Adversity and children experiencing family homelessness: Implications for health

An Exploration of Rural Housing Insecurity as a Public Health Problem in California's Rural Northern Counties

Although widely acknowledged as an important social determinant of health, until recently researchers and policymakers have primarily approached housing insecurity as an urban issue, obscuring the visibility of its impacts in rural contexts, including the ways in which housing insecurity intersects with other health and structural inequities facing rural populations. Working to address this gap in the existing literature, this paper explores the experiences of housing insecurity in a rural context by reporting on an analysis of 210 in-depth interviews with 153 adults between the ages of 18-35, living in California's rural North State, a relatively overlooked far northern region of the state comprised of 12 north central and north eastern counties. Using in-depth qualitative interview data, we conducted an exploratory pattern-level analysis of participants' narratives structured by four dimensions of housing insecurity defined in the literature (housing affordability, housing stability, housing conditions, and neighborhood context). Drawing attention to the pervasiveness of rural housing insecurity within our sample, this analysis highlights the unique ways in which rurality creates distinct experiences not currently captured in the existing literature. Further research is needed across different types of rural communities to better understand the various ways that housing insecurity affects the everyday lives and health of rural residents. By grounding research within the experiences of rural residents, we are better able to respond to the crisis of rural housing insecurity and develop solutions that are tailored to rural residents' unique needs.

Predicting homelessness: Housing risk insights from latent class analysis

Millions of families with children in the U.S. struggle to afford adequate housing. Housing cost burden places families at risk for homelessness, and prevention efforts are hindered by limited understanding of insecure housing experiences at the margins. The present study investigated variation in housing insecurity experiences in a sample of mothers, as well as which risk profiles were most strongly associated with subsequent homelessness. Latent class analysis identified four distinct subgroups of housing insecurity: "Stable," "Unstable," "Rent-Focused," and "Strategic Bill-Paying." Classes differed on whether they made rent or utility payments on time, experienced utility shutoffs, or were evicted. Mothers who missed rent payments were significantly more likely to experience subsequent homelessness, whereas those who prioritized rent were more likely to have their utilities shut off but remain housed. Policy efforts should emphasize increased wages, rent control, changes to zoning laws and tax codes to prioritize affordable housing, and benefits that help mothers maintain their incomes such as comprehensive healthcare, paid maternity leave, and subsidized childcare.

Building resilience in families experiencing homelessness through integration of health, parenting and child development programs

Children who experience homelessness are vulnerable to mental health problems, developmental delays and lower academic achievement. Research suggests that parental health literacy, sensitive parenting behaviour and child self-regulation are modifiable mechanisms that might enhance children's resilience to adversities associated with homelessness, yet empirical evidence on implementing such interventions in shelter settings is limited. Through a coordinated academic-community partnership, this study aimed to examine the (1) feasibility of conducting an integrated health approach in shelter settings and (2) the effectiveness of separate interventions on child and parent outcomes. Results are discussed in terms of best practices in shelter settings and building resilience in families experiencing homelessness with young children.

Families with young children in homeless shelters: Developmental contexts of multisystem risks and resources

We apply a multisystem perspective to three aims relevant to resilience for young children in emergency and transitional homeless shelters. We consider profiles of risks and resources before shelter, early childhood program enrollment during shelter, and the likelihood of returning to shelter or having a subsequent child welfare placement. We used longitudinal, city-wide data from multiple sources integrated at the individual level across the lifespan for 8 birth cohorts. Young children (N = 1,281) stayed in family shelters during an 18-month period during a multisystem intervention. Risk factor rates were high as were rates of early childhood program enrollment (66.1% in any program; 42.3% in a high-quality program), which may suggest positive effects of the multisystem intervention. Multilevel latent class analysis revealed four profiles, considering prior shelter stays, prior child welfare placements, prior elevated lead levels, perinatal factors (teenage mother, prenatal care, low maternal education, and poor birth outcomes), demographics, and early childhood program enrollment and quality. One profile with higher rates of child welfare placement before the shelter stay and considerable enrollment in high-quality early childhood programs corresponded to lower rates of subsequent child welfare placement. Profiles did not differ on the likelihood of returning to shelter.

