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Ellis JD, Dunn KE, Huhn AS. Harm Reduction for Opioid Use Disorder: Strategies and Outcome Metrics. Am J Psychiatry 2024; 181:372-380. [PMID: 38706335 DOI: 10.1176/appi.ajp.20230918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Tweet: The authors discuss harm reduction strategies and associated outcome metrics in relation to the ongoing opioid crisis.
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Affiliation(s)
- Jennifer D Ellis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore
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McGowan LJ, John DA, Kenny RPW, Joyes EC, Adams EA, Shabaninejad H, Richmond C, Beyer FR, Landes D, Watt RG, Sniehotta FF, Paisi M, Bambra C, Craig D, Kaner E, Ramsay SE. Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions. PLoS One 2024; 19:e0298885. [PMID: 38635524 PMCID: PMC11025870 DOI: 10.1371/journal.pone.0298885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/31/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours. METHODS AND FINDINGS From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use. CONCLUSION This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.
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Affiliation(s)
- Laura J. McGowan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Deepti A. John
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ryan P. W. Kenny
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emma C. Joyes
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emma A. Adams
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hosein Shabaninejad
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Richmond
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Fiona R. Beyer
- Evidence Synthesis Group and Innovation Observatory, Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - David Landes
- NHS England & Improvement, Newcastle Upon Tyne, United Kingdom
| | - Richard G. Watt
- Department of Epidemiology and Public Health, University College London, London, United Kingdom
| | - Falko F. Sniehotta
- NIHR Policy Research Unit Behavioural Science, Newcastle University, Newcastle Upon Tyne, United Kingdom
- Department of Public Health, Social and Preventive Medicine, Centre for Preventive Medicine and Digital Health (CPD), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martha Paisi
- Faculty of Medicine and Dentistry, Peninsula Dental School, University of Plymouth, Plymouth, United Kingdom
| | - Claire Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Eileen Kaner
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sheena E. Ramsay
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Armoon B, L'Espérance N, Fleury MJ. Variables Associated with Quality of Life Among Individuals Living in Permanent Supportive Housing. Community Ment Health J 2024; 60:259-271. [PMID: 37462796 DOI: 10.1007/s10597-023-01167-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/05/2023] [Indexed: 01/28/2024]
Abstract
This study identified individual sociodemographic and clinical characteristics and service use patterns associated with quality of life (QoL) among 308 individuals living in permanent supportive housing (PSH) in Québec (Canada). Data were collected between 2020 and 2022, and linear multivariate analyses produced. Results demonstrated that better individual psychosocial conditions were positively associated with higher QoL. As well, living in PSH located in good neighborhoods for at least 5 years, higher self-esteem and community integration were positively associated with greater QoL. Met needs, satisfaction with housing support services, and no use of acute care were also linked with positive QoL. Comprehensive efforts to improve treatment for mental health disabilities responsive to the needs of PSH residents, and sustained long-term housing may reinforce QoL. Encouraging active participation in community-based activities, incorporating biophilic design into the neighborhoods around PSH, and promoting satisfaction with care may also enhance QoL.
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Affiliation(s)
- Bahram Armoon
- Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Boulevard, Montréal, QC, H4H 1R3, Canada
- Department of Psychiatry, McGill University, Montréal, Québec, Canada
| | - Nadia L'Espérance
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Québec, Canada
| | - Marie-Josée Fleury
- Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Boulevard, Montréal, QC, H4H 1R3, Canada.
- Department of Psychiatry, McGill University, Montréal, Québec, Canada.
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Presnall L, Suchting R, Hicks G, Hamilton J. Predictors of self-reported general health status in people experiencing homelessness with serious mental illness. Qual Life Res 2023:10.1007/s11136-023-03370-9. [PMID: 36808283 PMCID: PMC9939866 DOI: 10.1007/s11136-023-03370-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2023] [Indexed: 02/23/2023]
Abstract
PURPOSE The growing homeless population in the U.S.A. is disproportionately impacted by poor mental and physical health status, including a higher incidence of acute and chronic health problems, increased hospitalizations, and premature mortality compared to the general population. This study examined the association between demographic, social, and clinical factors and perceptions of general health status among the homeless population during admission to an integrated behavioral health treatment program. METHODS The study sample included 331 adults experiencing homelessness with a serious mental illness or co-occurring disorder. Participants were enrolled in services at a day program for unsheltered homeless adults, a residential substance use treatment program for males experiencing homelessness, a psychiatric step-down respite program for those experiencing homelessness following psychiatric hospitalization, permanent supportive housing for formerly chronically homeless adults, a faith-based food distribution program, and homeless encampment sites in a large urban area. Participants were interviewed using The Substance Abuse and Mental Health Services Administration's National Outcome Measures tool and a validated health-related quality of life measurement tool, SF-36. Data were examined using in elastic net regression. RESULTS The study found seven factors to be particularly strong predictors of SF-36 general health scores. Male gender, "other" sexual identity, stimulant use, and Asian race were all associated with better perceptions of health status, while transgender status, inhalant use, and number of times arrested were associated with poorer perceptions. CONCLUSION This study suggests targeted areas for health screening within the homeless population; however, more studies are necessary to demonstrate generalizability of the results.
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Affiliation(s)
- Landon Presnall
- Icahn School of Medicine at Mount Sinai (Morningside/West), New York, USA. .,Baylor College of Medicine, Houston, TX, USA. .,Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center Houston, Houston, TX, USA.
| | - Robert Suchting
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center Houston, Houston, TX USA
| | - Gaybrielle Hicks
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center Houston, Houston, TX USA
| | - Jane Hamilton
- Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center Houston, Houston, TX USA
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Flike K, Foust JB, Hayman LL, Aronowitz T. Homelessness and Vulnerably-Housed Defined: A Synthesis of the Literature. Nurs Sci Q 2022; 35:350-367. [PMID: 35762065 DOI: 10.1177/08943184221092445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is no single accepted definition used in policy or research for the concepts of homelessness and vulnerably housed. Neuman's systems model (NSM) was the framework for this mixed-studies review, with the client system defined as these social issues and categorized as environmental stressors. Eighteen unique definitions of the concepts were identified in 30 studies. Extrapersonal stressors included housing history, interpersonal stressors included dependence on others for housing, and intrapersonal stressors included self-identification. Each level of stressor should be considered when defining these populations for inclusion in future research. Proposed definitions were formulated from the analysis of the results.
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Affiliation(s)
- Kimberlee Flike
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford Healthcare System, Bedford, MA, USA
| | - Janice B Foust
- Robert and Donna Manning College of Nursing & Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Laura L Hayman
- Robert and Donna Manning College of Nursing & Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Teri Aronowitz
- Tan Chingfen Graduate School of Nursing, UMass Chan Medical School, Worcester, MA, USA
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Flike K, Aronowitz T. Factors That Influence Quality of Life in People Experiencing Homelessness: A Systematic Mixed Studies Review. J Am Psychiatr Nurses Assoc 2022; 28:128-153. [PMID: 33478314 DOI: 10.1177/1078390320985286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An emerging category of morbidity in research among people experiencing homelessness (PEH) is quality of life (QoL). The Commission on Social Determinants of Health (CSDH) framework was used to explain the relationship between the resulting factors and their impact on QoL among PEH. AIMS The purpose of this systematic mixed studies review was to explore the factors that are associated with QoL among homeless individuals. METHOD A systematic mixed studies review was conducted using CINAHL, Medline, PubMed, and SocIndex databases. Quantitative, qualitative, and mixed methods studies were included and synthesized employing results-based convergent synthesis design. RESULTS The initial search resulted in 757 studies with 55 studies meeting the inclusion criteria. Thematic analysis revealed themes influencing QoL among PEH categorized by the CSDH determinants of structural, social cohesion and social capital, and intermediary determinants. Among these themes, higher social status, strong relationships, better reported physical and mental health, and a positive life outlook were associated with increased QoL. Social isolation, substance use, poorer life outlook, increased years spent homeless, and perceived quality of housing were associated with decreased QoL. Age, sex, and housing programs revealed inconsistent results on QoL. CONCLUSIONS While the factors presented in this review indicate some consistent relationships with QoL in PEH, this review has shown QoL among this population is complex and multifactorial. Future research should focus on relationships between the CSDH determinants, particularly the psychosocial factors and the QoL priorities defined by PEH, and how they may influence QoL among PEH.
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Affiliation(s)
- Kimberlee Flike
- Kimberlee Flike, MSN, UMass Boston, College of Nursing & Health Sciences, Boston, MA, USA
| | - Teri Aronowitz
- Teri Aronowitz, PhD, APRN, FNP-BC, FAAN, UMass Boston, College of Nursing & Health Sciences, Boston, MA, USA
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Kaltsidis G, Grenier G, Cao Z, Bertrand K, Fleury MJ. Predictors of change in housing status over 12 months among individuals using emergency shelters, temporary housing or permanent housing in Quebec, Canada. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:631-643. [PMID: 32985755 DOI: 10.1111/hsc.13168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/16/2020] [Accepted: 08/12/2020] [Indexed: 06/11/2023]
Abstract
Homelessness is an ongoing societal and public health problem in Canada and other countries. Housing services help homeless individuals along the transition towards stable housing, yet few studies have assessed factors that predict change in individual housing trajectories. This study identified predictors of change in housing status over 12 months for a sample of 270 currently or formerly homeless individuals using emergency shelters, temporary housing (TH) or permanent housing (PH) resources in Quebec. Participants recruited from 27 community or public organisations were interviewed between January and September 2017, and again 12 months later. Sociodemographic variables, housing history, health conditions, service use and client satisfaction were measured. Directors and programme coordinators from the selected organisations also completed a baseline questionnaire measuring strictness in residential codes of living/conduct, interorganisational collaboration and overall budget. Independent variables were organised into predisposing, enabling and needs factors, based on the Gelberg-Andersen Behavioral Model. Multilevel logistic regressions were used to test associations with the dependent variable: change in housing status over 12 months, whether positive (e.g. shelter to TH) or negative (e.g. PH to shelter). Predictors of positive change in housing status were as follows: residing in PH, being female, having children (predisposing factors); having consulted a psychologist, higher frequency in use of public ambulatory services (enabling factors); and not having physical illnesses (needs factor). The findings support strategies for helping this clientele obtain and maintain stable housing. They include deploying case managers to promote access to public ambulatory services, mainly among men or individuals without children who are less likely to seek help; greater use of primary care mental health teams; the establishment of more suitable housing for accommodating physical health problems; and reinforcing access to subsidised PH programmes.
