressive symptoms and stress. Barriers to healthy diet included financial constraints and a lack of access to cooking and storage facilities. Our study highlights low levels of food skills and healthy eating knowledge among service users and service providers. In order to address diet-related health disparities, health promotion initiatives should be targeted at building healthy public policy in relation to diet and nutrition and developing food skills with members of this population and service providers.

"We figured it out as we went along": Staff perspectives of COVID-19 response efforts at a large North American syringe services programme

Syringe services programmes face operational challenges to provide life-sustaining services to people who use substances and those who have substance use disorders. COVID-19 has disrupted operations at these programmes and is a threat to people with substance use disorder because of severe poverty, de-prioritisation of COVID-19 safety and high prevalence of comorbidities. This phenomenological qualitative study describes 16 in-depth interviews with staff of one of the largest syringe services programme in North America-Prevention Point Philadelphia, located in the Kensington neighbourhood of Philadelphia, Pennsylvania. Interviews were conducted from December 2020 to February 2021, audio-recorded, transcribed and coded to develop a thematic framework. Participants were mostly white (71.4%) and female (68.8%) with a median age of 31.5. Three main and four sub-themes related to the impact of COVID-19 on the syringe services programme were identified: (1) COVID-19 altered services provision (sub-theme: select service changes should be retained); (2) unclear or absent COVID-19 response guidance which compromised mitigation (sub-themes: COVID-19 messaging was difficult to translate to practice, learn-as-we-go); and (3) staff and clients experienced elevated mental anguish during the pandemic (sub-theme: already limited resources were further strained). COVID-19 presented complex challenges to an organisation normally strained in pre-pandemic times. A staff culture of resourcefulness and resiliency aided the syringe services programme to balance client needs and staff safety. However, staff experienced a serious psychological impact, largely attributable to being unable to find reprieve from the stressors of COVID-19 and the difficulties associated with navigating and acting-on contradictory public health messaging. Staff also shared a belief that the relaxing of some pre-pandemic barriers allowed staff to link clients more readily with services. Syringe services programmes should embrace the potential for lasting changes to health services delivery brought about by wide-scale changes in service provisions because of COVID-19.

Mental health needs of homeless and recently housed individuals in Canada: A meta-ethnography

Homeless individuals are disproportionately likely to experience mental health conditions, and typically face many systemic barriers to access mental health services. This study sought to determine the mental health needs of homeless and recently housed individuals in Canada. A meta-ethnography was conducted to synthesise existing qualitative data and translate themes across a broader context. Thirty-five studies on the experiences of 1511 individuals with a history of homelessness were included. Themes were interpreted by comparing and contrasting findings across multiple contexts. Distinct, yet highly interrelated, unmet mental health needs were revealed through personal narratives of trauma, stigmatisation, victimisation, and a lack of basic necessities. Six themes that characterised this population's mental health needs were ontological security, autonomy, hope and purpose, empowerment, social connection and belonging, and access to services. This study revealed homeless individuals' unmet mental health needs to inform social and policy change and improve psychological well-being.

Differential impacts of COVID-19 and associated responses on the health, social well-being and food security of users of supportive social and health programs during the COVID-19 pandemic: A qualitative study

The effects of the coronavirus disease-2019 (COVID-19) pandemic on the lives of underserved populations are underexplored. This study aimed to identify the impacts of the COVID-19 pandemic and associated public health responses on the health and social well-being, and food security of users of Housing First (HF) services in Toronto (Canada) during the first wave of the COVID-19 pandemic. This qualitative descriptive study was conducted from July to October 2020 in a subsample of 20 adults with a history of homelessness and serious mental disorders who were receiving HF services in Toronto. A semi-structured interview guide was used to collect narrative data regarding health and social well-being, food security and access to health, social and preventive services. A thematic analysis framework guided analyses and interpretation of the data. The COVID-19 pandemic and response measures had a variable impact on the health, social well-being and food security of participants. Around 40% of participants were minimally impacted by the COVID-19 pandemic. Conversely, among the remaining participants (impacted group), some experienced onset of new mental health problems (anxiety, stress, paranoia) or exacerbation of pre-existing mental disorders (depression, post-traumatic stress disorder and obsessive-compulsive disorder). They also struggled with isolation and loneliness and had limited leisure activities and access to food goods. The pandemic also contributed to disparities in accessing and receiving healthcare services and treatment continuity for non-COVID-19 health issues for the negatively impacted participants. Overall, most participants were able to adhere to COVID-19 public health measures and get reliable information on COVID-19 preventive measures facilitated by having access to the phone, internet and media devices and services. In conclusion, the COVID-19 pandemic and associated response measures impacted the health, social well-being, leisure and food security of people with experiences of homelessness and mental disorders who use supportive social and housing services in diverse ways.

