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Tsai J, Haley G, Kinney RL. Why some homeless individuals are unsheltered: A narrative review of self-reported reasons. Soc Sci Med 2024; 358:117179. [PMID: 39168065 DOI: 10.1016/j.socscimed.2024.117179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 07/13/2024] [Accepted: 08/02/2024] [Indexed: 08/23/2024]
Abstract
The rising rate of unsheltered homelessness is a troubling and important public health issue. This narrative review sought to answer the question: What are the reasons that homeless individuals report for being unsheltered? To identify studies, systematic search methods were applied to PubMed, Google Scholar, and PsycINFO databases using the following eligibility criteria: English-written, peer-reviewed studies published from 2000 to 2023 that reported qualitative or quantitative data related to reasons why homeless individuals in a Western country were unsheltered. After duplicates were removed, 14,690 studies were screened and filtered to 10 final studies that fit all eligibility criteria and were included in the review. Eight of the 10 studies reported qualitative data from interviews and focus groups; the two quantitative studies reported data from interviewer-administered surveys. Across studies, eight thematic categories were identified as barriers to staying in shelters or other sheltered locations: lack of safety, triggers for substance use, strict shelter rules, triggers for substance use, perceived inadequate care, unsanitary conditions, required treatment to participate in housing program, no pet or family accommodations, and lack of accessibility for individuals with disabilities. Together, these findings indicate the delicate balance needed in homeless shelters to have both an inclusive/permissive and structured/safe environment for homeless individuals. Attention to the design and operation of homeless shelters, as well as staff training and accommodation for clients with special needs may improve some of these issues.
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Affiliation(s)
- Jack Tsai
- National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs, Washington, DC, USA; Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - Gabrielle Haley
- National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Rebecca L Kinney
- National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs, Washington, DC, USA; Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA; Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Abramovich A, Marshall M, Webb C, Elkington N, Stark RK, Pang N, Wood L. Identifying 2SLGBTQ+ individuals experiencing homelessness using Point-in-Time counts: Evidence from the 2021 Toronto Street Needs Assessment survey. PLoS One 2024; 19:e0298252. [PMID: 38598425 PMCID: PMC11006143 DOI: 10.1371/journal.pone.0298252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/20/2023] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION The objective of this study was to utilize the data generated by the City of Toronto, Street Needs Assessment conducted in 2021 to explore the prevalence, causes, experiences, and characteristics of 2-spirit, lesbian, gay, bisexual, transgender, queer, and questioning (2SLGBTQ+) individuals experiencing homelessness in Toronto, Ontario, Canada. METHODS Data was collected by the City of Toronto during its Street Needs Assessment in April 2021. The Street Needs Assessment is a needs assessment survey and Point-in-Time count of people experiencing homelessness across the city of Toronto. Homelessness included any individual who was sleeping outdoors or staying in City-administered emergency/transitional shelters and shelter motels/hotels on the night of data collection. The Street Needs Assessment survey was administered to clients by trained shelter and outreach staff using a computer or mobile device. To ensure that survey questions were 2SLGBTQ+ inclusive, questions on sexual orientation, gender identity, and 2SLGBTQ+ identity were included in the survey. RESULTS Two hundred and eighty-eight 2SLGBTQ+ individuals completed the survey. Compared to non-2SLGBTQ+ individuals experiencing homelessness, 2SLGBTQ+ respondents were younger at the time of survey completion and when they first experienced homelessness, were more likely to have been in foster care or a group home, reported higher rates of conflict with and/or abuse by a parent/guardian as their main pathway into homelessness, and were more likely to experience chronic homelessness. CONCLUSION Our study results demonstrate that Street Needs Assessments and Point-in-Time counts can be used to examine homelessness in marginalized populations, including 2SLGBTQ+ individuals and that sexual orientation and gender identity questions need to be included on future government surveys. The consistency of findings from this study and previous research suggests that 2SLGBTQ+ individuals experience a significant need for population-based housing and social support services aimed at meeting the needs of 2SLGBTQ+ populations.
