Homelessness in pregnancy

OBJECTIVES

To evaluate the association, if any, of homelessness or refuge accommodation on delivery and short term perinatal outcomes in an Irish tertiary maternity hospital.

METHODS

A retrospective cohort study of 133 singleton pregnancies in women reporting to be homeless or living in refuge at their booking antenatal appointment between 2013 and 2022. Analysis compared sociodemographic characteristics and perinatal outcomes in this cohort to a reference population of 76,858 women with stable living arrangements.

RESULTS

Women in the homeless/refuge population were statistically more likely to be single (75.2 % vs 39.5 %, p < 0.001), have an unplanned pregnancy (73.7 % vs 27.2 %, p < 0.001), report a history of psychiatric illness (42.9 % vs 22.4 %, p < 0.001), domestic violence (18.8 % vs 0.9 %, p < 0.001) alcohol consumption in pregnancy (3.0 % vs 0.8 %, p < 0.001) or smoking in pregnancy (41.3 % vs 9.7 %, p < 0.001). They were significantly more likely to have a preterm birth (adjusted OR 1.71 (1.01-2.87) p = 0.04). They also had a significantly lower median birth weight compared to the reference population (birthweight 3270 g vs 3420 g, p < 0.001).

CONCLUSION

Women in the homeless and refuge population are more likely to experience poorer perinatal outcomes compared to women with stable living arrangements.

The effect of a financial incentive on COVID-19 vaccination uptake, and predictors of uptake, in people experiencing homelessness: A randomized controlled trial

People who are homeless are at increased risk of COVID-19 infection, and of poorer associated outcomes. Delivering vaccinations to, and ensuring uptake of multiple doses in, people who are homeless is complex. Financial incentives may improve vaccination uptake, particularly in people who have not received routine vaccinations previously, though evidence about the effect of incentives is limited and variable. This randomized controlled trial (ANZCTR 383156) assessed the effect of a financial incentive (an A$10 grocery voucher) on uptake of the second COVID-19 vaccination in Australian adults who were homeless, and who had received their first dose. Participants were recruited through a vaccination program for people experiencing homelessness between September 2021 and January 2022. They were followed-up for a minimum of 6.5 months. Uptake was measured 'on-time' at 6 weeks, and at any time during the trial period. Vaccination status was checked on the Australian Immunisation Register. Demographic and vaccination program characteristics associated with uptake were also investigated. Eighty-six people consented to participate, and 43 were randomly allocated to each of the 'incentive' and 'no incentive' groups. The incentive slightly increased the likelihood of a participant receiving a second vaccination on-time (risk difference (RD), 11.6 % [95 %CI, -9.0, 32.2 %]; p = 0.27), and at any time during the trial (RD, 14.0 % [95 %CI, -2.2, 30.1 %], p = 0.09). The incentive had a significant positive effect on uptake in people with no previous vaccination history, increasing their likelihood of receiving a second vaccination on-time (RD, 42.3 % [95 %CI, 15.7, 68.8 %]; p = 0.002) and at any time during the trial (RD, 38.7 % [95 %CI, 16.1, 61.3 %], p < 0.001). Financial incentives may increase COVID-19 vaccination uptake in people who are homeless, and particularly those who have no previous vaccination history. Future research should consider alternative incentive values, types, and cost-effectiveness.

Assessing the defecation practices of unsheltered individuals and their contributions to microbial water quality in an arid, urban watershed

Outdoor defecation by people experiencing homelessness is frequently perceived as a potentially large source of human fecal pollution and a significant source of health risk in urban waterbodies with recreational contact. The goal of this study was to count the number of people experiencing homelessness and quantifies their sanitation habits in an urban river corridor setting, then use this information for estimating human fecal pollutant loading on a watershed scale. Two types of census counts were conducted including periodic point-in-time counts over six years and weekly counts of encampments. While the population census varied from count-to-count, the range of population estimates in the river corridor varied from 109 to 349 individuals during the six-year span, which mirrored the weekly counts of encampments. A face-to-face survey of people experiencing homelessness assessed the sanitation habits of the unsheltered population (N = 63), including outdoor defecation frequency and containment practices. Overall, 95 % of survey respondents reported defecating outdoors; 36 % practiced outdoor defecation between 4 and 7 days/week and 27 % practiced outdoor defecation <1 day/week. Of those that did practice outdoor defecation, 75 % contained their feces in a bucket or bag, thereby limiting fecal material contributions to the river; 6.7 % reported defecating on low ground near the river that could wash off when flood waters rise during a storm event. Only a single survey respondent reported defecating directly into the river. Based on literature values for average HF183 output for an adult human, and the average rainfall in the urban watershed, the total watershed contribution of HF183 averaged 1.2 × 1010 gene copies per storm event (95 % CI: 0.9 × 1010-1.6 × 1010) along the 41 km stretch of river in this study. This human fecal loading estimate is at least two orders of magnitude less than cumulative HF183 loading from all human sources measured at the bottom of the watershed.

Providing holistic end-of-life care for people with a history of problem substance use: a mixed methods cohort study of interdisciplinary service provision and integrated care

Harmful use of illicit drugs and/or alcohol is linked to life-limiting illness and complex health and social care needs, but people who use substances and have complex needs do not receive timely palliative care and fail to achieve quality standards for a good death. They and their families often require support from multiple health and social care services which are shown to be poorly integrated and fail to deliver interdisciplinary care. This study aimed to identify the existing barriers and facilitators within and between services in providing this population with a good death. Using a mixed methods approach of survey, focus groups and semi-structured interviews, we explored the perspectives of practitioner and management staff across a range of health and social disciplines and organisations in one combined authority in a large city in the north west of England. Our findings indicate that practitioners want to provide better care for this client group, but face structural, organisational and professional boundary barriers to delivering integrated and shared care. Differences in philosophy of care, piecemeal commissioning and funding of services, and regulatory frameworks for different services, lead to poor and inequitable access to health and social care services. Ways forward for improving care are suggested as bespoke hostel-based accommodation for palliative care for this client group, and specialist link workers who can transcend professional and organisational boundaries to support co-ordination of services and support. We conclude that it is no longer adequate to call for more training, better communication and improved joint working. Complex care at the end of life requires creative and cohesive systemic responses that enable multi-disciplinary practitioners to provide the care they wish to give and enables individuals using substances to get the respect and quality service they deserve.

Healthcare and housing provision for a UK homeless community: a qualitative service evaluation

OBJECTIVES

Homelessness is both a significant determinant and consequence of health and social inequalities. To better meet healthcare needs, dedicated mental health and general nurses were implemented to deliver outreach healthcare to people experiencing homelessness in one United Kingdom (UK) county. During COVID-19, the UK Government also instructed local authorities to accommodate individuals sleeping rough and have a national target to end rough sleeping. This qualitative study explored experiences of this nurse-let outreach service and housing journeys during and beyond COVID-19 among people experiencing homelessness.

STUDY DESIGN

Face-to-face, narrative storytelling interviews were conducted via opportunistic sampling in community settings. Individuals with recent or current experiences of homelessness were eligible.

METHODS

Participants were informed about the study via known professionals and introduced to the researcher. Eighteen narrative interviews were conducted, transcribed, and analysed using reflective thematic analysis.

RESULTS

Individuals described complex journeys in becoming and being homeless. The nurse-led outreach service provided integral support, with reported benefits to person-centred and accessible care and improved outcomes in health and well-being. After being housed, individuals valued housing necessities and described new responsibilities. However, some participants did not accept or stay in housing provisions where they perceived risks.

CONCLUSIONS

Interviewed participants perceived that the dedicated nurse-led outreach service improved their access to care and health outcomes. In the absence of dedicated provisions, mainstream healthcare should ensure flexible processes and collaborative professional working. Local authorities must also be afforded increased resources for housing, as well as integrated support, to reduce social and health inequalities.

Sociodemographic and Behavioral Risk Correlates of PrEP Interest and Use Among Young Adults Experiencing Homelessness in Los Angeles

Young adults experiencing homelessness (YAEH) are at elevated risk for HIV compared to their stably housed peers. Preexposure prophylaxis (PrEP) is highly effective at preventing HIV infection, yet YAEH have been largely overlooked in PrEP efforts to date despite YAEH reporting high overall interest in PrEP. We assessed individual, social, and structural variables associated with PrEP interest and use among a sample of 195 YAEH (ages 18-25) recruited from drop-in centers across Los Angeles County who met criteria for HIV risk. In the current sample, though most had heard of PrEP (81.0%), the majority were not interested in taking PrEP (68.2%) and only a minority had used/were using PrEP (11.8%). YAEH who identified as sexual and/or gender minority, reported knowing someone who had used PrEP, or recently accessed sexual health services were more likely to have used and/or reported interest in using PrEP. Those who reported more episodes of heavy drinking were less likely to report having used PrEP. Suggestions are provided for better integrating PrEP-related services into existing behavioral and health service programs for YAEH, as well as leveraging peers and fostering positive social norms to reduce PrEP-related stigma and increase interest and use of PrEP among YAEH.

