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Sifat MS, Ehlke SJ, Ogunsanya M, Frank-Pearce SG, Boozary LK, Alexander AC, Businelle MS, Kendzor DE. Greater Discrimination Frequency and Lower Distress Tolerance Are Associated with Mental Health Problems Among Racially Privileged and Minoritized Adults Accessing an Urban Day Shelter. J Racial Ethn Health Disparities 2024; 11:45-61. [PMID: 36607564 PMCID: PMC10699794 DOI: 10.1007/s40615-022-01496-z] [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: 08/15/2022] [Revised: 11/29/2022] [Accepted: 12/15/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Discrimination experiences may be a contributing factor to the elevated prevalence of mental health problems among adults experiencing homelessness. METHODS Using survey data (N = 552) collected from adults seeking services at an urban day shelter, the relationships between everyday and major discrimination experiences, distress tolerance, and mental health problems (depression, anxiety, post-traumatic stress disorder, poor mental health days) were characterized. Distress tolerance was examined as a moderator of the relationship between discrimination and mental health problems. RESULTS Participants were predominantly from racially minoritized groups (59.6%), non-Hispanic (88.7%), and male (70.9%), with an average age of 45.7 years old (SD = 11.7). Descriptive analyses indicated that the main reason for discrimination differed between racially privileged (i.e., White participants) and racially minoritized participants (i.e., participants who identified as Black, American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, or multi-race), such that homelessness was most commonly endorsed among racially privileged participants while racial discrimination was most commonly reported among racially minoritized participants. Multivariate logistic regression analyses revealed associations between everyday discrimination, major discrimination, and distress tolerance with mental health problems. Distress tolerance did not moderate the relations between discrimination and mental health problems in most analyses. Notably, major discrimination was no longer associated with all mental health variables when both everyday and major discrimination were included in all models. CONCLUSION Findings suggest that reducing everyday discrimination and addressing the adverse impact of everyday discrimination experiences may have a beneficial impact on mental health.
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Affiliation(s)
- Munjireen S Sifat
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Sarah J Ehlke
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Psychology, Old Dominion University, Norfolk, VA, USA
| | - Motolani Ogunsanya
- College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Summer G Frank-Pearce
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Laili Kharazi Boozary
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Cellular and Behavioral Neurobiology, Psychology, University of Oklahoma, Norman, OK, USA
| | - Adam C Alexander
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Michael S Businelle
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Darla E Kendzor
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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Fine DR, Joyce A, Chang Y, Lewis E, Weinstock K, Wright J, Gaeta J, Song Z, Baggett TP. Health Care Utilization among Homeless-Experienced Adults Who Were Seen by a Mobile Addiction Health Clinic in Boston, Massachusetts: A Quasi-Experimental Study. Subst Use Misuse 2023; 58:1115-1120. [PMID: 37184078 PMCID: PMC10443101 DOI: 10.1080/10826084.2023.2212279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Background: Mobile health clinics improve access to care for marginalized individuals who are disengaged from the healthcare system. This study evaluated the association between a mobile addiction health clinic and health care utilization among people experiencing homelessness. Methods: Using Medicaid claims data, we evaluated adults who were seen by a mobile addiction health clinic in Boston, Massachusetts from 1/16/18-1/15/19 relative to a propensity score matched control cohort. We evaluated both cohorts from four years before to one year after the index visit date with the mobile clinic. The primary outcome was the number of outpatient visits; secondary outcomes were the number of hospitalizations and emergency department (ED) visits. We used Poisson regression to compare changes in outcomes from before to after the index date in a quasi-experimental design. Results: 138 adults were seen by the mobile clinic during the observation period; 29.7% were female, 16.7% were Black, 8.0% Hispanic, 68.1% White, and the mean age was 40.4 years. The mean number of mobile clinic encounters was 3.1. The yearly mean number of outpatient visits increased from 11.5 to 12.1 (p = 0.43; pdiff-in-diff = 0.15), the number of hospitalizations increased from 2.2 to 3.0 (p = 0.04; pdiff-in-diff = 0.87), and the number of ED visits increased from 5.4 to 6.5 (p = 0.04; pdiff-in-diff = 0.40). Conclusions: The mobile addiction health clinic was not associated with statistically significant changes in health care utilization in the first year. Further research in larger samples using a broader set of outcomes is needed to quantify the benefits of this innovative care delivery model.
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Affiliation(s)
- Danielle R. Fine
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Andrea Joyce
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Elizabeth Lewis
- Boston Health Care for the Homeless Program, 780 Albany Street, Boson, MA, 02118, USA
- Boston University School of Public Health, 715 Albany Street, Boson, MA, 02118, USA
| | - Karen Weinstock
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
| | - Joseph Wright
- Boston Health Care for the Homeless Program, 780 Albany Street, Boson, MA, 02118, USA
| | - Jessie Gaeta
- Boston Health Care for the Homeless Program, 780 Albany Street, Boson, MA, 02118, USA
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA
| | - Zirui Song
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Travis P. Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, 100 Cambridge Street, 16 Floor, Boston, MA, 02114, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
- Boston Health Care for the Homeless Program, 780 Albany Street, Boson, MA, 02118, USA
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Abstract
Despite its seeming breadth and diversity, the bulk of the personal (mental health) recovery literature has remained strangely 'silent' about the impact of various socio-structural inequalities on the recovery process. Such an inadequacy of the empirical literature is not without consequences since the systematic omission or downplaying, at best, of the socio-structural conditions of living for persons with lived experience of mental health difficulties may inadvertently reinforce a reductionist view of recovery as an atomised, individualised phenomenon. Motivated by those limitations in extant scholarship, a critical literature review was conducted to identify and critique relevant research to problematise the notion of personal recovery in the context of socio-structural disadvantage such as poverty, homelessness, discrimination and inequalities. The review illuminates the scarcity of empirical research and the paucity of sociologically-informed theorisation regarding how recovery is shaped by the socio-structural conditions of living. Those inadequacies are especially pertinent to homelessness research, whereby empirical investigations of personal recovery have remained few and undertheorised. The gaps in the research and theorising about the relational, contextual and socio-structural embeddedness of recovery are distilled. The critical review concludes that personal recovery has remained underresearched, underproblematised and undertheorised, especially in the context of homelessness and other forms of socio-structural disadvantage. Understanding how exclusionary social arrangements affect individuals' recovery, and the coping strategies that they deploy to negotiate those, is likely to inform anti-oppressive interventions that could eventually remove the structural constraints to human emancipation and flourishing.
