Comparing the housing trajectories of different classes within a diverse homeless population

Change in address in electronic health records as an early marker of homelessness

INTRODUCTION

Housing stability is a key health determinant and there is a need for early screening for instability with existing electronic health record (EHR) data to improve health outcomes. We aim to establish recorded address changes as a screening variable for housing instability and homelessness and to attempt to define the threshold of high churn.

METHODS

Our study is a single-center cross-sectional study of EHR data (2018-2024) conducted at a US academic center with eleven sites across Chicago. We include patients 18 years or older with at least three hospital encounters over three different years. We define address churn as the number of address changes recorded in the EHR corrected to three-year intervals. We compare demographic and clinical characteristics of individuals with varying address churn with the student T-test to look at distribution of address churn for patients with and without record of homelessness, ANOVA to evaluate the distribution of ages for different levels of churn, and the chi-square test to evaluate for association between churn and clinical diagnoses. We perform multivariable logistic regression to measure the association between people with a record of homelessness and address changes.

RESULTS

The study includes 1,068,311 patients with 756,222 having zero address changes, 156,911 having one address change, 137,491 with two address changes, 9,558 with three address changes, and 8,129 with four or more address changes. People with no record of homelessness in the EHR have mean address changes of 0.6 (SD 0.7) whereas people with record of homelessness have mean address changes of 1.8 (SD 1.3). Diagnostic profiles of the varying address change groups show increased prevalence of psychiatric diagnoses (65.2% in the 4 or more-address change group) compared to lower address change (27.7% in the 0-address change group). Address churn is significantly associated with homelessness with an odds ratio (OR) of 1.44 (95% CI =  [1.42-1.47], P < 0.001).

CONCLUSION

Our results support a role for residential address churn in screening for housing instability in healthcare systems and reinforce the association between psychiatric disorders and housing instability. Our findings can help public health policy makers in targeting vulnerable populations at risk of homelessness with multiple health comorbidities for housing interventions.

Housing assistance among people who are unstably housed and use drugs in Oregon: a cross-sectional study

BACKGROUND

Unstable housing has tremendous harms on health and well-being and people who use drug experience significant barriers to housing. The objectives of this study were to estimate the prevalence of housing assistance among people who use drugs experiencing unstable housing in Oregon and explore factors associated with obtaining housing assistance.

METHODS

We used cross-sectional survey data collected between March and November 2023 from people who were unstably housed and used drugs across eight counties in Oregon (N = 425). Unstable housing was defined as experiencing unsheltered or sheltered homelessness in the past year. Participants reported whether they obtained housing assistance in the past year. We explored associations between sociodemographic characteristics and housing assistance using multivariable log-binomial models.

RESULTS

There were 133 participants (31.3%) who reported obtaining housing assistance in the past year. There was a lower prevalence of housing assistance for cisgender men (versus cisgender women and gender expansive participants) (PR = 0.73, 95% CI: 0.55-0.98) and those interviewed in non-urban counties (versus urban counties) (PR = 0.72, 95% CI: 0.53-0.98). Using opioids 21 or more days (versus 0-20 days) was associated with a lower prevalence of obtaining housing assistance (PR = 0.67, 95% CI: 0.48-0.94) Community supervision was associated with a higher prevalence of housing assistance (PR = 1.70, 95% CI: 1.27-2.27).

CONCLUSION

We found a large gap in housing assistance for people who use drugs in Oregon and identified several factors associated with obtaining housing assistance. Our findings can inform future interventions to connect people who use drugs with stable housing.

Intersectional Anticipated Discrimination Among Women Experiencing Homelessness in Argentina

Women experiencing homelessness constitute a group with idiosyncratic characteristics and needs that have largely remained invisible. Their discriminatory situation has been studied very little which may limit the design of specific intervention strategies. Buenos Aires (Argentina) is one of the main megalopolises in Latin America, where information on women experiencing homelessness is scarcely available. The main objective of this paper is to analyze different aspects related to intersectional anticipated discrimination perceived by women experiencing homelessness in Buenos Aires (n = 72). A structured interview was used to collect the information. The findings show that the vast majority of women experiencing homelessness in Buenos Aires reported experiencing unfair treatment and anticipated discrimination. In addition, more than two-thirds of the women interviewed indicated that they felt they could be insulted or detained without cause, among other unfair treatment. Among the main reasons attributed by the interviewees to these situations of discrimination were the fact of being homeless, being women (cis or trans), and being poor. The results obtained may be useful to guide the design and implementation of policies, services, and programs for women experiencing homelessness with a gender perspective.

The Role of Childhood Violence in Adult Victimization Among Women Experiencing Homelessness in Spain

Persons experiencing homelessness represent one of the principal manifestations of the phenomenon of social exclusion, with homeless women constituting a group in a particularly vulnerable situation. The article analyzed the experience of violence in childhood and adolescence, and its implications in terms of violence experienced as an adult, in a sample of women experiencing homelessness in Madrid (Spain) (n = 138). All participants were of legal age and had spent the night before the interview in a shelter or other facility for the homeless, on the street, in public spaces or in places not suitable for sleeping. Information was gathered through a structured interview. The results show that the interviewees had experienced a high percentage of physical, psychological, and/or sexual violence, both in their childhood and adolescence and throughout their lives, with a strong correlation between the experience of violence in childhood and the experience of violence in adulthood, particularly sexual assaults, intimate partner violence, and sex work. The experience of childhood sexual abuse among women experiencing homelessness appears to have had particularly negative consequences in adulthood. Public policies, prevention programs, and care mechanisms with a gendered perspective must be implemented, aimed at reducing the number and intensity of situations of violence experienced by women and girls at risk of social exclusion or in a homeless situation.

Certified Peer Support in the Field of Homelessness: Stories Behind the Work

Certified peer support specialists (CPSS) are used as a paraprofessional workforce to engage hard-to-reach populations, including people experiencing homelessness. Thematic analysis was used to explore with CPSS (N = 7) what contributed to their effectiveness when working with this population. Participants were recruited at a HUD lead organization in the southeastern United States. Open-ended semi-structured questions were used in online, synchronous interviews. Themes related to three areas, experience, competence, and the organization, contributed to participants being effective. Specifically, interviewees observed that their lived experiences and abilities to speak a common language with clients contributed to their effectiveness. They identified how personal qualities and unique skillsets suited them for the work. Participants also valued the training they received; certification helped them to develop competencies and to balance vulnerability, empathy, and connection. Finally, participants attributed their effectiveness to clarity about their roles within the organization, supervision, attention to self-care, and co-worker support. Findings from this study may have implications for the value of lived and learned knowledge coexisting in organizations serving those who experience homelessness.