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Affiliation(s)
- Gesthika Kaltsidis
- Department of Psychiatry, McGill University, Montreal, QC, Canada
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Zhirong Cao
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Karine Bertrand
- Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Longueuil, QC, Canada
- Institut Universitaire sur les Dépendances, Montréal, QC, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada
- Institut Universitaire sur les Dépendances, Montréal, QC, Canada
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The Feasibility of a Primary Care Based Navigation Service to Support Access to Health and Social Resources: The Access to Resources in the Community (ARC) Model. Int J Integr Care 2022; 22:13. [PMID: 36474646 PMCID: PMC9695153 DOI: 10.5334/ijic.6500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 10/28/2022] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION We established a patient centric navigation model embedded in primary care (PC) to support access to the broad range of health and social resources; the Access to Resources in the Community (ARC) model. METHODS We evaluated the feasibility of ARC using the rapid cycle evaluations of the intervention processes, patient and PC provider surveys, and navigator log data. PC providers enrolled were asked to refer patients in whom they identified a health and/or social need to the ARC navigator. RESULTS Participants: 26 family physicians in four practices, and 82 of the 131 patients they referred. ARC was easily integrated in PC practices and was especially valued in the non-interprofessional practices. Patient overall satisfaction was very high (89%). Sixty patients completed the post-intervention surveys, and 33 reported accessing one or more service(s). CONCLUSION The ARC Model is an innovative approach to reach and support a broad range of patients access needed resources. The Model is feasible and acceptable to PC providers and patients, and has demonstrated potential for improving patients' access to health and social resources. This study has informed a pragmatic randomized controlled trial to evaluate the ARC navigation to an existing web and telephone navigation service (Ontario 211).
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Kosteniuk B, Salvalaggio G, Wild TC, Gelberg L, Hyshka E. Perceived unmet substance use and mental health care needs of acute care patients who use drugs: A cross-sectional analysis using the Behavioral Model for Vulnerable Populations. Drug Alcohol Rev 2021; 41:830-840. [PMID: 34854513 DOI: 10.1111/dar.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/01/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The perceived unmet service needs of acute care-seeking people who use illegal drugs (PWUD) have been poorly documented, despite evidence of frequent hospital utilisation. This study applies the Behavioral Model for Vulnerable Populations to investigate correlates of unmet service needs in this subpopulation. METHODS Survey data from 285 PWUD at three urban Canadian acute care centres were examined. The survey included the Perceived Need for Care Questionnaire, which measured service seeking and care satisfaction for mental health and substance use concerns across seven types of services, as well as barriers to having care needs met. The Behavioral Model for Vulnerable Populations was applied in hierarchical setwise logistic regression to examine associations between high unmet service need and socio-structural predictors (i.e. predisposing, enabling and need factors). RESULTS Almost half (46%) of participants reported a high level of unmet service need, despite seeking services during the past year. Participants reporting recent criminal activity, adverse childhood experiences, transitory sleeping, having no community support worker, and meeting screening criteria for depression were more likely to report a high level of unmet service needs. Structural barriers to care (57%) were more commonly reported than motivational barriers (43%). DISCUSSION AND CONCLUSIONS Acute care-seeking PWUD experience high rates of unmet service needs for their mental health and substance use problems. Strategies that can help overcome structural barriers to care are necessary to help address the service needs of this population.
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Affiliation(s)
- Brynn Kosteniuk
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Ginetta Salvalaggio
- Department of Family Medicine, University of Alberta, Edmonton, Canada.,Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, Canada
| | - T Cameron Wild
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Lillian Gelberg
- Family Medicine, University of California Los Angeles, Los Angeles, USA
| | - Elaine Hyshka
- School of Public Health, University of Alberta, Edmonton, Canada.,Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, Canada
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Gurrera RJ, Grosso D. Treatment Bed Utilization Following Placement in a Foster Care Program for Veterans with Serious Mental Illness. Community Ment Health J 2021; 57:1442-1448. [PMID: 33386531 DOI: 10.1007/s10597-020-00758-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 12/11/2020] [Indexed: 11/25/2022]
Abstract
Hospital and residential treatment bed utilization rates were measured before and after foster home placement in individuals with serious mental illness. Medical records of all Veterans consecutively enrolled in a Department of Veterans Affairs Community Residential Care (CRC) program during a 6 year period (N = 140) were reviewed retrospectively. Treatment bed days were tabulated by bed type (psychiatric hospital, inpatient detoxification, medical hospital, physical rehabilitation, and psychosocial residential treatment) for each patient during symmetric pre- and post-placement time intervals. Pre- and post-placement bed days were compared using the paired-sample t test in a naturalistic one-group pretest-posttest analytic design. Psychiatric hospital and residential treatment bed days were significantly reduced post-placement (-77.5% and -99.8%, respectively). Most patients (89.0%) had fewer psychiatric hospital bed days post-placement, and all patients with pre-placement residential treatment program bed days had fewer of those days post-placement. Longer CRC placements were associated with greater reductions in bed utilization.
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Affiliation(s)
- Ronald J Gurrera
- VA Boston Healthcare System, 940 Belmont Street (116A), Brockton, MA, 02301, USA.
- Department of Psychiatry, Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Darryl Grosso
- VA Boston Healthcare System, 940 Belmont Street (116A), Brockton, MA, 02301, USA
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Kerman N, Polillo A, Bardwell G, Gran-Ruaz S, Savage C, Felteau C, Tsemberis S. Harm reduction outcomes and practices in Housing First: A mixed-methods systematic review. Drug Alcohol Depend 2021; 228:109052. [PMID: 34601279 DOI: 10.1016/j.drugalcdep.2021.109052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Harm reduction is a central tenet of Housing First. As the intervention has been shown to stably house people experiencing chronic homelessness across the lifespan with complex behavioural health needs, it is critical to understand the harm reduction outcomes and practices in Housing First. METHODS A systematic review following PRISMA guidelines was conducted of five databases: PsycINFO, MEDLINE, Embase, CINAHL, and Google Scholar. Harm reduction outcomes and practices in Housing First were examined in four domains: substance-related harms, viral health, sexual health, and harm reduction service use. RESULTS A total of 35 articles were included in the review, 23 of which examined harm reduction outcomes and 12 of which investigated harm reduction practices in Housing First. Harm reduction outcome studies focused mostly on nonspecific substance use problems, with Housing First being found to have minimal effects in this domain. More severe harms, such as delirium tremens and substance use-related deaths, have been minimally explored, though preliminary evidence is promising. Viral health, sexual health, and harm reduction service use outcomes were the focus of few studies. Research on harm reduction practices highlighted that Housing First providers experience both flexibility and ambiguity in their work using a harm reduction approach, and the importance of empathetic working relationships for engagement in harm reduction work. CONCLUSIONS Harm reduction outcomes in Housing First remain underexamined and any conclusions of the intervention's impacts in this domain would be premature. Effective harm reduction practices in Housing First require strong working relationships between staff and tenants.
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Affiliation(s)
- Nick Kerman
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada.
| | - Alexia Polillo
- Centre for Addiction and Mental Health, 1051 Queen Street West, Toronto, Ontario, M6J 1H4, Canada; University of Toronto, Department of Psychiatry, 250 College Street, 8th Floor, Toronto, Ontario, M5T 1R8, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia, V6Z 2A9, Canada; University of British Columbia, Department of Medicine, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada
| | - Sophia Gran-Ruaz
- University of Ottawa, School of Psychology, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, Ontario, K1N 6N5, Canada
| | - Cathi Savage
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Charlie Felteau
- Sandy Hill Community Health Centre, 221 Nelson Street, Ottawa, Ontario, K1N 1C7, Canada
| | - Sam Tsemberis
- Pathways Housing First Institute, 1328 2nd Street, Santa Monica, CA, 90403, United States
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Typology of Currently or Formerly Homeless Individuals Based on Their Use of Health and Social Services. Community Ment Health J 2021; 57:948-959. [PMID: 32734310 DOI: 10.1007/s10597-020-00693-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
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.
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Moledina A, Magwood O, Agbata E, Hung J, Saad A, Thavorn K, Pottie K. A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1154. [PMID: 37131928 PMCID: PMC8356292 DOI: 10.1002/cl2.1154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness. Objectives The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness. Search Methods In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies. Selection Criteria Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income. Data Collection and Analysis Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model. Main Results The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services. Authors' Conclusions PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.
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Affiliation(s)
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research CentreBruyere Research InstituteOttawaCanada
| | - Eric Agbata
- Bruyere Research Institute, School of EpidemiologyPublic Health and Preventive MedicineOttawaCanada
| | - Jui‐Hsia Hung
- Faculty of Medicine, School of Epidemiology and Public HealthUniversity of OttawaOttawaCanada
| | - Ammar Saad
- Department of Epidemiology, C.T. Lamont Primary Care Research Centre, Bruyere Research InstituteUniversity of OttawaOttawaCanada
| | - Kednapa Thavorn
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaCanada
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Keenan C, Miller S, Hanratty J, Pigott T, Hamilton J, Coughlan C, Mackie P, Fitzpatrick S, Cowman J. Accommodation-based interventions for individuals experiencing, or at risk of experiencing, homelessness. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1165. [PMID: 37131929 PMCID: PMC8356295 DOI: 10.1002/cl2.1165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Globally, almost 1.6 billion individuals lack adequate housing. Many accommodation-based approaches have evolved across the globe to incorporate additional support and services beyond delivery of housing. Objectives This review examines the effectiveness of accommodation-based approaches on outcomes including housing stability, health, employment, crime, wellbeing, and cost for individuals experiencing or at risk of experiencing homelessness. Search Methods The systematic review is based on evidence already identified in two existing EGMs commissioned by the Centre for Homelessness Impact (CHI) and built by White et al. The maps were constructed using a comprehensive three stage search and mapping process. Stage one mapped included studies in an existing systematic review on homelessness, stage two was an extensive search of 17 academic databases, three EGM databases, and eight systematic review databases. Finally stage three included web searches for grey literature, scanning reference lists of included studies and consultation with experts to identify additional literature. We identified 223 unique studies across 551 articles from the effectiveness map on 12th April 2019. Selection Criteria We include research on all individuals currently experiencing, or at risk of experiencing homelessness irrespective of age or gender, in high-income countries. The Network Meta-Analysis (NMA) contains all study designs where a comparison group was used. This includes randomised controlled trials (RCTs), quasi-experimental designs, matched comparisons and other study designs that attempt to isolate the impact of the intervention on homelessness. The NMA primarily addresses how interventions can reduce homelessness and increase housing stability for those individuals experiencing, or at risk of experiencing, homelessness. Additional outcomes are examined and narratively described. These include: access to mainstream healthcare; crime and justice; employment and income; capabilities and wellbeing; and cost of intervention. These outcomes reflect the domains used in the EGM, with the addition of cost. Data Collection and Analysis Due to the diverse nature of the literature on accommodation-based approaches, the way in which the approaches are implemented in practice, and the disordered descriptions of the categories, the review team created a novel typology to allow meaningful categorisations for functional and useful comparison between the various intervention types. Once these eligible categories were identified, we undertook dual data extraction, where two authors completed data extraction and risk of bias (ROB) assessments independently for each study. NMA was conducted across outcomes related to housing stability and health.Qualitative data from process evaluations is included using a "Best Fit" Framework synthesis. The purpose of this synthesis is to complement the quantitative evidence and provide a better understanding of what factors influenced programme effectiveness. All included Qualitative data followed the initial framework provided by the five main analytical categories of factors of influence (reflected in the EGM), namely: contextual factors, policy makers/funders, programme administrators/managers/implementing agencies, staff/case workers and recipients of the programme. Main Results There was a total of 13,128 people included in the review, across 51 reports of 28 studies. Most of the included studies were carried out in the United States of America (25/28), with other locations including Canada and the UK. Sixteen studies were RCTs (57%) and 12 were nonrandomised (quasi-experimental) designs (43%). Assessment of methodological quality and potential for bias was conducted using the second version of the Cochrane Risk of Bias tool for Randomised controlled trials. Nonrandomised studies were coded using the ROBINS- I tool. Out of the 28 studies, three had sufficiently low ROB (11%), 11 (39%) had moderate ROB, and five (18%) presented serious problems with ROB, and nine (32%) demonstrated high, critical problems with their methodology. A NMA on housing stability outcomes demonstrates that interventions offering the highest levels of support alongside unconditional accommodation (High/Unconditional) were more effective in improving housing stability compared to basic support alongside unconditional housing (Basic/Unconditional) (ES=1.10, 95% confidence interval [CI] [0.39, 1.82]), and in comparison to a no-intervention control group (ES=0.62, 95% CI [0.19, 1.06]). A second NMA on health outcomes demonstrates that interventions categorised as offering Moderate/Conditional (ES= 0.36, 95% CI [0.03, 0.69]) and High/Unconditional (ES = 0.22, 95% CI [0.01, 0.43]) support were effective in improving health outcomes compared to no intervention. These effects were smaller than those observed for housing stability. The quality of the evidence was relatively low but varied across the 28 included studies. Depending on the context, finding accommodation for those who need it can be hindered by supply and affordability in the market. The social welfare approach in each jurisdiction can impact heavily on support available and can influence some of the prejudice and stigma surrounding homelessness. The evaluations emphasised the need for collaboration and a shared commitment between policymakers, funders and practitioners which creates community and buy in across sectors and agencies. However, co-ordinating this is difficult and requires sustainability to work. For those implementing programmes, it was important to invest time in developing a culture together to build trust and solid relationships. Additionally, identifying sufficient resources and appropriate referral routes allows for better implementation planning. Involving staff and case workers in creating processes helps drive enthusiasm and energy for the service. Time should be allocated for staff to develop key skills and communicate engage effectively with service users. Finally, staff need time to develop trust and relationships with service users; this goes hand in hand with providing information that is up to date and useful as well making themselves accessible in terms of location and time. Authors' Conclusions The network meta-analysis suggests that all types of accommodation which provided support are more effective than no intervention or Basic/Unconditional accommodation in terms of housing stability and health. The qualitative evidence synthesis raised a primary issue in relation to context: which was the lack of stable, affordable accommodation and the variability in the rental market, such that actually sourcing accommodation to provide for individuals who are homeless is extremely challenging. Collaboration between stakeholders and practitioners can be fruitful but difficult to coordinate across different agencies and organisations.