Benzodiazepine Prescriptions for Homeless Veterans Affairs Service Users With Mental Illness

OBJECTIVE

Despite elevated risk for substance use disorder and overdose death in the homeless population, benzodiazepine prescribing for this population has not been examined. In this study, the authors used data from the U.S. Department of Veterans Affairs (VA) health care system to examine benzodiazepine prescribing and risky and potentially inappropriate benzodiazepine prescribing practices for homeless VA service users.

METHODS

Using national VA administrative data (2018-2019), the authors conducted logistic regression to compare likelihood of benzodiazepine prescribing and t tests to compare indicators of risky and potentially inappropriate benzodiazepine prescribing patterns for homeless service users with mental illness (N=244,113) and their housed peers (N=2,763,513).

RESULTS

Unadjusted analyses showed that benzodiazepines were prescribed for 7.5% of homeless VA service users with mental illness, versus 9.4% of their housed peers (p<0.001). Analyses adjusted for sociodemographic and clinical characteristics and health care utilization showed that homeless service users were less likely than their housed peers to receive a benzodiazepine prescription (AOR=0.70, 99% CI=0.68-0.72). However, compared with their housed peers, homeless service users received higher rates of risky and potentially inappropriate benzodiazepine prescriptions, including multiple concurrent benzodiazepine prescriptions (9.4% vs. 7.0%, p<0.001) and concurrent prescriptions for benzodiazepines and opioids (36.9% vs. 31.2%, p<0.001) or sedatives (61.9% vs. 45.9%, p<0.001).

CONCLUSIONS

Although homeless VA service users with mental illness were less likely than their housed peers to receive a benzodiazepine prescription, benzodiazepine prescriptions for these service users had more characteristics of risky and potentially inappropriate prescribing.

Trajectories of alcohol and cannabis use among emerging adults with a history of unstable housing: Associations with functioning over a two-year period

INTRODUCTION

Research has documented high rates of alcohol and cannabis use among emerging adults experiencing homelessness. However, little is known about trajectories of use over time or how trajectories are associated with functioning (e.g., risk behaviors, mental and physical health, social functioning, economic well-being).

METHODS

Data come from a cohort of 18-25 year olds experiencing homelessness who were surveyed 5 times over 24 months. Parallel process growth mixture models were used to model heterogeneity in alcohol and cannabis use across the 5 timepoints, which allowed for the extraction of classes based on both alcohol and cannabis use trajectories. Classes were compared on demographics and functioning at baseline and 24-months.

RESULTS

Two trajectory classes of alcohol and cannabis use emerged: moderate decreasing cannabis and low stable alcohol use (75% of the sample) and heavy cannabis and alcohol use (25% of the sample). The heavy cannabis and alcohol use class reported a significantly higher likelihood for any non-cannabis drug use at baseline and 24-months, as well as greater depression and physical ailments at 24-months. In addition, at 24-months this class had a marginally higher likelihood of a positive screen for at least moderate anxiety and being recently unhoused.

CONCLUSIONS

The effects of heavy continued cannabis and alcohol co-use on multiple domains of functioning (e.g., risk behavior, mental and physical health) highlight the importance of a coordinated systems approach that addresses the often complex and interrelated challenges facing emerging adults with a history of homelessness.

A national analysis of burn injuries among homeless persons presenting to emergency departments

INTRODUCTION

Burn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs).

METHODS

Burn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling.

RESULTS

Of 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021).

CONCLUSION

Homeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients' unique presentation and triage to burn centers accordingly.

Loneliness among homeless-experienced older adults with cognitive or functional impairments: qualitative findings from the HOPE HOME study

BACKGROUND

Loneliness is more common in older adults and those who face structural vulnerabilities, including homelessness. The homeless population is aging in the United States; now, 48% of single homeless adults are 50 and older. We know little about loneliness among older adults who have experienced homelessness. We aimed to describe the loneliness experience among homeless-experienced older adults with cognitive and functional impairments and the individual, social, and structural conditions that shaped these loneliness experiences.

METHODS

We purposively sampled 22 older adults from the HOPE HOME study, a longitudinal cohort study among adults aged 50 years or older experiencing homelessness in Oakland, California. We conducted in-depth interviews about participants perceived social support and social isolation. We conducted qualitative content analysis.

RESULTS

Twenty participants discussed loneliness experience, who had a median age of 57 and were mostly Black (80%) and men (65%). We developed a typology of participants' loneliness experience and explored the individual, social, and structural conditions under which each loneliness experience occurred. We categorized the loneliness experience into four groups: (1) "lonely- distressed", characterized by physical impairment and severe isolation; (2) "lonely- rather be isolated", reflecting deliberate social isolation as a result of trauma, marginalization and aging-related resignation; (3) "lonely- transient", as a result of aging, acceptance and grieving; and (4) "not lonely"- characterized by stability and connection despite having experienced homelessness.

CONCLUSIONS

Loneliness is a complex and heterogenous social phenomenon, with homeless-experienced older adults with cognitive or functional impairments exhibiting diverse loneliness experiences based on their individual life circumstances and needs. While the most distressing loneliness experience occurred among those with physical impairment and mobility challenges, social and structural factors such as interpersonal and structural violence during homelessness shaped these experiences.

A feasibility (pilot) mixed methods study of an innovative non-pharmacological breath-based yoga and social-emotional intervention program in an at-risk youth sample in London, Canada

BACKGROUND

Various service provision models for youth at risk of homelessness have been researched and implemented, including access to housing and physical and mental health resources. However, even with these interventions, we remain unaware of how best to manage symptoms of depression and anxiety and the rate of drug use in these populations primarily because of a lack of feasibility data.

METHODS

This paper presents the results of a mixed-methods study in London, Canada, that examined the feasibility of implementing a biopsychosocial intervention, SKY Schools, in at-risk youth aged between 16 and 25 (n = 49). The study also recorded qualitative responses about the program's usefulness from the perspective of the service users. The SKY Schools intervention consisted of social-emotional learning combined with Sudarshan Kriya Yoga, a standardized yoga-based breathing exercise routine. The intervention program was divided into two phases: an active learning phase and a reinforcement phase. The following feasibility outcome measures were collected: (1) the number of potential participants approached per month, (2) number (proportion) who were successfully screened, (3) the proportion of screened participants who enrolled, (4) the rate of retention in the study, (5) rate of adherence to study protocol, (6) proportion of planned ratings that were completed, (7) intervention cost per case, (8) completeness of final data for analysis, (9) length of time to collect all data, (10) quality of all collected data, (11) determining if partnering community organizations were willing to conduct the study as per study protocol, (12) determining if there were any capacity issues with partners providing intervention and investigators being able to perform the tasks that they were committed to doing, (13) determining if there were any problems of entering the data into a computer, (14) preliminary data about the safety of the intervention, and (15) preliminary estimate of treatment effects.

RESULTS

All feasibility outcome measures were collectible. In the city of London, Canada it was feasible to conduct a pilot study in this population of youth at risk of homelessness. Foremost among the findings was a high retention rate (61.2%) and overall positive qualitative feedback with a number of potential suggestions to improve the delivery and quality of the intervention. However, we had a significantly low recruitment rate (0.27 participants per week) suggesting that multiple sites will be needed to achieve an adequate sample size for a subsequent definitive trial.

CONCLUSIONS

Future researchers may consider the findings of this feasibility study when designing a randomized control trial to further assess the efficacy and tolerability of SKY Schools.

TRIAL REGISTRATION

Trial registration: Clinicaltrials.gov, identifier NCT02749240. Registered April 22, 2016, https://clinicaltrials.gov/ct2/show/NCT02749240 .

Persistent Disparities: Trends in Rates of Sheltered Homelessness Across Demographic Subgroups in the USA

CONTEXT

Homelessness is a public health crisis affecting millions of Americans every year, with severe consequences for health ranging from infectious diseases to adverse behavioral health outcomes to significantly higher all-cause mortality. A primary constraint of addressing homelessness is a lack of effective and comprehensive data on rates of homelessness and who experiences homelessness. While other types of health services research and policy are based around comprehensive health datasets to successfully evaluate outcomes and link individuals with services and policies, there are few such datasets that report homelessness.

METHODS

Gathering archived data from the US Department of Housing and Urban Development, we created a unique dataset of annual rates of homelessness, nationally, as measured by persons accessing homeless shelter systems, for 11 years (2007-2017, including the Great Recession and prior to the start of the 2020 pandemic). Responding to the need to measure and address racial and ethnic disparities in homelessness, the dataset reports annual rates of homelessness across HUD selected, Census-based racial and ethnic categories.

FINDINGS

Between 2007 and 2017, across all types of sheltered homelessness, whether individual, family, or total, Black, American Indian or Alaska Native, and Native Hawaiian and Pacific Islander individuals and families were far more likely to experience homelessness than non-Hispanic White individuals and families. Particularly concerning about the rates of homelessness among these populations is the persistent and increasing nature of these disparities across the entire study period.

CONCLUSIONS

While homelessness is a public health problem, the hazard of experiencing homelessness is not uniformly distributed across different populations. Because homelessness is such a strong social determinant of health and risk factor across multiple health domains, it deserves the same careful annual tracking and evaluation by public health stakeholders as other areas of health and health care.

The association of sleep with physical and mental health among people experiencing homelessness

BACKGROUND

Sleep deprivation is a critical risk factor for physical and mental health problems. The current study examined whether sleep problems were related to housing status and physical and mental health among people experiencing homelessness.