Is breastfeeding duration related to the health of migrant mother-child dyads experiencing homelessness? The ENFAMS cross-sectional survey

BACKGROUND

Literature from the general population shows a consensus about the health benefits associated with breastfeeding for both mothers and children. However, studies investigating these issues in the context of homelessness and migration are rare. This research aimed to examine the relations of any breastfeeding duration with health outcomes among migrant mother-child dyads experiencing homelessness.

METHODS

Data were collected among sheltered and mainly foreign-born mothers experiencing homelessness, and their children aged 6 months to 5 years, from the ENFAMS cross-sectional survey (n = 481, 2013-Great Paris area). Any breastfeeding duration, along with various health outcomes of both the mother and her child, was ascertained by face-to-face questionnaires administered by trained interviewers to mothers (perceived physical and emotional health and maternal depression) or by trained psychologists to children (adaptive behaviours). Nurses measured weight and height [thus allowing them to calculate body mass index (BMI)] and haemoglobin concentration (mother-child dyad) and maternal blood pressure. Multivariable linear and modified Poisson regression analyses were performed to examine outcome-wide associations between any breastfeeding duration ≥6 months and the various mother-child outcomes.

RESULTS

Any breastfeeding ≥6 months was associated with lower systolic blood pressure in mothers (B = -0.40, 95% confidence interval = -0.68 to -0.12). No association was observed with the other outcomes.

CONCLUSIONS

The relevance of supporting breastfeeding to improve mothers' physical health holds true in the context of migration and homelessness. It is therefore important to support breastfeeding in these settings. Moreover, given the documented social complexity of breastfeeding practices, interventions should take mothers' socio-cultural heritage and the structural barriers they face into account.

The impact of living in an un- or under-furnished house on individuals who transitioned from homelessness

Very few empirical evaluations have been conducted on the impact of furniture on the lives of those who have transitioned from homelessness into permanent housing, especially within the United States. Our study contributes to this limited body of research by exploring the impact of furniture on the lives of 20 recently housed individuals residing in the Detroit Metropolitan Area. In partnership with the Furniture Bank of Southeast Michigan, we conducted semi-structured interviews with recently housed individuals that lived for a period of time in an un- or under-furnished house before receiving furniture support. Given the study's exploratory nature, interview questions were purposefully broad to allow themes to naturally emerge and were analyzed using a qualitative data analysis software package, NVivo (release 1.0). We present a conceptual model that outlines our findings and conclude with a discussion of the limitations of our approach, avenues for future research, and policy implications.

Early life adversity, inflammation, and immune function: An initial test of adaptive response models of immunological programming

Much research indicates that exposure to early life adversity (ELA) predicts chronic inflammatory activity, increasing one's risk of developing diseases of aging later in life. Despite its costs, researchers have proposed that chronic inflammation may be favored in this context because it would help promote immunological vigilance in environments with an elevated risk of infection and injury. Although intuitively appealing, the assumption that exaggerated inflammatory activity predicts favorable immunological outcomes among those exposed to ELA has not been tested. Here, we seek to address this gap, examining the links between exposure to ELA, inflammation, and immune function. Consistent with others' work, results revealed that those from low socioeconomic status (SES) childhood environments exhibited exaggerated unstimulated inflammatory activity relative to what was observed among those from higher SES childhood environments. Further, results revealed that - although levels of inflammation predicted the magnitude of immunological responses in those from higher SES backgrounds - for those who grew up in low SES environments, higher levels of inflammation were unrelated to the magnitude of immunological responses. Results suggest that exaggerated inflammatory activity in the context of ELA may not predict improved ability to manage acute immunological threats.

Self-harm in people experiencing homelessness: investigation of incidence, characteristics and outcomes using data from the Multicentre Study of Self-Harm in England

BACKGROUND

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.

