Mental health problems of homeless women and differences across subgroups

Depressive symptoms among people living with HIV in permanent supportive housing: Findings from a community-based participatory study in Vancouver, Canada

Permanent supportive housing (PSH) is an intervention addressing housing needs among marginally housed individuals. Little is known about whether and how PSH influences depressive symptoms among people living with HIV (PLHIV). This article shares results from a community-based study that, in 2016-2017, interviewed 24 residents of a PSH facility designated for PLHIV in Vancouver, Canada. The themes of taking control; social connectedness; conviviality; and relationships and supports described how the PSH environment affected depressive symptoms among the residents.

Homelessness in pregnancy: perinatal outcomes

OBJECTIVE

Investigate the association between maternal homelessness at the time of delivery and perinatal outcomes, with a focus on neonatal health outcomes.

STUDY DESIGN

Population-based cohort using California's statewide database included 1,520,253 women with linked birth and maternal discharge data, 2008-2012. Multivariable analysis assessed homelessness at time of delivery on perinatal outcomes, preterm delivery, and neonatal intensive care unit admission.

RESULT

A total of 672 women (0.05%) were homeless at the time of delivery. Homelessness was associated with premature delivery at multiple gestational age cutoffs (34w0d-36w6d; 32w0d-33w6d; 28w0d-31w6d; <28w0d) (range of aORs:1.62-2.19), and neonatal intensive care unit admission (aOR = 1.66, 95% CI:1.31-2.09). Among term infants, homelessness remained associated with increased odds of neonatal intensive care unit admission (aOR = 1.84, 95% CI:1.34-2.53), low birthweight (aOR = 1.99, 95% CI:1.36-2.90), neonatal abstinence syndrome (aOR = 2.13, 95% CI:1.35-2.53), hypoxic-ischemic encephalopathy (aOR = 14.38, 95% CI:3.90-53.01), and necrotizing enterocolitis (aOR = 14.94, 95% CI:2.68-83.20).

CONCLUSION

Homelessness in pregnancy was associated with adverse perinatal outcomes including increased odds of preterm delivery across all gestational ages, and increased risk of neonatal intensive care unit admission and low birth weight independent of preterm delivery.

Screening Discordance and Characteristics of Patients With Housing-Related Social Risks

INTRODUCTION

Healthcare systems are increasingly interested in identifying patients' housing-related risks, but minimal information exists to inform screening question selection. The primary study aim is to evaluate discordance among 5 housing-related screening questions used in health care.

METHODS

This was a cross-sectional multisite survey of social risks used in a convenience sample of adults seeking care for themselves or their child at 7 primary care clinics and 4 emergency departments across 9 states (2018-2019). Housing-related risks were measured using 2 questions from the Accountable Health Communities screening tool (current/anticipated housing instability, current housing quality problems) and 3 from the Children's HealthWatch recommended housing instability screening measures (prior 12-month: rent/mortgage strain, number of moves, current/recent homelessness). The 2-sided Fisher's exact tests analyzed housing-related risks and participant characteristics; logistic regression explored associations with reported health (2019-2020).

RESULTS

Of 835 participants, 52% screened positive for ≥1 housing-related risk (n=430). Comparing the tools, 32.8% (n=274) screened discordant: 11.9% (n=99) screened positive by Children's HealthWatch questions but negative by Accountable Health Communities, and 21.0% (n=175) screened positive by the Accountable Health Communities tool but negative by Children's HealthWatch (p<0.001). Worse health was associated with screening positive for current/anticipated housing instability (AOR=0.56, 95% CI=0.32, 0.96) or current/recent homelessness (AOR=0.57, 95% CI=0.34, 0.96).

CONCLUSIONS

The 5 housing questions captured different housing-related risks, contributed to different health consequences, and were relevant to different subpopulations. Before implementing housing-related screening initiatives, health systems should understand how specific measures surface distinct housing-related barriers. Measure selection should depend on program goals and intervention resources.