Estimating the Prevalence of Substance Use Disorders in the US Using the Benchmark Multiplier Method

Importance

Prevalence estimates of substance use disorders in the US rely on general population surveys. However, major population groups, such as homeless individuals and institutionalized individuals, are not captured by these surveys, and participants may underreport substance use.

Objective

To estimate the prevalence of substance use disorders in the US.

Design, Setting, and Participants

The benchmark multiplier method was used to estimate the prevalence of alcohol, cannabis, opioid, and stimulant use disorders based on data from the Transformed Medicaid Statistical Information System (T-MSIS) (the benchmark) and the National Survey on Drug Use and Health (NSDUH) (the multiplier) for 2018 and 2019. T-MSIS collects administrative data on Medicaid beneficiaries 12 years and older with full or comprehensive benefits. NSDUH is a nationally representative annual cross-sectional survey of people 12 years and older. Data were analyzed from February to June 2022.

Main Outcomes and Measures

Prevalence of substance use disorders was estimated using the benchmark multiplier method based on T-MSIS and NSDUH data. Confidence intervals for the multiplier method estimates were computed using Monte Carlo simulations. Sensitivity of prevalence estimates to variations in multiplier values was assessed.

Results

This study included Medicaid beneficiaries 12 years and older accessing treatment services in the past year with diagnoses of alcohol (n = 1 017 308 in 2018; n = 1 041 357 in 2019), cannabis (n = 643 737; n = 644 780), opioid (n = 1 406 455; n = 1 575 219), and stimulant (n = 610 858; n = 657 305) use disorders and NSDUH participants with 12-month DSM-IV alcohol (n = 3390 in 2018; n = 3363 in 2019), cannabis (n = 1426; n = 1604), opioid (n = 448; n = 369), and stimulant (n = 545; n = 559) use disorders. The benchmark multiplier prevalence estimates were higher than NSDUH estimates for every type of substance use disorder in both years and in the combined 2018 to 2019 sample: 20.27% (95% CI, 17.04-24.71) vs 5.34% (95% CI, 5.10-5.58), respectively, for alcohol; 7.57% (95% CI, 5.96-9.93) vs 1.68% (95% CI, 1.59-1.79) for cannabis; 3.46% (95% CI, 2.97-4.12) vs 0.68% (0.60-0.78) for opioid; and 1.91% (95% CI, 1.63-2.30) vs 0.85% (95% CI, 0.75-0.96) for stimulant use disorders. In sensitivity analyses, the differences between the benchmark multiplier method and NSDUH estimates persisted over a wide range of potential multiplier values.

Conclusions and Relevance

The findings in this study reflect a higher national prevalence of substance use disorders than that represented by NSDUH estimates, suggesting a greater burden of these conditions in the US.

Impacts of the COVID-19 pandemic, and of government responses to the pandemic, on people who are homeless in Australia: Mapping perceptions of a national sample of homelessness service workers

People who are homeless are disproportionately impacted by the COVID-19 pandemic, and by government responses to the pandemic. This study maps the perceptions of homelessness service workers in Australia, about the impacts of the COVID-19 pandemic and government responses to it on people who are homeless. An electronic survey was distributed to homelessness service across Australia in June/July 2020, following Australia's 'first wave' of COVID-19. Fifty-nine homelessness services from all eight states/territories responded. Perceptions of impacts on people who are homeless were mapped in six themes: (1) changes in the types of people presenting, (2) overall impacts on peoples' lives, (3) impacts on mental health, (4) impacts of changes in service delivery, (5) impacts of government support and (6) ongoing impacts. The COVID-19 pandemic, and government responses to the pandemic, have affected every aspect of the lives of people who are homeless in Australia. There is a continuing need to support people who are homeless as the world transitions to the 'new normal' of COVID-19, particularly as rates of homelessness increase. Understanding impacts is vital to informing relevant and effective health, social and other supports for this group.

Determinants of Hospital Use and Physician Services Among Adults With a History of Homelessness

Background:

People experiencing homelessness have diverse patterns of healthcare use. This study examined the distribution and determinants of healthcare encounters among adults with a history of homelessness.

Methods:

Administrative healthcare records were linked with survey data for a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness. Binary and count models were used to identify factors associated with hospital admissions, emergency department visits and physician visits for comparison across the 2 cohorts.