METHODS

Data were collected via an anonymous survey completed by adults accessing services at a day shelter in Oklahoma City, OK. Demographic characteristics, sleep problems, days of poor physical and mental health, and self-rated health were assessed and compared across housing subgroups. Logistic regression analyses were performed to examine potential associations between sleep and health.

RESULTS

Participants (N = 404) were predominantly male (71.0%) and racially minoritized (57.4%) with an average age of 47.0 (SD=11.6) years. Days of unintentional sleep over the past 30days differed significantly by housing status. Logistic regression analyses indicated that short sleep duration of ≤6 hours was associated with poorer self-rated health and more days of poor physical health over the past 30days compared to those who reported an optimal sleep duration of 7-9 hours. Additionally, reporting ≥1 day of unintentional daytime sleep was associated with more days of poor mental and physical health over the past 30-day. Reporting more days of inadequate sleep was associated with poorer self-rated health, and more days of poor physical and mental health over the past 30days.

CONCLUSION

Sleep problems were associated with poorer physical and mental health among people experiencing homelessness. Safe environments where adults experiencing homelessness can sleep comfortably and without interruption may be needed to support good physical and mental health.

Homeless Outreach Psychiatric Engagement for Lisboa (HOPE 4 Lisboa): One year of marontology, and one John Doe living with Diogenes syndrome

BACKGROUND

In Europe, psychiatric disorders seem to affect up to 50% of the homeless. In Portugal there were, at a certain time, circa 3,396 homeless people, half living in the capital city, Lisboa.

AIMS

The Homeless Outreach Psychiatric Engagement for Lisboa (HOPE 4 Lisboa) was created, in January 1st 2022, as a collaboration including staff from the local state asylum, medical school and town hall in Lisboa, Portugal, in order to provide better treatment for the super difficult cases of psychiatric patients living homeless in Lisboa.

METHOD

During 2022, the HOPE 4 team made night rounds, every 15 days on Tuesday's night (20:30 to 23:30) trying to reach, at least, one dozen of homeless psychiatric patients, previously identified.

RESULTS

The HOPE 4 Lisboa interviewed 101 patients (53.4%) out of the 189 programed visits. From this group, 72 (72%) had already a previous psychiatric diagnosis. From those 101 patients, reports for 47 (47%) were sent for an eventual compulsory psychiatric assessment. From those 47 only 21 patients (21%) were admitted in the psychiatry ward. Finally we discuss the most super difficult patient we found, as a small case report: a John Doe living in complete Diogenes syndrome.

CONCLUSIONS

there are still a few psychiatrists interested in treating homeless people completely or partially out of the classic mental health care systems. Some claim to be doing interstitial psychiatry, others street psychiatry, but we could also call it marontology.

Predictors of Housing Trajectories Among Young Adults Experiencing Homelessness in Los Angeles

Experiencing homelessness during young adulthood is associated with negative health outcomes and understanding housing trajectories of young adults experiencing homelessness may aid in the development of evidence-based public health programs designed to serve this at-risk age group. In the present study, the authors examined baseline predictors of 24-month trajectories of housing stability and unsheltered housing among a sample of 271 young adults aged 18 to 25 recruited from drop-in centers in Los Angeles. In multivariate models, the authors found that identifying as multi-racial/other and better friendship quality at baseline were associated with less steep increases in the likelihood of stable housing over time. Being employed at baseline was associated with a less steep decrease in the probability of being unsheltered over time, while illicit drug use days associated with a steeper decrease in the probability of being unsheltered over time. Continued research is needed to establish important factors determining young adults' long-term housing trajectories in the effort to promote greater access and engagement with housing services.

Vaccine acceptance, determinants, and attitudes toward vaccine among people experiencing homelessness: a systematic review and meta-analysis

BACKGROUND

COVID-19 has caused millions of deaths globally, with vulnerable populations such as people experiencing homelessness (PEH) at higher risk. This systematic review and meta-analysis aims to identify the prevalence and key factors contributing to vaccine acceptance experienced by PEH.

METHODS

The protocol of this study was registered in PROSPERO (CRD42023391659). We included studies that reported relevant information about vaccine acceptance or vaccine hesitant/refusal among PEH. Eight databases were systematically searched in January 2023. Meta-analysis was conducted for the prevalence of vaccine acceptance, vaccine uptake, and factors associated with vaccine acceptance. Attitudes toward vaccines were combined into bar charts.

RESULT

A total of 29 papers were included in this systematic review and 19 papers were included for meta-analysis. The pooled prevalence of COVID-19 vaccine acceptance among PEH was 66% (95%CI: 58%-73%). Our meta-regression showed vaccine acceptance was significantly increased over time. Moreover, subgroup meta-analysis showed that PEH were more likely to accept the COVID-19 vaccine after June 2021 (78%, 95%CI: 65%-86%) compared with earlier period (56%, 95%CI: 54%-59%). Subgroup meta-analysis also revealed that women and participants without underlying medical condition (chronic diseases) were significantly less likely to accept the COVID-19 vaccine, compared to men and those with medical conditions, respectively.

CONCLUSION

The study emphasizes the need for targeted public health interventions aimed at increasing vaccine acceptance among PEH, especially at the early stage of the pandemic, among females, those without underlying medical conditions, being Black (in Canada and the USA), and young people. These interventions should address the common concerns of vaccine safety, adverse effects, effectiveness, and distrust in health care systems. In addition to offering vaccinations in different areas convenient to them, education programs could be established to increase vaccine acceptance among PEH.

Nutritional needs, resources, and barriers among unhoused adults cared for by a street medicine organization in Chicago, Illinois: a cross-sectional study

BACKGROUND

Those experiencing houselessness rely on obtaining food from community organizers and donations. Simultaneously, the houseless face disproportionally high rates of medical conditions that may be affected by diet including diabetes, hypertension, and hyperlipidemia. There is limited literature on the resources and barriers of the houseless community regarding optimal nutrition from an actionable perspective. Further, less data is available on how street medicine organizations may best impact the nutrition of the unhoused they serve. Elucidating this information will inform how organizational efforts may best support the nutrition of the houseless community.

METHODS

In partnership with the medical student-run organization, Chicago Street Medicine, at Northwestern University Feinberg School of Medicine, twenty adults experiencing houselessness in Chicago, Illinois participated in the cross-sectional study. A 10-item survey was verbally administered to characterize the participants' daily food intake, food sources, barriers, resources, and nutritional preferences and needs. All data was directly transcribed into REDCap. Descriptive statistics were generated.

RESULTS

Individuals consumed a median of 2 snacks and meals per day (IQR: 1-3). No participant consumed adequate servings of every food group, with only one participant meeting the dietary intake requirements for one food group. Participants most often received their food from donations (n = 15), purchasing themselves (n = 11), food pantries (n = 4), and shelters (n = 3). Eleven of nineteen participants endorsed dental concerns as a major barrier to consuming certain foods. Twelve participants had access to a can opener and twelve could heat their meals on a stove or microwave. Seven had access to kitchen facilities where they may prepare a meal. Approximately half of participants had been counseled by a physician to maintain a particular diet, with most related to reducing sugar intake.

CONCLUSION

Most houseless participants were unable to acquire a balanced diet and often relied on organizational efforts to eat. Organizations should consider the chronic health conditions, dentition needs, and physical resources and barriers to optimal nutrition when obtaining food to distribute to the unhoused.

Critical illness among patients experiencing homelessness: a retrospective cohort study

PURPOSE

To understand the epidemiology and healthcare use of critically ill patients experiencing homelessness compared to critically ill patients with stable housing.

METHODS

This retrospective population-based cohort study included adults admitted to any ICU in Alberta, Canada, for a 3-year period. Administrative and clinical data from the hospital, ICU and emergency department were used to examine healthcare resource use (processes of care, ICU and hospital length of stay, hospital readmission and emergency room visits). Regression was used to quantify differences in healthcare use by housing status.

RESULTS

2.3% (n = 1086) of patients admitted to the ICU were experiencing homelessness; these patients were younger, more commonly admitted for medical reasons and had fewer comorbidities compared to those with stable housing. Processes of care in the ICU were mostly similar, but healthcare use after ICU was different; patients experiencing homelessness who survived their index hospitalization were more than twice as likely to have a visit to the emergency department (OR = 2.3 times, 95% CI 2.0-2.6, < 0.001) or be readmitted to hospital (OR = 2.1, 95% CI 1.8-2.4, p < 0.001) within 30 days, and stayed 10.1 days longer in hospital (95% CI 8.6-11.6, p < 0.001), compared with those who have stable housing.

CONCLUSIONS

Patients experiencing homelessness have different characteristics at ICU admission and have similar processes of care in ICU, but their subsequent use of healthcare resources was higher than patients with stable housing. These findings can inform strategies to prepare patients experiencing homelessness for discharge from the ICU to reduce healthcare resource use after critical illness.

Determinants of health-related quality of life (HRQoL) among homeless individuals during the COVID-19 pandemic

OBJECTIVE

Thus far, there is very limited knowledge regarding homeless individuals during the COVID-19 pandemic, particularly related to the health-related quality of life (HRQoL). Thus, our aim was to evaluate HRQoL and to clarify the determinants of HRQoL among homeless individuals during the COVID-19 pandemic in Germany.

