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Gaber SN, Franck J, Widing H, Hällgren J, Mattsson E, Westman J. Excess mortality among people in homelessness with substance use disorders: a Swedish cohort study. J Epidemiol Community Health 2024; 78:473-478. [PMID: 38772698 PMCID: PMC11287526 DOI: 10.1136/jech-2023-220989] [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: 06/12/2023] [Accepted: 12/03/2023] [Indexed: 05/23/2024]
Abstract
BACKGROUND People in homelessness have an increased risk of substance use disorders (SUDs) and poor health outcomes. This cohort study aimed to investigate the association between homelessness and mortality in people with SUDs, adjusting for age, sex, narcotic use, intravenous drug use and inpatient care for SUDs. METHODS Data from the Swedish National Addiction Care Quality Register in the Stockholm region were used to analyse mortality risk in people with SUDs (n=8397), including 637 in homelessness, 1135 in precarious housing and 6625 in stable housing, at baseline. HRs and CIs were calculated using Cox regression. RESULTS Mortality was increased for people in homelessness (HR 2.30; 95% CI 1.70 to 3.12) and precarious housing (HR 1.23; 95% CI 0.86 to 1.75) compared with those in stable housing. The association between homelessness and mortality decreased (HR 1.27; 95% CI 0.91 to 1.78) after adjusting for narcotic use (HR 1.28; 95% CI 1.00 to 1.63), intravenous drug use (HR 1.98; 95% CI 1.52 to 2.58) and inpatient care for SUDs (HR 1.96; 95% CI 1.57 to 2.45). Standardised mortality ratios (SMRs) showed that mortality among people in homelessness with SUDs was 13.6 times higher than the general population (SMR=13.6; 95% CI 10.2 to 17.9), and 3.7 times higher in people in stable housing with SUDs (SMR=3.7; 95% CI 3.2 to 4.1). CONCLUSION Homelessness increased mortality, but the risk decreased after adjusting for narcotic use, intravenous drug use and inpatient care for SUDs. Interventions are needed to reduce excess mortality among people in homelessness with SUDs.
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Affiliation(s)
- Sophie Nadia Gaber
- Department of Healthcare Sciences, Marie Cederschiöld högskola-Campus Ersta, Stockholm, Sweden
- Department of Women's and Children's Health, Healthcare Sciences and e-Health, Uppsala University, Uppsala, Sweden
- Faculty of Brain Sciences, Division of Psychiatry, University College London, London, UK
| | - Johan Franck
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Härje Widing
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Hällgren
- Academic Primary Care Center, Region Stockholm, Stockholm, Sweden
| | - Elisabet Mattsson
- Department of Healthcare Sciences, Marie Cederschiöld högskola-Campus Ersta, Stockholm, Sweden
- Department of Women's and Children's Health, Healthcare Sciences and e-Health, Uppsala University, Uppsala, Sweden
| | - Jeanette Westman
- Department of Healthcare Sciences, Marie Cederschiöld högskola-Campus Ersta, Stockholm, Sweden
- Academic Primary Care Center, Region Stockholm, Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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Park T, Issa M, Mikhail M, Duong S, Bedi H, Jiang S, Wylson V, Lebovic G, Lichter M. Ophthalmic findings in marginally housed women in a Canadian city. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024; 59:12-18. [PMID: 36442515 DOI: 10.1016/j.jcjo.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/05/2022] [Accepted: 11/06/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the prevalence and common causes of ocular pathology experienced by vulnerable women with marginalized housing and/or a history of abuse, violence, and trafficking. METHODS Using a stratified random sampling technique, we recruited 93 women living in 10 randomly selected women's shelters in Toronto, Canada between May and November of 2018. All English-speaking females older than the age of 18 were eligible to participate. Data on demographics, medical or ocular history, subjective visual acuity, and access to eye care were obtained. Comprehensive visual screening and dilated fundoscopy were performed for each participant. RESULTS The median age was 40 years (interquartile range, 30.5-54 years) and the median duration of homelessness was 8 months (interquartile range, 2.25-20.5 months); 63.4% of participants reported a history of abuse, 44.9% experienced head trauma, 15.9% experienced eye trauma, 22.5% identified as refugees, and 2.17% (2 of 92) had been victims of human trafficking. The above variables were not significantly related to vision problem severity on univariate analysis. Based on the presenting visual acuity, 27.8% of participants (95% CI [18.9-38.2]) were found to have visual impairment. Visual impairment was mainly related to refractive error (54.8% [51 of 93]), however, nonrefractive pathology was also observed. Of all the participants, 64.5% had one or more abnormal findings during the vision screening, and 40.9% needed follow-up by an ophthalmologist. Most participants (96.7%) expressed interest in accessing free eye examinations. CONCLUSIONS Visual impairment is highly prevalent among homeless women living in Toronto. Routine vision-screening programs present an opportunity to improve the ocular health of this vulnerable population.
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Affiliation(s)
- Teresa Park
- From the Faculty of Medicine, University of Toronto, Toronto, ON
| | - Mariam Issa
- From the Faculty of Medicine, University of Toronto, Toronto, ON
| | - Mirriam Mikhail
- From the Faculty of Medicine, University of Toronto, Toronto, ON
| | - Sophia Duong
- From the Faculty of Medicine, University of Toronto, Toronto, ON
| | - Harleen Bedi
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; and
| | - Shangjun Jiang
- From the Faculty of Medicine, University of Toronto, Toronto, ON
| | - Victoria Wylson
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; and
| | - Gerald Lebovic
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Myrna Lichter
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, ON; and.
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Amundsen EJ, Melsom AKM, Eriksen BO, Løchen ML. No decline in drug overdose deaths in Norway: An ecological approach to understanding at-risk groups and the impact of interventions. NORDIC STUDIES ON ALCOHOL AND DRUGS 2024; 41:111-130. [PMID: 38356787 PMCID: PMC10863554 DOI: 10.1177/14550725231195413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Aim: This Norwegian case study examines groups at risk of drug overdose deaths, evidence-based harm reduction interventions, low-threshold services and treatment implemented, as well as trends in drug overdose deaths between 2010 and 2021. We aimed to explore the relevance of interventions for at-risk groups and discuss their potential impact on drug overdose trends. Method/data: Using an ecological approach, we analysed the following: (1) groups identified through latent profile analysis (LPA) among a sample of 413 high-risk drug users collected in 2010-2012, supplemented with other relevant studies up to 2021; (2) published information on harm-reduction interventions, low-threshold services and treatment in Norway; and (3) nationwide drug overdose mortality figures supplemented with published articles on the topic. Results: High-risk drug users in 2010-2012 commonly engaged in frequent illegal drug use, injecting and poly-drug use (including pharmaceutical opioids), which continued into following decade. The interventions implemented between 2010 and 2021 were relevant for at-risk groups identified in the surveys. However, there was no decrease in the trend of drug overdose deaths up to 2021. While relevant interventions may have mitigated a theoretical increase in mortality, new at-risk groups may have contributed to fatal outcomes associated with pharmaceutical opioids. Conclusion: The interventions were relevant to the risk groups identified among high-risk drug users and potentially effective in preventing an increase in drug overdose trends. However, tailored interventions are needed for individuals at risk of death from prescribed opioids. Comprehensive studies encompassing all at-risk populations, including both legal and non-medical users of prescription opioids, are needed.
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Affiliation(s)
- Ellen J Amundsen
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
| | - Anne-Karine M Melsom
- Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway; Centre for Clinical Research and Education, University Hospital of North Norway, Tromsø, Norway
| | - Bjørn O Eriksen
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway; Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Maja-Lisa Løchen
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Riccò M, Baldassarre A, Corrado S, Bottazzoli M, Marchesi F. Respiratory Syncytial Virus, Influenza and SARS-CoV-2 in Homeless People from Urban Shelters: A Systematic Review and Meta-Analysis (2023). EPIDEMIOLOGIA 2024; 5:41-79. [PMID: 38390917 PMCID: PMC10885116 DOI: 10.3390/epidemiologia5010004] [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: 11/24/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Homeless people (HP) are disproportionally affected by respiratory disorders, including pneumococcal and mycobacterial infections. On the contrary, more limited evidence has been previously gathered on influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and very little is known about the occurrence of human respiratory syncytial virus (RSV), a common cause of respiratory tract infections among children and the elderly. The present systematic review was designed to collect available evidence about RSV, influenza and SARS-CoV-2 infections in HP, focusing on those from urban homeless shelters. Three medical databases (PubMed, Embase and Scopus) and the preprint repository medRxiv.org were therefore searched for eligible observational studies published up to 30 December 2023, and the collected cases were pooled in a random-effects model. Heterogeneity was assessed using the I2 statistics. Reporting bias was assessed by funnel plots and a regression analysis. Overall, 31 studies were retrieved, and of them, 17 reported on the point prevalence of respiratory pathogens, with pooled estimates of 4.91 cases per 1000 HP (95%CI: 2.46 to 9.80) for RSV, 3.47 per 1000 HP for influenza and 40.21 cases per 1000 HP (95%CI: 14.66 to 105.55) for SARS-CoV-2. Incidence estimates were calculated from 12 studies, and SARS-CoV-2 was characterized by the highest occurrence (9.58 diagnoses per 1000 persons-months, 95%CI: 3.00 to 16.16), followed by influenza (6.07, 95%CI: 0.00 to 15.06) and RSV (1.71, 95%CI: 0.00 to 4.13). Only four studies reported on the outcome of viral infections in HP: the assessed pathogens were associated with a high likelihood of hospitalization, while high rates of recurrence and eventual deaths were reported in cases of RSV infections. In summary, RSV, influenza and SARS-CoV-2 infections were documented in HP from urban shelters, and their potential outcomes stress the importance of specifically tailored preventive strategies.