How the War on Drugs Impacts Social Determinants of Health Beyond the Criminal Legal System

There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the "war on drugs" in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that "drug war logic" has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts.

KEY MESSAGES

• A drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.• The U.S. drug war's frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.• Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.Appeared originally in Ann Med 2022; 54:2024-2038.

Tackling Inequalities in Access to Medicines for People Experiencing Homelessness: A Meta-Ethnography and Qualitative Systematic Review

INTRODUCTION

Despite increased awareness of the detrimental relationship between homelessness and health, people experiencing homelessness remain an underserved population in health and social care research. Due to barriers affecting the accessibility of medicine and healthcare services, as well as reported competing priorities such as food and shelter, evidence has demonstrated that people experiencing homelessness are less likely to undergo routine examinations, receive diagnoses and adhere to prescribed medical treatments. To enhance service design and access for those experiencing homelessness, it is critical to better recognise, understand and address the barriers these individuals face. This meta-ethnography aims to identify barriers, enablers and interventions to begin addressing this inequality gap.

METHODS

A systematic literature search was undertaken in October and re-ran in December 2023 across four databases: MEDLINE, Embase, CINAHL and Scopus. Qualitative studies were included if they addressed barriers, enablers and interventions aimed at tackling medicines and health service inequalities among populations experiencing homelessness. Study quality was assessed using the Joanna Briggs Institute critical appraisal checklist. Data were synthesised using a meta-ethnographic approach, as outlined by Noblit and Hare. The review was registered on PROSPERO (CRD42024511502) and performed according to PRISMA guidelines.

RESULTS

This meta-ethnographic systematic review synthesised data from eight studies across multiple countries. Three overarching third-order constructs (termed 'themes') were developed through reciprocal translation and centred around: recognising and acknowledging the discrimination, stigma and barriers experienced when using current services; exploring safe and practical use of medicines and the promotion of general health education and appreciating strategies to tackle inequalities, namely community outreach programmes designed for homeless communities.

CONCLUSION

This work highlighted the barriers, enablers and interventions that sought to address the inequalities affecting people experiencing homelessness in accessing medication and healthcare services. Future research should utilise lived-experience narratives and co-design to further explore ways to tackle wider healthcare accessibility inequalities for this minoritised population.

TRIAL REGISTRATION

Not applicable, as this is a systematic review.

PATIENT OR PUBLIC CONTRIBUTION

Public contributors (minority research champions and one public health research champion, H.K.G. and T.G.) informed and shaped this project during study design and conceptualisation. They helped to ensure that the study was conducted, and the findings were reported with sensitivity.

Profiles of Permanent Supportive Housing Residents Related to Their Housing Conditions, Service Use, and Associated Sociodemographic and Clinical Characteristics

As permanent supportive housing (PSH) is the main strategy promoted to reduce homelessness, understanding how PSH resident profiles may be differentiated is crucial to the optimization of PSH implementation - and a subject that hasn't been studied yet. This study identified PSH resident profiles based on their housing conditions and service use, associated with their sociodemographic and clinical characteristics. In 2020-2021, 308 PSH residents from Quebec (Canada) were interviewed, with K-means cluster analysis produced to identify profiles and subsequent analyses to compare profiles and PSH resident characteristics. Of the three profiles identified, Profiles 1 and 2 (70% of sample) showed moderate or poor housing, neighborhood, and health conditions, and moderate or high unmet care needs and service use. Besides their "moderate" conditions, Profile 1 residents (52%) reported being in PSH for more than two years and being less educated. With the "worst" conditions and high service use, Profile 2 (18%) included younger individuals, while Profile 3 (30%) showed the "best" conditions and integrated individuals with more protective determinants (e.g., few in foster care, homelessness at older age, more self-esteem), with a majority living in single-site PSH and reporting higher satisfaction with support and community-based services. Profiles 1 and 2 may be provided with more psychosocial, crisis, harm reduction, and empowerment interventions, and peer helper support. Profile 2 may benefit from more intensive and integrated care, and better housing conditions. Continuous PSH may be sustained for Profile 3, with regular monitoring of service satisfaction and met needs.

Incontinence and homelessness

The fundamental principles of why specific people become homeless, can be grounded in a simple rationale or founded within sophisticated reasoning. For instance, people who suffer from substance abuse, addiction, alcohol, gambling, have mental health concerns or financial difficulties may be susceptible to homelessness. It is also identified that persons who experienced violence in their childhood or abuse by a partner are at a higher risk of becoming homeless. Homelessness knows no ethnic, cultural, religious or gender boundaries, and can impact all individuals' health and well-being. A health problem and worldwide phenomenon that affects all cohorts of the population, including the homeless, is urinary incontinence. The aim of this article is to increase the awareness of incontinence and highlight the impact it has on the lives of people that experience homelessness.

Harm Reduction Strategies for Severe Alcohol Use Disorder in the Context of Homelessness: A Rapid Review

Severe alcohol use disorder (AUD) in the context of housing instability remains one of the most complex health and social issues. Homelessness is related to increased vulnerability to stigma, marginalization and harmful ways of alcohol consumption, including non-beverage alcohol use (NBA). As a result, severe intoxication, alcohol poisoning, injury and death are common occurrences. Although harm minimization strategies have been readily proposed and examined in the context of drug use, applying the same principles to severe AUD remains controversial within the research and treatment community. This article summarizes the emerging research on managed alcohol programs to increase awareness about alcohol-related strategies that address severe AUD and provide other wrap-around supports such as housing, health and social services to mitigate various harms, including COVID-19.

How the war on drugs impacts social determinants of health beyond the criminal legal system

There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the "war on drugs" in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that "drug war logic" has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts. KEY MESSAGESA drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.The U.S. drug war's frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.

Representing the values of program participants: Endogenous evaluative criteria

Evaluative conclusions are grounded in implicit and explicit criteria that describe a successful or high-quality intervention. Most often, evaluative criteria are drawn from program objectives that reflect the values and priorities of program designers and funders. Yet, an exclusive focus on program goals risks overlooking the values of program participants, the extent to which their actual needs and priorities are addressed, and, in certain types of programs, the choices participants make and agency they exercise. This article presents concepts and methods to guide evaluators in drawing some of the criteria used in an evaluation from program participants. The article outlines a typology of evaluative criteria and seven methods for drawing outcomes-focused criteria from program participants. The article concludes with a discussion of implications and future directions for research and practice.