Association of Fear and Mistrust with Stress Among Sheltered Homeless Adults and the Moderating Effects of Race and Sex

In shelter settings, homeless individuals often congregate and sleep in proximity to one another, with limited secure places for belongings: a living environment that may engender perceived vulnerability to victimization. Fear of victimization and mistrust of others in the shelter environment may result in greater stress, and racial minority residents and women may be particularly affected. Here, we aimed to examine the associations between fear, mistrust, and fear and mistrust, and stress among sheltered homeless adults, and explore moderation by race and sex. Data were from a convenience sample of adults from a homeless shelter in Dallas, TX (N = 225; 67% black; 27% women). Participants completed the fear and mistrust scale and the urban life stressors scale. Linear regressions were used to measure associations of fear, mistrust, and fear and mistrust with stress, adjusted for age, education, sex, race, history of schizophrenia/schizoaffective disorder, and discrimination. Moderation was assessed with interaction terms. Adjusted results indicated that fear, mistrust, fear and mistrust was positively associated with stress (p < 0.001). Race, but not sex, was a significant moderator of associations between fear and stress, whereby black adults with high levels of fear were more likely than white adults to experience high stress levels. Thus, although more research is needed, results suggest that interventions aimed at reducing fear of victimization may reduce stress for black adults. Given the association of stress with myriad undesirable health outcomes that can further exacerbate known health disparities, further work in this area is critical. Future research should investigate environmental sources of fear to provide further direction for interventions.

Financial hardship among individuals with serious mental illness

This study explored financial hardship, defined as difficulty in obtaining food, shelter, or medicine in the past 12 months and its personal and clinical correlates in individuals with serious mental illness (SMI) in a sample of 271 adults with SMI newly admitted to two inner city community mental health centers. The study found that 59 percent (n = 161) reported experiencing financial hardship in the past 12 months. Patients with financial hardship were more likely to be female, to experience self-stigma, to experience medical care delays, and to use emergency services. Patients who experienced financial hardship typically had more severe psychiatric symptoms, including depressive symptoms, emotional lability, and interpersonal problems. Financial hardship persisted in nearly half of those with hardship interviewed a year later. The findings highlight the role of multiple social and economic challenges that the SMI patients face in recovery from serious mental illness and the importance of awareness of such challenges by providers treating this population. Though mental health treatment may help alleviate the psychiatric symptoms it alone is not sufficient in addressing persistent hardship. These findings highlight the need for multidisciplinary interventions in order to better serve this vulnerable population.

Mental Ill Health in Homeless Women: A Review

Research indicates that homeless women are reported to experience more mental health issues than women who are not homeless and are an increasing proportion of the overall homeless population. In addition, homeless women are more likely to have alcohol and/or other drug use disorders. We provide a comprehensive review of the contemporary literature that revealed homeless women experience a range of mental health problems including depression, anxiety, post-traumatic stress disorder and alcohol and other drug use disorders. Studies in this literature review indicate that some women have pre-existing mental health issues which precipitate homelessness while others develop mental illness because of their homelessness; domestic violence was also recognised as an antecedent to homelessness, although further research is needed in this area. The results of this study indicate that the homeless cohort is a complex one with distinct needs. We provide information that can help refine assessment processes and plan appropriate services to address the mental health needs of homeless women. Finally, recommendations for mental health nursing practice in regard to caring for homeless women are made.

Family reintegration of homeless in Maputo and Matola: a descriptive study

BACKGROUND

Homelessness is a global and local social problem with underestimated prevalence. It has been shown to increase the risk of mental illness, raising concerns from mental health providers about the need for effective interventions targeting this population.

OBJECTIVES

The aim of this paper is to describe the mental health status of the homeless people in two urban setting in a low-income country, through using standardised clinical and socio-demographic assessments as well assessing potential predictors of family integration versus non-family integration among a group of homeless individuals receiving psychiatric and psychosocial treatment.

METHODS

A descriptive study was performed in Maputo and Matola cities between 2008 and 2010. Homeless people with apparent mental illness were mapped and recruited. The participants were referred from community to hospital, using a multidisciplinary treatment model, according to their clinical condition and later entered a family reintegration process.

RESULTS

Seventy-one homeless people were recruited (93.0% male; 80.3% unemployed). The most common diagnosis was schizophrenia and other psychosis (46; 64.8%), followed by mental and behaviour disorder related to substance misuse (21; 29.6%), and intellectual disability (4; 5.6%). Family reintegration was achieved for 53.5% (38 patients). Patients with intellectual disability were less reintegrated and those with disorders related to substance use had better reinsertion in their families (Chi square (2)  = 6.1; p = 0.047).