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Affiliation(s)
- Ciara Keenan
- Campbell UK & Ireland, Centre for Evidence and Social InnovationQueen's UniversityBelfastUK
| | - Sarah Miller
- Campbell UK & Ireland, Centre for Evidence and Social InnovationQueen's UniversityBelfastUK
| | - Jennifer Hanratty
- Campbell UK & Ireland, Centre for Evidence and Social InnovationQueen's UniversityBelfastUK
| | - Terri Pigott
- School of Public HealthGeorgia State UniversityAtlantaGeorgiaUSA
| | - Jayne Hamilton
- Campbell UK & Ireland, Centre for Evidence and Social InnovationQueen's UniversityBelfastUK
| | - Christopher Coughlan
- Campbell UK & Ireland, Centre for Evidence and Social InnovationQueen's UniversityBelfastUK
| | | | | | - John Cowman
- Department of Social WorkHealth Service ExecutiveDublinIreland
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15
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Kaltsidis G, Grenier G, Cao Z, L'Espérance N, Fleury MJ. Typology of changes in quality of life over 12 months among currently or formerly homeless individuals using different housing services in Quebec, Canada. Health Qual Life Outcomes 2021; 19:128. [PMID: 33882927 PMCID: PMC8061013 DOI: 10.1186/s12955-021-01768-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Gesthika Kaltsidis
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Guy Grenier
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada.
| | - Zhirong Cao
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
| | - Nadia L'Espérance
- Centre Intégré Universitaire de Santé et de Services Sociaux, Trois-Rivières, Quebec, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Douglas Hospital Research Centre, Douglas Mental Health University Institute, 6875 LaSalle Blvd., Montreal, QC, H4H 1R3, Canada
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16
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Raven MC, Niedzwiecki MJ, Kushel M. A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services. Health Serv Res 2021; 55 Suppl 2:797-806. [PMID: 32976633 PMCID: PMC7518819 DOI: 10.1111/1475-6773.13553] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective To examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county‐funded services. Data Sources Between 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county‐funded health care, jail and shelter, and mortality. Study Design We conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county‐funded systems using multivariate regression analysis. Data Collection We extracted encounter data from an integrated database capturing health care at county‐funded facilities, shelter and jails, county housing placement, and death certificates. Principal Findings We enrolled 423 participants (199 intervention; 224 control). Eighty‐six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow‐up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died. Conclusions The intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one‐third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high‐risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.
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Affiliation(s)
- Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,Mathematica Policy Research, Oakland, CA, USA
| | - Matthew J Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, USA
| | - Margot Kushel
- Mathematica Policy Research, Oakland, CA, USA.,Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.,UCSF Benioff Homelessness and Housing Initiative, San Francisco, CA, USA
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Babayan M, Futrell M, Stover B, Hagopian A. Advocates Make a Difference in Duration of Homelessness and Quality of Life. SOCIAL WORK IN PUBLIC HEALTH 2021; 36:354-366. [PMID: 33722166 DOI: 10.1080/19371918.2021.1897055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Social support is known to protect against homelessness and improve the wellbeing of people experiencing homelessness, but the role of professional versus informal advocates has not been studied in relation to the duration of homelessness and quality of life. We measured the effect of the presence and quality of formal (professional) and informal (family or friend) advocates on these outcomes. Our team interviewed 67 adults experiencing homelessness at tiny house villages and self-organized encampments in Seattle/King County, Washington in 2018-2019. The duration of homelessness was 19.6 months shorter for those with a high-quality informal advocate, compared to those without, while controlling for race, age, gender, and sexuality. However, this difference did not reach statistical significance at the alpha 0.05 level (p = .069). Additionally, those with high-quality informal advocates had 5.3 times the odds (p = .010) of reporting high quality of life compared to those without. The effect of at least one high-quality, professional advocate was insignificant in our model. Our results suggest social workers and other professional advocates integrate methods that strengthen clients' informal relationships into their practice.
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Affiliation(s)
- Margaret Babayan
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - Marvin Futrell
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - Bert Stover
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
| | - Amy Hagopian
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington, USA
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Baral S, Bond A, Boozary A, Bruketa E, Elmi N, Freiheit D, Ghosh SM, Goyer ME, Orkin AM, Patel J, Richter T, Robertson A, Sutherland C, Svoboda T, Turnbull J, Wong A, Zhu A. Seeking shelter: homelessness and COVID-19. Facets (Ott) 2021. [DOI: 10.1139/facets-2021-0004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Those experiencing homelessness in Canada are impacted inequitably by COVID-19 due to their increased exposure, vulnerability of environment and medical comorbidities, and their lack of access to preventive care and treatment in the context of the pandemic. In shelter environments one is unable to effectively physically distance, maintain hygiene, obtain a test, or isolate. As a result, unique strategies are required for this population to protect them and those who serve them. Recommendations are provided to reduce or prevent further negative consequences from the COVID-19 pandemic for people experiencing homelessness. These recommendations were informed by a systematic review of the literature, as well as a jurisdictional scan. Where evidence did not exist, expert consensus from key providers and those experiencing homelessness throughout Canada was included. These recommendations recognize the need for short-term interventions to mitigate the immediate risk to this community, including coordination of response, appropriate precautions and protective equipment, reducing congestion, cohorting, testing, case and contact management strategies, dealing with outbreaks, isolation centres, and immunization. Longer-term recommendations are also provided with a view to ending homelessness by addressing the root causes of homelessness and by the provision of adequate subsidized and supportive housing through a Housing First strategy. It is imperative that meaningful changes take place now in how we serve those experiencing homelessness and how we mitigate specific vulnerabilities. These recommendations call for intersectoral, collaborative engagement to work for solutions targeted towards protecting the most vulnerable within our community through both immediate actions and long-term planning to eliminate homelessness.
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Affiliation(s)
- Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Inner City Health Associates, Toronto, ON M5C 1K6, Canada
| | - Andrew Bond
- Inner City Health Associates, Toronto, ON M5C 1K6, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
| | - Andrew Boozary
- Population Health and Social Medicine, University Health Network, Toronto, ON M5G 2C4, Canada
- University of Toronto, Toronto, ON M5S 1A8, Canada
- Columbia University, New York, NY 10032, USA
| | - Eva Bruketa
- Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Nika Elmi
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | | | - S. Monty Ghosh
- Department of General Internal Medicine & Neurology, University of Alberta, Edmonton, AB T6G 2G3, Canada
- Department of Medicine & Psychiatry, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Marie Eve Goyer
- Family Medicine and Emergency Department, University of Montréal, Montréal, QC H3T 1J4, Canada
| | - Aaron M. Orkin
- Inner City Health Associates, Toronto, ON M5C 1K6, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
- Department of Emergency Medicine, St. Joseph’s Health Centre, Toronto, ON M6R 1B5, Canada
- Department of Emergency Medicine, Humber River Hospital, Toronto, ON M3M 0B2, Canada
| | - Jamie Patel
- Faculty of Community Services, Ryerson University, Toronto, ON M5B 2K3, Canada
| | - Tim Richter
- Canadian Alliance to End Homelessness, Calgary, AB T3H 0N8, Canada
| | - Angela Robertson
- Parkdale Queen West Community Health Centre, Toronto, ON M6K 1L2, Canada
| | - Christy Sutherland
- PHS Community Services Society, Vancouver, BC V6A 1M9, Canada
- Department of Family Medicine, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Tomislav Svoboda
- Department of Family and Community Medicine, University of Toronto, Toronto, ON M5G 1V7, Canada
| | - Jeffrey Turnbull
- University of Ottawa, Ottawa, ON K1N 6N5, Canada
- Ottawa Inner City Health, Ottawa, ON K1N 5N7, Canada
| | - Alexander Wong
- Department of Medicine, University of Saskatchewan, Regina, SK S4T 0H8, Canada
| | - Alice Zhu
- University of Toronto, Toronto, ON M5S 1A8, Canada
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Lawson LV, Bowie B, Neufeld M. Program evaluation of a recuperative care pilot project. Public Health Nurs 2020; 38:93-97. [PMID: 33190328 PMCID: PMC7983925 DOI: 10.1111/phn.12834] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/22/2020] [Accepted: 10/23/2020] [Indexed: 11/30/2022]
Abstract
Objective A program evaluation to demonstrate the feasibility of a recuperative care pilot project to address the needs of unhoused individuals. Design The study is a descriptive postprogram evaluation. Sample A total of 73 referrals were made to the project with 23 admissions. Measure Data regarding number and type of referrals for admission, cost of respite care per guest and per day, hospital costs avoided, referrals to community services, and discharge destination were collected. Intervention A case management care model was used. The project staff included a public health nurse and an outreach worker. Results One local hospital accounted for 65% of all admissions. Admitting diagnoses were abscess/wound care (44%) followed by postsurgery recovery (17%). Housing resources (65%) was a common referral with 22% of guests discharged to stable housing. Actual length of stay exceeded the planned length by an average of 24 days. Total cost per guest per day was $157.45 which is an estimated savings to referring acute care facilities of between $18,000 and $48,000 per day. Conclusions The project demonstrated an ability to provide unhoused individuals a place to recuperate following hospitalization in a cost‐effective manner. Challenges and recommendations of the program going forward were identified.