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Affiliation(s)
- Alex Abramovich
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Max Marshall
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Christopher Webb
- Shelter, Support, and Housing Administration, City of Toronto, Toronto, Ontario, Canada
| | - Nicole Elkington
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Rowen K. Stark
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Nelson Pang
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Factor Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Linda Wood
- Shelter, Support, and Housing Administration, City of Toronto, Toronto, Ontario, Canada
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Sloan K, Kogan AC, Guller J, Feldman CT, Feldman BJ. Characteristics of Homeless Temporarily-Housed in Project RoomKey During the COVID-19 Pandemic. J Prim Care Community Health 2024; 15:21501319241234869. [PMID: 38491844 PMCID: PMC10943723 DOI: 10.1177/21501319241234869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 03/18/2024] Open
Abstract
INTRODUCTION People experiencing unsheltered homelessness (PEUH) have higher disease burden yet limited access to healthcare. COVID-19 introduced even greater risk for PEUH aged 65+ years with an underlying chronic health condition and were temporarily housed in hotels/motels for Project RoomKey (PRK). This study aimed to characterize a PRK cohort who received primary care from a street medicine program. METHODS This observational case series study included a sample of 35 PRK participants receiving primary care from a street medicine team at a single site from July to September 2020. We used the HOUSED BEDS assessment tool for taking history on PEUH. RESULTS Participants were 63% male, 40% Hispanic/Latino/a, 40% white, 94% English-speaking, and 73% had chronic health conditions. Assessment revealed: average Homelessness (H) of 4 years; 76% had no prior social service Outreach (O); average Utilization (U) was 4 emergency department visits in prior 6-months; 68% received Salary (S) from government income; Food access or Eat (E) was commonly purchased (29%) or donated (26%); clean water to Drink (D) for 59% of participants; 86% had access to a Bathroom (B); Encampment (E) was varied and 38% reported safety concerns; Daily routine (D) showed 76% could access a telephone, 32% received social support from family; 79% reported past or current Substance use (S). No participants contracted COVID-19 during study period. CONCLUSIONS This study describes health and demographic characteristics of PRK participants in Southern California. Findings inform policies to continue PRK that includes onsite healthcare such as via street medicine.
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Affiliation(s)
- Kylie Sloan
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Jodie Guller
- University of Southern California, Alhambra, CA, USA
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Seshadri S, Morgan O, Moore A, Parmar S, Schnur J, Montgomery G, Henderson A, Laban J. Analysis of older adult blood pressure readings and hypertension treatment rates among the unsheltered population of Miami-Dade County. Aging Med (Milton) 2023; 6:320-327. [PMID: 38239717 PMCID: PMC10792314 DOI: 10.1002/agm2.12272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/30/2023] [Accepted: 10/07/2023] [Indexed: 01/22/2024] Open
Abstract
Objective To assess prevalence of elevated blood pressure readings, rates of established hypertension diagnosis, and blood pressure control medication prescription rates in a cohort of older people experiencing unsheltered homelessness presenting to a Street Medicine clinic in Miami-Dade County, Florida. In addition, we will compare outcomes found in the study cohort to that of the general population. Methods Demographic information, clinical history, blood pressure control medication prescription, and blood pressure measurements were taken by a Street Medicine team of medical providers. The team routinely provides medical evaluations and care for people experiencing unsheltered homelessness who reside in rough sleeper tent encampments located on the street. Clinical information and vitals were recorded in REDCap. De-identified data from patients 65 years and above were downloaded and compared to a general population data set-the Centers for Disease Control National Health and Nutrition Examination Survey (CDC NHANES) 2017-2020 Pre-pandemic cohort. Data analysis was performed using R Studio version 4.3.2. Results Blood pressure was reported in 120 distinct interactions with older people experiencing homelessness. Compared to the age-matched NHANES data, older people experiencing unsheltered homelessness were at significantly increased relative risk for elevated blood pressure within the range of Stage 1 Hypertension (RR: 3.914, 95% CI: 2.560-5.892, P < 0.001), and within range of Stage 2 Hypertension (RR: 5.550, 95% CI: 4.272-7.210, P < 0.001). According to NHANES, 49.6% of adults over 60 with diagnosed hypertension receive treatment. Of study participants, 69% of those with elevated blood pressure had previously received a diagnosis of hypertension and 15.9% on medication to control blood pressure. Conclusion Our cohort of older people experiencing unsheltered homelessness had higher rates of elevated blood pressure and reduced rates of hypertension diagnosis and treatment as compared to the general population. Older people experiencing unsheltered homelessness are a growing population, and future research should seek to evaluate and understand older adult care vulnerabilities, including chronic disease management, to improve health outcomes for those who are aging, hypertensive, and unhoused.