CONCLUSIONS

Family reintegration was achieved in more than half of participants after hospitalization. Integration was higher in cases of substance misuse, with those with associated intellectual disability being more difficult to reintegrate. Trial registration Trial Registration Number: NCT02936141, date of registration: 14/10/2016, retrospectively registered.

Characteristics of Mothers Caring for Children During Episodes of Homelessness

This study provides a description of the physical, psychological, and substance use problems of adult homeless women who are and are not caring for children. We also examined differences in the characteristics of these two groups of women. Interviews were conducted with 148 homeless women from three mid-sized U.S. cities, 24.3 % of whom were caring for at least one child. Our results showed that women caring for children were more likely to be sheltered and have health insurance. Homeless women caring for children and solitary homeless women were generally similar in terms of substance abuse problems. However, rates of Borderline Personality Disorder were higher among women caring for children than among solitary homeless women. Our results are somewhat consistent with previous research, with the exception of substance abuse problems and mental health problems, which were shown to be equally problematic for all women, regardless of current caregiving status.

Neurocognitive impairment in a large sample of homeless adults with mental illness

OBJECTIVE

This study examines neurocognitive functioning in a large, well-characterized sample of homeless adults with mental illness and assesses demographic and clinical factors associated with neurocognitive performance.

METHOD

A total of 1500 homeless adults with mental illness enrolled in the At Home Chez Soi study completed neuropsychological measures assessing speed of information processing, memory, and executive functioning. Sociodemographic and clinical data were also collected. Linear regression analyses were conducted to examine factors associated with neurocognitive performance.

RESULTS

Approximately half of our sample met criteria for psychosis, major depressive disorder, and alcohol or substance use disorder, and nearly half had experienced severe traumatic brain injury. Overall, 72% of participants demonstrated cognitive impairment, including deficits in processing speed (48%), verbal learning (71%) and recall (67%), and executive functioning (38%). The overall statistical model explained 19.8% of the variance in the neurocognitive summary score, with reduced neurocognitive performance associated with older age, lower education, first language other than English or French, Black or Other ethnicity, and the presence of psychosis.

CONCLUSION

Homeless adults with mental illness experience impairment in multiple neuropsychological domains. Much of the variance in our sample's cognitive performance remains unexplained, highlighting the need for further research in the mechanisms underlying cognitive impairment in this population.

Maternal depression as a risk factor for family homelessness

OBJECTIVES

We estimated the effects of maternal depression during the postpartum year, which is often an unexpected event, on subsequent homelessness and risk of homelessness in a national sample of urban, mostly low-income mothers.

METHODS

We used logistic regression models to estimate associations between maternal depression during the postpartum year and both homelessness and risk of homelessness 2 to 3 years later, controlling for maternal and family history of depression, prenatal housing problems, and other covariates. Risk factors for homelessness included experiencing evictions or frequent moves and moving in with family or friends and not paying rent.

RESULTS

We found robust associations between maternal depression during the postpartum year and subsequent homelessness and risk of homelessness, even among mothers who had no history of mental illness, whose own mothers did not have a history of depressive symptoms, and who had no previous housing problems.

CONCLUSIONS

This study provides robust evidence that maternal mental illness places families with young children at risk for homelessness, contributes to the scant literature elucidating directional and causal links between mental illness and homelessness, and contributes to a stagnant but important literature on family homelessness.

Factors associated with poor mental health status among homeless women with and without dependent children

The purpose of this study was to estimate the prevalence of mental health problems among a representative sample of homeless women with and without dependent children and determine if the effects of risk factors for mental health are modified by the presence of dependent children. Homeless women (n = 522) were recruited in 2004-2005 from shelters and meal programs in Toronto, Canada. Linear and logistic regression was performed to identify factors associated with mental health status. Poor mental health was associated with low perceived access to social support, physical/sexual assault in the past 12 months, presence of a chronic health condition, and presence of a drug use problem in the past month. Efforts to improve mental health in this population will need to address the associated problems of victimization, substance abuse, and lack of social supports.

