Adverse childhood experiences and related outcomes among adults experiencing homelessness: a systematic review and meta-analysis

Exploring the prevalence of childhood adversity among university students in the United Kingdom: A systematic review and meta-analysis

OBJECTIVES

The focus of this review was to systematically review and meta-analyse the prevalence of ACEs among university students in the UK.

METHOD

The systematic searching of six electronic databases (conducted February 2024) identified ten relevant articles (peer-reviewed articles of a quantitative nature that included ACE prevalence). PROSPERO reference: CRD42022364799.

RESULTS

Pooled prevalence for number of ACEs endured was 55.4% (95% CI: 32.4% - 78.4%; I2 > 99.5%) for one or more, and 31.6% (7.5% - 55.6%; I2 > 99.5%) for three or more. Pooled prevalence was: 15.9% (7.0% - 24.7%; I2 > 94.5%) for physical abuse; 27.0% (18.1% - 35.9%; I2 > 94.5%) for emotional abuse; 12.1% (5.2% - 19.0%; I2 > 94.5%) for sexual abuse; 8.4% (1.7% - 15.1%; I2 > 95.4%) for physical neglect, and 30.0% (21.5% - 38.5%; I2 > 95.4%) for emotional neglect. Pooled prevalence for household dysfunction categories were: 34.4% (22.8% - 46.0%) for parental separation; 18.4% (10.1% - 26.8%) for domestic violence; 35.2% (23.6% - 46.8%) for mental health difficulties; 21.4% (12.9% - 29.9%) for substance use; and 5.7% (2.3% - 9.1%) for incarceration (I2 > 88.8% for all household dysfunction items). Significant heterogeneity was observed between studies for most categories of adversity, and it was not possible to explain/reduce this variance by removing small numbers of influential/discrepant studies. Further analyses suggested potential influences of measurement tool used, country of data collection, and age and sex of participants.

CONCLUSION

Results demonstrate considerable, largely unaccounted-for, heterogeneity in estimates of the prevalence of ACEs, impeding confidence in any summary statistics. Conclusions must be tentative due to analyses being underpowered given small numbers of papers, as well as potential confounds, meaning results may not be truly representative. However, results do suggest high prevalence rates which warrant further investigation, with appropriate support offered to students.

The impact of adverse childhood experiences on multimorbidity: a systematic review and meta-analysis

BACKGROUND

Adverse childhood experiences (ACEs) have been implicated in the aetiology of a range of health outcomes, including multimorbidity. In this systematic review and meta-analysis, we aimed to identify, synthesise, and quantify the current evidence linking ACEs and multimorbidity.

METHODS

We searched seven databases from inception to 20 July 2023: APA PsycNET, CINAHL Plus, Cochrane CENTRAL, Embase, MEDLINE, Scopus, and Web of Science. We selected studies investigating adverse events occurring during childhood (< 18 years) and an assessment of multimorbidity in adulthood (≥ 18 years). Studies that only assessed adverse events in adulthood or health outcomes in children were excluded. Risk of bias was assessed using the ROBINS-E tool. Meta-analysis of prevalence and dose-response meta-analysis methods were used for quantitative data synthesis. This review was pre-registered with PROSPERO (CRD42023389528).

RESULTS

From 15,586 records, 25 studies were eligible for inclusion (total participants = 372,162). The prevalence of exposure to ≥ 1 ACEs was 48.1% (95% CI 33.4 to 63.1%). The prevalence of multimorbidity was 34.5% (95% CI 23.4 to 47.5%). Eight studies provided sufficient data for dose-response meta-analysis (total participants = 197,981). There was a significant dose-dependent relationship between ACE exposure and multimorbidity (p < 0.001), with every additional ACE exposure contributing to a 12.9% (95% CI 7.9 to 17.9%) increase in the odds for multimorbidity. However, there was heterogeneity among the included studies (I2 = 76.9%, Cochran Q = 102, p < 0.001).

CONCLUSIONS

This is the first systematic review and meta-analysis to synthesise the literature on ACEs and multimorbidity, showing a dose-dependent relationship across a large number of participants. It consolidates and enhances an extensive body of literature that shows an association between ACEs and individual long-term health conditions, risky health behaviours, and other poor health outcomes.

Mixed methods on adverse childhood experiences predicting transitional and recurrent homelessness

AIMS

Research has associated lack of parental care, physical abuse, and parental substance abuse to homelessness, with the presence of two or more such factors dramatically increasing one's chances of becoming homeless as an adult. Less clear is which (cumulation of) factors may mediate the difference between transitional and recurrent homelessness.

METHODS

Quantitative analysis of four risk factors-addiction, weak social network, criminal activity, psychopathology-among 69 transitionally and recurrently homeless (RH) adults, followed by in-depth qualitative analysis of adverse childhood experiences (ACEs) among 30 selected participants.

RESULTS

RH participants had higher cumulative risk and a higher prevalence and broader range of ACEs than transitionally homeless participants, with the prevalence of childhood physical abuse marking the greatest difference between the two groups. Recurrent homelessness was also correlated with addiction to hard drugs, criminal activity, and weak social networks.

CONCLUSION

Longitudinal and intervention studies in larger groups are needed to assess causality.

Traumatic Brain Injury and Its Risk Factors in a Homeless Population

OBJECTIVE

To characterize the traumatic brain injury (TBI) profile and its associated risk factors in homeless individuals in Santa Clara County, CA.

DESIGN

Observational cohort study.

SETTING

Two homeless shelter health clinics in Santa Clara County, CA.

PARTICIPANTS

Currently or recently homeless individuals seeking health care at 2 homeless shelter health clinics between August 2013 and May 2014.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Demographics, TBI incidence and characteristics.

RESULTS

The findings indicate that TBI history in the homeless population was higher (79.7%) than in the general population (12%). Almost half of the population (49.2%) reported that their TBI occurred before the age of 18. Of the participants, 68.2% reported sustaining a TBI with loss of consciousness. TBI caused by violence (60%) was lower in this cohort than other homeless cohorts but was the main cause of injury regardless of age. Alcoholism was a risk factor for having more TBIs. No differences in TBI profile were found between sexes.

CONCLUSIONS

Our findings underscore the need for more research on the lifetime risk factors associated with TBI to prevent and reduce the number of brain injuries in homeless populations.

Exploring clinicians' knowledge and attitudes toward the care needs of complex adult users of an Emergency Department: A descriptive mixed methods study

BACKGROUND

Adults who frequently present (FPAs) to emergency departments (EDs) often have a history of adverse childhood experiences (ACEs) and related adult health sequelae. Implications for ED care of this group remains poorly understood. This study explored clinicians' knowledge and attitudes toward the care needs of FPAs who have an ACEs history, providing preliminary evidence to inform further research and interventions.

METHODS

A purposive sample of ED clinicians completed an investigator developed mixed-methods survey. Descriptive statistics and content analysis were applied.

RESULTS

Forty-three ED clinicians completed the survey. Most perceived that ACEs were common among FPAs and influenced their ED presentations. Clinicians were more aware of the psychosocial impacts of ACEs than the risks to physical health. While most clinicians agreed that FPAs should be asked about ACEs for management planning, most never asked, describing multiple barriers to doing so. Consumer's healthcare needs were often described as unmet by clinicians who desired additional support to provide care for this group.

CONCLUSIONS

This study highlights clinicians' perceptions of gaps in healthcare for this patient group and introduces requirements for appropriate knowledge and resources to partner with consumers to provide patient-centred and trauma-informed health care responses.

