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Smaha J, Falat J, Gažová A, Kužma M, Kyselovič J, Palkovič M, Kuruc R, Babál P, Payer J, Jackuliak P. Comparison of Causes of Mortality Between Hospitalized Unsheltered Homeless Patients and Non-Homeless Sex and Age-Matched Controls: A Retrospective Case-Control Study. Int J Public Health 2024; 69:1607642. [PMID: 39355756 PMCID: PMC11442349 DOI: 10.3389/ijph.2024.1607642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 09/06/2024] [Indexed: 10/03/2024] Open
Abstract
Objectives Roofless individuals represent the most severe category of homelessness. Their clinical characteristics and mortality patterns in Central and Eastern Europe are little known. Methods A single-center retrospective case-control study at the internal medicine department in Bratislava, Slovakia was conducted. 5694 mortality records from 2010 to 2023 were screened, and 141 (118 men, 23 women) roofless individuals were identified. Patients were sex- and age-matched, with 141 patients from the cohort of non-homeless deceased patients. Results Compared to controls, roofless people had a higher incidence of immobility (p = 0.02) and hypothermia (p < 0.0001) at admission. 83% of the roofless people were men, and 59% of the roofless people died before reaching old age (60+). Homeless men died more often from infectious disease (p = 0.02), pneumonia being the most common one (60%). Men from the control group died more often from liver diseases (p = 0.03). There were no significant differences in the causes of mortality between women. Conclusion These findings could help to reduce the invisibility of the issue of massive premature mortality amongst homeless populations and roofless individuals, in particular.
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Affiliation(s)
- Juraj Smaha
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Jakub Falat
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Andrea Gažová
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Martin Kužma
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Ján Kyselovič
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Michal Palkovič
- Institute of Pathological Anatomy, Faculty of Medicine, Comenius University, Bratislava, Slovakia
- The Health Care Surveillance Authority, Bratislava, Slovakia
| | - Roman Kuruc
- Institute of Forensic Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Pavel Babál
- Institute of Pathological Anatomy, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Juraj Payer
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Peter Jackuliak
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
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Decker H, Colom S, Evans JL, Graham-Squire D, Perez K, Kushel M, Wick E, Raven MC, Kanzaria HK. Association of housing status and cancer diagnosis, care coordination and outcomes in a public hospital: a retrospective cohort study. BMJ Open 2024; 14:e088303. [PMID: 39266319 PMCID: PMC11404260 DOI: 10.1136/bmjopen-2024-088303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2024] Open
Abstract
OBJECTIVES Cancer is a leading cause of death in unhoused adults. We sought to examine the association between housing status, stage at diagnosis and all-cause survival following cancer diagnosis at a public hospital. DESIGN Retrospective cohort study examining new cancer diagnoses between 1 July 2011 and 30 June 2021. SETTING A public hospital in San Francisco. EXPOSURE Housing status (housed, formerly unhoused, unhoused) was ascertained via a county-wide integrated dataset that tracks both observed and reported homelessness. METHODS We reported univariate analyses to investigate differences in demographic and clinical characteristics by housing group. We then constructed Kaplan-Meier curves stratified by housing group to examine unadjusted all-cause mortality. Finally, we used multivariable Cox proportional hazards models to compare the hazard rate of mortality for each housing status group, adjusting for demographic and clinical factors. RESULTS Our cohort included 5123 patients with new cancer diagnoses, with 4062 (79%) in housed patients, 623 (12%) in formerly unhoused patients and 438 (9%) in unhoused patients. Unhoused and formerly unhoused patients were more commonly diagnosed with stage 4 disease (28% and 27% of the time, respectively, vs 22% of housed patients). After adjusting for demographic and clinical characteristics, unhoused patients with stage 0-3 disease had a 50% increased hazard of death (adjusted HR (aHR) 1.5, 95% CI 1.1 to 1.9; p<0.004) as did formerly unhoused patients (aHR 1.5, 95% CI 1.2 to 1.9; p=0.001) compared with housed individuals 3 months after diagnosis. CONCLUSIONS Unhoused and formerly unhoused patients diagnosed with non-metastatic cancer had substantially increased hazards of death compared with housed patients cared for in a public hospital setting. Current or former lack of housing could contribute to poor outcomes following cancer diagnoses via multiple mechanisms.
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Affiliation(s)
- Hannah Decker
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Sara Colom
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Jennifer L Evans
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Dave Graham-Squire
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Kenneth Perez
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Margot Kushel
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Internal Medicine, UCSF, San Francisco, California, USA
| | - Elizabeth Wick
- Department of Surgery, UCSF, San Francisco, California, USA
| | - Maria C Raven
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hemal K Kanzaria
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
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Baggett TP, Sporn N, Barbosa Teixeira J, Rodriguez EC, Anandakugan N, Critchley N, Kennedy E, Hart K, Joyce A, Chang Y, Percac-Lima S, Park ER, Rigotti NA. Patient Navigation for Lung Cancer Screening at a Health Care for the Homeless Program: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:892-902. [PMID: 38856994 PMCID: PMC11165412 DOI: 10.1001/jamainternmed.2024.1662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 03/21/2024] [Indexed: 06/11/2024]
Abstract
Importance People experiencing homelessness die of lung cancer at rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, but the circumstances of homelessness create barriers to LCS participation. Objective To determine whether patient navigation, added to usual care, improved LCS LDCT receipt at a large Health Care for the Homeless (HCH) program. Design, Setting, and Participants This parallel group, pragmatic, mixed-methods randomized clinical trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that provides tailored, multidisciplinary care to nearly 10 000 homeless-experienced patients annually. Eligible individuals had a lifetime history of homelessness, had a BHCHP primary care practitioner (PCP), were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS (aged 55-77 years, ≥30 pack-year history of smoking, and smoking within the past 15 years). The study was conducted between November 20, 2020, and March 29, 2023. Intervention Participants were randomized 2:1 to usual BHCHP care either with or without patient navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted participants in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers. Main Outcomes and Measures The primary outcome was receipt of a 1-time LCS LDCT within 6 months after randomization, with between-group differences assessed by χ2 analysis. Qualitative interviews assessed the perceptions of participants and PCPs about the navigation intervention. Results In all, 260 participants (mean [SD] age, 60.5 [4.7] years; 184 males [70.8%]; 96 non-Hispanic Black participants [36.9%] and 96 non-Hispanic White participants [36.9%]) were randomly assigned to usual care with (n = 173) or without (n = 87) patient navigation. At 6 months after randomization, 75 participants in the patient navigation arm (43.4%) and 8 of those in the usual care-only arm (9.2%) had completed LCS LDCT (P < .001), representing a 4.7-fold difference. Interviews with participants in the patient navigation arm and PCPs identified key elements of the intervention: multidimensional social support provision, care coordination activities, and interpersonal skills of the navigator. Conclusions and Relevance In this randomized clinical trial, patient navigation support produced a 4.7-fold increase in 1-time LCS LDCT completion among HCH patients in Boston. Future work should focus on longer-term screening participation and outcomes. Trial Registration ClinicalTrials.gov Identifier: NCT04308226.
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Affiliation(s)
- Travis P. Baggett
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Institute for Research, Quality & Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Nora Sporn
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Joana Barbosa Teixeira
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | | | | | - Natalia Critchley
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Evangeline Kennedy
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Katherine Hart
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Andrea Joyce
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
| | - Yuchiao Chang
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Elyse R. Park
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Nancy A. Rigotti
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston
- Mongan Institute, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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McKee Hurwitz H, Shah C. Cancer Prevention for Women Experiencing Homelessness: Onsite Mammography, Navigation, and Education. JCO Oncol Pract 2024:OP2400188. [PMID: 38986028 DOI: 10.1200/op.24.00188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/20/2024] [Accepted: 05/29/2024] [Indexed: 07/12/2024] Open
Abstract
PURPOSE Persons experiencing homelessness (PEHs) represent a medically underserved population with a disproportionately high rate of late-stage cancer diagnoses and cancer mortality. During mobile onsite mammography and breast health education events, we studied PEH's barriers to and uptake of cancer screenings. METHODS This study used patient surveys and review of the electronic health record. The main outcome measures included mammogram and diagnostic imaging (as needed) results. A questionnaire assessed patient's views and barriers related to social determinants of health. The study included women accessing community organization resources who were 40 years or older or who met criteria for screening mammography. RESULTS Forty-six individuals completed mammograms and 41 individuals participated in the survey, for a response rate of 89%. Thirty-five participants (85%) held health insurance provided by a Medicaid managed plan. Thirty-six participants (87%) received a negative mammogram result, and five participants (12%) required follow-up for abnormal results. Of these five, two participants completed diagnostic follow-up with negative results, and three did not complete diagnostic follow-up. In addition to barriers related to housing insecurity, five patients (12%) reported transportation barriers. A majority (n = 28, 68%) disagreed or strongly disagreed with the statement, "I'm afraid the mammogram will be painful." A majority (n = 31, 76%) disagreed or strongly disagreed with the statement, "I'm busy and do not have time." Nearly all participants (n = 37, 90%) responded yes to the statement, "I believe in preventative care screenings." Eight participants (20%) completed at least one additional cancer screening. CONCLUSION By creating enduring programs offering screening, navigation, and education, academic-community partnerships may begin to address the increased cancer mortality among PEHs by improving screening adherence.
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Affiliation(s)
- Heather McKee Hurwitz
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Chirag Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Decker H, Colom S, Graham-Squire D, Wick E, Kushel MB, Raven M, Kanzaria HK. Housing Status and Acute Care Use After Cancer Diagnosis. JAMA Netw Open 2024; 7:e2419657. [PMID: 38954418 PMCID: PMC11220561 DOI: 10.1001/jamanetworkopen.2024.19657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/30/2024] [Indexed: 07/04/2024] Open
Abstract
This cohort study examines housing status and acute care use after a cancer diagnosis among individuals treated at a public hospital in San Francisco, California.
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Affiliation(s)
- Hannah Decker
- Department of Surgery, University of California, San Francisco
| | - Sara Colom
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital, California
| | - Dave Graham-Squire
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital, California
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
| | - Margot B. Kushel
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital, California
- Department of Internal Medicine, University of California, San Francisco
| | - Maria Raven
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital, California
- Department of Emergency Medicine, University of California, San Francisco
| | - Hemal K. Kanzaria
- Benioff Homelessness and Housing Initiative, Zuckerberg San Francisco General Hospital, California
- Department of Emergency Medicine, University of California, San Francisco
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Martinez Leal I, Siddiqi AD, Rogova A, Britton M, Chen TA, Williams T, Casey K, Sanchez H, Reitzel LR. Enablers and Inhibitors to Implementing Tobacco Cessation Interventions within Homeless-Serving Agencies: A Qualitative Analysis of Program Partners' Experiences. Cancers (Basel) 2024; 16:2162. [PMID: 38893280 PMCID: PMC11171900 DOI: 10.3390/cancers16112162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
Despite the high tobacco use rates (~80%) and tobacco-related cancers being the second leading cause of death among people experiencing homelessness within the United States, these individuals rarely receive tobacco use treatment from homeless-serving agencies (HSAs). This qualitative study explored the enablers and inhibitors of implementing an evidence-based tobacco-free workplace (TFW) program offering TFW policy adoption, specialized provider training to treat tobacco use, and nicotine replacement therapy (NRT) within HSAs. Pre- and post-implementation interviews with providers and managers (n = 13) pursued adapting interventions to specific HSAs and assessed the program success, respectively. The organizational readiness for change theory framed the data content analysis, yielding three categories: change commitment, change efficacy and contextual factors. Pre- to post-implementation, increasing challenges impacted the organizational capacity and providers' attitudes, wherein previously enabling factors were reframed as inhibiting, resulting in limited implementation despite resource provision. These findings indicate that low-resourced HSAs require additional support and guidance to overcome infrastructure challenges and build the capacity needed to implement a TFW program. This study's findings can guide future TFW program interventions, enable identification of agencies that are well-positioned to adopt such programs, and facilitate capacity-building efforts to ensure their successful participation.
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Affiliation(s)
- Isabel Martinez Leal
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Houston, TX 77030, USA; (A.D.S.); (M.B.); (H.S.); (L.R.R.)
| | - Ammar D. Siddiqi
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Houston, TX 77030, USA; (A.D.S.); (M.B.); (H.S.); (L.R.R.)
- Department of Biosciences, Rice University, 6100 Main Street, Houston, TX 77005, USA
| | - Anastasia Rogova
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA;
| | - Maggie Britton
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Houston, TX 77030, USA; (A.D.S.); (M.B.); (H.S.); (L.R.R.)
| | - Tzuan A. Chen
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd., Houston, TX 77204, USA;
- Health Research Institute, The University of Houston, 4349 Martin Luther King Blvd., Houston, TX 77204, USA
| | - Teresa Williams
- Integral Care, 1430 Collier Street, Austin, TX 78704, USA; (T.W.); (K.C.)
| | - Kathleen Casey
- Integral Care, 1430 Collier Street, Austin, TX 78704, USA; (T.W.); (K.C.)
| | - Hector Sanchez
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Houston, TX 77030, USA; (A.D.S.); (M.B.); (H.S.); (L.R.R.)
| | - Lorraine R. Reitzel
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, 1155 Pressler Street, Houston, TX 77030, USA; (A.D.S.); (M.B.); (H.S.); (L.R.R.)