AIMS

To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.

METHOD

Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.

RESULTS

There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04-1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94-2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32-1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41-3.57, P < 0.001).

CONCLUSIONS

People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

A systematic review and qualitative meta-synthesis of the roles of home-visiting nurses working with women experiencing family violence

AIMS

To systematically review and synthesize qualitative research exploring home-visiting nurses' roles and identify the challenges for nurses working with women experiencing family violence.

DESIGN

We undertook a thematic synthesis of qualitative studies, focusing on the family violence work of nurse home visitors.

DATA SOURCES

A systematic search of four scientific databases (ProQuest Central, CINAHL, MEDLINE, EMBASE) was undertaken in August 2021. Grey literature was searched, including government and non-government research documents, theses, clinical guidelines, policy documents and practice frameworks.

REVIEW METHODS

Inclusion criteria included research from high-income countries, peer-reviewed qualitative studies in English published from 1985 to 2021, and included research on home-visiting nurse family violence practice. The first author conducted the data search and the initial screening. The first and second authors independently reviewed the full text of 115 papers, identifying 26 for inclusion in the thematic synthesis (Figure 1-PRISMA flowchart).

RESULTS

The thematic synthesis identified two themes: (1) relationship building-with the client, with services and with colleagues/self; and (2) family violence practice-ask/screen, validate/name, assess risk/safety plan and safeguard children.

CONCLUSION

The thematic synthesis confirmed the multiple roles fulfilled by home-visiting nurses and enabled insight into the challenges they face as they undertake complex and demanding work. The roles of the home-visiting nurse have evolved, with the initial focus on safeguarding children leading to broader family violence nursing practice roles, including the identification of family violence and safety planning discussions with women.

IMPACT

Our meta-synthesis has confirmed the high-level communication and rapport-building skills required by nurses undertaking complex and conflicting roles. Nurses need support and supervision to undertake emotionally demanding work. Integrated health systems, clinical practice guidelines and tools, and training programmes need to encompass the breadth and complexity of the roles of these specialist practitioners.

Relationship of parent-rated and objectively evaluated executive function to symptoms of posttraumatic stress and attention-deficit/hyperactivity disorder in homeless youth

Compared to their stably housed peers, homeless, and highly mobile (HHM) youth experience disproportionately greater adversity and risk leading to a wide variety of poor developmental outcomes, and targeted interventions have the potential to mitigate such outcomes. A growing literature highlights the need for accurate diagnosis in high-risk populations given the considerable overlap between posttraumatic symptomology and behaviorally based disorders such as ADHD. Objective testing inferring neurobiological and circuit-based abnormalities in posttraumatic stress disorder (PTSD) and ADHD may provide a useful clinical tool to aid accurate diagnosis and treatment recommendations. This novel, exploratory study examined the relation between executive function (EF) as measured by objective testing and parent ratings with symptoms of posttraumatic stress and ADHD in 86 children (age 9 to 11) living in emergency homeless shelters. Parent-rated EF problems suggested broad impairment associated with ADHD symptoms but specific impairment in emotional/behavioral function associated with posttraumatic stress symptoms. While measures of inhibition and shifting EF were strongly associated with symptomology in bivariate correlations, they explained minimal variance in regression models. Internalizing behavior problems were associated with posttraumatic stress symptoms, while externalizing behavior problems were associated with ADHD symptoms. Implications for clinical practice and future research are discussed.

Threads of Practice: Enhanced Maternal and Child Health Nurses Working With Women Experiencing Family Violence

Family violence is a serious public health issue with significant health consequences for women and children. Enhanced Maternal and Child Health nurses (EMCH) in Victoria, Australia, work with women experiencing family violence; however, scholarly examination of the clinical work of nurses has not occurred. This qualitative study explored how EMCH nurses work with women experiencing abuse, describing the personal and professional challenges for nurses undertaking family violence work. Twenty-five nurses participated in semi-structured interviews. Using interpretive description methodology has enabled an insight into nurses' family violence work. Threads of practice identified included (1) Validating/Reframing; (2) Non-judgmental support/Safeguarding and (3) Following/Leading. The nurses highlighted the diversity of experience for women experiencing abuse and nurses' roles in family violence nurse practice. The research contributes to understanding how EMCH nurses traverse threads of practice to support women experiencing family violence.