Results:

During the 1-year follow-up period, a higher proportion of people in the cohort with a mental illness used any inpatient (27% vs 14%), emergency (63% vs 53%), or physician services (90% vs 76%) compared to the general homeless cohort. People from racialized groups were less likely use nearly all health services, most notably physician services. Other factors, such as reporting of a regular source of care, poor perceived general health, and diagnosed chronic conditions were associated with higher use of all health services except psychiatric inpatient care

Conclusion:

When implementing interventions for patients with the greatest health needs, we must consider the unique factors that contribute to higher healthcare use, as well as the barriers to healthcare access.

Substance use and homelessness: A longitudinal interview study conducted during COVID-19 with implications for policy and practice

BACKGROUND

People who are homeless and using substances frequently encounter barriers to accessing support. This paper aims to inform policy and practice by analysing changes in the tobacco, alcohol and illicit drug use of people experiencing homelessness.

METHODS

Data derive from a qualitative longitudinal study (undertaken 2020/2021) and involving telephone interviews (n = 310) conducted with 34 people accommodated in two London hotels provided as part of a UK policy response to COVID-19. The hotels offered various supports, including opioid replacement therapy, prescribed alcohol, licensed nicotine replacement therapy, and e-cigarettes. Participants' substance use data were organised by Iterative Categorization and subjected to a content analysis to identify patterns and themes..

RESULTS

At entry to the hotel, 5/34 participants (14.7%) had never used alcohol nor illicit drugs; 10/34 (29.4%) had only ever used alcohol (mostly without a problem); 11/34 (32.4%) had ever used illicit drugs but without a problem; and 8/34 (23.5%) had ever had a problem with illicit drugs. Sub-groups had different socio-demographic characteristics, particularly regarding being/not being a UK national, sex, and homelessness duration. Tobacco smoking was common across all sub-groups (18/34; 52.9%). Participants were often anxious about living with others who were using substances, and some worried about their own substance use. Substance use was changeable, with more decreases than increases. Changes related to intrapersonal (psychological), interpersonal (social) and structural (resource-based) factors. For example, decreases were precipitated by people feeling motivated to change, separation from others who used drugs, and receiving treatment or support.

CONCLUSION

Findings indicate that various interventions and accommodation models may benefit people who are homeless and using substances. An initiative that combined shelter and basic amenities, pharmacological treatment, psychosocial support, and space where substances were not available and other people using substances could be avoided resulted in an overall reduction in substance use amongst those accommodated.

The effects of supported housing for individuals with mental disorders

Societies face the challenge of providing appropriate arrangements for individuals who need living support due to their mental disorders. We estimate the effects of eligibility to the Dutch supported housing program (Beschermd Wonen), which offers a structured living environment in the community as an intermediate alternative to independent housing and inpatient care. For this, we use exogenous variation in eligibility based on conditionally random assignment of applications to assessors, and the universe of applications to supported housing in the Netherlands, linked to rich administrative data. Supported housing eligibility increases the probability of moving into supported housing and decreases the use of home care, resulting in higher total care expenditures. This increase is primarily due to the costs of supported housing, but potentially also higher consumption of curative mental health care. Supported housing eligibility reduces the total personal income and income from work. Findings do also suggest lower participation in the labor market by the individuals granted eligibility, but the labor participation of their parents increases in the long-run. Our study highlights the trade-offs of access to supported housing for those at the margin of eligibility, informing the design of long-term mental health care systems around the world.

Development and preliminary effectiveness of a smartphone-based, just-in-time adaptive intervention for adults with alcohol misuse who are experiencing homelessness

BACKGROUND

Adults experiencing homelessness have much higher rates of alcohol misuse than housed individuals. This study describes the development and preliminary effectiveness of a smartphone-based, just-in-time adaptive intervention (JITAI) to reduce alcohol use among adults experiencing homelessness.

METHODS

We conducted a pilot trial (N = 41; mean age [SD] = 45.2 [11.5]; 19.5% women) of the Smart-T Alcohol JITAI where participants completed brief ecological momentary assessments (EMAs) each day, received personalized treatment messages following each EMA, and accessed on-demand intervention content for 4 weeks. The prediction algorithm and treatment messages were developed based on an independent but similar sample as part of the trial. We examined three drinking outcomes: daily drinking (yes/no), drinks per day, and heavy episodic drinking, controlling for scores on the Alcohol Use Disorders Identification Test (AUDIT) at baseline, age, and sex using quadratic growth curve models.

RESULTS

Over the 4-week period, participants showed a decline in all alcohol use outcomes. Participants also reported high levels of satisfaction with the JITAI.

CONCLUSIONS

Use of the Smart-T Alcohol JITAI was well received and provided encouraging evidence that it may reduce any drinking, drinks per day, and heavy episodic drinking among adults experiencing homelessness.

