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Park S, Kim S, Kim HK, Tabarsi E, Hom B, Gallagher S, Ugarte C, Clark D, Schellenberg M, Martin M, Inaba K, Matsushima K. Unhoused and Injured: Injury Characteristics and Outcomes in Unhoused Trauma Patients. J Surg Res 2024; 301:365-370. [PMID: 39029258 DOI: 10.1016/j.jss.2024.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/27/2024] [Accepted: 06/24/2024] [Indexed: 07/21/2024]
Abstract
INTRODUCTION The unhoused population is known to be at high risk for traumatic injury. However, there are scarce data regarding injury patterns and outcomes for this patient group. This study aims to investigate any differences in injury characteristics and hospital outcomes between unhoused and housed patients presenting with traumatic injuries. METHODS We conducted a 3-y retrospective cohort study at a level 1 trauma center in a metropolitan area with a large unhoused population. All adult trauma patients who were identified as unhoused or housed underinsured (HUI) were included in the study. Injury characteristics, comorbidities, and hospital outcomes were compared between the two groups. RESULTS A total of 8450 patients were identified, of which 7.5% were unhoused. Compared to HUI patients, unhoused patients were more likely to sustain minor injuries (65.2% versus 59.1%, P = 0.003) and more likely to be injured by assault (17.9% versus 12.4%, P < 0.001), stab wound (17.7% versus 10.8%, P < 0.001), and automobile versus pedestrian or bike (21.0% versus 15.8% P < 0.001). We found that unhoused patients had higher odds of mortality (adjusted odds ratio [AOR]: 1.93, 95% confidence interval [CI]: 1.10-3.36, P = 0.021), brain death (AOR: 5.40, 95% CI: 2.11-13.83, P < 0.001), bacteremia/sepsis (AOR: 4.36, 95% CI: 1.20-15.81, P = 0.025), and increased hospital length of stay (regression coefficient: 0.08, 95% CI: 0.03-0.12, P = 0.003). CONCLUSIONS This study observed significant disparities in injury characteristics and hospital outcomes between the unhoused and HUI groups. Our results suggest that these disparities are impacted by social determinants of health unique to the unhoused population.
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Affiliation(s)
- Stephen Park
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Sean Kim
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Hye Kwang Kim
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Emiliano Tabarsi
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Brian Hom
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Shea Gallagher
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Chaiss Ugarte
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Damon Clark
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Matthew Martin
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Kenji Inaba
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, California.
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Bennett N, Chung JS, Lundstern MS, Bymaster A. Traumatic Brain Injury and Its Risk Factors in a Homeless Population. Arch Phys Med Rehabil 2024:S0003-9993(24)01166-3. [PMID: 39134235 DOI: 10.1016/j.apmr.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 09/08/2024]
Abstract
OBJECTIVE To characterize the traumatic brain injury (TBI) profile and its associated risk factors in homeless individuals in Santa Clara County, CA. DESIGN Observational cohort study. SETTING Two homeless shelter health clinics in Santa Clara County, CA. PARTICIPANTS Currently or recently homeless individuals seeking health care at 2 homeless shelter health clinics between August 2013 and May 2014. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Demographics, TBI incidence and characteristics. RESULTS The findings indicate that TBI history in the homeless population was higher (79.7%) than in the general population (12%). Almost half of the population (49.2%) reported that their TBI occurred before the age of 18. Of the participants, 68.2% reported sustaining a TBI with loss of consciousness. TBI caused by violence (60%) was lower in this cohort than other homeless cohorts but was the main cause of injury regardless of age. Alcoholism was a risk factor for having more TBIs. No differences in TBI profile were found between sexes. CONCLUSIONS Our findings underscore the need for more research on the lifetime risk factors associated with TBI to prevent and reduce the number of brain injuries in homeless populations.
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Affiliation(s)
- Naomi Bennett
- Rehabilitation Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA
| | - Joyce S Chung
- Rehabilitation Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA.
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Eshun E, Burke O, Do F, Maciver A, Mathur A, Mayne C, Mohamed Jemseed AA, Novak L, Siddique A, Smith E, Tapia-Stocker D, FitzGerald A. Exploring the Role of Rehabilitation Medicine within an Inclusion Health Context: Examining a Population at Risk from Homelessness and Brain Injury in Edinburgh. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:769. [PMID: 38929015 PMCID: PMC11203637 DOI: 10.3390/ijerph21060769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
People experiencing homelessness are at risk from a number of comorbidities, including traumatic brain injury, mental health disorders, and various infections. Little is known about the rehabilitation needs of this population. This study took advantage of unique access to a specialist access GP practice for people experiencing homelessness and a local inclusion health initiative to explore the five-year period prevalence of these conditions in a population of people experiencing homelessness through electronic case record searches and to identify barriers and facilitators to healthcare provision for this population in the context of an interdisciplinary and multispecialist inclusion health team through semi-structured interviews with staff working in primary and secondary care who interact with this population. The five-year period prevalence of TBI, infections, and mental health disorders was 9.5%, 4%, and 22.8%, respectively. Of those who had suffered a brain injury, only three had accessed rehabilitation services. Themes from thematic analysis of interviews included the impact of psychological trauma, under-recognition of the needs of people experiencing homelessness, resource scarcity, and the need for collaborative and adaptive approaches. The combination of quantitative and qualitative data suggests a potential role for rehabilitation medicine in inclusion health initiatives.
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Affiliation(s)
- Edwin Eshun
- Department of Rehabilitation Medicine, Astley Ainslie Hospital, NHS Lothian, 133 Grange Loan, Edinburgh EH9 2HL, UK;
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Orla Burke
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Florence Do
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Angus Maciver
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Anushka Mathur
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Cassie Mayne
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Aashik Ahamed Mohamed Jemseed
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Levente Novak
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Anna Siddique
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Eve Smith
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - David Tapia-Stocker
- Edinburgh Medical School, College of Medicine & Veterinary Medicine, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK (A.A.M.J.)
| | - Alasdair FitzGerald
- Department of Rehabilitation Medicine, Astley Ainslie Hospital, NHS Lothian, 133 Grange Loan, Edinburgh EH9 2HL, UK;
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Rapaport P, Kidd G, Jeraldo RE, Mason A, Knapp M, Manthorpe J, Shulman C, Livingston G. A qualitative exploration of older people's lived experiences of homelessness and memory problems - stakeholder perspectives. BMC Geriatr 2023; 23:556. [PMID: 37700235 PMCID: PMC10498566 DOI: 10.1186/s12877-023-04250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/23/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND The numbers of older people experiencing both homelessness and memory problems are growing, yet their complex health, housing and care needs remain undelineated and unmet. There is a critical gap in understanding what can improve the care, support and experiences of this group. In this qualitative study we explore how stakeholders understand memory problems among older people in the context of homelessness and consider what they judge gets in the way of achieving positive outcomes. METHOD We conducted reflexive thematic analysis of qualitative interviews (n = 49) using a semi-structured topic guide, with 17 older people (aged ≥ 50 years) experiencing memory problems and homelessness, 15 hostel staff and managers, and 17 health, housing and social care practitioners. We recruited participants from six homelessness hostels, one specialist care home and National Health and Local Authority Services in England. RESULTS We identified four overarching themes. The population is not taken seriously; multiple causes are hard to disentangle; risk of exploitation and vulnerability; and (dis)connection and social isolation. The transience and lack of stability associated with homelessness intensified the disorienting nature of memory and cognitive impairment, and those providing direct and indirect support required flexibility and persistence, with staff moving beyond traditional roles to advocate, provide care and safeguard individuals. Memory problems were perceived by frontline staff and older people to be overlooked, misinterpreted, and misattributed as being caused by alcohol use, resulting in pervasive barriers to achieving positive and desired outcomes. CONCLUSIONS Efforts to meet the needs of older people living with memory problems and experiencing homelessness and future interventions must reflect the complexity of their lives, often in the context of long-term alcohol use and current service provision and we make suggestions as to what could be done to improve the situation.
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Affiliation(s)
- Penny Rapaport
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK.
| | - Garrett Kidd
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Rosario Espinoza Jeraldo
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Ava Mason
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, King's College London, London, UK
- NIHR Applied Research Collaboration (ARC) South London, London, UK
| | - Caroline Shulman
- Pathway, London, UK
- Healthy London Partnership, London, UK
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, London, UK
| | - Gill Livingston
- UCL Department of Mental Health of Older People, Division of Psychiatry, Wing B, Floor 6 Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
- Camden and Islington NHS Foundation Trust, London, UK
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Chan V, Estrella MJ, Hanafy S, Colclough Z, Joyce JM, Babineau J, Colantonio A. Equity considerations in clinical practice guidelines for traumatic brain injury and homelessness: a systematic review. EClinicalMedicine 2023; 63:102152. [PMID: 37662521 PMCID: PMC10474365 DOI: 10.1016/j.eclinm.2023.102152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 09/05/2023] Open
Abstract
Background Clinical practice guidelines (CPGs) predominantly prioritise treatment and cost-effectiveness, which encourages a universal approach that may not address the circumstances of disadvantaged groups. We aimed to advance equity and quality of care for individuals experiencing homelessness and traumatic brain injury (TBI) by assessing the extent to which homelessness and TBI are integrated in CPGs for TBI and CPGs for homelessness, respectively, and the extent to which equity, including consideration of disadvantaged populations and the PROGRESS-Plus framework, is considered in these CPGs. Methods For this systematic review, CPGs for TBI or homelessness were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs on November 16, 2021 and March 16, 2023. The proportion of CPGs that integrated evidence regarding TBI and homelessness was identified and qualitative content analysis was conducted to understand how homelessness is integrated in CPGs for TBI and vice versa. Equity assessment tools were utilised to understand the extent to which equity was considered in these CPGs. This review is registered with PROSPERO (CRD42021287696). Findings Fifty-eight CPGs for TBI and two CPGs for homelessness met inclusion criteria. Only three CPGs for TBI integrated evidence regarding homelessness by recognizing the prevalence of TBI in individuals experiencing homelessness and identifying housing as a consideration in the assessment and management of TBI. The two CPGs for homelessness acknowledged TBI as prevalent and recognised individuals experiencing TBI and homelessness as a disadvantaged population that should be prioritised in guideline development. Equity was rarely considered in the content and development of CPGs for TBI. Interpretation Considerations for equity in CPGs for homelessness and TBI are lacking. To ensure that CPGs reflect and address the needs of individuals experiencing homelessness and TBI, we have identified several guideline development priorities. Namely, there is a need to integrate evidence regarding homelessness and TBI in CPGs for TBI and CPGs for homelessness, respectively and engage disadvantaged populations in all stages of guideline development. Further, this review highlights an urgent need to conduct research focused on and with disadvantaged populations. Funding Canada Research Chairs Program (2019-00019) and the Ontario Ministry of Health and Long-Term Care (Grant #725A).