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Bourgeois A, Horrill T, Mollison A, Stringer E, Lambert LK, Stajduhar K. Barriers to cancer treatment for people experiencing socioeconomic disadvantage in high-income countries: a scoping review. BMC Health Serv Res 2024; 24:670. [PMID: 38807237 PMCID: PMC11134650 DOI: 10.1186/s12913-024-11129-2] [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: 09/12/2023] [Accepted: 05/21/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Despite advances in cancer research and treatment, the burden of cancer is not evenly distributed. People experiencing socioeconomic disadvantage have higher rates of cancer, later stage at diagnoses, and are dying of cancers that are preventable and screen-detectable. However, less is known about barriers to accessing cancer treatment. METHODS We conducted a scoping review of studies examining barriers to accessing cancer treatment for populations experiencing socioeconomic disadvantage in high-income countries, searched across four biomedical databases. Studies published in English between 2008 and 2021 in high-income countries, as defined by the World Bank, and reporting on barriers to cancer treatment were included. RESULTS A total of 20 studies were identified. Most (n = 16) reported data from the United States, and the remaining included publications were from Canada (n = 1), Ireland (n = 1), United Kingdom (n = 1), and a scoping review (n = 1). The majority of studies (n = 9) focused on barriers to breast cancer treatment. The most common barriers included: inadequate insurance and financial constraints (n = 16); unstable housing (n = 5); geographical distribution of services and transportation challenges (n = 4); limited resources for social care needs (n = 7); communication challenges (n = 9); system disintegration (n = 5); implicit bias (n = 4); advanced diagnosis and comorbidities (n = 8); psychosocial dimensions and contexts (n = 6); and limited social support networks (n = 3). The compounding effect of multiple barriers exacerbated poor access to cancer treatment, with relevance across many social locations. CONCLUSION This review highlights barriers to cancer treatment across multiple levels, and underscores the importance of identifying patients at risk for socioeconomic disadvantage to improve access to treatment and cancer outcomes. Findings provide an understanding of barriers that can inform future, equity-oriented policy, practice, and service innovation.
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Affiliation(s)
- Amber Bourgeois
- Institute for Aging & Lifelong Health, University of Victoria, PO Box 1700, Victoria, BC, V8V 2Y2, Canada.
- BC Cancer, Nursing and Allied Health Research and Knowledge Translation, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada.
| | - Tara Horrill
- College of Nursing, University of Manitoba, 89 Curry Place, Winnipeg, MB, R3T 2N2, Canada
| | - Ashley Mollison
- Institute for Aging & Lifelong Health, University of Victoria, PO Box 1700, Victoria, BC, V8V 2Y2, Canada
| | - Eleah Stringer
- BC Cancer, Nursing and Allied Health Research and Knowledge Translation, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada
| | - Leah K Lambert
- BC Cancer, Nursing and Allied Health Research and Knowledge Translation, 686 West Broadway, Vancouver, BC, V5Z 1G1, Canada
- School of Nursing, University of British Columbia, 2211 Wesbrook Mall T201, Vancouver, BC, V6T 2B5, Canada
| | - Kelli Stajduhar
- Institute for Aging & Lifelong Health, University of Victoria, PO Box 1700, Victoria, BC, V8V 2Y2, Canada
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Coronado-Vázquez MDV, Gómez-Trenado R, Benito-Sánchez B, Barrio-Cortes J, Gil-Salmerón A, Amengual-Pliego M, Grabovac I. Cancer prevention in people experiencing homelessness: ethical considerations and experiences from the CANCERLESS project. Front Public Health 2024; 12:1371505. [PMID: 38655508 PMCID: PMC11036339 DOI: 10.3389/fpubh.2024.1371505] [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: 01/16/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
The incidence of cancer in Europe has been increasing in recent years. Despite this, cancer prevention has remained a low priority in health policies. Cancer is one of the main causes of mortality among people experiencing homelessness, who continue to have difficulties accessing prevention programs. A strategy that has been tested to favor cancer prevention is the health navigator figure. The objective of CANCERLESS project is to implement this model among populations experiencing homelessness in four European countries to foster the prevention and early detection of cancer. In this perspective, a presentation of CANCERLESS project is made, and its ethical aspects are discussed according to the ethics of public health, the ethics of care, solidarity, relational autonomy, and the social recognition of the virtue of just generosity. The ethical foundations of CANCERLESS project are rooted in social justice and in equity in access to health systems in general and cancer screening programs in particular. The ethics of public health guided by utilitarianism are insufficient in serving the interests of the most disadvantaged groups of the population. Hence, it is necessary to resort to relational bioethics that includes the ethics of care and solidarity and that recognizes the moral identity of socially excluded persons, reaffirming their position of equality in society. Relational autonomy therefore provides a broader conception by including the influence of living conditions in decisions. For this reason, the CANCERLESS project opts for a dialogue with those affected to incorporate their preferences and values into decisions about cancer prevention.
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Affiliation(s)
- María del Valle Coronado-Vázquez
- Healthcare Center Las Cortes, Gerencia 1 Healthcare Center Las Cortes, Gerencia Asistencial de Atención Primaria, Madrid, Spain
- Facultad de Medicina, Francisco de Vitoria University, Madrid, Spain
- B21-20R Group, Instituto Aragonés de Investigaciones Sanitarias, Universidad de Zaragoza, Zaragoza, Spain
| | - Rosa Gómez-Trenado
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), Madrid, Spain
- Health Work Department, Complutense University of Madrid, Madrid, Spain
| | - Beatriz Benito-Sánchez
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), Madrid, Spain
| | - Jaime Barrio-Cortes
- Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP), Madrid, Spain
- Faculty of Health, Camilo José Cela University, Madrid, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- Research Network on Chronicity, Primary Care and Prevention and Health Promotion, Carlos III Health Institute, Madrid, Spain
| | - Alejandro Gil-Salmerón
- International Foundation for Integrated Care, Oxford, United Kingdom
- International University of Valencia, Valencia, Spain
- Complutense University of Madrid, Madrid, Spain
| | - Miguel Amengual-Pliego
- B21-20R Group, Instituto Aragonés de Investigaciones Sanitarias, Universidad de Zaragoza, Zaragoza, Spain
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Medical University of Vienna, Vienna, Austria
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9
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Silver CM, Janczewski LM, Royan R, Chung JW, Bentrem DJ, Kanzaria HK, Stey AM, Bilimoria KY, Merkow RP. Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness. Ann Surg Oncol 2024; 31:1468-1476. [PMID: 38071712 DOI: 10.1245/s10434-023-14713-8] [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: 07/26/2023] [Accepted: 11/21/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH. METHODS This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP's "Homeless" variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs. RESULTS Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0-98.2%). Adjusted costs were 32.7% higher (95% CI 14.5-53.9%) among PEH. CONCLUSIONS PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.
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Affiliation(s)
- Casey M Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lauren M Janczewski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Regina Royan
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Jeannette W Chung
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hemal K Kanzaria
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anne M Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karl Y Bilimoria
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ryan P Merkow
- Department of Surgery, University of Chicago, Chicago, IL, USA.
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Asgary R. Cancer care and treatment during homelessness. Lancet Oncol 2024; 25:e84-e90. [PMID: 38301706 DOI: 10.1016/s1470-2045(23)00567-3] [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: 07/14/2023] [Revised: 09/24/2023] [Accepted: 10/27/2023] [Indexed: 02/03/2024]
Abstract
People experiencing homelessness have not yet benefited from the substantial progress made in managing cancers, including advances in chemotherapy and radiotherapy, surgical interventions, multidisciplinary team approaches, and integrated cancer care models. People experiencing homelessness are at higher risks of developing cancers and their mortality due to cancer is twice that of the general population. Potential interventions to improve access to cancer treatment include alliances and active engagement with community organisations and shelters, cancer case management and peer-to-peer support, mHealth and navigation strategies, tailored hospital discharge to adult group homes, well equipped subacute rehabilitation centres, and specialised shelters and respite housing to assure appropriate follow-up care. Other interventions include improving preventive care, expanding data, targeted policy efforts, and broader housing advocacy. In this Personal View, I discuss challenges and opportunities in cancer treatment, with a review of the current evidence on potential interventions, and highlight strategies to improve access to cancer care for homeless populations.
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Affiliation(s)
- Ramin Asgary
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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11
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Jeleff M, Haider S, Schiffler T, Gil-Salmerón A, Yang L, Barreto Schuch F, Grabovac I. Cancer risk factors and access to cancer prevention services for people experiencing homelessness. Lancet Public Health 2024; 9:e128-e146. [PMID: 38307679 DOI: 10.1016/s2468-2667(23)00298-0] [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: 06/29/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 02/04/2024]
Abstract
Cancer is one of the most pressing global health issues, and populations with complex needs, such as people experiencing homelessness, have higher cancer incidence and mortality rates compared with the housed population. We mapped the evidence on cancer risk factors as well as barriers and facilitators to cancer prevention services among people experiencing homelessness, which is key to localising research gaps and identifying strategies for tailored interventions adapted to people experiencing homelessness. The results of 40 studies contribute to an understanding of the dynamic, interactive factors at different levels that determine access to cancer prevention services: socioeconomic, psychological, and physical factors (individual level); practical support and relational loops between health-care providers and people experiencing homelessness (interpersonal level); housing and regular medical care (system level); and interventions to facilitate access to cancer prevention (policy level). Furthermore, studies reported higher prevalence of various cancer-associated risk factors among people experiencing homelessness with the most common being tobacco use, ranging from 26% to 73%. The results show the importance of interventions to facilitate cancer prevention services through social support and low-threshold interventions (eg, navigation programmes), and training health-care staff in creating supportive and trusting environments that increase the likelihood of the continuity of care among people experiencing homelessness.
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Affiliation(s)
- Maren Jeleff
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Sandra Haider
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria.
| | - Tobias Schiffler
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Alejandro Gil-Salmerón
- International Foundation for Integrated Care, Oxford, UK; International University of Valencia, Valencia, Spain; Complutense University of Madrid, Madrid, Spain
| | - Lin Yang
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Canada; Department of Oncology and Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Felipe Barreto Schuch
- Department of Sports Methods and Techniques, Federal University of Santa Maria, Santa Maria, Brazil; Faculty of Health Sciences, Universidad Autónoma de Chile, Providencia, Chile
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
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12
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Decker HC, Graham LA, Titan A, Hawn MT, Kanzaria HK, Wick E, Kushel MB. Housing Status Changes Are Associated With Cancer Outcomes Among US Veterans. Health Aff (Millwood) 2024; 43:234-241. [PMID: 38315919 DOI: 10.1377/hlthaff.2023.01003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Cancer is a leading cause of death in older unhoused adults. We assessed whether being unhoused, gaining housing, or losing housing in the year after cancer diagnosis is associated with poorer survival compared with being continuously housed. We examined all-cause survival in more than 100,000 veterans diagnosed with lung, colorectal, and breast cancer during the period 2011-20. Five percent were unhoused at the time of diagnosis, of whom 21 percent gained housing over the next year; 1 percent of veterans housed at the time of diagnosis lost housing. Continuously unhoused veterans and veterans who lost their housing had poorer survival after lung and colorectal cancer diagnosis compared with those who were continuously housed. There was no survival difference between veterans who gained housing after diagnosis and veterans who were continuously housed. These findings support policies to prevent and end homelessness in people after cancer diagnosis, to improve health outcomes.
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Affiliation(s)
- Hannah C Decker
- Hannah C. Decker , University of California San Francisco, San Francisco, California
| | - Laura A Graham
- Laura A. Graham, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Ashley Titan
- Ashley Titan, Stanford University, Stanford, California
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13
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Ozcan BB, Dogan BE, Mootz AR, Hayes JC, Seiler SJ, Schopp J, Kitchen DL, Porembka JH. Breast Cancer Disparity and Outcomes in Underserved Women. Radiographics 2024; 44:e230090. [PMID: 38127658 DOI: 10.1148/rg.230090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Women in the United States who continue to face obstacles accessing health care are frequently termed an underserved population. Safety-net health care systems play a crucial role in mitigating health disparities and reducing burdens of disease, such as breast cancer, for underserved women. Disparities in health care are driven by various factors, including race and ethnicity, as well as socioeconomic factors that affect education, employment, housing, insurance status, and access to health care. Underserved women are more likely to be uninsured or underinsured throughout their lifetimes. Hence they have greater difficulty gaining access to breast cancer screening and are less likely to undergo supplemental imaging when needed. Therefore, underserved women often experience significant delays in the diagnosis and treatment of breast cancer, leading to higher mortality rates. Addressing disparities requires a multifaceted approach, with formal care coordination to help at-risk women navigate through screening, diagnosis, and treatment. Mobile mammography units and community outreach programs can be leveraged to increase community access and engagement, as well as improve health literacy with educational initiatives. Radiology-community partnerships, comprised of imaging practices partnered with local businesses, faith-based organizations, homeless shelters, and public service departments, are essential to establish culturally competent breast imaging care, with the goal of equitable access to early diagnosis and contemporary treatment. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the Online Learning Center. See the invited commentary by Leung in this issue.