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Affiliation(s)
- Matteo Riccò
- AUSL-IRCCS di Reggio Emilia, Servizio di Prevenzione e Sicurezza Negli Ambienti di Lavoro (SPSAL), Local Health Unit of Reggio Emilia, 42122 Reggio Emilia, Italy
| | - Antonio Baldassarre
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Silvia Corrado
- ASST Rhodense, Dipartimento della Donna e Area Materno-Infantile, UOC Pediatria, 20024 Milan, Italy
| | - Marco Bottazzoli
- Department of Otorhinolaryngology, APSS Trento, 38122 Trento, Italy
| | - Federico Marchesi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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Heerde J, Borschmann R, Young J, Kinner SA, Sawyer SM, Patton GC. Mortality among people who have experienced homelessness: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e067182. [PMID: 36806070 PMCID: PMC9943969 DOI: 10.1136/bmjopen-2022-067182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
INTRODUCTION Homelessness is a major contributor to health inequalities. People who experience homelessness are at markedly increased risk of multiple and complex health morbidities which likely increase their susceptibility to early, preventable death. Despite this, the mortality burden in this group remains poorly understood, limited in part by insufficient synthesis of data at a global level. This systematic review will synthesise international literature examining rates of risk and protective factors for mortality among people who have experienced homelessness. METHODS AND ANALYSIS We will search MEDLINE, PsycINFO, Embase and PubMed for peer-reviewed cohort studies examining mortality among people who have experienced homelessness. No study eligibility restrictions will be placed on the date, country of origin, or language of publications, or age of the sample. We will assess the quality of included studies using the Methodological Standards for Epidemiological Research scale. Our measures of mortality will include: (A) incidence-all cause and cause specific, expressed as a crude mortality rate (CMR) per 1000 person-years, with 95% CI and (B) all cause and cause specific, indirectly standardised mortality ratios (SMRs) with 95%CI. Associations between risk and protective factors and all-cause and cause-specific mortality will be reported using pooled relative risk ratios with 95% CI. Where there are sufficient data, the influence of subgroup and methodological factors on CMRs, SMRs and predictive factors will be examined using meta-regression. ETHICS AND DISSEMINATION This study does not require institutional ethics review or approval as it will synthesise findings from published studies that have previously been granted relevant ethics approvals. Study findings will be disseminated through a peer-reviewed journal article, conference and seminar presentations. A plain language summary will be distributed through the authors' academic and professional networks. PROSPERO REGISTRATION NUMBER CRD42021272937.
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Affiliation(s)
- Jessica Heerde
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Centre for Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- School of Social Work, The University of Melbourne, Parkville, Victoria, Australia
| | - Rohan Borschmann
- Centre for Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Victoria, Australia
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Jesse Young
- Centre for Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
- National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
| | - Stuart A Kinner
- Centre for Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Justice Health Unit, Centre for Health Equity, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
- Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Susan M Sawyer
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Centre for Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - George C Patton
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Centre for Adolescent Health, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
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Darvishi FZ, Saadat M. Morphine may have a role in telomere shortening. Psychiatr Genet 2022; 32:87-89. [PMID: 34955515 DOI: 10.1097/ypg.0000000000000311] [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: 11/26/2022]
Abstract
Morphine/heroin may increase oxidative stress in drug-dependent persons. The imbalance between oxidative stress and antioxidant defense mechanisms can accelerate the shortening of telomere length. This article reports two sets of data; comparison of relative telomere length between heroin-dependent patients and healthy control group, as well as, investigation of the effect of morphine on the relative telomere length of human SH-SY5Y cells treated by morphine. Study participants were composed of 163 heroin-dependent patients and 166 unrelated healthy controls. SH-SY5Y cells were treated with (5 μM) morphine hydrochloride and incubated for 40 and 60 days. The relative telomere length was calculated as the T/S (telomere/single-copy gene) ratio using 36B4 as a reference for each sample, using quantitative real-time PCR. The mean (± SE) value of relative telomere length was 4.81 ± 0.21 and 6.38 ± 0.23 in leukocytes of heroin-dependent and control groups, respectively. The telomere length was significantly decreased in heroin-dependent participants (t = 4.97; df = 327; P < 0.0001). The relative telomere length in cells treated with morphine for 60 days was 4.50 ± 0.14 and in untreated cells was 5.75 ± 0.08. The difference was highly significant (t = 7.68; df = 4; P = 0.002). Our present findings indicate that morphine and dependency on heroin are significantly associated with shorter telomeres. The present findings may help to explain some of the adverse effects of drug dependency on health such as accelerating biologic processes related to aging.
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Mårtensson S, Johansen KS, Krarup J, Düring SW. REDD-PAC Cohort Description: Researching Dual Diagnosis - Prognosis and Characteristics. J Dual Diagn 2022; 18:111-122. [PMID: 35363594 DOI: 10.1080/15504263.2022.2055250] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Evidence from real-world integrated dual diagnosis treatment programs is limited. In 2017 we decided to establish the REDD-PAC cohort with the aim to provide more in-depth information regarding the effect of integrated treatment. METHODS The REDD-PAC cohort includes more than 2,500 patients with dual diagnosis that have been treated at an in-patient department specializing in the integrated treatment of both psychiatric illness and substance use disorder in Denmark in the period from 2002 to 2017. The collected data included information on diagnosis as well as patient-completed questionnaires regarding anxiety, depression, self-worth, and use of substances. Data regarding medications prescribed and administered, weight, height, and blood pressure were also included. RESULTS The primary diagnosis was psychosis spectrum disorder (37.0%), followed by affective disorders (18.8%). More than two-thirds of the patients were male, and most patients had a weak connection to the labor market and basic schooling. Patients were generally very motivated for treatment. CONCLUSIONS Further linking the data to Danish national register data makes it possible to follow individual trajectories pre- and post-admission as well as to access complete follow-up data regarding long-term outcomes, e.g., use of health services, mortality, morbidity, crime, and social circumstances. This article describes both the overarching aims of the REDD-PAC cohort and the basic diagnostic and sociodemographic characteristics of the cohort.
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Affiliation(s)
- Solvej Mårtensson
- Competency center for Dual diagnosis, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Katrine S Johansen
- Competency center for Dual diagnosis, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Jakob Krarup
- Department M, Mental Health Center Sct. Hans, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark
| | - Signe W Düring
- Competency center for Dual diagnosis, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark.,Department M, Mental Health Center Sct. Hans, Copenhagen University Hospital - Mental Health Services CPH, Copenhagen, Denmark.,Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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8
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Kruckow L, Tjagvad C, Clausen T, Banner J. Psychiatric disorders in a population of deceased drug users. Nord J Psychiatry 2021; 75:472-478. [PMID: 33650457 DOI: 10.1080/08039488.2021.1887350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To estimate the prevalence of psychiatric morbidity and dual diagnosis in a population of decedents with positive drug toxicology and evaluate changes over time between 2001-2002 and 2011-2012. MATERIALS AND METHODS A total of 520 autopsied drug users with positive toxicology were included in the study from 2001 to 2002 and from 2011 to 2012. Materials included autopsy reports, toxicological screening during autopsy and data from the Danish national health registers, including psychiatric diagnoses from psychiatric hospitals and ambulatory functions, dispensed prescription use from pharmacies and registered treatment for drug use disorders. RESULTS In 2001-2002, 63.3% of the decedents had only positive toxicology, 22.5% also had psychiatric morbidity, and 14.2% had a dual diagnosis. In 2011-2012, 56.4% had only positive toxicology, 26.1% also had psychiatric morbidity, and 17.5% had a dual diagnosis. None of the changes were significant. Decedents with only positive toxicology became older at time of death over time; decedents with psychiatric morbidity and a dual diagnosis did not. The prevalence of nonprescribed psychotropic medication, methadone and benzodiazepines increased. CONCLUSION Decedents with psychiatric morbidity and dual diagnosis did not increase their lifespan over a 10-year period. Decedents with only positive toxicology increasingly consumed nonprescribed psychotropic medication and may have suffered from undiagnosed psychiatric disorders. The prevalence of prescribed and nonprescribed benzodiazepines and methadone increased and may have contributed to premature mortality.