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Affiliation(s)
- Vincy Chan
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Maria Jennifer Estrella
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Sara Hanafy
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Zoe Colclough
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Julie Michele Joyce
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
| | - Jessica Babineau
- Library and Information Services, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
| | - Angela Colantonio
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
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Silver CM, Thomas AC, Reddy S, Sullivan GA, Plevin RE, Kanzaria HK, Stey AM. Injury Patterns and Hospital Admission After Trauma Among People Experiencing Homelessness. JAMA Netw Open 2023; 6:e2320862. [PMID: 37382955 PMCID: PMC10311388 DOI: 10.1001/jamanetworkopen.2023.20862] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/15/2023] [Indexed: 06/30/2023] Open
Abstract
Importance Traumatic injury is a major cause of morbidity for people experiencing homelessness (PEH). However, injury patterns and subsequent hospitalization among PEH have not been studied on a national scale. Objective To evaluate whether differences in mechanisms of injury exist between PEH and housed trauma patients in North America and whether the lack of housing is associated with increased adjusted odds of hospital admission. Design, Setting, and Participants This was a retrospective observational cohort study of participants in the 2017 to 2018 American College of Surgeons' Trauma Quality Improvement Program. Hospitals across the US and Canada were queried. Participants were patients aged 18 years or older presenting to an emergency department after injury. Data were analyzed from December 2021 to November 2022. Exposures PEH were identified using the Trauma Quality Improvement Program's alternate home residence variable. Main Outcomes and Measures The primary outcome was hospital admission. Subgroup analysis was used to compared PEH with low-income housed patients (defined by Medicaid enrollment). Results A total of 1 738 992 patients (mean [SD] age, 53.6 [21.2] years; 712 120 [41.0%] female; 97 910 [5.9%] Hispanic, 227 638 [13.7%] non-Hispanic Black, and 1 157 950 [69.6%] non-Hispanic White) presented to 790 hospitals with trauma, including 12 266 PEH (0.7%) and 1 726 726 housed patients (99.3%). Compared with housed patients, PEH were younger (mean [SD] age, 45.2 [13.6] years vs 53.7 [21.3] years), more often male (10 343 patients [84.3%] vs 1 016 310 patients [58.9%]), and had higher rates of behavioral comorbidity (2884 patients [23.5%] vs 191 425 patients [11.1%]). PEH sustained different injury patterns, including higher proportions of injuries due to assault (4417 patients [36.0%] vs 165 666 patients [9.6%]), pedestrian-strike (1891 patients [15.4%] vs 55 533 patients [3.2%]), and head injury (8041 patients [65.6%] vs 851 823 patients [49.3%]), compared with housed patients. On multivariable analysis, PEH experienced increased adjusted odds of hospitalization (adjusted odds ratio [aOR], 1.33; 95% CI, 1.24-1.43) compared with housed patients. The association of lacking housing with hospital admission persisted on subgroup comparison of PEH with low-income housed patients (aOR, 1.10; 95% CI, 1.03-1.19). Conclusions and Relevance Injured PEH had significantly greater adjusted odds of hospital admission. These findings suggest that tailored programs for PEH are needed to prevent their injury patterns and facilitate safe discharge after injury.
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Affiliation(s)
- Casey M. Silver
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Arielle C. Thomas
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Susheel Reddy
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Hemal K. Kanzaria
- Department of Emergency Medicine, University of California, San Francisco
| | - Anne M. Stey
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Barboza-Salerno GE, Kosloski A, Weir H, Thompson D, Bukreyev A. A Network Analysis of the Relationship Between Mental and Physical Health in Unsheltered Homeless Persons in Los Angeles County. JOURNAL OF INTERPERSONAL VIOLENCE 2023; 38:5902-5936. [PMID: 36300615 DOI: 10.1177/08862605221127222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Homelessness is a public health crisis both nationally, in the United States, and internationally. Nevertheless, due to the hidden vulnerabilities of persons who are without shelter, little is known about their experiences during periods of homelessness. The present research adopts a network approach that conceptualizes how the major risk factors of homelessness interact, namely substance abuse problems, poor mental health, disability, and exposure to physical or sexual violence by an intimate partner. Our analysis draws on a large demographic survey of over 5,000 unsheltered homeless persons conducted in 2017 by the Los Angeles Homeless Services Authority. We estimated a network structure for 12 survey items tapping individual risk using the graphical least absolute shrinkage and selection operator algorithm. We then examined network centrality metrics and implemented a community detection algorithm to detect communities in the network. Our results indicated that mental illness and intimate partner violence (IPV) are central measures that connect all other mental and physical health variables together and that post-traumatic stress disorder and IPV are both highly affected by changes in any part of the network and, in turn, affect changes in other parts of the network. A community detection analysis derived four communities characterized by disability, sexual victimization and health, substance use, and mental health issues. Finally, a directed acyclic graph revealed that drug abuse and physical disability were key drivers of the overall system. We conclude with a discussion of the major implications of our findings and suggest how our results might inform programs aimed at homelessness prevention and intervention.
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Affiliation(s)
| | - Anna Kosloski
- School of Public Affairs, University of Colorado Colorado Springs, Colorado Springs, CO, USA
| | - Henriikka Weir
- School of Public Affairs, University of Colorado Colorado Springs, Colorado Springs, CO, USA
| | | | - Alexey Bukreyev
- College of Arts, Letters and Sciences, University of Colorado Colorado Springs, Colorado Springs, CO, USA
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Kureshi N, Clarke DB, Feng C. Association between traumatic brain injury and mental health care utilization: evidence from the Canadian Community Health Survey. Inj Epidemiol 2023; 10:16. [PMID: 36915175 PMCID: PMC10012583 DOI: 10.1186/s40621-023-00424-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/24/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Mental health disorders are a common sequelae of traumatic brain injury (TBI) and are associated with worse health outcomes including increased mental health care utilization. The objective of this study was to determine the association between TBI and use of mental health services in a population-based sample. METHODS Using data from a national Canadian survey, this study evaluated the association between TBI and mental health care utilization, while adjusting for confounding variables. A log-Poisson regression model was used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% confidence intervals (CI). RESULTS The study sample included 158,287 TBI patients and 25,339,913 non-injured individuals. Compared with those were not injured, TBI patients reported higher proportions of chronic mental health conditions (27% vs. 12%, p < 0.001) and heavy drinking (33% vs. 24%, p = 0.005). The adjusted prevalence of mental health care utilization was 60% higher in patients with TBI than those who were not injured (PR = 1.60, 95%; CI 1.05-2.43). CONCLUSIONS This study suggests that chronic mental health conditions and heavy drinking are more common in individuals with TBI. The prevalence of mental health care utilization is 60% higher in TBI patients compared with those who are not injured after adjusting for sociodemographic factors, mental health conditions, and heavy drinking. Future longitudinal research is required to examine the temporality and direction of the association between TBI and the use of mental health services.
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Affiliation(s)
- Nelofar Kureshi
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS Canada
| | - David B. Clarke
- Division of Neurosurgery, Department of Surgery, Dalhousie University, Halifax, NS Canada
| | - Cindy Feng
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS Canada
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The Impact of COVID-19 on Access to Resources among Individuals Experiencing Homelessness and Traumatic Brain Injury. TRAUMA CARE 2023. [DOI: 10.3390/traumacare3010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
The rates of traumatic brain injury (TBI) are higher among individuals experiencing homelessness compared with the general population. Individuals experiencing homelessness and a TBI may experience barriers to care. COVID-19 may have further impacted access to basic resources, such as food, shelter, and transportation for individuals experiencing homelessness. This study aimed to answer the following research question: What is the impact of COVID-19 on access to resources among individuals experiencing homelessness and TBI? A cross-sectional study design and purposive sampling were utilized to interview 38 English-speaking adults experiencing homelessness and who had sustained a TBI (ages 21–73) in one Colorado city. Qualitative questions related to the impact of COVID-19 were asked and qualitative analysis was used to analyze the responses. Three primary themes emerged regarding the types of resources that were restricted by COVID-19: basic/biological needs, financial needs, and a lack of connection. COVID-19 has shown the social work field the need for continued innovation and better practice standards for individuals who are not housed. For those living with a reported TBI history and experiencing homelessness, COVID-19 made it difficult to access basic services for survival.
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10
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Fearn-Smith EM, Scanlan JN, Hancock N. Exploring and Mapping Screening Tools for Cognitive Impairment and Traumatic Brain Injury in the Homelessness Context: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3440. [PMID: 36834133 PMCID: PMC9966671 DOI: 10.3390/ijerph20043440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 06/18/2023]
Abstract
Cognitive impairment is common amongst people experiencing homelessness, yet cognitive screening and the collection of history of brain injury rarely features in homelessness service delivery practice. The purpose of this research was to scope and map strategies for screening for the potential presence of cognitive impairment or brain injury amongst people experiencing homelessness and identify instruments that could be administered by homelessness service staff to facilitate referral for formal diagnosis and appropriate support. A search was conducted across five databases, followed by a hand search from relevant systematic reviews. A total of 108 publications were included for analysis. Described in the literature were 151 instruments for measuring cognitive function and 8 instruments screening for history of brain injury. Tools that were described in more than two publications, screening for the potential presence of cognitive impairment or history of brain injury, were included for analysis. Of those regularly described, only three instruments measuring cognitive function and three measuring history of brain injury (all of which focused on traumatic brain injury (TBI)) may be administered by non-specialist assessors. The Trail Making Test (TMT) and the Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) are both potentially viable tools for supporting the identification of a likely cognitive impairment or TBI history in the homelessness service context. Further population-specific research and implementation science research is required to maximise the potential for practice application success.
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Affiliation(s)
- Erin M. Fearn-Smith
- Faculty of Medicine and Health, Centre for Disability Research and Policy, The University of Sydney, Camperdown, NSW 2050, Australia
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11
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Roca Lahiguera D, Bilbeny de Fortuny B, Clusa Gironella T, Fuertes Rodriguez T, Silva Ruiz P, Franch-Nadal J. [Analysis of the homeless population health in a disadvantaged district of Barcelona: ESSELLA study]. Aten Primaria 2022; 54:102458. [PMID: 36137444 PMCID: PMC9493295 DOI: 10.1016/j.aprim.2022.102458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/24/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022] Open
Abstract
Objetivo Conocer el estado de salud de la población sin hogar. Diseño Estudio descriptivo transversal. Emplazamiento Centro de Salud de Atención Primaria de Raval Sud (Barcelona). Participantes Personas mayores de edad en situación de sinhogarismo que han pernoctado en la calle en algún momento. Mediciones principales Datos sociodemográficos y tiempo en situación de sinhogarismo. Patologías crónicas, enfermedades infecciosas transmisibles, enfermedades mentales y trastornos por uso de sustancias adictivas. Cuestionario HAD sobre ansiedad y depresión. Cuestionario CVRS EQ-5D-3L. Estadística descriptiva. Resultados Se analizó la información de 146 pacientes con una media de edad de 51,6 años (DE = 12,8), 87% de sexo masculino y una media de 12 años (DE = 11,9) en situación de sinhogarismo. Se comparó la carga de enfermedad entre el perfil CAS Drogodependencias (Baluard) y el perfil sociosanitario (Arrels Fundació). Los usuarios del CAS presentaron mayores porcentajes de trastornos por uso de sustancias, enfermedades mentales y enfermedades infecciosas transmisibles. Las personas de perfil sociosanitario presentaron en mayor porcentaje enfermedades crónicas (respiratorias, cardiovasculares y oncológicas) y más de la mitad presentaron un trastorno por uso de alcohol y un mayor porcentaje de enfermedad asociada a su consumo. Conclusiones La población sin hogar presenta una elevada carga de enfermedad especialmente para enfermedad mental, adicciones y enfermedades infecciosas transmisibles. Creemos que son necesarios estudios para evaluar el exceso de enfermedad respecto a la población general con sus costes derivados y el diseño de nuevas estrategias para atender dicha carga de enfermedad y su especificidad.