Unhoused and unhireable? Examining employment biases in service contexts related to perceived warmth and competence of people experiencing houselessness

Lack of safe and stable housing is a pernicious and growing social concern, and stereotypes about individuals experiencing houselessness are generally quite negative. Little scholarly work has examined housing insecurity and its associated stereotypes in employment contexts. The purpose of the current research was to examine, in the context of the hospitality industry, whether housing status influences hiring managers' perceptions of hireability (Study 1) and customers' evaluations of an organization and its employees (Study 2) using the stereotype content model. Across two experimental studies, we assessed participant attitudes toward individuals experiencing houselessness. In Study 1, we instructed 148 hotel managers to listen to a hypothetical job interview with either an unhoused or housed job applicant, and then complete measures of hireability. In Study 2, we instructed 139 hotel customers to observe a hypothetical interaction with either an unhoused or housed employee, and then evaluate the employee and the organization. Study 1's findings suggested an indirect effect of housing status on perceived hireability through warmth, and this indirect relationship was moderated by gender. Men who were houseless were rated lower in warmth, and thus lower in hireability, than non-houseless men or women regardless of their housing status. However, houseless men were perceived by customers as warmer than non-houseless men as employees, driving higher evaluations of the organization and the employee (Study 2). Hiring initiatives targeted at providing short-term housing for unhoused employees will benefit employees, employers, and the larger communities they encompass.

Longitudinal high-frequency ethnographic interviewing to simulate and prepare for intensive smartphone data collection among veterans with homeless experience

Objective

While Veteran homelessness has steadily declined over the last decade, those who continue to be unhoused have complex health and social concerns. Housing instability interferes with access to healthcare, social services, and treatment adherence. Preventing unwanted housing transitions is a public health priority. This study is the first phase of a larger research agenda that aims to test the acceptability and feasibility of smartphone-enabled data collection with veterans experiencing homelessness. In preparation for the development of the smartphone data collection application, we utilized ethnographic methods guided by user-centered design principles to inform survey content, approach to recruitment and enrollment, and design decisions.

Methods

We used a case study design, selecting a small sample (n = 10) of veterans representing a range of homelessness experiences based on risk and length of time. Participants were interviewed up to 14 times over a 4-week period, using a combination of qualitative methods. Additionally, 2 focus group discussions were conducted. Interviews were audio-recorded and transcribed. Data were synthesized and triangulated through use of rapid analysis techniques.

Results

All participants had experience using smartphones and all but one owned one at the time of enrollment. Participants described their smartphones as “lifelines” to social network members, healthcare, and social service providers. Social relationships, physical and mental health, substance use, income, and housing environment were identified as being directly and indirectly related to transitions in housing. Over the course of ~30 days of engagement with participants, the research team observed dynamic fluctuations in emotional states, relationships, and utilization of services. These fluctuations could set off a chain of events that were observed to both help participants transition into more stable housing or lead to setbacks and further increase vulnerability and instability. In addition to informing the content of survey questions that will be programmed into the smartphone app, participants also provided a broad range of recommendations for how to approach recruitment and enrollment in the future study and design features that are important to consider for veterans with a range of physical abilities, concerns with trust and privacy, and vulnerability to loss or damage of smartphones.

Conclusion

The ethnographic approach guided by a user-centered design framework provided valuable data to inform our future smartphone data collection effort. Data were critical to understanding aspects of day-to-day life that important to content development, app design, and approach to data collection.

The vulnerability of women living homeless in Nicaragua: A comparison between homeless women and men in a low-income country

This article takes a gender perspective approach to a series of issues that may affect the vulnerability of people in a homeless situation in Nicaragua, focusing particularly on women. The study was completed using data obtained from two similarly-sized samples, one of homeless men (n = 32) and the other of homeless women (n = 30). The information was gathered using a structured interview. Results show that there are key similarities in the situation and characteristics of both men and women living homeless in Nicaragua. Results also support the thought that women living homeless - some with dependent children to care for - are in a situation of particular vulnerability, suffering violence, a greater need to find safe places to stay, greater "revolving door to homelessness," more barriers to finding work and more sex work. The analysis of the issues differentiating men from women may be of use in driving forward public policies and social care resources adapted to the specific characteristics and needs of these women and their children. As can be taken from this paper, people living homeless in low-income and high-income countries share a number of similar circumstances, which in turn could facilitate a global approach to the problem.

Identifying a typology of homelessness based on self-sufficiency: Implications for rapid re-housing interventions

Limited research exists on the characteristics of individuals experiencing homelessness who achieve positive housing outcomes in rapid re-housing (RRH) interventions. We aimed to identify a typology of homelessness based on Self-Sufficiency Matrix (SSM) domains and examine its relation to sociodemographic characteristics and housing placement through RRH. Homeless Management Information System data, including sociodemographics, SSM domains, and housing outcomes, were obtained for 261 Homelessness Prevention and Rapid Re-housing Program participants in Indianapolis, Indiana, from 2009 to 2012. Latent class analysis (LCA) and latent class regression (LCR) were used to identify subgroups and predict associations between the identified typology and sociodemographic variables and housing placement outcome, respectively. LCA revealed three classes based on SSM domains: "High Self-Sufficiency," "Low Socioeconomic Self-Sufficiency," and "Low Psychosocial Self-Sufficiency." LCR revealed that race significantly predicted class membership such that Black individuals had a significantly higher probability of being in the High Self-Sufficiency class than the other two classes. Latent class membership significantly predicted immediate housing placement. The Low Psychosocial Self-Sufficiency group was the least likely to exit RRH to a permanent housing placement compared to the two other subgroups. Results affirm that individuals with greater psychosocial self-sufficiency have better housing outcomes through RRH than those with more complex support needs. Future research is needed to understand factors influencing differential self-sufficiency, as measured by the SSM, among Black and White individuals.

Participation in Canadian Managed Alcohol Programs and Associated Probabilities of Emergency Room Presentation, Hospitalization and Death: A Retrospective Cohort Study

INTRODUCTION

Managed Alcohol Programs (MAPs) are designed to improve health and housing outcomes for unstably housed people with an alcohol use disorder (AUD). The present study assesses the association of MAP participation with healthcare and mortality outcomes.

METHODS

A retrospective cohort study assessed health outcomes for 205 MAP participants and 128 controls recruited from five Canadian cities in 2006-2017. Survival and negative binomial regression models were used to calculate hazard ratios (HR) of death and emergency room (ER) visits and hospital bed days (HBDs). Covariates included age, sex, AUD severity and housing stability score.