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Affiliation(s)
- Line Kruckow
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Christian Tjagvad
- Norwegian Centre for Addiction Research [SERAF], University of Oslo, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research [SERAF], University of Oslo, Oslo, Norway
| | - Jytte Banner
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
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Calvo F, Turró-Garriga O, Fàbregas C, Alfranca R, Calvet A, Salvans M, Giralt C, Castillejos S, Rived-Ocaña M, Calvo P, Castillo P, Garre-Olmo J, Carbonell X. Mortality Risk Factors for Individuals Experiencing Homelessness in Catalonia (Spain): A 10-Year Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:1762. [PMID: 33670288 PMCID: PMC7918849 DOI: 10.3390/ijerph18041762] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/04/2021] [Accepted: 02/04/2021] [Indexed: 12/05/2022]
Abstract
(1) Background: Current evidence suggests that mortality is considerably higher in individuals experiencing homelessness. The aim of this study was to analyze the mortality rate and the mortality risk factors in a sample of individuals experiencing homelessness in the city of Girona over a ten-year period. (2) Methods: We retrospectively examined the outcomes of 475 people experiencing homelessness with the available clinical and social data. Our sample was comprised of 84.4% men and 51.8% foreign-born people. Cox's proportional hazard models were used to identify mortality risk factors between origin groups. (3) Results: 60 people died during the ten-year period. The average age of death was 49.1 years. After adjusting for demographic characteristics and the duration of homelessness, the risk factors for mortality were origin (people born in Spain) (HR = 4.34; 95% CI = 1.89-10.0), type 2 diabetes (HR = 2.9; 95% CI = 1.62-5.30), alcohol use disorder (HR = 1.9; 95% CI = 1.12-3.29), and infectious diseases (HR = 1.6; 95% CI = 1.09-2.39). Our results show a high prevalence of infectious and chronic diseases. Type 2 diabetes emerges as an important risk factor in homelessness. The average age of death of individuals experiencing homelessness was significantly lower than the average age of death in the general population (which is greater than 80 years). (4) Conclusions: Foreign-born homeless people were generally younger and healthier than Spanish-born homeless people. Chronic diseases were controlled better in Spanish-born people, but this group showed an increased risk of mortality.
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Affiliation(s)
- Fran Calvo
- Departament de Pedagogia, Institut de Recerca Sobre Qualitat de Vida, Universitat de Girona, 17004 Girona, Spain;
- Department of Quality Assessment, Evaluation and Research, Health and Community Foundation, 08010 Barcelona, Spain
| | - Oriol Turró-Garriga
- Ageing, Disability and Health Research Group of Girona Biomedical Research Institute [IdIBGi], 17190 Salt, Spain; (O.T.-G.); (J.G.-O.)
| | - Carles Fàbregas
- Centre d’Acolliment i Serveis Socials “la Sopa”, Ajuntament de Girona, 17004 Girona, Spain;
| | - Rebeca Alfranca
- Centro de Atención Primaria Santa Clara, Institut Català de la Salut, 17004 Girona, Spain; (R.A.); (M.S.)
| | - Anna Calvet
- Unitat d’Aguts, Institut d’Assistència Sanitària, 17190 Salt, Spain; (A.C.); (P.C.)
| | - Mercè Salvans
- Centro de Atención Primaria Santa Clara, Institut Català de la Salut, 17004 Girona, Spain; (R.A.); (M.S.)
| | - Cristina Giralt
- Centro de Atención Primaria Blanes, Institut Català de la Salut, 17300 Blanes, Spain;
| | - Sandra Castillejos
- Departament de Pedagogia, Institut de Recerca Sobre Qualitat de Vida, Universitat de Girona, 17004 Girona, Spain;
| | - Mercè Rived-Ocaña
- Escola Universitària d’Infermeria i Teràpia Ocupacional, EUIT, Universitat Autònoma de Barcelona, UAB, 08221 Terrassa, Spain;
| | - Paula Calvo
- Department of Medical Sciences, School of Medicine, University of Girona, 17004 Girona, Spain;
| | - Paz Castillo
- Unitat d’Aguts, Institut d’Assistència Sanitària, 17190 Salt, Spain; (A.C.); (P.C.)
| | - Josep Garre-Olmo
- Ageing, Disability and Health Research Group of Girona Biomedical Research Institute [IdIBGi], 17190 Salt, Spain; (O.T.-G.); (J.G.-O.)
- Department of Medical Sciences, School of Medicine, University of Girona, 17004 Girona, Spain;
| | - Xavier Carbonell
- Facultat de Psicologia, Ciències de l’Educació i l’Esport Blanquerna, Universitat Ramon Llull, 08022 Barcelona, Spain;
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Lemoine C, Loubière S, Boucekine M, Girard V, Tinland A, Auquier P. Cost-effectiveness analysis of housing first intervention with an independent housing and team support for homeless people with severe mental illness: A Markov model informed by a randomized controlled trial. Soc Sci Med 2021; 272:113692. [PMID: 33545494 DOI: 10.1016/j.socscimed.2021.113692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/13/2020] [Accepted: 01/04/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Coralie Lemoine
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, 27 Boulevard Jean Moulin, 13005, Marseille, France; Department of Clinical Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique - Hôpitaux de Marseille, 27 Boulevard Jean Moulin, 13385, Marseille, France.
| | - Sandrine Loubière
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, 27 Boulevard Jean Moulin, 13005, Marseille, France; Department of Clinical Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique - Hôpitaux de Marseille, 27 Boulevard Jean Moulin, 13385, Marseille, France.
| | - Mohamed Boucekine
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, 27 Boulevard Jean Moulin, 13005, Marseille, France; Department of Clinical Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique - Hôpitaux de Marseille, 27 Boulevard Jean Moulin, 13385, Marseille, France.
| | - Vincent Girard
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, 27 Boulevard Jean Moulin, 13005, Marseille, France.
| | - Aurélie Tinland
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, 27 Boulevard Jean Moulin, 13005, Marseille, France; Department of Psychiatry, Sainte-Marguerite University Hospital, Boulevard Sainte Marguerite, 13009, Marseille, France.
| | - Pascal Auquier
- Aix-Marseille University, School of Medicine - La Timone Medical Campus, EA 3279: CEReSS - Health Service Research and Quality of Life Center, 27 Boulevard Jean Moulin, 13005, Marseille, France; Department of Clinical Research and Innovation, Support Unit for Clinical Research and Economic Evaluation, Assistance Publique - Hôpitaux de Marseille, 27 Boulevard Jean Moulin, 13385, Marseille, France.
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11
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Gjersing L, Helle MK. Injecting Alone is More Common among Men, Frequent Injectors and Polysubstance Users in a Sample of People Who Inject Drugs. Subst Use Misuse 2021; 56:2214-2220. [PMID: 34565289 DOI: 10.1080/10826084.2021.1981388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Injecting alone increases the risk of a fatal overdose. We examined the extent of such behavior in a sample of people who inject drugs (PWID) and the typical characteristics of those injecting alone at least once during the past four weeks. A cross-sectional study. PWID recruited from the street and from low-threshold services in seven Norwegian cities in September 2017 (n = 359). Associations between characteristics and injecting alone were examined using logistic regression analysis. The independent variables were gender (female/male), age, having received overdose-prevention education (no/yes), and, in the past four weeks; homelessness/shelter use (no/yes), in opioid substitution treatment (no/yes), injecting ≥ four days a week (no/yes), and substances injected (opioids only/opioids and other/other only/central stimulants (CS) only/CS and other/CS and opioids/CS, opioids and other). The adjusted odds ratios (aOR) and 95% Confidence Intervals (CI) were reported. Of the 359 PWID, 84.4% reported having injected alone. Males were more likely than females to inject alone (aOR = 1.88 95% CI 1.00-3.54). Furthermore, those injecting frequently (aOR = 1.99 95% CI 1.02-3.86) and those injecting multiple substances (CS, opioids and other) (aOR = 2.94 95% CI 1.01-8.58) were more likely to inject alone compared to those injecting less frequently and opioids only. Although not statistically significant, the effect sizes in the logistic regression models suggest that polysubstance use may be driven by CS use. Injecting alone was common in our sample of PWID, and male gender, frequent injecting and polysubstance injecting were associated with this behavior.
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Affiliation(s)
- Linn Gjersing
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
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12
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Stenius-Ayoade A, Haaramo P, Kautiainen H, Sunikka S, Gissler M, Wahlbeck K, Eriksson JG. Morbidity and housing status 10 years after shelter use-follow-up of homeless men in Helsinki, Finland. Eur J Public Health 2019; 28:1092-1097. [PMID: 29584880 DOI: 10.1093/eurpub/cky038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Homelessness is associated with increased mortality, morbidity and social difficulties and periods of homelessness are sometimes prolonged or repeated. However, there are no long-term follow-up studies focusing upon housing status among homeless people. The aim of this study was to examine morbidity and housing outcomes and to identify factors predicting being independently housed 10 years after shelter use. Methods By combining data from several registers we followed all 552 homeless men who stayed in shelter in Helsinki during 2004 and determined their housing situation and morbidity 10 years later. Their situation was compared with an age-matched control group from the general population (N = 946). Using logistic regression analysis, we assessed the predictive effects of socioeconomic factors and health service use at baseline on becoming independently housed. Results By the end of the follow-up 52.0% of the formerly homeless study group had died, compared with 14.6% of the controls. At 10 years, 6.0% were independently housed, 37.5% lived in supported housing and 4.5% were still or again homeless. Psychiatric disorders, including substance use disorder, were present in 77.5% of the homeless, compared with 16.1% among the controls. Being married (OR 8.3, 95% CI 3.0 to 23.2) and having less than four shelter nights in year 2004 (OR 9.1, 95% CI 2.7 to 30.8) strongly predicted being independently housed 10 years later. Conclusions Homeless staying in shelters have high mortality and morbidity and most of those surviving, are in need of support in their everyday lives even years after the shelter period.