Psychosocial factors associated with dispositional hope, agency thinking, and pathways thinking in a homeless adult population

Adults facing homelessness often perceive themselves to be at the bottom of society, which has implications for their current and future well-being. Snyder's hope theory, which posits that agency thinking and pathways thinking are necessary for achieving a hopeful outlook on life, may be helpful for understanding drivers of well-being among individuals experiencing homelessness. In this study, we examined dispositional hope, perceived goal attainment, social support, and perceived standing in society among 123 adults experiencing homelessness who were attending a support group at a daytime drop-in center in the United States. Participants completed self-report measures related to the aforementioned variables of interest. We discovered that higher levels of self-reported goal attainment, independent of the type of goal identified, were significantly associated with total hope and both its subscales, that social support was significantly associated with total hope and pathways thinking, and that perceived standing in society was significantly associated with total hope and agency thinking.

Chronic diseases and multi-morbidity in persons experiencing homelessness: results from a cross-sectional study conducted at three humanitarian clinics in Germany in 2020

Background

Persons experiencing homelessness (PEH) suffer a high burden of chronic diseases and multi-morbidity, yet face significant barriers in accessing healthcare services. These health inequalities were further aggravated during the COVID-19 pandemic. While there is a lack of comprehensive health data on PEH, even less is known about populations experiencing housing exclusion, a hidden form of homelessness. This study examines and compares chronic diseases and multi-morbidity in PEH, persons experiencing housing exclusion, and persons with secure housing who lacked access to regular healthcare services in the wake of the COVID-19 pandemic in Germany.

Methods

Study participants were adults who sought medical care at clinics of the humanitarian organisation “Ärzte der Welt” in Munich, Hamburg and Berlin in 2020. The patients were categorised into three housing groups according to the ETHOS classification of homelessness and housing exclusion. Socio-demographic characteristics, self-rated health, chronic diseases and multi-morbidity were described in each group. Logistic regression analysis was used to identify socio-demographic factors associated with higher odds of chronic diseases and multi-morbidity in each housing group.

Results

Of the 695 study participants, 333 experienced homelessness, 292 experienced housing exclusion and 70 had secure housing. 92.3% of all patients had either no or limited health coverage, and 96.7% were below the poverty line. Males and EU/EEA citizens were highly represented among PEH (74.2% and 56.8% respectively). PEH had lower self-rated health (47.8%, p = 0.04), and a higher prevalence of psychiatric illness (20.9%, p = 0.04). In adjusted analyses, belonging to the age group 35–49 and ≥ 50 years were associated with greater odds of chronic disease (AOR = 2.33, 95% CI = 1.68–3.24; AOR = 3.57, 95% CI = 2.55–5.01, respectively) while being ≥ 50 years old was associated with multi-morbidity (AOR = 2.01, 95% CI = 1.21, 3.33). Of the 18 participants tested for SARS-COV-2, 15 were PEH, 1 of whom tested positive.

Conclusions

Housing status was not an independent risk factor for chronic disease and multi-morbidity in our study population. However, PEH reported poorer self-rated and psychiatric health. Strategies to improve access to healthcare services amongst persons experiencing homelessness and housing exclusion are needed in Germany.

Exploring COVID-19 vaccine uptake, confidence and hesitancy among people experiencing homelessness in Toronto, Canada: protocol for the Ku-gaa-gii pimitizi-win qualitative study

INTRODUCTION

People experiencing homelessness are at high risk for COVID-19 and poor outcomes if infected. Vaccination offers protection against serious illness, and people experiencing homelessness have been prioritised in the vaccine roll-out in Toronto, Canada. Yet, current COVID-19 vaccination rates among people experiencing homelessness are lower than the general population. This study aims to characterise reasons for COVID-19 vaccine uptake and hesitancy among people experiencing homelessness, to identify strategies to overcome hesitancy and provide public health decision-makers with information to improve vaccine confidence and uptake in this priority population.

METHODS AND ANALYSIS

The Ku-gaa-gii pimitizi-win qualitative study (formerly the COVENANT study) will recruit up to 40 participants in Toronto who are identified as experiencing homelessness at the time of recruitment. Semistructured interviews with participants will explore general experiences during the COVID-19 pandemic (eg, loss of housing, social connectedness), perceptions of the COVID-19 vaccine, factors shaping vaccine uptake and strategies for supporting enablers, addressing challenges and building vaccine confidence.

ETHICS AND DISSEMINATION

Approval for this study was granted by Unity Health Toronto Research Ethics Board. Findings will be communicated to groups organising vaccination efforts in shelters, community groups and the City of Toronto to construct more targeted interventions that address reasons for vaccine hesitancy among people experiencing homelessness. Key outputs will include a community report, academic publications, presentations at conferences and a Town Hall that will bring together people with lived expertise of homelessness, shelter staff, leading scholars, community experts and public health partners.

