[Somatic diseases of homeless people in Germany. A narrative literature review for the years 2009-2019]

Immunity against measles, mumps, rubella, and varicella among homeless individuals in Germany - A nationwide multi-center cross-sectional study

Introduction

Homeless individuals suffer a high burden of vaccine-preventable infectious diseases. Moreover, they are particularly susceptible to adverse infection outcomes with limited access to the health care system. Data on the seroprevalence of measles, mumps, rubella, and varicella within this cohort are missing.

Methods

The seroprevalence of measles, mumps, rubella, and varicella was determined within the homeless population in Germany. Predictors of lacking immune protection were determined using multivariable logistic regression analysis.

Results

Homeless individuals in Germany (n = 611) showed a seroprevalence of 88.5% (95% CI: 85.8-91.0) for measles, 83.8% (95% CI: 80.6-86.6) for mumps, 86.1% (95% CI: 83.1-88.7) for rubella, and 95.7% (95% CI 93.8-97.2) for varicella. Measles seroprevalences declined from individuals born in 1965 to individuals born in 1993, with seroprevalences not compatible with a 95% threshold in individuals born after 1980. For mumps, seroprevalences declined from individuals born in 1950 to individuals born in 1984. Here, seroprevalences were not compatible with a 92% threshold for individuals born after 1975. Seronegativity for measles, mumps and rubella was associated with age but not with gender or country of origin.

Discussion

Herd immunity for measles and mumps is not achieved in this homeless cohort, while there was sufficient immune protection for rubella and varicella. Declining immune protection rates in younger individuals warrant immunization campaigns also targeting marginalized groups such as homeless individuals. Given that herd immunity thresholds are not reached for individuals born after 1980 for measles, and after 1975 for mumps, vaccination campaigns should prioritize individuals within these age groups.

[Health of homeless individuals during the COVID-19 pandemic]

The living situation and health of homeless people differs from the general population in many ways. It is reasonable to assume that the homeless population has been particularly vulnerable during the coronavirus disease 2019 (COVID-19) pandemic. This narrative review will summarize the current literature on the health and care of homeless people during the COVID-19 pandemic. The literature research was performed between December 2022 and February 2023. In addition to the current national and international literature, findings from the "National Survey on the Psychiatric and Somatic Health of Homeless Individuals" (NAPSHI study) will be synopsized, examining psychiatric and somatic diseases as well as the care for homeless people in Germany.Homeless individuals are often mentally and physically ill and have limited access to the regular medical care system. Facilities with group rooms and dormitories pose a risk for outbreaks during the COVID-19 pandemic. As suspected, evidence of Severe Acute Respiratory Syndrome Coronavirus Type 2 (SARS-CoV‑2) infections emerged more frequently in homeless individuals than in the general population during the pandemic. Many of the infected individuals were asymptomatic. High rates of those unknowingly infected homeless individuals may have contributed to the spread of the viral disease. However, uncontrolled COVID-19 outbreaks, as feared by some researchers at the beginning of the pandemic, were not observed.

A COVID-19 isolation facility for people experiencing homelessness in Berlin, Germany: a retrospective patient record study

Introduction

People experiencing homelessness (PEH) are disproportionately affected by the COVID-19 pandemic. For many PEH it is impossible to isolate due to the lack of permanent housing. Therefore, an isolation facility for SARS-CoV-2 positive PEH was opened in Berlin, Germany, in May 2020, offering medical care, opioid and alcohol substitution therapy and social services. This study aimed to assess the needs of the admitted patients and requirements of the facility.

Materials and methods

This was a retrospective patient record study carried out in the isolation facility for PEH in Berlin, from December 2020 to June 2021. We extracted demographic and clinical data including observed psychological distress from records of all PEH tested positive for SARS-CoV-2 by RT-PCR. Data on duration and completion of isolation and the use of the facilities' services were analyzed. The association of patients' characteristics with the completion of isolation was assessed by Student's t-test or Fisher's exact test.

Results

A total of 139 patients were included in the study (89% male, mean age 45 years, 41% with comorbidities, 41% non-German speakers). 81% of patients were symptomatic (median duration 5 days, range 1-26). The median length of stay at the facility was 14 days (range 2-41). Among the patients, 80% had non-COVID-19 related medical conditions, 46% required alcohol substitution and 17% opioid substitution therapy. Three patients were hospitalized due to low oxygen saturation. No deaths occurred. Psychological distress was observed in 20%, and social support services were used by 65% of PEH. The majority (82%) completed the required isolation period according to the health authority's order. We did not observe a statistically significant association between completion of the isolation period and sociodemographic characteristics.