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Affiliation(s)
- B Bersu Ozcan
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Başak E Dogan
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Ann R Mootz
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jody C Hayes
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Stephen J Seiler
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jennifer Schopp
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Deanna L Kitchen
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
| | - Jessica H Porembka
- From the Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, MC 8896, Dallas, TX 75390-8896
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Decker HC, Graham LA, Titan A, Kanzaria HK, Hawn MT, Kushel M, Wick E. Housing Status, Cancer Care, and Associated Outcomes Among US Veterans. JAMA Netw Open 2023; 6:e2349143. [PMID: 38127343 PMCID: PMC10739065 DOI: 10.1001/jamanetworkopen.2023.49143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Cancer is a leading cause of death among older people experiencing homelessness. However, the association of housing status with cancer outcomes is not well described. Objective To characterize the diagnosis, treatment, surgical outcomes, and mortality by housing status of patients who receive care from the US Department of Veterans Affairs (VA) health system for colorectal, breast, or lung cancer. Design, Setting, and Participants This retrospective cohort study identified all US veterans diagnosed with lung, colorectal, or breast cancer who received VA care between October 1, 2011, and September 30, 2020. Data analysis was performed from February 13 to May 9, 2023. Exposures Veterans were classified as experiencing homelessness if they had any indicators of homelessness in outpatient visits, clinic reminders, diagnosis codes, or the Homeless Operations Management Evaluation System in the 12 months preceding diagnosis, with no subsequent evidence of stable housing. Main Outcomes and Measures The major outcomes, by cancer type, were as follows: (1) treatment course (eg, stage at diagnosis, time to treatment initiation), (2) surgical outcomes (eg, length of stay, major complications), (3) overall survival by cancer type, and (4) hazard ratios for overall survival in a model adjusted for age at diagnosis, sex, stage at diagnosis, race, ethnicity, marital status, facility location, and comorbidities. Results This study included 109 485 veterans, with a mean (SD) age of 68.5 (9.7) years. Men comprised 92% of the cohort. In terms of race and ethnicity, 18% of veterans were Black, 4% were Hispanic, and 79% were White. A total of 68% of participants had lung cancer, 26% had colorectal cancer, and 6% had breast cancer. There were 5356 veterans (5%) experiencing homelessness, and these individuals more commonly presented with stage IV colorectal cancer than veterans with housing (22% vs 19%; P = .02). Patients experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. These patients also demonstrated higher rates of all-cause mortality 3 months after diagnosis for lung and colorectal cancers, with adjusted hazard ratios of 1.1 (95% CI, 1.1-1.2) and 1.3 (95% CI, 1.2-1.4) (both P < .001), respectively. Conclusions and Relevance In this large retrospective study of US veterans with cancer, homelessness was associated with later stages at diagnosis for colorectal cancer. Differences in lung and colorectal cancer survival between patients with housing and those experiencing homelessness were present but smaller than observed in other settings. These findings suggest that there may be important systems in the VA that could inform policy to improve oncologic outcomes for patients experiencing homelessness.
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Affiliation(s)
| | - Laura A. Graham
- Health Economics Resource Center, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- S-SPIRE, Stanford University, Stanford, California
| | - Ashley Titan
- Department of Surgery, Stanford University, Stanford, California
| | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
| | - Mary T. Hawn
- Department of Surgery, Stanford University, Stanford, California
| | - Margot Kushel
- Benioff Homelessness and Housing Initiative, University of California, San Francisco
- Division of General Internal Medicine, Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco
| | - Elizabeth Wick
- Department of Surgery, University of California, San Francisco
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Schiffler T, Jeleff M, Gil-Salmerón A, Yang L, Haider S, Schuch FB, Grabovac I. Cancer risk factors and access to cancer prevention services for people experiencing homelessness: a scoping review protocol. BMJ Open 2023; 13:e074710. [PMID: 37597871 PMCID: PMC10441056 DOI: 10.1136/bmjopen-2023-074710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/18/2023] [Indexed: 08/21/2023] Open
Abstract
INTRODUCTION Homelessness is a complex social issue that significantly impairs the health of those affected. People experiencing homelessness (PEH) have a higher prevalence of adverse health outcomes, including premature mortality, compared with the general population, with cancer being the second-leading cause of death. The objective of this scoping review is to map the evidence to assess the exposure of PEH to known cancer risk factors and identify barriers and facilitators PEH experience in accessing cancer prevention services. METHODS AND ANALYSIS This scoping review will be conducted in line with the Joanna Briggs Institute guidelines for scoping reviews. For a time window from the date of database establishment until 20 February 2023, the research team will create a detailed search strategy and apply it to the following databases: CINAHL, Embase, Global Index Medicus, PubMed, Scopus and Web of Science. In addition, we will search OpenGrey and Google for grey literature and contact non-governmental organisations to request relevant reports. In the first stage, eligibility criteria will be assessed through a blinded title/abstract assessment, and following this assessment, a full-text screening will be performed. Subsequently, the research team will perform the data extraction and synthesise all relevant information in relation to the scoping review question. ETHICS AND DISSEMINATION As this protocol does not involve gathering primary data, ethical approval is not necessary. The results of this review will be published in a peer-reviewed journal and on institutional websites.
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Affiliation(s)
- Tobias Schiffler
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Maren Jeleff
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Alejandro Gil-Salmerón
- International Foundation for Integrated Care, Oxford, UK
- International University of Valencia, Valencia, Spain
| | - Lin Yang
- Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
- Departments of Oncology and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Sandra Haider
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Felipe B Schuch
- Department of Sports Methods and Techniques, Federal University of Santa Maria, Santa Maria, Brazil
- Faculty of Health Sciences, Universidad Autonoma de Chile, Providencia, Chile
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, Vienna, Austria
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16
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Taylor SN, Munson D. Health Care of People Experiencing Homelessness: Part I. NEJM EVIDENCE 2023; 2:EVIDra2300123. [PMID: 38320148 DOI: 10.1056/evidra2300123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Homelessness and Health CarePeople who experience homelessness have high rates of medical illness. They struggle with conditions associated with living in crowded shelters, trauma, and exposure to extreme weather. Here, Taylor and Munson review the care of this vulnerable population.
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Affiliation(s)
| | - David Munson
- Massachusetts General Hospital, Boston
- Boston Health Care for the Homeless Program, Boston
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17
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Malden S, Doi L, Ng L, Cuthill F. Reducing hospital readmissions amongst people experiencing homelessness: a mixed-methods evaluation of a multi-disciplinary hospital in-reach programme. BMC Public Health 2023; 23:1117. [PMID: 37308856 PMCID: PMC10258765 DOI: 10.1186/s12889-023-16048-1] [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: 10/13/2022] [Accepted: 06/03/2023] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION People experiencing homelessness are at increased risk of experiencing ill-health. They are often readmitted to hospital after discharge, usually for the same or similar reasons for initial hospitalisation. One way of addressing this issue is through hospital in-reach initiatives, which have been established to enhance the treatment and discharge pathways that patients identified as homeless receive after hospital admission. Since 2020, the Hospital In-reach programme (which involves targeted clinical interventions and structured discharge support) has been piloted in two large National Health Service (NHS) hospitals in Edinburgh, United Kingdom (UK). This study describes an evaluation of the programme. METHODS This evaluation used a mixed method, pre-post design. To assess the effect of the programme on hospital readmission rates from baseline (12 months pre-intervention) and follow-up (12 months post-intervention), aggregate data describing the proportions of homeless-affected individuals admitted to hospital during the evaluation period were analysed using Wilcoxon signed rank test, with level of significance set at p = 0.05. Qualitative interviews were conducted with fifteen programme and hospital staff (nurses, general practitioners, homeless link workers) to assess the processes of the programme. RESULTS A total of 768 referrals, including readmissions, were made to the In-reach programme during the study period, of which eighty-eight individuals were followed up as part of the study. In comparison to admissions in the previous 12 months, readmissions were significantly reduced at 12 months follow-up by 68.7% (P = 0.001) for those who received an in-reach intervention of any kind. Qualitative findings showed that the programme was valued by hospital staff and homeless community workers. Housing services and clinical staff attributed improvements in services to their ability to collaborate more effectively in secondary care settings. This ensured treatment regimens were completed and housing was retained during hospital admission, which facilitated earlier discharge planning. CONCLUSIONS A multidisciplinary approach to reducing readmissions in people experiencing homelessness was effective at reducing readmissions over a 12-month period. The programme appears to have enhanced the ability for multiple agencies to work more closely and ensure the appropriate care is provided for those at risk of readmission to hospital among people affected by homelessness.
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Affiliation(s)
- Stephen Malden
- Scottish Collaboration for Public Health Research and Policy, University of Edinburgh, Edinburgh, EH8 9AG, Scotland.
| | - Lawrence Doi
- Scottish Collaboration for Public Health Research and Policy, University of Edinburgh, Edinburgh, EH8 9AG, Scotland
- Nursing Studies, School of Health in Social Science, University of Edinburgh, Edinburgh, Scotland
| | - Lauren Ng
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, Scotland
| | - Fiona Cuthill
- Nursing Studies, School of Health in Social Science, University of Edinburgh, Edinburgh, Scotland
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Bourgeois A, Horrill TC, Mollison A, Lambert LK, Stajduhar KI. Barriers to cancer treatment and care for people experiencing structural vulnerability: a secondary analysis of ethnographic data. Int J Equity Health 2023; 22:58. [PMID: 36998035 PMCID: PMC10064679 DOI: 10.1186/s12939-023-01860-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/13/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND A key pillar of Canada's healthcare system is universal access, yet significant barriers to cancer services remain for people impacted by structural vulnerability (e.g., poverty, homelessness, racism). For this reason, cancer is diagnosed at a later stage, resulting in worse patient outcomes, a reduced quality of life, and at a higher cost to the healthcare system. Those who face significant barriers to access are under-represented in cancer control services Consequently, these inequities result in people dying from cancers that are highly treatable and preventable, however; little is known about their treatment and care course. The aim of this study was to explore barriers to accessing cancer treatment among people experiencing structural vulnerability within a Canadian context. METHODS We conducted a secondary analysis of ethnographic data informed by critical theoretical perspectives of equity and social justice. The original research draws from 30 months of repeated interviews (n = 147) and 300 h of observational fieldwork with people experiencing health and social inequities at the end-of-life, their support persons, and service providers. RESULTS Our analysis identified four themes presenting as 'modifiable' barriers to inequitable access to cancer treatment: (1) housing as a key determinant for cancer treatment (2) impact of lower health literacy (3) addressing social care needs is a pre-requisite for treatment (4) intersecting and compounding barriers reinforce exclusion from cancer care. These inter-related themes point to how people impacted by health and social inequities are at times 'dropped' out of the cancer system and therefore unable to access cancer treatment. CONCLUSION Findings make visible the contextual and structural factors contributing to inequitable access to cancer treatment within a publically funded healthcare system. Identifying people who experience structural vulnerability, and approaches to delivering cancer services that are explicitly equity-oriented are urgently needed.