The Global Prevalence of Non-suicidal Self-injury, Suicide Behaviors, and Associated Risk Factors Among Runaway and Homeless Youth: A Meta-analysis

A meta-analysis was performed to determine pooled prevalence of non-suicidal self-injury (NSSI), suicide behaviors (including ideation, attempts), and associated risk factors among runaway and homeless youth (RHY). The databases PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant studies published from January 1995 to May 2023. Initially, 8465 papers were screened, resulting in 69 included studies. The results showed that among RHY, lifetime prevalence rates were 42% for NSSI, 38% for suicidal ideation, and 27% for suicide attempts. Lifetime prevalence of NSSI and suicide behaviors was higher among adolescent minors (aged 12-17 years) compared to young adults (aged 18-24 years). Also, NSSI and suicide behaviors were associated with having a childhood history of physical and sexual abuse. Developing an impactful community-based suicide prevention campaign tailored for RHY appears warranted. Peer groups and mentorship programs would provide invaluable support for young individuals, as supportive friendships protect against NSSI.

Impact of Adverse Childhood Experiences in Young Adults and Adults: A Systematic Literature Review

BACKGROUND

Investigations have shown the different impacts that ACEs have on an individual's adult life, on both physical and mental health, but they have not yet shown the issue of the influence of ACEs on adults and young adults. Objective/Participants and Setting: This systematic review, performed according to the PRISMA norms and guidelines, intended to understand the most frequent outcomes of adverse childhood experiences in the life of young adults and adults.

METHODS

Studies were identified through multiple literature search databases at EBSCOhost, Web of Science, and PubMed April 2023, and a total of 279 studies, published between 1999 and 2002, were excluded, 256 because of multiple factors: being duplicates, showing statistical analysis with correlations only, being systematic reviews or case studies, comprising individuals under the age of 18, and not meeting the intended theme; ultimately, we selected for the review a total of 23 studies.

RESULTS AND CONCLUSIONS

The impacts of the various articles are subdivided into three main themes: antisocial and criminal behaviour; sexual Behaviour and intimate partner violence; and attachment, quality of life, and therapeutic alliance.

Adverse Childhood Experiences (ACEs) in Unhoused Children Increase Odds of Psychiatric Illness, Physical Illness, and Psychiatric Admission

Unhoused children and adolescents have high rates of adverse childhood experiences (ACEs). The objective of this study was to characterize a large cohort of unhoused children and investigate rates of psychiatric diagnoses, medical diagnoses, and utilization of emergency department (ED) resources depending on the presence of additional documented ACEs. A retrospective cohort of all unhoused children who presented to the ED of a large Midwestern health system from January 2014 to July 2019 were included. Unhoused status was determined by address field or ICD-10 code for homelessness (Z59.0). Demographics and ED visits were extracted from the electronic health record. Past medical history, ACEs, chief complaint (CC), length of stay (LOS), imaging, and labs were extracted by chart review. T-tests, chi square tests, and Fisher's exact tests were completed for each sub-analysis. Unhoused children with at least one additional ACE had higher odds of the following psychiatric disorders: depression (OR = 5.2, 95% CI = 3.4- 7.9), anxiety (OR = 3.4, 95% CI = 32.1-5.5), behavioral disorder (OR = 7.2, 95% CI = 35.1- 10.4), psychoses (OR = 6.0, 1.9-18.4), bipolar disorder (OR = 19.8, 95% CI = 34.6-84.9), suicidal ideation (OR = 8.0, 95% CI = 34.8-13.4), post-traumatic stress disorder (OR = 10.1, 95% CI = 35.4-18.6), and attention deficit hyperactive disorder (OR = 4.1, 3.0-5.7). Patients with additional documented ACEs were also more likely to have a prior psychiatric admission (p < 0.001). Unhoused children and adolescents with exposure to additional documented ACEs are more likely to have some serious psychiatric and medical diagnoses compared to other unhoused children.

Homelessness, psychiatric disorders, and violence in Denmark: a population-based cohort study

BACKGROUND

Homelessness is associated with adverse health and social outcomes. People experiencing homelessness have been found to have a high risk of violent crime victimisation as well as high prevalence of psychiatric disorders. It is poorly understood whether experiencing homelessness is associated with additional risks of violent offending and whether psychiatric disorders contribute to these risks. We examined the association between homelessness, psychiatric disorders, and first violence offence leading to conviction.

METHODS

We did a nationwide, register-based cohort study of all Danish residents who were alive at least 1 day during the study period, born between Jan 1, 1980, and Dec 31, 2006, and aged 15 years or older retrieved from the Danish Civil Registration System, which was linked to registers with information on homelessness, health care, and criminality. The exposure was any experience of homelessness, which was defined as having at least one contact with a homeless shelter during the study period. The outcome was first violent offence leading to a conviction. We calculated incidence rates per 10 000 person-years, incidence rate ratios (IRRs) using Poisson regression analysis, and probability of conviction of a violent offence using an Aalen-Johansen estimator. Analyses were stratified by sex and adjusted for calendar year of the study period, age, other sociodemographic factors, and psychiatric disorders.

FINDINGS

The study cohort included 1 786 433 Danish residents aged 15-42 years living in Denmark at some point from Jan 1, 2001, to Dec 31, 2021, contributing to 21 336 322 person-years at risk, of whom 57 084 (3·2%) individuals had their first violent offence leading to conviction during follow-up. 10 years after their first contact with a homeless shelter, 22·9% (95% CI 21·6-24·2) of men and 7·7% (6·8-8·7) of women had committed at least one violent crime leading to conviction. The fully adjusted IRRs of a violent offence leading to conviction were 4·8 (4·5-5·1) in men and 6·3 (5·6-7·2) in women experiencing homelessness compared with individuals who had not experienced homelessness. The IRR for a violent offence leading to conviction was highest in individuals experiencing homelessness and having co-occurring psychiatric disorders compared with those not experiencing homelessness and without co-occurring psychiatric disorders, especially drug use disorders (IRR in those experiencing homelessness and having a drug use disorder: 15·3 [14·1-16·7] in men and 40·1 [33·9-47·5] in women compared with individuals not experiencing homelessness and having no drug use disorder).

INTERPRETATION

Individuals experiencing homelessness had higher risks of a violent offence leading to conviction than those who had not experienced homelessness. In addition to preventing homelessness, public health and policy should consider how to reduce the risk of adverse outcomes in people experiencing homelessness.

FUNDING

Lundbeck Foundation.

The Link Between Childhood Abuse Experiences and Homeless People's Quality of Life: A Longitudinal Study

Studies report a relatively high prevalence of childhood abuse experiences (CAE) among adult homeless people. Within homeless populations, people with CAE appear to be worse off than homeless people without such experiences. This study compares a broad set of factors influencing the quality of the daily lives of Dutch homeless people with and without CAE. It also examines the extent to which CAE are predictive of the rate of change in these factors 2.5 years after entering the social relief system. Data were used from an observational longitudinal multi-site cohort study following Dutch homeless people 2.5 years after entering the social relief system. The 4 constitutional conditions of the Social Quality Approach (living conditions, interpersonal embeddedness, societal embeddedness and self-regulation) were used to cluster the factors included in this study. Participants were interviewed twice, at baseline (N = 513) and at follow up (N = 378), using a quantitative questionnaire. At baseline and follow-up participants with CAE were more disadvantaged in each of the 4 conditions of social quality, except for societal embeddedness at follow-up. After 2.5 years, on average, all participants improved more or less at a similar rate on almost all factors, with a few exceptions: Significant differential changes over time were found regarding employment status, quality of relationships with family members and symptoms of depression and anxiety. Findings corroborate the broad, detrimental and persistent impact of CAE on the quality of daily lives of homeless people and the need for homelessness services to apply trauma-informed care.

