Forty Years of Research on Predictors of Homelessness

Longitudinal trends of sleep services for veterans with and without serious mental illness in VA electronic health records

Sleep problems commonly co-occur with serious mental illnesses (SMI) and are associated with negative outcomes, though may be underrecognized and undertreated. This study examined whether clinical services for sleep disorders among Veterans with and without SMI changed during the past decade. The sample included Veterans with a diagnosed sleep disorder in VA VISN 4 (Pennsylvania and sections of Ohio, New Jersey and Delaware) electronic health record data from 2011 to 2019 (N = 77,898). Results revealed that, across 9 years of data, half of Veterans received no sleep services, but among those that did, sleep medications were most common., Notably, Veterans with SMI and sleep disorders were more likely than those without SMI to receive any sleep services, but the proportion of all Veterans receiving sleep services declined across the study period. Results from this study demonstrate that the needs of Veterans with SMI and sleep disorders are met equally well as those of Veterans without SMI, but there remains a large unmet need for all Veterans with sleep disorders, half of whom did not receive any services. Future work should investigate provider and patient perspectives regarding barriers and facilitators to engaging with sleep services, particularly services other than medication.

Mechanisms to Promote Social Integration in a Temporary Housing Program for Older Persons Experiencing and At-Risk of Homelessness

BACKGROUND AND OBJECTIVES

Social integration-the degree to which a person is socially connected and engaged with other people-is a programmatic goal of supportive housing models and a predictor of successful housing outcomes among clients. Although research has examined social integration within permanent supportive housing models, minimal research has considered how social integration may be promoted within temporary housing programs (THPs), particularly for older persons. This study examines experiences of social integration, connection, and participation within a scattered-site THP for older persons experiencing homelessness in Vancouver, Canada.

RESEARCH DESIGN AND METHODS

We conducted semistructured qualitative interviews with 11 current and former clients. Data were analyzed using a critical realist-informed thematic analysis method wherein theme development attempts to link events (e.g., accessing a service) and experiences (e.g., feeling supported).

RESULTS

We identified 3 mechanisms: (a) technology access facilitates connection to individuals and organizations; (b) frequent communication with staff enhances feelings of social support and reduces isolation; and (c) accessible environments promote social connection and participation.

DISCUSSION AND IMPLICATIONS

Findings offer novel insights into promoting social integration in THPs, such as creating "third places," and suggestions for supporting older persons transitioning out of homelessness.

Exploring housing instability through a gender lens among people who inject drugs in Montreal, Canada

INTRODUCTION

Housing instability contributes to harm among people who inject drugs (PWID). We examined determinants of varying levels of housing instability and explored gender differences in housing instability and associated determinants among PWID.

METHOD

We used baseline data from HEPCO, a community-based cohort of PWID in Montreal, Canada (2011-2022). Housing (past 3 months) was categorised as stable, precarious (i.e., temporary accommodation) or unsheltered. Multinomial logistic regression was used to assess relationships between sociodemographic factors, recent drug use, and housing instability. A multivariable model was constructed using the full sample. Gender differences were explored via stratified and unadjusted analyses given the relatively small number of women.

RESULTS

A total of 911 PWID (748 men and 163 women) were included. In the multivariable model, not living in a marriage-like relationship, recent incarceration, and not reporting recent heroin use were associated with both precarious housing and being unsheltered, relative to stable housing. Employment, consumption of cocaine, amphetamines, and other opioids were only associated with being unsheltered. In stratified analyses, precarious and unsheltered housing was reported by 14.1% and 23.3% of women and 20.9% and 30.9% of men. Sociodemographic factors and drug use patterns also differed by gender. Although most associations with housing instability were in similar directions for men and women, several estimates differed in magnitude, denoting some signals of gender differences.

DISCUSSION AND CONCLUSION

Almost half the sample was unsheltered or precariously housed. Studies with larger samples of women should formally examine the relevance of developing gender-specific responses to housing instability.