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Affiliation(s)
- Amber Bourgeois
- School of Nursing, University of Victoria, Institute on Aging & Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada.
| | - Tara C Horrill
- College of Nursing, University of Manitoba, 89 Curry Place Winnipeg, R3T 2N2, Victoria, MB, Canada
| | - Ashley Mollison
- Social Dimensions of Health, University of Victoria Institute on Aging and Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada
| | - Leah K Lambert
- School of Nursing, University of British Columbia, BC Cancer Suite 500, 686 West Broadway, V5Z 1G1, Vancouver, BC, Canada
| | - Kelli I Stajduhar
- School of Nursing, University of Victoria, Institute on Aging & Lifelong Health, Stn. CSC Victoria, PO Box 1700, V8W 2Y2, Victoria, BC, Canada
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Drescher NR, Oladeru OT. Cancer Screening, Treatment, and Outcomes in Persons Experiencing Homelessness: Shifting the Lens to an Understudied Population. JCO Oncol Pract 2023; 19:103-105. [PMID: 36548925 DOI: 10.1200/op.22.00720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Nicolette R Drescher
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Oluwadamilola T Oladeru
- Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL
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20
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Kilic SS, Mayo ZS, Weleff J, Parker S, Strzalka C, Phelan MP, Suh JH, Campbell SR, Shah CS. Cancer Diagnoses and Use of Radiation Therapy Among Persons Experiencing Homelessness. Int J Radiat Oncol Biol Phys 2023; 116:79-86. [PMID: 36731679 DOI: 10.1016/j.ijrobp.2023.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 02/01/2023]
Abstract
PURPOSE Persons experiencing homelessness (PEH) have low rates of cancer screening and worse cancer mortality compared with persons not experiencing homelessness. Data regarding cancer diagnosis and treatment in PEH are limited. We investigated cancer prevalence and use of radiation therapy (RT) in PEH. METHODS AND MATERIALS Patients presenting between January 1, 2014, and September 27, 2021, at a large metropolitan hospital system were assessed for homelessness via intake screening or chart search. PEH data were cross-referenced with the institution's cancer database to identify PEH with cancer diagnoses. Demographic, clinical, and treatment variables were abstracted. RESULTS Of a total of 9654 (9250 evaluable) PEH with a median age of 42 years, 81 patients (0.88%) had at least 1 cancer diagnosis and 5 had multiple diagnoses, for a total of 87 PEH with at least 1 cancer diagnosis. The median age at diagnosis was 60 years. In total, 43% were female and 51% were Black, and 43% presented with advanced or metastatic disease. Lung (17%), prostate (15%), leukemia/lymphoma (13%), and head/neck (9%) were the most common diagnoses. In total, 17% of patients underwent surgery alone, 13% received chemotherapy alone, 14% received RT alone, and 6% received hormone therapy alone. A total of 8% of patients underwent no treatment, and 43% underwent multimodality therapy. In total, 58% of treated patients never achieved disease-free status. Of the 31 patients who received RT, 87% received external beam RT. Most patients (70%) received hypofractionated regimens. For patients who had multifraction treatment, the treatment completion rate was 85%, significantly lower than the departmental completion rate of 98% (P < .00001). CONCLUSIONS In a large cohort of PEH in a metropolitan setting, cancer diagnoses were uncommon and were frequently in advanced stages. Most patients underwent single-modality treatment or no treatment at all. Despite the use of hypofractionation, the RT completion rate was low, likely reflecting complex barriers to care. Further interventions to optimize cancer diagnosis and treatment in PEH are urgently needed.
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Affiliation(s)
- Sarah S Kilic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Zachary S Mayo
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, Ohio; Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Sean Parker
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | | | | | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Shauna R Campbell
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Chirag S Shah
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
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21
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Mavedatnia D, Hathi K, Feschuk AM, Grose EM, Eskander A. Individuals Experiencing Homelessness: A Systematic Review of Otolaryngology-Related Health Needs and Community-Based Interventions. Otolaryngol Head Neck Surg 2023; 168:1301-1311. [PMID: 36939409 DOI: 10.1002/ohn.214] [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: 08/04/2022] [Revised: 11/04/2022] [Accepted: 11/15/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Access to and use of physician services is limited for those experiencing homelessness. Homelessness may predispose patients to several Otolaryngology-Head and Neck Surgery (OHNS) health conditions and barriers to care may leave these unaddressed. The aim of this review was to synthesize the literature on OHNS health needs and community-based interventions for patients experiencing homelessness. DATA SOURCES English literature was searched in MEDLINE, EMBASE, and CINAHL. REVIEW METHODS Studies were included if they reported on OHNS-related conditions in patients experiencing homelessness and/or interventions related to providing OHNS care to this patient population. RESULTS Twelve hundred and one articles were screened, and 12 articles were included. Most studies reported on otologic conditions (n = 8) and head and neck-related conditions (n = 6). Nasal trauma, chronic rhinosinusitis, dysphonia, hearing loss, and cancerous/precancerous head and neck lesions were common OHNS conditions reported in this patient population. Identified barriers to care included lack of transportation, financial considerations, and lower health literacy. Three articles on community-based interventions were included. Most of these interventions were single visits to shelters, and ensuring adequate follow-up was identified as a challenge. CONCLUSION The current literature brings attention to certain OHNS diseases that are prevalent in this unique patient population and identifies unique barriers these patients experience when accessing care. Future studies should focus on further delineating the impact of OHNS diseases in patients experiencing homelessness and screening interventions that can be employed to mitigate the impact of diseases of the head and neck.
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Affiliation(s)
- Dorsa Mavedatnia
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kalpesh Hathi
- Faculty of Medicine, Dalhousie Medicine New Brunswick, Saint John, New Brunswick, Canada
| | - Aileen M Feschuk
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - Elysia M Grose
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Toronto, Canada
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Mayo ZS, Kilic SS, Weleff J, Parker SM, Strzalka C, Phelan M, Mian OY, Stephans KL, Suh JH, Tendulkar RD. Prostate Cancer Screening Disparities in Persons Experiencing Homelessness. JCO Oncol Pract 2022; 18:e1866-e1873. [PMID: 36206501 DOI: 10.1200/op.22.00412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE The purpose of this study was to assess prostate-specific antigen (PSA) testing rates in persons experiencing homelessness (PEH), identify factors associated with screening, and compare PSA screening rates in PEH with a matched cohort of persons not experiencing homelessness (non-PEH). MATERIALS AND METHODS We identified 9,249 potentially eligible PEH cared for at a large metropolitan hospital system from an institutional registry of all patients who presented to the health care system as homeless from 2014 to 2021. Homelessness was defined by the presence of the Z-code for homelessness (Z59), the listed address matching to the address of a homeless shelter or other transitional housing or a positive screen for homelessness. A matched cohort of 10,000 non-PEH was generated for comparison. Univariate chi-square analysis and multivariate logistic regression were performed to evaluate variables associated with PSA testing. RESULTS A total of 1,605 PEH and 3,413 non-PEH were eligible for PSA screening within the study timeframe. Half of PEH were Black (50%). Medicaid was the most common insurance (51%), followed by Medicare (18%). PEH were less likely to have a PCP (58% v 81%, P < .001) and had a significantly lower PSA testing rate (13% v 34%, P < .001) compared with non-PEH. Univariate analysis revealed that PSA testing was more common in PEH who were employed (P < .001), had private insurance or Medicare (P < .001), or had an established primary care provider (PCP; P < .001). Multivariate analysis confirmed that having a PCP (OR, 2.54; 95% CI, 1.62 to 4.00; P < .001) significantly increased the likelihood of PSA testing in PEH. CONCLUSION PEH experience low rates of prostate cancer screening. Interventions to increase screening in this population, including increased PCP access, are needed.
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Affiliation(s)
- Zachary S Mayo
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Sarah S Kilic
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Jeremy Weleff
- Department of Psychiatry and Psychology, Center for Behavioral Health, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Sean M Parker
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | | | - Michael Phelan
- Department of Emergency Medicine, Emergency Services Institute, Cleveland Clinic, Cleveland, OH
| | - Omar Y Mian
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Kevin L Stephans
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Rahul D Tendulkar
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Role of Occupation in Shaping Cancer Disparities. Cancers (Basel) 2022; 14:cancers14174259. [PMID: 36077790 PMCID: PMC9454748 DOI: 10.3390/cancers14174259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary The investigation of cancer disparities is of major importance. In this paper, we address this issue through the occupational point of view, trying to capture how work and its related factors impact on cancer inequalities. The data we provide may increase awareness relevant to cancer control, and stimulate further studies aimed at the identification of the occupational determinants of cancer disparities and the quantification of their role. Abstract Cancer occurrence is characterized globally by profound socioeconomic differences. Occupation is a fundamental component of socioeconomic status. In this review, we discuss the role of occupation as a determinant of cancer disparities. First, we address the issue of participation in cancer screening programs based on income, health insurance, occupational status and job title. Second, we review the role of occupation in contributing to disparities by acting as a mediator between cancer and (i) education and (ii) race/ethnicity. Lastly, we analyze data from a multicenter case−control study of lung cancer to calculate the mediating role of occupational exposure to diesel exhaust, silica and welding fumes in the association between education and lung cancer. By addressing the complex paths from occupation to cancer inequalities from multiple points of view, we provide evidence that occupational-related characteristics, such as income, health insurance, unemployment and hazardous exposures impinge on cancer control and outcomes. The increasing awareness of these aspects is fundamental and should lead to public health interventions to avoid inequalities rising from occupational factors.
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Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework. J Am Coll Surg 2022; 235:350-360. [PMID: 35839414 PMCID: PMC9668043 DOI: 10.1097/xcs.0000000000000214] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use. Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.
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Crown A, Ramiah K, Siegel B, Joseph KA. The Role of Safety-Net Hospitals in Reducing Disparities in Breast Cancer Care. Ann Surg Oncol 2022; 29:10.1245/s10434-022-11576-3. [PMID: 35357616 DOI: 10.1245/s10434-022-11576-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 12/22/2022]
Abstract
Advances in breast cancer screening and systemic therapies have been credited with profound improvements in breast cancer outcomes; indeed, 5-year relative survival rate approaches 91% in the USA (U.S. National Institutes of Health NCI. SEER Training Modules, Breast). While breast cancer mortality has been declining, oncologic outcomes have not improved equally among all races and ethnicities. Many factors have been implicated in breast cancer disparities; chief among them is limited access to care which contributes to lower rates of timely screening mammography and, once diagnosed with breast cancer, lower rates of receipt of guideline concordant care (Wu, Lund, Kimmick GG et al. in J Clin Oncol 30(2):142-150, 2012). Hospitals with a safety-net mission, such as the essential hospitals, historically have been dedicated to providing high-quality care to all populations and have eagerly embraced the role of caring for the most vulnerable and working to eliminate health disparities. In this article, we review landmark articles that have evaluated the role safety-net hospitals have played in providing equitable breast cancer care including to those patients who face significant social and economic challenges.
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Affiliation(s)
- Angelena Crown
- Breast Surgery, True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA
| | | | - Bruce Siegel
- America's Essential Hospitals, Washington, DC, USA
| | - Kathie-Ann Joseph
- Department of Surgery, New York University School of Medicine, NYC Health and Hospitals, Bellevue, New York, NY, USA.
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Brown HA, Roberts RD, Chen TA, Businelle MS, Obasi EM, Kendzor DE, Reitzel LR. Perceived Disease Risk of Smoking, Barriers to Quitting, and Cessation Intervention Preferences by Sex Amongst Homeless Adult Concurrent Tobacco Product Users and Conventional Cigarette-Only Users. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19063629. [PMID: 35329321 PMCID: PMC8948934 DOI: 10.3390/ijerph19063629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/08/2022] [Accepted: 03/16/2022] [Indexed: 11/16/2022]
Abstract
Adults experiencing homelessness smoke conventional cigarettes and engage in concurrent tobacco product use at very high rates; however, little is known about how use patterns, perceived disease risk, barriers to quitting smoking, and smoking cessation intervention preferences differ by sex in this group. Participants comprised a convenience sample of 626 adult conventional cigarette smokers experiencing homelessness. Participants self-reported their sex, smoking history, mental health and substance use diagnosis history, other concurrent tobacco product use (CU), disease risk perceptions, perceived barriers to quitting smoking, and preferences regarding tobacco cessation interventions via a computer-administered survey. CU rates were 58.1% amongst men and 45.3% amongst women smokers. In both sexes, CUs started smoking earlier (p-values < 0.001) and were more likely to have been diagnosed with a non-nicotine substance use disorder (p-values < 0.014) relative to cigarette-only users. Among men only, CUs were younger, smoked more cigarettes per day and were more likely to identify as non-Hispanic White (p-values < 0.003) than cigarette-only users. Additionally, male CUs reported a greater risk of developing ≥1 smoking-related disease if they did not quit for good; were more likely to endorse craving cigarettes, being around other smokers, habit, stress/mood swings, and coping with life stress as barriers for quitting smoking; and were less likely to prefer medications to quit smoking relative to male cigarette-only users (p-values < 0.04). On the other hand, female CUs reported a greater risk of developing ≥1 smoking-related disease even if they quit for good; were more likely to endorse stress/mood swings and coping with life stress as barriers for quitting smoking relative to female cigarette-only users (p-values < 0.05); and did not differentially prefer one cessation medication over another. Overall, findings confirm high rates of CU among both sexes, characterize those who may be more likely to be CUs, and reveal opportunities to educate men and women experiencing homeless on the benefits of evidence-based interventions for smoking cessation.
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Affiliation(s)
- Haleem A. Brown
- Department of Psychological, Health, and Learning Sciences, College of Education, The University of Houston, 491 Farish Hall, Houston, TX 77204, USA; (H.A.B.); (R.D.R.); (T.A.C.); (E.M.O.)
- HEALTH Research Institute, The University of Houston, 4349 Martin Luther King Blvd., Houston, TX 77204, USA;
| | - Rachel D. Roberts
- Department of Psychological, Health, and Learning Sciences, College of Education, The University of Houston, 491 Farish Hall, Houston, TX 77204, USA; (H.A.B.); (R.D.R.); (T.A.C.); (E.M.O.)
- HEALTH Research Institute, The University of Houston, 4349 Martin Luther King Blvd., Houston, TX 77204, USA;
| | - Tzuan A. Chen
- Department of Psychological, Health, and Learning Sciences, College of Education, The University of Houston, 491 Farish Hall, Houston, TX 77204, USA; (H.A.B.); (R.D.R.); (T.A.C.); (E.M.O.)