Effects of expanded adverse childhood experiences including school bullying, childhood poverty, and natural disasters on mental health in adulthood

The study aimed to examine the association of expanded adverse childhood experiences (ACEs) with psychological distress in adulthood. The data from nation-wide online cohort was used for analysis. Community dwelling adults in Japan were included. The ACEs was assessed by 15 items of ACE-J, including childhood poverty and school bullying. Severe psychological distress was determined as the score of Kessler 6 over 13. Multivariable logistic regression analysis was conducted, by using sample weighting. A total of 28,617 participants were analyzed. About 75% of Japanese people had one or more ACEs. The prevalence of those with ACEs over 4 was 14.7%. Those with ACEs over 4 showed adjusted odds ratio = 8.18 [95% CI 7.14-9.38] for severe psychological distress. The prevalence of childhood poverty was 29% for 50-64 year old participants and 40% of 65 or older participants. The impact of childhood poverty on psychological distress was less than other ACEs in these age cohorts. Bullying was experienced 21-27% in young generations, but 10% in 65 or older participants. However, the impact on psychological distress in adulthood was relatively high in all age groups. ACEs have impacted mental health for a long time. Future research and practice to reduce ACEs are encouraged.

Service restrictions from emergency shelters among people experiencing homelessness: Uncovering pathways into unsheltered homelessness and institutional circuitry

Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mapping to examine the antecedents and consequences of service restrictions from emergency shelters among people experiencing homelessness in two cities in Ontario, Canada. A total of 49 people experiencing homelessness who had been restricted from an emergency shelter program in the past year were recruited and included in the study analysis. A pragmatic and integrative approach was used for data analysis that involved the development of meta-matrices to identify prominent and divergent perspectives and experiences with regard to service restriction antecedents and consequences. Study findings underscored that service restrictions were often the result of violence and aggression, primarily between service users. There were regional differences in other service restriction reasons, including substance use and possession. Service restrictions affected the shelter status of almost all participants, with many subsequently experiencing unsheltered homelessness, and cycling through institutional health, social, and criminal justice services (i.e., institutional circuitry). Other health and social consequences included substance use relapses and hospitalizations; cold-related injuries due to post-restriction unsheltered homelessness; suicidality; food insecurity; diminished contact with support network and connections; and intense feelings of anger, fear, and hopelessness. Overall, the study findings advance our understanding of the role of homeless services in pathways into unsheltered homelessness and institutional circuitry, which raise critical questions about how to mitigate the harms associated with service restrictions, while concurrently facilitating safety and upholding the rights of people experiencing homelessness and emergency shelter staff.

Conceptualizing adverse childhood experiences as a latent factor: Tests of measurement invariance across five racial and ethnic groups

Adverse childhood experiences (ACEs) are conventionally measured using a cumulative-risk index without consideration of distinct measurement properties across racial and ethnic groups. Drawing from the 2018-2020 National Survey of Children's Health (N = 93,759; 48% female; average age: 9.52 years), we assess the measurement invariance of a latent-factor ACE model across five groups: Hispanic children (14%) and non-Hispanic White (73%), Black (7%), Asian/Pacific Islander (5%), and American Indian/Alaskan Native (1%) children. Results support configural and full metric invariance across groups. However, several ACE item thresholds differed across groups. Findings highlight the potential utility of a latent factor approach and underscore the need to assess differences across racial and ethnic groups in terms of the optimal conceptualization and measurement of ACEs.

Tobacco use behavior among adults exposed to cumulative adverse childhood experiences: A systematic review and meta analysis

BACKGROUND

Tobacco use remains one of the most used substances among adults globally and substantially impacts individuals and society. Adverse childhood experiences (ACEs) contribute to tobacco use. However, the association between cumulative ACEs and tobacco use behaviors (TUB) has not been established in the literature. In this review, we aimed to estimate the prevalence of ACEs among adult tobacco users and evaluated the relationship between cumulative ACEs and TUB.

METHODS

We identified original articles published before October 2022 by searching PubMed, CINAHL, and Psych INFO databases. Inclusion criteria were: English language, adults and used instruments assessing for cumulative ACEs defined as four or more ACEs.

RESULTS

Forty-two studies, totaling 674,087 participants; predominantly cohort and cross-sectional in study design (n = 33). Exposure to 4 ≥ ACEs was significantly associated with increasing the odds of current tobacco use (n = 35), ever or former tobacco use (n = 13), tobacco use initiation, (n = 3) nicotine dependence (n = 1), and ever using electronic cigarettes (n = 1). In the meta-analysis, as compared to those without ACEs, those with 4 ≥ ACEs were twice as likely to have ever used tobacco (OR = 2.16, 95 %CI:1.73-2.70) and approximately four times more likely to have used tobacco currently (OR = 3.73, 95 %CI:2.69-5.18).

CONCLUSION

The cumulative ACEs exposure can increase the risk for TUB. However, the evidence is limited primarily to cigarette use. Ongoing research into the effects of cumulative ACEs on TUB is needed to integrate trauma-informed intervention in treating tobacco use and guide public health initiatives aimed to reduce the prevalence of ACEs and TUB among adults.

Health literacy and its association with mental and spiritual well-being among women experiencing homelessness

Low health literacy (HL) has been linked to low self-rated health, reduced efficacy of behaviour change, and challenges in preventing, treating, or managing health conditions. People experiencing homelessness are at risk of poor HL; however, few studies have investigated HL in relation to mental and spiritual well-being among people experiencing homelessness in general, or women experiencing homelessness specifically. This cross-sectional study of 46 women experiencing homelessness in Stockholm, Sweden, recruited during the period October 2019-December 2020, aimed to examine how HL was associated with mental and spiritual well-being among women experiencing homelessness. Participants answered questions about socio-demographic characteristics (age, length of homelessness, education) and digital technology (mobile phone/the Internet) use, in addition to Swedish language versions of three questionnaires administered through structured, face-to-face interviews: the Communicative and Critical Health Literacy Scale, the General Health Questionnaire 12 and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being. Data were analysed using linear regression, which revealed statistically significant associations between HL and mental well-being (p = .009), and between HL and spiritual well-being (p = .022). However, neither socio-demographic characteristics nor digital technology use were significantly associated with HL. In conclusion, promoting HL may improve mental and spiritual well-being in this vulnerable population. An advisory board of women with lived experiences of homelessness (n = 5) supported the interpretation of the findings and emphasised the need to consider HL in relation to basic needs such as 'housing first'. Moreover, health information and services should be accessible to people with different degrees of HL.

Early-life influenza A (H1N1) infection independently programs brain connectivity, HPA AXIS and tissue-specific gene expression profiles

Early-life adversity covers a range of physical, social and environmental stressors. Acute viral infections in early life are a major source of such adversity and have been associated with a broad spectrum of later-life effects outside the immune system or "off-target". These include an altered hypothalamus-pituitary-adrenal (HPA) axis and metabolic reactions. Here, we used a murine post-natal day 14 (PND 14) Influenza A (H1N1) infection model and applied a semi-holistic approach including phenotypic measurements, gene expression arrays and diffusion neuroimaging techniques to investigate HPA axis dysregulation, energy metabolism and brain connectivity. By PND 56 the H1N1 infection had been resolved, and there was no residual gene expression signature of immune cell infiltration into the liver, adrenal gland or brain tissues examined nor of immune-related signalling. A resolved early-life H1N1 infection had sex-specific effects. We observed retarded growth of males and altered pre-stress (baseline) blood glucose and corticosterone levels at PND42 after the infection was resolved. Cerebral MRI scans identified reduced connectivity in the cortex, midbrain and cerebellum that were accompanied by tissue-specific gene expression signatures. Gene set enrichment analysis confirmed that these were tissue-specific changes with few common pathways. Early-life infection independently affected each of the systems and this was independent of HPA axis or immune perturbations.