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Affiliation(s)
- Suhas Seshadri
- Department of Internal MedicineUniversity of Illinois ChicagoChicagoIllinoisUSA
| | - Orly Morgan
- Department of Internal MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Alana Moore
- Department of Internal MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Shivangi Parmar
- Department of Internal MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Julie Schnur
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Guy Montgomery
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Armen Henderson
- Department of Internal MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Joshua Laban
- Department of Internal MedicineUniversity of Miami Miller School of MedicineMiamiFloridaUSA
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Richards J, Henwood BF, Porter N, Kuhn R. Examining the Role of Duration and Frequency of Homelessness on Health Outcomes Among Unsheltered Young Adults. J Adolesc Health 2023; 73:1038-1045. [PMID: 37578404 PMCID: PMC10890810 DOI: 10.1016/j.jadohealth.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 04/20/2023] [Accepted: 06/10/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE We examined the impact of duration and number of homelessness episodes on health outcomes for unsheltered homeless young adults. METHODS We analyzed the 2018/2019 Los Angeles County homeless youth demographic surveys. We addressed five summary health outcomes: physical health, mental health, substance use disorder, tri-morbidity, and any condition. Respondents were classified into three homeless trajectory groups: (1) short-term-homeless < 1 year in one episode, (2) episodic-homeless < 1 year and multiple episodes, and (3) long-term-homeless continuously for > 1 year. Weighted bivariate and multivariate logistic regression models tested the relationship between homeless trajectory group and health, with controls for sociodemographic factors and structural exposures. RESULTS Mental health and substance use were high among unsheltered young adults compared to national rates. Long-term homeless respondents were significantly more likely than short-term to report a mental health condition (53.3% vs. 39.8%, p < .001), substance use disorder (25.5% vs. 18.3%, p < .001), and physical conditions (26.0% vs. 15.6%, p = .008). Episodic respondents were more likely to report a mental health condition (50.5%, p < .001). In multivariate models, long-term respondents had twice the odds of tri-morbidity (odds ratio [OR] = 2.14, p < .05) and any health condition (OR 2.00, p < .01) as short term and significantly higher odds of a physical health condition (OR = 1.64, p < .05). DISCUSSION Youth with longer durations and more frequent episodes of homelessness have substantially poorer health outcomes. The association of longer duration to poorer health persisted in multivariate models. Longer duration of unsheltered homelessness may drive the onset of physical and mental health problems.
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Affiliation(s)
- Jessica Richards
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Benjamin F Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
| | - Natalie Porter
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Randall Kuhn
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California.
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Mitchell E, Waring T, Ahern E, O'Donovan D, O'Reilly D, Bradley DT. Predictors and consequences of homelessness in whole-population observational studies that used administrative data: a systematic review. BMC Public Health 2023; 23:1610. [PMID: 37612701 PMCID: PMC10463451 DOI: 10.1186/s12889-023-16503-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 08/10/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Homelessness is a complex societal and public health challenge. Limited information exists about the population-level health and social care-related predictors and consequences of persons with lived experience of homelessness (PEH). Studies that focus on population subgroups or ad hoc questionnaires to gather data are of relatively limited generalisability to whole-population health surveillance and planning. The aim of this study was to find and synthesise information about the risk factors for, and consequences of, experiencing homelessness in whole-population studies that used routine administrative data. METHOD We performed a systematic search using EMBASE, MEDLINE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO research databases for English-language studies published from inception until February 2023 that reported analyses of administrative data about homelessness and health and social care-related predictors and consequences. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS Of the 1224 articles reviewed, 30 publications met the inclusion criteria. The included studies examined a wide range of topic areas, and the homelessness definitions used in each varied considerably. Studies were categorised into several topic areas: Mortality, morbidity and COVID-19; health care usage and hospital re-admission; care home admission and shelter stay; and other (e.g. employment, crime victimisation). The studies reported that that the physical and mental health of people who experience homelessness was worse than that of the general population. Homeless individuals were more likely to have higher risk of hospitalisation, more likely to use emergency departments, have higher mortality rates and were at greater risk of needing intensive care or of dying from COVID-19 compared with general population. Additionally, homeless individuals were more likely to be incarcerated or unemployed. The effects were strongest for those who experienced being homeless as a child compared to those who experienced being homeless later on in life. CONCLUSIONS This is the first systematic review of whole-population observational studies that used administrative data to identify causes and consequences associated with individuals who are experiencing homelessness. While the scientific literature provides evidence on some of the possible risk factors associated with being homeless, research into this research topic has been limited and gaps still remain. There is a need for more standardised best practice approaches to understand better the causes and consequences associated with being homeless.
