Homeless people's trust and interactions with police and paramedics

RREACT: A mobile multidisciplinary response to overdose

Opioid overdose is a leading cause of death in the United States, and engaging with patients following overdose to provide harm reduction and recovery resources can prove difficult. Quick response models use mobile, multidisciplinary teams to establish a time-sensitive connection between individuals who overdosed and harm reduction and recovery resources that improve outcomes. These quick response models are consistent with the broader field of mobile-integrated health programs that are growing in number and acceptability, though the literature base is sparse and programs vary. We describe the 5-year reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework of the Rapid Response Emergency Addiction and Crisis Team (RREACT), a fire/emergency medical services-led, multidisciplinary (firefighter/paramedic, law enforcement officer, social worker) mobile outreach team. RREACT provides harm reduction, linkage/transportation to care and wrap-around services to individuals following a nonfatal opioid overdose that resulted in an emergency response in Columbus, Franklin County, Ohio, United States. Between 2018 and 2022, RREACT made 22,157 outreach attempts to 11,739 unique patients. RREACT recorded 3,194 direct patient contacts during this time, resulting in 1,200 linkages to care: 799 direct transports to opioid use disorder treatment and 401 warm handoffs to community treatment agencies. Furthermore, RREACT's staffing increased from 4 full-time equivalent staff in 2018 to 15.5 in 2022 and was supported by the surrounding community through 287 community outreach events and the development of an alumni program. These preliminary results further support the deployment of multidisciplinary mobile outreach teams to increase access to harm reduction and recovery resources following opioid overdose.

Suicide, Homicide, and Other Violent Deaths Among People Experiencing Homelessness in the United States: A Cross-sectional Study

OBJECTIVES

Limited information exists about violent deaths among people experiencing homelessness (PEH) across the United States. Using data from a national reporting system, we describe characteristics of suicides, homicides, and other deaths classified as violent among PEH in the United States.

METHODS

We obtained data on demographic characteristics, mechanisms of injury, and circumstances surrounding violent deaths from January 1, 2016, through December 31, 2018, in 31 states from the National Violent Death Reporting System.

RESULTS

Of 122 113 violent deaths in 31 states during 2016-2018, 1757 (1.4%) occurred among PEH and 3952 (3.2%) occurred among people for whom homelessness status was unknown or missing. Of all violent deaths among PEH, 878 were suicides (1.1% of all suicides), 458 were homicides (1.6% of all homicides), 352 were of undetermined intent (2.8% of all deaths of undetermined intent), and 59 were the result of legal interventions (3.8% of all deaths due to legal interventions). Hanging/suffocation/strangulation was the most common mechanism of suicide among PEH (44.4%), followed by deaths due to firearms (21.6%). Firearms were the most common mechanism of homicide deaths among PEH (48.0%). Black PEH were more likely to die by homicide than by suicide, and White PEH were more likely to die by suicide than by homicide. Among the 843 suicide victims for whom additional information was known, 345 (40.9%) had a history of suicidal thoughts or plans, 245 (29.1%) had disclosed intent to die by suicide, and 183 (21.7%) were receiving treatment for a mental health condition.

CONCLUSIONS

Efforts to reduce mortality and improve health outcomes among PEH should consider the high rates of violent deaths in this population.

Leveraging research to inform prevention and intervention efforts: Identifying risk and protective factors for rural and urban homeless families within transitional housing programs

This mixed method study spotlights hardships and supportive factors for unhoused families led by single mothers who have successfully graduated from two transitional housing programs, one rural and one urban. Data collection consisted of entry and exit surveys (n = 241) as well as qualitative interviews (n = 11). Binary logistic regression results indicated education and social support as significant predictors of successful program completion. Qualitative findings further illustrate narratives surrounding supportive factors and program supports (i.e., assistance securing employment, education courses, sense of community), as well as policy implications. Implications stress the need for enhancing supportive factors (i.e., education and social capital) in early prevention efforts (e.g., schools and community centers), as well as an intentional integration of addressing socio-emotional needs and resources within housing programs and services unique to rural and urban communities.

Engaging unhoused community members in the design of an alternative first responder program aimed at reducing the criminalization of homelessness

Police are often called to address concerns about people experiencing homelessness, with arrests often resulting from low-level, nonviolent crimes, and violations of minor nuisance ordinances. In Portland, Oregon, advocates lobbied for a new model of emergency response for 911 calls involving unhoused community members and people experiencing behavioral health crises. To ensure the program reflected the needs and perspectives of people experiencing homelessness, teams of researchers, community volunteers, and people with lived experience interviewed 184 people in camps, shelters, and parks. Teams asked unhoused people how the program should be designed, including who the first responders should be, how they should approach individuals in crisis, what resources they should provide, and how they should be trained. This article describes the methods, findings, and recommendations from our collaborative survey process aimed at ensuring that the voices of people experiencing homelessness informed the development of the Portland Street Response pilot program.