METHODS

Data were taken from the national survey on psychiatric and somatic health of homeless individuals during the COVID-19 pandemic-NAPSHI (n = 616). The established EQ-5D-5L was used to quantify problems in five health dimensions, and its visual analogue scale (EQ-VAS) was used to record self-rated health status. Sociodemographic factors were included in regression analysis.

RESULTS

Pain/discomfort was the most frequently reported problem (45.3%), thereafter anxiety/depression (35.9%), mobility (25.4%), usual activities (18.5%) and self-care (11.4%). Average EQ-VAS score was 68.97 (SD: 23.83), and the mean EQ-5D-5L index was 0.85 (SD: 0.24). Regressions showed that higher age and having a health insurance were associated with several problem dimensions. Being married was associated with higher EQ-VAS scores.

CONCLUSIONS

Overall, our study findings showed a quite high HRQoL among homeless individuals during the COVID-19 pandemic in Germany. Some important determinants of HRQoL were identified (e.g., age or marital status). Longitudinal studies are required to confirm our findings.

Medical centres for the homeless in Hamburg - consultation reasons and diagnoses compared to primary care patients in the regular health care system

BACKGROUND

In Germany, homeless people are entitled to health care within the regular health care system. However, due to their specific living conditions they make little use of these services. In 2013, three Medical centres for the homeless (MCH) were opened in Hamburg to provide general health care. This study aims to analyse the consultation reasons and diagnoses prevalent among the homeless in comparison to regular primary care patients. It also examines the means and obstacles of integrating the homeless into Germany's regular health care system.

METHODS

From 2013 to 2014, routine medical data of all patients of the MCH consenting to participate in the study were analysed descriptively, in particular consultation reasons (categorised by ICPC-2), ICD-10 diagnoses and data on health insurance status and the use of the regular health care system. Consultation reasons and diagnoses of homeless patients were compared descriptively with data from regular general practices. Additionally, anonymous data on patient numbers, gender and insurance status was exported from the MCH's software and analysed descriptively for the years 2013 to 2020.

RESULTS

A total of 840 homeless patients in 2013 and 2014 gave consent to the evaluation of consultation reasons and diagnoses. The most frequent consultation reasons in the MCH in 2013 were skin conditions (24%), musculoskeletal conditions (16%) and psychological disorders (14%), in GP practices these were musculoskeletal conditions (22%), conditions affecting the digestive system (14%) and skin conditions (12%). Essential (primary) hypertension, diabetes mellitus type 2 and back pain are among the top-10-diagnoses in GP practices, as well as in MCH. With regard to the other top-10-diagnoses, there are clear differences between GP practices and MCH: "Psychological behavioural disorder due to alcohol" and diagnoses in connection with trauma, skin infections and acute respiratory infections stand out in MCH. 35% of the homeless patients reported a lack of health insurance as the reason for "not making use of" the regular health care system, while 10% reported they were unable to visit a regular general practitioner due to physical or psychological reasons. In the years 2013-2020 46% to 73% of the 8.380 MCH patients had no health care insurance.

CONCLUSION

Patients consulting the MCH suffer from medical conditions typical for the homeless, namely skin diseases, wounds, injuries and behavioural disorders due to alcohol abuse, but also from "typical" symptoms in regular GP care as cough or lower back symptoms. Consultation reasons mostly are acute illnesses. Chronic diseases are equally present in regular GP and MCH patients, but pose a great challenge for the homeless among other things due to their irregular contact with the health care system. The lack of health insurance poses the greatest hurdle to the integration of the homeless into the regular health care system.

Perspectives of homeless veterans living with substance use disorders (SUD) and mental illness

Upon returning home from the military, America's veterans face complex challenges such as homelessness and substance use disorders (SUD). Veterans who have experienced SUDs and homelessness are more likely to struggle with depression and suicidal behaviors. This study aims to understand homeless veterans' lived experiences of their everyday life and social interactions. We used semi-structured interviews to conduct a phenomenological study of 14 homeless veterans with known SUDs living in the Baltimore-Washington D.C. Metropolitan area. A Social-Ecological Model (SEM) was used to create themes, a priori, then used open coding analytic methods to identify emerging themes. Two-thirds of veterans used illicit drugs or abused alcohol, and nearly all reported a history of depression or anxiety. Suicidal behaviors were present in a third of all veterans. We found that veteran homelessness and substance use are strongly associated with emotional and physical trauma suffered while on active duty. Consequently, once homeless, a veteran's community may encourage and exacerbate SUDs, thus impeding a path toward sobriety. Homeless veterans who have struggled with SUDs and later experience a death in their family often relapse to substance use. Deeply exploring a veteran's relationships with family, friends, and their immediate community may reveal opportunities to address these issues using healthcare and community interventions.

The homeless, seizures, and epilepsy: a review

This review aims to estimate the prevalence of seizures and epilepsy among homeless people in current literature as well as understand the main adversities that this group withstands. We conducted a search for "epilep*", "seizur*", and "homeles*" in titles and abstracts of articles in PubMed. Overall, 25 articles met the final inclusion criteria and warranted analyses. This study suggests that the prevalence of epilepsy in the homeless population is between 2 and 30%, whereas the prevalence of homelessness in people with epilepsy is between 2 and 4%. Every study included in this review corroborates the increased prevalence of seizures and epilepsy among the homeless, which puts them at risk for worse outcomes related to this condition and numerous associated comorbidities. Further evidence is needed to clarify the distinction of primary and secondary seizures in this group, which shows a high rate of confounding factors for seizures like substance abuse or withdrawal and head injury, and to decrease the burden of epilepsy and homelessness in an already resource-deficient community.

Predicting Response to Services for Homeless Adolescents and Transition Age Youth (TAY) with Substance Use And/Or Mental Health Disorders: Implications for Youth Treatment and Recovery

PURPOSE

This paper examines patterns of response to a multi-disciplinary wrap-around program for homeless adolescents and transition-aged youth with substance use and/or mental health disorders.

METHOD

A cluster analysis of outcome data from 148 youth was conducted.

RESULTS

Cluster 1 (n = 67) demonstrated significant decreases in risky behavior (e.g., engaging in unprotected sex, crime, and substance use) and poor interpersonal relationships (e.g. more interaction with family and friends and lower rates of violence) but experienced relatively fewer interactions with family and friends. Cluster 2 (n = 57) demonstrated a significant decrease in poor life functioning (e.g., lower rates of employment/education, better quality of life, and less symptoms of internalizing disorders). Cluster 3 (n = 24) experienced significant increases in risky behavior, poor life functioning, and poor interpersonal relationships.

DISCUSSION

Clusters 1 and 2 improved over six months of care. Cluster 3 deteriorated despite receiving similar services and used more opioids and stimulants.

CONCLUSIONS

Peer engagement in programs for this population are important. Recommendations for cluster 3 include targeted outreach, medication assisted treatment, and additional research-supported treatments. Further research is needed to test these interventions over longer periods of time.

Equity considerations in clinical practice guidelines for traumatic brain injury and homelessness: a systematic review

Background

Clinical practice guidelines (CPGs) predominantly prioritise treatment and cost-effectiveness, which encourages a universal approach that may not address the circumstances of disadvantaged groups. We aimed to advance equity and quality of care for individuals experiencing homelessness and traumatic brain injury (TBI) by assessing the extent to which homelessness and TBI are integrated in CPGs for TBI and CPGs for homelessness, respectively, and the extent to which equity, including consideration of disadvantaged populations and the PROGRESS-Plus framework, is considered in these CPGs.

Methods

For this systematic review, CPGs for TBI or homelessness were identified from electronic databases (MEDLINE, Embase, CINAHL, PsycINFO), targeted websites, Google Search, and reference lists of eligible CPGs on November 16, 2021 and March 16, 2023. The proportion of CPGs that integrated evidence regarding TBI and homelessness was identified and qualitative content analysis was conducted to understand how homelessness is integrated in CPGs for TBI and vice versa. Equity assessment tools were utilised to understand the extent to which equity was considered in these CPGs. This review is registered with PROSPERO (CRD42021287696).

Findings

Fifty-eight CPGs for TBI and two CPGs for homelessness met inclusion criteria. Only three CPGs for TBI integrated evidence regarding homelessness by recognizing the prevalence of TBI in individuals experiencing homelessness and identifying housing as a consideration in the assessment and management of TBI. The two CPGs for homelessness acknowledged TBI as prevalent and recognised individuals experiencing TBI and homelessness as a disadvantaged population that should be prioritised in guideline development. Equity was rarely considered in the content and development of CPGs for TBI.

Interpretation

Considerations for equity in CPGs for homelessness and TBI are lacking. To ensure that CPGs reflect and address the needs of individuals experiencing homelessness and TBI, we have identified several guideline development priorities. Namely, there is a need to integrate evidence regarding homelessness and TBI in CPGs for TBI and CPGs for homelessness, respectively and engage disadvantaged populations in all stages of guideline development. Further, this review highlights an urgent need to conduct research focused on and with disadvantaged populations.

Funding

Canada Research Chairs Program (2019-00019) and the Ontario Ministry of Health and Long-Term Care (Grant #725A).