Mental health, concurrent disorders, and health care utilization in homeless women

PURPOSE

This study assessed lifetime and current prevalence rates of mental disorders and concurrent mental and substance use disorders in a sample of homeless women. Current suicide risk and recent health service utilization were also examined in order to understand the complex mental health issues of this population and to inform the development of new treatment strategies that better meet their specific needs.

METHODS

A cross-sectional survey of 196 adult homeless women in three different Canadian cities was done. Participants were assessed using DSM-IV-based structured clinical interviews. Current diagnoses were compared to available mental health prevalence rates in the Canadian female general population.

RESULTS

Current prevalence rates were 63% for any mental disorder, excluding substance use disorders; 17% for depressive episode; 10% for manic episode; 7% for psychotic disorder; 39% for anxiety disorders, 28% for posttraumatic stress disorder; and 19% for obsessive-compulsive disorder; 58% had concurrent substance dependence and mental disorders. Lifetime prevalence rates were notably higher. Current moderate or high suicide risk was found in 22% of the women. Participants used a variety of health services, especially emergency rooms, general practitioners, and walk-in clinics.

CONCLUSION

Prevalence rates of mental disorders among homeless participants were substantially higher than among women from the general Canadian population. The percentage of participants with moderate or high suicide risk and concurrent disorders indicates a high severity of mental health symptomatology. Treatment and housing programs need to be accompanied by multidisciplinary, specialized interventions that account for high rates of complex mental health conditions.

Gender, hospitalization and mental disorders among homeless people compared with the general population in Stockholm

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.

Multidimensional social support and the health of homeless individuals

Homeless individuals often suffer from serious health problems. It has been argued that the homeless are socially isolated, with low levels of social support and social functioning, and that this lack of social resources contributes to their ill health. These observations suggest the need to further explore the relationship between social networks, social support, and health among persons who are homeless. The purpose of this study was to examine the association between multidimensional (cognitive/perceived and behavioral/received) social support and health outcomes, including physical health status, mental health status, and recent victimization, among a representative sample of homeless individuals in Toronto, Canada. Multivariate regression analyses were performed on social support and health outcome data from a subsample of 544 homeless adults, recruited from shelters and meal programs through multistage cluster sampling procedures. Results indicated that participants perceived moderately high levels of access to financial, emotional, and instrumental social support in their social networks. These types of perceived social supports were related to better physical and mental health status and lower likelihood of victimization. These findings highlight a need for more services that encourage the integration of homeless individuals into social networks and the building of specific types of social support within networks, in addition to more research into social support and other social contextual factors (e.g., social capital) and their influence on the health of homeless individuals.

A systematic review of cognitive deficits in homeless adults: implications for service delivery

OBJECTIVE

The primary goals of this systematic review were to assess studies of homeless adults and cognitive functioning, and to explore the clinical implications and potential impacts on social functioning of these cognitive deficits.

METHOD

The MEDLINE, CINAHL, EMBASE, PsycINFO, Applied Social Sciences Index and Abstracts, ERIC, Social Sciences Abstracts, Social Sciences Citation Index, Social Services Abstracts, and Sociological Abstracts databases were searched from 1970 (or their inception) to October 2007. Abstracts from 582 studies were screened and 22 studies were found to meet inclusion criteria (published in the English language, reported results of neuropsychological tests, or screening tests for cognitive dysfunction in homeless people aged 18 years or older). Two investigators independently reviewed each study and rated its quality based on well-defined criteria.

RESULTS

Ten studies were of good or fair quality. Studies that administered the Mini Mental State Examination indicate about 4% to 7% of homeless people exhibit global cognitive deficits. Focal deficits in verbal and visual memory, attention, speed of cognitive processing, and executive function were also apparent. No studies of the functional implications of cognitive deficits were found.

CONCLUSIONS

Cognitive deficits in homeless people likely have a significant mediating impact on the effectiveness of skills training and rehabilitation programs. Clinicians should be cognizant that cognitive deficits probably impair homeless patients' ability to maintain housing stability and follow treatment recommendations. Implications for housing options and health service delivery should also be considered. Research is lacking on interventions to improve cognitive functioning in the homeless.

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.