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Affiliation(s)
| | - Bonnie Bowie
- Seattle University College of Nursing, Seattle, WA, USA
| | - Melanie Neufeld
- Lake City Partners to End Homelessness, Seattle Mennonite Church, Seattle, WA, USA
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Lignes directrices de pratique clinique pour les personnes sans-abri, logées précairement, ou ayant connu l’itinérance. CMAJ 2020; 192:E1225-E1241. [PMID: 33051325 PMCID: PMC7588247 DOI: 10.1503/cmaj.190777-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kevin Pottie
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont.
| | - Claire E Kendall
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Tim Aubry
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Olivia Magwood
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Anne Andermann
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ginetta Salvalaggio
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - David Ponka
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Gary Bloch
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Vanessa Brcic
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Eric Agbata
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Kednapa Thavorn
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Terry Hannigan
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Andrew Bond
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Susan Crouse
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ritika Goel
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Esther Shoemaker
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Jean Zhuo Jing Wang
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Sebastian Mott
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Harneel Kaur
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Christine Mathew
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Syeda Shanza Hashmi
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Ammar Saad
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Thomas Piggott
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Neil Arya
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Nicole Kozloff
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Michaela Beder
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Dale Guenter
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Wendy Muckle
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Stephen Hwang
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Vicky Stergiopoulos
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
| | - Peter Tugwell
- Centre de recherche en soins de santé primaires C.T. Lamont (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Institut de recherche Bruyère; Département de médecine familiale ( Pottie, Kendall, Ponka, Shoemaker) et École d'épidémiologie et de santé publique (Pottie, Kendall), Université d'Ottawa; Institut de recherche de l'Hôpital d'Ottawa (Kendall, Shoemaker), Ottawa, Ont.; IRSS (Kendall, Shoemaker); Institut du savoir Li Ka Shing (Kendall), Hôpital St. Michael, Toronto, Ont.; École de psychologie (Aubry), Université d'Ottawa, Ottawa, Ont.; Départements de médecine familiale et d'épidémiologie, de biostatistiques et de santé du travail (Andermann), Faculté de médecine, Université McGill, Montréal, Qué.; Département de médecine familiale (Salvalaggio), Faculté de médecine et de dentisterie, Université de l'Alberta, Edmonton, Alta.; Centre de médecine Besrour pour l'avancement de la médecine de famille à l'échelle mondiale (Ponka), Collège des médecins de famille du Canada, Mississauga, Ont.; Département de médecine familiale et communautaire (Bloch), Hôpital St. Michael; Département de médecine familiale et communautaire (Bloch), Faculté de médecine, Université de Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Département de médecine familiale (Brcic), Université de la Colombie-Britannique, Vancouver, C.-B.; Départements de pédiatrie, d'obstétrique et gynécologie et de médecine préventive et santé publique (Agbata), Faculté de médecine, Université autonome de Barcelone; Institut de recherche de l'Hôpital d'Ottawa (Thavorn); École d'épidémiologie et de santé publique (Thavorn), Université d'Ottawa; Institut de recherche Bruyère (Mathew), Ottawa, Ont.; Département de médecine familiale et communautaire (Bond, Goel), Université de Toronto, Toronto, Ont.; Faculté de médecine (Crouse), Université Memorial, St. John's, T.-N.; Département de médecine familiale (Crouse), Université Dalhousie, Halifax, N.-É.; Faculté de médecine (Wang, Kaur, Hashmi), Université d'Ottawa, Ottawa, Ont.; Département de médecine familiale (Mott), Université McGill, Montréal, Qué.; Département des méthodes, des données et de l'impact de la recherche en santé (Piggott, Guenter), Université McMaster, Hamilton, Ont.; scientifique en résidence (Arya), Université Wilfrid Laurier, Waterloo, Ont.; Département de médecine familiale (Arya), Université McMaster, Hamilton, Ont.; Centre des dépendances et de santé mentale (Kozloff, Stergiopoulos); Département de psychiatrie et Institut des politiques de la gestion et de l'évaluation de la santé (Kozloff), Université de Toronto; Département de psychiatrie (Beder), Université de Toronto et Hôpital St. Michael, Toronto, Ont.; Département de médecine familiale (Guenter), Université McMaster, Hamilton, Ont.; Inner City Health (Muckle), Ottawa, Ont.; Centre MAP de solutions en santé urbaine (Hwang), Hôpital St. Michael, Toronto, Ont.; Département de médecine (Tugwell), Université d'Ottawa, Ottawa, Ont
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Effects of Residential Instability of Renters on Their Perceived Health Status: Findings from the Korean Welfare Panel Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197125. [PMID: 33003395 PMCID: PMC7579450 DOI: 10.3390/ijerph17197125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 01/21/2023]
Abstract
Identifying the impact of housing instability on the health status of renters with relatively high economic difficulties is important for the improvement of renters’ quality of life and their social security. Accordingly, this study adopted a panel data regression approach to examine the associations between residential instability and perceived health status—including physical and mental health—using 14 waves (2006–2019) of longitudinal data collected by the Korean Welfare Panel Study. The results showed that residential instability significantly affected perceived health status, and renters who experienced residential instability perceived worse health status and had more severe depression than those who did not experience residential instability. Moreover, failure to meet the minimum housing standard worsened depression in renters. Despite assistance benefits from the government, permanent rental housing and the national basic living security were also factors that worsened depression. Dissatisfaction with one’s residential environment and social relationships were also associated with increased depression. We recommend that the overall quality of housing welfare services, including a focus on the mental health of low-income renters, be improved by expanding the range of services, increasing the number of professional housing welfare workers, and supplying community facilities for increasing residential and social relationship satisfactions.
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Suh K, Beck J, Katzman W, Allen DD. Homelessness and rates of physical dysfunctions characteristic of premature geriatric syndromes: systematic review and meta-analysis. Physiother Theory Pract 2020; 38:858-867. [PMID: 32835565 DOI: 10.1080/09593985.2020.1809045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Homeless adults may experience accelerated aging, presenting earlier with geriatric syndromes such as falls and functional limitations. Though homelessness is surging in United States, data are scarce regarding rates of physical dysfunctions characteristic of geriatric syndromes experienced in this underserved population. PURPOSE Examine associations between homelessness, premature geriatric syndromes, and functional limitations. METHODS Two reviewers independently searched PubMed, CINAHL, and PEDro databases for prognostic studies reporting rates of geriatric syndromes in homeless adults aged 40 years and older. Two reviewers independently performed study selection. Data were extracted for homeless adults and community-dwelling controls regarding age, demographic information, limitations of activities of daily living (ADL) and instrumental ADL (IADL), frailty, and falls the past year. Risk ratio (RR) and 95% confidence interval (CI) were calculated across studies to compare groups. RESULTS Five studies met predetermined criteria. Meta-analysis revealed greater rates in homeless adults (average age 56) compared to housed adults (average age 78) for ADL limitation (RR = 1.50, 95% CI = 1.37-1.64) and IADL limitation (RR = 1.36, 95% CI = 1.28-1.45). Falls were three times more prevalent in homeless individuals (RR = 3.42, 95% CI = 3.16-3.70). Heterogeneous frailty data did not reach significance (RR = 2.59, 95% CI = 0.90-7.46). CONCLUSION Homeless adults have increased risk of premature geriatric syndromes. Limitations in ADL and IADL rates were 30-50% higher than adults with stable housing averaging 20 years older, and fall rates were three times higher than controls averaging 4.5 years older. These results underscore the need for healthcare providers such as physical therapists to address physical dysfunction in homeless adults.
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Affiliation(s)
- Kevin Suh
- Graduate Program in Physical Therapy, UCSF/SFSU, San Francisco, CA, USA
| | - Jordan Beck
- Graduate Program in Physical Therapy, UCSF/SFSU, San Francisco, CA, USA
| | - Wendy Katzman
- Graduate Program in Physical Therapy, UCSF/SFSU, San Francisco, CA, USA
| | - Diane D Allen
- Graduate Program in Physical Therapy, UCSF/SFSU, San Francisco, CA, USA
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23
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Effectiveness of permanent supportive housing and income assistance interventions for homeless individuals in high-income countries: a systematic review. LANCET PUBLIC HEALTH 2020; 5:e342-e360. [PMID: 32504587 DOI: 10.1016/s2468-2667(20)30055-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Permanent supportive housing and income assistance are valuable interventions for homeless individuals. Homelessness can reduce physical and social wellbeing, presenting public health risks for infectious diseases, disability, and death. We did a systematic review, meta-analysis, and narrative synthesis to investigate the effectiveness and cost-effectiveness of permanent supportive housing and income interventions on the health and social wellbeing of individuals who are homeless in high-income countries. METHODS We searched MEDLINE, Embase, CINAHL, PsycINFO, Epistemonikos, NIHR-HTA, NHS EED, DARE, and the Cochrane Central Register of Controlled Trials from database inception to Feb 10, 2020, for studies on permanent supportive housing and income interventions for homeless populations. We included only randomised controlled trials, quasi-experimental studies, and cost-effectiveness studies from high-income countries that reported at least one outcome of interest (housing stability, mental health, quality of life, substance use, hospital admission, earned income, or employment). We screened studies using a standardised data collection form and pooled data from published studies. We synthesised results using random effects meta-analysis and narrative synthesis. We assessed certainty of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. FINDINGS Our search identified 15 908 citations, of which 72 articles were included for analysis (15 studies on permanent supportive housing across 41 publications, ten studies on income interventions across 15 publications, and 21 publications on cost or cost-effectiveness). Permanent supportive housing interventions increased long-term (6 year) housing stability for participants with moderate support needs (one study; rate ratio [RR] 1·13 [95% CI 1·01-1·26]) and high support needs (RR 1·42 [1·19-1·69]) when compared with usual care. Permanent supportive housing had no measurable effect on the severity of psychiatric symptoms (ten studies), substance use (nine studies), income (two studies), or employment outcomes (one study) when compared with usual social services. Income interventions, particularly housing subsidies with case management, showed long-term improvements in the number of days stably housed (one study; mean difference at 3 years between intervention and usual services 8·58 days; p<0·004), whereas the effects on mental health and employment outcomes were unclear. INTERPRETATION Permanent supportive housing and income assistance interventions were effective in reducing homelessness and achieving housing stability. Future research should focus on the long-term effects of housing and income interventions on physical and mental health, substance use, and quality-of-life outcomes. FUNDING Inner City Health Associates.