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Affiliation(s)
- Dimitar Karadzhov
- Dimitar Karadzhov, Centre for
Health Policy, University of Strathclyde, 16 Richmond Street, Glasgow,
G1 1XQ, UK.
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4
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Canham SL, Rose JN, Weldrick R, Siantz E, Casucci T, McFarland MM. Understanding discrimination towards persons experiencing homelessness: A scoping review protocol. BMJ Open 2022; 12:e066522. [PMID: 36521892 PMCID: PMC9756145 DOI: 10.1136/bmjopen-2022-066522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Given the increasing rates of homelessness in recent years, there is an urgent need to address the ongoing discrimination and societal disinterest in preventing, reducing and ending homelessness. There is no systematic review of experiences of stigma and discrimination among persons experiencing homelessness or interventions to combat this discrimination. The objective for the proposed study is to identify ways in which persons experiencing homelessness have been stigmatised and discriminated against, the results of these experiences, and interventions to reduce stigma and discrimination towards persons experiencing homelessness. METHODS AND ANALYSIS We are conducting a scoping review with guidance from the JBI Manual for Evidence Synthesis and Arksey and O'Malley's framework. From 15 to 19 July 2022, we searched the following databases from our institutional licensed years of coverage: Medline, Embase, CINAHL Complete, Academic Search Ultimate, APA PsycINFO, Science Citation Index Expanded, Social Sciences Citation Index, Arts & Humanities Citation Index, Emerging Sources Citation Index, Left, PAIS International, PILOTS, Psychology & Behavioral Sciences Collection, Sociological Abstracts, and Dissertations and Theses Global. Two independent reviewers are screening study titles/abstracts and will independently screen the full texts. Study inclusion criteria include any study type reporting primary findings of English-language research on non-refugee persons experiencing homelessness in any type of setting or service worldwide. Three reviewers will then chart data of our included studies. Data will be extracted and organised into categories and subthemes in tabular form. To understand the validity of the scoping review findings in the local context and to gather additional perspectives on the topic, we will conduct an 'expert consultation' workshop. ETHICS AND DISSEMINATION This study has ethics approval from the University of Utah Institutional Review Board. Review findings will be disseminated through a peer-reviewed journal and at conferences. We plan to preregister this protocol with Open Science Framework.
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Affiliation(s)
- Sarah L Canham
- College of Social Work, University of Utah, Salt Lake City, Utah, USA
- Department of Gerontology, Simon Fraser University, Vancouver, British Columbia, Canada
- Department of City and Metropolitan Planning, The University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey N Rose
- Department of Parks, Recreation, and Tourism, College of Health, University of Utah, Salt Lake City, Utah, USA
| | - Rachel Weldrick
- Department of Gerontology, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Elizabeth Siantz
- College of Social Work, University of Utah, Salt Lake City, Utah, USA
| | - Tallie Casucci
- J. Willard Marriott Library, University of Utah, Salt Lake City, Utah, USA
| | - Mary M McFarland
- Eccles Health Sciences Library, University of Utah, Salt Lake City, Utah, USA
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5
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Slemon A, Susan Dahinten V, Stones C, Bungay V, Varcoe C. Analysis of the social consequences and value implications of the Everyday Discrimination Scale (EDS): implications for measurement of discrimination in health research. HEALTH SOCIOLOGY REVIEW : THE JOURNAL OF THE HEALTH SECTION OF THE AUSTRALIAN SOCIOLOGICAL ASSOCIATION 2022; 31:247-261. [PMID: 34416129 DOI: 10.1080/14461242.2021.1969980] [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: 01/22/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Abstract
The Everyday Discrimination Scale (EDS) is one of the most widely used measures of discrimination in health research, and has been useful for capturing the impact of discrimination on health. However, psychometric analysis of this measure has been predominantly among Black Americans, with limited examination of its effectiveness in capturing discrimination against other social groups. This paper explores the theoretical and historical foundations of the EDS, and draws on the analytic framework of Messick's theory of unified validity to examine the effectiveness of the EDS in capturing diverse experiences of discrimination. Encompassing both social consequences and value implications, Messick's unified validity contends that psychometric evaluation alone is insufficient to justify instrument use or ensure social resonance of findings. We argue that despite the robust psychometric properties and utility in addressing anti-Black race-related discrimination, the theoretical foundations and research use of the EDS have yet to respond to current discrimination theory, particularly intersectionality. This paper concludes with guidance for researchers in using the EDS in health research across diverse populations, including in data collection, analysis, and presentation of findings.
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Affiliation(s)
- Allie Slemon
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - V Susan Dahinten
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Cheyanne Stones
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Vicky Bungay
- School of Nursing, University of British Columbia, Vancouver, Canada
| | - Colleen Varcoe
- School of Nursing, University of British Columbia, Vancouver, Canada
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6
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Anvari MS, Kleinman MB, Massey EC, Bradley VD, Felton JW, Belcher AM, Magidson JF. "In their mind, they always felt less than": The role of peers in shifting stigma as a barrier to opioid use disorder treatment retention. J Subst Abuse Treat 2022; 138:108721. [PMID: 35067397 PMCID: PMC9167238 DOI: 10.1016/j.jsat.2022.108721] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/31/2021] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION A substantial, national need exists for culturally acceptable, accessible opioid use disorder (OUD) treatment. Medication for opioid use disorder (MOUD) is regarded as effective in treating OUD; however, retention in MOUD programs remains low nationally. One known barrier to MOUD retention is stigma, particularly within ethno-racial minority communities. Peer recovery specialists (PRSs), individuals with shared experience in substance use and recovery, may be particularly well suited to support patients in MOUD treatment, and may have capacity to play a key role in decreasing stigma-related barriers to MOUD retention. METHODS This study used qualitative methods to solicit feedback on how patients receiving methadone treatment (MT) experience stigma (i.e., toward substance use [SU] and MT). Study staff also gathered information regarding how a PRS role may reduce stigma and improve retention in care, including barriers and facilitators to the PRS role shifting stigma. Study staff conducted semi-structured qualitative interviews and focus groups (N = 32) with staff and patients receiving MT at an opioid treatment program as well as PRSs in Baltimore. RESULTS Participants identified experiences of internalized, as well as enacted and anticipated, MT and SU stigma, and described these as barriers to treatment. Participants also identified opportunities for PRSs to shift stigma-related barriers for patients receiving MT through unique aspects of the PRS role, such as their shared lived experience. CONCLUSIONS Reducing stigma surrounding SUD and MT is critical for improving MOUD outcomes, and future research may consider how the PRS role can support this effort.