RESULTS

In fully adjusted models, compared with times outside MAPs, participants had significantly reduced risk of mortality (HR = 0.37, P = 0.0001) and ER attendance (HR = 0.74, P = 0.0002), and fewer HBDs yearly (10.40 vs 20.08, P = 0.0184). Over the 12 years, people enrolled in a MAP at some point had significantly fewer HBDs per year than controls after MAP enrolment (12.78 vs 20.08, P = 0.0001) but not significantly different rates of death or ER presentation. MAP participants had significantly more alcohol-related but significantly fewer nonalcohol-related ER presentations than controls.

CONCLUSION

Attendance at a MAP was associated with reduced risk of mortality or morbidity and less hospital utilization for individuals with unstable housing and severe AUDs. MAPs are a promising approach to reduce mortality risk and time spent in hospital for people with an AUD and experiencing homelessness.

Multi-trajectory group profiles of well-being and associated predictors among adults experiencing homelessness and mental illness: findings from the At Home/Chez Soi study, Toronto site

PURPOSE

To conduct a multi-dimensional and time-patterned analysis to identify distinct well-being trajectory profiles over a 6-year follow-up period among adults experiencing homelessness and mental illness.

METHODS

Data from 543 participants of the At Home Chez Soi study's Toronto site were examined over a 6-year follow-up period, including measures of quality of life, community functioning, housing stability, and substance use. Well-being trajectories were identified using Group-Based Trajectory Modelling. Multinomial regression was used to identify predictor variables that were associated with each well-being trajectory profile.

RESULTS

Four well-being profiles were identified: low well-being, moderate well-being, good well-being, and high well-being. Factors associated with a greater likelihood of following a better well-being profile included receiving Housing First, reporting female gender and non-white ethnicity, having post-secondary studies, and reporting a high resilience level. Concurrently, factors associated with a lower likelihood of better well-being profiles were having a history of chronic homelessness, experiences of discrimination in the healthcare setting, having comorbid mental disorders and a high level of symptom severity, and reporting a history of traumatic brain injury and childhood adversity.

CONCLUSIONS

Individuals experiencing homelessness follow distinct well-being profiles associated with their socio-demographic characteristics, health status, trauma history, resilience capabilities, and access to housing and support services. This work can inform integrated housing and support services to enhance the well-being trajectories of individuals experiencing homelessness.

TRIAL REGISTRATION

At Home/Chez Soi trial was registered with ISRCTN, ISRCTN42520374, http://www.isrctn.com/ISRCTN42520374 .

Typology of Currently or Formerly Homeless Individuals Based on Their Use of Health and Social Services

This study identified profiles among 455 currently or formerly homeless individuals in Quebec (Canada), based on health and social service use. Using latent class analysis, four profiles were identified that grouped individuals with: (1) few health problems, and using few case managers and family doctors, but with high frequency of psychiatric consultations, emergency department (ED) visits and hospitalizations; (2) chronic physical illnesses, having case managers and family doctors, but low frequency of ED visits and hospitalizations; (3) moderate health problems and little service use; and (4) multiple and complex health problems and high frequency of service use. These profiles suggest the following recommendations to more adequately meet patient needs: regarding Class 1, improved outreach services, more ED liaison nurses and peer navigation; Class 2: more family doctors and case managers; Class 3: higher family doctors; and Class 4: more assertive or intensive case management, harm reduction and permanent housing resources.

A cross-sectional study of factors associated with unstable housing among marginalized people who use drugs in Ottawa, Canada

Introduction

Housing affects an individual’s physical and mental health, particularly among people who use substances. Understanding the association between individual characteristics and housing status can inform housing policy and help optimize the care of people who use drugs. The objective of this study was to explore the factors associated with unstable housing among people who use drugs in Ottawa.

Methods

This is a cross-sectional analysis of data from 782 participants in the Participatory Research in Ottawa: Understanding Drugs (PROUD) Study. PROUD is a prospective cohort study of people who use drugs in Ottawa. Between March and December 2013, participants were recruited through peer-based recruitment on the streets and in social services settings and completed a peer-administered questionnaire that explored socio-demographic information, drug use patterns, community integration, experiences with police and incarceration, and access to health care and harm reduction services. Eligibility criteria included age of 16 years or older, self-reported illicit drug use within the past 12 months and having lived in Ottawa for at least 3 months. Housing status was determined by self-report. “Stable housing” was defined as residence in a house or apartment and “unstable housing” was defined as all other residence types. Exploratory multivariable logistic regression analyses of the association between characteristics of people who use drugs and their housing status were conducted.

Results

Factors that were associated with unstable housing included: recent incarceration; not having a regular doctor; not having received support from a peer worker; low monthly income; income source other than public disability support payments; and younger age. Gender, language, ethnicity, education level, opioid use and injection drug use were not independently associated with housing status.

Conclusions

People who use drugs face significant barriers to stable housing. These results highlight key areas to address in order to improve housing stability among this community.

Differences in housing transitions and changes in health and self-determination between formerly homeless individuals

Background

To reduce homelessness, it is important to gain a better understanding of the differences between homeless people who remain in institutions and those who gain and can sustain independent housing. This longitudinal study explores differences in housing transitions and differences in changes in health and self-determination between formerly homeless people still living in institutions 2.5 years later and those now living in independent housing in the Netherlands.

Methods

This study mapped the housing transitions of 263 participants from when they entered the social relief system (SRS) to 2.5 years later when they were in independent housing or institutions. These individuals were compared at the 2.5-year mark in terms of gender, age and retrospectively in terms of duration of homelessness. They were also compared with regard to changes in psychological distress, perceived health, substance use and self-determination.

Results

Two and a half years after entering the SRS, 81% of participants were independently housed and 19% still lived in institutions. People in institutions had a longer lifetime duration of homelessness, were more often men, and their number of days of alcohol use had decreased significantly more, whereas independently housed people had shown a significant increase in their sense of autonomy and relatedness.

Conclusion

Formerly homeless people living in independent housing and in institutions show few health-related differences 2.5 years after entering the SRS, but changes in autonomy and relatedness are distinctly more prevalent, after the same period of time, in those who are independently housed.

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness

Background

Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness.

Objectives

The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness.

Search Methods

In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies.

Selection Criteria

Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income.

Data Collection and Analysis

Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model.

Main Results

The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services.

