Practical issues regarding implementing a randomized clinical trial in a homeless population: strategies and lessons learned

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

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

Association between psychosocial factors and co-morbid cigarette smoking and alcohol use in a population experiencing homelessness

The prevalence of combustible cigarette smoking in populations experiencing homelessness in the United States is five times that of the general population. The psychosocial well-being of persons who smoke and experience homelessness is poorer if such persons also use alcohol heavily. The PTQ2 study was a randomized clinical trial among persons experiencing homelessness who were also current smokers and heavy alcohol consumers. Secondary data analysis of the PTQ2 baseline data was conducted to examine associations among psychosocial variables (anxiety, depression, hopelessness, social network size), heaviness of smoking (cigarettes/day) and alcohol consumption (drinking days/month), and duration and frequency of homelessness. Among the 420 participants, the majority were male (75%), black (70%) and non-Hispanic (94%) with a mean age of 46.6 years (SD = 11.6).  Bivariate analyses show that heaviness of smoking was positively correlated with social network size (r = 0.16, p = .001). Heaviness of drinking was positively correlated with the MINI anxiety score (r = 0.13, p = .009) and marijuana use (median total number of drinks in past 30 days among those who used marijuana in past 30 days vs. did not use: 50 vs. 24, p < .0001), and associated with frequency of homelessness (median total number of drinks in past 30 days among those experiencing homelessness once vs. >1 time: 30 vs. 44, p = .022). The findings highlight the psychosocial factors that warrant consideration when addressing heavy smoking and alcohol consumption in persons experiencing homelessness.

The Challenges of Vaccine Trial Participation among Underserved and Hard-to-Reach Communities: An Internal Expert Consultation of the VACCELERATE Consortium

Underserved and hard-to-reach population groups are under-represented in vaccine trials. Thus, we aimed to identify the challenges of vaccine trial participation of these groups in member countries of the VACCELERATE network. Seventeen National Coordinators (NC), each representing their respective country (15 European countries, Israel, and Turkey), completed an online survey. From 15 eligible groups, those that were more frequently declared underserved/hard-to-reach in vaccine research were ethnic minorities (76.5%), persons experiencing homelessness (70.6%), illegal workers and refugees (64.7%, each). When prioritization for education on vaccine trials was considered, ethnic groups, migrants, and immigrants (5/17, 29.4%) were the groups most frequently identified by the NC as top targets. The most prominent barriers in vaccine trial participation affecting all groups were low levels of health literacy, reluctance to participate in trials due to engagement level, and low levels of trust in vaccines/vaccinations. This study highlighted population groups considered underserved/hard-to-reach in countries contained within the European region, and the respective barriers these groups face when participating in clinical studies. Our findings aid with the design of tailored interventions (within-and across-countries of the European region) and with the development of strategies to overcome major barriers in phase 2 and phase 3 vaccine trial participation.

Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries

BACKGROUND

Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night.

OBJECTIVE

To compare care patterns and outcomes between homeless and nonhomeless individuals with acute neurotraumatic injuries.

METHODS

Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, in-hospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk.

RESULTS

Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger ( P = .004), predominantly male ( P = .003), and less frail ( P = .003) but had similar presenting Glasgow Coma Scale scores ( P = .85), neurointensive care unit stay time ( P = .15), neurosurgical interventions ( P = .27), and in-hospital mortality ( P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]).

CONCLUSION

Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.

Tobacco use behaviors and views on engaging in clinical trials for tobacco cessation among individuals who experience homelessness

Background

Clinical trials that include contingency management for smoking cessation have shown promising results for short-term quitting, but none have explored this approach for long-term abstinence in people experiencing homelessness. We designed a clinical trial of an extended contingency management intervention for smoking cessation for people experiencing homelessness. This study has two aims: (1) to explore tobacco use behaviors, and views toward smoking cessation, and (2) to explore factors influencing acceptability of engaging in such a trial in a sample of adult smokers experiencing homelessness.