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Affiliation(s)
- Eileen Mitchell
- Centre for Public Health, Queen's University Belfast, Belfast, UK.
- Public Health Agency, Belfast, UK.
| | - Tanisha Waring
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | | | - Diarmuid O'Donovan
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Public Health Agency, Belfast, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Public Health Agency, Belfast, UK
| | - Declan T Bradley
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Public Health Agency, Belfast, UK
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Abstract
Context In recent years, cities across the world have seen widespread growth in unsheltered homelessness, in which a person sleeps in a place not meant for human habitation such as cars, parks, sidewalks, and abandoned buildings. It is widely understood that people experiencing homelessness have poorer health outcomes than the general population. Less is known about the health of people who are unsheltered, yet they may be exposed to greater health risks than their sheltered counterparts. The purpose of this literature review is to evaluate and summarize the evidence on unsheltered homelessness and health. Evidence Acquisition A literature search was conducted using PubMed to identify publications on unsheltered homelessness and health. A total of 42 studies were included for review. Evidence Synthesis Unsheltered populations experience higher rates of chronic disease, serious mental illness, and substance abuse than sheltered populations. Unsheltered homelessness is strongly associated with chronic homelessness that exacerbates serious mental illness and substance use, which is often co-occurring. Despite having large unmet health needs, unsheltered populations have lower healthcare utilization and often lack health insurance. Conclusions Evaluating the impact of shelter status on health outcomes has important implications for the allocation of housing and health services. Longitudinal studies are needed to examine the relationship between the duration of sheltered and unsheltered homelessness and health outcomes and explore the mediating mechanisms that lead to poor health among unsheltered populations. Despite these limitations, our results also suggest an urgent need to address the unique and severe challenges facing unsheltered populations and the need for intervention approaches that are sensitive to these unique disease burdens.
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Affiliation(s)
- Jessica Richards
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
| | - Randall Kuhn
- Department of Community Health Sciences, Jonathan and Karin Fielding School of Public Health, University of California Los Angeles, Los Angeles, California
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Rasul T, Mathew M, Morrison BW. Approaching the dermatologic care of people experiencing unsheltered homelessness through a volunteer street dermatology model. JAAD Int 2023; 11:52-54. [PMID: 36865612 PMCID: PMC9972392 DOI: 10.1016/j.jdin.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Affiliation(s)
| | | | - Brian W. Morrison
- Correspondence to: Brian W. Morrison, MD, 1295 NW 14th St, Miami, FL 33125
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Muacevic A, Adler JR. Cutaneous Fungal Infections in Patients Experiencing Homelessness and Treatment in Low-Resource Settings: A Scoping Review. Cureus 2022; 14:e30840. [PMID: 36451649 PMCID: PMC9704118 DOI: 10.7759/cureus.30840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 01/25/2023] Open
Abstract
Patients experiencing homelessness (PEH) suffer from a high burden of cutaneous fungal infections. Preventative treatment is important as such infections can lead to harmful complications such as cellulitis and even osteomyelitis. There are sparse data regarding cutaneous fungal infections of homeless populations and management in low-resource settings. A MEDLINE search was conducted using the key terms "cutaneous," "fungal," "infections," "dermatophytes," and "homeless." The search included case-control, cohort, and randomized controlled trials published in the English language. This scoping review of studies yielded information with regard to practical treatment advice for providers in low-resource settings, including medical, hygiene, prevention, and treatment options for PEH with cutaneous fungal infections, the most common of which were tinea pedis (3-38%) and onychomycosis (1.6-15.5%). Few studies have been conducted on the differences between sheltered and unsheltered homeless patients, which can have treatment implications. Systemic antifungal therapy should be carefully considered for diffuse, refractory, or nail-based cutaneous fungal infections if there is a history of alcohol use disorder or liver disease. While PEH have a high risk of alcohol use disorder, this can make definitive treatment challenging.