Authors' Conclusions

PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

Severe Psychopathology and Substance Use Disorder Modify the Association Between Housing Trajectories and Food Security Among Homeless Adults

Purpose: We examined the housing trajectories of homeless people with mental illness over a follow-up period of 6 years and the association of these trajectories with food security. We then examined the modifying role of psychopathology and alcohol and substance use disorders in this association. Materials and Methods: We followed 487 homeless adults with mental illness at the Toronto site of the At Home/Chez-Soi project-a randomized trial of Housing First. Food security data were collected seven times during the follow-up period. Psychopathology (Colorado Symptom Index score) and alcohol and substance use disorders were assessed at baseline. Housing trajectories were identified using group-based trajectory modeling. Logistic regression was used to estimate the association between housing trajectory groups and food security. Results: Three housing trajectory groups were identified: rapid move to consistent stable housing (34.7%), slow and inconsistent housing (52.1%), and never moved to stable housing (13.2%). Individuals included in the rapid move to consistent housing trajectory group had higher odds of remaining food secure compared with those in the never moved to stable housing trajectory group over the follow-up period [AOR 2.9, 95% CI: 1.3-6.6, P-value: 0.009]. However, when interactions were considered, this association was significant among those with moderate psychopathology but not severe psychopathology. Individuals with substance use disorder and in the never moved to stable housing group had the lowest food security status. Discussion: Severe psychopathology and substance use disorders modified the association between housing trajectories and food security. International Standard Randomized Control Trial Number Register (ISRCTN42520374).

Typology of changes in quality of life over 12 months among currently or formerly homeless individuals using different housing services in Quebec, Canada

Background

In health and social service evaluations, including research on homelessness, quality of Life (QOL) is often used as a key indicator of well-being among service users. However, no typology has been developed on changes in QOL over a 12-month period for a heterogenous sample of homeless individuals.

Methods

Cluster analysis was employed to identify a typology of change in QOL for 270 currently or formerly homeless individuals using emergency shelters, temporary housing (TH) and permanent housing (PH) services in Quebec (Canada). Participant interviews were conducted at baseline and 12 months later. An adapted Gelberg–Andersen Model helped organize QOL-related sociodemographic, clinical, and service use variables into predisposing, needs, and enabling factors, respectively. Comparison analyses were performed to determine group differences.

Results

Four groups emerged from the analyses: (1) young women in stable-PH or improved housing status with moderately high needs and specialized ambulatory care service use, with improved QOL over 12 months; (2) middle-age to older men with stable housing status, few needs and low acute care service use, with most improvement in QOL over 12 months; (3) older individuals residing in stable-PH or improved housing status with very high needs and reduced QOL over 12 months; and (4) men in stable-TH or worse housing status, with high substance use disorder, using few specialized ambulatory care services and showing decline in QOL over 12 months.

Conclusions

Findings suggest that positive change in QOL over 12 months was mainly associated with fewer needs, and stability in housing status more than housing improvement. Specific recommendations, such as assertive community treatment and harm reduction programs, should be prioritized for individuals with high needs or poor housing status, and among those experiencing difficulties related to QOL, whereas individuals with more favourable profiles could be encouraged to maintain stable housing and use services proportional to their needs.

Differences in Clinical Outcomes of Adults Referred to a Homeless Transitional Care Program Based on Multimorbid Health Profiles: A Latent Class Analysis

Background: People experiencing homelessness face significant medical and psychiatric illness, yet few studies have characterized the effects of multimorbidity within this population. This study aimed to (a) delineate unique groups of individuals based on medical, psychiatric, and substance use disorder profiles, and (b) compare clinical outcomes across groups. Methods: We extracted administrative data from a health system electronic health record for adults referred to the Durham Homeless Care Transitions program from July 2016 to June 2020. We used latent class analysis to estimate classes in this cohort based on clinically important medical, psychiatric and substance use disorder diagnoses and compared health care utilization, overdose, and mortality at 12 months after referral. Results: We included 497 patients in the study and found 5 distinct groups: "low morbidity" (referent), "high comorbidity," "high tri-morbidity," "high alcohol use," and "high medical illness." All groups had greater number of admissions, longer mean duration of admissions, and more ED visits in the 12 months after referral compared to the "low morbidity" group. The "high medical illness" group had greater mortality 12 months after referral compared to the "low morbidity" group (OR, 2.53, 1.03-6.16; 95% CI, 1.03-6.16; p = 0.04). The "high comorbidity" group (OR, 5.23; 95% CI, 1.57-17.39; p < 0.007) and "high tri-morbidity" group (OR, 4.20; 95% CI, 1.26-14.01; p < 0.02) had greater 12-month drug overdose risk after referral compared to the referent group. Conclusions: These data suggest that distinct groups of people experiencing homelessness are affected differently by comorbidities, thus health care programs for this population should address their risk factors accordingly.

Health, disability, and consumption of psychoactive substances among people in a homeless situation in León (Nicaragua)

Nicaragua is one of the countries in Latin America with lowest levels of development. In Nicaragua, people in a homeless situation are one of the most socially excluded groups, and there is a lack of data regarding their characteristics, circumstances, and needs. This study examines the state of health, disability, and substance use among people living homeless (n = 68) in the city of León (Nicaragua). Sixty percent of the homeless people contacted responded to a questionnaire which was administered with the respondents by means of an interview. The findings showed that people living homeless in León had very negative states of health and disability, worse than those observed in other socially excluded groups in the same city and homeless people in more developed countries. The interviewees also presented a high level of substance abuse - mainly of alcohol and inhaled glue.

Pathways Into Homelessness Among LGBTQ2S Adults

This article examines entries into homelessness among adults who identify as LGBTQ2S (lesbian, gay, bisexual, transgender, queer, two-spirit). Twenty LGBTQ2S adults who were currently or formerly homeless participated in one qualitative interview. The interview protocol included questions on the participants' history of homelessness, causes of homelessness, and relationship of their gender and/or sexual identity to their homelessness. Data were analyzed using an iterative coding process. Results demonstrated that the participants listed both structural (i.e., discrimination) and intrapersonal (i.e., substance use) variables related to their homelessness. In particular, substance abuse was a common antecedent of their homelessness, and some participants linked their homeless experiences to discrimination and victimization based on their sexual and/or gender identity. The results are discussed in terms of interventions to prevent homelessness among LGBTQ2S adults and support their exits out of homelessness.

Employment experiences of formerly homeless adults with serious mental illness in Housing First versus treatment first supportive housing programs

OBJECTIVE

This paper examines how formerly homeless adults with serious mental illness living in Housing First (HF) and "treatment first" (TF) supportive housing programs experience employment. Research questions include: How do these individuals experience employment in the context of their mental health recovery? What do they perceive as the benefits of and obstacles to attaining employment? Are there programmatic differences in their employment experiences?

METHOD

Case study analyses of data from a federally funded qualitative study were conducted of 40 individuals purposively sampled from HF and TF programs. Data were independently analyzed and consensually discussed to develop cross-case themes.