Methods

We administered a questionnaire to obtain information on tobacco use behaviors and conducted in-depth, semi-structured interviews with 26 patients who had experienced homelessness and were patients at a safety net health clinic in San Francisco, California, where we planned to pilot the intervention. We obtained information on triggers for tobacco use, prior cessation experiences, attitudes toward cessation, attitudes toward engaging in a clinical trial for cessation, and factors that might influence participation in our proposed contingency management clinical trial. We analyzed transcripts using content analysis.

Results

Participants described the normative experiences of smoking, co-occurring substance use, and the use of tobacco to relieve stress as barriers to quitting. Despite these barriers, most participants had attempted to quit smoking and most were interested in engaging in a clinical trial as a method to quit smoking. Participants noted that desirable features of the trial include: receiving financial incentives to quit smoking, having a flexible visit schedule, having the study site be easily accessible, and having navigators with lived experiences of homelessness.

Conclusion

A patient-centric clinical trial design that includes incentives, flexible visits and navigators from the community may increase feasibility of engaging in clinical trials among individuals experiencing homelessness.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

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.

The implementation of a smoking cessation and alcohol abstinence intervention for people experiencing homelessness

Background

In the United States, eighty percent of the adult homeless population smokes cigarettes compared to 15 percent of the general population. In 2017 Power to Quit 2 (PTQ2), a randomized clinical trial, was implemented in two urban homeless shelters in the Upper Midwest to address concurrent smoking cessation and alcohol treatment among people experiencing homelessness. A subset of this study population were interviewed to assess their experiences of study intervention. The objective of this study was to use participants’ experiences with the intervention to inform future implementation efforts of combined smoking cessation and alcohol abstinence interventions, guided by the Consolidated Framework for Implementation Research (CFIR).

Methods

Qualitative semi-structured interviews were conducted with 40 PTQ2 participants between 2016–2017 and analyzed in 2019. Interviews were audio-recorded, transcribed, and analyzed using a socially constructivist approach to grounded theory.

Results

Participants described the PTQ2 intervention in positive terms. Participants valued the opportunity to obtain both counseling and nicotine-replacement therapy products (intervention characteristics) and described forming a bond with the PTQ2 staff and reliance on them for emotional support and encouragement (characteristics of individuals). However, the culture of alcohol use and cigarette smoking around the shelter environment presented a serious challenge (outer setting). The study setting and the multiple competing needs of participants were reported as the most challenging barriers to implementation (implementation process).

Conclusion

There are unique challenges in addressing smoking cessation with people experiencing homelessness. For those in shelters there can be the difficulty of pro-smoking norms in and around the shelter itself. Considering pairing cessation with policy level interventions targeting smoke-free spaces, or pairing cessation with housing support efforts may be worthwhile.. Participants described a discord in their personal goals of reduction compared with the study goals of complete abstinence, which may pose a challenge to the ways in which success is defined for people experiencing homelessness.

Trial registration

Clinicaltrials.gov, NCT01932996, registered 08/30/2013.

Reducing lifestyle risk behaviours in disadvantaged groups in high-income countries: A scoping review of systematic reviews

High prevalence of risk behaviours may exacerbate existing poor health in disadvantaged groups. We aimed to identify and bring together systematic reviews with a focus on reducing risk behaviours in disadvantaged groups and highlight where evidence is lacking. We searched MEDLINE and Embase up to October 2020, with supplementary searching in Epistemonikos and Health Systems Evidence. We included systematic reviews that reported behavioural outcomes and targeted smoking, excessive alcohol use, unhealthy diet, or physical inactivity in groups with the following characteristics: low income or low socio-economic status (SES), unemployed people, homeless people, care leavers, prisoners, refugees or asylum seeker, Gypsies, Travellers, or Roma, people with learning disabilities and people living in disadvantaged areas. Reviews that included primary studies from any high-income country were eligible. Reviews were mapped based on the disadvantaged group(s) and behaviour(s) targeted. Ninety-two reviews were included, with the majority (n = 63) focusing on people with low income or low SES. We identified gaps in the evidence for care leavers; Gypsies, Travellers, and Roma and limited evidence for refugees and unemployed people. Few reviews targeted alcohol use. There was limited evidence on barriers and facilitators to behaviour change. This suggests there is insufficient evidence to inform policy and practice and new reviews or primary studies may be required.