Excess Hospital Burden Among Young People in Contact With Homelessness Services in South Australia: A Prospective Linked Data Study

PURPOSE

Youth homelessness remains an ongoing public health issue worldwide. We aimed to describe the burden of emergency department (ED) presentations and hospitalizations among a South Australian population of young people in contact with specialist homelessness services (SHS).

METHODS

This whole-of-population study used de-identified, linked administrative data from the Better Evidence Better Outcomes Linked Data (BEBOLD) platform on all individuals born between 1996 and 1998 (N = 57,509). The Homelessness2Home data collection was used to identify 2,269 young people in contact with SHS at ages 16-17 years. We followed these 57,509 individuals to age 18-19 years and compared ED presentations and hospital separations related to mental health, self-harm, drug and alcohol, injury, oral health, respiratory conditions, diabetes, pregnancy, and potentially preventable hospitalizations between those in contact and not in contact with SHS.

RESULTS

Four percent of young people had contact with SHS at ages 16-17 years. Young people who had contact with SHS were 2 and 3 times more likely to have presented to an ED and hospital respectively, compared to those who did not contact SHS. This accounted for 13% of all ED presentations and 16% of all hospitalizations in this age group. Excess burden causes included mental health, self-harm, drug and alcohol, diabetes, and pregnancy. On average, young people in contact with SHS experienced an increased length of stay in ED (+0.6 hours) and hospital (+0.7 days) per presentation, and were more likely to not wait for treatment in ED and to self-discharge from hospital.

DISCUSSION

The 4% of young people who contacted SHS at ages 16-17 years accounted for 13% and 16% of all ED presentations and hospitalizations respectively at age 18-19 years. Prioritizing access to stable housing and primary health-care services for adolescents in contact with SHS in Australia could improve health outcomes and reduce health-care costs.

Determinants of depression and anxiety in homeless people: A population survey of homeless people in Hong Kong

BACKGROUND

There are growing concerns about the homeless and mental health issues globally. This study aims to examine the mental health situation of homelessness and the determinants of anxiety and depression of them in Hong Kong.

METHOD

The data from the largest territory-wide study of the homeless population in 2021 was analyzed. Descriptive statistics and logistic regressions were used to investigate the association between mental health and socioeconomic variables, including demographic background, economic indicators, COVID-19 worries, government measures, and respect by others. The symptoms of depression and anxiety were assessed using Patient Health Questionnaire (PHQ) and General Anxiety Disorder (GAD).

RESULTS

The results showed that being female, food insecurity, and chronic diseases were the risk factors for anxiety and depression. A high level of respect by others was the protective factor for depression (adjusted OR 0.37, 95% CI [0.23, 0.61]) and anxiety (adjusted OR 0.40, 95% CI [0.24, 0.68]), compared to a low level of respect in the multivariate model.

CONCLUSIONS

Providing medical outreach services, additional resources for social services, implementation of homeless-friendly policies, and a progressive supply of public and transitional housing would help enhance the well-being of the homeless population.

Homelessness in the district of Nipissing of Ontario, Canada before, at the onset and during the COVID-19 pandemic: a trend analysis (2018-2021)

BACKGROUND

Homelessness is a growing social concern experienced across Canada. In Ontario, specifically in the District of Nipissing, the issue has become larger with an increasing number of homeless individuals. Previous research has described the demographic composition of the homeless population both in the Nipissing District of Ontario and in the city of North Bay. However, no studies have examined homelessness in this region before, at the beginning and during the COVID-19 pandemic. This research investigates structural and individual-level barriers and factors that are associated with becoming homeless or remaining homeless.

METHODS

This study utilizes data from the 2018 (n = 147), 2020 (n = 254), and 2021 (n = 207) homelessness enumeration surveys, conducted in the District of Nipissing, Ontario by the District of Nipissing Social Services Administration Board. This study employs quantitative, descriptive analyses to examine trends and socio-demographic variations in the reasons of homelessness, barriers to housing, episodic and chronic homelessness before, at the beginning, and during the COVID-19 pandemic.

RESULTS

The results revealed a rise in the proportion of male homeless (57% vs. 64%), and first-time homelessness among those aged 35-44 (3%, vs. 15%) and 55-64 (1% vs. 5%) at the onset and during the pandemic. The sleep location of homeless individuals was also influenced by the pandemic, where emergency shelter use dropped to half during 2020-2021(33% vs. 17%), while the use of locations (hotel/motels) where proper pandemic protocols and social distancing were possible increased sharply from 2 to 12% of homeless individuals. With the onset of the pandemic, chronic homelessness and one-episodic homelessness increased, suggesting that individuals are becoming homeless and staying homeless for prolonged periods. The barriers to housing during the pandemic were largely addiction, substance use and the inaccessibility of safe and secure rental units, while the corresponding barriers before the pandemic were mainly low income.

CONCLUSIONS

The rise in male homelessness, age at first-time homelessness and interpersonal conflict causing homelessness at the onset and during the pandemic suggest that policy makers need to focus on providing homeless supports to these groups of homeless populations at the time of pandemic.

Socio-economic outcomes of COVID-19 on the marginalised: Who have taken the hardest hit?

This article aims to examine the socioeconomic outcomes of COVID-19 for socially marginalised people who are clients of social care organisations (e.g. people experiencing homelessness), and the factors influencing these outcomes. We tested the role of individual and socio-structural variables in determining socioeconomic outcomes based on a cross-sectional survey with 273 participants from eight European countries and 32 interviews and five workshops with managers and staff of social care organisations in ten European countries. 39% of the respondents agreed that the pandemic has had a negative effect on their income and access to shelter and food. The most common negative socio-economic outcome of the pandemic was loss of work (65% of respondents). According to multivariate regression analysis, variables such as being of a young age, being an immigrant/asylum seeker or residing in the country without documentation, living in your own home, and having (in)formal paid work as the main source of income are related to negative socio-economic outcomes following the COVID-19 pandemic. Factors such as individual psychological resilience and receiving social benefits as the main source of income tend to "protect" respondents from negative impacts. Qualitative results indicate that care organisations have been an important source of economic and psycho-social support, particularly significant in times of a huge surge in demand for services during the long-term crises of pandemic.

Integrated cognitive behavioral treatment for substance use and depressive symptoms: a homeless case series and feasibility study

BACKGROUND

Homelessness is associated with high prevalence of psychiatric disorders such as substance use disorders, including alcohol use disorder, and depression.

METHODS

This case series and feasibility trial evaluated a novel integrated cognitive behavioral treatment (ICBT), which was adapted specifically for homeless individuals and developed to treat substance use and depressive symptoms simultaneously. The ICBT was delivered among four homeless individuals enrolled in the Treatment First program (a social services program where treatment is offered in conjunction with temporary transitional housing), who had access to stable and sober housing milieus.

RESULTS

The ICBT was rated high in expectancy of improvement, credibility, and satisfaction, with few treatment-related adverse events, and fairly high treatment retention. At 12 months follow-up, three of four participants were not homeless anymore. Some participants experienced short-term reductions in substance use and/or depressive symptoms.

CONCLUSIONS

The study provided preliminary support that the ICBT can be a feasible and potentially effective treatment for homeless individuals with substance use and/or depressive symptoms. However, the delivery format within the Treatment First program was not feasible. The ICBT could be offered within the social services Housing First program instead (where permanent housing is offered before treatment), or to non-homeless individuals.

TRIAL REGISTRATION

The study was registered retrospectively at ClinicalTrials.gov (NCT05329181).

Impact of the Domestic Violence Housing First Model on Survivors' Safety and Housing Stability: Six Month Findings

Intimate partner violence (IPV) is a leading cause of homelessness, yet little evidence exists about effective strategies to assist IPV survivors as they work to avoid homelessness while freeing themselves from abuse. An ongoing demonstration evaluation is examining if and how one promising model assists IPV survivors in obtaining safe and stable housing over time. The Domestic Violence Housing First (DVHF) model involves providing IPV survivors with mobile advocacy and/or flexible funding, depending on individual needs, in order to attain these goals. We hypothesized that those receiving DVHF would experience greater housing stability and less re-abuse compared to survivors receiving services as usual. The current study evaluated the short-term efficacy of the DVHF model with a sample of 345 homeless or unstably housed survivors who sought services and who completed in-person interviews shortly after contacting the DV agency, as well as six months later. Those who received the DVHF model showed greater improvement in their housing stability compared to those receiving services as usual, as well as decreased economic abuse. Both groups experienced a sharp decline in all forms of abuse. The Domestic Violence Housing First model shows promise in helping unstably housed DV survivors achieve safe and stable housing. Study findings have implications for DV agencies as well as those funding such services. Understanding which interventions work best for which survivors is critical to ensuring that service providers are effectively working toward long-term housing stability and well-being for IPV survivors and their children.

Interventions addressing maternal and child health among the urban poor and homeless: an overview of systematic reviews

BACKGROUND

Inequalities in access to and utilization of maternal and child health (MCH) care are hampering progress on the path to achieving the Sustainable Development Goals. In a number of Low- and Middle-Income Countries (LMICs) population subgroups at disproportionate risk of being left behind are the urban poor. Within this neglected group is the further neglected group of the homeless. Concomitantly, a number of interventions from the antenatal period onward have been piloted, tested, and scaled in these contexts. We carried out an overview of systematic reviews (SRs) to characterize the evidence around maternal and child health interventions relevant to urban poor homeless populations in LMICs.