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Grotts JH, Mead MM, Rab S, Walker IJ, Choi KR. Geospatial analysis of associations among mental health need, housing need, and involuntary psychiatric hospitalizations of people experiencing homelessness in Los Angeles County. Soc Sci Med 2022; 311:115343. [PMID: 36126473 DOI: 10.1016/j.socscimed.2022.115343] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/15/2022] [Accepted: 08/30/2022] [Indexed: 11/20/2022]
Abstract
The purpose of this study was to use geospatial indicators of mental health need and homelessness in Los Angeles County Service Planning Areas (SPAs) and a psychiatric sample of adults who were homeless to investigate 1) overlap between SPA level of mental health need and corresponding volume of involuntary psychiatric hospitalizations over time; 2) overlap between SPA level of unsheltered homelessness and corresponding volume of involuntary psychiatric hospitalizations over time; and 3) associations between SPA level of mental health need, SPA level of unsheltered homelessness, and initiation of a mental health conservatorship for grave disability. A sample of 373 adults who were homeless and hospitalized on an involuntary psychiatric hold from 2016 to 2018 were linked to data from the Greater Los Angeles Homeless Count on unsheltered homelessness and from the California Health Interview Survey on need for mental health services and suicidality, using admission zip codes to link variables at the SPA level. Geospatial mapping and bivariate tests were used to examine geographic overlap of SPA mental health need and unsheltered homelessness with volume of involuntary psychiatric admissions over the study period. Multiple logistic regression modeling was used to examine associations of SPA mental health need and unsheltered homelessness with conservatorship initiation. The volume of patients admitted from SPAs with higher levels of mental illness need grew from 2016 to 2018 (Tau = 0.27, P < 0.001; Tau = 0.40, P < 0.001), but there were fewer patients admitted from SPAs with higher levels of unsheltered homelessness over the same years (Tau of -0.33, P < 0.001). Being admitted from SPAs with the highest levels of unsheltered homelessness was associated with higher odds of conservatorship initiation (OR = 1.73, 95% CI = 1.82-16.74). Results suggest a need for targeted mental health and housing services to reach areas of highest need in Los Angeles County.
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Affiliation(s)
- Joseph H Grotts
- School of Nursing, UCLA; 700 Tiverton Ave Los Angeles, CA, 90049, USA
| | - Meredith M Mead
- Gateways Hospital and Mental Health Center, 1891 Effie St Los Angeles, CA, USA
| | - Shayan Rab
- Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, UCLA, 10833 Le Conte Ave, Los Angeles, CA, 90095, USA
| | - Imani J Walker
- Gateways Hospital and Mental Health Center, 1891 Effie St Los Angeles, CA, USA
| | - Kristen R Choi
- School of Nursing, UCLA; 700 Tiverton Ave Los Angeles, CA, 90049, USA; Gateways Hospital and Mental Health Center, 1891 Effie St Los Angeles, CA, USA; Department of Health Policy & Management, Fielding School of Public Health, UCLA; 650 Charles E Young Dr S, Los Angeles, CA, 90095, USA.
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11
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Unmet health needs and barriers to health care among people experiencing homelessness in San Francisco's Mission District: a qualitative study. BMC Public Health 2022; 22:1071. [PMID: 35637496 PMCID: PMC9150384 DOI: 10.1186/s12889-022-13499-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022] Open
Abstract
Background People experiencing homelessness have unique health needs and barriers to medical and behavioral health care (mental health, substance use disorder, and overall well-being) compared to housed people. It remains unclear why many people experiencing homelessness do not access care when community-based homeless health care resources are available at low or no cost. This qualitative study examined perspectives of people experiencing homelessness and staff members at community-based homeless health and service organizations in San Francisco’s Mission District on unmet medical and behavioral health needs and barriers to accessing care. Methods We conducted 34 interviews between September and November 2020: 23 with people experiencing homelessness and 11 with staff at community-based homeless health and service organizations in the Mission District. Qualitative interviews were transcribed, coded, and analyzed using the Framework Method on NVivo Qualitative Data Analysis Software. Results Both staff and homeless participants reported unmet and common health needs of mental illness, physical injury and disability, food and nutrition insecurity, and substance use disorder. Barriers to care included negative prior health care experiences, competing priorities, and provider turnover. Recommendations for improving services included building more trust with people experiencing homelessness by training clinic staff to treat patients with respect and patience and expanding clinical outreach and health education programs. Conclusions People experiencing homelessness face many different health needs and barriers to care, some of which community-based organizations have the ability to address. These findings can help inform future strategies for homeless health care programs to identify and target the specific unmet health needs and barriers to care of people experiencing homelessness in their communities.
