A WISH to be Housed: Exploring the Winter Interim Solution to Homelessness (WISH) Temporary Accommodation Model in London, Canada

Health impacts of cold exposure among people experiencing homelessness: A narrative systematic review on risks and risk-reduction approaches

OBJECTIVE

To systematically review evidence from high income countries on health risks from cold weather exposure among people experiencing homelessness (PEH) and assess evidence on risk-reduction interventions and their effectiveness.

STUDY DESIGN

Narrative systematic review.

METHODS

Keyword-structured searches were performed in CINAHL, Emcare, Medline, SocINDEX, Scopus, OpenGrey, Social Policy and Practice and Web of Science, and supplemented by grey literature searches in a selection of other databases, from 1973 to 2024. Articles were double-screened on title/abstract and full text. Extracted data included information on study setting and population, health risks from cold exposure, intervention characteristics and effect sizes where reported. Studies were critically appraised using Joanna Briggs Institute checklists.

RESULTS

24 studies were included, predominantly from the UK and US. People sleeping rough were found to be at greater risk than the general population of mortality due to hypothermia, and of hypothermic injury. Studies assessing health service utilisation indicated higher than population average admission rates due to cold exposure among PEH. Studies on interventions to reduce health risks from cold exposure in these populations all addressed multi-component programmes including shelter provision as a central component. Evidence of effectiveness was very limited.

CONCLUSION

PEH are at greater risk of death from hypothermia, and of hypothermic injury due to cold exposure than the general population. The use of overnight shelters and severe weather emergency plans are established approaches in high income settings for reducing risks from cold exposure among those sleeping rough, but further evidence on effectiveness is needed.

Opioid-related overdose deaths among people experiencing homelessness, 2017 to 2021: A population-based analysis using coroner and health administrative data from Ontario, Canada

AIMS

To measure the change in proportion of opioid-related overdose deaths attributed to people experiencing homelessness and to compare the opioid-related fatalities between individuals experiencing homelessness and not experiencing homelessness at time of death.

DESIGN, SETTING AND PARTICIPANTS

Population-based, time-trend analysis using coroner and health administrative databases from Ontario, Canada from 1 July 2017 and 30 June 2021.

MEASUREMENTS

Quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness. We also obtained socio-demographic and health characteristics of decedents, health-care encounters preceding death, substances directly contributing to death and circumstances surrounding deaths.

FINDINGS

A total of 6644 individuals (median age = 40 years, interquartile range = 31-51; 74.1% male) experienced an accidental opioid-related overdose death, among whom 884 (13.3%) were identified as experiencing homelessness at the time of death. The quarterly proportion of opioid-related overdose deaths attributed to people experiencing homelessness increased from 7.2% (26/359) in July-September 2017 to 16.8% (97/578) by April-June 2021 (trend test P < 0.01). Compared with housed decedents, those experiencing homelessness were younger (61.3 versus 53.1% aged 25-44), had higher prevalence of mental health or substance use disorders (77.1 versus 67.1%) and more often visited hospitals (32.1 versus 24.5%) and emergency departments (82.6 versus 68.5%) in the year prior to death. Fentanyl and its analogues more often directly contributed to death among people experiencing homelessness (94.0 versus 81.4%), as did stimulants (67.4 versus 51.6%); in contrast, methadone was less often present (7.8 versus 12.4%). Individuals experiencing homelessness were more often in the presence of a bystander during the acute toxicity event that led to death (55.8 versus 49.7%); and where another individual was present, more often had a resuscitation attempted (61.7 versus 55.1%) or naloxone administered (41.2 versus 28.9%).

CONCLUSIONS

People experiencing homelessness account for an increasing proportion of fatal opioid-related overdoses in Ontario, Canada, reaching nearly one in six such deaths in 2021.