Childhood Homelessness as an Adverse Childhood Experience (ACE): Adult Mental Health Outcomes

Adverse childhood experiences (ACEs) are experiences of abuse, neglect, and other household problems occurring before age 18 and contribute to the development of both physical and mental health concerns. People experiencing homelessness report disproportionately higher rates of ACEs and negative mental health concerns; however, little research has been conducted regarding the relationship between ACEs and mental health outcomes specifically for homeless populations. A dearth of research also exists regarding how childhood experiences of homelessness interact with ACEs and mental health outcomes. The present study examined the mental health outcomes for people experiencing homelessness, as well as how childhood experiences of homelessness may fit into the ACEs model using archival data. People experiencing homelessness (n = 100) completed the ACEs questionnaire, a demographics questionnaire, and a health appraisal questionnaire. Results found ACEs significantly predicted negative mental health outcomes for people experiencing homelessness. Childhood experiences of homelessness were predictive of negative mental health outcomes; however, this relationship became negligible when acting as a covariate with ACEs. This result suggests that the ACEs framework adequately explains the effects of traumatic events for children experiencing homelessness and the subsequent negative mental health outcomes.

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.

Beyond Housing First: rethinking neoliberal policies impacting homelessness

This article critically examines the Housing First model within the broader context of neoliberal policies impacting homelessness, particularly at the intersection of mental illness, poverty, and addiction. While Housing First is celebrated for its effectiveness in providing immediate housing to chronically homeless individuals, this model's alignment with neoliberal principles prioritizes cost effectiveness and visible outcomes over comprehensive care. As a harm reduction approach, Housing First often overlooks the underlying mental health and addiction issues that maintain homelessness, resulting in a cycle of dependency rather than long-term recovery. In this article, we argue that the reduction in funding for transitional housing and mental health services, driven by neoliberal policies, has exacerbated the challenges faced by marginalized populations. A call is made for a shift toward more holistic and integrated approaches that balance immediate housing solutions with robust mental health care and social support systems, aiming for sustained recovery, independence, and social reintegration for individuals experiencing homelessness.

Material hardship, forced displacement, and negative health outcomes among unhoused people who use drugs in Los Angeles, California and Denver, Colorado: a latent class analysis

BACKGROUND

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

METHODS

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

RESULTS

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

CONCLUSIONS

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

The global prevalence of mental health disorders among runaway and homeless youth: A meta-analysis

A meta-analysis was performed to identify the pooled prevalence of mental health disorders (MHDs) among runaway and homeless youth (RHY). Relevant studies published between December 1, 1985, and October 1, 2023, were identified in the PubMed, Scopus, Web of Science, and Cochrane Library databases. A preliminary screening of 11,266 papers resulted in the inclusion of 101 studies. The pooled-prevalence estimates were obtained using a random-effects model. The findings showed varying lifetime prevalence rates of MHDs: 47% (conduct disorders and psychological distress), 43% (depression), 34% (major depressive disorders), 33% (post-traumatic stress disorder), 27% (personality disorders), 25% (attention-deficit/hyperactivity disorder), 23% (bipolar disorders), 22% (anxiety), 21% (oppositional defiant disorders), 15% (anorexia), 15% (adjustment disorders), 14% (dysthymia), 11% (schizophrenia), 9% (obsessive-compulsive disorders), and 8% (gambling disorder). The current prevalence rates were: 31% (depression), 23% (major depressive disorder), 23% (anxiety), 21% (post-traumatic stress disorder), 16% (attention-deficit/hyperactivity disorder), 15% (bipolar disorder), 13% (personality disorders), 13% (oppositional defiant disorders), 8% (schizophrenia), and 6% (obsessive-compulsive disorders). Regular screening and the implementation of evidence-based treatments and the promotion of integration and coordination between mental health services for adolescent minors and young adults with other service systems are recommended.

Material Hardship, Forced Displacement, and Negative Health Outcomes Among Unhoused People Who Use Drugs in Los Angeles, California and Denver, Colorado: A Latent Class Analysis

Background

Homelessness is a growing concern in the United States, especially among people who use drugs (PWUD). The degree of material hardship among this population may be linked to worse health outcomes. PWUD experiencing homelessness in urban areas are increasingly subjected to policies and social treatment, such as forced displacement, which may worsen material hardship. It is critical to describe hardship among PWUD and examine if it is linked to health outcomes.