- HEALTH Research Institute, The University of Houston, 4349 Martin Luther King Blvd., Houston, TX 77204, USA;
| | - Michael S. Businelle
- HEALTH Research Institute, The University of Houston, 4349 Martin Luther King Blvd., Houston, TX 77204, USA;
- TSET Health Promotion Research Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Ezemenari M. Obasi
- Department of Psychological, Health, and Learning Sciences, College of Education, The University of Houston, 491 Farish Hall, Houston, TX 77204, USA; (H.A.B.); (R.D.R.); (T.A.C.); (E.M.O.)
- HEALTH Research Institute, The University of Houston, 4349 Martin Luther King Blvd., Houston, TX 77204, USA;
| | - Darla E. Kendzor
- TSET Health Promotion Research Center, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Lorraine R. Reitzel
- Department of Psychological, Health, and Learning Sciences, College of Education, The University of Houston, 491 Farish Hall, Houston, TX 77204, USA; (H.A.B.); (R.D.R.); (T.A.C.); (E.M.O.)
- HEALTH Research Institute, The University of Houston, 4349 Martin Luther King Blvd., Houston, TX 77204, USA;
- Correspondence: ; Tel.: +1-713-743-6679
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Guest Support for Outdoor Smoke-Free Policies within a Homeless Shelter. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042408. [PMID: 35206595 PMCID: PMC8872137 DOI: 10.3390/ijerph19042408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/10/2022]
Abstract
Roughly 70-80% of adults experiencing homelessness smoke cigarettes. Smoke-free living/workplace policies are an empirically-supported tobacco control intervention. However, homeless shelters may be reluctant to implement smoke-free policies due to fears of it discouraging current/potential shelter guests from taking refuge there. The current study was meant to characterize guest support for on-property smoke-free policies within a homeless shelter with an extant indoor tobacco use ban amongst never smokers, former smokers, and current smokers to provide data on this point. Participants comprised a convenience sample of adult guests of a homeless shelter in Texas (N = 394, 28.2% women; 10.2% former; and 75.9% current smokers). Participant sociodemographics, smoking status, behavioral health diagnoses, and support for two versions of an on-property outdoor courtyard smoke-free policy (one partial, one complete) were assessed. Data were collected in two waves in a repeated cross-sectional design. Overall, 64.0% of participants supported a partial, and 32.0% a full smoking ban. Logistic regressions, controlling for wave of data collection, age, sex, and any additional significant predictors from a semi-adjusted model, examined associations between participant characteristics and policy support. Older participants (OR = 1.024, CI0.95 = 1.005-1.044), non-veterans (OR = 2.523, CI0.95 = 1.156-5.506), former smokers (OR = 2.730, CI0.95 = 1.191-6.258), and those without severe mental illness (OR = 1.731, CI0.95 = 1.061-2.824) had significantly greater odds of supporting a partial smoking ban. Relative to current smokers, never smokers (OR = 3.902, CI0.95 = 2.133-7.137) and former smokers (OR = 8.257, CI0.95 = 3.951-17.258) had significantly greater odds of supporting a complete smoking ban. The implementation of smoke-free living/workplace policies in homeless shelters may enjoy more support from guests-specifically, non-smokers-than anticipated by shelter administrators. Aside from reducing ambient smoke exposure for never and former smokers, these policies can help to reduce ubiquitous smoking cues for those who may want to quit, are undergoing a quit attempt, or are trying to maintain abstinence. Interventionists might partner with shelter guests, particularly smokers, to inform the roll-out of such policies for maximal acceptance and adoption.
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Riley ED, Delucchi K, Rubin S, Weiser SD, Vijayaraghavan M, Lynch K, Tsoh JY. Ongoing tobacco use in women who experience homelessness and unstable housing: A prospective study to inform tobacco cessation interventions and policies. Addict Behav 2022; 125:107125. [PMID: 34673360 DOI: 10.1016/j.addbeh.2021.107125] [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] [Received: 05/17/2021] [Revised: 08/30/2021] [Accepted: 09/23/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Tobacco use is common in people who experience homelessness. However, despite biological differences in use by sex and lower quit rates in women, research in homeless and unstably housed (HUH) women is sparse. We identified correlates of use specific to this population, with the goal of informing tobacco cessation programs tailored for HUH women. METHODS We conducted a prospective study among HUH women recruited from San Francisco homeless shelters, street encampments, free meal programs and low-income hotels. Between June 2016 and January 2019, study participants completed six monthly interviews to examine factors associated with tobacco use, defined as urinary cotinine >10 pg/mL or self-reported prior 30-day use. RESULTS Among 245 participants, 40% were Black, the median age was 53, 75% currently used tobacco and 89% had ≥one 24-hour quit attempt in the prior year. Tobacco use was more common in women with PTSD (66% vs. 48%) and depression (54% vs. 35%) compared to women without these conditions. Adjusted odds of tobacco use decreased significantly with increasing age (OR/5 yrs: 0.81; 95% CI:0.68, 0.96) and increased with an increasing number of additional substances used (OR: 2.52; 95% CI: 1.88, 3.39). CONCLUSION Outside of a treatment setting and within a community-recruited sample population composed of HUH women, the number of additional substances used is a primary correlate of ongoing tobacco use. Tailored cessation interventions that prioritize the issue of multiple substance use, and public health policies that allocate funding to address it, may increase tobacco cessation in this population.
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Baggett TP, Barbosa Teixeira J, Rodriguez EC, Anandakugan N, Sporn N, Chang Y, Percac-Lima S, Park ER, Rigotti NA. Patient navigation to promote lung cancer screening in a community health center for people experiencing homelessness: Protocol for a pragmatic randomized controlled trial. Contemp Clin Trials 2022; 113:106666. [PMID: 34971796 DOI: 10.1016/j.cct.2021.106666] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers. METHODS The Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results. DISCUSSION This trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Institute for Research, Quality & Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, United States of America.
| | - Joana Barbosa Teixeira
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Elijah C Rodriguez
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; New York University Grossman School of Medicine, New York, NY, United States of America
| | - Nillani Anandakugan
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Nora Sporn
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elyse R Park
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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Nicholas W, Greenwell L, Henwood BF, Simon P. Using Point-in-Time Homeless Counts to Monitor Mortality Trends Among People Experiencing Homelessness in Los Angeles County, California, 2015‒2019. Am J Public Health 2021; 111:2212-2222. [PMID: 34878861 PMCID: PMC8667842 DOI: 10.2105/ajph.2021.306502] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 11/04/2022]
Abstract
Objectives. To report trends in mortality rates, mortality rate ratios (MRRs), and causes of death among people experiencing homelessness (PEH) in Los Angeles County, California, by using annual point-in-time homeless counts and to compare findings to published longitudinal cohort studies of homeless mortality. Methods. We enumerated homeless deaths and determined causes by using 2015-2019 medical examiner‒coroner data matched to death certificate data. We estimated midyear homeless population denominators by averaging consecutive January point-in-time homeless counts. We used annual demographic surveys of PEH to estimate age- and gender-adjusted MRRs. We identified comparison studies through a literature review. Results. Mortality rates increased from 2015 to 2019. Drug overdose was the leading cause of death. Mortality was higher among White than among Black and Latino PEH. Compared with the general population, MRRs ranged from 2.8 (95% confidence interval [CI] = 2.7, 3.0) for all causes to 35.1 (95% CI = 31.9, 38.4) for drug overdose. Crude mortality rates and all-cause MRRs from comparison cohort studies were similar to those in the current study. Conclusions. These methods can be adapted by other urban jurisdictions seeking to better understand and reduce mortality in their homeless populations. (Am J Public Health. 2021;111(12):2212-2222. https://doi.org/10.2105/AJPH.2021.306502).
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Affiliation(s)
- Will Nicholas
- Will Nicholas, Lisa Greenwell, and Paul Simon are with the Los Angeles County Department of Public Health, Los Angeles, CA. Benjamin F. Henwood is with the Suzanne Dworak-Peck School of Social Work, University of Southern California. Los Angeles
| | - Lisa Greenwell
- Will Nicholas, Lisa Greenwell, and Paul Simon are with the Los Angeles County Department of Public Health, Los Angeles, CA. Benjamin F. Henwood is with the Suzanne Dworak-Peck School of Social Work, University of Southern California. Los Angeles
| | - Benjamin F Henwood
- Will Nicholas, Lisa Greenwell, and Paul Simon are with the Los Angeles County Department of Public Health, Los Angeles, CA. Benjamin F. Henwood is with the Suzanne Dworak-Peck School of Social Work, University of Southern California. Los Angeles
| | - Paul Simon
- Will Nicholas, Lisa Greenwell, and Paul Simon are with the Los Angeles County Department of Public Health, Los Angeles, CA. Benjamin F. Henwood is with the Suzanne Dworak-Peck School of Social Work, University of Southern California. Los Angeles
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Abstract
Background Homeless persons are those who carry out their activities of daily living in city parks and other facilities. Little is known about homeless patients with lung cancer in Japan. Therefore, we characterized the clinical features and outcomes of homeless people in metropolitan Tokyo. Methods Between January 2014 and August 2018, 2,068 homeless patients were admitted to the homeless patient care unit at Tokyo Saiseikai Central Hospital. Of these, 13 patients were treated for primary lung cancer. We retrospectively analyzed the patients' clinical characteristics, including their age, gender, treatment, and outcome, obtained from the hospital's electronic medical records. Results A total of 13 patients were treated for lung cancer. The median age was 66.2 (range, 51-77) years old. Twelve patients (92.3%) were smokers. All of the patients were men and had advanced lung cancer. Of these, four patients had adenocarcinoma, four had squamous carcinoma, and four had other histologies. Ten patients received chemotherapy, and 3 received chemoradiotherapy (carboplatin, n=8; cisplatin, n=2, immune check point inhibitor, n=2; other, n=1). Of the patients on first-line treatment, 58% discontinued treatment, with 71% doing so willfully. The median overall survival was 7.5 (1-44) months. During the study, nine patients died in the hospital, and four were lost to follow up. Conclusion It is difficult for homeless patients to continue chemotherapy, and they often quit therapy willfully. Therefore, it is necessary to develop an education and health insurance support system to ensure treatment continuity in a good social environment.
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Affiliation(s)
- Tomoyo Oguri
- Department of Respiratory Medicine, Tokyo Saiseikai Central Hospital, Japan
- Department of Clinical Oncology, St. Marianna University School of Medicine, Japan
| | - Shinji Sasada
- Department of Respiratory Medicine, Tokyo Saiseikai Central Hospital, Japan
| | - Takashi Shimada
- Department of Respiratory Medicine, Tokyo Saiseikai Central Hospital, Japan
- Department of Internal Medicine, Hino Municipal Hospital, Japan
| | - Kota Ishioka
- Department of Respiratory Medicine, Tokyo Saiseikai Central Hospital, Japan
| | - Saeko Takahashi
- Department of Respiratory Medicine, Tokyo Saiseikai Central Hospital, Japan
| | - Tomohide Adachi
- Department of General Internal Medicine, Tokyo Saiseikai Central Hospital, Japan
| | - Morio Nakamura
- Department of Respiratory Medicine, Tokyo Saiseikai Central Hospital, Japan
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Bongaerts THG, Ridder M, Vermeer-Mens JCJ, Plukkel JJ, Numans ME, Büchner FL. Cervical Cancer Screening Among Marginalized Women: A Cross-Sectional Intervention Study. Int J Womens Health 2021; 13:549-556. [PMID: 34135643 PMCID: PMC8197586 DOI: 10.2147/ijwh.s302002] [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: 01/14/2021] [Accepted: 05/04/2021] [Indexed: 11/23/2022] Open
Abstract
Background Many countries organize population-based cervical cancer screening programs (CSP). In the Netherlands, eligible women are invited by mail. Marginalized women living in unstable conditions and homeless women often fail to receive the invitation letter. These women also experience access barriers to regular healthcare. Consequently, despite presumably being at higher risk of developing cervical cancer due to prevalent risk factors, marginalized women are rarely screened for cervical cancer. The aim of the study was to identify the prevalence of (pre)cancerous abnormalities among marginalized women, and subsequently explore invitation approaches to enhance their screening participation. Methods A cross-sectional intervention study was conducted in Rotterdam, the Netherlands. Between February and May 2019, marginalized women aged 20–60 years were invited to participate in cervical screening. A participant was considered screen-positive when they tested positive for high-risk human papilloma virus (HR-HPV) and showed cytological abnormalities. Data of the study population were compared with regional data of the Dutch CSP. Various invitation approaches were used to recruit women. Results Out of 74 included women, 12 participants (16%) were found screen-positive, against 3.4% in women screened by the Dutch CSP. The prevalence ratio for the study population was 4.4 (95% CI 1.9–8.6) compared with women screened by the Dutch CSP. Using a direct, pro-active approach resulted in participation of 92% of the included women. Conclusion Marginalized women have an increased risk of (pre)cancerous cervical abnormalities in screening, compared with women screened by the Dutch CSP. A direct pro-active approach was the most effective to stimulate screening participation. Enhancement of screening uptake for this population needs special effort.