Persistent Homelessness and Violent Victimization Among Older Adults in the HOPE HOME Study

The homeless population is aging; older homeless adults may be at high risk of experiencing violent victimization. To examine whether homelessness is independently associated with experiencing physical and sexual abuse, we recruited 350 adults, aged 50 and older in Oakland, California, who met criteria for homelessness between July 2013 and June 2014. We interviewed participants at 6-month intervals for 3 years in Oakland about key variables, including housing status. Using generalized estimating equations, we examined whether persistent homelessness in each follow-up period was independently associated with having experienced physical or sexual victimization, after adjusting for known risk factors. The majority of the cohort was men (77.4%) and Black American (79.7%). At baseline, 10.6% had experienced either physical or sexual victimization in the prior 6 months. At 18-month follow-up, 42% of the cohort remained homeless. In adjusted models, persistent homelessness was associated with twice the odds of victimization (adjusted odds ratio [AOR] = 2.01; 95% confidence interval [CI]: [1.41, 2.87]). Older homeless adults experience high rates of victimization. Re-entering housing reduces this risk. Policymakers should recognize exposure to victimization as a negative consequence of homelessness that may be preventable by housing.

Impact of a Brief Educational Intervention on Knowledge, Perceived Knowledge, Perceived Safety, and Resilience of the Public During COVID-19 Crisis

Extraordinary and unprecedented public health measures have been implemented to contain the ongoing spread of the coronavirus disease 2019 (COVID-19) pandemic. There is paramount importance of cooperation and population engagement in reducing disease infection rates and relieving an outbreak’s burden on society. The civil society’s engagement may be achieved through disaster education interventions. In this cross-sectional study, a pre-post questionnaire was used to investigate the impact of a brief educational intervention on knowledge, perceived knowledge, perceived safety, and the individual resilience of the population relating to the COVID-19 outbreak. The results of the study display the benefits of the educational intervention to include a significant overall increase in all examined variables. The study also reviewed the overall trust of the public concerning the main responding authorities, as well as practices concerning protective measures for COVID-19. This study demonstrates that educational interventions, such as the brief video, provide an easily implementable design and effective means for educating and empowering the public and should, thus, be considered as a component of future outbreak responses.

Policies and procedures for patient transfers from community clinics to emergency departments under the mental health act: Review and policy scan

OBJECTIVE

The objective of this commentary is to summarize the few findings from the scientific literature pertaining to humane mental health transfer practices in the province of Ontario as well as the broader Canadian and international context. These findings are juxtaposed with a policing policy scan concerning the Ontario and Canadian contexts. The practice of default restraint use during transfers is surprisingly widespread practice, despite advocacy to the contrary, and is presented as the consequence of stigma and the lack of codified restriction of restraint use by police in their policy guidelines.

METHODS

(1) Literature search to discover relevant articles which were summarized using narrative review due to the lack of high-quality studies available in this area, and (2) Scan of publicly available policy documents in use by Ontario police agencies in March and April of 2018, as well as contacting several police agencies and community resources to review policies and procedures.

RESULTS

We review the available evidence on the use and impact of restraints in patient transfer to emergency departments from police settings, highlight police practices in four Ontario jurisdictions, and summarize recommendations from police and mental health advocates regarding mental health transfers.

DISCUSSION

Synthesizing the available evidence, policies, and procedures, we illustrate that the Ontario-wide variability in both who transfers PMI on a Form 1 to hospital and whether restraints are utilized reflect systemic failures to utilize least restrictive means of transfer. We offer a look at future areas of research and advocacy to improve practices in Canada.

Ethical conflicts in patient relationships: Experiences of ambulance nursing students

Background

Working as an ambulance nurse involves facing ethically problematic situations with multi-dimensional suffering, requiring the ability to create a trustful relationship. This entails a need to be clinically trained in order to identify ethical conflicts.

Aim

To describe ethical conflicts in patient relationships as experienced by ambulance nursing students during clinical studies.

Research design

An exploratory and interpretative design was used to inductively analyse textual data from examinations in clinical placement courses.

Participants

The 69 participants attended a 1-year educational programme for ambulance nurses at a Swedish university.

Ethical considerations

The research was conducted in accordance with the Declaration of Helsinki. Participants gave voluntary informed consent for this study.

Findings

The students encountered ethical conflicts in patient relationships when they had inadequate access to the patient’s narrative. Doubts regarding patient autonomy were due to uncertainty regarding the patient’s decision-making ability, which forced students to handle patient autonomy. Conflicting assessments of the patient’s best interest added to the conflicts and also meant a disruption in patient focus. The absence of trustful relationships reinforced the ethical conflicts, together with an inadequacy in meeting different needs, which limited the possibility of providing proper care.