METHODS

We searched Medline, Cochrane Library, Health Systems Evidence and EBSCOhost databases for SRs published between January 2009 and 2020 (with an updated search through November 2021). Our population of interest was women or children from urban poor settings in LMICs; interventions and outcomes corresponded with the World Health Organization's (WHO) guidance document. Each SR was assessed by two reviewers using established standard critical appraisal checklists. The overview was registered in PROSPERO (ID: CRD42021229107).

RESULTS

In a sample of 33 high quality SRs, we found no direct relevant evidence for pregnant and lactating homeless women (and children) in the reviewed literature. There was a lack of emphasis on evidence related to family planning, safe abortion care, and postpartum care of mothers. There was mixed quality evidence that the range of nutritional interventions had little, unclear or no effect on several child mortality and development outcomes. Interventions related to water, sanitation, and hygiene, ensuring acceptability of community health services and health promotion type programs could be regarded as beneficial, although location seemed to matter. Importantly, the risk of bias reporting in different reviews did not match, suggesting that greater attention to rigour in their conduct is needed.

CONCLUSION

The generalizability of existing systematic reviews to our population of interest was poor. There is a clear need for rigorous primary research on MCH interventions among urban poor, and particularly homeless populations in LMICs, as it is as yet unclear whether the same, augmented, or altogether different interventions would be required.

COVID-19 in the homeless population: a scoping review and meta-analysis examining differences in prevalence, presentation, vaccine hesitancy and government response in the first year of the pandemic

AIMS

People experiencing homelessness (PEH) have been identified as being increasingly susceptible to Coronavirus disease (COVID-19), with policies enacted to test, isolate, increase hygiene practices and prioritise vaccines among this population. Here, we conduct a scoping review of the current evidence-base pertaining to the prevalence and presentation of COVID-19 in PEH, COVID-vaccine hesitancy rates and government interventions enacted within the first year of the pandemic for PEH.

MATERIALS AND METHODS

A systematic search was conducted on Pubmed, Cochrane, Embase and MedRxiv databases for studies reporting primary data on COVID-19 prevalence and clinical characteristics in PEH, vaccine uptake for PEH and policies enacted targeting PEH. Study qualities were assessed with The National Heart, Lung and Blood Institute's set of Study Quality.

RESULTS

Eighty-three studies were included in our final analysis. The overall prevalence of symptomatic COVID-19 infection in PEH is estimated at 35%. The most common symptoms found were cough and shortness of breath, followed by fever. Concerns regarding vaccine hesitancy amongst PEH related to thoroughness of COVID-19 vaccine clinical trials, side effects and mistrust of the government. The main strategies implemented by governments were mass testing, adaption of healthcare service provision, provision of alternative housing, encouraging personal hygiene (hand sanitation and mask wearing), and inter-organisational communication.

DISCUSSION

In our meta-analysis, 35% of PEH with a COVID-19 infection presented symptomatically; the low prevalence of symptomatic COVID-19 infection suggests widespread testing following outbreaks would be beneficial for this group of individuals. Temporary recuperation units and measures for housing stability in the pandemic, namely provision of alternative housing and stopping evictions, were found to be highly effective. High rates of vaccine hesitancy means that education and encouragement towards vaccination would be beneficial for this vulnerable population, where comorbidities are common. Finally increased focus in research should be placed on the mental health burden of COVID-19 and the pandemic on PEH moving forwards.

Diagnostic Accuracy of a Rapid SARS-CoV-2 Antigen Test Among People Experiencing Homelessness: A Prospective Cohort and Implementation Study

INTRODUCTION

Detection strategies in vulnerable populations such as people experiencing homelessness (PEH) need to be explored to promptly recognize severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks. This study investigated the diagnostic accuracy of a rapid SARS-CoV-2 Ag test in PEH during two pandemic waves compared with gold standard real-time multiplex reverse transcription polymerase chain reaction (rtRT-PCR).

METHODS

All PEH ≥ 18 years requesting residence at the available shelters in Verona, Italy, across two cold-weather emergency periods (November 2020-May 2021 and December 2021-April 2022) were prospectively screened for SARS-CoV-2 infection by means of a naso-pharyingeal swab. A lateral flow immunochromatographic assay (Biocredit^® COVID-19 Ag) was used as antigen-detecting rapid diagnostic test (Ag-RDT). The rtRT-PCR was performed with Allplex™ SARS-CoV-2 assay kit (Seegene). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated as measures for diagnostic accuracy.

RESULTS

Overall, 503 participants were enrolled during the two intervention periods for a total of 732 paired swabs collected: 541 swabs in the first period and 191 in the second. No significant differences in demographic and infection-related characteristics were observed in tested subjects in the study periods, except for the rate of previous infection (0.8% versus 8%; p < 0.001) and vaccination (6% versus 73%; p < 0.001). The prevalence of SARS-CoV-2 in the cohort was 8% (58/732 swabs positive with rtRT-PCR). Seventeen swabs were collected from symptomatic patients (7%). Among them, the concordance between rtRT-PCR and Ag-RDT was 100%, 7 (41.2%) positive and 10 negative pairs. The overall sensitivity of Ag-RDT was 63.8% (95% CI 60.3-67.3) and specificity was 99.8% (95% CI 99.6-100). PPV and NPV were 97.5% and 96.8%, respectively. Sensitivity and specificity did not change substantially across the two periods (65.1% and 99.8% in 2020-2021 vs. 60% and 100% in 2021-2022).

CONCLUSIONS

A periodic Ag-RDT-based screening approach for PEH at point of care could guide preventive measures, including prompt isolation, without referral to hospital-based laboratories for molecular test confirmation in case of positive detection even in individuals asymptomatic for COVID-19. This could help reduce the risk of outbreaks in shelter facilities.

SMS texting for uncontrolled diabetes among persons experiencing homelessness: Study protocol for a randomized trial

BACKGROUND

Diabetes mellitus (DM) is common among persons experiencing homelessness (PEH), often inadequately managed, and carries significant costs. mHealth strategies including short messaging service (SMS) texting have been feasible and acceptable, and improved control of chronic diseases including DM. SMS strategies for DM have not been tested among PEH despite the accessibility of mobile phones. We propose an SMS strategy could offer better communication, education, and information management; improve outreach; facilitate care coordination; explore barriers to care; and support behavior changes.

METHODS AND ANALYSIS

This mixed-methods (RCT and qualitative) study will be implemented in shelter-clinics in New York City in collaboration with community organizations, allowing for sustainability and scalability. Aim 1 will evaluate the efficacy of a 6-month SMS program for DM management versus an attention control on changes in HbA1c and adherence to DM self-care activities, medications, and appointments at 9 months in adult PEH with uncontrolled DM (n = 100). Outcomes will be measured at 0, 3, 6, &9 months. AIM 2 will assess patients' and providers' attitudes, acceptability, and experience of the program through semi-structured interviews with PEH (n = 20) and providers (n = 10).

DISCUSSION

DM is not well-addressed among PEH. SMS strategies for DM have never been tested in PEH despite evidence of their effectiveness and access to mobile phones among PEH. Results from this study will provide important empirical data to inform evidence-based strategies to avert personal suffering and significant costs. It will have broader policy implications in control of DM and other chronic diseases.

Homelessness and Gender: Differences in Characteristics and Comorbidity of Substance Use Disorders at Admission to Services

Background: Substance use disorders and homelessness are two closely related behavioral health issues. This study examines associations between homelessness and severity of substance use disorder (SUD) characteristics (inclusive of alcohol and other legal and illegal drugs) and presence of mental health comorbidity among individuals entering treatment for SUD. We also examine differences in SUD and mental health comorbidity by gender within a sample of clients experiencing homelessness upon admission to treatment. Methods: Using the 2017 Treatment Episodes Data Set, we used logistic regression models to examine the association between homelessness and indicators of severity (e.g., frequency of use, route of transmission) and the presence of mental health conditions, and to examine the association between gender and these dependent variables among only individuals experiencing homelessness at treatment admission. Results: After controlling for covariates, homelessness is significantly associated with increased odds of cocaine and methamphetamine use compared to all other substances, higher frequency of use, younger age of first use, use of more substances, injection drug use, and co-occurring mental health conditions. Female gender is inversely associated with younger age at first use and highly associated with co-occurring mental health conditions among those experiencing homelessness at admission to treatment. Conclusions: Individuals experiencing homelessness enter substance use services with different characteristics of substance use disorders, different patterns of use, and with higher rates of mental health comorbidity. Within homeless admissions, women have significant differences in substance use and higher likelihood of mental health comorbidity than men. Future research should focus on the specific treatment needs of individuals experiencing homelessness, and how the combination of homelessness and gender affects barriers and challenges to treatment.

Comparing Trauma Treatment Outcomes Between Homeless and Housed Veterans in a VA PTSD Clinical Program

Homeless veterans are likely to experience Post Traumatic Stress Disorder (PTSD). Homelessness itself is traumatic, and PTSD may exacerbate homelessness risk for veterans. Often, PTSD goes untreated in this subpopulation of veterans. Our study examined trauma-focused treatment (TFT) and non-TFT initiation and completion in a sample of housed and homeless veterans being served by a PTSD clinical team in Washington, DC. Findings included a high percentage of veterans who experienced homelessness in the sample and lower treatment completion rates among homeless veterans compared to housed veterans. This difference was no longer significant when comparing only those veterans who engaged in treatment, reinforcing the critical role of treatment engagement in successful treatment completion across populations.

