Violence and Emergency Department Use among Community-Recruited Women Who Experience Homelessness and Housing Instability

Examining the Role of Self-Harm in the Relationship between Emergency Department Service Utilization and Trauma-Induced Homelessness among Homeless Individuals in Texas

Homelessness is a complex public health problem in the United States. Current or ongoing history of trauma among individuals adds to the complexity and challenges of homelessness. Our study assessed the moderating role of self-harm in the association between emergency department (ED) service utilization and trauma-induced homelessness (TIH) among adults in Texas. Homeless adults (N = 282) who completed their baseline Vulnerability Index Service Prioritization Decision Assistance Prescreen Tool survey between February 2021 and February 2022 at a Local Mental Health Authority in Texas were selected. The outcome variable, TIH, was assessed by current period of homelessness due to experiencing trauma or abuse. The main independent variable was ED utilization, while self-harm in the past year was assessed as the moderating variable. A multivariate logistic regression with a moderation analysis was conducted while adjusting for the covariates. Individuals who utilized ED services and engaged in self-harm and risky behaviors had greater odds of experiencing current period of TIH. Male respondents were less likely to experience TIH. Finally, engaging in self-harm significantly moderated the association between ED service use and TIH. This study may help inform efforts to develop tailored interventions and promote resilience-based approaches to improve health outcomes among individuals experiencing homelessness due to TIH.

Health Care of People Experiencing Homelessness: Part I

Homelessness and Health CarePeople who experience homelessness have high rates of medical illness. They struggle with conditions associated with living in crowded shelters, trauma, and exposure to extreme weather. Here, Taylor and Munson review the care of this vulnerable population.

Trends, Characteristics, and Maternal Morbidity Associated With Unhoused Status in Pregnancy

Importance

Unhoused status is a substantial problem in the US. Pregnancy characteristics and maternal outcomes of individuals experiencing homelessness are currently under active investigation to optimize health outcomes for this population.

Objective

To assess the trends, characteristics, and maternal outcomes associated with unhoused status in pregnancy.

Design, Setting, and Participants

This cross-sectional study analyzed data from the Healthcare Cost and Utilization Project National (Nationwide) Inpatient Sample. The study population included hospitalizations for vaginal and cesarean deliveries from January 1, 2016, to December 31, 2020. Unhoused status of these patients was identified from use of International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code Z59.0. Statistical analysis was conducted from December 2022 to June 2023.

Main Outcomes and Measures

Primary outcomes were (1) temporal trends; (2) patient and pregnancy characteristics associated with unhoused status, which were assessed with a multivariable logistic regression model; (3) delivery outcomes, including severe maternal morbidity (SMM) and mortality at delivery, which used the Centers for Disease Control and Prevention definition for SMM indicators and were assessed with a propensity score-adjusted model; and (4) choice of long-acting reversible contraception method and surgical sterilization at delivery.

Results

A total of 18 076 440 hospital deliveries were included, of which 18 970 involved pregnant patients who were experiencing homelessness at the time of delivery, for a prevalence rate of 104.9 per 100 000 hospital deliveries. These patients had a median (IQR) age of 29 (25-33) years. The prevalence of unhoused patients increased by 72.1% over a 5-year period from 76.1 in 2016 to 131.0 in 2020 per 100 000 deliveries (P for trend < .001). This association remained independent in multivariable analysis. In addition, (1) substance use disorder (tobacco, illicit drugs, and alcohol use disorder), (2) mental health conditions (schizophrenia, bipolar, depressive, and anxiety disorders, including suicidal ideation and past suicide attempt), (3) infectious diseases (hepatitis, gonorrhea, syphilis, herpes, and COVID-19), (4) patient characteristics (Black and Native American race and ethnicity, younger and older age, low or unknown household income, obesity, pregestational hypertension, pregestational diabetes, and asthma), and (5) pregnancy characteristics (prior uterine scar, excess weight gain during pregnancy, and preeclampsia) were associated with unhoused status in pregnancy. Unhoused status was associated with extreme preterm delivery (<28-week gestation: 34.3 vs 10.8 per 1000 deliveries; adjusted odds ratio [AOR], 2.76 [95% CI, 2.55-2.99]); SMM at in-hospital delivery (any morbidity: 53.8 vs 17.7 per 1000 deliveries; AOR, 2.30 [95% CI, 2.15-2.45]); and in-hospital mortality (0.8 vs <0.1 per 1000 deliveries; AOR, 10.17 [95% CI, 6.10-16.94]), including case fatality risk after SMM (1.5% vs 0.3%; AOR, 4.46 [95% CI, 2.67-7.45]). Individual morbidity indicators associated with unhoused status included cardiac arrest (AOR, 12.43; 95% CI, 8.66-17.85), cardiac rhythm conversion (AOR, 6.62; 95% CI, 3.98-11.01), ventilation (AOR, 6.24; 95% CI, 5.03-7.74), and sepsis (AOR, 5.37; 95% CI, 4.53-6.36).