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Affiliation(s)
- Thomas H G Bongaerts
- Leiden University Medical Center LUMC-Campus the Hague, Department of Public Health and Primary Care, The Hague, the Netherlands
| | - Marlieke Ridder
- Leiden University Medical Center LUMC-Campus the Hague, Department of Public Health and Primary Care, The Hague, the Netherlands.,Municipal Health Service Rotterdam-Rijnmond, Rotterdam, the Netherlands
| | | | | | - Mattijs E Numans
- Leiden University Medical Center LUMC-Campus the Hague, Department of Public Health and Primary Care, The Hague, the Netherlands
| | - Frederike L Büchner
- Leiden University Medical Center LUMC-Campus the Hague, Department of Public Health and Primary Care, The Hague, the Netherlands
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Facer BD, Bingham B, Fleisch SB, Walker JN, Ahmad M, Osmundson EC. Radiation Therapy Adherence Among Patients Experiencing Homelessness. Int J Radiat Oncol Biol Phys 2021; 109:1019-1027. [PMID: 33127492 DOI: 10.1016/j.ijrobp.2020.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/20/2020] [Accepted: 10/23/2020] [Indexed: 11/18/2022]
Abstract
PURPOSE Radiation therapy is a valuable, yet time- and resource-intense therapy. Patients experiencing homelessness (PEH) face many barriers related to the timely receipt of radiation therapy. Owing to a paucity of data regarding cancer treatment and homelessness, clinicians have a limited evidence base when recommending therapy to PEH. This study was performed to evaluate adherence to radiation therapy treatment regimens in PEH with cancer. METHODS AND MATERIALS The study cohort was primarily derived from the Vanderbilt University Medical Center Homeless Health Services program. Patients in the Homeless Health Services program with radiation oncology visits were identified by query of the electronic medical record. Manual chart review was performed to gather standard treatment parameters and data describing missed appointments. A comparison group of patients not experiencing homelessness (non-PEH) was generated by aggregating appointment data for all other patients receiving similar treatments at Vanderbilt University Medical Center during multiple, consecutive years. RESULTS In the study, 3408 PEH were identified, of whom 48 underwent radiation oncology consultation. Thirty-two were prescribed at least 1 course of radiation therapy, for a total of 54 unique courses. Out of these courses, 34 (62.9%) were completed as prescribed without delay, 12 (22.2%) were completed with delay(s), and 8 (14.8%) were not fully completed. Although the PEH cohort had significantly higher rates of delayed and undelivered fractions, the proportion of delayed or incomplete courses was not significantly different from the comparison group of non-PEH, particularly for courses with 10 or fewer fractions. Reasons for missed appointments for PEH were variable. CONCLUSIONS This is the first publication describing adherence to radiation therapy in PEH. Our data suggest that PEH are as likely as non-PEH to complete a course of radiation therapy, albeit with more treatment interruptions. When treatment courses of >10 fractions are expected, PEH may benefit from more hypofractionated regimens, provided they have equivalent clinical efficacy to longer regimens. Documenting reasons for missed appointments will be essential to further understanding the needs of PEH. This study serves as a foundation for further analysis regarding homelessness and radiation therapy.
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Affiliation(s)
- Benjin D Facer
- Vanderbilt University School of Medicine, Nashville, Tennessee; University of Texas Rio Grande Valley, Edinburg, Texas.
| | - Brian Bingham
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sheryl B Fleisch
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica N Walker
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mahmoud Ahmad
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Evan C Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
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Kohler RE, Roncarati JS, Aguiar A, Chatterjee P, Gaeta J, Viswanath K, Henry C. Trauma and cervical cancer screening among women experiencing homelessness: A call for trauma-informed care. WOMEN'S HEALTH (LONDON, ENGLAND) 2021; 17:17455065211029238. [PMID: 34225506 PMCID: PMC8264729 DOI: 10.1177/17455065211029238] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/28/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Women experiencing homelessness are at increased risk of cervical cancer and have disproportionately low Pap screening behaviors compared to the general population. Prevalence of Pap refusals and multiple kinds of trauma, specifically sexual trauma, are high among homeless women. This qualitative study explored how trauma affects Pap screening experiences, behaviors, and provider practices in the context of homelessness. METHODS We conducted 29 in-depth interviews with patients and providers from multiple sites of a Federally Qualified Health Center as part of a study on barriers and facilitators to cervical cancer screening among urban women experiencing homelessness. The Health Belief Model and trauma-informed frameworks guided the analysis. RESULTS Trauma histories were common among the 18 patients we interviewed. Many women also had strong physical and psychological reactions to screening, which influenced current behaviors and future intentions. Although most women had screened at least once in their lifetime, many patients experienced anticipated anxiety and retraumatization which pushed them to delay or refuse Paps. We recruited 11 providers who identified strategies they used to encourage screening, including emphasizing safety and shared decision-making before and during the exam, building strong patient-provider trust and communication, and individually tailoring education and counseling to patients' needs. We outlined suggestions and implications from these findings as trauma-informed cervical cancer screening. CONCLUSION Discomfort with Pap screening was common among women experiencing homelessness, especially those with histories of sexual trauma. Applying a trauma-informed approach to cervical cancer screening may help address complex barriers among women experiencing homelessness, with histories of sexual trauma, or others who avoid, delay, or refuse the exam.
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Affiliation(s)
- Racquel E Kohler
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Jill S Roncarati
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | | | - Pritha Chatterjee
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jessie Gaeta
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Kasisomayajula Viswanath
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Boston Health Care for the Homeless Program, Boston, MA, USA
| | - Cassis Henry
- Boston Health Care for the Homeless Program, Boston, MA, USA
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Reuven SM, Chen TA, Zvolensky MJ, Businelle MS, Kendzor DE, Reitzel LR. Examining the moderating effect of anxiety sensitivity on past-month pain severity and heaviness of smoking among adult smokers experiencing homelessness. Addict Behav 2021; 112:106610. [PMID: 32861987 DOI: 10.1016/j.addbeh.2020.106610] [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: 06/12/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pain and cigarette smoking are reciprocally related. Domiciled smokers with higher anxiety sensitivity (AS) - the fear of behaviors/sensations associated with the experience of anxiety - consume more cigarettes and report greater tobacco dependence than smokers with lower AS. AS treatment can reduce chronic pain and facilitate smoking cessation. Here, we examine the potentially moderating role of AS in the association between past-month pain (PMP) and heaviness of smoking (HS) among smokers experiencing homelessness. METHODS Participants (N = 461; 64.9% men, Mage = 43.1 ± 11.8) were smokers recruited from 6 homeless serving agencies in Oklahoma City, OK. Participants self-reported the presence and severity of PMP ("How much bodily pain have you had during the past four weeks?"), HS was measured via the heaviness of smoking index (HSI), and AS was measured via the Anxiety Sensitivity Index-III (ASI-III) and its 3 subscales: physical, cognitive, and social concerns. Linear regressions were used to examine potential ASI moderation controlling for age, sex, race, education, health insurance, perceived stress, and major depression. RESULTS ASI-III total, cognitive, and physical concerns each significantly moderated associations of PMP and HSI (ps < 0.05), whereas social concerns did not. Individuals with high AS had greater cigarette dependence as PMP values increased. CONCLUSION Similar to research with domiciled smokers, current results suggest that smokers experiencing homelessness who have high AS may benefit from AS-based interventions to reduce the association between PMP and HS, which may facilitate smoking cessation among this vulnerable group.
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Dickins KA, Philpotts LL, Flanagan J, Bartels SJ, Baggett TP, Looby SE. Physical and Behavioral Health Characteristics of Aging Homeless Women in the United States: An Integrative Review. J Womens Health (Larchmt) 2020; 30:1493-1507. [PMID: 33290147 DOI: 10.1089/jwh.2020.8557] [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] [Indexed: 11/12/2022] Open
Abstract
Background: The average age of the homeless population is and will continue to rise. Although women comprise a significant and growing percentage of this vulnerable population, their age- and sex-specific health characteristics are poorly understood. Materials and Methods: This integrative review appraises published research addressing the physical and behavioral health characteristics of aging homeless women (≥50 years) in the United States (2000-2019). The authors searched six electronic databases to identify eligible studies. Studies were screened for methodological quality by using the Johns Hopkins Nursing Evidence-Based Practice model. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: Ten primary studies met the review eligibility criteria. All were level III (non-experimental); nine appraised as "good" quality (level B), and one as "lower" quality (level C). Aging homeless women demonstrate elevated rates of physical health conditions, related to suboptimal nutrition, lower than expected preventive health screening uptake, and geriatric concerns. Disproportionate rates of mental health conditions are compounded by substance use and interpersonal trauma. Familial and social dynamics and socioeconomic disadvantage contribute to social health concerns. Spiritual health is a critically important yet underexplored protective factor. Conclusions: Studies are limited, though collective findings suggest that aging homeless women endure a disproportionate physical, behavioral, and social health burden compared with aging non-homeless women and aging homeless men. Implications for research on early aging, preventative health strategies, and homelessness among women, and clinical practice in the context of geriatric and women's health are described.
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Affiliation(s)
- Kirsten A Dickins
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa L Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jane Flanagan
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- William F. Connell School of Nursing, Boston College, Boston, Massachusetts, USA
| | - Stephen J Bartels
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Travis P Baggett
- Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Boston Health Care for the Homeless Program, Boston, Massachusetts, USA
| | - Sara E Looby
- Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
- Metabolism Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Understanding the Associations between Smoking-Related Risk Perception, Interest in Quitting Smoking, and Interest in Lung Cancer Screening among Homeless Adult Smokers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17238817. [PMID: 33260975 PMCID: PMC7729438 DOI: 10.3390/ijerph17238817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/17/2020] [Accepted: 11/25/2020] [Indexed: 12/19/2022]
Abstract
Individuals experiencing homelessness smoke cigarettes at high rates, suffer a disproportionate incidence of lung cancer, but are unlikely to be screened to enhance early detection. Understanding correlates of lung cancer screening (LCS) interest within this vulnerable group may lend insight into prevention and treatment efforts and reduce their smoking-related morbidity and mortality. This study sought to understand how risk perception and interest in quitting smoking relate to LCS interest among homeless adults. Participants comprised a convenience sample of CO-verified current smokers (N = 310; 72.6% men, Mage = 43 + 11.7) from a homeless shelter in Dallas, TX. Participants self-reported risk perception, interest in quitting smoking, and interest in LCS. The average risk perception was 6.7 + 3.2 (range 0-10), 74.8% (n = 232) agreed or strongly agreed with interest in LCS, and 65.8% (n = 204) were interested in quitting smoking. Greater interest in quitting smoking, but not greater risk perception, was associated with greater interest in LCS (adjusted OR: 1.968, (95% CI: 1.213, 3.191), p = 0.006). Risk perception and interest in quitting smoking did not interact in their association with interest in LCS. Results suggest that homeless smokers with an interest in quitting may be receptive to LCS: a diagnostic tool by which cancers can be caught at earlier stages and prior to metastasis. However, few in the current sample would be eligible for LCS based on current guidelines; results have implications for altered screening practices among chronic smokers experiencing homelessness.
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Taing M, Kyburz B, Leal IM, Le K, Chen TA, Correa-Fernandez V, Williams T, O’Connor DP, Obasi EM, Casey K, Koshy L, Reitzel LR. Clinician Training in the Adaptation of a Comprehensive Tobacco-Free Workplace Program in Agencies Serving the Homeless and Vulnerably Housed. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6154. [PMID: 32854185 PMCID: PMC7503354 DOI: 10.3390/ijerph17176154] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/07/2020] [Accepted: 08/21/2020] [Indexed: 11/16/2022]
Abstract
Tobacco use is exceedingly high among those who are homeless or at risk of homelessness but not commonly addressed by clinicians. Taking Texas Tobacco Free (TTTF) is a tobacco control program that addresses known clinician barriers to intervention (e.g., low training receipt, limited resources). Here, we examine the process and outcomes of TTTF's adaptation within four agencies that provide housing or other services to individuals who are homeless or vulnerably housed. Pre- and post-implementation data were collected from clinicians (N = 68) to assess changes in training receipt, knowledge, and intervention behaviors, relative to program goals. Results indicated significant gains in clinicians' receipt of training in 9 (of 9) target areas (p's ≤ 0.0042) and a 53% knowledge gain (p < 0.0001). From pre- to post-implementation, there were mean increases in the use of the 5As (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with significant gains seen in assisting residents/clients to quit, arranging follow-ups, and providing or referring for non-nicotine medications (p's ≤ 0.0491). All program goals, except gains related to advising smokers to quit and the use of specific interventions (behavioral counseling), were met. Overall, TTTF improved clinicians' capacity to address tobacco use among homeless and vulnerably housed individuals and can serve as a model for tobacco control efforts in similar agencies.