Why were COVID-19 infections lower than expected amongst people who are homeless in London, UK in 2020? Exploring community perspectives and the multiple pathways of health inequalities in pandemics

High rates of COVID-19 infections and deaths amongst people who are homeless in London, UK were feared. Rates however stayed much lower than expected throughout 2020; an experience that compares to other settings globally. This study sought a community level perspective to explore this rate of infections, and through this explore relationships between COVID-19 and existing health inequalities. Analyses are reported from ongoing qualitative studies on COVID-19 and homeless health service evaluation in London, UK. Repeated in-depth telephone interviews were implemented with people experiencing homelessness in London (n=17; 32 interviews in total) as well as street outreach workers, nurses and hostel staff (n=10) from September 2020 to early 2021. Thematic analysis generated three themes to explore peoples' experiences of, and perspectives on, low infections: people experiencing homelessness following, creating and breaking social distancing and hygiene measures; social distancing in the form of social exclusion as a long-running feature of life; and a narrative of 'street immunity' resulting from harsh living conditions. Further study is needed to understand how these factors combine to prevent COVID-19 and how they relate to different experiences of homelessness. This community perspective can ensure that emerging narratives of COVID-19 prevention success don't ignore longer running causes of homelessness and reinforce stigmatising notions of people who are homeless as lacking agency. Our findings aid theorisation of how health inequalities shape pandemic progression: severe exclusion may substantially delay epidemics in some communities, although with considerable other non-COVID-19 impacts.

Mental illness among 500 people living homeless and referred for psychiatric evaluation in Lisbon, Portugal

BACKGROUND

Our goal was to identify the demographic profile of the people living homeless with mental illness in Lisboa, Portugal, and their relationship with the national healthcare system. We also tried to understand which factors contribute to the number and duration of psychiatric admissions among these homeless people.

METHODS

We used a cross-sectional design, collecting data for 4 years among homeless people, in Lisboa, Portugal, that were referred as possible psychiatric patients to Centro Hospitalar Psiquiátrico de Lisboa (CHPL). In total, we collected data from 500 homeless people, then cross-checked these people in our CHPL hospital electronic database and obtained 467 patient matches.

RESULTS

The most common psychiatric diagnosis in our sample was drug abuse (34%), followed by alcohol abuse (33%), personality disorder (24%), and acute stress reaction (23%). Sixty-two percent of our patients had multiple diagnoses, a subgroup with longer follow-ups, more psychiatric hospitalizations, and longer psychiatric hospitalizations. The prevalence of psychotic disorders was high: organic psychosis (17%), schizophrenia (15%), psychosis not otherwise specified (14%), and schizoaffective disorder (11%), that combined altogether were present in more than half (57%) of our homeless patients.

CONCLUSION

The people living homeless with multiple diagnoses have higher mental health needs and worse determinants of general health. An ongoing effort is needed to identify and address this subgroup of homeless people with mental illness to improve their treatment and outcomes.

Cardiovascular Disease in Australians Experiencing Homelessness

Australia has one of the highest rates of homelessness in the world, at 498 per 100,000 people, and Australians experiencing homelessness (AEH) are a particularly vulnerable cohort, with a greater prevalence of cardiovascular disease, and poorer health outcomes, when compared to the general population. This narrative review explores how a combination of inadequately managed traditional and non-traditional cardiovascular risk factors, along with several personal, practical and relationship challenges with the health system, have created unique barriers in the diagnosis and management of cardiovascular disease in AEH. To help address these inequalities, we propose a targeted and collaborative strategy, which includes government proactivity, stable and affordable housing, and involvement of specialist health professionals, community leaders and major homelessness organisations. Furthermore, the delivery of health care needs to be a combination of outreach and opportunistic services, with a focus on flexible and individualised preventative care.

Implementation of a threefold intervention to improve palliative care for persons experiencing homelessness: a process evaluation using the RE-AIM framework

Background

Palliative care provision for persons experiencing homelessness is often poor. A threefold consultation service intervention was expected to increase knowledge of palliative care and multidisciplinary collaboration, and improve palliative care for this population. This intervention comprised: 1) consultation of social service professionals by palliative care specialists and vice versa; 2) multidisciplinary meetings with these professionals; and 3) training and education of these professionals. We aimed to evaluate the implementation process and its barriers and facilitators of this service implemented within social services and healthcare organizations in three Dutch regions.

Methods

A process evaluation using structured questionnaires among consultants, semi-structured individual and group interviews among professionals involved, and (research) diaries. Qualitative data were analysed using thematic analysis. The process evaluation was structured using the Reach, Adoption, Implementation and Maintenance dimensions of the RE-AIM framework.

Results

All three regions adopted all three activities of the intervention, with differences between the three regions in the start, timing and frequency. During the 21-month implementation period there were 34 consultations, 22 multidisciplinary meetings and 9 training sessions. The professionals reached were mainly social service professionals. Facilitators for adoption of the service were a perceived need for improving palliative care provision and previous acquaintance with other professionals involved, while professionals’ limited skills in recognizing, discussing and prioritizing palliative care hindered adoption. Implementation was facilitated by a consultant’s expertise in advising professionals and working with persons experiencing homelessness, and hindered by COVID-19 circumstances, staff shortages and lack of knowledge of palliative care in social service facilities. Embedding the service in regular, properly funded meetings was expected to facilitate maintenance, while the limited number of persons involved in this small-scale service was expected to be an obstacle.

Conclusions

A threefold intervention aimed at improving palliative care for persons experiencing homelessness is evaluated as being most usable when tailored to specific regions, with bedside and telephone consultations and a combination of palliative care consultants and teams of social service professionals. It is recommended to further implement this region-tailored intervention with palliative care consultants in the lead, and to raise awareness and to remove fear of palliative care provision.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01083-3.

Trends and factors associated with change in COVID-19 vaccination intent among residents and staff in six Seattle homeless shelters, March 2020 to August 2021

Introduction

Achieving high COVID-19 vaccination coverage in homeless shelters is critical in preventing morbidity, mortality, and outbreaks, however, vaccination coverage remains lower among people experiencing homelessness (PEH) than the general population.

Methods

We conducted a cross-sectional study to retrospectively describe attitudes and identify factors associated with change in COVID-19 vaccination intent among shelter residents and staff during March 2020 - August 2021. To identify factors associated with change in COVID-19 vaccine intent becoming more positive overall compared to other attitudes, we utilized a Poisson model to calculate Risk Ratios with robust standard errors, adjusting for confounding by shelter site and demographic variables determined a priori.

Results

From July 12 - August 2, 2021, 97 residents and 20 staff participated in surveys across six shelters in Seattle King County, Washington. Intent to be vaccinated against COVID-19 increased from 45.3 % (n = 53) when recalling attitudes in March 2020 to 74.4 % (n = 87) as of August 2021, and was similar among residents and staff. Many participants (43.6 %, n = 51) indicated feeling increasingly accepting about receiving a COVID-19 vaccine since March 2020, while 13.7 % (n = 16) changed back and forth, 10.3 % (n = 12) became more hesitant, and 32.5 % (n = 38) had no change in intent. In the model examining the relationship between becoming more positive about receiving a COVID-19 vaccine compared to all other attitudes (n = 116), we found a 57.2 % increase in vaccine acceptability (RR 1.57; 95 % CI: 1.01, 2.45) among those who reported worsening mental health since the start of the pandemic.

Conclusions

Findings highlight opportunities to improve communication with residents and staff about COVID-19 vaccination and support a need for continued dialogue and a person-centered approach to understanding the sociocultural complexities and dynamism of vaccine attitudes at shelters.Clinical Trial Registry Number: NCT04141917.

Serosurvey of anti-Toxocara canis antibodies in people experiencing homelessness and shelter workers from São Paulo, Brazil

BACKGROUND

Despite being one of the most prevalent helminth parasitic zoonoses worldwide and particularly in socioeconomically vulnerable populations, toxocariasis remains to be fully investigated in persons experiencing homelessness. Accordingly, the present study has aimed to assess the seroprevalence and associated risk factors of Toxocara spp. exposure in persons experiencing homelessness and shelter workers from a day-shelter in São Paulo city, Brazil.

METHODS

Anti-Toxocara IgG antibodies were detected by enzyme-linked immunosorbent assay (ELISA). Univariable and multivariable logistic regression models were performed to assess the risks for toxocariasis.

RESULTS

Overall, anti-Toxocara IgG antibodies were detected in 89/194 (45.9%, 95% CI: 39.0-52.9%) persons experiencing homelessness, twice as high (OR = 2.2; 95% CI = 1.245-3.873; P = 0.0089) than the frequency of 22/79 (27.8%, 95% CI: 19.2-38.6) in shelter workers. College education was the only protective factor for Toxocara spp. exposure (OR: 0.23; P = 0.018) revealed by logistic regression.