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Kertesz SG, DeRussy AJ, Riggs KR, Hoge AE, Varley AL, Montgomery AE, Austin EL, Blosnich JR, Jones AL, Gabrielian SE, Gelberg L, Gordon AJ, Richman JS. Characteristics Associated With Unsheltered Status Among Veterans. Am J Prev Med 2021; 61:357-368. [PMID: 34419233 PMCID: PMC8864732 DOI: 10.1016/j.amepre.2021.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/11/2021] [Accepted: 03/31/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test for interactions between these characteristics. METHODS In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July-August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status. RESULTS Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0-1) to 8.4% (2-3) and to 24.2% (4-11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p<0.05). CONCLUSIONS Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels.
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Affiliation(s)
- Stefan G Kertesz
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama; Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama; Department of Health Behavior, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama.
| | - Aerin J DeRussy
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama
| | - Kevin R Riggs
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama; Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - April E Hoge
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama
| | - Allyson L Varley
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama; Department of Medicine, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Ann Elizabeth Montgomery
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama; Department of Health Behavior, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Erika L Austin
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama; Department of Biostatistics, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| | - John R Blosnich
- Department of Social Change and Innovation, University of Southern California Suzanne Dworak-Peck School of Social Work, Los Angeles, California; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah; Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Sonya E Gabrielian
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, California
| | - Lillian Gelberg
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California; Department of Family Medicine, University of California Los Angeles, Los Angeles, California
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah; Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Joshua S Richman
- Research Service, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama; Department of Surgery, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
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13
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Ra CK, Hébert ET, Alexander A, Kendzor DE, Suchting R, Businelle MS. Unsheltered homeless and unstably housed adults have higher levels of stress and more health risk factors than sheltered homeless adults. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2021; 32:42-50. [PMID: 37346936 PMCID: PMC10281693 DOI: 10.1080/10530789.2021.1961990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/08/2021] [Accepted: 07/18/2021] [Indexed: 06/23/2023]
Abstract
In the United States, approximately 580,000 individuals were homeless on a single night in 2020. Homelessness can be categorized into three subgroups: sheltered homeless, unsheltered homeless, and unstably housed. Few studies have examined the relations between homelessness subtypes, shelter service utilization, levels of stress experienced, and health risk factors. This study aimed to empirically examine whether shelter status the previous night was related to current stress, recent utilization of shelter-based mental health services, and current health risk factors. Data were collected at multiple homeless shelters in 2016 in the Oklahoma City area (N=575). All participants completed assessments of demographic characteristics, including age, sex, race, marital status, years of education, and incarceration history and victimization. Multiple linear and logistic regression analyses were conducted to examine relations between homelessness subgroups and outcomes (shelter-based service utilization, health risk factors, and stressors). Results indicated that the sheltered group was younger and more likely to be White than the unsheltered group, had higher levels of education, and reported more lifetime months in jail than the unstably housed group. In addition, unsheltered homeless and unstably housed adults used fewer shelter-based health services, exhibited more health risk factors, experienced greater levels of stress, and had higher levels of food insecurity than sheltered homeless adults. Homeless adults who reside at shelters benefit most from available shelter services. The development of policies and programs targeted toward increasing sheltering options for unsheltered and unstably housed adults is needed.