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Affiliation(s)
- Agnes Stenius-Ayoade
- Folkhälsan Research Center, Helsinki, Finland.,National Institute for Health and Welfare, Mental Health Unit, Helsinki, Finland.,Department of Social Services and Health Care, City of Helsinki, Helsinki, Finland
| | - Peija Haaramo
- National Institute for Health and Welfare, Public Health Promotion Unit, Helsinki, Finland
| | - Hannu Kautiainen
- Folkhälsan Research Center, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland.,Unit of Primary Health Care, Kuopio University Hospital, Kuopio, Finland
| | - Sanna Sunikka
- Department of Social Services and Health Care, City of Helsinki, Helsinki, Finland.,The Finnish Foundation for Supporting Ex-Offenders, Helsinki, Finland
| | - Mika Gissler
- Information Services Department, National Institute for Health and Welfare, Helsinki, Finland.,Research Centre for Child Psychiatry, University of Turku, Turku, Finland.,Division of Family Medicine, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | | | - Johan G Eriksson
- Folkhälsan Research Center, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, and Helsinki University Hospital, Helsinki, Finland.,National Institute for Health and Welfare, Chronic Disease Prevention Unit, Helsinki, Finland
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13
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SURVIVE: let the dead help the living—an autopsy-based cohort study for mapping risk markers of death among those with severe mental illnesses. SCANDINAVIAN JOURNAL OF FORENSIC SCIENCE 2019. [DOI: 10.2478/sjfs-2018-0002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: Forensic autopsy strategies may improve differential diagnostics both post-mortem and ante-mortem and aid in clinical settings concerning preventive efforts for premature mortality. Excess mortality and reduced life expectancy affect persons with severe mental illnesses (SMI) for multi-faceted reasons that remain controversial. Somatic conditions, medical treatment and lifestyle diseases, which are primarily examined in the living, contribute to premature deaths. The underlying pathophysiological mechanisms are unclear, though, and the benefits of a focused, standardised autopsy remain unproven. We have developed and implemented an optimised molecular–biological autopsy for deceased persons with SMI. Our aim is to map the occurrence of 1) somatic diseases and organ changes; 2) metabolic syndrome; 3) use and abuse of alcohol, pharmaceuticals and psychoactive substances; 4) pharmacokinetic and pharmacodynamic factors in the metabolism of pharmaceuticals; and 5) genetic variations (acquired and/or congenital) in sudden cardiac death. Additionally, we hope to contribute to diagnostic treatments and preventive measures to benefit those living with SMI. Methods: SURVIVE: let the dead help the living is a prospective, autopsy-based study on 500 deceased persons with SMI subjected to forensic autopsies under the Danish Act on Forensic Inquests and Autopsy. The autopsies followed an extended, standardised autopsy protocol comprised of whole-body computed tomography scanning, magnetic resonance imaging of the heart and brain and an extended forensic autopsy, including a wide panel of analyses (toxicology, microbiology, genetics, histology and biochemical analysis). Additionally, post-mortem data were linked to ante-mortem health data extracted from Danish national health registers.
Discussion: The SURVIVE autopsy procedure, including tissue sampling and bio banking, has been shown to be effective. We expect that the SURVIVE study will provide unique opportunities to unravel the mechanisms and causes of premature death in persons with SMI. We also expect that identifying prognostic biomarkers for comorbidities will contribute to prevention of premature deaths and comorbidities in persons with SMI.
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14
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Ivers JH, Zgaga L, O’Donoghue-Hynes B, Heary A, Gallwey B, Barry J. Five-year standardised mortality ratios in a cohort of homeless people in Dublin. BMJ Open 2019; 9:e023010. [PMID: 30782692 PMCID: PMC6352814 DOI: 10.1136/bmjopen-2018-023010] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/09/2018] [Accepted: 09/18/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To calculate standardised mortality ratios (SMRs) for a cohort of homeless people in the Dublin region over a 5-year period and to examine leading causes of death. SETTING Homeless services reporting deaths from homeless persons in their care across the Dublin Homeless Region. METHODS Death data among people who experience homelessness was acquired from the Dublin Region Homeless Executive (2011-2015) and validated from both death certificates and records from the Dublin Coroner's Office. PARTICIPANTS Two hundred and nine deaths were recorded; of these 201 were verified (n=156 males, 77.6%). Deaths that could not be verified by certificate or coroners record were excluded from the study. RESULTS SMRs were 3-10 times higher in homeless men and 6-10 times higher in homeless women compared with the general population. Drug and alcohol-related deaths were the leading cause of death, accounting for 38.4% of deaths in homeless individuals. These were followed by circulatory (20%) and respiratory causes (13%). CONCLUSION Mortality rates among homeless persons are exceptionally high. Services and programmes, particularly housing and those targeting overdose and alcoholism, are urgently needed to prevent premature mortality in this vulnerable population.
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Affiliation(s)
- Jo-Hanna Ivers
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Lina Zgaga
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | | | - Aisling Heary
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Brian Gallwey
- Research, Dublin Regional Homeless Executive, Dublin, Ireland
| | - Joe Barry
- Department of Public Health and Primary Care, Institute of Population Health, School of Medicine, Trinity College Dublin, Dublin, Ireland
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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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16
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Ben Khelil M, Zgarni A, Bellali M, Thaljaoui W, Zhioua M, Hamdoun M. Deaths among homeless in northern Tunisia: a 10-year study (2005-2014). Public Health 2018; 162:41-47. [PMID: 29958113 DOI: 10.1016/j.puhe.2018.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/13/2018] [Accepted: 04/30/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the victims profile related to death among homeless people. STUDY DESIGN A descriptive, retrospective, and cross-sectional study. METHODS We included all deaths among homeless people that occurred during a 10-year period (2005-2014) that were autopsied in the Department of Legal Medicine of the Charles Nicolle Hospital of Tunis. Causes of death were classified according to the International Statistical Classification of Diseases and Related Health Problems 10th Revision. Data were classified in three sections: sociodemographic data, circumstances of death, and autopsy findings. A univariate data analysis was performed. RESULTS The sex ratio (M/F) was of 7.45. The average age was of 59 years. The majority of deaths (80.9%) occurred in the metropolis of Tunis with a significant occurrence of cases in other governorates after the 2011 revolution (P = 0.002). Deaths occurred more often during winter (34.8%). The bodies were frequently discovered in public places (36.0%) and private locations (34.0%). The deaths of 55.3% of cases were attributed to natural causes, significantly affecting the elderly, whereas the accidental causes (25.7%) were more frequent before the age of 49 years, followed by suicides (3.9%) and homicides (3.3%). CONCLUSIONS Our study highlighted a phenomenon not yet studied in Tunisia. Our results highlight an urgent need for preventive measures focused on the improvement of healthcare measures among homeless people.
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Affiliation(s)
- M Ben Khelil
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Department of Legal Medicine, Charles Nicolle Hospital, Tunis, Tunisia.
| | - A Zgarni
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia
| | - M Bellali
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Department of Legal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
| | - W Thaljaoui
- Department of Legal Medicine, Regional Hospital of Sidi Bouzid, Tunisia
| | - M Zhioua
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Department of Legal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
| | - M Hamdoun
- Faculty of Medicine, University of Tunis El Manar, Tunis, Tunisia; Department of Legal Medicine, Charles Nicolle Hospital, Tunis, Tunisia
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Gjersing L, Bretteville-Jensen AL. Patterns of substance use and mortality risk in a cohort of 'hard-to-reach' polysubstance users. Addiction 2018; 113:729-739. [PMID: 28987019 DOI: 10.1111/add.14053] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 06/23/2017] [Accepted: 10/03/2017] [Indexed: 11/28/2022]
Abstract
AIMS To examine the mortality risk in a cohort of 'hard-to-reach' polysubstance users and its putative associations with substance use. Specifically, we estimated all-cause mortality risk as a function of individual substance use indicators, and then as a function of their complex, 'real-life' patterns as identified through latent class analysis (LCA). DESIGN Prospective cohort study among street- and low-threshold service-recruited polysubstance users included between September and November 2013 and followed through the National Cause of Death Registry until 31 October 2015. SETTING Seven Norwegian cities. PARTICIPANTS A total of 884 users of illegal opioids and/or stimulants. Of these, 357 were in opioid substitution treatment (OST) at the time of inclusion. Forty-four participants died during follow-up. MEASUREMENTS Primary outcome: all-cause mortality risk. Unadjusted and adjusted Cox proportional hazard (PH) regression models (covariates: male, age, homelessness/shelter use, overdose experience, OST status, years of injecting, individual substance use indicators, city, use patterns). LCA models estimated separately for those in and those not in OST due to measurement invariance. FINDINGS The crude mortality rate was 2.52 per 100 person-years. Standardized mortality ratio was 26.11 [95% confidence interval (CI) = 10.06-54.87] for women and 10.71 (95% CI = 6.39-16.81) for men. No single drug use indicator, such as 'heroin injection' or 'number of drugs used', was associated with the mortality risk. However, meaningful use patterns were identified; three OST and non-OST patterns each. The non-OST patterns 'polysubstance injectors' [hazard ratio (HR) = 3.45, 95% CI = 0.98-12.14] and 'low frequent injectors' (HR = 3.17, CI = 1.05-9.56) were associated significantly with the mortality risk even when adjusted for other known risk factors. CONCLUSIONS In a Norwegian prospective cohort study, 'hard-to-reach' polysubstance users had a more than 10 times higher mortality risk than the general population. Mortality risk was not a function of any single drug use indicator, but two distinct combinations of substances, frequencies and routes of administration were associated with the mortality risk.