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Affiliation(s)
- Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA.
| | - Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Ebonie C Massey
- Center for Substance Abuse Research (CESAR), University of Maryland, College Park, College Park, MD, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Julia W Felton
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Annabelle M Belcher
- Department of Psychiatry, University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
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7
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Moledina A, Magwood O, Agbata E, Hung J, Saad A, Thavorn K, Pottie K. A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1154. [PMID: 37131928 PMCID: PMC8356292 DOI: 10.1002/cl2.1154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
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Affiliation(s)
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research CentreBruyere Research InstituteOttawaCanada
| | - Eric Agbata
- Bruyere Research Institute, School of EpidemiologyPublic Health and Preventive MedicineOttawaCanada
| | - Jui‐Hsia Hung
- Faculty of Medicine, School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
| | - Ammar Saad
- Department of Epidemiology, C.T. Lamont Primary Care Research Centre, Bruyere Research InstituteUniversity of OttawaOttawaCanada
| | - Kednapa Thavorn
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
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Mejia-Lancheros C, Lachaud J, Woodhall-Melnik J, O'Campo P, Hwang SW, Stergiopoulos V. Longitudinal interrelationships of mental health discrimination and stigma with housing and well-being outcomes in adults with mental illness and recent experience of homelessness. Soc Sci Med 2021; 268:113463. [DOI: 10.1016/j.socscimed.2020.113463] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/03/2020] [Accepted: 10/16/2020] [Indexed: 02/06/2023]
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9
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Durbin A, Nisenbaum R, Wang R, Hwang SW, Kozloff N, Stergiopoulos V. Recovery Education for Adults Transitioning From Homelessness: A Longitudinal Outcome Evaluation. Front Psychiatry 2021; 12:763396. [PMID: 34880792 PMCID: PMC8645597 DOI: 10.3389/fpsyt.2021.763396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/26/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Grounded in principles of adult education, Recovery Education Centres (RECs) hold promise in promoting recovery for adults with mental health challenges, but research on recovery outcomes for hard-to-reach populations participating in RECs is scant. This quasi-experimental study compares 12-month recovery outcomes of adults with histories of homelessness and mental health challenges enrolled in a REC, to those of participants of other community services for this population. Methods: This pre-post quasi-experimental study compared participants enrolled in a REC for people with histories of homelessness and mental health challenges (n = 92) to an age-and-gender frequency matched control group participating in usual services (n = 92) for this population in Toronto, Ontario. Changes from program enrollment to 12 months in personal empowerment (primary outcome), disease specific quality of life, recovery, health status, health related quality of life, and mastery were assessed. Post-hoc analyses compared subgroups with 1-13 h (n = 37) and 14+ h (n = 37) of REC participation during the study period to the control group. Linear mixed models estimated mean changes and differences in mean changes and 95% confidence intervals. Results: Mean change in perceived empowerment from program enrollment to 12 months in the intervention group [0.10 (95% CI: 0.04, 0.15)] was not significantly different from the control group [0.05 (-0.01, 0.11)], mean difference, 0.05 [(-0.03, 0.13), P = 0.25]. In the post-hoc analysis, the mean change in perceived empowerment for the intervention subgroup with 14+ h of REC participation [0.18 (0.10, 0.26)] was significantly different than in the control group [0.05 (-0.01, 0.11)] mean difference, 0.13 [(0.03, 0.23), P < 0.01]. Mean change in mastery was also significantly different for the intervention subgroup with 14+ h of REC participation [2.03 (1.04, 3.02)] vs. controls [0.60 (-0.15, 1.35)], mean difference, 1.43 [(0.19, 2.66), P = 0.02]. There were no significant differences in other outcomes. Conclusion: With sufficient hours of participation, recovery education may be a helpful adjunct to health and social services for adults with mental health challenges transitioning from homelessness.
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Affiliation(s)
- Anna Durbin
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluatives Sciences, Toronto, ON, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Ri Wang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicole Kozloff
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluatives Sciences, Toronto, ON, Canada.,Slaight Centre for Youth in Transition, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
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10
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Determinants of healthcare use by homeless people with schizophrenia or bipolar disorder: results from the French Housing First Study. Public Health 2020; 185:224-231. [DOI: 10.1016/j.puhe.2020.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/29/2020] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
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11
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Hernandez DC, Daundasekara SS, Zvolensky MJ, Reitzel LR, Maria DS, Alexander AC, Kendzor DE, Businelle MS. Urban Stress Indirectly Influences Psychological Symptoms through Its Association with Distress Tolerance and Perceived Social Support among Adults Experiencing Homelessness. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5301. [PMID: 32717884 PMCID: PMC7432521 DOI: 10.3390/ijerph17155301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 11/18/2022]
Abstract
Traditionally, intrapersonal characteristics (distress tolerance) and interpersonal characteristics (social support) have been studied separately rather than simultaneously. In the current study, we address this gap by simultaneously examining these characteristics as potential indirect associations linking established urban stress-depression and urban stress-Post-Traumatic Stress Disorder (PTSD) relationships. Adults experiencing homelessness were recruited from six homeless shelters in Oklahoma City (n = 567). Participants self-reported urban life stress (Urban Life Stress Scale), distress tolerance (Distress Tolerance Scale), social support (Interpersonal Support Evaluation List 12), major depressive disorder (Patient Health Questionnaire-8), and PTSD symptoms (Primary Care Post-Traumatic Stress Disorder screener). Covariate-adjusted structural equation models indicated a significant indirect effect of distress tolerance on the urban stress-depression (b = 0.101, 95% CI = 0.061, 0.147) and urban stress-PTSD (b = 0.065, 95% CI = 0.023, 0.112) relationships. Additionally, a significant indirect effect of social support on the urban stress-depression (b = 0.091, 95% CI = 0.053, 0.133) and urban stress-PTSD relationships (b = 0.043, 95% CI = 0.006, 0.082) was evident. Further, both the urban stress-depression (b = 0.022, 95% CI = 0.011, 0.037) and urban stress-PTSD relationships (b = 0.014, 95% CI = 0.005, 0.026) were associated indirectly through social support to distress tolerance. Interventions that aim to increase social support may also increase distress tolerance skills and indirectly reduce depressive and PTSD symptoms in the context of urban stress among adults experiencing homelessness.