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Affiliation(s)
- Chaelin K. Ra
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
| | - Emily T. Hébert
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Adam Alexander
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
| | - Darla E. Kendzor
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Robert Suchting
- UTHealth McGovern Medical School, Faillace Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston, Houston, TX
| | - Michael S. Businelle
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, Oklahoma City, OK
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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14
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Gabrielian S, Jones AL, Hoge AE, deRussy AJ, Kim YI, Montgomery AE, Blosnich JR, Gordon AJ, Gelberg L, Austin EL, Pollio D, Holmes SK, Varley AL, Kertesz SG. Enhancing Primary Care Experiences for Homeless Patients with Serious Mental Illness: Results from a National Survey. J Prim Care Community Health 2021; 12:2150132721993654. [PMID: 33543675 PMCID: PMC7871055 DOI: 10.1177/2150132721993654] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objectives: Patients experiencing homelessness (PEH) with serious mental illness (SMI) have poor satisfaction with primary care. We assessed if primary care teams tailored for homeless patients (Homeless-Patient Aligned Care Teams (H-PACTs)) provide this population with superior experiences than mainstream primary care and explored whether integrated behavioral health and social services were associated with favorable experiences. Methods: We surveyed VA PEH with SMI (n = 1095) to capture the valence of their primary care experiences in 4 domains (Access/Coordination, Patient-Clinician Relationships, Cooperation, and Homeless-Specific Needs). We surveyed clinicians (n = 52) from 29 H-PACTs to elucidate if their clinics had embedded mental health, addiction, social work, and/or housing services. We counted these services in each H-PACT (0-4) and classified H-PACTs as having high (3-4) versus low (0-2) service integration. We controlled for demographics, housing history, and needs in comparing H-PACT versus mainstream experiences; and experiences in high versus low integration H-PACTs. Results: Among respondents, 969 (91%) had complete data and 626 (62%) were in H-PACTs. After covariate adjustment, compared to mainstream respondents, H-PACT respondents were more likely (P < .01) to report favorable experiences (AORs = 1.7-2.1) and less likely to report unfavorable experiences (AORs = 0.5-0.6) in all 4 domains. Of 29 H-PACTs, 27.6% had high integration. High integration H-PACT respondents were twice as likely as low integration H-PACT respondents to report favorable access/coordination experiences (AOR = 1.7). Conclusions: Homeless-tailored clinics with highly-integrated services were associated with better care experiences among PEH with SMI. These observational data suggest that tailored primary care with integrated services may improve care perceptions among complex patients.
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Affiliation(s)
- Sonya Gabrielian
- VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.,University of California Los Angeles, Los Angeles, CA, USA
| | - Audrey L Jones
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - April E Hoge
- Birmingham VA Medical Center, Birmingham, AL, USA
| | | | - Young-Il Kim
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Ann Elizabeth Montgomery
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - John R Blosnich
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,University of Southern California, Los Angeles, CA, USA
| | - Adam J Gordon
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lillian Gelberg
- VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.,University of California Los Angeles, Los Angeles, CA, USA
| | - Erika L Austin
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Public Health, Birmingham, AL, USA
| | - David Pollio
- University of Alabama at Birmingham College of Letters and Sciences, Birmingham, AL, USA
| | | | | | - Stefan G Kertesz
- Birmingham VA Medical Center, Birmingham, AL, USA.,University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
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15
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Huang S, Choi KJ, Pham CH, Collier ZJ, Dang JM, Kiwanuka H, Sheckter CC, Yenikomshian HA, Gillenwater TJ. Homeless Tent Fires: A Descriptive Analysis of Tent Fires in the Homeless Population. J Burn Care Res 2021; 42:886-893. [PMID: 34058010 DOI: 10.1093/jbcr/irab095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Tent fires are a growing issue in regions with large homeless populations given the rise in homelessness within the US and existing data that suggest worse outcomes in this population. The aim of this study is to describe the characteristics and outcomes of tent fire burn injuries in the homeless population. A retrospective review was conducted involving two verified regional burn centers with patients admitted for tent fire burns between January 2015 and December 2020. Variables recorded include demographics, injury characteristics, hospital course, and patient outcomes. Sixty-nine patients met the study inclusion criteria. The most common mechanisms of injury were by portable stove accident, assault, and tobacco or methamphetamine-related. Median percent total body surface area (%TBSA) burned was 6% (IQR 9%). Maximum depth of injury was partial thickness in 65% (n=45) and full thickness in 35% (n=24) of patients. Burns to the upper and lower extremities were present in 87% and 54% of patients, respectively. Median hospital Length-of-Stay (LOS) was 10 days (IQR=10.5) and median ICU LOS was 1 day (IQR=5). Inhalation injury was present in 14% (n=10) of patients. Surgical intervention was required in 43% (n=30) of patients, which included excision, debridement, skin grafting, and escharotomy. In-hospital mortality occurred in 4% (n=3) of patients. Tent fire burns are severe enough to require inpatient and ICU level of care. A high proportion of injuries involved the extremities and pose significant barriers to functional recovery in this vulnerable population. Strategies to prevent these injuries are paramount.