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Spector AL, Quinn KG, McAuliffe TL, DiFranceisco W, Bendixen A, Dickson-Gomez J. Health-related quality of life and related factors among chronically homeless adults living in different permanent supportive housing models: a cross-sectional study. Qual Life Res 2020; 29:2051-2061. [PMID: 32222931 DOI: 10.1007/s11136-020-02482-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Permanent supportive housing (PSH) is an effective intervention to improve residential stability and reduce the utilization of costlier healthcare services for the chronically homeless. However, there has been little focus on health-related quality of life (HRQL) once they enter PSH, and the potential influence of other factors including the PSH model. Study results can shed light on the HRQL of the PSH population and inform strategies to improve PSH program effectiveness in this area. METHODS In this cross-sectional study, survey methods were used to assess the HRQL of PSH residents in the Chicago metropolitan area. The survey also included questions on socio-demographics, health behaviors, housing and neighborhood characteristics, and housing satisfaction. The SF-36 was used to obtain physical (PCS) and mental component summary (MCS) scores for HRQL. Other variables were selected using the Wilson and Cleary HRQL model. Statistical analyses included summary statistics, bivariate analyses, and fully adjusted linear regression models. RESULTS The study sample included 855 adults currently in PSH. The sample was predominantly African American men with an average age of 53 years. Mean scores for PCS and MCS were 39.4 and 46.1, respectively, (out of 100). In adjusted analyses, older age and being on disability were associated with worse PCS. Having HIV was associated with better PCS. Being non-Hispanic Black, living in fixed-sited housing, and being in PSH for longer durations were associated with better MCS. More depressive symptoms was associated with worse PCS and MCS. CONCLUSION While both aspects of the PSH model (housing configuration and service provision) were initially associated with HRQL in unadjusted analyses, housing configuration was the only PSH model variable that remained significant once accounting for other factors. Depressive symptomology and the social environment also appear to be important correlates of HRQL and are potential areas to target in PSH programs.
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Affiliation(s)
- Antoinette L Spector
- Department of Epidemiology, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA.
| | - Katherine G Quinn
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2701 N. Summit Ave., Milwaukee, WI, 53202, USA
| | - Timothy L McAuliffe
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2701 N. Summit Ave., Milwaukee, WI, 53202, USA
| | - Wayne DiFranceisco
- Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2701 N. Summit Ave., Milwaukee, WI, 53202, USA
| | | | - Julia Dickson-Gomez
- Department of Epidemiology, Institute for Health and Equity, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA.,Department of Psychiatry and Behavioral Medicine, Center for AIDS Intervention Research, Medical College of Wisconsin, 2701 N. Summit Ave., Milwaukee, WI, 53202, USA
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25
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Pottie K, Kendall CE, Aubry T, Magwood O, Andermann A, Salvalaggio G, Ponka D, Bloch G, Brcic V, Agbata E, Thavorn K, Hannigan T, Bond A, Crouse S, Goel R, Shoemaker E, Wang JZJ, Mott S, Kaur H, Mathew C, Hashmi SS, Saad A, Piggott T, Arya N, Kozloff N, Beder M, Guenter D, Muckle W, Hwang S, Stergiopoulos V, Tugwell P. Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience. CMAJ 2020; 192:E240-E254. [PMID: 32152052 PMCID: PMC7062440 DOI: 10.1503/cmaj.190777] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont.
| | - Claire E Kendall
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Tim Aubry
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Olivia Magwood
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Anne Andermann
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ginetta Salvalaggio
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - David Ponka
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Gary Bloch
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Vanessa Brcic
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Eric Agbata
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Kednapa Thavorn
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Terry Hannigan
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Andrew Bond
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Susan Crouse
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ritika Goel
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Esther Shoemaker
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Jean Zhuo Jing Wang
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Sebastian Mott
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Harneel Kaur
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Christine Mathew
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Syeda Shanza Hashmi
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Ammar Saad
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Thomas Piggott
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Neil Arya
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Nicole Kozloff
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Michaela Beder
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Dale Guenter
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Wendy Muckle
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Stephen Hwang
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Vicky Stergiopoulos
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
| | - Peter Tugwell
- C.T. Lamont Primary Health Care Research Centre (Pottie, Kendall, Magwood, Shoemaker, Saad, Hannigan, Wang, Kaur), Bruyère Research Institute; Department of Family Medicine (Pottie, Kendall, Ponka, Shoemaker), and School of Epidemiology and Public Health (Pottie, Kendall), University of Ottawa; Ottawa Hospital Research Institute (Kendall, Shoemaker), Ottawa, Ont.; ICES (Kendall, Shoemaker); Li Ka Shing Knowledge Institute (Kendall), St. Michael's Hospital, Toronto, Ont.; School of Psychology (Aubry), University of Ottawa, Ottawa, Ont.; Departments of Family Medicine, and Epidemiology, Biostatistics and Occupational Health (Andermann), Faculty of Medicine, McGill University, Montréal, Que.; Department of Family Medicine (Salvalaggio), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alta.; Besrour Centre for Global Family Medicine (Ponka), College of Family Physicians of Canada, Mississauga, Ont.; Department of Family and Community Medicine (Bloch), St. Michael's Hospital; Department of Family and Community Medicine (Bloch), Faculty of Medicine, University of Toronto; Inner City Health Associates (Bloch, Bond, Hwang, Goel), Toronto, Ont.; Department of Family Practice (Brcic), University of British Columbia, Vancouver, BC; Department of Pediatrics, Obstetrics and Gynecology and Preventive Medicine and Public Health (Agbata), Faculty of Medicine, Universitat Autònoma de Barcelona; Ottawa Hospital Research Institute (Thavorn); School of Epidemiology and Public Health (Thavorn), University of Ottawa; Bruyère Research Institute (Mathew), Ottawa, Ont.; Department of Family and Community Medicine (Bond, Goel), University of Toronto, Toronto, Ont.; Faculty of Medicine (Crouse), Memorial University, St. John's, NL; Department of Family Medicine (Crouse), Dalhousie University, Halifax, NS; Faculty of Medicine (Wang, Kaur, Hashmi), University of Ottawa, Ottawa, Ont.; Department of Family Medicine (Mott), McGill University, Montréal, Que.; Department of Health Research Methods, Evidence, and Impact (Piggott, Guenter), McMaster University, Hamilton, Ont.; scholar in residence (Arya), Wilfrid Laurier University, Waterloo, Ont.; Department of Family Medicine (Arya), McMaster University, Hamilton, Ont.; Centre for Addiction and Mental Health (Kozloff, Stergiopoulos); Department of Psychiatry, and Institute of Health Policy, Management and Evaluation (Kozloff), University of Toronto; Department of Psychiatry (Beder), University of Toronto and St. Michael's Hospital, Toronto, Ont.; Department of Family Medicine (Guenter), McMaster University, Hamilton, Ont.; Ottawa Inner City Health (Muckle), Ottawa, Ont.; MAP Centre for Urban Health Solutions (Hwang), St. Michael's Hospital, Toronto, Ont.; Department of Medicine (Tugwell), University of Ottawa, Ottawa, Ont
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Chhabra M, Spector E, Demuynck S, Wiest D, Buckley L, Shea JA. Assessing the relationship between housing and health among medically complex, chronically homeless individuals experiencing frequent hospital use in the United States. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:91-99. [PMID: 31476092 DOI: 10.1111/hsc.12843] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 06/10/2023]
Abstract
In the United States and abroad, health systems have begun to address housing insecurity through programs that adhere to the Housing First model. The model provides permanent supportive housing without disqualification due to current mental health problems or substance use, along with optional case management services. This study used qualitative methods to explore how housing stability affected chronic disease management and social and community relationships among individuals with complex health and social needs and patterns of high hospital utilisation who were housed as part of a scattered-site Housing First program in a mid-size city in the northeastern United States. 26 individual, semi-structured interviews were conducted with Housing First clients in their homes or day program sites between March and July 2017. Interviews were digitally recorded and transcripts were analysed using a qualitative descriptive methodology until thematic saturation was reached. Findings suggest that housing provided the physical location to manage the logistical aspects of care for these clients, and an environment where they were better able to focus on their health and wellness. Study participants reported less frequent use of emergency services and more regular interaction with primary care providers. Additionally, case managers' role in connecting clients to behavioural health services removed barriers to care that clients had previously faced. Housing also facilitated reconnection with family and friends whose relationships with participants had become strained or distant. Changes to physical and social communities sometimes resulted in experiences of stigmatisation and exclusion, especially for clients who moved to areas with less racial and socioeconomic diversity, but participation in the program promoted an increased sense of safety and security for many clients.
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Affiliation(s)
- Manik Chhabra
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine at the Cpl. Michael Crescenz VA Medical Center, U.S. Department of Veterans Affairs, Philadelphia, PA, USA
| | - Emily Spector
- Camden Coalition of Health Care Providers, Camden, NJ, USA
| | - Sophia Demuynck
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Dawn Wiest
- Camden Coalition of Health Care Providers, Camden, NJ, USA
| | - Laura Buckley
- Camden Coalition of Health Care Providers, Camden, NJ, USA
| | - Judy A Shea
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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27
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Convergent validity of the EQ-5D-3L in a randomized-controlled trial of the Housing First model. BMC Health Serv Res 2019; 19:482. [PMID: 31300051 PMCID: PMC6626335 DOI: 10.1186/s12913-019-4310-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health utility assessments are important for economic evaluations but few instruments have been validated in homeless people with mental illness. We examined the convergent validity of the EuroQol-5 Dimension 3-level questionnaire (EQ-5D-3L) as a measure of quality of life in homeless adults with mental illness. METHODS Data were from Toronto participants in At Home/Chez Soi, a 24-month randomized controlled trial of Housing First (immediate access to scattered site housing and mental health support services) compared to treatment as usual for homeless adults with a mental disorder (n = 575). Participants completed the EQ-5D-3L at 6 month intervals. We tested convergent validity, hypothesizing strong correlation (r > 0.6) with the Lehman Quality of Life Interview 20 (QOLI-20) index and moderate correlations (r > 0.3) with the Colorado Symptom Index (CSI), Recovery Assessment Scale (RAS), and number of comorbidities. We also examined correlations between EQ-5D-3L scores and the QOLI-20 over time using a linear mixed-effects model. RESULTS The EQ-5D-3L was not strongly correlated with the QOLI-20 (r ranged from 0.31-0.52 at various time points). The EQ-5D-3L was moderately correlated with the CSI, RAS, and number of comorbidities. The Snijders/Bosker r2 for longitudinal validity between the EQ-5D-3L and QOLI-20 within subjects over time was 0.2094 (square-root r = 0.4576). CONCLUSIONS The EQ-5D-3L did not demonstrate strong convergent validity in homeless people with mental illness but was moderately correlated with several instruments. Further research is warranted to determine the optimal method for measuring health utilities in this population. TRIAL REGISTRATION International Standard Randomised Control Trial Registry ISRCTN42520374 assigned on August 18, 2009.