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Affiliation(s)
- Daphne C. Hernandez
- Cizik School of Nursing, The University of Texas Health Science Center, Houston, TX 77030, USA;
| | | | - Michael J. Zvolensky
- Department of Psychology, University of Houston, Houston, TX 77204, USA;
- HEALTH Research Institute, University of Houston, Houston, TX 77204, USA;
| | - Lorraine R. Reitzel
- HEALTH Research Institute, University of Houston, Houston, TX 77204, USA;
- Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, TX 77204, USA
| | - Diane Santa Maria
- Cizik School of Nursing, The University of Texas Health Science Center, Houston, TX 77030, USA;
| | - Adam C. Alexander
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, OK 73104, USA; (A.C.A.); (D.E.K.); (M.S.B.)
| | - Darla E. Kendzor
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, OK 73104, USA; (A.C.A.); (D.E.K.); (M.S.B.)
| | - Michael S. Businelle
- Oklahoma Tobacco Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma, OK 73104, USA; (A.C.A.); (D.E.K.); (M.S.B.)
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12
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Mejia-Lancheros C, Lachaud J, O’Campo P, Wiens K, Nisenbaum R, Wang R, Hwang SW, Stergiopoulos V. Trajectories and mental health-related predictors of perceived discrimination and stigma among homeless adults with mental illness. PLoS One 2020; 15:e0229385. [PMID: 32106225 PMCID: PMC7046214 DOI: 10.1371/journal.pone.0229385] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 02/04/2020] [Indexed: 12/27/2022] Open
Abstract
Stigma and discrimination toward individuals experiencing homelessness and mental disorders remain pervasive across societies. However, there are few longitudinal studies of stigma and discrimination among homeless adults with mental illness. This study aimed to identify the two-year group trajectories of stigma and discrimination and examine the predictive role of mental health characteristics among 414 homeless adults with mental illness participating in the extended follow-up phase of the Toronto At Home/Chez Soi (AH/CS) randomized trial site. Mental health-related perceived stigma and discrimination were measured at baseline, one, and two years using validated scales. Group-based-trajectory modelling was used to identify stigma and discrimination group trajectory memberships and the effect of the Housing First treatment (rent supplements and mental health support services) vs treatment as usual on these trajectories. The associations between mental health-related characteristics and trajectory group memberships were also assessed using multinomial logistic regression. Over two-years, three group trajectories of stigma and discrimination were identified. For discrimination, participants followed a low, moderate, or increasingly high discrimination group trajectory, while for stigma, participants followed a low, moderate or high stigma group trajectory. The Housing First treatment had no significant effect on discrimination or stigma trajectories groups. For the discrimination trajectories, major depressive episode, mood disorder with psychotic features, alcohol abuse, suicidality, severity of mental health symptoms, and substance use severity in the previous year were predictors of moderate and increasingly high discrimination trajectories. History of discrimination within healthcare setting was also positively associated with following a moderate or high discrimination trajectory. For the stigma trajectories, substance dependence, high mental health symptoms severity, substance use severity, and discrimination experiences within healthcare settings were the main predictors for the moderate trajectory group; while substance dependence, suicidality, mental health symptom severity, substance use severity and discrimination experiences within health care setting were also positive predictors for the high stigma trajectory group. Ethno-racial status modified the association between having a major depression episode, alcohol dependence, and the likelihood of being a member of the high stigma trajectory group. This study showed that adults experiencing mental illness and homelessness followed distinct stigma and discrimination group trajectories based on their mental health-problems. There is an urgent need to increase focus on strategies and policies to reduce stigma and discrimination in this population.
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Affiliation(s)
- Cilia Mejia-Lancheros
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - James Lachaud
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Patricia O’Campo
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Kathryn Wiens
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Applied Health Research Centre, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Ri Wang
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Stephen W. Hwang
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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13
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Karadzhov D, Yuan Y, Bond L. Coping amidst an assemblage of disadvantage: A qualitative metasynthesis of first-person accounts of managing severe mental illness while homeless. J Psychiatr Ment Health Nurs 2020; 27:4-24. [PMID: 31099122 DOI: 10.1111/jpm.12524] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 03/17/2019] [Accepted: 05/13/2019] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT?: Understanding what strategies individuals use to cope with serious mental illness is vital for enhancing their quality of life, mental well-being and recovery, and effective use of services; An episode of homelessness can be a profoundly disruptive event that often leads to chronic stress, social isolation, a negative belief about oneself and restricted access to care, among other adverse experiences; WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: In contrast to existing reviews of qualitative research focusing on escaping homelessness, managing problem substance use and growing resilience, the current review offers an in-depth, interpretive account of coping with serious mental illness during an episode of homelessness; This paper integrates evidence showing the diverse and intricate processes via which homelessness can impede an individual's ability to successfully cope with life stressors and with chronic mental illness; Despite experiencing severe social disadvantage, many individuals demonstrate positive adaptation and coping, and even personal growth; WHAT ARE THE IMPLICATIONS FOR PRACTICE?: It is important to be aware of the many ways in which coping with serious mental illness can be influenced by adverse environmental factors such as poverty, homelessness, traumatic life experiences and institutional discrimination; Nursing practice should recognize that coping efforts by individuals facing multiple forms of social disadvantage may be shaped by acute adverse life events and institutional interactions, as well as by the stresses and strains of living on the streets; Nursing practice should focus not only on reducing clients' mental illness symptoms and facilitating positive coping behaviours, but also on helping create the conditions that aid clients in leveraging inner resources for personal growth and constructive meaning-making. Abstract Introduction An evidence gap persists concerning the impact of extreme socio-structural disadvantage, such as homelessness, on the nature and effectiveness of coping with severe mental illness (SMI). While existing reviews of qualitative research into homelessness have focused on processes such as escaping homelessness and managing concurrent problem substance use, as well as on the experiences of specific vulnerable groups such as women and youth, no analogical review has been dedicated to understanding the management of SMI during an episode of homelessness. Aim/Question A qualitative metasynthesis of first-person accounts was conducted to understand how individuals cope with SMI when experiencing homelessness. Method The systematic search strategy yielded 481 potentially eligible sources. Following the team-based full-text screening and the two-tiered quality appraisal, 14 studies involving 377 participants with lived experience were synthesized following Noblit and Hare's metaethnographic method. Results Seven third-order concepts were derived capturing the complex nature and processual character of coping, as well as the web of contextual influences upon coping strategies. The resultant line-of-argument synthesis reveals the dialectical relationship between the two higher-order constructs-"the continuum of coping" and "the assemblage of disadvantage." Discussion Despite the profoundly adverse impacts of biographical and socio-structural conditions, many individuals mobilized internal and external resources to enable various coping processes. Coping in the context of multiple disadvantage is not a monolith but rather a multidimensional, contingent and fluid phenomenon. Implications for practice Nursing practice should espouse a humanizing, structurally competent, and strength- and meaning-oriented approach in order to meet the complex and multifaceted needs of such multiply disadvantaged persons.