Association between Psychological Integration and Permanent Supportive Housing: An Exploratory Study with a Focus on Ethnicity

There is limited research on the association between Permanent Supportive Housing (PSH) and psychological integration. The purpose of this study was to explore this association among individuals with mental illness and/or substance use disorder (SUD) enrolled in PSH and to identify variables associated with sense of belonging. Given differences in outcomes of PSH by ethnicity, we were interested to determine if an association existed between PSH and psychological integration and whether it was equally observed among Hispanics and non-Hispanics. The target population included individuals who were chronically homeless and diagnosed with a mental illness and/or SUD. Baseline data were collected upon intake (N = 370). Follow-up data were collected at six-months post baseline (N = 286) and discharge (N = 143). Predictor and control variables included demographics, overall health, PTSD symptom severity, interactions with family and friends, and participation in recovery-related groups in the community. Psychological integration scores increased significantly from the baseline to the 6-month follow-up (t = −3.41, p = 0.003) and between the 6-month follow-up and discharge (t = −2.97, p = 0.007). Significant predictors of psychological integration included overall health, interactions with family and/or friends, PTSD symptoms, income, education, and diagnosis. No differences were observed between Hispanics and non-Hispanics. The findings from this exploratory study suggest that future research in this area is warranted.

Homelessness and Research: Methodological Obstacles and Lessons Learned from a Psychological Study in Parisian Homeless Services

Homelessness, defined as a lack of appropriate, stable, and permanent housing, is a common issue in many societies and is linked to both structural and individual factors. These factors include psychological mechanisms and disorders which can trigger or worsen already precarious situations. In order for these factors to be taken into account in social rehabilitation programs, they need to be precisely described. However, at present, studies in this field are lacking in France. Despite homelessness being an issue across the country, few studies have evaluated the underlying psychological or neuropsychological mechanisms. More data are needed, not only to provide an accurate description of the situation in France, but also to ensure that foreign observations and interventions are relevant for application to the homeless population. In order to achieve this, more quantitative and qualitative data and investigative methodologies and studies are needed. Sharing experience and methods within the scientific community is one way to support further research, particularly in complex domains such as homelessness. At the moment, only a few such papers have been published. In this paper, we share our experiences from a research project that started in 2020 (currently unpublished) on the prevalence of cognitive disorders among homeless service users in Paris. We describe the exploratory phase of our project, obstacles encountered during the implementation of the study, including how we dealt with ethical issues, and data collection. We end the paper with recommendations for future psychological studies on homelessness.

Interventions to reduce tobacco use in people experiencing homelessness

BACKGROUND

Populations experiencing homelessness have high rates of tobacco use and experience substantial barriers to cessation. Tobacco-caused conditions are among the leading causes of morbidity and mortality among people experiencing homelessness, highlighting an urgent need for interventions to reduce the burden of tobacco use in this population.

OBJECTIVES

To assess whether interventions designed to improve access to tobacco cessation interventions for adults experiencing homelessness lead to increased numbers engaging in or receiving treatment, and whether interventions designed to help adults experiencing homelessness to quit tobacco lead to increased tobacco abstinence. To also assess whether tobacco cessation interventions for adults experiencing homelessness affect substance use and mental health.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register, MEDLINE, Embase and PsycINFO for studies using the terms: un-housed*, homeless*, housing instability, smoking cessation, tobacco use disorder, smokeless tobacco. We also searched trial registries to identify unpublished studies. Date of the most recent search: 06 January 2020.

SELECTION CRITERIA

We included randomized controlled trials that recruited people experiencing homelessness who used tobacco, and investigated interventions focused on the following: 1) improving access to relevant support services; 2) increasing motivation to quit tobacco use; 3) helping people to achieve abstinence, including but not limited to behavioral support, tobacco cessation pharmacotherapies, contingency management, and text- or app-based interventions; or 4) encouraging transitions to long-term nicotine use that did not involve tobacco. Eligible comparators included no intervention, usual care (as defined by the studies), or another form of active intervention.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Tobacco cessation was measured at the longest time point for each study, on an intention-to-treat basis, using the most rigorous definition available. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) for smoking cessation for each study where possible. We grouped eligible studies according to the type of comparison (contingent reinforcement in addition to usual smoking cessation care; more versus less intensive smoking cessation interventions; and multi-issue support versus smoking cessation support only), and carried out meta-analyses where appropriate, using a Mantel-Haenszel random-effects model. We also extracted data on quit attempts, effects on mental and substance-use severity, and meta-analyzed these outcomes where sufficient data were available.