Conclusion

The specialized facility allowed PEH a high compliance with completion of the isolation period. Medical care, opioid and alcohol substitution, psychological care, language mediation and social support are essential components to address the specific needs of PEH. Besides contributing to infection prevention and control, isolation facilities may allow better access to medical care for SARS-CoV-2 infected PEH with possibly positive effects on the disease course.

Determinants of COVID-19 vaccine acceptance and access among people experiencing homelessness in Germany: A qualitative interview study

Introduction

People experiencing homelessness face lower life expectancy, higher prevalence of somatic and mental diseases and a more difficult access to healthcare compared to people in secure living. During the COVID-19 pandemic transmission rates were higher among people experiencing homelessness and preventive public health measures were not properly adapted to the specific needs of people experiencing homelessness. Thus, goal of our study was understanding the determinants of acceptability and access of the COVID-19 vaccine.

Materials and methods

We conducted a qualitative interview study with twenty guideline interviews with adult people currently experiencing homelessness in Berlin, Germany (August 2021 - April 2022). Participants were approached in a purposive sampling strategy. The interviews were analyzed with qualitative content analysis according to Mayring.

Results

Acceptance and attitude toward the COVID-19 vaccine is influenced by confidence in the vaccine as well as in the political and healthcare system, the individual COVID-19 risk perception and sense of collective responsibility. Overall, the acceptance of the vaccine was high among our participants. Facilities offering low threshold COVID-19 vaccines for people experiencing homelessness were perceived as helpful. Language barriers and the need for identity documents were major barriers to access the COVID 19 vaccine.

Discussion

People experiencing homelessness are a marginalized and vulnerable group often underrepresented in the public and scientific discourse. During the COVID-19 pandemic, preventive public health measures, including the COVID-19 vaccine, failed to consider specific needs of people experiencing homelessness. Multidimensional strategy to enhance inclusive healthcare are needed to improve access and to reduce discrimination and stigmatization.

[Health Service Utilization by Homeless Persons: Analysis of the Role of Enabling Factors, Pain and Gender using the Gelberg-Andersen Model]

The aim of the study was to find factors that influence health service utilization by homeless people. In a field study, a sample of 51 homeless men and 47 homeless women in the German county of Baden-Württemberg participated in face-to-face-interviews with a questionnaire designed for this study. Analyses were performed using multiple logistic regression models. Variables were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Satisfied subsistence needs (OR 1.33, 95%-CI [1.03-1.72] regarding utilization of vaccinations), a stable source of primary care (OR 12.2 [1.81-82] regarding utilization of early detection examinations; quasi-complete separation regarding use of GP services) social networks (OR 2.9 [1.13-7.5] regarding utilisation of early detection examinations; OR 0.63 [0.41-0.98] regarding emergency department visits) and technological ressources (OR 2.2 [1.13-4.4] regarding use of GP services) had a positive influence on the pattern of health service utilization. Pain was correlated with more emergency department visits (OR 1.72 [1.22-2.4]) and hospitalizations (OR 1.66 [1.19-2.3]). The results showed differences between homeless men and women. The factors of influence found in this study should be addressed in the care of homeless persons. Integration of social care into the regular health care system is necessary for early detection and treatment of complex social and medical needs of vulnerable populations. This requires interprofessional approaches in medical education and training focussing on the situation of vulnerable populations and on social determinants of health.

Predictors of Loneliness among Homeless Individuals in Germany during the COVID-19 Pandemic

PURPOSE

The aim of the study was to identify the frequency of loneliness and to examine the factors associated with loneliness among homeless individuals in Germany during the COVID-19 pandemic.

METHODS

Data were taken from the 'national survey on the psychiatric and somatic health of homeless individuals during the COVID-19 pandemic'. The data collection took place from 26th July to 17th September 2021 (the analytical sample included n = 491 observations). The well-established UCLA-3 tool was used to quantify loneliness. Independent variables included sex, age, marital status, the existence of children and pets, level of education, country of origin, duration of homelessness, alcohol and drug consumption, mental health concerns and concerns regarding COVID-19 illness. Multiple logistic regressions were used to examine the predictors of loneliness.