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Affiliation(s)
- Dimitar Karadzhov
- Centre for Health Policy, International Public Policy Institute, School of Social Work and Social Policy, University of Strathclyde, Glasgow, UK
| | - Yeqing Yuan
- Silver School of Social Work, New York University, New York, New York
| | - Lynden Bond
- Silver School of Social Work, New York University, New York, New York
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14
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Craig KD, Holmes C, Hudspith M, Moor G, Moosa-Mitha M, Varcoe C, Wallace B. Pain in persons who are marginalized by social conditions. Pain 2020; 161:261-265. [PMID: 31651578 PMCID: PMC6970566 DOI: 10.1097/j.pain.0000000000001719] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/31/2019] [Accepted: 10/03/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Kenneth D. Craig
- Department of Psychology, University of British Columbia, Vancouver, BC, Canada
| | - Cindy Holmes
- School of Social Work, University of Victoria, Victoria, BC, Canada
| | | | | | | | - Colleen Varcoe
- School of Nursing, University of British Columbia, Vancouver, BC, Canada
| | - Bruce Wallace
- School of Social Work, University of Victoria, Victoria, BC, Canada
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15
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Marshall CA, Boland L, Westover LA, Wickett S, Roy L, Mace J, Gewurtz R, Barbic S, Kirsh B. Occupational experiences of homelessness: A systematic review and meta-aggregation. Scand J Occup Ther 2019; 27:394-407. [DOI: 10.1080/11038128.2019.1689292] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Carrie Anne Marshall
- Occupational Therapy, Faculty of Health Sciences, Elborn College, Western University, London, Canada
| | - Leonie Boland
- Occupational Therapy, Faculty of Health and Human Sciences, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
| | | | - Sarah Wickett
- Bracken Health Sciences Library, Queen’s University, Kingston, Canada
| | - Laurence Roy
- School of Physical and Occupational Therapy, McGill University, Montréal, Canada
| | - Jenni Mace
- Department of Occupational Science and Therapy, Auckland University of Technology, Auckland, New Zealand
| | - Rebecca Gewurtz
- School of Rehabilitation Sciences, McMaster University, Hamilton, Canada
| | - Skye Barbic
- Occupational Science & Occupational Therapy, Faculty of Medicine, Vancouver, Canada
| | - Bonnie Kirsh
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada
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16
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Gebreyesus H, Mamo A, Teweldemedhin M, Gidey B, Hdush Z, Birhanu Z. Experiences of homeless women on maternity health service utilization and associated challenge in Aksum town, Northern Ethiopia. BMC Health Serv Res 2019; 19:359. [PMID: 31170981 PMCID: PMC6554879 DOI: 10.1186/s12913-019-4201-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Homeless women are a highly vulnerable group for risks of pregnancy and childbirth-related complications. They may also face multiple challenges to access and utilize maternity healthcare services. This study was aimed to explore the experience of homeless women on maternity healthcare service utilization and associated challenges in Aksum Town, Northern Ethiopia. METHODS An exploratory qualitative study was employed using in-depth interviews among 22 study participants from February to March 2016. Purposive sampling was used to recruit 12 homeless mothers who gave birth when being homeless in the last 12 months and 10 healthcare providers as key informants. Data were captured using audio recorders and field notes and transcribed, translated verbatim and thematic analysis approach was facilitated using ATLAS.ti7 software. RESULTS The finding reveals that homeless women did not use any of the basic maternity health care services, namely antenatal care, skilled birth attendance, and postnatal care. Lack of permanent place and awareness, and fear of stigma and discrimination were some reasons hindering homeless women from using the services. CONCLUSIONS Even though maternity health service utilization is the most crucial intervention to reduce maternal and newborn deaths, this finding shows that maternity health service utilization among homeless women was limited. Socio-cultural, socioeconomic and healthcare-related factors contributed to the non-use of these services. Efforts should be made to address the challenges faced by homeless women to utilize maternity health services.