When a house is never a home: Housing instability among youth affected by parental drug abuse

BACKGROUND

The negative consequences of parental substance abuse are significant and longstanding for children. Among other risks, these youth are more likely to experience housing instability. The most common predictor of a child not living with their biological parent is parental substance use. Research shows that these youth are at higher risks of housing instability; however, little is known about their housing experiences, from their perspective. This study explored the housing experiences of youth affected by parental substance abuse.

PARTICIPANTS AND SETTING

Fourteen African American young adults ages 18 to 24 years old who identified having at least one biological parent with a history of substance use participated in this study. The study is based in Baltimore, MD, USA; an urban city with one of the highest rates of drug overdose and substantial disadvantage.

METHODS

In-depth interviews were conducted among fourteen young adults (18-24) affected by parental drug use to discuss their housing experiences throughout childhood and adolescence. Five research team members developed a codebook, double coded all transcripts and analyzed inductively using a qualitative content analytic approach.

RESULTS

Three themes emerged to characterize housing experiences: frequent housing transitions, repeated trauma exposures related to housing instability, and the lasting effects of housing instability.

CONCLUSION

The residual impacts of parental substance use have caused youth to experience the toxic stress and trauma associated with housing instability. It is important that young people have safe, stable and reliable housing to promote child health and normative development.

Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health

By focusing on the safe, stable, and nurturing relationships (SSNRs) that buffer adversity and build resilience, pediatric care is on the cusp of a paradigm shift that could reprioritize clinical activities, rewrite research agendas, and realign our collective advocacy. Driving this transformation are advances in developmental sciences as they inform a deeper understanding of how early life experiences, both nurturing and adverse, are biologically embedded and influence outcomes in health, education, and economic stability across the life span. This revised policy statement on childhood toxic stress acknowledges a spectrum of potential adversities and reaffirms the benefits of an ecobiodevelopmental model for understanding the childhood origins of adult-manifested disease and wellness. It also endorses a paradigm shift toward relational health because SSNRs not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future. To translate this relational health framework into clinical practice, generative research, and public policy, the entire pediatric community needs to adopt a public health approach that builds relational health by partnering with families and communities. This public health approach to relational health needs to be integrated both vertically (by including primary, secondary, and tertiary preventions) and horizontally (by including public service sectors beyond health care). The American Academy of Pediatrics asserts that SSNRs are biological necessities for all children because they mitigate childhood toxic stress responses and proactively build resilience by fostering the adaptive skills needed to cope with future adversity in a healthy manner.

Health and adverse childhood experiences among homeless youth

BACKGROUND

Homelessness is associated with health problems and with adverse childhood experiences (ACEs). The risk of chronic health conditions for homeless compared to housed youth, and how this risk interacts with ACEs remains unclear. This study investigated the relationship between ACEs, housing, and child health, and whether: 1) ACEs and health vary by housing context; 2) ACEs and homelessness confer independent health risks; and 3) ACEs interact with housing with regard to adolescent health.

METHODS

Using data from 119,254 8th-11th graders, we tested independent and joint effects of ACEs and past-year housing status (housed, family homelessness, unaccompanied homelessness) on overall health and chronic health conditions, controlling for sociodemographic covariates.

RESULTS

The prevalence of ACEs varied by housing status, with 34.1% of housed youth experiencing ≥1 ACE vs. 56.3% of family-homeless and 85.5% of unaccompanied-homeless youth. Health status varied similarly. Homelessness and ACEs were independently associated with low overall health and chronic health conditions, after adjusting for covariates. Compared to housed youth, both family-homeless youth and unaccompanied-homeless youth had increased odds of low overall health and chronic physical and/or mental health conditions. All ACE x housing-status interactions were significant (all p < 0.001), such that ACE-related health risks were moderated by housing status.