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Affiliation(s)
- Daniel Roca Lahiguera
- Centro de Atención Primaria (CAP) Raval Sud, Institut Català de la Salut, Barcelona, España; Centro de Atención y Seguimiento de las Drogadicciones Baluard (CAS Baluard), Barcelona, Asociación Bienestar y Desarrollo (ABD). Agencia de Salud Pública de Barcelona (ASPB), Barcelona, España.
| | | | - Thaïs Clusa Gironella
- Centro de Atención Primaria (CAP) Raval Sud, Institut Català de la Salut, Barcelona, España
| | | | - Pau Silva Ruiz
- Centro de Atención Primaria (CAP) Raval Sud, Institut Català de la Salut, Barcelona, España
| | - Josep Franch-Nadal
- Centro de Atención Primaria (CAP) Raval Sud, Institut Català de la Salut, Barcelona, España; Unitat de Suport a la Recerca de Barcelona, Fundació IDIAP Jordi Gol, Barcelona, España
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Garduño-Ortega O, Li H, Smith M, Yao L, Wilson J, Zarate A, Bushnik T. Assessment of the individual and compounding effects of marginalization factors on injury severity, discharge location, recovery, and employment outcomes at 1 year after traumatic brain injury. Front Neurol 2022; 13:942001. [PMID: 36090882 PMCID: PMC9462705 DOI: 10.3389/fneur.2022.942001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/03/2022] [Indexed: 12/03/2022] Open
Abstract
Objective The aim of this study is to examine the effect of eight distinct marginalized group memberships and explore their compounding effect on injury severity, recovery, discharge location, and employment outcomes 1-year after traumatic brain injury (TBI). Methods Individuals with medically confirmed, complicated mild-severe TBI (N = 300) requiring inpatient rehabilitation care between the ages of 18 and 65 were recruited at two urban (public and private) health systems between 2013 and 2019. Data were collected from self-report and medical record abstraction. Marginalized group membership (MGM) includes racial and ethnic minority status, less than a high school diploma/GED, limited English proficiency, substance abuse, homelessness, psychiatric hospitalizations, psychiatric disorders, and incarceration history. Membership in four or more of these groups signifies high MGM. In addition, these factors were explored individually. Unadjusted and adjusted linear and logistic regressions and Kruskal–Wallis tests were used to assess the associations of interest in RStudio. Results After adjusting for age, sex, and cause of injury, compared to TBI patients with low MGM, those with high MGM experience significantly longer post-traumatic amnesia (95% CI = 2.70, 16.50; p = 0.007) and are significantly more likely to have a severe TBI (per the Glasgow-Coma Scale) (95% CI = 1.70, 6.10; p ≤ 0.001) than a complicated mild-moderate injury. Individuals with high MGM also are significantly less likely to be engaged in competitive paid employment 1 year after injury (95% CI = 2.40, 23.40; p = 0.001). Patients with high MGM are less likely to be discharged to the community compared to patients with low MGM, but this association was not significant (95% CI = 0.36, 1.16; p = 0.141). However, when assessing MGMs in isolation, certain associations were not significant in unadjusted or adjusted models. Conclusion This exploratory study's findings reveal that when four or more marginalization factors intersect, there is a compounding negative association with TBI severity, recovery, and employment outcomes. No significant association was found between high MGM and discharge location. When studied separately, individual MGMs had varying effects. Studying marginalization factors affecting individuals with TBI has critical clinical and social implications. These findings underline the importance of addressing multidimensional factors concurrent with TBI recovery, as the long-term effects of TBI can place additional burdens on individuals and their economic stability.
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Affiliation(s)
- Olga Garduño-Ortega
- Research Department, Rusk Rehabilitation, Grossman School of Medicine, NYU Langone Health, New York, NY, United States
- *Correspondence: Olga Garduño-Ortega
| | - Huihui Li
- Research Department, Rusk Rehabilitation, Grossman School of Medicine, NYU Langone Health, New York, NY, United States
| | - Michelle Smith
- Research Department, Rusk Rehabilitation, Grossman School of Medicine, NYU Langone Health, New York, NY, United States
| | - Lanqiu Yao
- Department of Population Health, Grossman School of Medicine, NYU Langone Health, New York, NY, United States
| | - Judith Wilson
- Occupational Therapy Department, Bellevue Hospital, Health and Hospitals, New York, NY, United States
| | - Alejandro Zarate
- Research Department, Rusk Rehabilitation, Grossman School of Medicine, NYU Langone Health, New York, NY, United States
| | - Tamara Bushnik
- Research Department, Rusk Rehabilitation, Grossman School of Medicine, NYU Langone Health, New York, NY, United States
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Fornaro M, Dragioti E, De Prisco M, Billeci M, Mondin AM, Calati R, Smith L, Hatcher S, Kaluzienski M, Fiedorowicz JG, Solmi M, de Bartolomeis A, Carvalho AF. Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials. BMC Med 2022; 20:224. [PMID: 35818057 PMCID: PMC9273695 DOI: 10.1186/s12916-022-02423-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/30/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population. METHODS Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted. RESULTS Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant. CONCLUSION While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.
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Affiliation(s)
- Michele Fornaro
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Elena Dragioti
- Pain and Rehabilitation Centre, and Department of Medical and Health Sciences, Linköping University, SE-581 85 Linköping, Sweden
| | - Michele De Prisco
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Martina Billeci
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Anna Maria Mondin
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
| | - Raffaella Calati
- Department of Psychology, University of Milan-Bicocca, Piazza dell’Ateneo Nuovo, 1, 20126 Milan, Italy
- Department of Adult Psychiatry, Nimes University Hospital, 4 Rue du Professeur Robert Debré, 30029 Nimes, France
| | - Lee Smith
- Cambridge Centre for Health, Performance and Wellbeing, Anglia Ruskin University, Cambridge, UK
| | - Simon Hatcher
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Mark Kaluzienski
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
| | - Jess G. Fiedorowicz
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Marco Solmi
- Department of Psychiatry, University of Ottawa, Ottawa, ON Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, ON Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON Canada
- Early Psychosis: Interventions and Clinical-Detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, London, UK
- Faculty of Environmental and Life Sciences, Center for Innovation in Mental Health, School of Psychology, University of Southampton, Southampton, UK
| | - Andrea de Bartolomeis
- Section of Psychiatry, Department of Neuroscience, Reproductive Science, and Odontostomatology, Federico Ii University of Naples, Naples, Italy
- UNESCO staff, Chair - “Education for Health and Sustainable Development”, University of Naples, Federico II Naples, Naples, Italy
| | - André F. Carvalho
- IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Barwon Health, Deakin University, Geelong, Australia
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Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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O'Connor TA, Panenka WJ, Livingston EM, Stubbs JL, Askew J, Sahota CS, Feldman SJ, Buchanan T, Xu L, Hu XJ, Lang DJ, Woodward ML, Thornton WL, Gicas KM, Vertinsky AT, Heran MK, Su W, MacEwan GW, Barr AM, Honer WG, Thornton AE. Traumatic brain injury in precariously housed persons: Incidence and risks. EClinicalMedicine 2022; 44:101277. [PMID: 35252825 PMCID: PMC8888336 DOI: 10.1016/j.eclinm.2022.101277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/19/2021] [Accepted: 01/10/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Homeless and precarious housed persons are particularly prone to traumatic brain injuries (TBIs), but existent incidence rates are hampered by poor case acquisition. We rigorously documented TBIs in precariously housed persons transitioning in and out of homelessness. METHODS Between December 2016 and May 2018, 326 precariously housed participants enrolled in a longitudinal study in Vancouver, Canada were assessed monthly for TBI occurrences after education on sequelae. Over one participant-year, 2433 TBI screenings were acquired for 326 person-years and variables associated with odds of incident TBI were evaluated. FINDINGS One hundred participants acquired 175 TBIs, yielding an observed incidence proportion of 30·7% and event proportion of 53·7%. Of the injured, 61% reported one TBI and 39% reported multiple injuries. Acute intoxication was present for more than half of the TBI events assessed. Additionally, 9·7% of TBI events occurred in the context of a drug overdose. Common injury mechanisms were falls (45·1%), assaults (25·1%), and hitting one's head on an object (13·1%). In this community-based but non-randomly recruited sample, exploratory analyses identified factors associated with odds of an incident TBI over one year of follow-up, including: schizophrenia disorders (odds ratio (OR) = 0·43, 95% confidence interval (CI) 0·19, 0·94), role functioning (OR = 0·69, 95% CI 0·52, 0·91), opioid dependence (OR = 2·17, 95% CI 1·27, 3·72) and those reporting past TBIs (OR = 1·99, 95% CI 1·13, 3·52). INTERPRETATION Given the ubiquity of TBIs revealed in this precariously housed sample, we identify an underappreciated and urgent healthcare priority. Several factors modified the odds of incident TBI, which can facilitate investigations into targeted prevention efforts. FUNDING Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, William and Ada Isabelle Steel Research Fund, Simon Fraser University Vice-President Research Undergraduate Student Research Award and Simon Fraser University Psychology Department Research Grant.
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Affiliation(s)
- Tiffany A. O'Connor
- Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute
| | - William J. Panenka
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Emily M. Livingston
- Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute
| | - Jacob L. Stubbs
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Julia Askew
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Charanveer S. Sahota
- Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute
| | | | - Tari Buchanan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Linwan Xu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, BC, Canada
| | - X. Joan Hu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, BC, Canada
| | - Donna J. Lang
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Melissa L. Woodward
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | | | - Kristina M. Gicas
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
- Department of Psychology, York University, Toronto, ON, Canada
| | | | - Manraj K. Heran
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Wayne Su
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - G. William MacEwan
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Alasdair M. Barr
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William G. Honer
- British Columbia Mental Health and Substance Use Services Research Institute
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Allen E. Thornton
- Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
- British Columbia Mental Health and Substance Use Services Research Institute
- Correspondence to: Allen E. Thornton, Human Neuropsychology Laboratory, Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.