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28
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Davies A, Wood LJ. Homeless health care: meeting the challenges of providing primary care. Med J Aust 2019; 209:230-234. [PMID: 30157413 DOI: 10.5694/mja17.01264] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/19/2018] [Indexed: 11/17/2022]
Abstract
People experiencing homelessness have multiple complex health conditions yet are typically disengaged from primary health care services and place a significant burden on the acute health system. Barriers preventing people who are homeless from accessing primary care can be both personal and practical and include competing needs and priorities, illness and poor health, physical access to health services, difficulty in contacting services, medication security, and the affordability of health care. Differences in social status and perceptions of being judged can lead to relationship barriers to accessing primary care. Key solutions include prioritising access to stable housing, continuity of health care, specialised homeless general practice, hospital inreach, discharge planning and coordinated care, general practice outreach, and medical recovery centres.
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29
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Gentil L, Grenier G, Bamvita JM, Dorvil H, Fleury MJ. Profiles of Quality of Life in a Homeless Population. Front Psychiatry 2019; 10:10. [PMID: 30761023 PMCID: PMC6364333 DOI: 10.3389/fpsyt.2019.00010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 01/09/2019] [Indexed: 11/13/2022] Open
Abstract
Quality of life (QOL) is a key indicator in mental health planning, program evaluation, and evaluation of patient outcomes. Yet few studies have focused on QOL in homeless populations. More specifically, research has yet to identify profiles of homeless individuals based on their QOL using cluster analysis. This study developed a typology of QOL for a sample of 455 homeless individuals recruited from 27 community and public organizations in Quebec (Canada). The typology was developed based on QOL scores, as well as sociodemographic, clinical, and service use variables. Study participants had to be at least 18 years old, with current or previous experience of homelessness. A questionnaire including socio-demographics, residential history, service utilization, and health-related variables was administered. Four clusters were identified using a two-step cluster analysis. QOL was highest in the cluster consisting of older women with low functional disability, and relatively few episodes of homelessness. The second cluster with high QOL scores included individuals living in temporary housing with relatively few mental health or substance use disorders (SUDs). The third cluster with low QOL included middle-aged women living in temporary housing, with criminal records, personality disorders, and SUDs. QOL was also lower in the fourth cluster composed of individuals with multiple homeless episodes and complex health problems as well as high overall service use. Findings reinforced the importance of disseminating specific programs adapted to the diverse profiles of homeless individuals, with a view toward increasing their QOL.
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Affiliation(s)
- Lia Gentil
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Research Center, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Guy Grenier
- Research Center, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Jean-Marie Bamvita
- Research Center, Douglas Mental Health University Institute, Montreal, QC, Canada
| | - Henri Dorvil
- School of Social Work, Université du Québec à Montréal, Montreal, QC, Canada
| | - Marie-Josée Fleury
- Department of Psychiatry, McGill University, Montreal, QC, Canada.,Research Center, Douglas Mental Health University Institute, Montreal, QC, Canada
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30
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Giordano TP, Gallagher K, Davich JAW, Rathore M, Borne D, Davies E, Altice FL, Cabral H. The Impact of Housing and HIV Treatment on Health-Related Quality of Life Among People With HIV Experiencing Homelessness or Unstable Housing. Am J Public Health 2018; 108:S531-S538. [PMID: 32941776 DOI: 10.2105/ajph.2018.304731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To determine the impact of improvements in housing and HIV clinical parameters on health-related quality of life (HRQOL) in persons with HIV infection experiencing homelessness.Methods. This prospective cohort study took place in 9 US sites. Local efforts sought to improve HIV and housing status. Longitudinal data analyses determined the impact of changes in housing status, HIV suppression, and CD4 cell counts on HRQOL at 12 months, measured as mental and physical component summary scores.Results. Among 909 participants enrolled from 2013 to 2016, 75.1% were homeless, 51.6% did not have HIV suppression, and 23.6% had a CD4 count less than 200 cells per cubic millimeter. Median mental and physical component summary scores were 35.4 and 38.9, respectively. These 5 parameters all improved by 6 months. In multivariate modeling, maintaining or achieving stable housing predicted higher PCS at 12 months, but CD4 count and HIV suppression improvements did not. Improvements in housing, CD4 count, and HIV suppression did not predict mental component score at 12 months.Conclusions. Housing and HIV treatment are necessary but not sufficient to improve HRQOL in this challenging population. The high prevalence of socioeconomic and mental health needs we found support the call for patient-centered comprehensive care.
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Affiliation(s)
- Thomas P Giordano
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
| | - Kerrin Gallagher
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
| | - Jo Ann Whitlock Davich
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
| | - Mobeen Rathore
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
| | - Deborah Borne
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
| | - Erika Davies
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
| | - Frederick L Altice
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
| | - Howard Cabral
- Thomas P. Giordano is with the Department of Medicine, Baylor College of Medicine, the Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center; and Thomas Street Health Center, Harris Health System, Houston, TX. Kerrin Gallagher is with Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA. Jo Ann Whitlock Davich is with Multnomah County Health Department, Portland, OR. Mobeen Rathore is with University of Florida Center for HIV/AIDS Research, Education, and Service, University of Florida, Jacksonville, FL. Deborah Borne is with the San Francisco Department of Public Health, San Francisco, CA. Erika Davies is with the City of Pasadena Public Health Department, Pasadena, CA. Frederick L. Altice is with the Department of Internal Medicine, Yale University School of Medicine, Yale School of Epidemiology and Public Health, New Haven, CT. Howard Cabral is with the Department of Biostatistics, Boston University School of Public Health
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Choi SA, Hastings JF. Religion, spirituality, coping, and resilience among African Americans with diabetes. JOURNAL OF RELIGION & SPIRITUALITY IN SOCIAL WORK 2018; 38:93-114. [PMID: 31607831 PMCID: PMC6788765 DOI: 10.1080/15426432.2018.1524735] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 09/13/2018] [Indexed: 05/28/2023]
Abstract
Study aims were to explore how religion and spirituality impacted attitudes about self-management practices among African Americans with homelessness histories and to understand resilience in diabetes care practices. Qualitative semi-structured face-to-face interviews were conducted with 42 African Americans older than 18 years. All audio-taped interviews lasted between 1-1.5 hr, transcribed verbatim, and analyzed using ATLAS.ti (version 7.0). Five resilience themes emerged. While participants recognized diabetes as an illness requiring professional treatment, the context of balancing treatment with religion and spiritual practices mattered. The study findings highlight the importance of spirituality, religious beliefs, and coping strategies in diabetes self-care activities.
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Affiliation(s)
- Sung Ah Choi
- School of Social Welfare, University at Albany, SUNY, Albany, New York, USA
| | - Julia F. Hastings
- School of Social Welfare, University at Albany, SUNY, Albany, New York, USA
- School of Public Health, Health Policy, Management, & Behavior University at Albany, SUNY, Rensselaer, New York, USA
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Rhoades H, La Motte-Kerr W, Duan L, Woo D, Rice E, Henwood B, Harris T, Wenzel SL. Social networks and substance use after transitioning into permanentsupportive housing. Drug Alcohol Depend 2018; 191:63-69. [PMID: 30086424 PMCID: PMC6224132 DOI: 10.1016/j.drugalcdep.2018.06.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 06/17/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Substance use disorders are common among persons experiencing homelessness, and research has identified social networks as important correlates of substance use in this population. Permanent supportive housing (PSH), particularly Housing First, which uses a harm reduction model not requiring substance abstinence, is a key solution for ending homelessness. However, conflicting evidence exists regarding the associations between moving into PSH and changes in substance use, and there is limited understanding of how networks may influence such changes. METHODS Using observational, longitudinal data from 421 persons before they moved in and over their first year in PSH (collected as part of a HIV-risk study), this paper assesses substance use change (alcohol, marijuana, and illicit drugs) and associations between perceived network characteristics and individual substance use. RESULTS Substance use remained relatively stable among participants over their first year living in PSH, although illicit substance use reduced somewhat at six months compared to baseline levels (from 18.5%-14.5%) and marijuana use increased slightly at 12 months (from 26.6% at baseline to 32.9%). Substance use among social network members was consistently associated with individual-level substance use, both cross-sectionally and longitudinally. Specific network substance use characteristics, such as proximity, location met, and social support, had differential relationships with particular substance types. CONCLUSIONS These findings provide longitudinal evidence that changes within substance-using social networks are associated with subsequent changes in individual use and underscore the importance of interventions aimed at promoting positive social relationships for formerly homeless persons and improving PSH's social environments.
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Affiliation(s)
- Harmony Rhoades
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 S. Hill Street, Los Angeles, CA, 90015, United States.
| | - Wichada La Motte-Kerr
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 S. Hill Street, Los Angeles, CA, 90015, United States
| | - Lei Duan
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 S. Hill Street, Los Angeles, CA, 90015, United States
| | - Darlene Woo
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 S. Hill Street, Los Angeles, CA, 90015, United States
| | - Eric Rice
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 S. Hill Street, Los Angeles, CA, 90015, United States
| | - Benjamin Henwood
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 S. Hill Street, Los Angeles, CA, 90015, United States
| | - Taylor Harris
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1149 S. Hill Street, Los Angeles, CA, 90015, United States
| | - Suzanne L Wenzel
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669 West 34th Street, Los Angeles, CA, 90089, United States
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Parsell C, ten Have C, Denton M, Walter Z. Self-management of health care: multimethod study of using integrated health care and supportive housing to address systematic barriers for people experiencing homelessness. AUST HEALTH REV 2018; 42:303-308. [DOI: 10.1071/ah16277] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/01/2017] [Indexed: 11/23/2022]
Abstract
Objectives The aims of the present study were to examine tenants’ experiences of a model of integrated health care and supportive housing and to identify whether integrated health care and supportive housing improved self-reported health and healthcare access. Methods The present study used a mixed-method survey design (n = 75) and qualitative interviews (n = 20) performed between September 2015 and August 2016. Participants were tenants of permanent supportive housing in Brisbane (Qld, Australia). Qualitative data were analysed thematically. Results Integrated health care and supportive housing were resources for tenants to overcome systematic barriers to accessing mainstream health care experienced when homeless. When homeless, people did not have access to resources required to maintain their health. Homelessness meant not having a voice to influence the health care people received; healthcare practitioners treated symptoms of poverty rather than considering how homelessness makes people sick. Integrated healthcare and supportive housing enabled tenants to receive treatment for health problems that were compounded by the barriers to accessing mainstream healthcare that homelessness represented. Conclusions Extending the evidence about housing as a social determinant of health, the present study shows that integrated health care and supportive housing enabled tenants to take control to self-manage their health care. In addition to homelessness directly contributing to ill health, the present study provides evidence of how the experience of homelessness contributes to exclusions from mainstream healthcare. What is known about the topic? People who are homeless experience poor physical and mental health, have unmet health care needs and use disproportionate rates of emergency health services. What does the paper add? The experience of homelessness creates barriers to accessing adequate health care. The provision of onsite multidisciplinary integrated health care in permanent supportive housing enabled illness self-management and greater control over lifestyle, and was associated with self-reported improved health and life satisfaction in formerly homeless tenants. What are the implications for practitioners? Integrated health care and supportive housing for the formerly homeless can improve self-reported health outcomes, enable healthier lifestyle choices and facilitate pathways into more appropriate and effective health care.