Methods

Data were collected as part of a prospective cohort study of PWUD in Los Angeles, California and Denver, Colorado (n = 476). Analysis sample size was smaller (N = 395) after selecting for people experiencing homelessness and for whom data were complete. Five indicators assessing hardship (difficulty finding food, clothing, restrooms, places to wash/shower, and shelter) in the past three months were obtained from participants at baseline and were used in latent class analysis (LCA). We chose a base latent class model after examination of global fit statistics. We then built three auxiliary models using the three-step Bolck-Croon-Hagenaars (BCH) method to test the relationship of latent class membership to several hypothesized social and health variables in this same three month time period.

Results

Fit statistics, minimum classification probabilities, and ease of interpretation indicated a three-class solution for level of material difficulty. We termed these classes "High Difficulty" (n = 82), "Mixed Difficulty" (n = 215), and "Low Difficulty" (n = 98). Average classification probabilities indicated good class separability. "High Difficulty" participants had high probabilities of usually having difficulty accessing all five resources. "Mixed Difficulty" participants indicated a range of difficulty accessing all resources, with restrooms and bathing facilities being the most difficult. "Low Difficulty" participants were defined by high probabilities of never having access difficulty. In auxiliary analyses, there were significant (p < 0.05) differences in experiences of displacement, opioid withdrawal symptoms, nonfatal overdose, and violent victimization between classes.

Conclusions

This LCA indicates that among PWUD experiencing homelessness there exist distinct differences in resource access and material hardship, and that these differences are linked with political, social, substance use, and other health outcomes. We add to the literature on the relationship between poverty and health among PWUD. Policies which increase difficulty accessing necessary material resources may negatively impact health in this population.

Violent Victimization in Emerging Adulthood and Its Longitudinal Impacts on Well-Being: A Study of Ever-Homeless Persons

Persons who have experienced homelessness have higher lifetime risks of violent victimization relative to the general population. However, the long-term impacts of violent victimization on various facets of well-being are poorly understood among ever-homeless persons, particularly when violence is experienced in early adulthood. Here, using data from the National Longitudinal Study of Adolescent to Adult Health, we focus on a subsample of emerging adults who reported ever suffering homelessness (N = 481). Drawing primarily from Waves III and IV of the data, a series of regression models are specified to determine whether violent victimization in emerging adulthood is related to a range of negative outcomes later in life among ever-homeless persons (economic hardship, binge drinking, drug use, depression, offending, and victimization). Results indicate that victimization in emerging adulthood increases the risks for subsequent victimization for ever-homeless persons, but that it has no robust associations with any other outcomes examined. We explain these findings through processes of disadvantage saturation, in which the consequences of victimization may be more subdued among individuals who experience an array of hardships and disadvantages in their lives. The implications of these findings for policy are future research are discussed, and we emphasize the need for a context-contingent approach to the study of victimization and its life course consequences.

Mental Health and Substance Misuse Indicators Associated with First-Time Homelessness among a Community Sample of Sexual and Gender Minority Adults

Homelessness is a priority public health issue in the United States (U.S.) given its strong associations with multiple adverse health outcomes. While overall rates of homelessness have decreased over the last decade, some populations-such as sexual and gender minorities-have not seen equitable decreases. The present study explores the relationship between experiences of first-time homelessness with substance misuse (assessed via the DAST-10) and depression and anxiety (assessed via the PHQ-4) in an adult sample of SGM individuals in South Central Texas. The analytic sample (n = 907) was majority gay/lesbian or same-gender loving (55.8%) followed by bisexual or pansexual (34.7%) or another sexual identity (9.5%) and 12.5% were transgender. First-time homelessness was more common in childhood than adulthood. Multivariate logistic regression models were used to evaluate relationships between first-time homelessness and outcomes of interest. The odds of substance misuse (DAST > 3) were marginally higher for those experiencing first-time homelessness in childhood and significantly higher for those reporting first-time homelessness in adulthood. The odds of experiencing past 2-week depression were significantly greater for those reporting homelessness in childhood or adulthood. However, only first-time homelessness in adulthood was significantly associated with past two-week anxiety. These findings underscore the need to consider intersectionality when exploring solutions to existing health disparities, as this work suggests that both sexual and gender identity and homelessness are important factors in shaping mental and behavioral health outcomes.