Ethnic differences in the correlates of mental distress among homeless women

BACKGROUND

Homeless women experience high rates of mental distress. We sought to determine whether ethnic differences exist in the relationship between the predisposing and enabling domains of the Gelberg-Andersen Behavioral Model for Vulnerable Populations and mental distress.

METHODS

We selected 821 homeless women in the Los Angeles area using a representative probability sampling design and invited them to participate in face-to-face interviews. The sample was 67% African American, 17% Hispanic, and 16% White.

RESULTS

We identified a number of ethnic differences in the correlates of mental distress. Being partnered or married was associated with greater distress among African American and White women, and experiencing competing needs was predictive of distress for African Americans and Hispanics.

CONCLUSION

A variety of factors contribute to mental distress among different ethnic groups of homeless women; these differences should be considered in the development of culturally appropriate services designed to address mental health problems among homeless populations.

Students’ Experience of Nursing Presence With Poor Mothers

An awareness of the health impact of poverty is core to effective nursing practice. Consequently, a clinical course for nursing students, the focus of which was the impact of poverty upon mental, physical, and spiritual health, was developed and implemented. As the students' understanding of poverty developed, they appreciated that a nurse's spirituality and nursing presence can empower poor and marginalized mothers. Nursing presence can provide a vital form of support for poor childbearing women that may reduce risk of poor birth outcomes.

Toward a more comprehensive understanding of violence against impoverished women

Research and knowledge of violence against impoverished women continues to be limited. To achieve a more comprehensive understanding of violence against impoverished women and therefore inform prevention and intervention efforts for this population, the authors report on recent (past 6 months) physical, sexual, and psychological violence among 898 women who were randomly sampled from temporary shelter settings (n = 460) and low-income housing (n = 438) in Los Angeles County. Women experienced notable rates of violence during the past 6 months (e.g., 23% of sheltered women and 9% of housed women reported physical violence). Perpetrators were diverse, particularly for the sheltered women, including sexual partners, family, and strangers. These findings, and others suggesting that the different types of violence are distinct and severe, may call for more comprehensive screening and intervention efforts to enhance the safety of impoverished women.

Unmet need for medical care among homeless adults with serious mental illness

OBJECTIVE

The objective of this study was to determine the rates and predictors of unmet medical needs among homeless adults with serious mental illness entering a community-based case management program and those of receipt of medical care in the subsequent 3-month period.

METHODS

We analyzed baseline and follow-up data for 7213 homeless clients in the multisite Access to Community Care and Effective Services and Supports program.

RESULTS

Overall, 43.6% of the sample reported having an unmet need for medical care at baseline; of these subjects, only 36.1% received medical services during the 3 months following program entry. Using multivariate logistic regression modeling, we found that, at baseline, independent correlates of an unmet medical need included lower educational level, increased depressive and psychotic symptoms and greater number of potentially competing needs. None of these variables, however, adversely affected the likelihood of receiving medical care during follow-up. Factors associated with receiving medical services in the 3 months following program entry included receiving outpatient psychiatric services and reporting stronger therapeutic alliance with one's case manager.

CONCLUSIONS

Collaborative case management may play an important role in meeting mentally ill homeless persons' medical needs. Greater efforts are needed to identify and link at-risk clients with appropriate medical services.

Physical violence against impoverished women: a longitudinal analysis of risk and protective factors

Violence represents a significant threat to the health of impoverished women. Few studies have examined what characteristics might be associated with increased risk of violence or protection from physical violence directed at such women, although this information is important in informing violence prevention and intervention efforts. This is the first study to our knowledge that has prospectively examined, in representative probability samples of impoverished women, multiple risk and protective factors to understand their relative importance to physical victimization. Study participants were 810 women in Los Angeles County, 402 in shelters and 408 in Section 8 low-income housing, who completed structured interviews at baseline and 6-month follow-up. Significant (p < .05) multivariate predictors of physical violence experienced during the 6 months prior to follow-up interview were physical or sexual violence experienced as a child, physical violence experienced during the 6 months prior to baseline interview, having multiple sexual partners, psychological distress, and poor social support. Results of this study highlight the persistence of physical violence in the lives of impoverished women and plausible, prospective risk factors for this violence. Findings also highlight opportunities to reduce women's risk of experiencing violence through enhancing women's social support and mental health.