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Baggett TP, Barbosa Teixeira J, Rodriguez EC, Anandakugan N, Sporn N, Chang Y, Percac-Lima S, Park ER, Rigotti NA. Patient navigation to promote lung cancer screening in a community health center for people experiencing homelessness: Protocol for a pragmatic randomized controlled trial. Contemp Clin Trials 2022; 113:106666. [PMID: 34971796 DOI: 10.1016/j.cct.2021.106666] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/13/2021] [Accepted: 12/23/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lung cancer is a major cause of death among people experiencing homelessness, with mortality rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) could reduce lung cancer deaths in this population, although the circumstances of homelessness present multiple barriers to LCS LDCT completion. Patient navigation is a promising strategy for overcoming these barriers. METHODS The Investigating Navigation to Help Advance Lung Equity (INHALE) Study is a pragmatic randomized controlled trial of patient navigation for LCS among individuals receiving primary care at Boston Health Care for the Homeless Program (BHCHP). Three hundred BHCHP patients who meet Medicare/Medicaid criteria for LCS will be randomized 2:1 to usual care with (n = 200) or without (n = 100) LCS navigation. Following a structured, theory-based protocol, the patient navigator assists with each step in the LCS process, providing lung cancer education, facilitating shared decision-making visits with primary care providers (PCPs), assisting in making and attending LCS LDCT appointments, arranging follow-up when needed, and offering tobacco cessation support for smokers. The primary outcome is receipt of LCS LDCT at 6 months. Using a sequential explanatory mixed methods approach, qualitative interviews with participants and PCPs will aid in interpreting and contextualizing the trial results. DISCUSSION This trial will produce the first experimental evidence on patient navigation for cancer screening in a homeless health care setting. Results could inform cancer health equity efforts at the 299 Health Care for the Homeless programs that serve over 900,000 patients annually in the US.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America; Institute for Research, Quality & Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, United States of America.
| | - Joana Barbosa Teixeira
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Elijah C Rodriguez
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; New York University Grossman School of Medicine, New York, NY, United States of America
| | - Nillani Anandakugan
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Nora Sporn
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Sanja Percac-Lima
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Elyse R Park
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Mongan Institute, Massachusetts General Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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Mollayeva T, Tran A, Chan V, Colantonio A, Escobar MD. Sex-specific analysis of traumatic brain injury events: applying computational and data visualization techniques to inform prevention and management. BMC Med Res Methodol 2022; 22:30. [PMID: 35094688 PMCID: PMC8802441 DOI: 10.1186/s12874-021-01493-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/29/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The interplay of host, agent, and environment implicated in traumatic brain injury (TBI) events is difficult to account for in hypothesis-driven research. Data-driven analysis of injury data can enable insight into injury events in novel ways. This research dissected complex and multidimensional data at the time of the TBI event by exploiting data mining and information visualization methods. METHODS We drew upon population-based decade-long health administrative data collected through the routine operation of the publicly funded health system in Ontario, Canada. We applied a computational approach to categorize health records of 235,003 patients with TBI versus the same number of reference patients without TBI, individually matched based on sex, age, place of residence, and neighbourhood income quantile. We adopted the basic concepts of the Haddon Matrix (host, agent, environment) to organize emerging factors significantly related to TBI versus non-TBI events. To explore sex differences, the data of male and female patients with TBI were plotted on heatmaps and clustered using hierarchical clustering algorithms. RESULTS Based on detected similarities, the computational technique yielded 34 factors on which individual TBI-event codes were loaded, allowing observation of a set of definable patterns within the host, the agent, and the environment. Differences in the patterns of host, agent and environment were found between male and female patients with TBI, which are currently not identified based on data from injury surveillance databases. The results were internally validated. CONCLUSIONS The study outlines novel areas for research relevant to TBI and offers insight into how computational and visual techniques can be applied to advance the understanding of TBI event. Results highlight unique aspects of sex differences of the host and agent at the injury event, as well as differences in exposure to adverse social and environmental circumstances, which can be a function of gender, aiding in future studies of injury prevention and gender-transformative care.
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Affiliation(s)
- Tatyana Mollayeva
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada Ontario
- Trinity College Institute of Neuroscience, Global Brain Health Institute, Dublin, Ireland
| | - Andrew Tran
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada Ontario
| | - Vincy Chan
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario Canada
| | - Angela Colantonio
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario Canada
- Acquired Brain Injury Research Lab, University of Toronto, Toronto, Ontario Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada Ontario
| | - Michael D. Escobar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada Ontario
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Geller JM. Street medicine: caring for the pets of the homeless. J Am Vet Med Assoc 2021; 260:181-185. [PMID: 34890362 DOI: 10.2460/javma.21.05.0249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Formosa A, Dobronyi I, Topolovec-Vranic J. The educational needs of Canadian homeless shelter workers related to traumatic brain injury. Work 2021; 70:1165-1175. [PMID: 34864707 DOI: 10.3233/wor-205111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) has a higher prevalence in the homeless population. Caregivers to individuals who have TBIs may require better education surrounding screening, diagnosis and management of this disease to tailor interventions to their clients' needs. OBJECTIVE To assess the insight and educational needs of homeless care providers in recognizing and dealing with clients who had experienced a TBI. METHODS A survey assessing the point of views of homeless care providers across Canada regarding their level of confidence in identifying and managing symptoms of TBI. RESULTS Eight-eight completed surveys were included. Overall, frontline workers expressed a moderate level of confidence in identifying and managing TBI, stating that educational initiatives in this context would be of high value to themselves and their clients. CONCLUSIONS Frontline workers to homeless clients rate their educational needs on the identification and management of TBI to be high such that educational initiatives for shelter workers across Canada may be beneficial to increase their knowledge in identifying and managing the TBI-related symptoms. Improved education would not only benefit frontline workers but may also have a positive effect on health outcomes for their clients.
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Affiliation(s)
- Amanda Formosa
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | | | - Jane Topolovec-Vranic
- Interprofessional Practice Based Research, Unity Health Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Canada
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Chan V, Estrella MJ, Babineau J, Colantonio A. Protocol for a scoping review on rehabilitation among individuals who experience homelessness and traumatic brain injury. BMJ Open 2021; 11:e052942. [PMID: 34740933 PMCID: PMC8573664 DOI: 10.1136/bmjopen-2021-052942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/18/2021] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Rehabilitation is key to improving outcomes and quality of life after traumatic brain injury (TBI). However, individuals experiencing homelessness are rarely represented in research that informs evidence-based rehabilitation guidelines even though TBI is disproportionately prevalent among this population. This protocol is for a scoping review to explore the extent to which rehabilitation, including the types of rehabilitation interventions, is available to, or used by, individuals who experience homelessness and TBI to inform (1) opportunities to integrate rehabilitation for individuals experiencing homelessness and TBI, (2) considerations for existing clinical and practice guidelines for rehabilitation and (3) recommendations for future research. METHODS AND ANALYSIS The scoping review will be guided by six stages described in scoping review methodology frameworks. Electronic databases (MEDLINE, Embase and Embase Classic, Cochrane CENTRAL Register of Clinical Trials, CINAHL, APA PsycINFO, Applied Social Sciences Index and Abstracts, and Nursing and Allied Health), reference list of included articles and scoping or systematic reviews identified from the search and grey literature, defined as reports from relevant brain injury, housing and rehabilitation organisations, will be searched. Two reviewers will independently screen all articles based on predetermined inclusion and exclusion criteria. A descriptive numerical summary of data items will be provided and qualitative content analytic techniques will be used to identify and report common themes. Preliminary findings will be shared with stakeholders to seek feedback on the implications of the results. ETHICS AND DISSEMINATION Ethics review will not be required, as only publicly available data will be analysed. Findings from the scoping review will be published in a peer-reviewed journal and presented at scientific meetings and to stakeholders, defined as service providers in the housing and TBI sectors; health professionals who provide care for individuals with TBI and/or homelessness; health administrators, decision-makers and policy-makers; researchers; and caregivers or family members of individuals with lived experience of TBI and homelessness.
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Affiliation(s)
- Vincy Chan
- KITE, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maria Jennifer Estrella
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Babineau
- Library & Information Services, University Health Network, Toronto, Ontario, Canada
- The Institute for Education Research, University Health Network, Toronto, Ontario, Canada
| | - Angela Colantonio
- KITE, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Ontario, Canada
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21
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Wood L, Flatau P, Seivwright A, Wood N. Out of the trenches; prevalence of Australian veterans among the homeless population and the implications for public health. Aust N Z J Public Health 2021; 46:134-141. [PMID: 34709717 DOI: 10.1111/1753-6405.13175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 06/01/2021] [Accepted: 09/01/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To examine the prevalence of Australian Defence Force veterans among people sleeping rough and explore their health and social needs relative to non-veteran rough sleepers. METHOD Analysis of responses to the Vulnerability Index - Service Prioritisation Decision Assistance Tool (VI-SPDAT) collected from 8,027 rough sleepers across five Australian States from 2010-2017. RESULTS Veterans were found to comprise 5.6% of people sleeping rough in Australia, with veterans reporting having spent an average of 6.3 years on the street or in emergency accommodation (compared with an average of five years for their non-veterans counterparts). Veterans had a higher prevalence of self-reported physical health, mental health and social issues compared with non-veteran rough sleepers. CONCLUSIONS This is the first study of its kind to elucidate the presence of Australian veterans among people sleeping rough. That they are likely to have spent more years on the street, and have a higher prevalence of health and social issues, highlights the imperative for earlier intervention and prevention of veteran homelessness itself, and its health impacts. Implications for public health: Veteran homelessness has been comparatively hidden in Australia compared to other countries, and consequently the myriad of health, psychosocial and adjustment issues faced by homeless veterans has also been hidden. With heightened attention on veteran suicide and self-harm, earlier intervention to prevent veterans becoming homeless constitutes sound public health prevention and mental health policy.
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Affiliation(s)
- Lisa Wood
- School of Population and Global Health, University of Western Australia
| | - Paul Flatau
- Centre for Social Impact, Business School, University of Western Australia
| | - Ami Seivwright
- Centre for Social Impact, Business School, University of Western Australia
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22
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Abstract
Objective To determine if low resting basal AM cortisol and flat diurnal cortisol slope that has been reported in female abuse victims, which is dysregulated in the same way in female violent perpetrators, could be corrected and if healthier diurnal cortisol patterns are associated with less aggression in adult female victims. Design and Methods A non-experimental, naturalistic study evaluated if bio-behavioral rehabilitation could occur for females living in a Delaware homeless mission and participating in their programs. Basal salivary cortisol (AM, PM & slope), aggression, neurological conditions, general health, alcohol use, having been a victim of abuse, religion, spirituality and forgiveness were evaluated over one month between 2018 and 2019. Results T tests revealed significant improvement in mean cortisol (AM, PM & slope), aggression, emotional/ behavioral dyscontrol, and health over one month while participating in the mission’s programs. Paired t-tests however were only significant for aggression and health. Healthier cortisol was significantly correlated with greater time since last alcohol, greater time since last abuse, less aggression, better health and greater religion, spirituality and forgiveness. Conclusion Community programs could be cost effective methods of post-traumatic bio-behavioral rehabilitation. Forgiveness may play a critical role for abuse victims. A larger sample and more settings are needed, although these findings are promising.
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23
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Mollayeva T, Mollayeva S, Pacheco N, Colantonio A. Systematic Review of Sex and Gender Effects in Traumatic Brain Injury: Equity in Clinical and Functional Outcomes. Front Neurol 2021; 12:678971. [PMID: 34566834 PMCID: PMC8461184 DOI: 10.3389/fneur.2021.678971] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/09/2021] [Indexed: 01/12/2023] Open
Abstract
Background: Although traumatic brain injury (TBI) is a leading cause of death and disability in male and female patients worldwide, little is known about the effect of sex and gender on TBI outcomes. Objectives: This systematic review summarizes the evidence on the effect of sex and gender on core TBI outcomes. Methods: All English-language studies from six literature databases that addressed core outcomes in adults with TBI and included sex or gender, TBI severity, and age in their analyses were considered eligible. Two reviewers extracted data, and two reviewers assessed study quality using tools recommended by the National Institutes of Health. The results were sorted according to time post-injury, injury severity, gender equity ranking of the study's country of origin, and outcomes studied. The results from the included studies were grouped based on the approach taken in reporting their respective findings. Results and Limitations: Of 172 articles assessed, 58 studies were selected, comprising 1, 265, 955 participants with TBI (67% male across all studies) of all injury severities. All studies were conducted in countries with a very high or high human development index, while the Gender Inequality Index (GII) varied. While the heterogeneity across studies limited any meaningful conclusions with respect to the role of sex and gender, we did observe that as gender equality ranking improved, differences between male and female participants in outcomes would diminish. Inclusion of social equity parameters in the studies was limited. Conclusions and Implications: The non-uniform findings observed bring forth the need to develop and use a comprehensive and consistent methodology in the study of sex and gender post-TBI, incorporating social equity parameters to uncover the potential social underpinnings of gender effects on health and functional outcomes. Systematic Review Registration: CRD42018098697.