Conclusions and Relevance

Results of this national cross-sectional study suggest that unhoused status in pregnancy gradually increased in the US during the 5-year study period and that pregnant patients with unhoused status were a high-risk pregnancy group.

Injury Patterns and Hospital Admission After Trauma Among People Experiencing Homelessness

Importance

Traumatic injury is a major cause of morbidity for people experiencing homelessness (PEH). However, injury patterns and subsequent hospitalization among PEH have not been studied on a national scale.

Objective

To evaluate whether differences in mechanisms of injury exist between PEH and housed trauma patients in North America and whether the lack of housing is associated with increased adjusted odds of hospital admission.

Design, Setting, and Participants

This was a retrospective observational cohort study of participants in the 2017 to 2018 American College of Surgeons' Trauma Quality Improvement Program. Hospitals across the US and Canada were queried. Participants were patients aged 18 years or older presenting to an emergency department after injury. Data were analyzed from December 2021 to November 2022.

Exposures

PEH were identified using the Trauma Quality Improvement Program's alternate home residence variable.

Main Outcomes and Measures

The primary outcome was hospital admission. Subgroup analysis was used to compared PEH with low-income housed patients (defined by Medicaid enrollment).

Results

A total of 1 738 992 patients (mean [SD] age, 53.6 [21.2] years; 712 120 [41.0%] female; 97 910 [5.9%] Hispanic, 227 638 [13.7%] non-Hispanic Black, and 1 157 950 [69.6%] non-Hispanic White) presented to 790 hospitals with trauma, including 12 266 PEH (0.7%) and 1 726 726 housed patients (99.3%). Compared with housed patients, PEH were younger (mean [SD] age, 45.2 [13.6] years vs 53.7 [21.3] years), more often male (10 343 patients [84.3%] vs 1 016 310 patients [58.9%]), and had higher rates of behavioral comorbidity (2884 patients [23.5%] vs 191 425 patients [11.1%]). PEH sustained different injury patterns, including higher proportions of injuries due to assault (4417 patients [36.0%] vs 165 666 patients [9.6%]), pedestrian-strike (1891 patients [15.4%] vs 55 533 patients [3.2%]), and head injury (8041 patients [65.6%] vs 851 823 patients [49.3%]), compared with housed patients. On multivariable analysis, PEH experienced increased adjusted odds of hospitalization (adjusted odds ratio [aOR], 1.33; 95% CI, 1.24-1.43) compared with housed patients. The association of lacking housing with hospital admission persisted on subgroup comparison of PEH with low-income housed patients (aOR, 1.10; 95% CI, 1.03-1.19).

Conclusions and Relevance

Injured PEH had significantly greater adjusted odds of hospital admission. These findings suggest that tailored programs for PEH are needed to prevent their injury patterns and facilitate safe discharge after injury.

Housing Instability and Evictions Linked to Elevated Intimate Partner and Workplace Violence Among Women Sex Workers in Vancouver, Canada: Findings of a Prospective, Community-Based Cohort, 2010-2019

Objectives. To model the relationship of unstable housing and evictions with physical and sexual violence perpetrated against women sex workers in intimate and workplace settings. Methods. We used bivariate and multivariable logistic regression with generalized estimating equations to model the association of unstable housing exposure and evictions with intimate partner violence (IPV) and workplace violence among a community-based longitudinal cohort of cisgender and transgender women sex workers in Vancouver, Canada, from 2010 through 2019. Results. Of 946 women, 85.9% experienced unstable housing, 11.1% eviction, 26.2% IPV, and 31.8% workplace violence. In multivariable generalized estimating equation models, recent exposure to unstable housing (adjusted odds ratio [AOR] = 2.04; 95% confidence interval [CI] = 1.45, 2.87) and evictions (AOR = 2.45; 95% CI = 0.99, 6.07) were associated with IPV, and exposure to unstable housing was associated with workplace violence (AOR = 1.46; 95% CI = 1.06, 2.00). Conclusions. Women sex workers face a high burden of unstable housing and evictions, which are linked to increased odds of intimate partner and workplace violence. Increased access to safe, women-centered, and nondiscriminatory housing is urgently needed. (Am J Public Health. 2023;113(4):442-452. https://doi.org/10.2105/AJPH.2022.307207).