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Affiliation(s)
- Matthew Taing
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
| | - Bryce Kyburz
- Integral Care, Austin, TX, USA; (B.K.); (T.W.); (K.C.)
| | - Isabel Martinez Leal
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
| | - Kathy Le
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
- Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
| | - Tzu-An Chen
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
| | - Virmarie Correa-Fernandez
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
| | | | - Daniel P. O’Connor
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
- Department of Health & Human Performance, The University of Houston, 3875 Holman Street, Garrison Gymnasium, Room 104, Houston, TX 77204, USA
| | - Ezemenari M. Obasi
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
| | | | - Litty Koshy
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
| | - Lorraine R. Reitzel
- Department of Psychological, Health & Learning Sciences, The University of Houston, 3657 Cullen Blvd Stephen Power Farish Hall, Houston, TX 77204-5029, USA; (M.T.); (I.M.L.); (K.L.); (T.-A.C.); (V.C.-F.); (E.M.O.); (L.K.)
- HEALTH Research Institute, The University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA;
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Dickins KA, Buchholz SW, Ingram D, Braun LT, Hamilton RJ, Earle M, Karnik NS. Supporting Primary Care Access and Use among Homeless Persons. SOCIAL WORK IN PUBLIC HEALTH 2020; 35:335-357. [PMID: 32865153 DOI: 10.1080/19371918.2020.1809589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.
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Affiliation(s)
- Kirsten A Dickins
- Massachusetts General Hospital, Yvonne L. Munn Center for Nursing Research , Boston, Massachusetts, USA
| | | | - Diana Ingram
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Lynne T Braun
- Rush University College of Nursing , Chicago, Illinois, USA
| | | | - Melinda Earle
- Rush University College of Nursing , Chicago, Illinois, USA
| | - Niranjan S Karnik
- Rush Medical College Department of Psychiatry, Rush University College of Nursing , Chicago, Illinois, USA
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Concannon KF, Thayer JH, Wu QV, Jenkins IC, Baik CS, Linden HM. Outcomes Among Homeless Patients With Non-Small-Cell Lung Cancer: A County Hospital Experience. JCO Oncol Pract 2020; 16:e1004-e1014. [PMID: 32525753 PMCID: PMC7489482 DOI: 10.1200/jop.19.00694] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Lung cancer remains the leading cause of cancer death in the United States, with outcomes likely worsened by the presence of poorer outcomes among vulnerable populations such as the homeless. We hypothesized that homeless patients experience delays in biopsy, decreased appointment adherence, and increased overall mortality rates. METHODS We conducted a retrospective electronic medical record-based review of all patients with non-small-cell lung cancer (NSCLC; N = 133) between September 2012 and September 2018 at an academic county hospital in Seattle, Washington. RESULTS Of the 133 patients treated for NSCLC, 22 (17%) were homeless at the time of their treatment. Among homeless patients with localized lung cancer, the mean time from radiographic finding to biopsy was 248 days, compared with 116 days among housed patients (P = .37). Homeless patients with advanced disease missed a mean of 26% of appointments in the year after diagnosis, compared with 16% among housed patients (P = .03). Homeless patients with advanced NSCLC had a median survival of 0.58 years, versus 1.30 years in housed patients (P = .48). CONCLUSION To our knowledge, this is the first US study comparing outcomes among homeless and housed patients with NSCLC within the same institution; we found homeless patients had longer delays to biopsy, increased rates of missed appointments, and a trend toward decreased survival. This study shows potential areas where interventions could be implemented to improve lung cancer outcomes in this patient population.
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Affiliation(s)
| | | | - Qian V Wu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Isaac C Jenkins
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Christina S Baik
- University of Washington, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
| | - Hannah M Linden
- University of Washington, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
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Festa K, Hirsch AE, Cassidy MR, Oshry L, Quinn K, Sullivan MM, Ko NY. Breast Cancer Treatment Delays at an Urban Safety Net Hospital Among Women Experiencing Homelessness. J Community Health 2020; 45:452-457. [PMID: 31625050 DOI: 10.1007/s10900-019-00759-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Disparities in outcomes for vulnerable women is an ongoing problem. Homelessness and breast cancer treatment outcomes is understudied. This is a descriptive study exploring types of homelessness and treatment delays at an urban safety net hospital providing care to a vulnerable patient population.This study is a retrospective chart review of homeless female patients diagnosed with breast cancer between January 1, 2000 and December 31, 2014. Data for this study were acquired from the hospital cancer registry and electronic medical record. All demographic characteristics, time to treatment and factors related to delays to treatment were analyzed descriptively, reporting frequencies and proportions. The total number of individuals analyzed was 24. All except two subjects were delayed to treatment (≥ 30 days from diagnosis to treatment). Most women in this cohort were categorized as chronically homeless (46%) with the rest categorized as transitionally (29%) or episodically (12%) homeless. The majority of subjects (70%) were Black, non-Hispanic. All except one subject were publicly insured (71% Medicaid; 12% Medicare) or uninsured (8%). Regardless of type of homelessness, most subjects were either 30-60 or 60-90 days delayed. Those who were chronically homeless experienced significantly more delays to first treatment (56% of those who were delayed 30-60 days and 57% of those who were delayed 60-90 days; p value 0.006) than those who were episodically or transitionally homeless. Significant delays and barriers to breast cancer treatment exist among women experiencing homelessness. Further studies to improve breast cancer care for homeless women are warranted.
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Affiliation(s)
| | - Ariel E Hirsch
- Department of Radiation Oncology, Boston Medical Center, Boston, MA, USA
| | - Michael R Cassidy
- Section of Surgical Oncology, Department of Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Lauren Oshry
- Section of Hematology and Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | - Kathryn Quinn
- Section of Hematology and Oncology, Boston Medical Center, Boston University, Boston, MA, USA
| | | | - Naomi Y Ko
- Section of Hematology and Oncology, Boston Medical Center, Boston University, Boston, MA, USA.
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Association of Problematic Alcohol Use and Food Insecurity among Homeless Men and Women. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17103631. [PMID: 32455769 PMCID: PMC7277400 DOI: 10.3390/ijerph17103631] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/11/2022]
Abstract
Food insecurity results from unreliable access to affordable and nutritious food. Homeless adults are particularly vulnerable to both food insecurity and problematic alcohol use. The current study examined the link between problematic alcohol use and food insecurity among homeless adults. Participants (N = 528; 62.7% men; Mage = 43.6 ± 12.2) were recruited from homeless-serving agencies in Oklahoma City. Problematic alcohol use was measured using the Alcohol Quantity and Frequency Questionnaire and the Patient Health Questionnaire. The latter used DSM-IV diagnostic criteria to assess probable alcohol use dependence/abuse. Heavy drinking was considered >7 drinks (women) and >14 drinks (men) per week. Food insecurity was measured with the USDA Food Security Scale-Short Form. The link between alcohol problems and food insecurity was examined with logistic regression analyses controlling for sex, age, education, income, and months homeless. Overall, 28.4% of the sample had probable alcohol dependence, 25% were heavy drinkers, and 78.4% were food insecure. Probable alcohol dependence and heavy drinking were correlated at 0.53 (p < 0.001). Results indicated that heavy drinking (OR = 2.12, CI.95 = 1.21, 3.73) and probable alcohol dependence/abuse (OR = 2.72, CI.95 = 1.55, 4.77) were each associated with increased odds of food insecurity. Food insecurity and problematic alcohol use are major issues among homeless populations; this study suggests they are associated. Future research is needed to shed light on potential causal mechanisms and on whether alcohol may take precedence over eating or food purchases.
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Multimorbidity and emergency department visits by a homeless population: a database study in specialist general practice. Br J Gen Pract 2019; 69:e515-e525. [PMID: 31262848 DOI: 10.3399/bjgp19x704609] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 12/14/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Estimating healthcare needs of the homeless is associated with challenges in identifying the eligible population. AIM To explore the demographic characteristics, disease prevalence, multimorbidity, and emergency department visits of the homeless population. DESIGN AND SETTING EMIS electronic database of patient medical records and Quality and Outcomes Framework (QOF) data of all 928 patients registered with a major specialist homeless primary healthcare centre based in the West Midlands in England, from the period of October 2016 to 11 October 2017. METHOD Prevalence data on 21 health conditions, multimorbidity, and visits to emergency departments were explored and compared with the general population datasets. RESULTS Most homeless people identified were male (89.5%), with a mean age of 38.3 (SD = 11.5) years, and of white British origin (22.1%). Prevalence of substance (13.5%) and alcohol dependence (21.3%), hepatitis C (6.3%), and multimorbidity (21.3%) were markedly higher than in the general population. A third (32.5%) had visited the emergency department in the preceding 12 months. Emergency department visits were associated with a patient history of substance (odds ratio [OR] = 2.69) and alcohol dependence (OR = 3.14). CONCLUSION A high prevalence of substance and alcohol dependence, and hepatitis C, exists among the homeless population. Their emergency department visit rate is 60 times that of the general population and the extent of multimorbidity, despite their lower mean age, is comparable with that of 60-69-year-olds in the general population. Because of multimorbidity, homeless people are at risk of fragmentation of care. Diversification of services under one roof, preventive services, and multidisciplinary care are imperative.
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Baggett TP, McGlave C, Kruse GR, Yaqubi A, Chang Y, Rigotti NA. SmokefreeTXT for Homeless Smokers: Pilot Randomized Controlled Trial. JMIR Mhealth Uhealth 2019; 7:e13162. [PMID: 31165717 PMCID: PMC6746087 DOI: 10.2196/13162] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/27/2019] [Accepted: 04/23/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Homeless smokers want to quit smoking but face numerous barriers to doing so, including pervasive smoking among peers and a lack of social support for quitting. An SMS (short message service) text messaging intervention could address these challenges by providing virtual daily support for homeless smokers who are trying to quit but coping with multiple triggers to smoke. OBJECTIVE This study aimed to assess whether a free SMS text messaging program, added to evidence-based pharmacotherapy and counseling, improved smoking abstinence among homeless adult smokers. METHODS From October 2015 to June 2016, we conducted an 8-week pilot randomized controlled trial (RCT) of nicotine patch therapy and weekly in-person counseling with (n=25) or without (n=25) SmokefreeTXT, a free SMS text messaging service administered by the National Cancer Institute (NCI) at Boston Health Care for the Homeless Program. All participants were provided with a mobile phone and a 2-month prepaid voice and text plan at no cost. SmokefreeTXT enrollees were sent 1 to 5 automated SMS text messages daily for up to 8 weeks and could receive on-demand tips for managing cravings, mood symptoms, and smoking lapses. The primary outcome was smoking abstinence, defined as an exhaled carbon monoxide count of <8 parts per million, assessed 14 times over 8 weeks of follow-up, and analyzed using repeated-measures logistic regression with generalized estimating equations. Other outcomes were use of SmokefreeTXT, assessed by data obtained from NCI; perceptions of SmokefreeTXT, assessed by surveys and qualitative interviews; and mobile phone retention, assessed by self-report. RESULTS Of the SmokefreeTXT arm participants (n=25), 88% (22) enrolled in the program, but only 56% (14) had confirmed enrollment for ≥2 weeks. Among 2-week enrollees, the median response rate to interactive messages from SmokefreeTXT was 2.1% (interquartile range 0-10.5%). Across all time points, smoking abstinence did not differ significantly between SmokefreeTXT and control arm participants (odds ratio 0.92, 95% CI 0.30-2.84). Of SmokefreeTXT enrollees who completed exit surveys (n=15), two-thirds were very or extremely satisfied with the program. However, qualitative interviews (n=14) revealed that many participants preferred in-person intervention formats over phone-based, found the SMS text messages impersonal and robotic, and felt that the messages were too frequent and repetitive. Only 40% (10/25) of SmokefreeTXT arm participants retained their study-supplied mobile phone for the 8-week duration of the trial, with phone theft being common. Storing and charging phones were cited as challenges. CONCLUSIONS SmokefreeTXT, added to nicotine patch therapy and in-person counseling, did not significantly improve smoking abstinence in this 8-week pilot RCT for homeless smokers. SMS text messaging interventions for this population should be better tuned to the unique circumstances of homelessness and coupled with efforts to promote mobile phone retention over time. TRIAL REGISTRATION ClinicalTrials.gov NCT02565381; https://clinicaltrials.gov/ct2/show/NCT02565381 (Archived by WebCite at http://www.webcitation.org/78PLpDptZ).