Discussion

Contextual circumstances add complexity to ethical conflicts regarding patient autonomy, dependency and the patient’s best interest. Students felt they were fluctuating between paternalism and letting the patient choose, and were challenged by considerations regarding the patient’s communication and decision-making ability, the views of third parties, and the need for prioritisation.

Conclusion

The essence of the patient relationship is a struggle to preserve autonomy while focusing on the patient’s best interest. Hence, there is a need for education and training that promotes ethical knowledge and ethical reflection focusing on the core nursing and caring values of trust and autonomy, particularly in situations that affect the patient’s decision-making ability.

Interactions between Police and Persons Who Experience Homelessness and Mental Illness in Toronto, Canada: Findings from a Prospective Study

OBJECTIVE

We aimed to describe interactions between police and persons who experience homelessness and serious mental illness and explore whether housing status is associated with police interactions.

METHOD

We conducted a secondary analysis of 2008 to 2013 data from the Toronto, Canada, site of the At Home/Chez Soi study. Using police administrative data, we calculated the number and types of police interactions, the proportion of charges for acts of living and administration of justice, and the proportion of occurrences due to victimization, involuntary psychiatric assessment, and suicidal behavior. Using generalized estimating equations, we estimated the odds of police interaction by housing status.

RESULTS

This study included 547 adults with mental illness who were homeless at baseline. In the year prior to randomization, 55.8% of participants interacted with police, while 51.7% and 43.0% interacted with police in Study Years 1 and 2, respectively. Of 2,228 charges against participants, 12.6% were due to acts of living and 21.2% were for administration of justice. Of 518 occurrences, 41.1% were for victimization, 45.6% were for mental health assessment, and 22.2% were for suicidal behavior. The odds of any police interaction during the past 90 days was 47% higher for those who were homeless compared to those who were stably housed (95% CI 1.26 to 1.73).

CONCLUSIONS

For people who experience homelessness and mental illness in Toronto, Canada, interactions with police are common. The provision of stable housing and changes in policy and practice could decrease harms and increase health benefits associated with police interactions for this population.

Why are some people who have received overdose education and naloxone reticent to call Emergency Medical Services in the event of overdose?

BACKGROUND

Overdose Education and Naloxone Distribution (OEND) training for persons who inject drugs (PWID) underlines the importance of summoning emergency medical services (EMS). To encourage PWID to do so, Colorado enacted a Good Samaritan law providing limited immunity from prosecution for possession of a controlled substance and/or drug paraphernalia to the overdose victim and the witnesses who in good faith provide emergency assistance. This paper examines the law's influence by describing OEND trained PWIDs' experience reversing overdoses and their decision about calling for EMS support.

METHODS

Findings from two complementary studies, a qualitative study based on semi-structured interviews with OEND trained PWID who had reversed one or more overdoses, and an on-going fieldwork-based project examining PWIDs' self-identified health concerns were triangulated to describe and explain participants' decision to call for EMS.

RESULTS

In most overdose reversals described, no EMS call was made. Participants reported several reasons for not doing so. Most frequent was the fear that despite the Good Samaritan law, a police response would result in arrest of the victim and/or witness for outstanding warrants, or sentence violations. Fears were based on individual and collective experience, and reinforced by the city of Denver's aggressive approach to managing homelessness through increased enforcement of misdemeanors and the imposition of more recent ordinances, including a camping ban, to control space. The city's homeless crisis was reflected as well in the concern expressed by housed PWID that an EMS intervention would jeopardize their public housing.

CONCLUSION

Results suggest that the immunity provided by the Good Samaritan law does not address PWIDs' fear that their current legal status as well as the victim's will result in arrest and incarceration. As currently conceived, the Good Samaritan law does not provide immunity for PWIDs' already enmeshed in the criminal justice system, or PWID fearful of losing their housing.

Predictors of criminal justice system trajectories of homeless adults living with mental illness

OBJECTIVES

This study examines whether baseline profiles of criminal justice involvement are independently associated with 24-month trajectories of arrests in a sample of homeless adults living with mental illness.

METHODS

Interviews with justice-involved participants from the At Home/Chez soi project, a multisite trial of Housing First in Canada, yielded information related to arrests, as well as demographic, clinical, and contextual predictors of criminal justice system involvement. All potential predictors were entered into logistic and negative binomial regression models to assess their effect on re-arrest.