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Affiliation(s)
- Samantha Huang
- Keck School of Medicine, University of Southern California, Los Angeles, CA.,Los Angeles County Regional Burn Center, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
| | - Katherine J Choi
- Keck School of Medicine, University of Southern California, Los Angeles, CA.,Los Angeles County Regional Burn Center, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
| | - Christopher H Pham
- Keck School of Medicine, University of Southern California, Los Angeles, CA.,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Los Angeles County Regional Burn Center, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
| | - Zachary J Collier
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Los Angeles County Regional Burn Center, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
| | - Justin M Dang
- Los Angeles County Regional Burn Center, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
| | - Harriet Kiwanuka
- Northern California Regional Burn Center at Santa Clara Valley Medical Center, San Jose CA; Stanford University, Stanford, CA
| | - Clifford C Sheckter
- Northern California Regional Burn Center at Santa Clara Valley Medical Center, San Jose CA; Stanford University, Stanford, CA
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Los Angeles County Regional Burn Center, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
| | - T Justin Gillenwater
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.,Los Angeles County Regional Burn Center, Los Angeles County + University of Southern California Medical Center, Los Angeles, CA
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16
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Hajek A, Bertram F, Heinrich F, van Rüth V, Ondruschka B, Kretzler B, Schüler C, Püschel K, König HH. Determinants of health care use among homeless individuals: evidence from the Hamburg survey of homeless individuals. BMC Health Serv Res 2021; 21:317. [PMID: 33827570 PMCID: PMC8026095 DOI: 10.1186/s12913-021-06314-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/22/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND To identify the determinants of health care use among homeless individuals. METHODS Data were taken from the Hamburg survey of homeless individuals (n = 100 individuals in the here used model, mean age 44.8 years, SD 12.5) focusing on homeless individuals in Hamburg, Germany. The number of physician visits in the past 3 months and hospitalization in the preceding 12 months were used as outcome measures. Drawing on the Andersen model of health care use as a conceptual framework, predisposing characteristics, enabling resources and need factors as well as psychosocial variables were included as correlates. RESULTS Negative binomial regressions showed that increased physician visits were associated with being female (IRR: 4.02 [95% CI: 1.60-10.11]), absence of chronic alcohol consume (IRR: 0.26 [95% CI: 0.12-0.57]) and lower health-related quality of life (IRR: 0.97 [95% CI: 0.96-0.98]). Furthermore, logistic regressions showed that the likelihood of hospitalization was positively associated with lower age (OR: 0.93 [95% CI: 0.89-0.98]), having health insurance (OR: 8.11 [2.11-30.80]) and lower health-related quality of life (OR: 0.97 [95% CI: 0.94-0.99]). CONCLUSIONS Our study showed that predisposing characteristics (both age and sex), enabling resources (i.e., health insurance) and need factors in terms of health-related quality of life are main drivers of health care use among homeless individuals. This knowledge may assist in managing health care use.
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Affiliation(s)
- André Hajek
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Franziska Bertram
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Heinrich
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Victoria van Rüth
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Ondruschka
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Kretzler
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Schüler
- Deutsches Rotes Kreuz Kreisverband Hamburg Altona und Mitte e.V, Hamburg, Germany
| | - Klaus Püschel
- Institute of Legal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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17
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Villegas C, Ibabe I, Arnoso A. People at risk of social exclusion: mental health, structural-economic factors and sociocultural factors ( Personas en riesgo de exclusión social: salud mental, factores económico-estructurales y socio-culturales). INTERNATIONAL JOURNAL OF SOCIAL PSYCHOLOGY 2020. [DOI: 10.1080/02134748.2020.1840235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | - Izaskun Ibabe
- Universidad del País Vasco / Euskal Herriko Unibertsitatea
| | - Ainara Arnoso
- Universidad del País Vasco / Euskal Herriko Unibertsitatea
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