Housing trajectories and the risk of homelessness among new mental health service users: Protocol for the AMONT study

AIMS

High rates of mental illness among individuals experiencing homelessness, as well as documented contacts with psychiatric services prior to episodes of homelessness, indicate that early intervention could play a key role in homelessness prevention. Decision-makers and clinical teams need longitudinal data on housing trajectories following initial contact with psychiatric services, as well as on predictors of risk of housing instability and homelessness. This paper describes the AMONT study, a mixed-methods naturalistic longitudinal cohort study of individuals identified as new psychiatric service users in seven clinical sites across the province of Québec (Canada).

METHODS

The goal of AMONT is to examine the housing situations of individuals over 36 months after their initial contact with psychiatric services, and to identify environmental and individual correlates and predictors of housing outcomes. Participants complete a broad battery of instruments at baseline and follow-up assessments after 24 and 36 months. We explore housing stability following an initial episode of psychiatric service use from the perspective of service users, family members, and service providers, through qualitative interviews.

RESULTS AND CONCLUSIONS

The findings from the AMONT study will yield a better understanding of the residential pathways of individuals with mental illness, from their first contact with psychiatric services and for 3 years subsequently. This will inform service providers, decision-makers and managers on the specific housing concerns and issues that affect first-time mental health service users. This in turn can lead to the development and implementation of evidence-informed practices and policies that aim to prevent instability and homelessness.

Perspectives in poverty and mental health

In recent years, different forms of poverty and their interaction with mental illness have been in the focus of research, although the implementation of action in mental health care and policy making so far is scarce. This perspective article offers different perspectives of poverty and its reciprocal association with mental illness and outlines possible future research and policy implications. We will approach the topic of poverty from various levels: On a micro-level, focusing on absolute poverty with precarious housing and malnutrition. On a meso-level, on neighborhood-related poverty as a factor in individuals' mental illness. On a macro-level, on effects of income inequality on mental health. In several studies, it has been shown that on each level, poverty has a profound impact on mental health, though it must be noted that in some fields, research is still scarce. In the future, an inter- and transdisciplinary approach is of considerable importance, since poverty and its impact on mental health should be addressed from different perspectives, reaching from targeted programs for individual groups (e.g., homeless people) up to national policy measures.

Housing Outcomes of Adults Who Were Homeless at Admission to Substance Use Disorder Treatment Programs Nationwide

OBJECTIVE

Substance use disorders affect 30%-50% of single homeless adults, and specialized homelessness service programs enable homeless persons to exit homelessness at rates of about 80%. However, many such adults are treated in substance use disorder treatment programs. This study examined housing outcomes in these programs.

METHODS

Data from the Treatment Episode Data Set: Discharges database were used to examine housing status at discharge from substance use disorder treatment programs of adults who were homeless at admission. Associations of outcomes with sociodemographic characteristics, treatment programs and processes, and clinical variables were further evaluated with bivariate and multivariate logistic regressions. Odds ratios of ≥1.5 or ≤0.67 were considered meaningful.

RESULTS

Of 1,200,105 persons admitted to the programs, 192,838 (16.1%) were homeless at admission; 68.7% remained homeless at discharge, 16.3% were discharged to dependent housing, and only 15.0% were discharged to independent housing. Factors associated with remaining homeless included being age ≥55 years, being unemployed, admission for detoxification (vs. rehabilitation or residential treatment or ambulatory treatment), shorter stays, and program noncompletion. Factors associated with discharge to independent versus dependent housing included employment, admission to nonintensive outpatient treatment, and, unexpectedly, shorter stays.

CONCLUSIONS

Most adults experiencing homelessness at admission to substance use disorder treatment programs remained homeless at discharge, and only half of those no longer homeless were independently housed. These outcomes are considerably worse than outcomes typically reported by specialized homelessness service programs. Evidence-based service models that support exit from homelessness could be provided through augmented internal programming or links with specialized programs.