RESULTS

Three themes emerged: (a) the meaning of work, (b) working within the system, and (c) balancing treatment requirements and work. While none of the study participants had full-time jobs, more HF program clients had part-time employment than their TF counterparts. Of the 12 employed participants, all but 2 worked within their respective programs. Participants in both groups described similar benefits of obtaining employment, but TF program requirements inhibited job-seeking.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

These findings provide insight into the challenges of obtaining employment for formerly homeless individuals with serious mental illness residing in supportive housing. Despite the motivation to work, individual, structural, and organizational factors impeded employment. To address this problem, factors at each of these levels will need to be considered. Interventions such as supported employment offer promise to supportive housing programs committed to employment as a contributor to recovery. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Change in Housing Status among Homeless and Formerly Homeless Individuals in Quebec, Canada: A Profile Study

Housing stability is a key outcome in studies evaluating housing services for the homeless population. Housing stability has typically been defined dichotomously and based on a fixed duration of maintenance in housing accommodations, which does not fully capture change in housing status among homeless individuals. Moreover, few typologies have examined housing trajectories across different housing types. Cluster analysis was used to develop a typology of housing status change for 270 currently or formerly homeless individuals in Quebec (Canada) residing in shelters and temporary and permanent housing. Participants were interviewed at baseline (T0) and 12 months later (T1). The Gelberg–Andersen Model was used to organize housing-related variables into predisposing, needs and enabling factors. Comparison analyses were conducted to assess group differences. Three groups (Groups 1, 3 and 4) had more favorable and two (Groups 2 and 5) less favorable, housing status at T1. Findings suggest that maintenance or improvement of housing status requires suitable types and frequencies of service use (enabling factors) that are well adapted to the nature and complexity of health problems (needs factors) among homeless individuals. Specific interventions, such as outreach programs and case management, should be prioritized for individuals at higher risk for returning to homelessness.

Pathways to Recovery among Homeless People with Mental Illness: Is Impulsiveness Getting in the Way?

OBJECTIVE

This study investigates the association between impulsiveness and six dimensions of recovery among homeless people with mental illness.

METHOD

The sample was composed of 418 participants of a randomized controlled trial of Housing First, a recovery-oriented program that provides immediate access to permanent housing. The reliable change index method was used to provide an estimate of the statistical and clinical significance of the change from baseline to 24 months (i.e., clinically meaningful improvement), on outcomes that pertain to recovery dimensions: psychiatric symptoms (clinical), physical health and substance use problems (physical), residential stability (functional), arrests (criminological), community integration (social), and hope and personal confidence (existential). We tested for the effect of impulsiveness, assessed with the Barratt Impulsiveness Scale-11, on clinically meaningful improvement on each specific outcome, adjusting for age, gender and intervention assignment, as both intervention arms were included in the analysis.

RESULTS

For every increase in total impulsiveness score by one standard deviation, the odds of experiencing clinically meaningful improvement decreased by 29% (OR = 0.71, 95% CI, 0.55 to 0.91) on the clinical dimension and by 53% (OR = 0.47, 95% CI, 0.32 to 0.68) on the existential dimension. However, changes in outcomes pertaining to physical, functional, criminological, and social dimensions were not significantly influenced by impulsiveness.

CONCLUSIONS

Findings highlight the importance of addressing impulsiveness in the context of recovery-oriented interventions for homeless people with mental illness. Further research may be required to improve interventions that are responsive to unique needs of impulsive individuals to support clinical and existential recovery.

A qualitative exploration of substance misuse among homeless women in Addis Ababa, Ethiopia

BACKGROUND

Substance use among homeless people is higher compared to the general population. In some studies, reported rates of problematic drug use among the homeless vary, with estimates ranging from 25 to 70%. There is a common perception that substance abuse and homelessness are linked, but there is considerable debate about the direction of the relationship. Despite observations of high levels of substance use among the homeless population in Addis Ababa, there are limited studies to date conducted on the topic. This study aims to explore the factors associated with onset of substance use and its continued use, patterns of substance use and its social and health consequences among female residents of a shelter in Addis Ababa, Ethiopia.

METHODS

A qualitative study was conducted in 2019. In-depth interviews were conducted on 14 study participants who were selected purposively. The qualitative data analysis software QDA Miner 5.0.30 was used for data processing and analysis.

RESULTS

Four major thematic areas were identified and they comprised the categories under which sub-themes were identified and coded. The major segments or categories included the following: reasons for the onset of substance use after becoming homeless, experiences of substance use and reasons for continued use, the harms which resulted on them from substance use, and the means of obtaining supply of the substances.

CONCLUSION

Factors related to life on streets were strong reasons for onset of substance use, as well as for its continued use. Homeless women suffered untimely death, addiction, and ill health from use of substances; however, they gave priority to obtaining substances than any other thing, and used every means to grab a supply of the substances.

The effectiveness of case management interventions for the homeless, vulnerably housed and persons with lived experience: A systematic review

BACKGROUND

Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations.

METHODS AND FINDINGS

We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management.

CONCLUSIONS

Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Predictors of Emergency Department Use among Individuals with Current or Previous Experience of Homelessness

This study assessed the contributions of predisposing, enabling, and needs factors in predicting emergency department (ED) use among 270 individuals with current or previous experience of homelessness. Participants were recruited from three different types of housing (shelter, temporary housing and permanent housing) in Montreal, Quebec (Canada). They were interviewed at baseline (T0), and again 12 months after recruitment (T1). Longitudinal data analyses were conducted on associations between a set of baseline predictors (T0) with the dependent variable (ED users vs. non-users) from T1. Predictors were identified according to the Gelberg-Andersen Behavioral Model. Findings revealed two needs factors associated with ED use: having a substance use disorder (SUD) and low perceived physical health. Two enabling factors, use of ambulatory specialized services and stigma, were also related to ED use. No predisposing factors were retained in the model, and ED use was not associated with type of housing. Improvements are needed in SUD and physical health management in order to reduce ED use, as well as interventions aimed at stigma prevention for this vulnerable population.

The Particularly Vulnerable Situation of Women Living Homeless in Madrid (Spain)

People in homeless situation are one of the major embodiments of the phenomenon of social exclusion, and women living homeless are considered a particularly vulnerable group. This paper examines different variables that may affect the situation of vulnerability experienced by women living homeless in Madrid (Spain). The study was carried out using data obtained from a representative sample of homeless men in Madrid (n = 158) and a sample of homeless women in Madrid of a similar size (n = 138). The information was gathered using a structured interview in shelters or other facilities for people in a homeless situation, on the street and in other places not initially designed for sleeping. The results show that woman living homeless are highly vulnerable compared to the domiciled population and, in some respects, to homeless men as well, especially in the number of times homeless (χ2 = 10.314; p < .01), in the time working with a contract and/or self-employed (t = 5.754; p < .001), and in the use of sedatives (χ2= 14.741; p < .001). It is however noted that homeless women show in some aspects greater strengths than homeless men. Such strengths could serve as a supporting point for their social inclusion processes. The analysis of issues that differentiate women in a homeless situation from their male counterparts could be useful for developing public policies and care resources adapted to the specific characteristics and needs of women living homeless.