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Affiliation(s)
- Hailay Gebreyesus
- Department of Public Health, College of Health Sciences, Aksum University, Aksum, Ethiopia.
| | - Abebe Mamo
- Department of Health, Behavior and Society, Institutes of Health, Jimma University, Jimma, Ethiopia
| | - Mebrahtu Teweldemedhin
- Department of Medical Laboratory Science, College of Health Sciences, Aksum University, Aksum, Ethiopia
| | - Berihu Gidey
- Department of Public Health, College of Health Sciences, Aksum University, Aksum, Ethiopia
| | - Znabu Hdush
- Department of Public Health, Mekelle University, Mekelle, Ethiopia
| | - Zewdie Birhanu
- Department of Health, Behavior and Society, Institutes of Health, Jimma University, Jimma, Ethiopia
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17
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Wrighting Q, Reitzel LR, Chen TA, Kendzor DE, Hernandez DC, Obasi EM, Shree S, Businelle MS. Characterizing Discrimination Experiences by Race among Homeless Adults. Am J Health Behav 2019; 43:531-542. [PMID: 31046884 DOI: 10.5993/ajhb.43.3.8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objectives: Among domiciled samples, racial discrimination is a known stressor linked with poorer quality of life. However, homeless adults may be particularly vulnerable to discrimination due to multiple factors beyond race. In this study, we characterized perceived discrimination and its reported impact on quality of life in a sample of adults who were homeless. Methods: Homeless adults recruited from Oklahoma City self-reported their socio-demographics, past discrimination experiences, and their impact on quality of life via the MacArthur Major Experiences of Discrimination Questionnaire. Descriptive statistics and frequencies were used to characterize perceived discrimination experiences and impact. Racial differences were examined using ANO- VAs/Kruskal-Wallis tests and chi-square tests. Results: Discrimination experiences attributed to homelessness were common and consistent between the races. Black adults perceived significantly more lifetime discrimination experiences than white adults, and attributed the majority to race. Relative to Whites and American Indians, black adults were more likely to endorse links between discrimination and having a harder life. Conclusions: Results suggest that black homeless adults may represent the most vulnerable racial subgroup for hardships in life as a conse- quence of perceived discrimination among homeless adults.
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18
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Jones AL, Hausmann LRM, Kertesz SG, Suo Y, Cashy JP, Mor MK, Pettey WBP, Schaefer JH, Gordon AJ, Gundlapalli AV. Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes: The Veterans Health Administration's Homeless Patient Aligned Care Teams. Med Care 2019; 57:270-278. [PMID: 30789541 PMCID: PMC7773035 DOI: 10.1097/mlr.0000000000001070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In 2012, select Veterans Health Administration (VHA) facilities implemented a homeless-tailored medical home model, called Homeless Patient Aligned Care Teams (H-PACT), to improve care processes and outcomes for homeless Veterans. OBJECTIVE The main aim of this study was to determine whether H-PACT offers a better patient experience than standard VHA primary care. RESEARCH DESIGN We used multivariable logistic regressions to estimate differences in the probability of reporting positive primary care experiences on a national survey. SUBJECTS Homeless-experienced survey respondents enrolled in H-PACT (n=251) or standard primary care in facilities with H-PACT available (n=1527) and facilities without H-PACT (n=10,079). MEASURES Patient experiences in 8 domains from the Consumer Assessment of Healthcare Provider and Systems surveys. Domain scores were categorized as positive versus nonpositive. RESULTS H-PACT patients were less likely than standard primary care patients to be female, have 4-year college degrees, or to have served in recent military conflicts; they received more primary care visits and social services. H-PACT patients were more likely than standard primary care patients in the same facilities to report positive experiences with access [adjusted risk difference (RD)=17.4], communication (RD=13.9), office staff (RD=13.1), provider ratings (RD=11.0), and comprehensiveness (RD=9.3). Standard primary care patients in facilities with H-PACT available were more likely than those from facilities without H-PACT to report positive experiences with communication (RD=4.7) and self-management support (RD=4.6). CONCLUSIONS Patient-centered medical homes designed to address the social determinants of health offer a better care experience for homeless patients, when compared with standard primary care approaches. The lessons learned from H-PACT can be applied throughout VHA and to other health care settings.
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Affiliation(s)
- Audrey L. Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stefan G. Kertesz
- Birmingham VA Medical Center, Birmingham, AL; and Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - John P. Cashy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Warren B. P. Pettey
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - James H. Schaefer
- Department of Veterans Affairs Office of Reporting, Analytics, Performance, Improvement and Deployment, Durham, NC
| | - Adam J. Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT
| | - Adi V. Gundlapalli
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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19
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Stergiopoulos V, Gozdzik A, Nisenbaum R, Durbin J, Hwang SW, O'Campo P, Tepper J, Wasylenki D. Bridging Hospital and Community Care for Homeless Adults with Mental Health Needs: Outcomes of a Brief Interdisciplinary Intervention. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:774-784. [PMID: 29716396 PMCID: PMC6299183 DOI: 10.1177/0706743718772539] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study examines health and service use outcomes and associated factors among homeless adults participating in a brief interdisciplinary intervention following discharge from hospital. METHOD Using a pre-post cohort design, 223 homeless adults with mental health needs were enrolled in the Coordinated Access to Care for the Homeless (CATCH) program, a 4- to 6-month interdisciplinary intervention offering case management, peer support, access to primary psychiatric care, and supplementary community services. Study participants were interviewed at program entry and at 3- and 6-month follow-up visits and assessed for health status, acute care service use, housing outcomes, mental health, substance use, quality of life, and their working alliance with service providers. Linear mixed models and generalized estimating equations were performed to examine outcomes longitudinally. Additional post hoc analyses evaluated differences between CATCH participants and a comparison group of homeless adults experiencing mental illness who received usual services over the same period. RESULTS In the pre-post analyses, CATCH participants had statistically significant improvements in mental and physical health status and reductions in mental health symptoms, substance misuse, and the number of hospital admissions. The strength of the working alliance between participants and their case manager was associated with reduced health care use and mental health symptoms. Post hoc analyses suggest that CATCH may be associated with statistically significant improvements in mental health symptoms in the study population. CONCLUSIONS A brief interdisciplinary intervention may be a promising approach to improving health outcomes among homeless adults with unmet health needs. Further rigorous research is needed into the effectiveness of brief interventions following discharge from hospital.