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Affiliation(s)
- Tatyana Mollayeva
- KITE Toronto Rehabilitation Institute University Health Network, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,School of Occupational Therapy, Western University, London, ON, Canada
| | - Shirin Mollayeva
- Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada
| | - Nicole Pacheco
- Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,School of Occupational Therapy, Western University, London, ON, Canada
| | - Angela Colantonio
- KITE Toronto Rehabilitation Institute University Health Network, Toronto, ON, Canada.,Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Acquired Brain Injury Research Lab, Temerty Faculty of Medicine University of Toronto, Toronto, ON, Canada.,Department of Epidemiology, Dalla Lana School of Public Health University of Toronto, Toronto, ON, Canada
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24
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Post-Traumatic Bio-Behavioral Rehabilitation of Adult Female Victims. Dela J Public Health 2021. [DOI: 10.32481/djph.2021.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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25
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Dell KC, Staph J, Hillary FG. Traumatic brain injury in the homeless: health, injury mechanisms, and hospital course. Brain Inj 2021; 35:1192-1200. [PMID: 34460346 DOI: 10.1080/02699052.2021.1958009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Primary ObjectiveEstablished literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations.Research DesignWe leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home.Methods and ProceduresWe implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups.Main Outcomes and ResultsHomelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home.ConclusionGiven the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.
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Affiliation(s)
- Kristine C Dell
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Jason Staph
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States
| | - Frank G Hillary
- Department of Psychology, The Pennsylvania State University, University Park, Pennsylvania, United States.,Department of Neurology, Hershey Medical Center, Hershey, Pennsylvania, United States
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26
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Zeiler KJ, Gomez A, Mathieu F, Zeiler FA. Health Determinants among North Americans Experiencing Homelessness and Traumatic Brain Injury: A Scoping Review. Neurotrauma Rep 2021; 2:303-321. [PMID: 34901934 PMCID: PMC8655803 DOI: 10.1089/neur.2021.0010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Traumatic brain injury (TBI) in those experiencing homelessness has been described in recent literature as a contributor to increased morbidity, decreased functional independence, and early mortality. In this systematically conducted scoping review, we aimed to better delineate the health determinants-as defined by Health Canada/Centers for Disease Control and Prevention (CDC)-associated with TBI in North Americans experiencing homelessness. BIOSIS, MEDLINE, CINAHL, EMBASE, SCOPUS, and Global Health were searched from inception to December 30, 2020. Gray literature search consisted of relevant meeting proceedings. A two-step process was undertaken, assessing title/abstract and full articles, respectively, based on inclusion/exclusion criteria, leading to the final 20 articles included in the review. Data were abstracted, assessing the aims, literature quality, and bias. Five health determinants displayed strong associations with TBI in those North Americans experiencing homelessness, including male gender, poor physical environment, negative personal health behaviors, adverse childhood experiences (ACEs), and low educational attainment. In those studies displaying a comparator population experiencing homelessness without TBI, the TBI group displayed trends toward increased disparity in Health Canada and CDC defined health determinants. Most studies suffered from moderate limitations. There are associations between male gender, poor physical environment, negative personal health behaviors, ACEs, and limited education in those experiencing homelessness and TBI. The results suggest that those experiencing homelessness with TBI in North America suffer poorer health consequences than those without TBI. Future research on TBI in North Americans experiencing homelessness should focus on health determinants as potential areas for intervention, which may lead to improved outcomes for those experiencing both homelessness and TBI.
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Affiliation(s)
- Kaitlin J. Zeiler
- Undergraduate Psychology Program, Faculty of Arts, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Francois Mathieu
- Section of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
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27
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Gutwinski S, Schreiter S, Deutscher K, Fazel S. The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis. PLoS Med 2021; 18:e1003750. [PMID: 34424908 PMCID: PMC8423293 DOI: 10.1371/journal.pmed.1003750] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/07/2021] [Accepted: 08/02/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Homelessness continues to be a pressing public health concern in many countries, and mental disorders in homeless persons contribute to their high rates of morbidity and mortality. Many primary studies have estimated prevalence rates for mental disorders in homeless individuals. We conducted a systematic review and meta-analysis of studies on the prevalence of any mental disorder and major psychiatric diagnoses in clearly defined homeless populations in any high-income country. METHODS AND FINDINGS We systematically searched for observational studies that estimated prevalence rates of mental disorders in samples of homeless individuals, using Medline, Embase, PsycInfo, and Google Scholar. We updated a previous systematic review and meta-analysis conducted in 2007, and searched until 1 April 2021. Studies were included if they sampled exclusively homeless persons, diagnosed mental disorders by standardized criteria using validated methods, provided point or up to 12-month prevalence rates, and were conducted in high-income countries. We identified 39 publications with a total of 8,049 participants. Study quality was assessed using the JBI critical appraisal tool for prevalence studies and a risk of bias tool. Random effects meta-analyses of prevalence rates were conducted, and heterogeneity was assessed by meta-regression analyses. The mean prevalence of any current mental disorder was estimated at 76.2% (95% CI 64.0% to 86.6%). The most common diagnostic categories were alcohol use disorders, at 36.7% (95% CI 27.7% to 46.2%), and drug use disorders, at 21.7% (95% CI 13.1% to 31.7%), followed by schizophrenia spectrum disorders (12.4% [95% CI 9.5% to 15.7%]) and major depression (12.6% [95% CI 8.0% to 18.2%]). We found substantial heterogeneity in prevalence rates between studies, which was partially explained by sampling method, study location, and the sex distribution of participants. Limitations included lack of information on certain subpopulations (e.g., women and immigrants) and unmet healthcare needs. CONCLUSIONS Public health and policy interventions to improve the health of homeless persons should consider the pattern and extent of psychiatric morbidity. Our findings suggest that the burden of psychiatric morbidity in homeless persons is substantial, and should lead to regular reviews of how healthcare services assess, treat, and follow up homeless people. The high burden of substance use disorders and schizophrenia spectrum disorders need particular attention in service development. This systematic review and meta-analysis has been registered with PROSPERO (CRD42018085216). TRIAL REGISTRATION PROSPERO CRD42018085216.
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Affiliation(s)
- Stefan Gutwinski
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Stefanie Schreiter
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Biomedical Innovation Academy, Berlin Institute of Health, Berlin, Germany
| | - Karl Deutscher
- Department of Psychiatry and Psychotherapy, Charité–Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Seena Fazel
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
- * E-mail:
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28
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Gilmer C, Buccieri K. Homeless Patients Associate Clinician Bias With Suboptimal Care for Mental Illness, Addictions, and Chronic Pain. J Prim Care Community Health 2021; 11:2150132720910289. [PMID: 32133906 PMCID: PMC7059226 DOI: 10.1177/2150132720910289] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To determine how accessible health care services are for people who are experiencing homelessness and to understand from their perspectives what impact clinician bias has on the treatment they receive. Methods: Narrative interviews were conducted with 53 homeless/vulnerably housed individuals in Ontario, Canada. Visit history records were subsequently reviewed at 2 local hospitals, for 52 of the interview participants. Results: Of the 53 participants only 28% had a primary care provider in town, an additional 40% had a provider in another town, and 32% had no access to a primary care provider at all. A subset of the individuals were frequent emergency department users, with 15% accounting for 75% of the identified hospital visits, primarily seeking treatment for mental illness, pain, and addictions. When seeking primary care for these 3 issues participants felt medication was overprescribed. Conversely, in emergency care settings participants felt prejudged by clinicians as being drug-seekers. Participants believed they received poor quality care or were denied care for mental illness, chronic pain, and addictions when clinicians were aware of their housing status. Conclusion: Mental illness, chronic pain, and addictions issues were believed by participants to be poorly treated due to clinician bias at the primary, emergency, and acute care levels. Increased access to primary care in the community could better serve this marginalized population and decrease emergency department visits but must be implemented in a way that respects the rights and dignity of this patient population.
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Affiliation(s)
| | - Kristy Buccieri
- Trent University, Peterborough, Ontario,
Canada
- Kristy Buccieri, Department of Sociology,
Trent University, 1600 West Bank Drive, Peterborough, Ontario K9L 0G2, Canada.
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29
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Spinola S, Hoff RA, Tsai J. A psychosocial mediational model of homelessness among U.S. male and female veterans who served in Iraq and Afghanistan. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:453-463. [PMID: 32662176 DOI: 10.1111/hsc.13106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 05/11/2020] [Accepted: 06/20/2020] [Indexed: 06/11/2023]
Abstract
Few studies have focused on homelessness among Operations Iraqi Freedom, Enduring Freedom and New Dawn (OEF/OIF/OND) veterans, especially female veterans. An explanatory model of homelessness was constructed and tested for each gender. Data collected in the United States from 833 OEF/OIF/OND veterans (41.5% female; Mage = 35.22, SD = 8.86) who completed the baseline assessment of the Survey of the Experiences of Returning Veterans between September 2011 and July 2014 were analysed. Path analysis was used to examine associations between risk factors and any lifetime homelessness, stratified by gender. Adverse childhood events (ACEs) and low social support were significantly associated with lifetime homelessness for both genders. Social support mediated associations between ACEs and homelessness, after controlling for sociodemographic factors. While sociodemographic risk factors are often considered in homeless prevention, these findings highlight the importance of social support among male and female OEF/OIF/OND veterans, underscoring the need to target this life domain in preventing homelessness.
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Affiliation(s)
- Suzanne Spinola
- U.S. Department of Veterans Affairs, New England Mental Illness Research, Education, and Clinical Center, West Haven, CT, USA
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Rani A Hoff
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- U.S. Department of Veterans Affairs, Northeast Program Evaluation Center, West Haven, CT, USA
| | - Jack Tsai
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, West Haven, CT, USA
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30
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Cusimano MD, Korman MB, Carpino M, Feher A, Puvirajasingam J, Zhang S, Hwang SW, Tepperman L. The Temporal Relations of Traumatic Brain Injury, Victimization, Aggression, and Homelessness: A Developmental Trajectory. Neurotrauma Rep 2021; 2:103-114. [PMID: 33748815 PMCID: PMC7968566 DOI: 10.1089/neur.2020.0050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Traumatic brain injury (TBI) occurs more frequently in homeless persons than the general public. Both homelessness and TBI have been linked to experiences of violence (e.g., aggression and victimization). This study aimed to understand the temporal occurrences of events over the life course that contribute to vulnerabilities to TBI, victimization, aggression, and homelessness. A life-course perspective was used in this thematic analysis of in-person interviews with homeless persons. A total of 33 homeless persons met the inclusion criteria. Twenty-five of 33 (76%) participants had a self-reported history of TBI. Seventy-six percent of TBI events occurred before the onset of homelessness. Assault was the most common mechanism of TBI. During childhood, TBI was a frequently reported event, and parent- or guardian-related physical and sexual abuse were also accentuated with peer abuse, which may have contributed to a unique developmental trajectory. Aggressive behaviors were reported more commonly in persons who previously endured physical, sexual, and emotional victimization early in childhood. The cumulative effect of early adverse events, including TBI and other forms of victimization, subsequent aggression, and further TBI occurring later in life, may create an “at-risk” or vulnerable state preceding homelessness. Precipitating events during adulthood may contribute to a state of homelessness. Homelessness itself may facilitate the context for recurring physical and emotional injury, some of which may be preventable. Future studies should examine the temporality of events related to victimization by physical trauma, such as TBI, aggression, and homelessness.