Evaluation of General Health Status of Persons Living in Socio-Economically Disadvantaged Neighborhoods in a Large European Metropolitan City

Background: Living in socio-economically disadvantaged neighborhoods can predispose persons to numerous health conditions. The purpose of this study was to report the general health conditions of persons living in disadvantaged neighborhoods in Rome, Italy, a large European metropolitan city. Participants were reached through the mobile facilities of the primary care services of the Dicastery for the Charity Services, Vatican City. Methods: People living in disadvantaged neighborhoods were reached with mobile medical units by doctors, nurses, and paramedics. Demographic characteristics, degree of social integration, housing conditions, and history of smoking and/or alcohol use were investigated. Unstructured interviews and general health assessments were performed to investigate common acute and/or chronic diseases, and history of positivity to COVID-19. Basic health parameters were measured; data were collected and analyzed. Results: Over a 10-month period, 436 individuals aged 18–95 years were enrolled in the study. Most lived in dormitories, whereas a few lived in unsheltered settings. Most participants (76%) were unemployed. Smoking and drinking habits were comparable to the general population. The most common pathological conditions were cardiovascular diseases in 103 subjects (23.39%), diabetes in 65 (14.9%), followed by musculoskeletal system disorders (11.7%), eye diseases (10.5%), psychiatric conditions such as anxiety and depression (9.2%), and chronic respiratory conditions (8.7%). Conclusions: Subjects in our sample showed several pathologic conditions that may be related to their living conditions, thus encouraging the development of more efficient and effective strategies for a population-tailored diagnosis and treatment.

The Prevalence of Problem Gambling and Gambling Disorder Among Homeless People: A Systematic Review And Meta-Analysis

Gambling problems are often associated with homelessness and linked to elevated psychiatric morbidity and homelessness chronicity. We performed a systematic review and meta-analysis on prevalence rates of problem gambling (PG) and gambling disorder (GD) in homeless people. Following PRISMA guidelines, we searched databases Medline, Embase and PsycINFO from inception of databases to 4th may 2021. We included studies reporting prevalence estimates on clinical gambling problems in representative samples of homeless people based on standardized diagnostics. Risk of bias was assessed. A random effects meta-analysis was performed, and subgroup analyses based on methodological characteristics of primary studies were conducted. We identified eight studies from five countries, reporting information on 1938 participants. Prevalence rates of clinically significant PG and GD ranged from 11.3 to 31.3%. There was evidence for substantial heterogeneity with I2 = 86% (95% CI 63–97%). A subgroup of four low risk of bias studies displayed a significantly lower results ranging from 11.3 to 23.6%. Additionally, high rates of subclinical problem gambling were reported (11.6–56.4%). At least one in ten homeless persons experiences clinically significant PG or GD. Social support and health care services for the homeless should address this problem by implementing models for early detection and treatment.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

BACKGROUND

Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population.

METHODS

Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted.

RESULTS

Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant.

CONCLUSION

While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

A systematic review of the nutritional status of adults experiencing homelessness

OBJECTIVES

To identify, appraise, and describe studies focussing on the nutritional characteristics of people experiencing homelessness (PEH).

STUDY DESIGN

Systematic (narrative) review.

METHODS

We identified full-text studies of any design and in the English language of adults (≥18 years) fulfilling the European Typology criteria for homelessness, based in community or hospital settings, and which report nutritional measures. Five electronic databases, 13 grey literature sources, reference lists, and forward citations were searched. Data on study characteristics and nutrition measures were collected and synthesised narratively. Risk of bias was assessed using relevant checklists for each study type.

RESULTS

A total of 1130 studies were identified and retrieved. After screening, six studies were included for review: three cross-sectional studies; two case-control studies; and one randomised control trial, involving a total of 1561 participants from various settings including shelters, drop-in centres, hospitals, and hostels. All included studies were from high-income countries. Studies reported a range of nutrition measures including anthropometry (e.g., body mass index (BMI)), serum micronutrients and biomarkers, and dietary intake. Between 33.3% and 68.3% of participants were overweight or obese; 3.5%-17% were underweight; and low blood levels of iron, folate, vitamins C, D, and B12, and haemoglobin were prevalent. PEH consumed high amounts of dietary fats and alcohol, and low amounts of fruits and vegetables compared with national guidelines and housed individuals. There was moderate to high risk of selection and measurement bias and confounding in included studies.

CONCLUSIONS

A majority of PEH are within unhealthy BMI ranges and are deficient in serum micronutrients and nutritional biomarkers. Studies using large data sets that examine multiple aspects of nutrition are needed to describe the nutritional characteristics of PEH.

REGISTRATION

This systematic review is based on a prespecified protocol registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42021218900).

The Hidden Face of the Moon: Unveiling the Minutiae of a Black Woman’s Experience on the Streets

The homeless population is mostly male. When it comes to the female presence, especially when considering the markers of race, gender and class, the invisibility and delegitimization are even more insidious. The aim of this article is to identify the singularities of a black woman living on the streets and to understand them based on the relationships she establishes with the territory. The method used was the case study of a homeless black woman, constructed through body map storytelling. Thematic analysis of the empirical content was used in the light of decolonial criticism. Luna, the protagonist of the story, reveals in her narratives, the multiple dimensions of the presence of the female body on the street, the process of taking care of oneself and the other, considering the intrinsic relationships with the territory, with the use of drugs and with the male figure. Thus, unveiling society’s views in relation to the place of invisibility of these women and creating strategies to face the colonial, racist and patriarchal logic of valuing knowledge is what Luna makes explicit with her trajectory of struggle, survival, and resilience on the streets.