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Stafford A, Wood L. Tackling Health Disparities for People Who Are Homeless? Start with Social Determinants. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:E1535. [PMID: 29292758 PMCID: PMC5750953 DOI: 10.3390/ijerph14121535] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Homelessness is associated with enormous health inequalities, including shorter life expectancy, higher morbidity and greater usage of acute hospital services. Viewed through the lens of social determinants, homelessness is a key driver of poor health, but homelessness itself results from accumulated adverse social and economic conditions. Indeed, in people who are homeless, the social determinants of homelessness and health inequities are often intertwined, and long term homelessness further exacerbates poor health. Aggregated health service data can mask this, and case histories thus provide important insights. METHODS This paper presents three case histories of homeless patients seen at an inner city public hospital in Perth, Western Australia. The case histories draw on several data sources: hospital data, information collected from rough sleepers and clinical observations. Estimates of the cost to the health system of the observed hospital usage by the three patients are included. FINDINGS The case histories illustrate the interplay of social determinants of health in homelessness that help explain the high level of hospital usage by rough sleepers. The cumulative healthcare costs for the three individuals over a 33 months period were substantial. Hospital attendance plummeted even in the short term when housing needs were addressed. CONCLUSIONS Treating homelessness as a combined health and social issue is critical to improving the abysmal health outcomes of people experiencing homelessness. In addition, the enormous economic costs of hospital care for people who are homeless can be reduced when housing and other social determinants are taken into account.
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Affiliation(s)
| | - Lisa Wood
- School of Population and Global Health and Centre for Social Impact, The University of Western Australia, Crawley, WA 6009, Australia.
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van der Laan J, van Straaten B, Boersma SN, Rodenburg G, van de Mheen D, Wolf JRLM. Predicting homeless people's perceived health after entering the social relief system in The Netherlands. Int J Public Health 2017; 63:203-211. [PMID: 28821908 PMCID: PMC5829105 DOI: 10.1007/s00038-017-1026-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 07/15/2017] [Accepted: 07/29/2017] [Indexed: 11/16/2022] Open
Abstract
Objectives We explored whether changes in the perceived health of homeless people after entering the social relief system (SRS) in The Netherlands were predicted by housing, income, hours of work, social support, unmet care needs, arrests, physical and mental health, substance use, and experiences of autonomy, competence and relatedness, in addition to perceived health at baseline, demographics, suspected intellectual disability, the duration of homelessness and the company of children in the shelter facility. Methods A hierarchical regression analysis was used to explore the significant predictors of the perceived health of 344 homeless persons 18 months after entering the social relief system. Results A decrease in psychological distress and an increase in hours of (paid/voluntary) work as well as competence predicted a better perceived health. Conclusions Perceived health is not only influenced by objective circumstances related to work and mental health, but also self-determination, as shown by the influence of competence. Services should aim to reduce psychological distress of homeless people, support them in increasing their working hours and focus on strengthening their competence.
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Affiliation(s)
- Jorien van der Laan
- Department of Primary and Community Care, Radboud University Medical Center, Impuls - Netherlands Center for Social Care Research, Nijmegen, The Netherlands.,Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Barbara van Straaten
- Erasmus Medical Centre, Rotterdam, The Netherlands.,IVO Addiction Research Institute, Rotterdam, The Netherlands
| | - Sandra N Boersma
- Department of Primary and Community Care, Radboud University Medical Center, Impuls - Netherlands Center for Social Care Research, Nijmegen, The Netherlands
| | - Gerda Rodenburg
- Erasmus Medical Centre, Rotterdam, The Netherlands.,IVO Addiction Research Institute, Rotterdam, The Netherlands
| | - Dike van de Mheen
- Erasmus Medical Centre, Rotterdam, The Netherlands.,IVO Addiction Research Institute, Rotterdam, The Netherlands.,Tilburg University, Scientific Centre for Care and Welfare (Tranzo), Tilburg, The Netherlands
| | - Judith R L M Wolf
- Department of Primary and Community Care, Radboud University Medical Center, Impuls - Netherlands Center for Social Care Research, Nijmegen, The Netherlands.
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Fenelon A, Mayne P, Simon AE, Rossen LM, Helms V, Lloyd P, Sperling J, Steffen BL. Housing Assistance Programs and Adult Health in the United States. Am J Public Health 2017; 107:571-578. [PMID: 28207335 PMCID: PMC5343706 DOI: 10.2105/ajph.2016.303649] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To examine whether access to housing assistance is associated with better health among low-income adults. METHODS We used National Health Interview Survey data (1999-2012) linked to US Department of Housing and Urban Development (HUD) administrative records (1999-2014) to examine differences in reported fair or poor health and psychological distress. We used multivariable models to compare those currently receiving HUD housing assistance (public housing, housing choice vouchers, and multifamily housing) with those who will receive housing assistance within 2 years (the average duration of HUD waitlists) to account for selection into HUD assistance. RESULTS We found reduced odds of fair or poor health for current public housing (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.57, 0.97) and multifamily housing (OR = 0.75; 95% CI = 0.60, 0.95) residents compared with future residents. Public housing residents also had reduced odds of psychological distress (OR = 0.59; 95% CI = 0.40, 0.86). These differences were not mediated by neighborhood-level characteristics, and we did not find any health benefits for current housing choice voucher recipients. CONCLUSIONS Housing assistance is associated with improved health and psychological well-being for individuals entering public housing and multifamily housing programs.
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Affiliation(s)
- Andrew Fenelon
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
| | - Patrick Mayne
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
| | - Alan E Simon
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
| | - Lauren M Rossen
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
| | - Veronica Helms
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
| | - Patricia Lloyd
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
| | - Jon Sperling
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
| | - Barry L Steffen
- Andrew Fenelon is with the Department of Health Services Administration, University of Maryland, College Park. Patrick Mayne is with the Department of Sociology, Brown University, Providence, RI. Alan E. Simon is with the Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC. Lauren M. Rossen and Patricia Lloyd are with the National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD. Veronica Helms, Jon Sperling, and Barry L. Steffen are with the Office of Policy Development and Research, US Department of Housing and Urban Development, Washington, DC
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Dickson-Gomez J, Quinn K, Bendixen A, Johnson A, Nowicki K, Ko Ko T, Galletly C. Identifying variability in permanent supportive housing: A comparative effectiveness approach to measuring health outcomes. THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2017; 87:414-424. [PMID: 28301175 DOI: 10.1037/ort0000232] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Supportive housing has become the dominant model in the United States to provide housing to the chronically homeless and to improve their housing stability and health. Most supportive housing programs follow a "housing first" paradigm modeled after the Pathways to Housing program in New York City. However, components of housing first supportive housing models were poorly defined, and supportive models have varied considerably in their dissemination and implementation to other parts of the country. Recently, research has been conducted to determine the fidelity by which specific housing programs adhere to the Pathways Housing First model. However, evidence regarding which combination of components leads to better health outcomes for particular subpopulations is lacking. This article presents results from qualitative interviews with supportive housing providers in the Chicago, Illinois, metropolitan area. Supportive housing varied according to housing configuration (scattered-site vs. project-based) and service provision model (low-intensity case management, intensive case management and behavioral health), resulting in 6 basic types. Supportive housing programs also differed in services they provided in addition to case management and the extent to which they followed harm-reduction versus abstinence policies. Results showed advantages and disadvantages of each of the 6 basic types. Comparative effectiveness research may help identify which program components lead to better health outcomes among different subpopulations of homeless. Future longitudinal research will use the identified typology and other factors to compare the housing stability and health outcomes of supportive housing residents in programs that differ along these dimensions. (PsycINFO Database Record
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Affiliation(s)
| | | | | | | | | | - Thant Ko Ko
- Institute for Public and Community Health, Medical College of Wisconsin
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Beaudoin I. Efficacité de l’approche « logement d’abord » : une revue systématique. ACTA ACUST UNITED AC 2016. [DOI: 10.7202/1037732ar] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Les personnes itinérantes aux prises avec des problèmes de santé mentale et de toxicomanie qui souhaitent obtenir un logement se butent à des programmes dans lesquels l’abstinence et les traitements psychiatriques sont obligatoires. Ce type de programmes se base sur l’approche « traitement d’abord » selon laquelle ces personnes doivent d’abord être traitées avant de pouvoir aller en logement.
Cette approche est remise en question et un changement de paradigme s’opère à la suite de l’implantation aux États-Unis du modèle Pathways to Housing. Ce modèle est fondé sur le principe qu’une personne doit être logée avant de pouvoir se concentrer sur ses autres besoins. Les logements privés sont privilégiés dans ce modèle et ceux-ci sont offerts conjointement avec un soutien d’intensité variable ou un suivi intensif dans la communauté.
Le modèle Pathways to Housing a influencé la création de plusieurs programmes hybrides basés sur l’approche « logement d’abord » combinée à une offre de services et de logements diversifiés. Cette approche est basée sur la même philosophie d’obligation minimale que le modèle original, voulant que les personnes n’aient pas à être abstinentes ou à suivre un traitement psychiatrique pour accéder à un logement.
Au Canada, le gouvernement envisage de subventionner principalement les programmes basés sur cette approche. Cette annonce a mené à un soulèvement au Québec, notamment en raison des logements sociaux qui y sont actuellement priorisés.
Cet article présente les résultats d’une revue systématique de la littérature réalisée afin de statuer sur l’efficacité des programmes basés sur l’approche « logement d’abord ».
Les résultats de cette revue nous permettent de conclure que la mise en place au Québec de programmes basés sur cette approche devrait être favorisée. Les modalités et interventions offertes dans ces programmes auraient également avantage à être diversifiées.