Profiles of Clinical Need Among Homeless Individuals with Dual Diagnoses

This study explored patterns of clinical need among homeless individuals with dual diagnoses, and explored whether certain profiles are characteristic of different demographic groups. Data were drawn from two larger studies conducted with dually diagnosed, homeless individuals (n = 373). Hierarchical cluster analysis identified four subgroups: (1) Clinically least severe, characterized by less frequent psychological symptoms and no history of physical or sexual abuse; (2) Moderate clinical needs, including shorter history of substance use and less frequent psychological symptoms, but symptoms consistent with severe mental illness; (3) Clinically severe, with frequent anxiety, depression, past and recent physical or sexual abuse, and long history of substance use; (4) Least frequent psychological symptoms, but frequent history of physical or sexual abuse and long history of drug use. Women veterans were mostly likely to be classified in cluster 3, and male civilians in cluster 2. Subgroups of homeless individuals with dual diagnoses demonstrated different clusters of clinical needs, having implications for service delivery to the population.

Profiles of Service Users with Severe Mental Disorders Based on Adequacy of Help

This study has for aims to develop a typology describing adequacy of help based on socio-demographic, clinical and service utilization variables for 204 service users with severe mental disorders treated in the community. Study participants were recruited in an urban area of Quebec (Canada). Adequacy of help was assessed with the Montreal Assessment of Needs Questionnaire. A cluster analysis identified five profiles of service users. Adequacy of help was mainly related to continuity of care, help given by services, seriousness of needs and, to some extent, quality of life (QOL). Adequacy of help was highest among Class 3 participants, described as older individuals with mood disorders, who lived in autonomous housing and enjoyed good QOL. They received substantial help from both relatives and services. Adequacy of help was lowest for Class 5, which included individuals affected by co-occurring mental disorders but who also lived autonomously. Health service utilization was more strongly related to adequacy of help for this sample than were the socio-demographic and clinical factors tested.

A randomized controlled trial of the effectiveness of Housing First in a small Canadian City

Background

The paper presents two-year findings from a study investigating the effectiveness of Housing First (HF) with assertive community treatment (ACT) in helping individuals with serious mental illness, who are homeless or precariously housed and living in a small city, to become stably housed.

Methods

The research design was a parallel group non-blinded RCT with participants randomly assigned after the baseline interview to receive HF with ACT (N = 100) or treatment as usual (TAU; N = 101). Participants were interviewed every 3 months over 21/24 months to investigate changes on a range of housing and psychosocial outcomes. The primary outcomes were housing stability (as defined by a joint function of number of days housed and number of moves) and improvement in community functioning. Secondary predicted outcomes were improvements in self-rated physical and mental health status, substance use problems, quality of life, community integration, and recovery.

Results

An intent-to-treat analysis was conducted. Compared to TAU participants, HF participants who entered housing did so more quickly (23.30 versus 88.25 days, d = 1.02, 95% CI [0.50–1.53], p < 0.001), spent a greater proportion of time stably housed (Z = 5.30, p < 0.001, OR = 3.12, 95% CI [1.96–4.27]), and rated the quality of their housing more positively (Z = 4.59, p < 0.001, d = 0.43, 95% CI [0.25–0.62]). HF participants were also more likely to be housed continually in the final 6 months (i.e., 79.57% vs. 55.47%), χ² (2, n = 170) = 11.46, p = .003, Cramer’s V = 0.26, 95% CI [0.14–0.42]). HF participants showed greater gains in quality of life, (Z = 3.83, p < 0.001, ASMD = 0.50, 95% CI [0.24–0.75]), psychological integration (Z = 12.89, p < 0.001, pooled ASMD = 0.91, 95% CI [0.77–1.05]), and perceived recovery (Z = 2.26, p = 0.03, ASMD = 0.39, 95% CI [0.05–0.74]) than TAU participants.

Conclusions

The study indicates that HF ends homelessness significantly more rapidly than TAU for a majority of individuals with serious mental illness who have a history of homelessness and live in a small city. In addition, compared to TAU, HF produces psychosocial benefits for its recipients that include an enhanced quality of life, a greater sense of belonging in the community, and greater improvements in perceived recovery from mental illness.

Trial registration

International Standard Randomized Control Trial Number Register Identifier: ISRCTN42520374, assigned August 18, 2009.

The entrepreneurship of survival among urban adults experiencing homelessness and mental illness

AIMS

Using an entrepreneurship lens, this study examined the narratives of urban adults experiencing homelessness and living with mental illness, to explore strategies used for day-to-day survival.

METHODS

Semi-structured qualitative interviews were conducted with 14 females, 30 males, and one individual identifying as "other," living in a mid-sized Canadian city. The average age was 39 years. Data were transcribed verbatim and analyzed using thematic analysis informed by grounded theory.

FINDINGS

Participants described creative and intentional strategies for managing life on the street without permanent shelter, including recognition of opportunities, mobilization of their own or acquired resources, and use of social connections and communication skills, and strategies that demonstrated entrepreneurial processes.

CONCLUSIONS

Findings suggest that participants used survival entrepreneurship strategies and processes to navigate daily life while experiencing homelessness. Recognition and validation of the propensity for enterprise and self-sufficiency are central for both individual recovery and ending homelessness within similar populations.

The Role of Masculinity and Depressive Symptoms in Predicting Suicidal Ideation in Homeless Men

Men's suicide rates may be influenced by difficulties recognizing externalizing depressive symptoms in men that adhere to hegemonic masculine gender role norms. The purpose of this study was to investigate the ability of externalizing depressive symptoms, internalizing depressive symptoms, and hegemonic masculinity in predicting the existence and severity of suicidal ideation. Homeless men (n = 94) completed questionnaires at a resource center in the Rocky Mountain Western United States. Internalizing symptoms predicted the existence of suicidal ideation, and both externalizing and internalizing symptoms predicted increased severity of suicidal ideation. The masculine norms violence and playboy were correlated with men's suicidal ideation. An externalizing-internalizing model of predicting suicide in men and men's adherence to certain masculine gender role norms may be valuable to further efforts in suicide assessment and prevention.