Gambling and homelessness in older adults: a qualitative investigation

BACKGROUND AND AIMS

Homelessness is one of the most significant harms associated with gambling and appears to affect older adults disproportionately, but the relationship has received little research attention. This exploratory study investigated how gambling and homelessness is linked in older adults.

METHODS

Using qualitative research methods, we undertook in-depth semi structured face-to-face individual and group interviews to gather data from a purposive sample (n = 48) of key informants working in service provision for older adults (aged 50+ years) experiencing gambling-related harm and/or homelessness in Victoria, Australia. Thematic analysis of data focused on evaluating mechanisms and identifying contextual conditions that activate pathways between gambling and homelessness.

RESULTS

The relationship between gambling and homelessness in older adults is often indirect and non-linear, and can represent a reflexive cycle. Experiencing periods of homelessness into older age can contribute to gambling, often because the adverse impacts of homelessness on older adults' mental and material wellbeing increase the appeal of gambling. Additionally, comorbidities (e.g. substance use, mental illness, past trauma) and structural conditions (e.g. gambling accessibility, poverty, housing insecurity) can activate gambling. Furthermore, because gambling in the older homeless adult population is frequently hidden and regularly overlooked by service providers, it often continues unabated. Gambling in older adults can also contribute to the onset of first-time homelessness. Large and rapid losses from high-intensity gambling frequently characterize this route to homelessness. Such gambling is often triggered by major life events and changes (e.g. bereavement, job loss, relationship difficulties), and the outcomes are often worsened by the conduct of gambling operators and creditors.

CONCLUSIONS

The link between gambling and homelessness in older adults is complex, with connecting mechanisms often contingent upon individual, interpersonal and structural conditions and contexts. There is potential for preventative and ameliorative action given many of the underlying conditions appear modifiable through policy intervention.

A protocol for analysing the effects on health and greenhouse gas emissions of implemented climate change mitigation actions

Background: It is crucial to understand the benefits to human health from decarbonisation to galvanise action among decision makers. Most of our existing evidence comes from modelling studies and little is known about the extent to which the health co-benefits of climate change mitigation actions are realised upon implementation. We aim to analyse evidence from mitigation actions that have been implemented across a range of sectors and scales, to identify those that can improve and sustain health, while accelerating progress towards a zero-carbon economy.

Objectives: To understand the implementation process of actions and the role of key actors; explain the contextual elements influencing these actions; summarise what effects, both positive and negative, planned and unplanned they may have on emissions of greenhouse gases and health; and to summarise environmental, social, or economic co-benefits.

Data: We will review evidence collected through partnership with existing data holders and an open call for evidence. We will also conduct a hand search of reference lists from systematic reviews and websites of organisations relevant to climate change mitigation.

Screening: Screening will be done by two reviewers according to a pre-defined inclusion and exclusion criteria.

Analysis: We will identify gaps where implementation or evaluation of implementation of mitigation actions is lacking. We will synthesise the findings to describe how actions were implemented and how they achieved results in different contexts, identifying potential barriers and facilitators to their design, implementation, and uptake. We will also synthesise their effect on health outcomes and other co-benefits. Quantitative synthesis will depend on the heterogeneity of outcomes and metrics.

Conclusions: Findings will be used to identify lessons that can be learned from successful and unsuccessful mitigation actions, to make inferences on replicability, scalability, and transferability and will contribute to the development of frameworks that can be used by policy makers.

A protocol for analysing the effects on health and greenhouse gas emissions of implemented climate change mitigation actions