Associations between early child adversity and lifetime suicide attempts among gender diverse individuals: A moderated mediation

BACKGROUND

This study examines the effect of adverse childhood experiences (ACEs) on lifetime suicide attempts (LSA) across five gender subgroups (i.e., transgender men, transgender women, transgender non-binary, cisgender men and cisgender women).

OBJECTIVE

To examine (1) the prevalence of LSA across gender identity subgroups; (2) whether the association between ACEs and LSA is moderated by gender identity subgroup; (3) depressive symptoms, alcohol use disorder, social support, and social well-being as mechanisms linking ACEs with LSA; and (4) the moderating role of gender identity on the four putative mediators.

PARTICIPANTS AND SETTINGS

We used nationally representative data from a population-based survey of N = 1368 transgender and cisgender individuals collected between 2016 and 2019.

METHODS

Structural equation modeling was used to explore the indirect effect of depressive symptoms on the relation between ACEs and LSA, and the moderating impact of gender identity.

RESULTS

LSA was significantly more prevalent among transgender respondents (cisgender man = 5 %; cisgender woman = 9 %; transgender man = 42 %; transgender woman = 33 %; transgender non-binary = 37 %; p < 0.001). Individuals with more ACEs had a greater risk of engaging in LSA regardless of gender identity; however, moderation results showed that the impact of each additional ACE on LSA was stronger for individuals with transgender identities: the likelihood of engaging in LSA was statistically similar for transgender men with no ACEs and cisgender men with all 8 ACEs. Indirect effects of ACEs on LSA via depressive symptoms were also observed, and the mediating effect was moderated by gender identity.

CONCLUSIONS

By examining the mechanisms linking childhood adversity to LSA, this study demonstrates that not all ACEs impact gender minority subgroups equally.

Association between traumatic events with suicidality among adolescents: A large-scale cross-sectional study of 260,423 participants

Traumatic events have significant negative impacts throughout one's life. We aimed to comprehensively examine the early associations between traumatic events and suicidality among adolescents. In a cross-sectional sample of 260,423 adolescents in Deyang, China in September 2021, we assessed individual traumatic events, cumulative types, and patterns, alongside suicide risk scores and ideation, attempts, or plans. Linear and Poisson regression models adjusted for demographic confounders evaluated the association. Robust associations existed between interpersonal violence-related traumatic events and higher suicidality, with physical abuse demonstrating the strongest correlation. Moreover, suicide risk scores displayed a clear trend, indicating a progressively stronger association with suicidality as cumulative traumatic event types increased. Four distinct traumatic patterns emerged, including low traumas, high physical abuse, high death/serious injuries of a loved one, and multiple traumas, with the latter showing the strongest association with suicidality. Notably, the stratified analysis showed these associations were more pronounced in females, urban residents, only children, left-behind children, and those aged 13-15, while weaker in participants from families with intact parental relationships and middle socioeconomic status. Understanding the role of demographic factors and traumatic patterns in identifying at-risk youth can enable early detection and targeted interventions for suicide-related concerns.

Gambling Harm Experienced by Children Exposed to Parental Gambling: An Online Survey of Australians

Although child wellbeing is known to be negatively affected by gambling, relatively little is known about the specific harms experienced by children exposed to parental gambling problems. The current study aimed to better understand gambling harm directly attributed to regular parental gambling in key areas of child wellbeing: financial, psychological, interpersonal wellbeing and intergenerational transmission of problem gambling. Using data from a national survey of Australian adults exposed to parental gambling under the age of 18 (n = 211), the results show that parental gambling was related significant levels of financial harm, abuse, neglect as well as relational and psychological problems as a direct result of parental gambling. The likelihood of experiencing gambling harms was positively associated with parental problem gambling severity. Harmful impacts of parental gambling as a child were also associated with a range of psychological problems in adulthood including depression, anxiety, Post-Traumatic Stress Disorder and intimate partner violence victimisation. Parental problem gambling severity was negatively associated with own lifetime gambling problems, suggesting a specific pattern of intergenerational transmission of problem gambling in children of regular, or heavy, gamblers. This research highlights the need for more supports for families with children in which at least one parent gambles regularly.

Adverse Childhood Experiences and Depression among Homeless Young Adults: A Social Determinants of Health Perspective

Homelessness is a pervasive issue in the United States that presents significant challenges to public health. Homeless young adults (HYAs) are at particular risk for increased incidence and severity of depression. Using primary survey data (n = 205) collected in the Phoenix Metropolitan Area, Arizona, from June to August 2022, this study aims to examine the relationship between adverse childhood experiences (ACEs) and depression among HYAs. We adopted the ACEs 10-item scale to measure childhood traumatic experiences, whereas depression was measured by using a PHQ-4 depression scale and diagnosed depression. Regression models were conducted to test the relationships between ACEs and depression outcomes while controlling for the covariates at the individual, interpersonal, and socioeconomic/living environment levels. The average PHQ-4 score was 5.01 (SD = 3.59), and 59.69% of HYAs reported being diagnosed previously with depression. The mean ACEs score was 5.22 out of 10. Other things being equal, for every one unit increase in ACEs scores, the odds of being diagnosed with depression increased by 11.5%, yet it was not statistically significant, while the PHQ-4 score increased by 0.445 (p < 0.001). Overall, HYAs were disproportionately affected by depression. This study elucidates the complex relationship between ACEs and depression among HYAs.

Predictors of Housing Trajectories Among Young Adults Experiencing Homelessness in Los Angeles

Experiencing homelessness during young adulthood is associated with negative health outcomes and understanding housing trajectories of young adults experiencing homelessness may aid in the development of evidence-based public health programs designed to serve this at-risk age group. In the present study, the authors examined baseline predictors of 24-month trajectories of housing stability and unsheltered housing among a sample of 271 young adults aged 18 to 25 recruited from drop-in centers in Los Angeles. In multivariate models, the authors found that identifying as multi-racial/other and better friendship quality at baseline were associated with less steep increases in the likelihood of stable housing over time. Being employed at baseline was associated with a less steep decrease in the probability of being unsheltered over time, while illicit drug use days associated with a steeper decrease in the probability of being unsheltered over time. Continued research is needed to establish important factors determining young adults' long-term housing trajectories in the effort to promote greater access and engagement with housing services.

Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a stystematic review and meta-analysis

Background: Adverse childhood experiences (ACEs) have been shown to negatively affect health in adulthood. Estimates of associations between ACEs and chronic painful conditions are lacking.Objectives: This systematic review and meta-analysis aimed to evaluate associations between exposure to ACEs and chronic pain and pain-related disability in adults.Methods: We searched 10 electronic databases from inception to February 2023. We included observational studies assessing associations between direct ACEs (childhood sexual, physical, emotional abuse, or neglect) alone or in combination with indirect ACEs (witnessing domestic violence, household mental illness), and adult chronic pain (≥3 months duration) and pain-related disability (daily activities limited by chronic pain). Pairs of reviewers independently extracted data and assessed study risks of bias. Random-effect models were used to calculate pooled adjusted odds ratios [aOR]. Tau square [T2], 95% prediction intervals [95%PI] and I2 expressed the amount of heterogeneity, and meta-regressions and subgroup meta-analyses investigated sources of heterogeneity (PROSPERO: CRD42020150230).Results: We identified 85 studies including 826,452 adults of which 57 studies were included in meta-analyses. Study quality was generally good or fair (n = 70). The odds of reporting chronic pain in adulthood were significantly higher among individuals exposed to a direct ACE (aOR, 1.45, 95%CI, 1.38-1.53). Individuals reporting childhood physical abuse were significantly more likely to report both chronic pain (aOR, 1.50, 95CI, 1.39-1.64) and pain-related disability (1.46, 95CI, 1.03-2.08) during adulthood. Exposure to any ACEs alone or combined with indirect ACEs significantly increase the odds of adult chronic painful conditions (aOR, 1.53, 95%CI, 1.42-1.65) and pain-related disability (aOR, 1.29; 95%CI, 1.01-1.66). The risk of chronic pain in adulthood significantly increased from one ACE (aOR, 1.29, 95%CI, 1.22-1.37) to four or more ACEs (1.95, 95%CI, 1.73-2.19).Conclusions: Single and cumulative ACEs are significantly associated with reporting of chronic pain and pain-related disability as an adult.