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Affiliation(s)
- Vicky Stergiopoulos
- 1 Centre for Addiction and Mental Health, Toronto, Ontario.,2 Department of Psychiatry, University of Toronto, Toronto, Ontario.,3 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario
| | - Agnes Gozdzik
- 3 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario
| | - Rosane Nisenbaum
- 3 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario.,4 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Janet Durbin
- 1 Centre for Addiction and Mental Health, Toronto, Ontario.,5 University of Toronto, Toronto, Ontario
| | - Stephen W Hwang
- 3 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario.,6 Faculty of Medicine, University of Toronto, Toronto, Ontario.,7 Division of General Internal Medicine, University of Toronto, Toronto, Ontario
| | - Patricia O'Campo
- 3 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario.,4 Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | | | - Don Wasylenki
- 2 Department of Psychiatry, University of Toronto, Toronto, Ontario.,9 St. Michael's Hospital, Toronto, Ontario
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20
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Jones AL, Hausmann LRM, Haas GL, Mor MK, Cashy JP, Schaefer JH, Gordon AJ. A national evaluation of homeless and nonhomeless veterans' experiences with primary care. Psychol Serv 2018; 14:174-183. [PMID: 28481602 DOI: 10.1037/ser0000116] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record
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Affiliation(s)
- Audrey L Jones
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Gretchen L Haas
- VISN 4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - John P Cashy
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - James H Schaefer
- Department of Veterans Affairs Office of Analytics and Business Intelligence
| | - Adam J Gordon
- VA Center for Health Equity Research and Promotion, VISN4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
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21
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Paul S, Corneau S, Boozary T, Stergiopoulos V. Coping and resilience among ethnoracial individuals experiencing homelessness and mental illness. Int J Soc Psychiatry 2018; 64:189-197. [PMID: 29291667 DOI: 10.1177/0020764017748986] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The multiple challenges that ethnoracial homeless individuals experiencing mental illness face are well documented. However, little is known about how this homeless subpopulation copes with the compounding stressors of racial discrimination, homelessness and mental illness. AIMS This study is an in-depth investigation of the personal perceived strengths, attitudes and coping behaviors of homeless adults of diverse ethnoracial backgrounds experiencing homelessness and mental illness in Toronto, Canada. METHOD Using qualitative methods, 36 in-depth semi-structured interviews were conducted to capture the perspectives of ethnoracial homeless participants with mental illness on coping and resilience. Transcripts were analyzed using thematic analysis. RESULTS Similar to prior findings in the general homeless population, study participants recognized personal strengths and attitudes as great sources of coping and resilience, describing hope and optimism, self-esteem and confidence, insight into their challenges and spirituality as instrumental to overcoming current challenges. In addition, participants described several coping strategies, including seeking support from family, friends and professionals; socializing with peers; engaging in meaningful activities; distancing from overwhelming challenges; and finding an anchor. CONCLUSION Findings suggest that homeless adults with mental illness from ethnoracial groups use similar coping strategies and sources of resilience with the general homeless population and highlight the need for existing services to foster hope, recognize and support individual coping strategies and sources of resilience of homeless individuals experiencing complex challenges.
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Affiliation(s)
- Sayani Paul
- 1 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Simon Corneau
- 2 Département de sexologie, Université du Québec à Montréal, Montréal, QC, Canada
| | - Tanya Boozary
- 1 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Vicky Stergiopoulos
- 1 Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,3 Centre for Addiction and Mental Health, Toronto, ON, Canada
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Rotenberg M, Tuck A, McKenzie K. Psychosocial stressors contributing to emergency psychiatric service utilization in a sample of ethno-culturally diverse clients with psychosis in Toronto. BMC Psychiatry 2017; 17:324. [PMID: 28865428 PMCID: PMC5581931 DOI: 10.1186/s12888-017-1487-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 08/25/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Understanding the psychosocial stressors of people with psychoses from minority ethnic groups may help in the development of culturally appropriate services. This study aimed to compare psychosocial factors associated with attendance at an emergency department (ED) for six ethnic groups. Preventing crises or supporting people better in the community may decrease hospitalization and improve outcomes. METHOD A cohort was created by retrospective case note analysis of people of East-Asian, South-Asian, Black-African, Black-Caribbean, White-North American and White-European origin groups attending a specialized psychiatric ED in Toronto with a diagnosis of psychosis between 2009 and 2011. The psychological or social stressors which were linked to the presentation at the ED that were documented by the attending physicians were collected for this study. Logistic regression models were constructed to analyze the odds of presenting with specific stressors. RESULTS Seven hundred sixty-five clients were included in this study. Forty-four percent of the sample did not have a psychiatrist, and 53% did not have a primary care provider. Social environmental stressors were the most frequent psychosocial stressor across all six groups, followed by issues in the primary support group, occupational and housing stressors. When compared to White-North American clients, East-Asian and White-European origin clients were less likely to present with a housing stressor, while Black-African clients had decreased odds of presenting with primary support group stressor. Having a primary care provider or psychiatrist were predominantly protective factors. CONCLUSION In Toronto, moving people with chronic mental health conditions out of poverty, increasing the social safety net and improving access to primary care and community based mental health services may decrease many of the stressors which contribute to ED attendance.
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Affiliation(s)
- Martin Rotenberg
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
- Centre for Addiction and Mental Health, 33 Russell Street, Room 2017, Toronto, ON M5S 3B1 Canada
| | - Andrew Tuck
- Centre for Addiction and Mental Health, 33 Russell Street, Room 2017, Toronto, ON M5S 3B1 Canada
| | - Kwame McKenzie
- Department of Psychiatry, University of Toronto, Toronto, ON Canada
- Centre for Addiction and Mental Health, 33 Russell Street, Room 2017, Toronto, ON M5S 3B1 Canada
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23
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Perceived Discrimination in Health Care and Mental Health/Substance Abuse Treatment Among Blacks, Latinos, and Whites. Med Care 2017; 55:173-181. [PMID: 27753743 DOI: 10.1097/mlr.0000000000000638] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Experiences of discrimination in health care settings may contribute to disparities in mental health outcomes for blacks and Latinos. We investigate whether perceived discrimination in mental health/substance abuse visits contributes to participants' ratings of treatment helpfulness and stopped treatment. RESEARCH METHODS We used data from 3 waves of the California Quality of Life Survey, a statewide population-based telephone survey assessing mental health/substance disorders and their treatment. In a sample of 1099 adults (age 18-72) who indicated prior year mental health/substance abuse visits, we examined: experiences of discrimination that occurred during health care and mental health/substance abuse visits, ratings of treatment helpfulness, and reports of stopping treatment early. RESULTS Fifteen percent of California adults reported discrimination during a health care visit and 4% specifically during mental health/substance abuse visits. Latinos, the uninsured, and those with past year mental disorders were twice as likely as others to report health care discrimination [adjusted odds ratio (AORs)=2.08, 2.77, and 2.51]. Uninsured patients were 7 times more likely to report discrimination in mental health/substance abuse visits (AOR=7.27, P<0.01). The most commonly reported reasons for health care discrimination were race/ethnicity for blacks (52%) and Latinos (31%), and insurance status for whites (40%). Experiences of discrimination in mental health/substance abuse visits were associated with less helpful treatment ratings for Latinos (AOR=0.09, P<0.05) and whites (AOR=0.25, P<0.01), and early treatment termination for blacks (AOR=13.38, P<0.05). CONCLUSIONS Experiences of discrimination are associated with negative mental health/substance abuse treatment experiences and stopped treatment, and could be a factor in mental health outcomes.