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Affiliation(s)
- Linn Gjersing
- Department of Drug Policy, Norwegian Institute of Public Health, Oslo, Norway
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Benjaminsen L, Birkelund JF. Explaining excess morbidity amongst homeless shelter users: A multivariate analysis for the Danish adult population. Scand J Public Health 2018. [PMID: 29528774 DOI: 10.1177/1403494818759839] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aims: This article analyses excess morbidity amongst homeless shelter users compared to the general Danish population. The study provides an extensive control for confounding and investigates to what extent excess morbidity is explained by homelessness or other risk factors. Methods: Data set includes administrative micro-data for 4,068,926 Danes who were 23 years or older on 1 January 2007. Nationwide data on shelter use identified 14,730 individuals as shelter users from 2002 to 2006. Somatic diseases were measured from 2007 to 2011 through diagnosis data from hospital discharges. The risk of somatic diseases amongst shelter users was analysed through a multivariate model that decomposed the total effect into a direct effect and indirect effects mediated by other risk factors. Results: The excess morbidity associated with shelter use is substantially lower than in studies that did not include an extensive control. Approximately 80% of excess morbidity amongst shelter users is attributed to other risk factors. A large part of the excess morbidity is explained by substance abuse problems and lack of employment, whilst mental illness, low income, low education, civil status and ethnic minority background explain only a limited part. However, when conducting an extensive control for confounding, a significantly higher morbidity was identified amongst shelter users for infectious diseases, lung, skin, blood and digestive diseases, injuries, and poisoning. Conclusions: Ill health amongst homeless shelter users is widely explained by substance abuse problems and other risk factors. Nonetheless, for many diseases homelessness poses an additional risk to the health.
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Affiliation(s)
- Lars Benjaminsen
- The Danish Center for Social Science Research, Copenhagen, Denmark
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Homelessness as a predictor of mortality: an 11-year register-based cohort study. Soc Psychiatry Psychiatr Epidemiol 2018; 53:63-75. [PMID: 29124292 DOI: 10.1007/s00127-017-1456-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 10/30/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE The purpose of this study was to examine the association between homelessness and psychiatric disorders, including substance use disorders, on one hand, and cause-specific and all-cause mortality on the other in a high-income country. METHODS A historical nationwide register-based cohort study of the Danish population from 15 years of age between 2000 and 2011 was conducted. The association between homelessness, psychiatric disorders, and mortality was analysed by Poisson Regression adjusting for important confounders. Standardised mortality ratios (SMRs) were calculated for people with a history of homelessness compared with the general population using direct age-standardisation. RESULTS During 51,892,324 person-years of observation, 656,448 died. People with at least one homeless shelter contact accounted for 173,592 person-years with 4345 deaths. The excess mortality in the population experiencing homelessness compared with the general population was reduced by 50% after adjusting for psychiatric diagnoses, including substance use disorders (mortality rate ratio (MRR) for men 3.30, 95% CI 3.18-3.41; women 4.41, 95% CI 4.14-4.71). Full adjustment including physical comorbidity and socioeconomic factors in a sub-cohort aged 15-29 years resulted in an MRR of 3.94 (95% CI 3.10-5.02) compared with the general population. The excess mortality associated with homelessness differed according to psychiatric diagnosis, sex, and cause of death. CONCLUSIONS A mental health or a substance use disorder combined with homelessness considerably increases the risk of death. However, homelessness is also independently associated with high mortality. Differences in the association between homelessness and mortality in men and women suggest the need for sex-tailored interventions.
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Vuillermoz C, Vandentorren S, Brondeel R, Chauvin P. Unmet healthcare needs in homeless women with children in the Greater Paris area in France. PLoS One 2017; 12:e0184138. [PMID: 28877209 PMCID: PMC5587267 DOI: 10.1371/journal.pone.0184138] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 08/18/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite their poor health status, homeless women encounter many barriers to care. The objectives of our study were to estimate the prevalence of unmet healthcare needs in homeless women and to analyse associated relationships with the following factors: financial and spatial access to care, housing history, migration status, healthcare utilisation, victimization history, caring for children, social network and self-perceived health status. METHODS We used data from 656 homeless women interviewed during the ENFAMS representative survey of sheltered homeless families, conducted in the Paris region in 2013. Structural equation models (SEM) were used to estimate the impact of various factors on homeless women's unmet healthcare needs. RESULTS Among those interviewed, 25.1% (95%CI[21.3-29.0]) had at least one unmet healthcare need over the previous year. Most had given up on visiting general practitioners and medical specialists. No association with factors related to financial access or to health insurance status was found. However, food insecurity, poor spatial health access and poor self-perceived health were associated with unmet healthcare needs. Self-perceived health appeared to be affected by victimization and depression. DISCUSSION The lower prevalence of unmet healthcare needs in homeless women compared with women in stable housing situations suggests that homeless women have lower needs perceptions and/or lower expectations of the healthcare system. This hypothesis is supported by the results from SEM. Strategies to provide better access to care for this population should not only focus on financial interventions but also more broadly on spatial healthcare access, cultural norms, and perceptions of health. Reducing their unmet needs and improving their access to healthcare and prevention must include an improvement in their living, financial and housing conditions.
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Affiliation(s)
- Cécile Vuillermoz
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique (IPLESP UMRS 1136), Department of Social Epidemiology, Paris, France
- * E-mail:
| | - Stéphanie Vandentorren
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique (IPLESP UMRS 1136), Department of Social Epidemiology, Paris, France
- Direction des régions, Santé publique France, Saint Maurice, France
| | - Ruben Brondeel
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique (IPLESP UMRS 1136), Nemesis team, Paris, France
| | - Pierre Chauvin
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique (IPLESP UMRS 1136), Department of Social Epidemiology, Paris, France
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Somers JM, Moniruzzaman A, Patterson M, Currie L, Rezansoff SN, Palepu A, Fryer K. A Randomized Trial Examining Housing First in Congregate and Scattered Site Formats. PLoS One 2017; 12:e0168745. [PMID: 28076358 PMCID: PMC5226665 DOI: 10.1371/journal.pone.0168745] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 12/07/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE No previous experimental trials have investigated Housing First (HF) in both scattered site (SHF) and congregate (CHF) formats. We hypothesized that CHF and SHF would be associated with a greater percentage of time stably housed as well as superior health and psychosocial outcomes over 24 months compared to treatment as usual (TAU). METHODS Inclusion criteria were homelessness, mental illness, and high need for support. Participants were randomised to SHF, CHF, or TAU. SHF consisted of market rental apartments with support provided by Assertive Community Treatment (ACT). CHF consisted of a single building with supports equivalent to ACT. TAU included existing services and supports. RESULTS Of 800 people screened, 297 were randomly assigned to CHF (107), SHF (90), or TAU (100). The percentage of time in stable housing over 24 months was 26.3% in TAU (reference; 95% confidence interval (CI) = 20.5, 32.0), compared to 74.3% in CHF (95% CI = 69.3, 79.3, p<0.001) and 74.5% in SHF (95% CI = 69.2, 79.7, p<0.001). Secondary outcomes favoured CHF but not SHF compared to TAU. CONCLUSION HF in scattered and congregate formats is capable of achieving housing stability among people experiencing major mental illness and chronic homelessness. Only CHF was associated with improvement on select secondary outcomes. REGISTRATION Current Controlled Trials: ISRCTN57595077.