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Affiliation(s)
- Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute and Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Melissa B Korman
- Li Ka Shing Knowledge Institute and Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Melissa Carpino
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Anita Feher
- Li Ka Shing Knowledge Institute and Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Sociology, University of Toronto, Toronto, Ontario, Canada
| | - Jeevithaa Puvirajasingam
- Li Ka Shing Knowledge Institute and Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Stanley Zhang
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute and Keenan Research Centre, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Lorne Tepperman
- Department of Sociology, University of Toronto, Toronto, Ontario, Canada
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31
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Nelson RE, Byrne TH, Suo Y, Cook J, Pettey W, Gundlapalli AV, Greene T, Gelberg L, Kertesz SG, Tsai J, Montgomery AE. Association of Temporary Financial Assistance With Housing Stability Among US Veterans in the Supportive Services for Veteran Families Program. JAMA Netw Open 2021; 4:e2037047. [PMID: 33566108 PMCID: PMC8015862 DOI: 10.1001/jamanetworkopen.2020.37047] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/19/2020] [Indexed: 11/14/2022] Open
Abstract
Importance Temporary financial assistance (TFA) for housing-related expenses is a key component of interventions to prevent homelessness or to quickly house those who have become homeless. Through the US Department of Veterans Affairs (VA) Supportive Services for Veteran Families (SSVF) program, the department provides TFA to veterans in need of housing assistance. Objective To assess the association between TFA and housing stability among US veterans enrolled in the SSVF program. Design, Setting, and Participants This retrospective cohort study analyzed data on veterans who were enrolled in the SSVF program at 1 of 203 partner organizations in 49 US states and territories. Some veterans had repeat SSVF episodes, but only the first episodes were included in this analysis. An episode was defined as the period between entry into and exit from the program occurring between October 1, 2015, and September 30, 2018. Exposures Receipt of TFA. Main Outcomes and Measures The main outcome was stable housing, defined as permanent, independent residence with payment by the program client or housing subsidy after exit from the SSVF program. Covariates included demographic characteristics, monthly income and source, public benefits, health insurance, use of other VA programs for homelessness, comorbidities, and geographic location. Multivariable mixed-effects logistic regression, inverse probability of treatment weighting, and instrumental variable approaches were used. Results The overall cohort consisted of 41 969 veterans enrolled in the SSVF program, of whom 29 184 (mean [SD] age, 50.4 [12.9] years; 25 396 men [87.0%]) received TFA and 12 785 (mean [SD] age, 50.0 [13.3] years; 11 229 men [87.8%]) did not receive TFA. The mean (SD) duration of SSVF episodes was 90.5 (57.7) days. A total of 69.5% of SSVF episodes involved receipt of TFA, and the mean (SD) amount of TFA was $6070 ($7272). Stable housing was obtained in 81.4% of the episodes. Compared with those who did not receive TFA, veterans who received TFA were significantly more likely to have stable housing outcomes (risk difference, 0.253; 95% CI, 0.240-0.265). An association between the amount of TFA received and stable housing was also found, with risk differences ranging from 0.168 (95% CI, 0.149-0.188) for those who received $0 to $2000 in TFA to 0.226 (95% CI, 0.203-0.249) for those who received more than $2000 to $4000 in TFA. Conclusions and Relevance This study found that receipt of TFA through the SSVF program was associated with increased rates of stable housing. These results may inform national policy debates regarding the optimal solutions to prevent and reduce housing instability.
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Affiliation(s)
- Richard E. Nelson
- Informatics, Decision-Enhancement and Analytic
Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake
City, Utah
- Department of Internal Medicine, The University of
Utah School of Medicine, Salt Lake City
- VA National Center on Homelessness Among Veterans,
Washington, DC
| | - Thomas H. Byrne
- VA National Center on Homelessness Among Veterans,
Washington, DC
- Boston University School of Social Work, Boston,
Massachusetts
- Center for Healthcare Organization and Implementation
Research, Bedford VA Medical Center, Bedford, Massachusetts
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic
Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake
City, Utah
- Department of Internal Medicine, The University of
Utah School of Medicine, Salt Lake City
| | - James Cook
- Informatics, Decision-Enhancement and Analytic
Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake
City, Utah
- Department of Internal Medicine, The University of
Utah School of Medicine, Salt Lake City
| | - Warren Pettey
- Informatics, Decision-Enhancement and Analytic
Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake
City, Utah
- Department of Internal Medicine, The University of
Utah School of Medicine, Salt Lake City
| | - Adi V. Gundlapalli
- Informatics, Decision-Enhancement and Analytic
Sciences (IDEAS) Center, Veterans Affairs (VA) Salt Lake City Health Care System, Salt Lake
City, Utah
- Department of Internal Medicine, The University of
Utah School of Medicine, Salt Lake City
| | - Tom Greene
- Department of Internal Medicine, The University of
Utah School of Medicine, Salt Lake City
- Department of Population Health Science, The
University of Utah School of Medicine, Salt Lake City
| | - Lillian Gelberg
- Department of Family Medicine, University of
California, Los Angeles, Los Angeles
- VA Greater Los Angeles Healthcare System, Los Angeles,
California
| | - Stefan G. Kertesz
- VA National Center on Homelessness Among Veterans,
Washington, DC
- Birmingham VA Medical Center, Birmingham,
Alabama
- Department of Medicine, University of Alabama at
Birmingham, Birmingham
| | - Jack Tsai
- VA National Center on Homelessness Among Veterans,
Washington, DC
- The University of Texas Health Sciences Center
School of Public Health, San Antonio
| | - Ann Elizabeth Montgomery
- VA National Center on Homelessness Among Veterans,
Washington, DC
- Birmingham VA Medical Center, Birmingham,
Alabama
- Department of Health Behavior, University of Alabama
at Birmingham School of Public Health, Birmingham
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Mejia-Lancheros C, Lachaud J, Stergiopoulos V, Matheson FI, Nisenbaum R, O'Campo P, Hwang SW. Effect of Housing First on violence-related traumatic brain injury in adults with experiences of homelessness and mental illness: findings from the At Home/Chez Soi randomised trial, Toronto site. BMJ Open 2020; 10:e038443. [PMID: 33277277 PMCID: PMC7722391 DOI: 10.1136/bmjopen-2020-038443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES People experiencing homelessness have a high prevalence and incidence of traumatic brain injury (TBI) due to violence. Little is known about the effectiveness of interventions to reduce TBI in this population. This study assessed the effect of Housing First (HF) on violence-related TBI in adults with experiences of homelessness and mental illness. DESIGN Pragmatic randomised trial. PARTICIPANTS 381 participants in the Toronto site of the At Home/Chez randomised trial. INTERVENTION HF participants were provided with scattered-site housing using rent supplements and supports from assertive community treatment or intensive case management teams (n=218, 57.2%). Control participants had access to treatment as usual (TAU) in the community (n=163, 42.8%). MAIN OUTCOME MEASURES Primary outcomes were an incident physical violence-related TBI event and the number of physical violence-related TBI events during the follow-up period (January 2014 to March 2017). Interval-censored survival time regression and zero-inflated negative binomial regression were used to assess the effect of HF on primary outcomes. RESULTS Among study participants, 9.2% (n=35) had an incident physical violence-related TBI event, and the mean physical violence-related TBI events was 0.16 (SD ±0.6). Compared with TAU participants, HF participants did not have a significantly lower risk of an incident violence-related TBI event (adjusted HR : 0.58 (95% CI, 0.29 to 1.14)), but they had a significantly lower number of physical violence-related TBI events (unadjusted incidence rate ratio (IRR): 0.22 (95% CI, 0.06 to 0.78); adjusted IRR: 0.15 (95% CI, 0.05 to 0.48)). CONCLUSION HF may be a useful intervention to reduce the burden of TBI due to physical violence among homeless individuals with mental illness. TRIAL REGISTRATION NUMBER ISRCTN42520374.
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Affiliation(s)
- Cilia Mejia-Lancheros
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - James Lachaud
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Vicky Stergiopoulos
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Flora I Matheson
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Centre for Criminology and Sociolegal Studies, University of Toronto, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Patricia O'Campo
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Differences in Utilization of Medical and Dental Services among Homeless People in South Korea. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155304. [PMID: 32717950 PMCID: PMC7432539 DOI: 10.3390/ijerph17155304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/17/2022]
Abstract
(1) Background: Homelessness contributes to both needs for care and barriers to access. This study aimed to explore the utilization of medical or dental services using Andersen's model for a vulnerable population of homeless in South Korea. (2) Methods: The data were applied from the first national survey for homeless people in South Korea, 2016. Totally 2032 persons participated in the interview survey. This study team requested the raw data through the public portal and analyzed them. (3) Results: The participants who were homeless for more than ten years, staying in small rooming house or shelter, non-employed, earning less than 500,000 won per month, and having a medical condition showed a significantly higher chance of using Medicaid. The use of outreach programs had a significant relationship with gender, duration of homelessness, and monthly income. Among dental patients, the homeless who did not consume alcohol, stayed in a shelter, and were employed had higher chances of using dental service. (4) Conclusions: Medicaid service was strongly related to enabling factors but outreach programs with predisposing factors. Dental service showed strong relationships with the enabling domain, but the pattern was opposite: the jobless had less chance to avail it. The policymakers need to consider these domains of service utilization to provide equitable access to healthcare services.