Risk of death among homeless women: a cohort study and review of the literature

BACKGROUND

Homeless people are at high risk for illness and have higher death rates than the general population. Patterns of mortality among homeless men have been investigated, but less attention has been given to mortality rates among homeless women. We report mortality rates and causes of death in a cohort of women who used homeless shelters in Toronto. We also compare our results with those of other published studies of homeless women and with data for women in the general population.

METHODS

A cohort of 1981 women not accompanied by dependent children who used homeless shelters in Toronto in 1995 was observed for death over a mean of 2.6 years. In addition, we analyzed data from published studies of mortality rates among homeless women in 6 other cities (Montreal, Copenhagen, Boston, New York, Philadelphia and Brighton, UK).

RESULTS

In Toronto, mortality rates were 515 per 100,000 person-years among homeless women 18-44 years of age and 438 per 100,000 person-years among those 45-64 years of age. Homeless women 18-44 years of age were 10 times more likely to die than women in the general population of Toronto. In studies from a total of 7 cities, the risk of death among homeless women was greater than that among women in the general population by a factor of 4.6 to 31.2 in the younger age group and 1.0 to 2.0 in the older age group. In 6 of the 7 cities, the mortality rates among younger homeless women and younger homeless men were not significantly different. In contrast, in 4 of the 6 cities, the mortality rates were significantly lower among older homeless women than among older homeless men.

INTERPRETATION

Excess mortality is far greater among homeless women under age 45 years than among older homeless women. Mortality rates among younger homeless women often approach or equal those of younger homeless men. Efforts to reduce deaths of homeless women should focus on those under age 45.

Healthy housing: a structured review of published evaluations of US interventions to improve health by modifying housing in the United States, 1990-2001

We sought to characterize and to evaluate the success of current public health interventions related to housing. Two reviewers content-analyzed 72 articles selected from 12 electronic databases of US interventions from 1990 to 2001. Ninety-two percent of the interventions addressed a single condition, most often lead poisoning, injury, or asthma. Fifty-seven percent targeted children, and 13% targeted seniors. The most common intervention strategies employed a one-time treatment to improve the environment; to change behavior, attitudes, or knowledge; or both. Most studies reported statistically significant improvements, but few (14%) were judged extremely successful. Current interventions are limited by narrow definitions of housing and health, by brief time spans, and by limited geographic and social scales. An ecological paradigm is recommended as a guide to more effective approaches.

Determinants of receipt of ambulatory medical care in a national sample of mentally ill homeless veterans

BACKGROUND AND OBJECTIVES

This study used the Behavioral Model for Vulnerable Populations to identify determinants of receipt of outpatient medical care within 6 months of initial contact with a national homeless veterans outreach program.

RESEARCH DESIGN

Prospective study.

SUBJECTS

Homeless veterans contacted through the program in 1999 (n = 26,926).

MEASURES

Data from structured interviews conducted at the time of program intake were merged with Veterans Affairs administrative data to determine subsequent medical service use. Logistic regression modeling was used to identify predisposing, enabling, and need factors from traditional and vulnerable domains predictive of receiving medical care.

RESULTS

Overall, 41.8% of subjects received at least one medical visit in the 6 months after program intake; of these, 48.7% had three or more visits. In multivariate analyses, the likelihood of receiving medical care was, among other things, positively associated with age, female gender, and placement in residential treatment and negatively associated with duration of homelessness and being contacted through outreach versus referred or self-referred into the homeless program. Mental illness did not appear to be an additional barrier to initiating medical care; however, a diagnosis of substance abuse or schizophrenia was associated with a decreased likelihood of receiving three or more visits.

CONCLUSION

A majority of homeless veterans contacted through a national outreach program failed to receive medical services within 6 months of program entry. Vulnerable-domain factors were important supplements to traditional variables in predicting use of medical services in the homeless population. Greater efforts are needed to ensure that mentally ill homeless persons are successfully linked with and engaged in medical treatment.