CONCLUSIONS

Although indicating a multifactorial origin of toxocariasis, the present study has assessed a highly vulnerable population with high disease risks and premature death. Thus, the living conditions of the homeless population have influenced the high prevalence of anti-Toxocara antibodies verified here compared with domiciled shelter workers. Despite being less exposed, shelter and other outdoor workers may present an occupational risk to toxocariasis. Future studies should establish whether such environmental exposure might occur in persons experiencing homelessness in other regions worldwide.

Addressing Mental Health and Trauma-Related Needs of Sheltered Children and Families with Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)

Children and adolescents ("youth") experiencing homelessness are at a disproportionately high risk of exposure to potentially traumatic events (PTE). However, limited evidence exists as to what interventions are effective when implemented with this high-risk population. The purpose of this study was to (1) document the mental health and trauma-related needs of sheltered youth and their mothers, and (2) examine the feasibility/effectiveness of Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) administered within the context of a homeless shelter. Three hundred and twenty-one youth (Mage = 10.06 years, SD = 3.24 years, 56.4% male, 70.1% Black/African American, 34.6% Hispanic/Latinx) and their mothers were recruited from a homeless shelter and provided 10 weeks of TF-CBT, with the option for up to eight additional weeks of therapy based on clinical need. Families completed pre- and post-intervention assessments. Results demonstrated clinically elevated pre-intervention PTSD symptoms and rates of exposure to PTE in sheltered youth well above those previously reported in the general population. TF-CBT resulted in substantial reductions in both maternal and self-reported severity of youth PTSD symptomology, which were largely attributable to reductions in re-experiencing and arousal. Effectiveness of TF-CBT varied by age and the number of exposures to PTE. Overall, these findings illustrate the importance of assessing and addressing the mental health and trauma-related needs of sheltered youth and the feasibility and efficacy of embedding an evidence-based trauma-focused treatment protocol within a shelter environment. Additional implications of these findings are discussed.

The sociodemographic characteristics and social determinants of visual impairment in a homeless population in the Montreal area

OBJECTIVE

Homelessness is a serious social and public health concern in Canada. Individuals experiencing homelessness face numerous health problems and barriers in accessing health services. Visual impairment can exacerbate the lower quality of life experienced by people who are homeless, but its incidence among this population has been poorly documented in the literature. Our study aimed to describe health and sociodemographic characteristics and determine their association with visual impairment, ocular pathology and uncorrected refractive errors in a homeless population in Montreal, Canada.

METHODS

This cross-sectional study was conducted between May 2019 and September 2020 in eight homeless shelters selected using a stratified random sampling approach on the island of Montreal. An eye examination was performed on all participants, who were also administered a survey on social determinants of health. Descriptive analysis was used to analyze survey data, and logistic regression was used for each of the three study outcomes.

RESULTS

A total of 124 individuals experiencing homelessness (93 men, 31 women) were recruited. Participants were mostly Caucasian (> 70%) with an average age of 48 years (standard deviation = 13 years). Our sample reported a high level of education (68% had a high school diploma or higher), a high level of health insurance coverage (77%), social assistance benefits (71%), and social support (over 50%). There was a high prevalence of chronic conditions including diabetes (14%), hypertension (25%), and HIV/AIDS (3%). Results from eye examinations showed a high prevalence of visual impairment (22%), ocular pathology (23%), and uncorrected refractive error (75%). Age was statistically significantly associated with each outcome variable.

CONCLUSION

Despite a high level of social and health support, individuals experiencing homelessness in Montreal, Canada, experience high levels of chronic conditions and visual impairment. Our study highlights the unmet need for eye healthcare among homeless populations, and that eye health can be a unique entry point for intervening with homeless populations.

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.

Access to Healthcare and the Utilization of Sexually Transmitted Infections Among Homeless Medicaid Patients 15 to 44 Years of Age

Homelessness poses a direct threat to public health in the US as many individuals face debilitating health outcomes and barriers to adequate health care. Access to STI care for the homeless Medicaid population of USA has not been well-studied using administrative claims data. Our study aims to compare health services utilization, STI screening and diagnoses among people experiencing homelessness (PEH) vs. those who are non-PEH using ICD10 codes. We used 2019 MarketScan Medicaid claims data to analyze men and women aged 15-44 years with a diagnosis code for PEH (Z59.0), non-PEH (without Z59.0) and assessed their emergency department and outpatient visits and STI/HIV diagnoses and screening rates. We identified 5135 PEH men and 3571 PEH women among 1.3 million men and 2.1 million women in the 2019 US Medicaid database. PEH patients were more likely to have ED visits (94.80% vs 33.04%) and ≥ 20 outpatient clinic visits (60.29% vs 16.16%) than non-PEH patients in 2019. Higher diagnoses were observed for syphilis 1.57% (CI 1.32-1.86) vs 0.11% (CI 0.11-0.11), HIV 3.93% (CI 3.53-4.36) vs 0.41% (CI 0.41-0.42), chlamydia 1.94% (CI 1.66-2.25) vs 0.85% (CI 0.84-0.86) and gonorrhea 1.26% (CI 1.04-1.52) vs. 0.33% (CI 0.33-0.34) (p < 0.0001) among PEH compared to non-PEH. Among PEH, higher STI/HIV diagnoses rates indicate an increase in STI burden and suboptimal STI testing indicates an underutilization of STI services despite having a higher percentage of health care visits compared to non-PEH patients. Focused STI/HIV interventions are needed to address health care needs of PEH patients.

Mental health correlates of quitting cigarette smoking in youth experiencing homelessness

Smoking prevalence among youth experiencing homelessness (YEH) is three times higher than smoking prevalence among the general population. Many YEH who smoke are interested in quitting smoking, but also report smoking to cope with mental health symptoms. Research on factors that facilitate or impede successful smoking cessation among YEH is limited. This study examined mental health correlates (i.e., anxiety and depression symptoms) of quitting-related factors (i.e., quit attempts, perceived barriers to quitting) and whether smoking to cope moderates these relationships among this vulnerable population. The sample consisted of 77 YEH cigarette smokers between the ages of 18-25 who were interested in quitting. Participants completed a survey assessing various behavioral and cognitive factors related to tobacco use. Analyzing two separate models, hierarchical negative binomial and hierarchical linear regression were used to examine hypothesized correlates of the number of past year quit attempts and perceived barriers to quitting. Smoking to cope moderated the relationships of depression with past year quit attempts and perceived barriers to quitting. Those high in depression and smoking to cope had the fewest number of quit attempts and reported the greatest perceived barriers. Anxiety symptoms were not significantly associated with quit attempts or perceived barriers. Smoking cessation interventions that address using smoking to cope with mental health symptoms may be important for YEH with depression.

Evaluating the perceived added value of a threefold intervention to improve palliative care for persons experiencing homelessness: a mixed-method study among social service and palliative care professionals

BACKGROUND

Palliative care for persons experiencing homelessness who reside in social service facilities is often late or lacking. A threefold intervention was implemented to improve palliative care for this population by increasing knowledge and collaboration between social service and palliative care professionals. This consultation service comprised: 1) consultations between social service professionals and palliative care professionals; 2) multidisciplinary meetings involving these professionals; and 3) training of these professionals. This study aims to evaluate the perceived added value of this threefold consultation service in three regions in the Netherlands.

METHODS

A mixed-methods evaluation study using structured questionnaires for consultants, requesting consultants, and attendees of multidisciplinary meetings, semi-structured group and individual interviews with social service and palliative care professionals involved, weekly diaries filled out by consultants, and an implementation diary. Qualitative data were analyzed following the principles of thematic analysis. Quantitative data were analyzed descriptively.

RESULTS

Thirty-four consultations, 22 multidisciplinary meetings and 9 training sessions were studied during the implementation period of 21 months. Social service professionals made up the majority of all professionals reached by the intervention. In all regions the intervention was perceived to have added value for collaboration and networks of social service and palliative care professionals (connecting disciplines reciprocally and strengthening collaborations), the competences of especially social service professionals involved (competency in palliative care provision, feeling emotionally supported in complex situations), and the quality and timing of palliative care (more focus on quality of life and dying, advance care planning and looking ahead, and greater awareness of death and palliative care).

CONCLUSIONS

The threefold consultation service particularly helps social service professionals connect with palliative care professionals. It helps them to identify palliative care needs in good time and to provide qualitatively better palliative care to persons experiencing homelessness.

Transitioning to independent living: Experiences of homeless young adults in rapid rehousing

Rapid rehousing (RRH) is an intervention that is being adopted nationally to assist adolescents and emerging adults who are homeless. RRH provides short-term rental assistance for independent scattered-site housing, in addition to an array of support services for approximately 12-24 months. The aim of this study is to explore the experiences of young adults (18-23 years old) who had previously been homeless and who were enrolled in RRH programs set in two urban Northeastern cities, and their subsequent preparedness for independent living. Our sample mostly consisted of non-Hispanic Black females, many of whom identified as LGBTQ. Semi-structured interviews (n = 15) were conducted after participants had been in the program for nine months - three months prior to their initial program completion date. Thematic analysis revealed three themes: the importance of tangible support, communication among all parties: staff lead the way, and "I gotta start learning to do it on my own". These domains provided essential assistance for young people to attain their goals and through this process they learned skills to live independently and transition into adulthood. These findings suggest that rapid rehousing programs and service providers should focus on these domains to facilitate successful transition to independent living for this population.