'I went for rehab many times and it never worked, but the harm reduction process has given me renewed hope'. Perceptions on the effectiveness of harm reduction and community-based opioid substitution therapy

ISSUE ADDRESSED

The accessibility of opioid substitution therapy (OST), one of the recommended treatments for opioid dependence, remains low. This study sought to explore the perceived effectiveness of OST from the perspectives of peer outreach workers and OST clients in a community-based harm reduction programme.

METHODS

The research was done within the Community-Oriented Substance Use Programme (COSUP) in Tshwane, South Africa. Fifteen peer educators (13 males and 2 females) took part in two focus group discussions. Thereafter, there were semi-structured interviews in which 15 OST clients (11 males and 4 females) participated. A convenience cross-sectional study was used. Interviews were audio-recorded. Using thematic analysis, themes were examined to evaluate how OST and the harm reduction approach were perceived to contribute to the improved health status of people with opioid dependence.

RESULTS

Peer outreach workers and COSUP clients significantly endorsed OST as an effective treatment for opioid dependence. Participants perceived greater effectiveness of OST compared to abstinence-centred inpatient rehabilitation programmes. However, there were sentiments that more community education on OST was needed to motivate people with opioid dependence to access services and to address misconceptions about OST.

CONCLUSIONS

There is a lack of multi-level and multi-sectoral engagement of various stakeholders in opioid dependence services, needed to accelerate utilisation of OST services. SO WHAT?: The research unpacks the need for an integrated approach to service use optimisation, and the need to evaluate the role that increased awareness and community education on harm reduction strategies can play in enhancing the utilisation of OST services.

The Global Prevalence of Non-suicidal Self-injury, Suicide Behaviors, and Associated Risk Factors Among Runaway and Homeless Youth: A Meta-analysis

A meta-analysis was performed to determine pooled prevalence of non-suicidal self-injury (NSSI), suicide behaviors (including ideation, attempts), and associated risk factors among runaway and homeless youth (RHY). The databases PubMed, Scopus, Web of Science, and Cochrane Library were searched for relevant studies published from January 1995 to May 2023. Initially, 8465 papers were screened, resulting in 69 included studies. The results showed that among RHY, lifetime prevalence rates were 42% for NSSI, 38% for suicidal ideation, and 27% for suicide attempts. Lifetime prevalence of NSSI and suicide behaviors was higher among adolescent minors (aged 12-17 years) compared to young adults (aged 18-24 years). Also, NSSI and suicide behaviors were associated with having a childhood history of physical and sexual abuse. Developing an impactful community-based suicide prevention campaign tailored for RHY appears warranted. Peer groups and mentorship programs would provide invaluable support for young individuals, as supportive friendships protect against NSSI.

First Decade of Supportive Services for Veteran Families Program and Homelessness, 2012-2022

As homelessness remains an urgent public health crisis in the United States, specific programs in the US Department of Veterans Affairs (VA) system may serve as a roadmap for addressing it. We examine lessons learned from the first decade (2012-2022) of the Supportive Services for Veteran Families (SSVF) program, a cornerstone in the VA continuum of homeless services aimed at both preventing homelessness among those at risk and providing rapid rehousing for veterans and their families who are currently experiencing homelessness. Drawing on information from annual reports and other relevant literature, we have identified 3 themes of SSVF that emerged as features to comprehensively deliver support for homeless veterans and their families: (1) responsiveness and flexibility, (2) coordination and integration, and (3) social resource engagement. Using these strategies, SSVF reached nearly three quarters of a million veterans and their families in its first decade, thereby becoming one of the VA's most substantial programmatic efforts designed to address homelessness. We discuss how each feature might apply to addressing homelessness in the general population as well as future research directions. (Am J Public Health. 2024;114(6):610-618. https://doi.org/10.2105/AJPH.2024.307625).

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.

Trajectories of homelessness and association with mental health and substance use disorders among young people transitioning from out-of-home care in Australia

BACKGROUND

Researchers have examined sub-groups that may exist among young people transitioning from out-of-home care (OHC) using various theoretical models. However, this population group has not been examined for trajectories of homelessness risk.

OBJECTIVES

To examine whether different subtypes of homelessness risk exist among young people transitioning from care and whether these trajectories of homelessness are associated with mental health and substance use disorders.