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Affiliation(s)
- Travis P Baggett
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States
- Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Claire McGlave
- Harvard TH Chan School of Public Health, Boston, MA, United States
| | - Gina R Kruse
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Awesta Yaqubi
- Boston University School of Medicine, Boston, MA, United States
| | - Yuchiao Chang
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
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Holowatyj AN, Heath EI, Pappas LM, Ruterbusch JJ, Gorski DH, Triest JA, Park HK, Beebe-Dimmer JL, Schwartz AG, Cote ML, Schwartz KL. The Epidemiology of Cancer Among Homeless Adults in Metropolitan Detroit. JNCI Cancer Spectr 2019; 3:pkz006. [PMID: 30944890 PMCID: PMC6433093 DOI: 10.1093/jncics/pkz006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Homeless individuals suffer and die disproportionately from chronic diseases and disorders. We describe the epidemiology of cancer among homeless persons in metropolitan Detroit. METHODS A retrospective cohort study was performed using 1973-2014 data from the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry and member of the National Institutes of Health-National Cancer Institute's Surveillance, Epidemiology, and End Results program. Homeless adults were identified through address at diagnosis listed as a homeless shelter, hospital, or supplemental field indicating homelessness. Age-adjusted, sex-specific proportional incidence ratios (PIR) compared cancer incidence proportions by primary tumor site of homeless patients to the nonhomeless referent population. Kaplan-Meier curves depicted unadjusted survival differences in a propensity score matched sample. Differences in 10-year survival were assessed using the score test with a sandwich estimator accounting for matched cluster effects. Statistical tests were two-sided. RESULTS A total of 388 individuals experienced homelessness at first primary invasive cancer diagnosis. Statistically significantly higher proportions of respiratory system (PIR = 1.51; 95% confidence interval = 1.28 to 1.79) and female genital system (PIR = 1.83; 95% confidence interval = 1.31 to 2.55) cancers were observed among homeless men and women, respectively. Homeless persons had poorer overall and cancer-reported survival compared with a propensity score matched referent population (median: overall survival, 20.0 vs 38.0 months, respectively, P < .001; cancer-reported survival, 38.0 vs 64.0 months, respectively, P < .001). CONCLUSION Disparities in disease burden exist between adults who are experiencing homelessness compared with the nonhomeless population at cancer diagnosis. These findings provide clinically relevant information to understand the cancer burden in this medically underserved population and suggest an urgent need to develop cancer prevention and intervention programs to reduce disparities and improve the health of homeless persons.
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Affiliation(s)
- Andreana N Holowatyj
- Correspondence to: Andreana N. Holowatyj, PhD, MS, Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Room 4746, Salt Lake City, UT 84112 (e-mail: )
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46
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Garey L, Reitzel LR, Neisler J, Kendzor DE, Zvolensky MJ, Neighbors C, Hernandez DC, Businelle MS. Health-Related Quality of Life Among Homeless Smokers: Risk and Protective Factors of Latent Class Membership. Behav Med 2019; 45:40-51. [PMID: 29558273 PMCID: PMC6148434 DOI: 10.1080/08964289.2018.1447905] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Health-related quality of life (HRQoL) is a multidimensional assessment of well-being and health status. Most work in this area assumes that HRQoL is a homogenous construct; however, it is possible HRQoL subgroups may exist. The purpose of the study was to characterize common classes of HRQoL among adult, homeless smokers, a particularly vulnerable group of the larger population, and to evaluate risk and protective factors of HRQoL class membership. Homeless smokers (N = 456; 65.1% male; Mage = 43.19 years [SD = 11.77]) completed self-report measures of sociodemographics, smoking characteristics, anxiety sensitivity, stress, social support, and the Center for Disease Control (CDC) four-item HRQoL measure. A latent class analysis was conducted for HRQoL. Multinomial regression models were used to simultaneously test correlates of class membership. A three-class solution, consisting of poor HRQoL, moderate HRQoL, and excellent HRQoL, demonstrated superior fit. Correlates of class membership included sex, age, lifetime months of being homeless, smoking characteristics, anxiety sensitivity, stress, and social support. The current findings provide novel evidence for three distinct classes of HRQoL among homeless smokers. Results suggest that older smokers with greater emotional distress, as evidenced by greater anxiety sensitivity, greater stress, and less social support, may be particularly vulnerable to poorer HRQoL.
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Affiliation(s)
- Lorra Garey
- The University of Houston, Department of Psychology, 126 Heyne Building, Houston, TX 77204-5029
| | - Lorraine R. Reitzel
- The University of Houston, Department of Psychological, Health, and Learning Sciences, 491 Farish Hall, Houston, TX 77204-5029
| | - Julie Neisler
- The University of Houston, Department of Psychological, Health, and Learning Sciences, 491 Farish Hall, Houston, TX 77204-5029
| | - Darla E. Kendzor
- The University of Oklahoma Health Sciences Center, Oklahoma Tobacco Research Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104
| | - Michael J. Zvolensky
- The University of Houston, Department of Psychology, 126 Heyne Building, Houston, TX 77204-5029,The University of Texas MD Anderson Cancer Center, Department of Behavioral Science, Unit 1330, P.O. Box 301439, Houston, TX 77230-1439
| | - Clayton Neighbors
- The University of Houston, Department of Psychology, 126 Heyne Building, Houston, TX 77204-5029
| | - Daphne C. Hernandez
- The University of Houston, Department of Health and Human Performance, Houston, TX, USA
| | - Michael S. Businelle
- The University of Oklahoma Health Sciences Center, Oklahoma Tobacco Research Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104
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McCloud RF, Bekalu MA, Maddox N, Minsky SJ, Viswanath K. Leveraging Breadth and Depth: Strategies to Characterize Population Diversity to Address Cancer Disparities in the DF/HCC Catchment Area. Cancer Epidemiol Biomarkers Prev 2018; 28:435-441. [PMID: 30341096 DOI: 10.1158/1055-9965.epi-18-0799] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/09/2018] [Accepted: 10/09/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND NCI-Designated Cancer Centers provide key cancer research, prevention, and treatment services to members of their catchment area. Characterization of these areas may be complex given the diverse needs of the populations within, particularly those from low socioeconomic position (SEP). The purpose of this paper is to describe the characterization of the Dana-Farber/Harvard Cancer Center (DF/HCC) catchment area through using a two-pronged approach. METHODS Participants (n = 1,511) were recruited through (i) an online, probability-based survey (n = 1,013) and (ii) a supplementary, in-person survey from priority groups (African Americans, Latinos, blue-collar workers, low SEP, homeless; n = 498) within Massachusetts. Study staff worked closely with community partners across the state to reach individuals who may not usually be included in online surveys. RESULTS There were several differences across samples, with the community-based sample having a higher percentage of low SEP, low education, African Americans, and Latinos compared with the online sample. Differences were also noted in the cancer-related behaviors of the samples, with the community-based sample having higher rates of smoking, particularly within those who were homeless or make less than $20,000 per year. Fewer community-based subgroups were current with cancer screenings, and more showed more indication of potential communication inequalities compared with statewide estimates. CONCLUSIONS The sampling strategy used to characterization of the DF/HCC catchment area provided broad, statewide estimates and additional focus on vulnerable populations, highlighting several potential areas for intervention. IMPACT This study provides data to highlight the value of using multiple sampling strategies when characterizing cancer center catchment areas.
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Affiliation(s)
| | - Mesfin Awoke Bekalu
- Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Nicole Maddox
- Department of Social and Political Sciences, Bocconi University, Milan, Italy
| | - Sara J Minsky
- Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - K Viswanath
- Center for Community-Based Research, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Pedersen M, Bring C, Brünés N, Andersen O, Petersen J, Jarden M. Homeless people's experiences of medical respite care following acute hospitalisation in Denmark. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:538-546. [PMID: 29488273 DOI: 10.1111/hsc.12550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/02/2018] [Indexed: 06/08/2023]
Abstract
The aim of this study was to explore homeless people's health perspectives and experiences of a 2-week medical respite care programme following acute hospitalisation. There is a high level of health inequality when comparing the health status of homeless people to the general population, including increased mortality and morbidity. Homelessness predisposes an increased risk of infectious disease, cancer and chronic illness, such as diabetes and cardiovascular disease. Moreover, homeless people have a higher frequency of acute hospitalisation than general population estimates. In order to facilitate the transition from hospitalisation back to life on the streets, homeless people who were acutely hospitalised in the Capital Region of Denmark were offered 2 weeks of medical respite care from the day of discharge by a non-governmental organisation. This is a qualitative study with a phenomenological hermeneutical approach based on narrative interviews of 12 homeless people who received medical respite care from 1 March 2016 to 30 September 2016. Data were collected through individual semi-structured interviews and analysed according to Lindseth and Norberg's presentation of Paul Ricoeur's theory of interpretation. The analysis identified four themes: (i) basic needs are of highest priority; (ii) a safe environment provides security and comfort; (ii) social support is just as important as healthcare; and (iv) restitution facilitates reflection. The findings indicated that the medical respite care centre provided a place of rest and restitution following hospitalisation, which made room for self-reflection among the homeless people regarding their past and present life, and also their wishes for a better future. This study also indicates that a medical respite care stay can contribute to the creation of a temporary condition in which the basic needs of the homeless people are met, enabling them to be more hopeful and to think more positively about the future.
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Affiliation(s)
- Maja Pedersen
- Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Denmark
| | - Camilla Bring
- Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Denmark
| | - Nina Brünés
- Copenhagen University Hospital, Hvidovre, Denmark
| | - Ove Andersen
- Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Denmark
| | - Janne Petersen
- Optimed, Clinical Research Center, Copenhagen University Hospital, Hvidovre, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mary Jarden
- University Hospitals Centre for Health Research (UCSF), Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Asgary R. Cancer screening in the homeless population. Lancet Oncol 2018; 19:e344-e350. [PMID: 30084381 DOI: 10.1016/s1470-2045(18)30200-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 03/06/2018] [Accepted: 03/07/2018] [Indexed: 01/05/2023]
Abstract
Annually, 100 million people experience homelessness worldwide. Most adults that are struggling with homelessness are living to age 50 years or older and need age-appropriate screening for cancer. Cancer-related death in homeless adults is twice as high as the average in the adult population in the USA. However, few studies have examined the rates of and barriers to cancer screening in homeless people. This Review explores cancer-related health disparities between homeless people and the general population by providing a review of data and definitions relating to homelessness, an analysis of barriers to screening in this population, and a discussion of the current and potential interventions and strategies to improve cancer screening in homeless individuals. Recommendations include implementing appropriate data collection methods for this population, supporting cancer screening in places where homeless people usually access care, assessing the effectiveness of approaches to increasing cancer screening in homeless people, and addressing adequate housing as a fundamental social factor.
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Affiliation(s)
- Ramin Asgary
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA; Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA; Department of Population and Family Studies, Mailman School of Public Health of Columbia University, New York, NY, USA; Doctors Without Borders-USA, New York, NY, USA.
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50
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Baggett TP, Yaqubi A, Berkowitz SA, Kalkhoran SM, McGlave C, Chang Y, Campbell EG, Rigotti NA. Subsistence difficulties are associated with more barriers to quitting and worse abstinence outcomes among homeless smokers: evidence from two studies in Boston, Massachusetts. BMC Public Health 2018; 18:463. [PMID: 29631559 PMCID: PMC5891993 DOI: 10.1186/s12889-018-5375-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/26/2018] [Indexed: 02/07/2023] Open
Abstract
Background Three-quarters of homeless people smoke cigarettes. Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. We analyzed data from two samples of homeless smokers to examine the associations between subsistence difficulties and 1) smoking cessation readiness, confidence, and barriers in a cross-sectional study, and 2) smoking abstinence during follow-up in a longitudinal study. Methods We conducted a survey of homeless smokers (N = 306) in 4/2014–7/2014 and a pilot randomized controlled trial (RCT) for homeless smokers (N = 75) in 10/2015–6/2016 at Boston Health Care for the Homeless Program. In both studies, subsistence difficulties were characterized as none, low, or high based on responses to a 5-item scale assessing the frequency of past-month difficulty finding shelter, food, clothing, a place to wash, and a place to go to the bathroom. Among survey participants, we used linear regression to assess the associations between subsistence difficulty level and readiness to quit, confidence to quit, and a composite measure of perceived barriers to quitting. Among RCT participants, we used repeated-measures logistic regression to examine the association between baseline subsistence difficulty level and carbon monoxide-defined brief smoking abstinence assessed 14 times over 8 weeks of follow-up. Analyses adjusted for demographic characteristics, substance use, mental illness, and nicotine dependence. Results Subsistence difficulties were common in both study samples. Among survey participants, greater subsistence difficulties were associated with more perceived barriers to quitting (p < 0.001) but not with cessation readiness or confidence. A dose-response relationship was observed for most barriers, particularly psychosocial barriers. Among RCT participants, greater baseline subsistence difficulties predicted less smoking abstinence during follow-up in a dose-response fashion. In adjusted analyses, individuals with the highest level of subsistence difficulty had one-third the odds of being abstinent during follow-up compared to those without subsistence difficulties (OR 0.33, 95% CI 0.11–0.93) despite making a similar number of quit attempts. Conclusions Homeless smokers with greater subsistence difficulties perceive more barriers to quitting and are less likely to do so despite similar readiness, confidence, and attempts. Future studies should assess whether addressing subsistence difficulties improves cessation outcomes in this population. Trial registration ClinicalTrials.gov: NCT02565381.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA. .,Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA.
| | - Awesta Yaqubi
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA
| | - Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Sara M Kalkhoran
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Claire McGlave
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Eric G Campbell
- Department of Medicine, Harvard Medical School, Boston, MA, USA.,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA
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