RESULTS

The frequency of loneliness was 41.7% for the total sample. Multiple logistic regression analysis stratified by gender showed that a higher likelihood of loneliness was associated with being born in Germany, being middle aged (40 to 49 years compared to 18 to 29 years), having mental health problems and a short period of homelessness (1 month compared to longer periods) among women. In men, a higher likelihood of loneliness was associated with a higher fear of COVID-19 and a short period of homelessness.

CONCLUSIONS

Our study revealed a high frequency rate of loneliness among homeless individuals. The study results highlight the associations between some explanatory variables (i.e., the duration of homelessness and mental health problems). Identifying the factors associated with loneliness may help to adequately address the problems of homeless individuals at risk of loneliness. Longitudinal studies are required to confirm our findings.

The Mental and Physical Health of the Homeless

BACKGROUND

The health status of homeless individuals in Germany has been described incompletely. Mental and somatic illnesses seem to contribute to the high mortality in this cohort.

METHODS

In this national, multicenter, cross-sectional study, data were collected on the health of 651 homeless individuals in the metropolitan regions of Hamburg, Frankfurt, Leipzig, and Munich metropolitan regions. The lifetime prevalences of physician-diagnosed mental and somatic illnesses were determined with interviewbased questionnaires. Furthermore, clinical and laboratory examinations were carried out. Multivariable regressions were performed to identify determinants of health status and access to care.

RESULTS

High prevalences of both mental and somatic illnesses were confirmed. Particularly, cardiovascular and metabolic diseases were highly prevalent. Evidence for possible unrecognized arterial hypertension and possible unrecognized hypercholesterolemia was found in 27.5% and 15.6% of homeless individuals, respec - tively. 23.1% of study participants reported having received a diagnosis of a mental illness. Evidence for a possible unrecognized mental illness was found in 69.7%. A history of immigration from another country to Germany was found to be an important determinant of the summed scores for mental, somatic, and possible unrecognized illness. Homeless individuals of non-German origin were more likely to be living without shelter (p = 0.03) and to lack health insurance (p < 0.001).

CONCLUSION

High prevalence rates for mental and somatic illnesses and limited access to mainstream medical care were found. Homeless individuals appear to receive inadequate care for mental illness. Healthcare programs for homeless individuals in Germany should pay particular attention to homeless migrants.

[Challenges of medical care in urban areas - a conceptual framework for primary care in the city]

BACKGROUND

Germany already has a high degree of urbanisation, and the share of urban population is expected to increase further. Thus, it is important to explore urban primary care from a scientific point of view.

METHOD

In this article, the author suggests a framework for urban primary care.

RESULTS AND CONCLUSION

Three core characteristics of urban areas are a high population density, a high population heterogeneity (including socioeconomic heterogeneity) and a fragmentation of health care and social care. These characteristics influence the health of urban dwelling population. Thus, these characteristics form the future challenges for urban primary care.

A retrospective analysis of the health and social situation of homeless people in Berlin: study protocol

BACKGROUND

Homelessness is often described as both a driver and a consequence of poor health, social exclusion and economic marginalisation. The present protocol provides a detailed description of the study Examining the health situation of homeless people in Berlin: a retrospective analysis of data from the health centre for the homeless of the Jenny De la Torre Foundation from 2006 to 2020 (GIG study). The primary objective of the GIG study is to describe and analyse the social and health situation of homeless people in Berlin.

METHODS

A retrospective secondary data analysis of an anonymous full census of medical records for the years 2006 until 2020 from a health centre for homeless people will be carried out. The main outcome is the description and analysis of the social and health situation of homeless people in Berlin. Total and cross-sectional sample characteristics will be presented in a descriptive analysis using Chi-Square Test, Mann-Whitney-U-Test or independent t-Test as appropriate to test (sub) group differences. Further, outcomes will be analysed using finite mixture modelling in order to distinguish different types of social and health conditions. Latent variable regressions will be applied in order to identify sociodemographic and disease-related factors associated with decreasing health conditions.

DISCUSSION

Given the high number of homeless individuals in Germany, it is of great importance to examine their social and health situation in order to gain a better understanding of challenges and needs of homeless people and work on new approaches and solutions to effectively address these.

TRAIL REGISTRATION

The study was prospectively registered with the German Clinical Trials Register (trial registration number: DRKS00021172 ). Registered 26 June 2020.