CONCLUSIONS

ACEs and housing status independently predict health status during adolescence beyond other sociodemographic risks. Experiencing homelessness, whether unaccomapnied or with family, is associated with increased health risk, and every additional ACE increases this risk. Clinicians and health systems should advocate for policies that include stable housing as a protective factor.

Childhood homelessness, resilience, and adolescent mental health: A prospective, person-centered approach

School districts and other service providers are increasingly aware of the substantial mental health needs of students experiencing family homelessness. Past findings are mixed regarding whether homelessness conveys unique risk beyond the risks associated with extreme poverty. With prospective longitudinal data on homelessness experiences across childhood, we utilized latent profile analysis as a person-centered approach to conceptualizing mental health outcomes in adolescence for 3,778 youth. We considered literal family homelessness as well as families living doubled-up, and we employed propensity score matching to identify a comparison group of non-homeless students balanced across a range of covariates to address systematic bias. Results indicated that students who experienced literal homelessness during childhood were significantly less likely to demonstrate profiles of resilience in mental health functioning. We considered our approach and findings in light of challenges and opportunities particularly relevant to the school context.

Health Risks and Outcomes of Homelessness in School-Age Children and Youth: A Scoping Review of the Literature

Despite reports that over 1.3 million school-age children (ages 5-18) were homeless in 2019, little is known about the effects of homelessness on their overall health and well-being. To better understand where gaps exist, a scoping review of the literature was conducted to identify studies of the physical, mental, and behavioral health risks and outcomes of school-age children experiencing homelessness or housing instability. Following the Joanna Briggs Institute framework and Preferred Reporting Items (PRISMA) guidelines, seven electronic databases were searched using key words: homelessness, children, health, and well-being. Of the 4,372 records, 23 articles met inclusion criteria. Most examined mental health and high-risk activities or behavioral risks related to school achievement. Few studies tracked the long-term health outcomes of homeless school-age children. Findings have implications for school nurses who have contact with children experiencing homelessness and are in position to intervene to prevent negative health sequelae in this vulnerable population.

Medical and Psychosocial Risk Profiles for Low Birthweight and Preterm Birth

OBJECTIVES

Low birthweight and preterm birth are risk factors for infant mortality and persistent problems. This study uses representative data to assess whether distinct latent profiles of co-occurring medical and psychosocial factors have implications for preterm birth and low birthweight.

METHODS

Data are from the Pregnancy Risk Assessment Monitoring System, a cross-sectional survey constituting representative data on pregnancies from 2012 to 2013. Latent class analysis derived classes of pregnant women potentially at risk for low birthweight and/or preterm birth.

RESULTS

Latent class analysis identified five homogenous profiles of interrelated psychosocial and medical factors. Risk was greatest for the profile marked by high rates of medical factors, followed by a high risk for a profile marked by a combination of very low income and psychosocial factors. Two profiles involving low income and very low income also indicated greater risk for adverse birth outcomes related to socioeconomic status.

CONCLUSIONS

More attention should be paid to screening for and addressing psychosocial risk in concert with prenatal care. Women who show high-risk profiles can be monitored and supported by an interdisciplinary care team, when warranted.

Housing Interventions and the Chronic and Acute Risks of Family Homelessness: Experimental Evidence for Education

This study considers risk associated with family homelessness for school functioning and experimental evidence on the effects of different housing interventions over time. Students in homeless families (N = 172; M_age  = 7.31; SD = 4.15) were randomized to housing interventions that focus on acute risks (community-based rapid rehousing), chronic risks (permanent subsidy), or usual care (UC). A matched group of low-income, housed students served as an additional reference for effects on attendance, school mobility, and reading and math achievement across 4 years. Findings partially support the chronic-risk hypothesis that family homelessness interferes with achievement through its relation to deep poverty. Children randomly assigned to UC perform as well or better than children assigned to housing interventions in this municipality.