PARTICIPANTS AND SETTING

A retrospective population-based cohort study was conducted from a population of 1018 young people (aged 15-18 years) who transitioned from out-of-home in 2013 to 2014 in the state of Victoria, Australia, with follow-up to 2018.

METHODS

Latent Class Growth Analysis was conducted using linked data from homelessness data collections, child protection, mental health information systems, alcohol and drug use, and youth justice information systems.

RESULTS

Three sub-groups of young people were identified. The 'moving on' group (88 %) had the lowest levels of homelessness, with the slope of this trajectory remaining almost stable. The 'survivors' (7 %) group started off with a high risk of homelessness, followed by a sharp decrease in homelessness risk over time. The 'complex' (5 %) group started off with a low risk of homelessness but faced sharp increases in the risk of homelessness over time.

CONCLUSIONS

Our study demonstrates that subgroups of young people transitioning from care exist with distinct longitudinal trajectories of homelessness, and these classes are associated with different risk factors. Early intervention and different approaches to tackling homelessness should be considered for these three distinct groups before transitioning from care and during the first few years after leaving care.

Changes in Health Care Utilization and Associated Costs After Supportive Housing Placement by an Urban Community Mental Health Center

Permanent supportive housing (PSH) for individuals experiencing homelessness and living with mental illness can reduce utilization of crisis care services and increase utilization of outpatient care, although the extent to which pre-housing utilization patterns influence post-housing utilization remains unclear. Therefore, pre- and post-housing health service utilization was examined in 80 individuals living with a chronic mental illness who were and were not utilizing health care services in the years pre- and post-housing. Overall, the proportion of tenants utilizing outpatient services, including outpatient behavioral health services, increased from pre- to post-housing. Tenants who did not use outpatient behavioral health services prior to housing were disproportionately less likely than their peers to use those services after being housed. Among tenants who utilized crisis care services prior to being housed, reductions were observed in the number of crisis care visits. Results suggest PSH leads to changes in health care utilization and associated costs.

The Cost of Living Index as a Primary Driver of Homelessness in the United States: A Cross-State Analysis

BACKGROUND

Homelessness persists as a critical global issue despite myriad interventions. This study analyzed state-level differences in homelessness rates across the United States to identify influential societal factors to help guide resource prioritization.

METHODS

Homelessness rates for 50 states and Washington, DC, were compared using the most recent data from 2020 to 2023. Twenty-five variables representing potential socioeconomic and health contributors were examined. The correlation between these variables and the homelessness rate was calculated. Decision trees and regression models were also utilized to identify the most significant factors contributing to homelessness.

RESULTS

Homelessness rates were strongly correlated with the cost of living index (COLI), housing costs, transportation costs, grocery costs, and the cigarette excise tax rate (all: P < 0.001). An inverse relationship was observed between opioid prescription rates and homelessness, with increased opioid prescribing associated with decreased homelessness (P < 0.001). Due to collinearity, the combined cost of living index was used for modeling instead of its individual components. Decision tree and regression models identified the cost of living index as the strongest contributor to homelessness, with unemployment, taxes, binge drinking rates, and opioid prescription rates emerging as important factors.

CONCLUSION

This state-level analysis revealed the cost of living index as the primary driver of homelessness rates. Unemployment, poverty, and binge drinking were also contributing factors. An unexpected negative correlation was found between opioid prescription rates and homelessness. These findings can help guide resource allocation to address homelessness through targeted interventions.

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.

Assessment of Disruptive Life Events for Individuals Diagnosed With Schizophrenia or Bipolar I Disorder Using Data From a Consumer Credit Reporting Agency

Importance

There is a dearth of population-level data on major disruptive life events (defined here as arrests by a legal authority, address changes, bankruptcy, lien, and judgment filings) for patients with bipolar I disorder (BPI) or schizophrenia, which has limited studies on mental health and treatment outcomes.

Objective

To conduct a population-level study on disruptive life events by using publicly available data on disruptive life events, aggregated by a consumer credit reporting agency in conjunction with electronic health record (EHR) data.