"When I think about my future, I just see darkness": How youth exiting homelessness navigate the hazy, liminal space between socioeconomic exclusion and inclusion

OBJECTIVES

The overarching objective of this mixed methods longitudinal study was to understand whether and how rent subsidies and mentorship influenced socioeconomic inclusion outcomes for youth exiting homelessness. The focus of this paper is on the qualitative objectives, which evolved from a primary focus on exploring how study mentorship was working as a facilitator of socioeconomic inclusion to focusing on how participants navigated the hazy, liminal space between socioeconomic exclusion and inclusion.

METHODS

This was a convergent mixed methods study scaffolded by community-based participatory action axiology. The quantitative component is reported elsewhere and involved a 2-year pilot randomized controlled trial where 24 participants received rent subsidies and 13 were randomly assigned a study mentor; proxy indicators of socioeconomic inclusion were measured every 6 months for 2.5 years. Qualitative objectives were explored using a qualitative descriptive design and theoretically framed using critical social theory. The lead author interviewed 12 participants every 6 months for 2.5 years. Qualitative interviews were analyzed using reflexive thematic analysis with an emphasis on critical interpretation.

RESULTS

Navigating the liminal space between socioeconomic exclusion and inclusion was complex and non-linear, and the way youth navigated that journey was more strongly associated with factors like informal mentorship (naturally occurring "coach-like" mentorship) and identity capital (sense of purpose, control, self-efficacy, and self-esteem), rather than whether or not they were assigned a formal study mentor.

CONCLUSION

A holistic approach integrating coaching and attention to identity capital alongside economic supports may be key to helping youth exiting homelessness achieve socioeconomic inclusion.

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

Intergenerational Transmission of Parental Adverse Childhood Experiences and Children's Outcomes: A Scoping Review

Adverse childhood experiences (ACEs) are among the leading environmental causes of morbidity and mortality. Extending research on within-generation effects, more recent scholarship has explored between-generation consequences of ACEs. Despite growing interest in the intergenerational effects of parents' ACEs on children's outcomes, this line of scholarship has yet to be coalesced into a comprehensive review. The current study is a scoping review on the intergenerational transmission of parental ACEs and children's outcomes. Ten databases such as PubMed, APA PsycArticles, and Social Work Abstracts were searched. To be included, empirical studies must have been published in English and analyzed associations between a cumulative measure of at least four parental ACEs and children's outcomes. Sixty-eight studies qualified for the review and, among these, 60 were published in the most recent 5 years (2018-2022). Fifty-one studies had sample sizes smaller than 500, and 55 focused on the effect of maternal ACEs. Nearly all studies demonstrated that parental ACEs could affect children's outcomes directly or indirectly via mechanisms like maternal mental health problems or parenting-related factors. By scoping the extant literature, this review advances the knowledge base regarding the intergenerational impacts of parental childhood trauma and children's outcomes. It also reveals methodological limitations that should be addressed in future research to strengthen causal inferences along with practical implications for interventions that aim to interrupt the intergenerational transmission of trauma.

Adverse childhood experiences, morbidity, mortality and resilience in socially excluded populations: protocol for a systematic review and meta-analysis

INTRODUCTION

Socially excluded populations, defined by homelessness, substance use disorder, sex work or criminal justice system contact, experience profound health inequity compared with the general population. Cumulative exposure to adverse childhood experiences (ACEs), including neglect, abuse and household dysfunction before age 18, has been found to be independently associated with both an increased risk of social exclusion and adverse health and mortality outcomes in adulthood.Despite this, the impact of ACEs on health and mortality within socially excluded populations is poorly understood.

METHODS AND ANALYSIS

We will search MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Educational Resources Information Center, PsycINFO, Applied Social Science Index and Abstracts and Criminal Justice Database for peer-reviewed studies measuring ACEs and their impact on health and mortality in socially excluded populations.Three review questions will guide our data extraction and analysis. First, what is the prevalence of ACEs among people experiencing social exclusion in included studies? Second, what is the relationship between ACEs and health and mortality outcomes among people experiencing social exclusion? Does resilience modify the strength of association between ACEs and health outcomes among people experiencing social exclusion?We will meta-analyse the relationship between ACE exposure and health outcomes classified into six a prior categories: (1) substance use disorders; (2) sexual and reproductive health; (3) communicable diseases; (4) mental illness; (5) non-communicable diseases and (6) violence victimisation, perpetration and injury. If there are insufficient studies for meta-analysis, we will conduct a narrative synthesis. Study quality will be assessed using the MethodologicAl STandards for Epidemiological Research scale.

ETHICS AND DISSEMINATION

Our findings will be disseminated in a peer-reviewed journal, in presentations at academic conferences and in a brief report for policy makers and service providers. We do not require ethics approval as this review will use data that have been previously published.

PROSPERO REGISTRATION NUMBER

CRD42022357565.

Adverse childhood experiences: a meta-analysis of prevalence and moderators among half a million adults in 206 studies

Exposure to adverse childhood experiences (ACEs), including maltreatment and family dysfunction, is a major contributor to the global burden of disease and disability. With a large body of international literature on ACEs having emerged over the past 25 years, it is timely to now synthetize the available evidence to estimate the global prevalence of ACEs and, through a series of moderator analyses, determine which populations are at higher risk. We searched studies published between January 1, 1998 and August 5, 2021 in Medline, PsycINFO and Embase. Study inclusion criteria were using the 8- or 10-item ACE Questionnaire (±2 items), reporting the prevalence of ACEs in population samples of adults, and being published in English. The review protocol was registered with PROSPERO (CRD42022348429). In total, 206 studies (208 sample estimates) from 22 countries, with 546,458 adult participants, were included. The pooled prevalence of the five levels of ACEs was: 39.9% (95% CI: 29.8-49.2) for no ACE; 22.4% (95% CI: 14.1-30.6) for one ACE; 13.0% (95% CI: 6.5-19.8) for two ACEs; 8.7% (95% CI: 3.4-14.5) for three ACEs, and 16.1% (95% CI: 8.9-23.5) for four or more ACEs. In subsequent moderation analyses, there was strong evidence that the prevalence of 4+ ACEs was higher in populations with a history of a mental health condition (47.5%; 95% CI: 34.4-60.7) and with substance abuse or addiction (55.2%; 95% CI: 45.5-64.8), as well as in individuals from low-income households (40.5%; 95% CI: 32.9-48.4) and unhoused individuals (59.7%; 95% CI: 56.8-62.4). There was also good evidence that the prevalence of 4+ ACEs was larger in minoritized racial/ethnic groups, particularly when comparing study estimates in populations identifying as Indigenous/Native American (40.8%; 95% CI: 23.1-59.8) to those identifying as White (12.1%; 95% CI: 10.2-14.2) and Asian (5.6%; 95% CI: 2.4-10.2). Thus, ACEs are common in the general population, but there are disparities in their prevalence. They are among the principal antecedent threats to individual well-being and, as such, constitute a pressing social issue globally. Both prevention strategies and downstream interventions are needed to reduce the prevalence and mitigate the severity of the effects of ACEs and thereby reduce their deleterious health consequences on future generations.