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Affiliation(s)
- Julian M. Somers
- Somers Research Group Faculty of Health Sciences Simon Fraser University Burnaby, Canada
- * E-mail:
| | - Akm Moniruzzaman
- Somers Research Group Faculty of Health Sciences Simon Fraser University Burnaby, Canada
| | - Michelle Patterson
- Somers Research Group Faculty of Health Sciences Simon Fraser University Burnaby, Canada
| | - Lauren Currie
- Somers Research Group Faculty of Health Sciences Simon Fraser University Burnaby, Canada
| | - Stefanie N. Rezansoff
- Somers Research Group Faculty of Health Sciences Simon Fraser University Burnaby, Canada
| | - Anita Palepu
- School of Population and Public Health University of British Columbia Vancouver, Canada
| | - Karen Fryer
- Somers Research Group Faculty of Health Sciences Simon Fraser University Burnaby, Canada
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Murillo LG, Ramos-Olazagasti MA, Mannuzza S, Castellanos FX, Klein RG. Childhood Attention-Deficit/Hyperactivity Disorder and Homelessness: A 33-Year Follow-Up Study. J Am Acad Child Adolesc Psychiatry 2016; 55:931-936. [PMID: 27806860 PMCID: PMC5533180 DOI: 10.1016/j.jaac.2016.07.772] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/16/2016] [Accepted: 08/26/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To examine whether childhood attention-deficit/hyperactivity disorder (ADHD) predicts homelessness in adulthood, and whether the persistence of childhood ADHD through adolescence influences the likelihood of homelessness. METHOD A 33-year prospective, controlled, follow-up was performed of clinic-referred, 6- to 12-year-old boys of white ethnicity with ADHD (probands; mean = 8), at a mean age of 41 years (follow-up [FU] = 41). Comparisons, children without ADHD from the same medical center, were matched for age and socioeconomic status (SES). Both groups were evaluated at a mean age of 18 years (FU18). Homelessness was assessed at FU41 in 134 of 207 probands (65%) and 136 of 178 (76%) comparisons. We tested the following: the relationship between childhood ADHD and homelessness; whether adolescent dysfunctions (conduct disorder, non-alcohol substance use disorder, arrests, and school dropout) accounted for this relationship, if found; and whether ADHD that persisted through FU18 elevated probands' homelessness rate. RESULTS Probands had significantly higher rates of homelessness than comparisons (23.7% vs. 4.4%; χ21 = 21.15, df = 1, p < .001). In a multivariate analysis, including childhood ADHD and covariates, the probands' significant elevation of homelessness remained (odds ratio [OR] = 3.60, 95% CI = 1.32-9.76, p = .01). Probands with persistent ADHD through adolescence had significantly more homelessness than remitted probands (χ21 = 12.73, p < .001), but this relationship was no longer significant when conduct disorder at FU18 was controlled (OR = 1.97, 95% CI = 0.89-4.38, p = .09). CONCLUSION Among boys of white ethnicity who were followed into adulthood, childhood ADHD was associated with an elevated rate of homelessness. Findings point to the need for clinical monitoring of childhood ADHD through adolescence, even when ADHD does not persist, in hopes of mitigating a cascade of malfunction that includes homelessness.
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Affiliation(s)
| | | | | | - Francisco Xavier Castellanos
- The Child Study Center at New York University Langone Medical Center, New York. Nathan Kline Institute for Psychiatric Research, Orangeburg, NY
| | - Rachel G. Klein
- The Child Study Center at New York University Langone Medical Center, New York
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Håkanson C, Sandberg J, Ekstedt M, Kenne Sarenmalm E, Christiansen M, Öhlén J. Providing Palliative Care in a Swedish Support Home for People Who Are Homeless. QUALITATIVE HEALTH RESEARCH 2016; 26:1252-1262. [PMID: 25994318 DOI: 10.1177/1049732315588500] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Despite high frequencies of multiple, life-limiting conditions relating to palliative care needs, people who are homeless are one of the most underserved and rarely encountered groups in palliative care settings. Instead, they often die in care places where palliative competence is not available. In this qualitative single-case study, we explored the conditions and practices of palliative care from the perspective of staff at a Swedish support home for homeless people. Interpretive description guided the research process, and data were generated from repeated reflective conversations with staff in groups, individually, and in pairs. The findings disclose a person-centered approach to palliative care, grounded in the understanding of the person's health/illness and health literacy, and how this is related to and determinant on life as a homeless individual. Four patterns shape this approach: building trustful and family-like relationships, re-dignifying the person, re-considering communication about illness and dying, and re-defining flexible and pragmatic care solutions.
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Affiliation(s)
| | | | | | | | | | - Joakim Öhlén
- Ersta Sköndal University College, Stockholm, Sweden
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Vuillermoz C, Aouba A, Grout L, Vandentorren S, Tassin F, Moreno-Betancur M, Jougla É, Rey G. Mortality among homeless people in France, 2008-10. Eur J Public Health 2016; 26:1028-1033. [PMID: 27335327 DOI: 10.1093/eurpub/ckw083] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Studies in various countries have shown that homeless people have high mortality levels. The aims of this study concerning the French population were to investigate mortality among the homeless and to study their causes of death in comparison to those of the general population. METHODS A representative sample of 1145 homeless deaths registered by an association was matched to the national database of medical causes of death using common descriptive variables. Log-binomial regression was used to compare mortality among the homeless to that of the general population. Multiple imputation was used to manage missing causes of deaths. RESULTS Out of the 1145 registered homeless deaths, 693 were matched to the causes of death database. Homeless deaths were young (average age: 49). Overall, homeless deaths were slightly more frequent during winter. Among all deaths, the probability of being homeless was higher when dying from hypothermia (RR = 6.4), alcohol-related deaths (RR = 1.7), mental disorders, diseases of the digestive and circulatory systems, and undetermined causes (RR from 1.5 to 3.7). CONCLUSION The homeless died at 49 years old on average compared with 77 in the general population in 2008-10. The health of homeless people should be considered not only in winter periods or in terms of alcohol- or cold-related conditions. This study also highlights the need for more precise data to estimate the mortality risks of the homeless in France.
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Affiliation(s)
- Cécile Vuillermoz
- INSERM, CépiDc, Le Kremlin-Bicêtre, France .,Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Department of Social Epidemiology, 75012, Paris, France
| | | | - Lise Grout
- Le Collectif Les Morts de la Rue, Paris, France
| | - Stéphanie Vandentorren
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136), Department of Social Epidemiology, 75012, Paris, France.,Department of Infectious diseases, French Institute of Public Health Surveillance, Saint-Maurice, France
| | - Fanny Tassin
- Observatoire National de la Pauvreté et de l'Exclusion Sociale, Paris, France
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Termorshuizen F, van Bergen APL, Smit RBJ, Smeets HM, van Ameijden EJC. Mortality and psychiatric disorders among public mental health care clients in Utrecht: a register-based cohort study. Int J Soc Psychiatry 2014; 60:426-35. [PMID: 23812410 DOI: 10.1177/0020764013491942] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Different studies have shown similar or even lower mortality among homeless persons with compared to homeless persons without a severe mental disorder. AIMS To clarify the association between presence of a psychiatric diagnosis and mortality among the socially marginalized. METHODS The Public Mental health care (PMHc) is a legal task of the municipal authority aiming at prevention and intervention in case of (imminent) homelessness among persons with a serious shortage of self-sufficiency. The data of PMHc clients (N=6,724) and personally matched controls (N=66,247) were linked to the registries of Statistics Netherlands and analysed in a Cox model. RESULTS The increased mortality among PMHc clients, compared to the general population (HR=2.99, 95%-CI: 2.63-3.41), was associated with a broad range of death causes. Clients with a record linkage to the Psychiatric Case Registry Middle Netherlands ('PMHc+') had an increased risk of suicide (HR=2.63, 0.99-7.02, P=0.052), but a lower risk of natural death causes (HR=0.71, 0.54-0.92, P=0.011), compared to clients without this record linkage ('PMHc-'). Compared to controls, however, 'PMHc-' clients experienced substantially increased risks of suicide (HR=3.63, 1.42-9.26, P=0.007) and death associated with mental and behavioural disorders (ICD-10 Ch.V) (HR=7.85, 3.54-17.43, P<0.001). CONCLUSION Psychiatric services may deliver an important contribution to the prevention of premature natural death among the socially marginalized. KEYPHRASES The earlier observed lower mortality among vulnerably housed and homeless persons with a psychiatric diagnosis compared to vulnerably housed and homeless persons without a psychiatric diagnosis appears to be due to a significantly lower risk of natural causes of death. Compared to controls from the general population, vulnerably housed and homeless persons without registered diagnosis at a local psychiatric service have a significantly increased mortality associated both with natural death causes and with suicide and death due to mental and behavioural disorders. Services for mental health care may deliver an important contribution to the prevention of premature death due to somatic disorders among the socially marginalized.