RESULTS

Of the 584 individuals involved with the criminal justice system at baseline, and for whom follow-up data was obtained, 347 (59%) were re-arrested within two years. Of those, 283 (82%) had an episodic pattern of re-arrest and 64 (18%) had a continuous trajectory of re-arrest. Results indicate that participants involved with the legal system for minor (mostly theft and public order) offenses at baseline were most likely to be repeatedly arrested. Gender, Aboriginal status, and recent victimization were also independently associated with re-arrest.

CONCLUSIONS

These findings have implications for the delivery of police and clinical services alike, as well as for policies that aim to divert vulnerable individuals who commit minor crimes from a long-term trajectory of justice involvement.

Protecting Urban Health and Safety: Balancing Care and Harm in the Era of Mass Incarceration

This paper explores theoretical, spatial, and mediatized pathways through which policing poses harms to the health of marginalized communities in the urban USA, including analysis of two recent and widely publicized incidents of officer-involved killings in Ferguson, Missouri and Staten Island, New York. We examine the influence of the "broken windows" model in both policing and public health, revealing alternate institutional strategies for responding to urban disorder in the interests of the health and safety of the city. Drawing on ecosocial theory and medical anthropology, we consider the roles of the segregated built environment and historical experience in the embodiment of structural vulnerability with respect to police violence. We examine the recent shootings of Eric Garner and Michael Brown as the most visible, most circulated symbols of this complex and contradictory terrain, focusing on the pathways through which theories of causality authorize violent and/or caring intervention by the state. We show how police killings reveal an underlying and racialized association between disorder and deviance that becomes institutionalized and embodied through spatial and symbolic pathways. If public health workers and advocates are to play a role in responding to the call of the Black Lives Matter movement, it is important to understand the interpretations and translations of urban social life that circulate on the streets, in the media, in public policy, and in institutional practice.

Police use of handcuffs in the homeless population leads to long-term negative attitudes within this group

The police interact with homeless individuals frequently. However, there has been relatively little research on the attitudes of homeless individuals towards the police, and how police interactions may impact these. This is important since the attitudes of homeless individuals can impact how often they report crimes, and how well they support police when they are investigating crimes in this population. We interviewed 213 homeless individuals in a single city, representing approximately 10% of the total homeless population. They were interviewed at either homeless shelters, or events held specifically for the homeless population. Of these individuals, 75% were male, and 47% had interacted with a police officer within the past month. Self-reports suggested that 60% had a drug and/or alcohol issue and 78% had a mental illness. We found a highly statistically significant difference between the group that had been handcuffed and/or arrested compared to those that had not. This was across multiple domains and included how the individual regarded the police in terms of their empathy and communication skills, and how much they trusted the police. These changes were long-term, and if a homeless individual had been arrested or handcuffed (and verbal reporting suggested that being handcuffed was the by far the most important factor) then these negative attitudes lasted at least 2 years. The primary conclusion from this study is that when police handcuff a homeless individual, this can lead to long-term negative views about the police across several domains that appear to be long lasting, and were linked to feelings of not being respected by the police. It is therefore proposed that police officers should be made aware of the potential long-term negative consequences of this single action, and that police forces should consider providing specific training to minimize any unnecessary overuse of handcuffs.

Exploring the experiences of violence among individuals who are homeless using a consumer-led approach

Homelessness increases vulnerability to violence victimization; however, the precise factors associated with victimization and injury are not clearly understood. Thus, this study explores the prevalence of and characteristics associated with violence victimization among homeless individuals by surveying approximately 500 individuals experiencing homelessness in 5 cities across the United States. Our findings reveal that nearly one-half of our sample reported experiencing violence and that prolonged duration of homelessness (greater than 2 years) and being older increased the risk of experiencing a violent attack. In addition, increased length of homelessness and female gender predicted experiencing rape. Women were also significantly more likely to know one's perpetrator and experience continued suffering after a violent attack. We conclude that certain subpopulations within the homeless population are at an increased risk for victimization and, subsequently, require added protective services; implications for health care and policy recommendations are also discussed.

Global health ethics for students

As a result of increased interest in global health, more and more medical students and trainees from the 'developed world' are working and studying in the 'developing world'. However, while opportunities to do this important work increase, there has been insufficient development of ethical guidelines for students. It is often assumed that ethics training in developed world situations is applicable to health experiences globally. However, fundamental differences in both clinical and research settings necessitate an alternative paradigm of analysis. This article is intended for teachers who are responsible for preparing students prior to such experiences. A review of major ethical issues is presented, how they pertain to students, and a framework is outlined to help guide students in their work.

The effect of traumatic brain injury on the health of homeless people

BACKGROUND

We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario.

METHODS

We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004-2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions.

RESULTS

The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (-8.3 points, 95% CI -11.1 to -5.5) and poorer mental health status (-6.0 points, 95% CI -8.3 to -3.7).

INTERPRETATION

Prior traumatic brain injury is very common among homeless people and is associated with poorer health.