MAIN RESULTS

We identified 10 studies involving 1634 participants who smoked combustible tobacco at enrolment. One of the studies was ongoing. Most of the trials included participants who were recruited from community-based sites such as shelters, and three included participants who were recruited from clinics. We judged three studies to be at high risk of bias in one or more domains. We identified low-certainty evidence, limited by imprecision, that contingent reinforcement (rewards for successful smoking cessation) plus usual smoking cessation care was not more effective than usual care alone in promoting abstinence (RR 0.67, 95% CI 0.16 to 2.77; 1 trial, 70 participants). We identified very low-certainty evidence, limited by risk of bias and imprecision, that more intensive behavioral smoking cessation support was more effective than brief intervention in promoting abstinence at six-month follow-up (RR 1.64, 95% CI 1.01 to 2.69; 3 trials, 657 participants; I² = 0%). There was low-certainty evidence, limited by bias and imprecision, that multi-issue support (cessation support that also encompassed help to deal with other challenges or addictions) was not superior to targeted smoking cessation support in promoting abstinence (RR 0.95, 95% CI 0.35 to 2.61; 2 trials, 146 participants; I² = 25%). More data on these types of interventions are likely to change our interpretation of these data. Single studies that examined the effects of text-messaging support, e-cigarettes, or cognitive behavioral therapy for smoking cessation provided inconclusive results. Data on secondary outcomes, including mental health and substance use severity, were too sparse to draw any meaningful conclusions on whether there were clinically-relevant differences. We did not identify any studies that explicitly assessed interventions to increase access to tobacco cessation care; we were therefore unable to assess our secondary outcome 'number of participants receiving treatment'.

AUTHORS' CONCLUSIONS

There is insufficient evidence to assess the effects of any tobacco cessation interventions specifically in people experiencing homelessness. Although there was some evidence to suggest a modest benefit of more intensive behavioral smoking cessation interventions when compared to less intensive interventions, our certainty in this evidence was very low, meaning that further research could either strengthen or weaken this effect. There is insufficient evidence to assess whether the provision of tobacco cessation support and its effects on quit attempts has any effect on the mental health or other substance-use outcomes of people experiencing homelessness. Although there is no reason to believe that standard tobacco cessation treatments work any differently in people experiencing homelessness than in the general population, these findings highlight a need for high-quality studies that address additional ways to engage and support people experiencing homelessness, in the context of the daily challenges they face. These studies should have adequate power and put effort into retaining participants for long-term follow-up of at least six months. Studies should also explore interventions that increase access to cessation services, and address the social and environmental influences of tobacco use among people experiencing homelessness. Finally, studies should explore the impact of tobacco cessation on mental health and substance-use outcomes.

Evaluating a specialist primary care service for patients experiencing homelessness: a qualitative study

BACKGROUND

People experiencing homelessness (PEH) often experience poor health, multimorbidity, and early mortality and experience barriers to accessing high quality health care. Little is known about how best to provide specialist primary care for these patients.

AIM

To evaluate the health care provided to patients experiencing homelessness who were seen in a specialist primary care service.

DESIGN & SETTING

A qualitative evaluation of a city centre primary healthcare service for excluded and vulnerable people, such as rough sleepers, who find it difficult to visit mainstream GP services.

METHOD

Data on patient characteristics and service use were extracted from primary care records using electronic and free-text searches to provide context to the evaluation. Semi-structured interviews with 11 patients and four staff were used to explore attitudes and experiences.

RESULTS

Patients had high needs compared with the general population. Patients valued continuity of care, ease of access, multidisciplinary care, and person-centred care. Staff were concerned that they lacked opportunities for reflection and learning, and that low clinical capacity affected service safety and quality. Staff also wanted more patient involvement in service planning.