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Kahan D, Poremski D, Wise-Harris D, Pauly D, Leszcz M, Wasylenki D, Stergiopoulos V. Perceived Case Management Needs and Service Preferences of Frequent Emergency Department Users: Lessons Learned in a Large Urban Centre. PLoS One 2016; 11:e0168782. [PMID: 28002491 PMCID: PMC5176181 DOI: 10.1371/journal.pone.0168782] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 12/06/2016] [Indexed: 11/25/2022] Open
Abstract
Objectives This study aimed to explore the service needs and preferences of frequent emergency department users with mental health and addictions concerns who participated in a brief intensive case management intervention. Methods We conducted semi-structured individual interviews with 20 frequent emergency department users with mental health and addictions challenges, 13 service providers involved in the delivery of a brief case management intervention, and a focus group with intervention case managers. Thematic analysis was used to explore perceived service user profiles, service needs and preferences of care. Results Service users experienced complex health and social needs and social isolation, while exhibiting resilience and the desire to contribute. They described multiple instances of stigmatization in interactions with healthcare professionals. Components of the brief intensive case management intervention perceived to be helpful included system navigation, advocacy, intermediation, and practical needs assistance. Frequent service users valued relational responsiveness, a non-judgmental stance, and a recovery orientation in case managers. Conclusion Interventions for frequent service users in mental health may be enhanced by focusing on the engagement of formal and informal social supports, practical needs assistance, system navigation, advocacy and intermediation, and attention to the recovery goals of service users.
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Affiliation(s)
- Deborah Kahan
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Poremski
- Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Mental Health, Singapore
| | - Deborah Wise-Harris
- Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Daniel Pauly
- Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Molyn Leszcz
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Donald Wasylenki
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Vicky Stergiopoulos
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- * E-mail:
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25
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Scoping Review of Interventions Supporting Mothers with Mental Illness: Key Outcomes and Challenges. Community Ment Health J 2016; 52:927-936. [PMID: 27339325 DOI: 10.1007/s10597-016-0037-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 06/15/2016] [Indexed: 10/21/2022]
Abstract
Despite the fact that more than 60 % of women experiencing mental distress also care for dependent children, little is known about the efficacy of interventions supporting parents with mental illness. A scoping review of the literature published between 1997 and 2014 was conducted to obtain an overview of empirically evaluated interventions and to typify their outcomes. Our review identified 19 publications reporting on 9 interventions. The efficacy of programs was apparent and key components used by programs were recognized. To enhance the well-being of mothers with mental illness and their children an increased knowledge transfer in this field is required.
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Stergiopoulos V, Gozdzik A, Misir V, Skosireva A, Connelly J, Sarang A, Whisler A, Hwang SW, O'Campo P, McKenzie K. Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial. PLoS One 2015; 10:e0130281. [PMID: 26176621 PMCID: PMC4503775 DOI: 10.1371/journal.pone.0130281] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 05/18/2015] [Indexed: 11/30/2022] Open
Abstract
Housing First (HF) is being widely disseminated in efforts to end homelessness among homeless adults with psychiatric disabilities. This study evaluates the effectiveness of HF with Intensive Case Management (ICM) among ethnically diverse homeless adults in an urban setting. 378 participants were randomized to HF with ICM or treatment-as-usual (TAU) in Toronto (Canada), and followed for 24 months. Measures of effectiveness included housing stability, physical (EQ5D-VAS) and mental (CSI, GAIN-SS) health, social functioning (MCAS), quality of life (QoLI20), and health service use. Two-thirds of the sample (63%) was from racialized groups and half (50%) were born outside Canada. Over the 24 months of follow-up, HF participants spent a significantly greater percentage of time in stable residences compared to TAU participants (75.1% 95% CI 70.5 to 79.7 vs. 39.3% 95% CI 34.3 to 44.2, respectively). Similarly, community functioning (MCAS) improved significantly from baseline in HF compared to TAU participants (change in mean difference = +1.67 95% CI 0.04 to 3.30). There was a significant reduction in the number of days spent experiencing alcohol problems among the HF compared to TAU participants at 24 months (ratio of rate ratios = 0.47 95% CI 0.22 to 0.99) relative to baseline, a reduction of 53%. Although the number of emergency department visits and days in hospital over 24 months did not differ significantly between HF and TAU participants, fewer HF participants compared to TAU participants had 1 or more hospitalizations during this period (70.4% vs. 81.1%, respectively; P=0.044). Compared to non-racialized HF participants, racialized HF participants saw an increase in the amount of money spent on alcohol (change in mean difference = $112.90 95% CI 5.84 to 219.96) and a reduction in physical community integration (ratio of rate ratios = 0.67 95% CI 0.47 to 0.96) from baseline to 24 months. Secondary analyses found a significant reduction in the number of days experiencing problems due to alcohol use among foreign-born (vs. Canadian-born) HF participants at 24 months (ratio of rate ratios = 0.19 95% 0.04 to 0.88), relative to baseline. Compared to usual care, HF with ICM can improve housing stability and community functioning and reduce the days of alcohol related problems in an ethnically diverse sample of homeless adults with mental illness within 2-years.
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Affiliation(s)
- Vicky Stergiopoulos
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Agnes Gozdzik
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Vachan Misir
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Anna Skosireva
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Jo Connelly
- Toronto North Support Services, Toronto, Ontario, Canada
| | | | - Adam Whisler
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Patricia O'Campo
- Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Kwame McKenzie
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Health Services and Health Equity Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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