Preexisting Mental Health Illness Among Victims of Sexual Assault: Case Studies to Inform Sexual Assault Nurse Examiner Practice

BACKGROUND

Sexual assault is a pervasive problem associated with negative long- and short-term consequences related to mental health consequences, educational function, physical health, and sexual and relationship functioning. People with mental illness, particularly those with psychotic disorders, have a significantly higher risk of becoming victims of violence compared with the general population.

METHODS

Three case studies of women with preexisting mental health problems who were sexually assaulted and requested a sexual assault examination are presented. These cases illustrate common mental health problems, how mental health problems can be associated with an increased risk for sexual assault, and things the sexual assault nurse examiner (SANE) should consider in the care and treatment of these patients.

RESULTS

These cases illustrate important ideas regarding the care of people who have been sexually assaulted: prioritizing safety, ethical issues related to consent, the importance of empathetic communication, and the need for SANEs to expand their knowledge to improve care of patients with mental health disorders.

DISCUSSION

Being sexually assaulted can contribute to destabilization, prolongation, and exacerbation of existing mental illness, placing patients at an increased risk for sexual assault, beginning a vicious cycle of mental illness and violence. Working effectively with the interdisciplinary team, the SANE can help break this devastating cycle of violence.

Association of Social Needs and Housing Status Among Urban Emergency Department Patients

Introduction

People experiencing homelessness have high rates of social needs when presenting for emergency department (ED) services, but less is known about patients with housing instability who do not meet the established definitions of homelessness.

Methods

We surveyed patients in an urban, safety-net ED from June–August 2018. Patients completed two social needs screening tools and responded to additional questions on housing. Housing status was determined using validated questions about housing stability.

Results

Of the 1,263 eligible patients, 758 (60.0%) completed the survey. Among respondents, 40% identified as Latinx, 39% Black, 15% White, 5% Asian, and 8% other race/ethnicities. The median age was 42 years (interquartile range [IQR]: 29–57). and 54% were male. Of the 758 patients who completed the survey, 281 (37.1%) were housed, 213 (28.1%) were unstably housed, and 264 (34.8%) were homeless. A disproportionate number of patients experiencing homelessness were male (63.3%) and Black (54.2%), P <0.001, and a disproportionate number of unstably housed patients were Latinx (56.8%) or were primarily Spanish speaking (49.3%), P <0.001. Social needs increased across the spectrum of housing from housed to unstably housed and homeless, even when controlling for demographic characteristics.

Conclusion

Over one in three ED patients experience homelessness, and nearly one in three are unstably housed. Notable disparities exist by housing status, and there is a clear increase of social needs across the housing spectrum. Emergency departments should consider integrating social screening tools for patients with unstable housing.

Attention to Women's Sexual and Reproductive Health at the Street Outreach Office

The aim of study was to understand care strategies for homeless women, focusing on aspects of sexual and reproductive health from the perspective of Street Outreach Office strategy professionals. This is a qualitative study carried out in a large city in the countryside of São Paulo, Brazil. Data were collected from December 2020 to April 2021 through semi-structured interviews, and the results were obtained through content analysis and thematic modality. Nine health professionals participated in this study, and the analysis of the interviews allowed identifying three thematic categories: (i) being female and sex on the streets (violence and oppression); (ii) gynecology as a gateway to comprehensive care for homeless women; and (iii) pregnancy, puerperium and motherhood in the context of the streets. This study contributes to the reflection of professional practices within the Street Outreach Office, allowing the understanding of challenges in assisting homeless women, aiming to raise awareness of professionals and services that make up the health care network.

Emergency Department Use by Women Experiencing Homelessness in Los Angeles, California, USA

Background:

This article reports on the use of hospital Emergency Departments (EDs) in women experiencing homelessness in Los Angeles, California. Women 18 years of age or older were recruited from homeless day centers in Los Angeles to participate in this study.

Materials and Methods:

A self-report questionnaire on health status, demographics, and emergency service use was completed by study participants.

Results:

In this study of women experiencing homelessness, 64% utilized the ED within the past year. The mean number of ED use was 3.63 (range 0–20) visits in the past year. Higher frequency visits were significantly associated with several mental health conditions (p = 0.016), physical disability (p = 0.001), and traumatic brain injury (p = 0.013).