CONCLUSION

PEH's complex health and social problems benefited from a specialist primary care service, which is thought to reduce barriers to access, treat potentially challenging patients in a non-judgmental way, and provide personal continuity of care in order to develop trust.

Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States

This article investigates the gap in access to and quality of mental health care in the United States. This work first discusses how minority populations are most affected by the treatment gap. It summarizes recent literature on the topic for better understanding the needs of psychiatrically underserved and disenfranchised populations and the causes of mental health disparities. It reviews some of the barriers to behavioral health care, including lack of insurance coverage, lack of community-based interventions, unequal access to evidence-based practices, stigma, mental health workforce shortages, and geographical maldistribution of providers. Second, it reviews opportunities to address these disparities. The article provides examples of effective interventions that researchers worldwide have already implemented to address the gap of mental health services within the collaborative care model and global mental health initiatives. Telepsychiatry and improvements in training of the mental health workforce are also listed as useful implementations to overcome the treatment gap for patients seeking mental health care.

"It's a hard thing to manage when you're homeless": the impact of the social environment on smoking cessation for smokers experiencing homelessness

BACKGROUND

Up to 80% of the adult homeless population use tobacco, and smoking cessation programs could offer an important opportunity to address preventable mortality and morbidity for this population. This population faces serious challenges to smoking cessation, including the impact of the social environment.

METHODS

Forty participants (11 female; 29 male) from an ongoing smoking cessation randomized clinical trial conducted at 2 urban homeless shelters in the Upper Midwest were invited to take part in semi-structured interviews in 2016-2017. An interviewer used a semi-structured interview guide asking participants to describe their experience of how the social environment impacted their attempt to quit smoking.

RESULTS

Participants described feeling pressure to smoke and drink in and around shelters, and that this pressure had led some to start smoking or resume smoking, along with making it very challenging to quit. Participants described being motivated to quit, and seeing smoking cessation as positively impacting the time and focus they felt they had for finding housing. However many felt more interested in reducing their smoking, rather than quitting.

CONCLUSIONS

Addressing smoking cessation for people experiencing homelessness is both an important public health opportunity, and a challenge. There is a need to consider cessation in the context of the social and environmental factors impacting smokers who are experiencing homelessness. In particular, there is a need to address the collective value placed on smoking in social interactions. Despite these challenges, there are high levels of motivation and interest in addressing smoking.

TRIAL REGISTRATION

NCT01932996 . Date of registration 30th August 2013. Prospectively registered.

The provision of cell phones as a recruitment and retention strategy for people who inject drugs enrolling in a randomized trial

BACKGROUND

Studies of drug-using populations often restrict enrollment by limiting participation to those with a working telephone. It is unknown whether supplying phones could broaden recruitment and sustain retention among an urban population of people who inject drugs (PWID). We compare the feasibility of offering pay-by-month phones to gift card compensation as part of an ongoing randomized controlled trial of hospitalized PWID.

METHODS

Participants were recruited from inpatient services at an urban hospital in Boston, MA to participate in an ongoing randomized trial testing a motivational interviewing (MI) intervention. Participants who did not have their own phone at the time of enrollment were offered a pay-by-month phones as compensation for study participation.

RESULTS

Eighty-one participants met study criteria, were enrolled, and completed the study at the time of analysis. We used a generalized estimating equation to compare the overall likelihood of attending interviews during the 12-month follow-up period. Participants receiving phones tended to have lower mean educational attainment (11.4 years vs. 12.1 years), were significantly (Fisher's exact p < 0.001) more likely to report homelessness during the past 90 days (86.7% vs. 37.3%), and were significantly less likely (Fisher's exact p = .044) to be employed (3.3% vs. 20.4%) compared to those receiving gift cards. Participants in each group were equally likely to attend follow-up interviews during the study (83.3% vs. 88.3%, p = 0.53).

CONCLUSION

Offering phones as a compensation method allows recruitment of a more disenfranchised population without impacting study retention and therefore may improve generalizability of study results.