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Affiliation(s)
- Isabelle Beaudoin
- Ph.D., Professionnelle scientifique en services sociaux, Institut national d’excellence en santé et en services sociaux (INESSS)
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The relationship between housing subsidies and supportive housing on neighborhood distress and housing satisfaction: does drug use make a difference? SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2016; 11:20. [PMID: 27233496 PMCID: PMC4884364 DOI: 10.1186/s13011-016-0064-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 05/12/2016] [Indexed: 11/10/2022]
Abstract
Background Since the 1970s, the dominant model for U.S. federal housing policy has shifted from unit-based programs to tenant-based vouchers and certificates. Because housing vouchers allow recipients to move to apartments and neighborhoods of their choice, such programs were designed to improve the ability of poor families to move into neighborhoods with less concentrated poverty. However, little research has examined whether housing voucher recipients live in less distressed neighborhoods than those without housing vouchers. There is much reason to believe that drug users may not be able to access or keep federal housing subsidies due to difficulties drug users, many of whom may have criminal histories and poor credit records, may have in obtaining free market rental housing. In response to these difficulties, permanent supportive housing was designed for those who are chronically homeless with one or more disabling condition, including substance use disorders. Little research has examined whether residents of permanent supportive housing units live in more or less economically distressed neighborhoods compared to low-income renters. Methods This paper uses survey data from 337 low-income residents of Hartford, CT and geospatial analysis to determine whether low-income residents who receive housing subsidies and supportive housing live in neighborhoods with less concentrated poverty than those who do not. We also examine the relationships between receiving housing subsidies or supportive housing and housing satisfaction. Finally, we look at the moderating effects of drug use and race on level of neighborhood distress and housing satisfaction. Results Results show that low-income residents who receive housing subsidies or supportive housing were not more or less likely to live in neighborhoods with high levels of distress, although Black residents with housing subsidies lived in more distressed neighborhoods. Regarding housing satisfaction, those with housing subsidies perceived significantly more choice in where they were living while those in supportive housing perceived less choice. In addition, those with rental subsidies or supportive housing reported living closer to needed services, unless they also reported heavy drug use. Conclusions Housing subsidies and supportive housing have little impact on the level of neighborhood distress in which recipients live, but some effects on housing satisfaction.
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Integrated Social Housing and Health Care for Homeless and Marginally-Housed Individuals: A Study of the Housing and Homelessness Steering Committee in Ontario, Canada. SOCIAL SCIENCES 2016. [DOI: 10.3390/socsci5020015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Cheung A, Somers JM, Moniruzzaman A, Patterson M, Frankish CJ, Krausz M, Palepu A. Emergency department use and hospitalizations among homeless adults with substance dependence and mental disorders. Addict Sci Clin Pract 2015; 10:17. [PMID: 26242968 PMCID: PMC4636835 DOI: 10.1186/s13722-015-0038-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 07/16/2015] [Indexed: 11/14/2022] Open
Abstract
Background Homelessness, substance use, and mental disorders each have been associated with higher rates of emergency department (ED) use and hospitalization. We sought to understand the correlation between ED use, hospital admission, and substance dependence among homeless individuals with concurrent mental illness who participated in a ‘Housing First’ (HF) intervention trial. Methods The Vancouver At Home study consisted of two randomized controlled trials addressing homeless individuals with mental disorders who have “high” or “moderate” levels of need. Substance dependence was determined at baseline prior to randomization, using the Mini International Neuropsychiatric Interview diagnostic tool, version 6.0. To assess health service use, we reviewed the number of ED visits and the number of hospital admissions based on administrative data for six urban hospitals. Negative binomial regression modeling was used to test the independent association between substance dependence and health service use (ED use and hospitalization), adjusting for HF intervention, age, gender, ethnicity, education, duration of lifetime homelessness, mental disorders, chronic health conditions, and other variables that were selected a priori to be potentially associated with use of ED services and hospital admission. Results Of the 497 homeless adults with mental disorders who were recruited, we included 381 participants in our analyses who had at least 1 year of follow-up and had a personal health number that could be linked to administrative health data. Of this group, 59% (n = 223) met criteria for substance dependence. We found no independent association between substance dependence and ED visits or hospital admissions [rate ratio (RR) = 0.85; 95% CI 0.62–1.17 and RR = 1.21; 95% CI 0.83–1.77, respectively]. The most responsible diagnoses (defined as the diagnosis that accounts for the length of stay) for hospital admissions were schizo-affective disorder, schizophrenia-related disorder, or bipolar affective disorder; collectively reported in 48% (n = 263) of admissions. Fifteen percent (n = 84) of hospital admissions listed substance dependence as the most responsible diagnosis. Conclusions Substance dependence was not independently associated with ED use or hospital admission among homeless adults with mental disorders participating in an HF trial. Hospital admissions among this cohort were primarily associated with severe mental disorders. Trial registration: ISRCTN57595077 and ISRCTN66721740
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Affiliation(s)
- Adrienne Cheung
- Department of Medicine, Centre for Health Evaluation and Outcome Sciences, University of British Columbia, 588B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Julian M Somers
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada.
| | - Akm Moniruzzaman
- Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada.
| | | | | | - Michael Krausz
- School of Population and Public Health, Vancouver, Canada. .,Department of Psychiatry, University of British Columbia, Vancouver, Canada.
| | - Anita Palepu
- Department of Medicine, Centre for Health Evaluation and Outcome Sciences, University of British Columbia, 588B-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing. J Gen Intern Med 2014; 29 Suppl 4:835-44. [PMID: 25355085 PMCID: PMC4239291 DOI: 10.1007/s11606-014-3025-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)'s national effort to end Veteran homelessness represents an externally focused organizational endeavor. OBJECTIVE Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals. DESIGN This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs). PARTICIPANTS Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012. APPROACH Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM). KEY RESULTS Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation. CONCLUSION Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.
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Ito K, Morikawa S, Okamura T, Shimokado K, Awata S. Factors associated with mental well-being of homeless people in Japan. Psychiatry Clin Neurosci 2014; 68:145-53. [PMID: 24552636 DOI: 10.1111/pcn.12108] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 07/30/2013] [Accepted: 08/04/2013] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to determine the frequency of low mental well-being and associated factors among homeless people in Japan. METHODS A community-based cross-sectional study was conducted. Data were collected through in-person interviews of 423 homeless persons living in two areas of Tokyo. Mental well-being was assessed using the Japanese version of the World Health Organization-Five Well-being Index. RESULTS The overall sample comprised 392 (92.7%) men and 31 (7.3%) women. Average age was 60.6 ± 11.9 years. The mean score on the World Health Organization-Five Well-being Index for the 396 participants with no missing values was 11.81 ± 5.35. Based on a cut-off criterion of 12/13, the frequency of low mental well-being among the participants was 57.1%. In multiple logistic regression analyses, the subjective perception of poor health (odds ratio [OR] = 3.88, 95% confidence interval [CI] = 2.32-6.49), lack of perceived emotional social support (OR = 2.77, 95% CI = 1.70-4.49), dwelling without roof (OR = 2.70, 95% CI = 1.47-4.97), and pain (OR = 1.96, 95% CI = 1.12-3.42) were significantly associated with low mental well-being in this population. CONCLUSION The findings suggest that comprehensive intervention programs that provide supportive housing, emotional social support, and health-care services, may be needed to improve the mental well-being of homeless people.
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Affiliation(s)
- Kae Ito
- Research Team for Promoting Independence of the Elderly, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan; Geriatrics and Vascular Medicine, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
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Lebrun-Harris LA, Baggett TP, Jenkins DM, Sripipatana A, Sharma R, Hayashi AS, Daly CA, Ngo-Metzger Q. Health status and health care experiences among homeless patients in federally supported health centers: findings from the 2009 patient survey. Health Serv Res 2012; 48:992-1017. [PMID: 23134588 DOI: 10.1111/1475-6773.12009] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts. DATA SOURCES/STUDY SETTING Nationally representative data from the 2009 Health Center Patient Survey. STUDY DESIGN Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients' health care experiences. DATA COLLECTION Computer-assisted personal interviews were conducted with health center patients. PRINCIPAL FINDINGS Homeless patients had worse health status-lifetime burden of chronic conditions, mental health problems, and substance use problems-compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24-3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37-2.92). CONCLUSIONS There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.
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Affiliation(s)
- Lydie A Lebrun-Harris
- US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Primary Health Care, Rockville, MD 20857, USA.
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Burra TA, Hwang SW, Rourke SB, Stergiopoulos V. Homeless and Housed Inpatients with Schizophrenia: Disparities in Service Access upon Discharge from Hospital. Int J Ment Health Addict 2012. [DOI: 10.1007/s11469-012-9392-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Dickson-Gomez J, McAuliffe T, Convey M, Weeks M, Owczarzak J. Access to housing subsidies, housing status, drug use and HIV risk among low-income U.S. urban residents. Subst Abuse Treat Prev Policy 2011; 6:31. [PMID: 22112385 PMCID: PMC3283493 DOI: 10.1186/1747-597x-6-31] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 11/23/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Much research has shown an association between homelessness and unstable housing and HIV risk but most has relied on relatively narrow definitions of housing status that preclude a deeper understanding of this relationship. Fewer studies have examined access to housing subsidies and supportive housing programs among low-income populations with different personal characteristics. This paper explores personal characteristics associated with access to housing subsidies and supportive housing, the relationship between personal characteristics and housing status, and the relationship between housing status and sexual risk behaviors among low-income urban residents. METHODS Surveys were conducted with 392 low-income residents from Hartford and East Harford, Connecticut through a targeted sampling plan. We measured personal characteristics (income, education, use of crack, heroin, or cocaine in the last 6 months, receipt of welfare benefits, mental illness diagnosis, arrest, criminal conviction, longest prison term served, and self-reported HIV diagnosis); access to housing subsidies or supportive housing programs; current housing status; and sexual risk behaviors. To answer the aims above, we performed univariate analyses using Chi-square or 2-sided ANOVA's. Those with significance levels above (0.10) were included in multivariate analyses. We performed 2 separate multiple regressions to determine the effects of personal characteristics on access to housing subsidies and access to supportive housing respectively. We used multinomial main effects logistic regression to determine the effects of housing status on sexual risk behavior. RESULTS Being HIV positive or having a mental illness predicted access to housing subsidies and supportive housing, while having a criminal conviction was not related to access to either housing subsidies or supportive housing. Drug use was associated with poorer housing statuses such as living on the street or in a shelter, or temporarily doubling up with friends, acquaintances or sex partners. Living with friends, acquaintances or sex partners was associated with greater sexual risk than those living on the street or in other stable housing situations. CONCLUSIONS Results suggest that providing low-income and supportive housing may be an effective structural HIV prevention intervention, but that the availability and accessibility of these programs must be increased.
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Affiliation(s)
- Julia Dickson-Gomez
- Department of Psychiatry and Behavioral Health, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Avenue, Milwaukee, WI 53202, USA
| | - Timothy McAuliffe
- Department of Psychiatry and Behavioral Health, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Avenue, Milwaukee, WI 53202, USA
| | - Mark Convey
- Institute for Community Researh, 2 Hartford Square West, Suite 100, Harford, CT 06106, USA
| | - Margaret Weeks
- Institute for Community Researh, 2 Hartford Square West, Suite 100, Harford, CT 06106, USA
| | - Jill Owczarzak
- Department of Psychiatry and Behavioral Health, Center for AIDS Intervention Research, Medical College of Wisconsin, 2071 North Summit Avenue, Milwaukee, WI 53202, USA
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