Smoking characteristics of a homeless population

When addressing tobacco control and smoking cessation measures, the homeless have been perceived as a difficult to reach population. The purpose of this study was to examine the smoking characteristics of a homeless population. Data were derived from a larger study that examined smoking among inner-city residents. Homeless smokers (n = 107) were compared to nonhomeless smokers (n = 491) on sociodemographics, smoking characteristics, motivation to quit, and smoking cessation experiences. Results showed that homeless smokers were more likely to be white, smoke more cigarettes per day, initiate smoking at a younger age, and have a longer smoking history. Knowledge about the risks of smoking and the benefits of quitting was equally high in both groups. Homeless smokers were less likely to be preparing to quit smoking compared to nonhomeless smokers. These factors place homeless smokers at increased risk of tobacco-related diseases. Programs are needed to design and test effective cessation interventions for homeless smokers.

How accessible is medical care for homeless women?

BACKGROUND

Women have become a major segment of the homeless population, yet little is known about their access to health care or the relationship between access to care and vulnerability of homelessness.

OBJECTIVE

To examine homeless women's access to health care using the Expanded Behavioral Model for Vulnerable Populations.

RESEARCH DESIGN

Population-based cross-sectional study using a probability sample of homeless women.

SETTING

Seventy-eight homeless shelters and soup lines in Los Angeles County.

SUBJECTS

Nine hundred seventy-four homeless women interviewed between January and October of 1997.

OUTCOME MEASURES

Hospitalization, not for delivery, in the past 12 months; number of outpatient visits in the past 12 months; and number of preventive health screens in the past 12 months.

RESULTS

Among homeless women, those living on the streets were least likely to be hospitalized and had the fewest ambulatory visits and health screens. Multivariate analyses showed that key enabling factors associated with improved access were having: (1) health insurance, which increased the odds of being hospitalized by almost 3 times, and the number of ambulatory visits received; and (2) a regular source of care which increased the number of outpatient visits and health screens (all at P <0.01).

CONCLUSIONS

The findings from the analysis of this large representative sample of homeless women indicate that women living on the streets have especially limited access to all types of medical care. The provision of health insurance and a regular source of care may substantially improve access for this vulnerable population.

Providers of primary care to homeless women in Los Angeles County

Little is known about the access barriers homeless women face at the sites where they are most likely to receive primary health care. To investigate this issue, we administered a mail survey to administrators and clinicians at clinic sites that were actual or potential providers of primary health care to homeless women in Los Angeles County in 1997. The response rate was 65%. Ninety percent of the homeless women seen by responding sites were seen at only 34% of those sites (designated as "major providers"). Deficiencies were identified in several structural and process characteristics that enhance access to and quality of care for homeless women, including clinician training in care for homeless persons; formal screening for homeless status and associated risk factors; and on-site provision of comprehensive health services, including mental health, substance abuse, reproductive health, and ancillary services. Some, but not all, deficiencies were less severe at major providers. Our results suggest that, although providers of care to homeless women share challenges faced by many safety net providers, there are several policy interventions that could improve access to and quality of care for homeless women.

Stressors, resources, and distress among homeless persons: a longitudinal analysis

Relations among stressors, resources, and psychological distress were examined using two waves of data obtained from a probability sample of homeless persons (N = 430) residing in a large, demographically diverse county in North California. The focus of research was to examine whether and how social resources and housing resources directly affect distress and mediate the impact of stress factors on depressive symptoms. Path analysis results revealed that levels of psychological distress were responsive to change in objective housing circumstances, with the attainment of domicile status being associated with fewer distress symptoms. Our findings, however, indicated only modest effects of social resources on psychological distress through direct effects and mediating effects of life stressors on distress. Overall, the study suggests that the relationships among stressors, resources, and distress for homeless persons may be understood within the same analytical framework for the general population.

Antecedents of physical and sexual victimization among homeless women: a comparison to homeless men

Homeless women experience extensive health risks including physical and sexual victimization. Few studies that have gathered information on homeless persons have reported results separately for women or have compared them directly with men. Research that both investigates antecedents of victimization among homeless women and compares them to those for men is necessary to determine whether prevention efforts must be different for each group. We investigated potential antecedents of recent (past 30 days) physical and sexual victimization in a probability sample of 394 homeless women and compared findings to those for 1159 homeless men. As hypothesized, mental disorder, substance dependence, and engaging in economic survival strategies significantly predicted victimization among homeless women. With few dissimilarities, these characteristics also predicted victimization among homeless men. Although differences in the needs and experiences of homeless women and men must be recognized, both women and men require assistance to establish and maintain safe residences, treatment of any substance use and mental disorder, and alternatives to economic survival strategies that place them at risk for victimization.