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Stubbs JL, Thornton AE, Sevick JM, Silverberg ND, Barr AM, Honer WG, Panenka WJ. Traumatic brain injury in homeless and marginally housed individuals: a systematic review and meta-analysis. LANCET PUBLIC HEALTH 2019; 5:e19-e32. [PMID: 31806487 DOI: 10.1016/s2468-2667(19)30188-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Homelessness is a global public health concern, and traumatic brain injury (TBI) could represent an underappreciated factor in the health trajectories of homeless and marginally housed individuals. We aimed to evaluate the lifetime prevalence of TBI in this population, and to summarise findings on TBI incidence and the association between TBI and health-related or functioning-related outcomes. METHODS For this systematic review and meta-analysis, we searched without date restrictions for original research studies in English that reported data on the prevalence or incidence of TBI, or the association between TBI and one or more health-related or function-related outcome measures. Studies were included if they had a group or clearly identifiable subgroup of individuals who were homeless, marginally housed, or seeking services for homeless people. With use of random-effects models, we calculated pooled estimates of the lifetime prevalence of any severity of TBI and the lifetime prevalence of moderate or severe TBI. We used meta-regression and subgroup analysis to evaluate potential moderators of prevalence estimates and the leave-one-out method for sensitivity analyses. We then summarised findings from all studies that evaluated TBI incidence and the association between TBI and health-related or functioning-related outcomes. All statistical analyses were done using R version 3.5.1. The study is registered with PROSPERO, number CRD42019119678. FINDINGS Of 463 potentially eligible studies identified by the search, 38 studies were included in the systematic review and 22 studies were included in the meta-analysis. The lifetime prevalence of any severity of TBI in homeless and marginally housed individuals (18 studies, n=9702 individuals) was 53·1% (95% CI 46·4-59·7; I2=97%) and the lifetime prevalence of moderate or severe TBI (nine studies, n=5787) was 22·5% (13·5-35·0; I2=99%). The method used to ascertain TBI history, the age of the sample, and the sample size significantly moderated estimated lifetime prevalence of any severity of TBI. TBI was consistently associated with poorer self-reported physical and mental health, higher suicidality and suicide risk, memory concerns, and increased health service use and criminal justice system involvement. INTERPRETATION The lifetime prevalence of TBI is high among homeless and marginally housed individuals, and a history of TBI is associated with poorer health and general functioning. Health-care providers and public health officials should have an increased awareness of the burden of TBI in this population. Prospective and longitudinal studies are needed to better understand how the health of this population is affected by TBI. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Jacob L Stubbs
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada.
| | - Allen E Thornton
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada; Department of Psychology, Simon Fraser University, Burnaby, BC, Canada
| | - Jessica M Sevick
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - Noah D Silverberg
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada; Rehabilitation Research Program, Vancouver Coastal Health Research Institute, BC, Canada
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - William G Honer
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - William J Panenka
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada; British Columbia Provincial Neuropsychiatry Program, Vancouver, BC, Canada
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Gallant C, Good D. Alcohol misuse and traumatic brain injury: a review of the potential roles of dopaminergic dysfunction and physiological underarousal post-injury. APPLIED NEUROPSYCHOLOGY-ADULT 2019; 28:501-511. [PMID: 31561716 DOI: 10.1080/23279095.2019.1670181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although many researchers have demonstrated an increase in alcohol use following traumatic brain injury (TBI), there is also a body of research indicating that alcohol misuse predisposes one to injury and precedes TBI. Accordingly, various mechanisms have been proposed (e.g., self-medication, dampened levels of arousal, dopaminergic dysfunction, etc.) and variable results have emerged. This paper reviews the empirical evidence, for and against, TBI as a risk factor for alcohol misuse. In particular, this paper focuses on the brain-behavior relationships involved and examines the roles of physiological underarousal and dopaminergic dysfunction in the development of alcohol misuse after injury. Alcohol misuse impedes community reintegration among TBI survivors and creates additional rehabilitative challenges. Thus, in order to inform and improve treatment outcomes among this vulnerable population, a deeper understanding of the neural mechanisms implicated is needed.
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Affiliation(s)
- Caitlyn Gallant
- Department of Psychology, Brock University, St. Catharines, ON, Canada
| | - Dawn Good
- Department of Psychology, Brock University, St. Catharines, ON, Canada.,Centre for Neuroscience, Brock University, St. Catharines, ON, Canada
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Doran KM, Ran Z, Castelblanco D, Shelley D, Padgett DK. "It Wasn't Just One Thing": A Qualitative Study of Newly Homeless Emergency Department Patients. Acad Emerg Med 2019; 26:982-993. [PMID: 31418514 DOI: 10.1111/acem.13677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Emergency departments (EDs) frequently care for patients who are homeless or unstably housed. One promising approach taken by the homeless services system is to provide interventions that attempt to prevent homelessness before it occurs. Experts have suggested that health care settings may be ideal locations to identify and intervene with patients at risk for homelessness, yet little is known even about the basic characteristics of patients who might benefit from such interventions. METHODS We conducted in-depth, one-on-one qualitative interviews with ED patients who had become homeless within the past 6 months. Using a semistructured interview guide, we asked patients about their pathways into homelessness and what might have prevented them from becoming homeless. Interviews were digitally recorded and professionally transcribed. Transcripts were coded line by line by multiple investigators who then met as a group to discuss and refine codes in an iterative fashion. RESULTS Interviews were completed with 31 patients. Mean interview length was 42 minutes. Four main themes emerged: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected. CONCLUSIONS These findings demonstrate gaps in current homeless prevention services and can help inform future interventions for unstably housed and homeless ED patients. More immediately, the findings provide rich, unique context to the lives of a vulnerable patient population commonly seen in EDs.
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Affiliation(s)
- Kelly M. Doran
- Department of Emergency Medicine NYU School of Medicine New York NY
- Department of Population Health NYU School of Medicine New York NY
| | - Ziwei Ran
- NYU Silver School of Social Work New York NY
| | | | - Donna Shelley
- Department of Population Health NYU School of Medicine New York NY
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Adams RS, Corrigan JD, Dams-O'Connor K. Opioid Use among Individuals with Traumatic Brain Injury: A Perfect Storm? J Neurotrauma 2019; 37:211-216. [PMID: 31333067 DOI: 10.1089/neu.2019.6451] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.,VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
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38
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Exploring the experiences and needs of homeless aboriginal and torres strait islander peoples with neurocognitive disability. BRAIN IMPAIR 2019. [DOI: 10.1017/brimp.2019.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:The current study explored the experiences and aspirations of a cohort of Aboriginal and Torres Strait Islander adults with neurocognitive disability residing in a homeless shelter in regional Queensland, Australia. Neurocognitive disability (NCD) refers to any acquired disorder or injury to the brain where the primary clinical deficit is in cognitive function.Method:The data reported on in this paper emerged from a broader study that aimed to understand the extent and nature of neurocognitive disability amongst homeless Aboriginal and Torres Strait Islander people. The broader study found high levels of NCD which impacted on people’s ability to participate in society. As part of the study, qualitative information was sought regarding participant life experiences. A culturally safe and acceptable structure of “past, present and future” was applied to open-ended questions.Results:Thematic analysis of the data identified four broad themes of i) normalisation of illness and disability; ii) trauma and loss; iii) socioeconomic disadvantage; and iv) hope and disempowerment. This paper reports on these themes and experiences, which occurred across the life span, intersected with NCD, and contributed to what we have termed ‘complex disablement’ amongst this cohort.Conclusions:While causal links between life experience, disability and disablement are not always clear, our findings suggest that attempts to address homelessness must engage with this complexity. The application of holistic, intersectoral supports, which encompass culturally informed, community driven approaches are needed. Understanding the impacts of individual and intergenerational trauma is crucial to safe and effective service provision for this cohort.
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39
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Stone B, Dowling S, Cameron A. Cognitive impairment and homelessness: A scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2019; 27:e125-e142. [PMID: 30421478 PMCID: PMC6849546 DOI: 10.1111/hsc.12682] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/20/2018] [Accepted: 10/12/2018] [Indexed: 06/09/2023]
Abstract
This paper reports the findings of a scoping review designed to identify research which has explored the relationship between cognitive impairment and homelessness. A systematic search of databases for articles published between 2007 and 2017 was conducted using keywords relating to cognitive impairments and homelessness. Sources were expanded using manual searches of citations and grey literature. Forty studies represented in 45 papers were selected for review using predefined inclusion criteria. Sources were subject to quality appraisal and data were extracted in line with review questions. Prevalence studies were over-represented in the review, while qualitative data were lacking. Aetiology of impairments was delineated by acquired and developmental causes. A variety of measures were employed by studies which were not validated in homeless populations. Studies did not give sufficient consideration to co-occurring disorders and overlapping symptoms between aetiologies. Because of these factors, it was difficult to conclude that all studies had accurately measured what they set out to; however, the evidence suggested that cognitive impairment was disproportionately over-represented in homeless populations. Cognitive impairment was found to be both a risk factor to and perpetuator of homelessness. Risk factors for homelessness were similar to those of the general population, though exaggerated by sequelae of certain cognitive impairments. The results of this review suggest that more attention needs to be paid to the underlying socioeconomic disadvantages, persons with cognitive impairments face which may lead to homelessness. Further research should prioritise the voice of homeless persons with cognitive impairments, to better understand both causes of homelessness and effective methods of rehabilitation.
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40
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Rosendale N, Guterman EL, Betjemann JP, Josephson SA, Douglas VC. Hospital admission and readmission among homeless patients with neurologic disease. Neurology 2019; 92:e2822-e2831. [PMID: 31127074 DOI: 10.1212/wnl.0000000000007645] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 02/07/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize the most common neurologic diagnoses leading to hospitalization for homeless compared to housed individuals and to assess whether homelessness is an independent risk factor for 30-day readmission after an admission for a neurologic illness. METHODS We performed a retrospective serial cross-sectional study using data from the Healthcare Cost and Utilization Project California State Inpatient Database from 2006 to 2011. Adult patients with a primary neurologic discharge diagnosis were included. The primary outcome was 30-day readmission. We used multilevel logistic regression to examine the association between homelessness and readmission after adjustment for patient factors. RESULTS We identified 1,082,347 patients with a neurologic primary diagnosis. The rate of homelessness was 0.37%. The most common indications for hospitalization among homeless patients were seizure and traumatic brain injury, both of which were more common in the homeless compared to housed population (19.3% vs 8.1% and 31.9% vs 9.2%, respectively, p < 0.001). A multilevel mixed-effects model controlling for patient age, sex, race, insurance type, comorbid conditions, and clustering on the hospital level found that homelessness was associated with increased 30-day readmission (odds ratio 1.5, 95% confidence interval 1.4-1.6, p < 0.001). This association persisted after this analysis was repeated within specific diagnoses (patients with epilepsy, trauma, encephalopathy, and neuromuscular disease). CONCLUSION The most common neurologic reasons for admission among homeless patients are seizure and traumatic brain injury; these patients are at high risk for readmission. Future interventions should target the drivers of readmissions in this vulnerable population.
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Affiliation(s)
- Nicole Rosendale
- From the Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco.
| | - Elan L Guterman
- From the Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco
| | - John P Betjemann
- From the Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco
| | - S Andrew Josephson
- From the Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco
| | - Vanja C Douglas
- From the Department of Neurology and Weill Institute for Neurosciences, University of California, San Francisco
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41
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Lewer D, Aldridge RW, Menezes D, Sawyer C, Zaninotto P, Dedicoat M, Ahmed I, Luchenski S, Hayward A, Story A. Health-related quality of life and prevalence of six chronic diseases in homeless and housed people: a cross-sectional study in London and Birmingham, England. BMJ Open 2019; 9:e025192. [PMID: 31023754 PMCID: PMC6501971 DOI: 10.1136/bmjopen-2018-025192] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To compare health-related quality of life and prevalence of chronic diseases in housed and homeless populations. DESIGN Cross-sectional survey with an age-matched and sex-matched housed comparison group. SETTING Hostels, day centres and soup runs in London and Birmingham, England. PARTICIPANTS Homeless participants were either sleeping rough or living in hostels and had a history of sleeping rough. The comparison group was drawn from the Health Survey for England. The study included 1336 homeless and 13 360 housed participants. OUTCOME MEASURES Chronic diseases were self-reported asthma, chronic obstructive pulmonary disease (COPD), epilepsy, heart problems, stroke and diabetes. Health-related quality of life was measured using EQ-5D-3L. RESULTS Housed participants in more deprived neighbourhoods were more likely to report disease. Homeless participants were substantially more likely than housed participants in the most deprived quintile to report all diseases except diabetes (which had similar prevalence in homeless participants and the most deprived housed group). For example, the prevalence of chronic obstructive pulmonary disease was 1.1% (95% CI 0.7% to 1.6%) in the least deprived housed quintile; 2.0% (95% CI 1.5% to 2.6%) in the most deprived housed quintile; and 14.0% (95% CI 12.2% to 16.0%) in the homeless group. Social gradients were also seen for problems in each EQ-5D-3L domain in the housed population, but homeless participants had similar likelihood of reporting problems as the most deprived housed group. The exception was problems related to anxiety, which were substantially more common in homeless people than any of the housed groups. CONCLUSIONS While differences in health between housed socioeconomic groups can be described as a 'slope', differences in health between housed and homeless people are better understood as a 'cliff'.