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Affiliation(s)
| | - Addi P L van Bergen
- Department of Health Promotion and Epidemiology, Municipal Health Service Utrecht, Utrecht, The Netherlands
| | - Ronald B J Smit
- Department of Social Health Care, Municipal Health Service Utrecht, Utrecht, The Netherlands
| | - Hugo M Smeets
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik J C van Ameijden
- Department of Health Promotion and Epidemiology, Municipal Health Service Utrecht, Utrecht, The Netherlands
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Estimating the number of homeless deaths in France, 2008-2010. BMC Public Health 2014; 14:690. [PMID: 24999114 PMCID: PMC4227048 DOI: 10.1186/1471-2458-14-690] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 07/02/2014] [Indexed: 11/10/2022] Open
Abstract
Background The homeless population of France has increased by 50% over the last 10 years. Studies have shown that homelessness is associated with a high risk of premature death. The aim of this study was to estimate the number of homeless deaths in France between 2008 and 2010, using a reproducible method. Methods We used the capture-recapture method to estimate the number of homeless deaths in France using two independent sources. An associative register of homeless deaths was matched with the national exhaustive database of the medical causes of death, using several matching approaches based on various combinations of the following variables: gender, age, place of death, date of death. Results The estimated number of homeless deaths between 2008 and 2010 was 6730 (95% CI: [4381–9079]), a number greatly underestimated by the two sources considered separately (less than 20%). Conclusions In the absence of a register of the homeless deaths, the capture-recapture method provides an order of magnitude for evaluation of the resources that may be allocated by policy makers to manage the issue. Based on common and routinely produced databases, this estimate may therefore be used to monitor the mortality of the homeless population. Further studies about homeless mortality, particularly on the lead causes of deaths, are needed to manage this issue and to implement strategy to decrease the number of homeless deaths.
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Mortality and life expectancy in homeless men and women in Rotterdam: 2001-2010. PLoS One 2013; 8:e73979. [PMID: 24098329 PMCID: PMC3788767 DOI: 10.1371/journal.pone.0073979] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 08/01/2013] [Indexed: 11/26/2022] Open
Abstract
Background Data on mortality among homeless people are limited. Therefore, this study aimed to describe mortality patterns within a cohort of homeless adults in Rotterdam (the Netherlands) and to assess excess mortality as compared to the general population in that city. Methods Based on 10-year follow-up of homeless adults aged ≥ 20 years who visited services for homeless people in Rotterdam in 2001, and on vital statistics, we assessed the association of mortality with age, sex and type of service used (e.g. only day care, convalescence care, other) within the homeless cohort, and also compared mortality between the homeless and general population using Poisson regression. Life tables and decomposition methods were used to examine differences in life expectancy. Results During follow-up, of the 2096 adult homeless 265 died. Among the homeless, at age 30 years no significant sex differences were found in overall mortality rates and life expectancy. Compared with the general Rotterdam population, mortality rates were 3.5 times higher in the homeless cohort. Excess mortality was larger in women (rate ratio [RR] RR 5.56, 95% CI 3.95–7.82) as compared to men (RR 3.31, 95% CI 2.91–3.77), and decreased with age (RR 7.67, 95% CI 6.87–8.56 for the age group 20–44 and RR 1.63, 95% CI 1.41–1.88 for the age group 60+ years). Life expectancy at age 30 years was 11.0 (95% CI 9.1–12.9) and 15.9 (95% CI 10.3–21.5) years lower for homeless men and women compared to men and women in the general population respectively. Conclusion Homeless adults face excessive losses in life expectancy, with greatest disadvantages among homeless women and the younger age groups.
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Alcohol and cannabis use and mortality in people with schizophrenia and related psychotic disorders. J Psychiatr Res 2012; 46:987-93. [PMID: 22595870 PMCID: PMC3392453 DOI: 10.1016/j.jpsychires.2012.04.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 04/20/2012] [Accepted: 04/23/2012] [Indexed: 11/22/2022]
Abstract
The impact of co-morbid substance use on mortality is not well studied in psychotic disorders. The objective of this study was to examine the impact of substance use on mortality in people with psychotic disorders and alcohol and/or drug use. We examined the rate of substance use and the risk of substance use on mortality risk over a 4-10 year period in 762 people with psychotic disorders. Deceased patients were identified from the Social Security Death Index and the Maryland Division of Vital Records. Substance use was defined as regular and heavy use or abuse or dependence. Seventy seven percent had co-morbid lifetime substance use, with co-morbid cannabis and alcohol use occurring most commonly. Out of 762 subjects, 62 died during follow up. In a Cox model, predicted mortality risk was higher in age group 35-55 compared to <35 years and in males, but reduced in cannabis users. Overall five- (3.1% vs 7.5%) and ten-year mortality risk (5.5% vs. 13.6%) was lower in cannabis users than in non-users with psychotic disorders (p = 0.005) in a survival model. Alcohol use was not predictive of mortality. We observed a lower mortality risk in cannabis-using psychotic disorder patients compared to cannabis non-users despite subjects having similar symptoms and treatments. Future research is warranted to replicate these findings and to shed light on the anti-inflammatory properties of the endocannabinoid system and its role in decreased mortality in people with psychotic disorders.
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Sun S, Irestig R, Burström B, Beijer U, Burström K. Health-related quality of life (EQ-5D) among homeless persons compared to a general population sample in Stockholm County, 2006. Scand J Public Health 2012; 40:115-25. [PMID: 22327187 DOI: 10.1177/1403494811435493] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS To describe and compare health-related quality of life (HRQoL) among homeless persons with a general population sample in Stockholm County, 2006, and to analyse the importance of certain social determinants of health among the homeless. METHODS Face-to-face interviews with 155 homeless persons and a postal survey to a general population sample, mainly based on the same questionnaire, including questions on social determinants of health and HRQoL measured with the EQ-5D. RESULTS Chronic illness was three times more common among the homeless. HRQoL was worse among homeless persons than in the general population sample: the homeless reported more problems, especially more severe problems, in all the EQ-5D dimensions and had considerably lower EQ-5D(index) and EQ(VAS) score than the general population. Most problems were reported in the dimension anxiety/depression. Among the homeless, longer duration and more severe degree of homelessness lowered HRQoL, but few determinants were statistically significantly related to HRQoL. Having mental disease significantly lowered HRQoL. CONCLUSIONS This study was an attempt to include hard-to-reach groups in an assessment of population health. Homeless persons had considerably worse HRQoL than the general population and reported most problems in the dimension anxiety/depression. Some diseases may contribute to causing homelessness; others may be seen as consequences. Homeless persons are a vulnerable group in society. Further interview studies are needed based on larger sample of homeless persons to explore health determinants such as sex, age, socioeconomic factors, duration and degree of homelessness, and health-related behaviours among the homeless persons.
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Affiliation(s)
- Sun Sun
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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30
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Girard V, Sarradon-Eck A, Payan N, Bonin JP, Perrot S, Vialars V, Boyer L, Tinland A, Simeoni MC. [The analysis of a mobile mental health outreach team activity: from psychiatric emergencies on the street to practice of hospitalization at home for homeless people]. Presse Med 2012; 41:e226-37. [PMID: 22244723 DOI: 10.1016/j.lpm.2011.09.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Revised: 08/29/2011] [Accepted: 09/07/2011] [Indexed: 11/15/2022] Open
Abstract
CONTEXT AND OBJECTIVE Since their creation in 2005 in France, mobile mental health outreach teams (EMPP) have been working to improve the health of the homeless who, for 30 to 50% of them, present severe mental disorders. Their missions are defined by ministerial circular's specifications. Few studies have been undertaken in France to analyze the practices of these teams' professionals, nor the characteristics of the populations with whom they are involved. The EMPP described in this paper had in 2010 a greater staff than other French EMPPs. It has 15 full-time staff, including four doctors (two psychiatrists, one GP, one house physician), two nurses, two educators, one social worker, three peer-workers, one secretary and two coordinators. The article analyzes the way of support developed within the range of EMPP's missions defined by the ministerial circular. METHODS Descriptive statistical analysis was carried out using standardized data from four different sources (round sheet, record of activity, record of hospitalization, housing information, interviews conducted by medical and social professionals with patients). Another source of data consists of records describing the operation of the team (reference framework) and annual activities (annual report). RESULTS The method of care was developed based on a street working, involving a full medical and its relationship with the hospital and a place to live in a semi-community context. The Mobile Mental Health Outreach team documented 318 rounds in 2010, describing 666 contacts among whom 87.9% were followed regularly thereafter. It focuses to a target population. The team actively followed 198 people including 161 for whom a psychiatric diagnosis was done: 48.5% of the patients followed presented schizophrenic-type disorders, 21.8% bipolar disorders and other mood-linked problems, 13% behavioral disorders and 6.2% substance-use disorders. A percentage of 44.9 presented with a physical disease. Among the 89 hospitalizations, 86.5% were motivated by psychiatric disorders and 43% were forced. In about one third of the cases, hospitalizations were motivated by a double indication - psychiatric and physical - and in 13.5% for only a physical indication. Thirty people of the actively followed people had stayed in a halfway house as an alternative to hospitalization, restoring a continuity of care and allowing to resolve social problems that had until then been hopeless. PERSPECTIVES The strategies developed by this Mobile Health Outreach Team ensure local community medical, psychiatric and social care for "hard to reach" people. The results confirm the interest of the link between the street work, the hospital and the halfway home, both as a living facility and an alternative to hospitalization. They suggest the importance of a critical minimum size for these EMPP that allows them a street work with doctors providing guidance. The presence of a GP is another welcome development because of the severity and the entanglement of somatic and psychiatric problems of these populations.