Design, Setting, and Participants

This study used EHR data from 2 large, integrated health care systems, Kaiser Permanente Southern California and Henry Ford Health. Cohorts of patients diagnosed from 2007 to 2019 with BPI or schizophrenia were matched 1:1 by age at analysis, age at diagnosis (if applicable), sex, race and ethnicity, and Medicaid status to (1) an active comparison group with diagnoses of major depressive disorder (MDD) and (2) a general health (GH) cohort without diagnoses of BPI, schizophrenia, or MDD. Patients with diagnoses of BPI or schizophrenia and their respective comparison cohorts were matched to public records data aggregated by a consumer credit reporting agency (98% match rate). Analysis took place between November 2020 and December 2022.

Main Outcomes and Measures

The differences in the occurrence of disruptive life events among patients with BPI or schizophrenia and their comparison groups.

Results

Of 46 167 patients, 30 008 (65%) had BPI (mean [SD] age, 42.6 [14.2] years) and 16 159 (35%) had schizophrenia (mean [SD], 41.4 [15.1] years). The majoriy of patients were White (30 167 [65%]). In addition, 18 500 patients with BPI (62%) and 6552 patients with schizophrenia (41%) were female. Patients with BPI were more likely to change addresses than patients in either comparison cohort (with the incidence ratio being as high as 1.25 [95% CI, 1.23-1.28]) when compared with GH cohort. Patients with BPI were also more likely to experience any of the financial disruptive life events with odds ratio ranging from 1.15 [95% CI, 1.07-1.24] to 1.50 [95% CI, 1.42-1.58]). The largest differences in disruptive life events were seen in arrests of patients with either BPI or schizophrenia compared with GH peers (3.27 [95% CI, 2.84-3.78] and 3.04 [95% CI, 2.57-3.59], respectively). Patients with schizophrenia had fewer address changes and were less likely to experience a financial event than their matched comparison cohorts.

Conclusions and Relevance

This study demonstrated that data aggregated by a consumer credit reporting agency can support population-level studies on disruptive life events among patients with BPI or schizophrenia.

Social capital and women's narratives of homelessness and multiple exclusion in northern England

Women experiencing three or more co-occurring issues (homelessness, substance misuse, mental health) are a highly vulnerable population associated with multimorbidity. Taking women's life stories of trajectories into social exclusion in the north of England as its focus, this paper aims to explore the complexity of social contexts in which women navigate extreme health inequalities. Of the few studies that have examined women's experiences of homelessness through the lens of social capital, most have focused on network size, rather than the quality and influence of the relationships which precipitate or contextualise experiences of social exclusion. We utilise case studies to offer a theoretically-grounded analysis which illustrates the relationship between social capital and homelessness within this population. Our results illustrate how structural contexts, and specifically social capital accrual and social bonding processes particularly pertinent to women can act to both ameliorate and perpetuate social exclusion. We conclude by arguing that health inequalities cannot be tackled as single-issue processes but instead are multi-layered and complex.

Understanding Homelessness among Migrants to Thunder Bay using Machine Learning (Preprint)

BACKGROUND

Over the past years, homelessness has become a substantial issue around the globe. The largest social services organization in Thunder Bay, Ontario, Canada, has observed that a majority of the people experiencing homelessness in the city were from outside of the city or province. Thus, to improve programming and resource allocation for people experiencing homelessness in the city, including shelter use, it was important to investigate the trends associated with homelessness and migration.

OBJECTIVE

This study aimed to address 3 research questions related to homelessness and migration in Thunder Bay: What factors predict whether a person who migrated to the city and is experiencing homelessness stays or leaves shelters? If an individual stays, how long are they likely to stay? What factors predict stay duration?

METHODS

We collected the required data from 2 sources: a survey conducted with people experiencing homelessness at 3 homeless shelters in Thunder Bay and the database of a homeless information management system. The records of 110 migrants were used for the analysis. Two feature selection techniques were used to address the first and third research questions, and 8 machine learning models were used to address the second research question. In addition, data augmentation was performed to improve the size of the data set and to resolve the class imbalance problem. The area under the receiver operating characteristic curve value and cross-validation accuracy were used to measure the models' performances while avoiding possible model overfitting.