Conclusions:

The physical and psychological impacts of the homelessness experience can be enormous, affecting the homeless individually and collectively. Study findings may help to understand how to improve services that support and meet the needs of women experiencing homelessness such as patient and family-centered care and trauma-informed care in the ED.

A Scoping Review of Current Social Emergency Medicine Research

INTRODUCTION

Social emergency medicine (EM) is an emerging field that examines the intersection of emergency care and social factors that influence health outcomes. We conducted a scoping review to explore the breadth and content of existing research pertaining to social EM to identify potential areas where future social EM research efforts should be directed.

METHODS

We conducted a comprehensive PubMed search using Medical Subject Heading terms and phrases pertaining to social EM topic areas (e.g., "homelessness," "housing instability") based on previously published expert consensus. For searches that yielded fewer than 100 total publications, we used the PubMed "similar publications" tool to expand the search and ensure no relevant publications were missed. Studies were independently abstracted by two investigators and classified as relevant if they were conducted in US or Canadian emergency departments (ED). We classified relevant publications by study design type (observational or interventional research, systematic review, or commentary), publication site, and year. Discrepancies in relevant publications or classification were reviewed by a third investigator.

RESULTS

Our search strategy yielded 1,571 publications, of which 590 (38%) were relevant to social EM; among relevant publications, 58 (10%) were interventional studies, 410 (69%) were observational studies, 26 (4%) were systematic reviews, and 96 (16%) were commentaries. The majority (68%) of studies were published between 2010-2020. Firearm research and lesbian, gay, bisexual, transgender, and queer (LGBTQ) health research in particular grew rapidly over the last five years. The human trafficking topic area had the highest percentage (21%) of interventional studies. A significant portion of publications -- as high as 42% in the firearm violence topic area - included observational data or interventions related to children or the pediatric ED. Areas with more search results often included many publications describing disparities known to predispose ED patients to adverse outcomes (e.g., socioeconomic or racial disparities), or the influence of social determinants on ED utilization.

CONCLUSION

Social emergency medicine research has been growing over the past 10 years, although areas such as firearm violence and LGBTQ health have had more research activity than other topics. The field would benefit from a consensus-driven research agenda.

Non-beverage alcohol consumption among individuals experiencing chronic homelessness in Edmonton, Canada: a cross-sectional study

BACKGROUND

Among individuals experiencing homelessness, the prevalence of alcohol use disorder is extremely high. Alcohol-related harms are compounded by the use of non-beverage alcohol (NBA; e.g. rubbing alcohol, cooking wine). The dangers of NBA consumption pose significant risks to the individual and to others when consumed in large quantities and when mixed with other substances. The objectives of this paper are to describe the alcohol consumption patterns of individuals experiencing homelessness, identify substance use patterns, psychological stressors, and related harms associated with NBA consumption, and compare NBA consumers to non-NBA consumers in relation to their use of services and perceived barriers to care.

METHODS

Using a cross-sectional survey, 150 individuals experiencing homelessness were recruited from Edmonton's inner city and adjoining areas. Frequency, quantity, and volume of alcohol consumption were used to assess patterns of alcohol use in the last 6 months. Descriptive statistics and bivariate analyses were used to compare participants reporting NBA consumption and non-NBA consumption (p ≤ 0.05).

RESULTS

The majority of participants were male (71.3%) and self-identified as Indigenous (74.0%). Overall, 24% (n = 36) reported NBA consumption within the last six months. NBA consumers were older than non-NBA consumers (p = 0.005), reported different perceived living stability (p = 0.022), and had higher psychological distress (p = 0.038). The majority of NBA consumers reported not receiving harm reduction services while also not needing such services (n = 18, 51.4%), which differed from non-NBA consumers (p = 0.003). Structural barriers (e.g. availability, location, cost) were most frequently reported as reasons for unmet harm reduction (60.9%) and hospital care (58.3%) needs, while barriers to skills training (58.5%) and counselling services (53.6%) were mostly motivational (e.g. personal beliefs).

CONCLUSIONS

Within such an already marginalized population experiencing homelessness, individuals who consume NBA represent a vulnerable subpopulation who require adapted and distinct health and social services to stabilize and recover. Current harm reduction services are not prepared to effectively assist this group of individuals, and specific treatment programs are rare. Managed alcohol programs are a feasible approach but must be tailored to the specific needs of those who consume NBA, which is especially important for Indigenous people. More comprehensive assessments of NBA consumption are needed for program development and policy recommendations.