Intergenerational transmission of child protective services involvement: Exploring the role of ACEs and domestic violence among families who receive home visiting services

BACKGROUND

Adverse childhood experiences (ACEs) are associated with negative outcomes over the life course and across generations, including domestic violence (DV) and child maltreatment. However, no studies have examined the connection between parents' ACEs and their child's risk of child protective services (CPS) involvement or possible mechanisms of transmission.

OBJECTIVE

In addition to describing the prevalence and correlates of CPS involvement, our primary aims are to test whether parental adversity in childhood is associated with CPS involvement and whether DV victimization mediates the ACE-CPS association.

PARTICIPANTS AND SETTING

The sample included 3039 primary caregivers and 3343 children served by home visiting programs in Wisconsin between 2014 and 2019.

METHODS

Using matched home visiting and CPS records, we generated prevalence estimates of screened-in CPS reports and assessed bivariate associations between CPS involvement and ACEs, DV, and household demographics. We then conducted a two-stage path analysis to test the association between ACEs and CPS involvement and whether DV mediated the ACE-CPS association.

RESULTS

Overall, 22.8 % of caregivers had a screened-in report. Prevalence rates were higher among women who endured ACEs and DV, and they varied by demographic characteristics. ACEs were directly linked to DV and CPS involvement, and there was an indirect pathway linking ACEs to CPS involvement through DV exposure.

CONCLUSIONS

Home visiting programs serve families that frequently interact with the child welfare system. By enhancing the trauma-responsive potential of these interventions, it may be possible to interrupt intergenerational mechanisms that contribute to child abuse and neglect and CPS involvement.

Health Care of People Experiencing Homelessness: Part II

Health Care of People Experiencing HomelessnessIn this second part of a two-part review of health care for people experiencing homelessness, Taylor and Munson discuss approaches to care that are tailored to this population.

Prevalence, correlates, and mental health burden associated with homelessness in U.S. military veterans

BACKGROUND

Homelessness is a major public health problem among U.S. military veterans. However, contemporary, population-based data on the prevalence, correlates, and mental health burden of homelessness among veterans are lacking.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of veterans (n = 4069). Analyses examined the prevalence and correlates of homelessness, as well as the independent associations between homelessness and current probable psychiatric conditions, suicidality, and functioning.

RESULTS

The lifetime prevalence of homelessness was 10.2% (95% confidence interval 9.3-11.2). More than 8-of-10 veterans reported experiencing their first episode of homelessness following military service, with a mean of 10.6 years post-discharge until onset (s.d. = 12.6). Adverse childhood experiences (ACEs), cumulative trauma burden, current household income, younger age, and drug use disorder emerged as the strongest correlates of homelessness (49% of total explained variance). Veterans with a history of homelessness had elevated odds of lifetime suicide attempt, attempting suicide two or more times, and past-year suicide ideation [odd ratios (ORs) 1.3-3.1]. They also had higher rates of current probable posttraumatic stress disorder, major depressive, generalized anxiety, and drug use disorders (ORs 1.7-2.4); and scored lower on measures of mental, physical, cognitive, psychosocial functioning (d = 0.11-0.15).

CONCLUSIONS

One in ten U.S. veterans has experienced homelessness, and these veterans represent a subpopulation at substantially heightened risk for poor mental health and suicide. ACEs were the strongest factor associated with homelessness, thus underscoring the importance of targeting early childhood adversities and their mental health consequences in prevention efforts for homelessness in this population.

The Effects of Traumatic Events on Mental Health Among Women Experiencing Homelessness: A Longitudinal Study

In this longitudinal study, we aim to evaluate the prevalence and impact of interpersonal and non-interpersonal traumatic events among women experiencing homelessness in Madrid (Spain) (N  =  136). The information was collected through a structured interview and standardized instruments at baseline and at a 12-month follow-up. The most prevalent events were physical assaults, intimate partner violence, and severe illnesses or accidents. Path analysis revealed that personal and non-interpersonal traumatic events had direct effects on mental health, but also had differential indirect effects. Greater efforts are needed to address the effects of various types of potentially traumatic events and to design effective trauma-informed interventions for women experiencing homelessness.

The Consequences of Child Abuse

This review provides an overview of the consequences of early adverse experiences across various domains of life. Drawing on the Adverse Childhood Experiences (ACEs) conceptual framework, we discuss the ACE pyramid and the varying degrees of consequences that ACE exposure may elicit. Using online search engines such as Google Scholar, the authors sifted through empirical research to locate relevant articles and research to help prepare this review. This article sheds light on the implications of ACEs for health, socio-emotional and psychosocial well-being, relationships, personality, and cognitive functioning.

Spousal concordance in adverse childhood experiences and the association with depressive symptoms in middle-aged and older adults: findings across China, the US, and Europe

Background

Adverse childhood experiences (ACEs) are associated with higher depressive risks in adulthood. Whether respondents' ACEs are associated with their own depressive symptoms in adulthood and whether this association extends to their spouses' depressive symptoms remain unexplored.

Methods

Data were from China Health and Retirement Longitudinal Study (CHARLS), the Health and Retirement Study (HRS), and the Survey of Health, Ageing and Retirement in Europe (SHARE). ACEs were categorized into overall, intra-familial, and extra-familial ACEs. Correlations of couples' ACEs were calculated using Cramer's V and partial Spearman's correlation. Associations of respondents' ACEs with spousal depressive symptoms were assessed using logistic regression, and mediation analyses were conducted to explore the mediating role of respondents' depressive symptoms.

Results

Significant associations between husbands' ACEs and wives' depressive symptoms, with odds ratios (ORs) and 95% confidence intervals (CIs) of 2.09 (1.36-3.22) for 4 or more ACEs in CHARLS, and 1.25 (1.06-1.48) and 1.38 (1.06-1.79) for 2 or more ACEs in HRS and SHARE. However, wives' ACEs were associated with husbands' depressive symptoms only in CHARLS and SHARE. Findings in intra-familial and extra-familial ACEs were consistent with our main results. Additionally, respondents' depressive symptoms mediated more than 20% of the effect of respondents' ACEs on spousal depressive symptoms.

Conclusion

We found that ACEs were significantly correlated between couples. Respondents' ACEs were associated with spousal depressive symptoms, with respondents' depressive symptoms mediating the association. The bidirectional implications of ACEs on depressive symptoms should be considered within household and effective interventions are warranted.

Adverse childhood experiences, mental health, and social functioning: A scoping review of the literature

BACKGROUND

Adverse childhood experiences (ACEs) negatively impact people's physical and mental health and social functioning. Research literature focuses on the impact of ACEs on physical and mental health, yet to our knowledge, no study has examined the literature on ACEs, mental health, and social functioning outcomes.

OBJECTIVE

To map how ACEs, mental health, and social functioning outcomes have been defined, assessed, and studied in the empirical literature and identify gaps in the current research which need further investigation.

METHODS

A scoping review methodology following a five-step framework was implemented. Four databases were searched CINAHL, Ovid (Medline, Embase) and PsycInfo. The analysis involved both numerical and a narrative synthesis in line with the framework.

RESULTS

Fifty-eight studies were included in the analysis, and three key issues were identified a) the limitations of research samples to date, b) the choice of outcome measures for ACEs, social and mental health outcomes, and c) the limitations of current study designs.

CONCLUSION

The review demonstrates variability in the documentation of participant characteristics and inconsistencies in the definitions and applications of ACEs, social and mental health and related measurements. There is also a lack of longitudinal and experimental study designs, studies on severe mental illness, and studies including minority groups, adolescents, and older adults with mental health problems. Existing research is highly variable methodologically and limits our broader understanding of the relationships between ACEs, mental health, and social functioning outcomes. Future research should implement robust methodologies to provide evidence that could be used for developing evidence-based interventions.