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Affiliation(s)
- Dan Lewer
- Institute of Epidemiology and Healthcare, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
- Collaborative Centre for Inclusion Health, University College London, London, UK
| | - Robert W Aldridge
- Institute of Health Informatics, University College London, London, UK
- Collaborative Centre for Inclusion Health, University College London, London, UK
| | - Dee Menezes
- Institute of Health Informatics, University College London, London, UK
| | - Clare Sawyer
- Find & Treat, University College London Hospitals NHS Foundation Trust, London, London, UK
| | - Paola Zaninotto
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Martin Dedicoat
- Infectious Diseases and Tropical Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Imtiaz Ahmed
- Respiritory Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Serena Luchenski
- Institute of Epidemiology and Healthcare, University College London, London, UK
- Institute of Health Informatics, University College London, London, UK
- Collaborative Centre for Inclusion Health, University College London, London, UK
| | - Andrew Hayward
- Institute of Epidemiology and Healthcare, University College London, London, UK
- Collaborative Centre for Inclusion Health, University College London, London, UK
| | - Alistair Story
- Collaborative Centre for Inclusion Health, University College London, London, UK
- Find & Treat, University College London Hospitals NHS Foundation Trust, London, London, UK
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Mollayeva T, Mollayeva S, Colantonio A. Traumatic brain injury: sex, gender and intersecting vulnerabilities. Nat Rev Neurol 2018; 14:711-722. [DOI: 10.1038/s41582-018-0091-y] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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43
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Ma Z, Bayley MT, Perrier L, Dhir P, Dépatie L, Comper P, Ruttan L, Lay C, Munce SEP. The association between adverse childhood experiences and adult traumatic brain injury/concussion: a scoping review. Disabil Rehabil 2018; 41:1360-1366. [DOI: 10.1080/09638288.2018.1424957] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Zechen Ma
- Hull-Ellis Concussion Research Centre, Toronto Rehabilitation Institute, Toronto, Canada
| | - Mark T. Bayley
- Hull-Ellis Concussion Research Centre, Toronto Rehabilitation Institute, Toronto, Canada
| | - Laure Perrier
- Gerstein Science Information Centre, University of Toronto, Toronto, Canada
| | - Priya Dhir
- Faculty of Medicine, University of Toronto, Toronto, Canada
- The Hospital for Sick Children, Toronto, Canada
| | | | - Paul Comper
- Hull-Ellis Concussion Research Centre, Toronto Rehabilitation Institute, Toronto, Canada
| | - Lesley Ruttan
- Hull-Ellis Concussion Research Centre, Toronto Rehabilitation Institute, Toronto, Canada
| | - Christine Lay
- Centre for Headache, Women’s College Hospital, Toronto, Canada
| | - Sarah E. P. Munce
- Hull-Ellis Concussion Research Centre, Toronto Rehabilitation Institute, Toronto, Canada
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44
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Schmitt T, Thornton AE, Rawtaer I, Barr AM, Gicas KM, Lang DJ, Vertinsky AT, Rauscher A, Procyshyn RM, Buchanan T, Cheng A, MacKay S, Leonova O, Langheimer V, Field TS, Heran MK, Vila-Rodriguez F, O'Connor TA, MacEwan GW, Honer WG, Panenka WJ. Traumatic Brain Injury in a Community-Based Cohort of Homeless and Vulnerably Housed Individuals. J Neurotrauma 2017; 34:3301-3310. [DOI: 10.1089/neu.2017.5076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Toby Schmitt
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Allen E. Thornton
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Iris Rawtaer
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alasdair M. Barr
- Department of Pharmacology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kristina M. Gicas
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Donna J. Lang
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - A. Talia Vertinsky
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander Rauscher
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ric M. Procyshyn
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tari Buchanan
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Cheng
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah MacKay
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Olga Leonova
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Verena Langheimer
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thalia S. Field
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manraj K. Heran
- Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fidel Vila-Rodriguez
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tiffany A. O'Connor
- Department of Psychology, Simon Fraser University, Burnaby, British Columbia, Canada
| | - G. William MacEwan
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - William G. Honer
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - William J. Panenka
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Neuropsychiatry Program, Simon Fraser University, Burnaby, British Columbia, Canada
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Brenner LA, Hostetter TA, Barnes SM, Stearns-Yoder KA, Soberay KA, Forster JE. Traumatic brain injury, psychiatric diagnoses, and suicide risk among Veterans seeking services related to homelessness. Brain Inj 2017; 31:1731-1735. [DOI: 10.1080/02699052.2017.1376758] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Lisa A. Brenner
- Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
- Departments of Psychiatry, Neurology, and Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Trisha A. Hostetter
- Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
| | - Sean M. Barnes
- Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Kelly A. Stearns-Yoder
- Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Kelly A. Soberay
- Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
- Military Suicide Research Consortium, Denver, CO, USA
| | - Jeri E. Forster
- Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC), Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
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Hurstak E, Johnson JK, Tieu L, Guzman D, Ponath C, Lee CT, Jamora CW, Kushel M. Factors associated with cognitive impairment in a cohort of older homeless adults: Results from the HOPE HOME study. Drug Alcohol Depend 2017; 178:562-570. [PMID: 28738314 PMCID: PMC5568464 DOI: 10.1016/j.drugalcdep.2017.06.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/27/2017] [Accepted: 06/01/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND We evaluated cognitive function and factors associated with cognitive impairment in a cohort of older homeless adults. We hypothesized that substance use and a history of traumatic brain injury would be associated with cognitive impairment. METHODS We recruited 350 homeless individuals aged ≥50 years using population-based sampling and conducted structured interviews and neuropsychological testing. We evaluated alcohol use with the Alcohol Use Disorder Identification Test, defining high-severity alcohol use as a total score ≥16 or ≥4 on the alcohol dependency sub-scale. We assessed global cognition with the Modified Mini-Mental State Test (3MS) and processing speed and executive function with the Trail Making Test (TMTB), defining impairment as performing 1.5 standard deviations below the standardized mean. We used multivariable logistic regression to examine the association between alcohol use and cognition. RESULTS Participants had a median age of 58 years [IQR 54-61], 76.7% were men, and 79.9% were African American. A quarter (25.1%) of participants met criteria for impairment on the 3MS; 32.9% met criteria for impairment on TMTB. In models adjusted for sociodemographic variables and health conditions, high-severity alcohol use was associated with global cognitive impairment (AOR 2.39, CI 1.19-4.79) and executive dysfunction (AOR 3.09, CI 1.61-5.92). CONCLUSIONS Older homeless adults displayed a prevalence of cognitive impairment 3-4 times higher than has been observed in general population adults aged 70 and older. Impaired cognition in older homeless adults could impact access to housing programs and the treatment of health conditions, including the treatment of alcohol use disorders.
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Affiliation(s)
- Emily Hurstak
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA.
| | - Julene K Johnson
- Institute for Health and Aging, University of California, San Francisco, San Francisco, CA, USA; Center for Aging in Diverse Communities, University of California, San Francisco, San Francisco, CA, USA
| | - Lina Tieu
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - David Guzman
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Claudia Ponath
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Christopher T Lee
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA
| | - Christina Weyer Jamora
- Center for Aging in Diverse Communities, University of California, San Francisco, San Francisco, CA, USA; Department of Psychiatry, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA
| | - Margot Kushel
- Division of General Internal Medicine, University of California, San Francisco, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA, USA; Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, CA, USA.
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Incidence and Associated Risk Factors of Traumatic Brain Injury in a Cohort of Homeless and Vulnerably Housed Adults in 3 Canadian Cities. J Head Trauma Rehabil 2017; 32:E19-E26. [DOI: 10.1097/htr.0000000000000262] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The high burden of traumatic brain injury and comorbidities amongst homeless adults with mental illness. J Psychiatr Res 2017; 87:53-60. [PMID: 28006664 DOI: 10.1016/j.jpsychires.2016.12.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 11/22/2016] [Accepted: 12/01/2016] [Indexed: 01/26/2023]
Abstract
OBJECTIVE characterize the prevalence of self-reported head injury with loss of consciousness (LOC) and associated demographic, clinical and service use factors in a sample of homeless adults with mental illness. METHOD Participants in the At Home/Chez Soi study were interviewed at the time of study enrollment regarding their history of head injuries, mental and physical health diagnoses and justice system and healthcare interactions. Sociodemographic and clinical data were also collected. RESULTS Over half of the 2088 study respondents (52.6%, n = 1098) reported a history of head injury with a LOC, which was associated with several demographic, clinical and service use variables in this population. With respect to specific mental health conditions, a history of head injury with LOC was associated with higher odds of current depression (OR = 2.18, CI: 1.83-2.60), manic episode or hypomanic episode (OR = 1.91, CI: 1.45-2.50), PTSD (OR = 2.98, CI: 2.44-3.65), panic disorder (OR = 2.37, CI:1.91-2.93), mood disorder (OR = 1.78, CI: 1.40-2.26) and alcohol (OR = 2.09, CI: 1.75-2.49) and drug (OR = 1.73, CI: 1.46-2.06) misuse disorders, but reduced odds of having diagnosis of a psychotic disorder (OR = 0.63, CI: 0.53-0.76). A history of head injury with LOC was also associated with increased use of variety of services, including family medicine (OR = 1.33, CI: 1.12-1.59), criminal justice system (OR = 1.50, CI: 1.25-1.80) and the emergency department (OR = 1.03, CI: 1.01-1.05). CONCLUSIONS Amongst homeless adults with mental illness having a history of head injuries with LOC was independently associated with various adverse outcomes. These individuals constitute a high-risk group who may benefit from specialized services.
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Raven MC, Tieu L, Lee CT, Ponath C, Guzman D, Kushel M. Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study. Acad Emerg Med 2017; 24:63-74. [PMID: 27520382 DOI: 10.1111/acem.13070] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/27/2016] [Accepted: 07/29/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older. METHODS We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use. RESULTS In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates. CONCLUSIONS A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.
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Affiliation(s)
- Maria C. Raven
- Department of Emergency Medicine University of California at San Francisco San Francisco CA
- Philip R. Lee Institute for Health Policy Studies University of California at San Francisco San Francisco CA
| | - Lina Tieu
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Christopher T. Lee
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Claudia Ponath
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - David Guzman
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
| | - Margot Kushel
- Division of General Internal Medicine University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
- Center for Vulnerable Populations University of California at San Francisco/San Francisco General Hospital and Trauma Center San Francisco CA
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