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Affiliation(s)
- Vincent Girard
- Assistance Publique des Hôpitaux de Marseille, hôpital La Timone, pôle de santé publique, EA 3279 Évaluation des systèmes de soins et mesure de la santé perçue, 13385 Marseille, France
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Nielsen SF, Hjorthøj CR, Erlangsen A, Nordentoft M. Psychiatric disorders and mortality among people in homeless shelters in Denmark: a nationwide register-based cohort study. Lancet 2011; 377:2205-14. [PMID: 21676456 DOI: 10.1016/s0140-6736(11)60747-2] [Citation(s) in RCA: 110] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The increased mortality of homeless people compared with non-homeless people might be linked to psychiatric disorders. However, homeless people are, because of their insufficient accommodation, difficult to sample and monitor, which has limited previous studies. We aimed to assess registered psychiatric disorders, mortality, and predictors of mortality in the homeless shelter population in Denmark. METHODS We did a nationwide, prospective, register-based cohort study of homeless people aged 16 years and older who were registered in the Danish Homeless Register between Jan 1, 1999, and Dec 31, 2009. We calculated the proportion of registered psychiatric disorders, overall and cause-specific standardised mortality ratio (SMR), and life expectancy. Hazard ratios (HRs) were used to assess predictors of death. FINDINGS 32,711 homeless people (23,040 men and 9671 women) were included in the study population. 14,381 men (62·4%) and 5632 women (58·2%) had registered psychiatric disorders, and 11,286 men (49·0%) and 3564 women (36·9%) had a substance abuse diagnosis. During the study period, 3839 men (16·7%) and 951 women (9·8%) died. The overall SMR for men was 5·6 (95% CI 5·4-5·8) and for women was 6·7 (6·2-7·1), and external causes accounted for 1161 (27·9%) of 4161 deaths for which information on the cause was available. Remaining life expectancy at age 15-24 years was 21·6 years (95% CI 21·2-22·1) and 17·4 years (16·4-18·5) lower for homeless men and women, respectively, than the general population. Registered substance abuse disorder was associated with the highest mortality risk compared with no psychiatric contact registered (adjusted HR 1·4, 95% CI 1·3-1·5 for men; 1·7, 1·4-2·1 for women). INTERPRETATION Health problems are extensive in the homeless shelter population and there is an urgent need for more sustained efforts to reduce the high morbidity and mortality, especially from external causes. Register data is an important resource to supplement existing knowledge on homeless people with more valid and detailed information. FUNDING The Danish Council for Independent Research.
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Affiliation(s)
- Sandra Feodor Nielsen
- Mental Health Centre Copenhagen and Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Affiliation(s)
- John R Geddes
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK.
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Beijer U, Andreasson S, Agren G, Fugelstad A. Mortality and causes of death among homeless women and men in Stockholm. Scand J Public Health 2011; 39:121-7. [PMID: 21247970 DOI: 10.1177/1403494810393554] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To study the mortality and causes of death among homeless men and women in relation to the risk indicators, previous treatment for alcohol and drug abuse, previous treatment for mental disorders and non-Swedish citizenship. METHODS The mortality was studied in a cohort comprising 1,757 men and 526 women compared with the general population and persons with inpatient treatment for alcohol- and drug-related disorders. The follow-up period was from 1995 to 1997 until the end of 2005. The causes of death were analyzed. RESULTS 421 deaths occurred during the follow-up period. The relative risk of death was 3.1, with no difference in mortality between homeless men and homeless women. Previous treatment for alcohol and drug abuse disorders was related to excess mortality and previous treatment for mental disease to lower mortality. Homeless people with inpatient treatment for alcohol or drug use disorders had no higher mortality than the general population in Stockholm with a similar history. There was a dominance of alcohol- and drug-related causes of death. DISCUSSION Compared with previous studies of homeless people in Stockholm the excess mortality among men found in this study is of the same magnitude. Mortality among women is lower. The mortality rate in homeless people with previous treatment for an alcohol and illicit drug use disorder did not differ from those treated for these disorders in the general population. CONCLUSIONS The most important finding is that excess mortality among homeless men and women in Stockholm is entirely related to alcohol and drug abuse.
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Beijer U, Andréasson S. Gender, hospitalization and mental disorders among homeless people compared with the general population in Stockholm. Eur J Public Health 2010; 20:511-6. [PMID: 20371499 DOI: 10.1093/eurpub/ckq033] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The aim was to study the prevalence of mental disorders among homeless men and women admitted for inpatient treatment in hospitals. METHODS Hospital care utilization of homeless people, 1364 men and 340 women, was compared with a control group consisting of 3750 men and 1250 women from the general population, 1996-2002. RESULTS Homeless women ran a higher risk for mental disorders than women in the population [risk ratio (RR) 20.88]; their risk was also higher than the risk for homeless men (RR 1.20). Younger homeless women had the highest risk (RR 2.17). Alcohol use disorders were equally common among homeless men and women, but women had more drug use disorders (RR 1.32). Women had higher risk of schizophrenia (RR 2.79), and personality disorders (RR 2.73). When adjustment was made for substance use disorders, no increased risk for mental disorder was found in the homeless group. CONCLUSION The elevated risk for mental disorders among the homeless was mainly related to substance use problems. Younger homeless women had the highest risk of mental disorder.
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Affiliation(s)
- Ulla Beijer
- Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden.
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Hwang SW, Wilkins R, Tjepkema M, O'Campo PJ, Dunn JR. Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study. BMJ 2009; 339:b4036. [PMID: 19858533 PMCID: PMC2767481 DOI: 10.1136/bmj.b4036] [Citation(s) in RCA: 257] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine mortality in a representative nationwide sample of homeless and marginally housed people living in shelters, rooming houses, and hotels. DESIGN Follow-up study. SETTING Canada 1991-2001. PARTICIPANTS 15 100 homeless and marginally housed people enumerated in 1991 census. MAIN OUTCOME MEASURES Age specific and age standardised mortality rates, remaining life expectancies at age 25, and probabilities of survival from age 25 to 75. Data were compared with data from the poorest and richest income fifths as well as with data for the entire cohort RESULTS Of the homeless and marginally housed people, 3280 died. Mortality rates among these people were substantially higher than rates in the poorest income fifth, with the highest rate ratios seen at younger ages. Among those who were homeless or marginally housed, the probability of survival to age 75 was 32% (95% confidence interval 30% to 34%) in men and 60% (56% to 63%) in women. Remaining life expectancy at age 25 was 42 years (42 to 43) and 52 years (50 to 53), respectively. Compared with the entire cohort, mortality rate ratios for men and women, respectively, were 11.5 (8.8 to 15.0) and 9.2 (5.5 to 15.2) for drug related deaths, 6.4 (5.3 to 7.7) and 8.2 (5.0 to 13.4) for alcohol related deaths, 4.8 (3.9 to 5.9) and 3.8 (2.7 to 5.4) for mental disorders, and 2.3 (1.8 to 3.1) and 5.6 (3.2 to 9.6) for suicide. For both sexes, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases. CONCLUSIONS Living in shelters, rooming houses, and hotels is associated with much higher mortality than expected on the basis of low income alone. Reducing the excessively high rates of premature mortality in this population would require interventions to address deaths related to smoking, alcohol, and drugs, and mental disorders and suicide, among other causes.
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Affiliation(s)
- Stephen W Hwang
- Centre for Research on Inner City Health, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
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Beijer U, Andréasson S. Physical diseases among homeless people: gender differences and comparisons with the general population. Scand J Public Health 2009; 37:93-100. [PMID: 19141558 DOI: 10.1177/1403494808099972] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM To study morbidity amongst homeless men and women by comparing prevalence of hospital care for somatic diseases and injuries with a control group of men and women from the general population. METHODS A cohort of 1,364 men and 340 women were documented as homeless in 1996. Comparisons are made concerning hospital care for somatic diseases and injuries (1996-2002) among 3,750 men and 1,250 women from the general population. RESULTS The relative risk (RR) for homeless men and women of being hospitalised was double that of the men and women in the controls (1.93 and 1.96 respectively). Homeless women had a slightly, not significant, increased risk compared to homeless men (RR 1.10). Younger homeless women had a significant higher risk. Among diagnostic categories, the highest prevalence was found among homeless men in the diagnosis group injury/poisoning (22%). The highest risk was found for skin diseases (RR 36.96) and concerned homeless women. There were a number of gender specific diagnoses, where risks were considerably elevated, such as diseases of the genital organs, viral hepatitis, and poisoning for homeless women, and cerebrovascular diseases, diseases of the liver, and concussion for homeless men. CONCLUSIONS Homeless people had twice the risk of being hospitalised for physical diseases compared to the general population. Younger women were particularly at risk compared to homeless men and to women in the controls. There were a number of gender specific diagnoses that are important to take into account when planning services for homeless people.
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Affiliation(s)
- Ulla Beijer
- Karolinska Institute, Department of Public Health Sciences, Division of Social Medicine, Stockholm, Sweden.
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