Measurement properties of the Center for Epidemiologic Studies-Depression Scale in a homeless population

The measurement properties of the Center for Epidemiologic Studies--Depression Scale (CES-D; L. S. Radloff, 1977) were evaluated in a probability sample of homeless adults residing in a large and demographically diverse community. The findings from this investigation suggest that the CES-D is a reliable measure of depressive symptoms among homeless adults and that the factor structure of the scale replicates the factor structure found in the general population. Change in the CES-D scores was associated with change in residential status, with participants who had made a transition from homelessness to regular domicile, reporting significantly lower levels of depressive symptomatology. This result indicates the scale's sensitivity to current depressive mood, as affected by significant life events encountered by homeless persons.

The patient's diagnosis: explanatory models of mental illness

The purpose of the study was to develop a grounded theory about individuals' perception of the situation of being a psychiatric patient. Thirty-five inpatients (19 males, 16 females), ages 18 to 68, in two psychiatric units of an urban, public facility were interviewed on a biweekly basis from admission to discharge. Data were analyzed using the constant comparative method, and the data indicated that participants used the basic social process of managing self-worth to deal with the stigmatizing social predicament of being a mental patient. Events occurring before admission that shaped their responses were substance abuse, medication noncompliance, and the lack of social capital, which led to norm violations and subsequent hospitalization. Six attribution categories emerged: problem, disease, crisis, punishment, ordination, and violation. Findings support the need for professionals to improve their practice by acknowledging the effects of patients' subjective assessments on their response to hospitalization and by placing more emphasis on assisting patients to deal with the stigmatizing effects of a psychiatric diagnosis.

Homeless youths and young adults in Los Angeles: prevalence of mental health problems and the relationship between mental health and substance abuse disorders

Although understanding of the subsistence patterns, service utilization, and HIV-risk behaviors of homeless youths and young adults in increasing, relatively little is known about the epidemiology of mental health problems in this group or the relationships between mental health problems and substance use. This study measured symptoms of depression, low self-esteem, ADHD, suicidality, self-injurious behavior (SIB), and drug and alcohol use disorder in a sample of homeless youth and young adults living in Hollywood, CA. Results indicated extremely high prevalences of mental health problems as compared with corresponding rates of mental health problems found among housed youths in previous studies. Prevalence of mental health problems differed by age and ethnicity. African Americans were at lower risk of suicidal thoughts and SIB than were those of other ethnicities. Older respondents and females were at increased risk of depressive symptoms, and younger respondents were at increased risk of SIB. Previous history of sexual abuse and/or assault was associated with increased risk of suicidality and SIB. Risk factors for drug abuse disorders included ethnicity other than African American, homelessness for 1 year or more, suicidality, SIB, depressive symptoms, and low self-esteem. Risk factors for alcohol abuse disorder included male gender, white ethnicity, homelessness for 1 year or more, suicidality, and SIB. Extremely high rates of mental health problems and substance abuse disorders in this sample suggest the need for street-based and nontraditional mental health services targeted toward these youths and young adults.

Drug use disorders and treatment contact among homeless adults in Alameda County, California

OBJECTIVES

This study estimates the extent and distribution of specific drug problems among homeless adults.

METHODS

A countywide probability sample of 564 homeless adults received structured interviews that included a standardized assessment of substance use disorders.

RESULTS

Two thirds of the sample (69.1%) had a lifetime history of a substance use disorder (including abuse of or dependence on alcohol [52.6%] or drugs [52.2%]); half had a current (52.4%) substance use disorder (including alcohol [38.8%] or drugs [31.3%]). Current drug disorders were higher among respondents who were younger, homeless longer, or sampled from the city of Oakland, Calif. Alcohol use disorders were higher among men than among women; surprisingly, drug use disorders were not.

CONCLUSION

Rates of current drug use disorders for homeless adults were more than eight times higher than general population estimates. However, estimates of drug problems among homeless adults vary as a function of case ascertainment and sampling strategy. Estimates based only on samples from urban areas may overestimate drug problems among the area's larger homeless populations.