Background: It is crucial to understand the benefits to human health from decarbonisation to galvanise action among decision makers. Most of our existing evidence comes from modelling studies and little is known about the extent to which the health co-benefits of climate change mitigation actions are realised upon implementation. We aim to analyse evidence from mitigation actions that have been implemented across a range of sectors and scales, to identify those that can improve and sustain health, while accelerating progress towards a zero-carbon economy. Objectives: To understand the implementation process of actions and the role of key actors; explain the contextual elements influencing these actions; summarise what effects, both positive and negative, planned and unplanned they may have on emissions of greenhouse gases and health; and to summarise environmental, social, or economic co-benefits. Data: We will review evidence collected through partnership with existing data holders and an open call for evidence. We will also conduct a hand search of reference lists from systematic reviews and websites of organisations relevant to climate change mitigation. Screening: Screening will be done by two reviewers according to a pre-defined inclusion and exclusion criteria. Analysis: We will identify gaps where implementation or evaluation of implementation of mitigation actions is lacking. We will synthesise the findings to describe how actions were implemented and how they achieved results in different contexts, identifying potential barriers and facilitators to their design, implementation, and uptake. We will also synthesise their effect on health outcomes and other co-benefits. Quantitative synthesis will depend on the heterogeneity of outcomes and metrics. Conclusions: Findings will be used to identify lessons that can be learned from successful and unsuccessful mitigation actions, to make inferences on replicability, scalability, and transferability and will contribute to the development of frameworks that can be used by policy makers.

Community Supervision, Housing Insecurity, & Homelessness

In recent decades, the United States has seen the simultaneous rise of mass incarceration and homelessness. The two crises interact with and worsen one another. Mass incarceration and homelessness are driven by the same structural factors and exacerbate one another in a feedback loop. People on community supervision face many barriers to housing, putting them at high risk of experiencing homelessness in the months following release. People experiencing homelessness are at heightened risk of criminal justice involvement, including violating the terms of their community supervision, for engaging in survival behaviors in public spaces. This paper presents evidence-based approaches to improving housing strategies for reentry populations, preventing homelessness among those in community supervision, and rehousing members of the reentry community experiencing homelessness. It concludes with recommendations for policymakers interested in improving housing outcomes and overall reentry success for people on community supervision.

Challenges and adaptations to public involvement with marginalised groups during the COVID-19 pandemic: commentary with illustrative case studies in the context of patient safety research

Patient and public involvement (PPI) is integral to research on patient safety in the NIHR Greater Manchester Patient Safety Translational Research Centre (NIHR GMPSTRC), and is central to our patient safety research within our theme focusing on people in marginalised groups. Due to the impact of COVID-19, researchers had to adapt how they do PPI. For marginalised groups, remote working and digital adaptations (the key adaptations made in accessing and utilising health services in the United Kingdom during COVID-19) can potentially lead to further marginalisation of people already marginalised and provide new barriers to others. This editorial showcases three case examples of PPI with marginalised groups during COVID-19, these are with: (1) adults with vision impairments, (2) adults and carers with lived experience of self-harm and/ or suicide and (3) adults with lived experience of homelessness. In these case examples, we focus on challenges relating to key aspects of PPI during the pandemic. First, setting up a PPI advisory group and secondly maintaining relationships and effective PPI with a pre-existing advisory group. We contrast these examples using more traditional ways of 'doing PPI' i.e. involving public contributors in various stages of the research cycle, with a more fully 'co-produced' approach to research when developing a new patient safety intervention. Important considerations for PPI with marginalised groups during COVID-19 include: how to avoid exacerbating the digital divide when using video conferencing for PPI, the need for enhanced awareness around flexibility and resources, and the value of working closely with specialist charities to enable adaptations that are sensitive to the changed circumstances and needs of PPI contributors.

"A place to be safe, feel at home and get better": including the experiential knowledge of potential users in the design of the first wet service in Montreal, Canada

Background

The harmful use of alcohol is one of the leading health risk factors for people’s health worldwide, but some populations, like people who experience homelessness, are more vulnerable to its detrimental effects. In the past decades, harm reduction interventions that target these complex issues has been developed. For example, wet services include a wide range of arrangements (wet shelters, drop-in centers, transitory housing, etc.) that allow indoor alcohol use and Managed Alcohol Programs provide regulated doses of alcohol in addition to accommodation and services. Although the positive impacts of these interventions have been reported, little is known about how to integrate the knowledge of people experiencing homelessness and alcohol dependence into the design of such programs. The aim of this study is to present the findings of such an attempt in a first wet service in Montreal, Canada.

Methods

Community based participatory research approach and qualitative methods—including semi-structured interviews and focus groups—were used to collect the knowledge of potential users (n = 34) of the wet service. The data collected was thematically analyzed.

Results

Participants reported experiencing harsh living conditions, poverty, stigmatization and police harassment, which increased their alcohol use. The intersection between participants’ alcohol dependence and homelessness with the high barriers to access public services translated into their exclusion from several of such services. Participants envisioned Montreal’s wet service as a safe space to drink, a place that would provide multiple services, a home, and a site of recovery.

Conclusions

Integrating the knowledge of potential users into the design of harm reduction interventions is essential to develop better and more adapted services to meet complex needs. We propose that it could fosters users’ engagement and contribute to their sense of empower, which is crucial for a group that is typically discriminated against and suffers from marginalization.