Substance use and posttraumatic stress disorder: 12-month outcomes among adults experiencing chronic homelessness in Australia

INTRODUCTION

Substance use disorder and posttraumatic stress disorder (PTSD) are highly prevalent among individuals who experience homelessness. However, evaluations of interventions that combine housing and mental health services have reported inconsistent mental health and substance use outcomes when compared to usual services. We investigated 12-month change in substance use severity and PTSD symptom severity among adults experiencing chronic homelessness and tested whether observed differences were associated with housing, support from mental health services or the Journey to Social Inclusion (J2SI) program.

METHODS

A randomised controlled trial compared the J2SI program with standard service provision (N = 135). Secondary analyses compared those who obtained housing or received mental health services with those who did not. Primary outcomes were alcohol and illicit substance use severity (alcohol, smoking and substance involvement screening test) and PTSD symptom severity (six-item PTSD checklist).

RESULTS

There was significant improvement at 12 months in alcohol use severity, illicit substance use severity and PTSD symptoms in the overall sample. Having seen a mental health professional in the previous 12 months was associated with a significant reduction in alcohol and illicit substance use severity but was not associated with changes in PTSD symptom severity. Being housed at 12 months was associated with significantly higher alcohol use severity.

DISCUSSION AND CONCLUSIONS

Findings highlight the importance of access to mental health care for people with a history of chronic homelessness. Research is needed to develop and test therapeutic and housing approaches to reduce PTSD symptom severity among people with experience of homelessness.

Health of Young Adults Experiencing Social Marginalization and Vulnerability: A Cross-National Longitudinal Study

People who experience social marginalization and vulnerability have uniquely complex health needs and are at risk of poor health outcomes. Regression analyses using longitudinal data from a cross-national, population-based sample of young adults participating in the International Youth Development Study, tested associations between social marginalization and vulnerabilities and physical health, mental health, and substance use outcomes. Participants from Victoria, Australia, and Washington State in the US were surveyed at ages 25 (2014) and 29 years (2018; N = 1944; 46.7% male). A history of adverse childhood experiences (ACEs), LGBT identity, financial insecurity, and justice system involvement at age 25 predicted poor health outcomes at age 28, including lower perceived health status, risk for chronic illness, depression and anxiety symptoms, and diagnosed mental health/substance use disorders. Tests of model equivalence across states showed that a history of ACEs was more strongly related to health status and serious injury at age 28 and justice system involvement at age 25 was more strongly related to age 28 serious injury in Victoria than in Washington State. Findings strengthen the case for future population-based research identifying life-course interventions and state policies for reducing poor health and improving health equity among members of socially marginalized groups.

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial

INTRODUCTION

People experiencing homelessness suffer from poor outcomes after hospitalisation due to systemic barriers to care, suboptimal transitions of care, and intersecting health and social burdens. Case management programmes have been shown to improve housing stability, but their effects on broad posthospital outcomes in this population have not been rigorously evaluated. The Navigator Programme is a Critical Time Intervention case management programme that was developed to help homeless patients with their postdischarge needs and to link them with community-based health and social services. This randomised controlled trial examines the impact of the Navigator Programme on posthospital outcomes among adults experiencing homelessness.

METHODS AND ANALYSIS

This is a pragmatic randomised controlled trial testing the effectiveness of the Navigator Programme at an urban academic teaching hospital and an urban community teaching hospital in Toronto, Canada. Six hundred and forty adults experiencing homelessness who are admitted to the hospital will be randomised to receive support from a Homeless Outreach Counsellor for 90 days after hospital discharge or to usual care. The primary outcome is follow-up with a primary care provider (physician or nurse practitioner) within 14 days of hospital discharge. Secondary outcomes include postdischarge mortality or readmission, number of days in hospital, number of emergency department visits, self-reported care transition quality, and difficulties meeting subsistence needs. Quantitative outcomes are being collected over a 180-day period through linked patient-reported and administrative health data. A parallel mixed-methods process evaluation will be conducted to explore intervention context, implementation and mechanisms of impact.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Unity Health Toronto Research Ethics Board. Participants will be required to provide written informed consent. Results of the main trial and process evaluation will be reported in peer-reviewed journals and shared with hospital leadership, community partners and policy makers.

TRIAL REGISTRATION NUMBER

NCT04961762.

An Umbrella Review of the Links Between Adverse Childhood Experiences and Substance Misuse: What, Why, and Where Do We Go from Here?

BACKGROUND AND OBJECTIVES

A wealth of research has identified adverse childhood experiences (ACEs; abuse, neglect, violence or disorder in the home) as a strong risk factor for substance misuse. Synthesis of the existing evidence is critical to shape policy and inform directions for future research. Existing reviews have focused on specific substances or substance use outcomes (eg, disorder), and do not include discussion of the mechanisms that operate between ACEs and substance misuse. The current umbrella review aims to synthesize reviews on the relationship between ACEs and substance misuse, review the evidence on the mechanisms linking these, identify existing gaps in our knowledge, and discuss critical directions for future research, practice, and public policy.

METHODS

Two electronic databases (PsycINFO and Medline) were searched for reviews published between 1998 and 2022 on the link between ACEs and substance misuse. Twenty articles met eligibility criteria and were qualitatively synthesized.

RESULTS

Results overwhelmingly demonstrated an elevated risk of substance misuse or disorder, among adolescents and adults exposed to ACEs. Research on the mechanisms that explain this link highlights a multitude of potential intervention targets, with childhood stress propelling a cascade of effects across neurobiological, endocrine, immune, metabolic, and nervous systems, impacting psychosocial and cognitive functioning. Nonetheless, the literature is subject to limitations surrounding potential unmeasured cofounders and causality, as well as decontextualizing childhood adversity from broader structural issues that influence the link between ACEs and substance misuse. Research, policy, and practice that seek to holistically understand and address the relationship between ACEs and substance misuse within the broader social determinants of health is crucial.

Converting commercial and industrial property into rented residential accommodation: development of a decision support tool

Purpose

This study aims to develop a decision-making tool that assesses the economic feasibility of converting commercial and industrial buildings into rented residential accommodation. This tool also enables developers to provide high-quality rented residential accommodation that contribute to the gentrification of formerly industrialised inner city or developed areas.

Design/methodology/approach

The overarching epistemological approach adopted used inductive reasoning and a postpositivist philosophical design to structure the research problem and devise new theories about the phenomena under investigation. From an operational perspective, a two-phase “waterfall” research approach was adopted. Phase one used extant literature to identify development factors and variables for consideration, risks posed and conversion appraisal criteria. Two case studies formed the basis of a cross comparative analysis, namely, a new build and conversion of a former industrial building into rented residential accommodation. Phase two identified development appraisal criteria, conducted a cost analysis and premised upon the findings, developed a decision support appraisal tool as a “proof of concept”.

Findings

The research combined key decision factors and variables that assist property developers when evaluating whether to convert commercial and industrial property into rented residential accommodation. The appraisal tool’s functionality was validated via a focus group discussion with senior property developers to ensure that assessment criteria and development weightings were appropriate. Feedback revealed that the tool was suitable for purpose and should now be adopted in practice and refined as appropriate and with usage.

Research limitations/implications

The appraisal tool presented could yield a far more accurate means of decision-making which, in turn, could ensure that predicted investment returns are received (thus reducing errors and lowering risk for investors). Future work is required to robustly test and validate the tool’s accuracy in practice. It is envisaged that future projects will provide a rich stream of data for such testing.