Longitudinal Determinants of Housing Stability Among People Living With HIV/AIDS Experiencing Homelessness

Objectives. To examine patterns of and factors associated with housing stability over time among people living with HIV (PLWH) experiencing homelessness with co-occurring substance use and mental health disorders enrolled in a patient-centered medical home (PCMH) intervention.Methods. Between September 2013 and February 2017, we ascertained housing trajectories among PLWH in 9 sites in the United States by conducting interviews at baseline, 6, and 12 months after and dichotomized them as improved consistently versus did not improve consistently. We identified covariates affecting housing stability using the socioecological model.Results. Forty-three percent (n = 198) experienced consistent housing improvement. Participants with history of mental health diagnosis (adjusted odds ratio [AOR] = 1.55; 95% confidence interval [CI] = 1.02, 2.35; P = .04) or trauma (AOR = 1.72; 95% CI = 1.22, 2.41; P = .006) had improved housing status; those with recent injecting drug use (AOR = 0.41; 95% CI = 0.19, 0.90; P = .03) had less consistent housing improvement.Conclusions. Improved housing stability may possibly reflect the importance of PCMH interventions that integrate housing, health, and behavioral services with patient navigators to address complex needs of PLWH experiencing homelessness.

Comparing Perceived Adequacy of Help Received Among Different Classes of Individuals with Severe Mental Disorders at Five-Year Follow-Up: A Longitudinal Cluster Analysis

This study developed a typology describing change in the perceived adequacy of help received among 204 individuals with severe mental disorders, 5 years after transfer to the community following a major mental health reform in Quebec (Canada). Participant typologies were constructed using a two-step cluster analysis. There were significant differences between T0 and T2 for perceived adequacy of help received and other independent variables, including seriousness of needs, help from services or relatives, and care continuity. Five classes emerged from the analysis. Perceived adequacy of help received at T2 increased for Class 1, mainly comprised of older women with mood disorders. Overall, greater care continuity and levels of help from services and relatives related to higher perceived AHR. Changes in perceived adequacy of help received resulting from several combinations of associated variables indicate that MH service delivery should respond to specific profiles and determinants.

Perceptions of Housing and Shelter among People with Histories of Unstable Housing in three Cities in Canada: A Qualitative Study

Housing is a key social determinant of health that contributes to the well-documented relationship between socioeconomic status and health. This study explored how individuals with histories of unstable and precarious housing perceive their housing or shelter situations, and the impact of these settings on their health and well-being. Participants were recruited from the Health and Housing in Transition study (HHiT), a longitudinal, multi-city study that tracked the health and housing status of people with unstable housing histories over a 5-year period. For the current study, one-time semi-structured interviews were conducted with a subset of HHiT study participants (n = 64), living in three cities across Canada: Ottawa, Toronto, and Vancouver. The findings from an analysis of the interview transcripts suggested that for many individuals changes in housing status are not associated with significant changes in health due to the poor quality and precarious nature of the housing that was obtained. Whether housed or living in shelters, participants continued to face barriers of poverty, social marginalization, inadequate and unaffordable housing, violence, and lack of access to services to meet their personal needs.

Microsystems of Recovery in Homeless Services: The Influence of Service Provider Values on Service Users' Recovery Experiences

There is still much to learn about how aspects of the ecology of homelessness shape homeless adults' recovery experiences. In the present mixed-methods study, the relationship of service providers' work-related values to their service users' recovery experiences in the microsystem of homelessness were examined. Service providers completed semi-structured qualitative interviews about their service users, daily work activities, and work-related goals. At three time points, their service users completed quantitative measures of choice, mastery, and recovery in four life domains: physical health, psychiatric symptoms, substance use, and community integration. Service providers' interview transcripts were coded for three indicators of values: assumptions, actions, and end-states. Summative Content Analysis was used to transform qualitative codes into numeric data so they could be used to predict service users' recovery. In a series of growth curve models, the extent to which service providers' end-state values, as an indicator of consumer-led values, was shown to indirectly predict service users' recovery experiences, through their perceived choice and mastery. Findings confirm that providers' values are an important influence on service users' recovery. Results are discussed in terms of their implications for recovery-oriented theory and practice.

Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada

OBJECTIVE

Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study.

METHODS

In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months.

RESULTS

Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4-2.11), hospitalization (AOR = 1.45; 95% CI, 1.16-1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05-1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders.

CONCLUSIONS

Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.

Drug use patterns and predictors among homeless youth: Results of an ecological momentary assessment

BACKGROUND

Alcohol and drug use is associated with significant morbidity and mortality and is highly prevalent among homeless youth. Ecological Momentary Assessments (EMA) have been used to examine the effect of urges on drug use, though not among homeless youth.

OBJECTIVES

We assessed the patterns of drug use and the correlation between real-time contextual factors and drug use using EMA collected daily. We identified predictors of drug use among a sample of homeless youth 18-25 years old in Houston, Texas.

METHODS

Homeless youth (n = 66, 62% male) were recruited from a drop-in center between September 2015 and May 2016. We used generalized linear mixed models and cross-validation methods to determine the best predictive model of drug use.

RESULTS

The overall drug use was high: 61% and 32% of participants reported using drugs or alcohol at least one day, respectively. Marijuana and synthetic marijuana use (i.e., Kush, K2, incense packs) were reported most frequently; 86% and 13% of the total drug use EMAs, respectfully. Drug use urge was reported on 26% of days and was the highest on drug use days. Drug use was predicted by discrimination, pornography use, alcohol use, and urges for drugs, alcohol, and to steal.

CONCLUSIONS

EMA can be used to predict drug use among homeless youth. Drug use treatment among homeless youth should address the role of experiencing discrimination, pornography and alcohol use, and urge management strategies on drug use. Research is needed to determine if EMA informed just-in-time interventions targeting these predictors can reduce use.

A Comparison of the Use of Physical and Mental Health Services by Homeless People With Severe Mental Health Problems in the Moncton Area Through the At Home/Chez Soi Program

The At Home / Chez Soi demonstration project was conducted to investigate the effectiveness of the Housing First model in 5 Canadian cities. Using a randomized controlled trial design, this study evaluates the impact of this project on the use of health services by people with severe and persistent mental health problems and a history of homelessness in the greater Moncton area. The sample comprised 193 homeless persons, 95 in the control group and 98 in the treatment group. The results show a significant difference between the 2 groups only in the number of days of hospitalization, particularly in the psychiatric unit. Factors associated with the use of health services by people who are homeless and who have severe mental health problems need to be further investigated.