RESULTS

Factors predicting an individual's stay duration included home or previous district, highest educational qualification, recent receipt of mental health support, migrating to visit family or friends, and finding employment upon arrival. For research question 2, among the classification models developed for predicting the stay duration of migrants, the random forest and gradient boosting tree models presented better results with area under the receiver operating characteristic curve values of 0.91 and 0.93, respectively. Finally, home district, band membership, status card, previous district, and recent support for drug and/or alcohol use were recognized as the factors predicting stay duration.

CONCLUSIONS

Applying machine learning enables researchers to make predictions related to migrants' homelessness and investigate how various factors become determinants of the predictions. We hope that the findings of this study will aid future policy making and resource allocation to better serve people experiencing homelessness. However, further improvements in the data set size and interpretation of the identified factors in decision-making are required.

'Grounding a PIE in the sky': Laying empirical foundations for a psychologically informed environment (PIE) to enhance well-being and practice in a homeless organisation

While psychologically informed environments (PIEs) are gaining in prominence in efforts to improve well-being and practice in the homeless sector, their empirical foundations remain tenuous. We present a unique scoping needs analysis of staff and client well-being, staff attitudes and the social-therapeutic climate in a UK-based homeless prevention organisation (prior to PIE implementation). Our aims were: (a) to apply a robust framework to pinpoint need and target forthcoming PIE initiatives and (b) to establish a validated needs baseline that informs and measures efficacy of PIE for its future development. Four established personal and practice well-being measures were administered to 134 (predominantly 'frontline') staff and 50 clients. Staff completed the: Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), Professional Quality of Life Scale (measuring compassion satisfaction [CS], burnout [BO] and secondary traumatic stress [STS]), Attitudes related to Trauma-informed Care Scale (ARTIC-10; measuring practice attitudes towards trauma-informed values) and the Essen Climate Evaluation Schema (EssenCES; measuring perceptions of client cohesion, safety and practitioner relationships in housing projects). Clients completed the WEMWBS and EssenCES. Vulnerability to STS was evident in nearly two-thirds of frontline staff and it was a statistically significant predictor of BO. It was not, however, associated with lesser levels of CS. We discuss this complex dynamic in relation to highlighted strategic recommendations for the PIE framework, and the identified potential challenges in implementing trauma-informed and reflective practice in the organisation. We conclude with a critique of the value and the lessons learnt from our efforts to integrate stronger empirical substance into the PIE approach.

Housing instability and adverse perinatal outcomes: a systematic review

OBJECTIVE

Our objective was to conduct a systematic review of the published literature on housing instability during pregnancy and adverse pregnancy outcomes and perinatal healthcare utilization.

DATA SOURCES

We performed a systematic search in November 2020 using Embase, MEDLINE, Cochrane Library, and Scopus using terms related to housing instability during pregnancy, adverse pregnancy outcomes, and perinatal healthcare utilization. The search was limited to the United States.

STUDY ELIGIBILITY CRITERIA

Studies examining housing instability (including homelessness) during pregnancy and adverse pregnancy outcomes (including preterm birth, low birthweight neonates, and maternal morbidity) and perinatal healthcare utilization were included.

METHODS

Two authors screened abstracts and full-length articles for inclusion. The final cohort consisted of 14 studies. Two authors independently extracted data from each article and assessed the study quality using the Grading of Recommendations, Assessment, Development, and Evaluation tool. Risk of bias was assessed using the National Institutes of Health Study Quality Assessment Tools.

RESULTS

All included studies were observational, including retrospective cohort (n=10, 71.4%), cross-sectional observational (n=3, 21.4%), or prospective cohort studies (n=1, 7.1%). There was significant heterogeneity in the definitions of housing instability and homelessness. Most of the studies only examined homelessness (n=9, 64.3%) and not lesser degrees of housing instability. Housing instability and homelessness during pregnancy were significantly associated with preterm birth, low birthweight neonates, neonatal intensive care unit admission, and delivery complications. Among studies examining perinatal healthcare utilization, housing instability was associated with inadequate prenatal care and increased hospital utilization. All studies exhibited moderate, low, or very low study quality and fair or poor internal validity.

CONCLUSION

Although data on housing instability during pregnancy are limited by the lack of a standardized definition, a consistent relationship between housing instability and adverse pregnancy outcomes has been suggested by this systematic review. The evaluation and development of a standardized definition and measurement of housing instability among pregnant individuals is warranted to address future interventions targeted to housing instability during pregnancy.