Originality/value

To the best of the authors’ knowledge, this work constitutes the first attempt to conceptualise a decision support tool for rented residential property development.

Effect of Portable Rent Subsidies and Mentorship on Socioeconomic Inclusion for Young People Exiting Homelessness: A Community-Based Pilot Randomized Clinical Trial

IMPORTANCE

There have been no published randomized clinical trials with a primary outcome of socioeconomic inclusion for young people who have experienced homelessness.

OBJECTIVE

To explore whether young people exiting homelessness who received rent subsidies and adult mentorship experienced more socioeconomic inclusion relative to young people who received only rent subsidies.

DESIGN, SETTING, AND PARTICIPANTS

This was a convergent mixed-methods, unblinded, 2-group, parallel randomized clinical trial with 1:1 allocation embedded within a community-based framework in 3 cities in Ontario, Canada. Participants were enrolled between March 1 and September 30, 2019, and were followed up through March 31, 2022.

INTERVENTIONS

Participants (n = 24) were randomly assigned adult mentors (n = 13) who had been recruited and screened by community partner agencies. All participants received portable rent subsidies (subsidy not tied to a specific location) for 2 years.

MAIN OUTCOMES AND MEASURES

Primary quantitative outcomes were self-reported measures of community integration (psychological and physical) and self-esteem-proxy indicators of socioeconomic inclusion. Community integration was measured with the Community Integration Scale, with a score range of 1 to 7 for the physical component and 4 to 20 for the psychological component; higher scores indicate higher integration. Self-esteem was measured with the Rosenberg Self-Esteem Scale, with a score range of 0 to 30; higher scores indicate greater self-esteem. Secondary quantitative outcomes included social connectedness, hopelessness, and academic and vocational participation. All analyses followed the intention-to-treat principle.

RESULTS

A total of 24 youths (12 women [50.0%]; mean [SD] age, 21.8 [2.2] years [range, 18-26 years]; race and ethnicity: 10 White [41.7%], 8 Black [33.3%], 2 Asian [8.3%], 2 Indigenous [8.3%], and 2 different choice [8.3%]) transitioned out of homelessness and into market-rent housing. All youths in the group that received mentorship and in the group that did not receive mentorship had stable or nonsignificant improvements in all study outcomes at the primary end point of 18 months compared with baseline (mean [SD] Community Integration Scale psychological score: mentorship group, 11.3 [2.6] at baseline and 11.2 [3.9] at 18 months; no-mentorship group, 10.8 [4.1] at baseline and 13.2 [2.9] at 18 months; mean [SD] Rosenberg Self-Esteem Scale score: mentorship group, 16.0 [4.6] at baseline and 18.1 [5.2] at 18 months; no-mentorship group, 16.3 [6.1] at baseline and 19.6 [5.7] at 18 months). However, there were no significant differences between the 2 groups in the Community Integration Scale psychological score (adjusted mean difference, -2.0; 95% CI, -5.0 to 1.0; P = .18) and Rosenberg Self-Esteem Scale score (adjusted mean difference, -1.4; 95% CI, -5.0 to 2.3; P = .44) 18 months after randomization. Ancillary analysis suggested that youths with informal mentors (mentors outside the study) at baseline felt more psychologically integrated at 18 months relative to those with no informal mentors at baseline (adjusted mean difference, 3.6; 95% CI, 0.4-6.8; P = .03).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, COVID-19 pandemic-related restrictions made it challenging for mentors and mentees to connect, which may have affected the findings. Steady socioeconomic outcomes-potentially attributable to portable rent subsidies-are noteworthy, given the socioeconomic inequities this population has faced during the COVID-19 pandemic. The possible benefit of informal mentorship warrants further investigation. This small pilot study was designed with the intention of generating data and hypotheses for a full-scale study; findings should be interpreted with caution.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03779204.

Effectiveness of eHealth Self-management Interventions in Patients With Heart Failure: Systematic Review and Meta-analysis

BACKGROUND

Heart failure (HF) is a common clinical syndrome associated with substantial morbidity, a heavy economic burden, and high risk of readmission. eHealth self-management interventions may be an effective way to improve HF clinical outcomes.

OBJECTIVE

The aim of this study was to systematically review the evidence for the effectiveness of eHealth self-management in patients with HF.

METHODS

This study included only randomized controlled trials (RCTs) that compared the effects of eHealth interventions with usual care in adult patients with HF using searches of the EMBASE, PubMed, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL databases from January 1, 2011, to July 12, 2022. The Cochrane Risk of Bias tool (RoB 2) was used to assess the risk of bias for each study. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria were used to rate the certainty of the evidence for each outcome of interest. Meta-analyses were performed using Review Manager (RevMan v.5.4) and R (v.4.1.0 x64) software.

RESULTS

In total, 24 RCTs with 9634 participants met the inclusion criteria. Compared with the usual-care group, eHealth self-management interventions could significantly reduce all-cause mortality (odds ratio [OR] 0.83, 95% CI 0.71-0.98, P=.03; GRADE: low quality) and cardiovascular mortality (OR 0.74, 95% CI 0.59-0.92, P=.008; GRADE: moderate quality), as well as all-cause readmissions (OR 0.82, 95% CI 0.73-0.93, P=.002; GRADE: low quality) and HF-related readmissions (OR 0.77, 95% CI 0.66-0.90, P<.001; GRADE: moderate quality). The meta-analyses also showed that eHealth interventions could increase patients' knowledge of HF and improve their quality of life, but there were no statistically significant effects. However, eHealth interventions could significantly increase medication adherence (OR 1.82, 95% CI 1.42-2.34, P<.001; GRADE: low quality) and improve self-care behaviors (standardized mean difference -1.34, 95% CI -2.46 to -0.22, P=.02; GRADE: very low quality). A subgroup analysis of primary outcomes regarding the enrolled population setting found that eHealth interventions were more effective in patients with HF after discharge compared with those in the ambulatory clinic setting.

CONCLUSIONS

eHealth self-management interventions could benefit the health of patients with HF in various ways. However, the clinical effects of eHealth interventions in patients with HF are affected by multiple aspects, and more high-quality studies are needed to demonstrate effectiveness.

Prevalence of Housing Insecurity in Survivors of Traumatic Injury

BACKGROUND

Almost 20% of the US population are housing insecure (HI) due to inadequate living conditions, imbalanced costs to income, nonsustainable shelter, or overcrowding. Housing insecure and physical trauma share similar risk factors, but their direct association is not well elucidated. The objective of our study was to determine the prevalence of HI in survivors of traumatic injury.

METHODS

We conducted a prospective cohort study at an urban, level 1 trauma center. A survey on social determinants of health was administered to adult patients, and demographic, injury specifics, and clinical outcomes data were collected. HI was defined by affirmative answers to questions related to history of homelessness or concern about sustainable shelter. The cohort was stratified by HI; groups were compared using the Mann-Whitney U and Fisher exact tests, as appropriate.

RESULTS

Of 116 study participants, four were excluded due to missing data. Of the 112, 42 (37.8%) reported HI and most were black (69%) males (73.8%). There were no demographic differences between groups. Conversely, HI patients had a higher rate of penetrating traumatic injury (34.1% vs 14.5%, P-value = .03) and were significantly less educated compared to secure participants (P-value = .03) [no degree (26.2% vs 10.3%), high school degrees (21.4% vs 41.2%)] with concomitant illicit drug use (63.4% vs 27.9%, P < .001), and history of addiction (52.4% vs 7.2%, P < .001).

CONCLUSION

HI far exceeds national averages in our cohort. Although difficult to ascertain a cause-effect relationship, HI may be a modifiable risk factor for trauma that negatively influences outcomes.