Gun violence against unhoused and unstably housed women: A cross-sectional study that highlights links to childhood violence

Background

Unstably housed women experience high levels of violence. While previous studies have investigated psychological, physical, and sexual violence, weapon and gun violence are rarely delineated. We examined factors associated with experiencing violence as an adult among unhoused and unstably housed women, with a focus on gun violence.

Methods

We recruited women with a history of housing instability from San Francisco homeless shelters, street encampments, free meal programs, low-income hotels, and health clinics. Participants completed interviews including questions regarding both childhood and adult violence. We used multivariable logistic regression to examine associations of specific types of childhood violence (i.e., physical, sexual, gun, other weapon-involved violence), age, race, ethnicity, educational attainment, and sexual orientation, with risk of experiencing specific types of violence as an adult (i.e., gun, other weapon-involved, physical violence). Because the violence outcomes were not rare, odds ratios were transformed to approximate risk ratios.

Results

Nearly half of women (n = 110, 45%) had been attacked with a gun as an adult. Violent victimization in adulthood was common, with 33% having experienced all three forms of violence. The probability of being attacked with a gun as an adult was almost 70% higher among women who had been hit or kicked hard enough to cause injury as a child (RR = 1.68; 95% CI = 1.24, 2.11), and this association was present for all three violence outcomes. No other risk factors explored, including other types of violence experienced as a child, met the statistical threshold to be considered significant.

Conclusions

The high prevalence of gun violence reported here is consistent with prior studies of violence conducted in similar populations. Considered in combination with prior research, findings suggest multi-generational violence prevention interventions for low-income women and girls are needed. They also emphasize the need to more actively include people who experience unstable housing in statewide and national violence surveys to better understand the extent of the problem and address on a broader scale the high rates of violence experienced by unstably housed populations, which have been consistently documented in local research.

Media framing of emergency departments: a call to action for nurses and other health care providers

BACKGROUND

As part of a larger study focused on interventions to enhance the capacity of nurses and other health care workers to provide equity-oriented care in emergency departments (EDs), we conducted an analysis of news media related to three EDs. The purpose of the analysis was to examine how media writers frame issues pertaining to nursing, as well as the health and social inequities that drive emergency department contexts, while considering what implications these portrayals hold for nursing practice.

METHODS

We conducted a search of media articles specific to three EDs in Canada, published between January 1, 2018 and May 1, 2019. Media items (N = 368) were coded by story and theme attributes. A thematic analysis was completed to understand how writers in public media present issues pertaining to nursing practice within the ED context.

RESULTS

Two overarching themes were found. First, in ED-related media that portrays health care needs of people experiencing health and social inequities, messaging frequently perpetuates stigmatizing discourses. Second, media writers portray pressures experienced by nurses working in the ED in a way that evades structural determinants of quality of care. Underlying both themes is an absence of perspectives and authorship from practicing nurses themselves.

CONCLUSIONS

We recommend that frontline nurses be prioritized as experts in public media communications. Nurses must be supported to gain critical media skills to contribute to media, to destigmatize the health care needs of people experiencing inequity who attend their practice, and to shed light on the structural causes of pressures experienced by nurses working within emergency department settings.

Is homelessness a traumatic event? Results from the 2019-2020 National Health and Resilience in Veterans Study

METHODS

Data from a nationally representative sample of 4,069 U.S. veterans in 2019-2020 were used to examine the prevalence of full and subthreshold PTSD in veterans with a history of homelessness; identify characteristics associated with PTSD; examine the proportion of veterans who reported homelessness as an index trauma event and screened positive for PTSD.

RESULTS

Among veterans with a history of homelessness, lifetime prevalence of full and subthreshold PTSD was 33.0% and 32.0%; and past-month prevalence of full and subthreshold PTSD was 5.6% and 12.7%. These prevalence estimates were more than five times higher than nonhomeless veterans. Among veterans with a history of homelessness, 14.1% reported that homelessness was their "worst" traumatic event which was associated with a fivefold greater odds of current PTSD and nearly threefold greater odds of subthreshold PTSD even after adjustment for other trauma exposures.

CONCLUSIONS

Veterans who have been homeless have extensive trauma histories and both events that occur during homelessness and the experience of homelessness itself may be traumatic and lead to PTSD, substantiating efforts to provide trauma-informed care for this population.