Proof of concept of a sexual health outreach program led by community health workers in homeless hostels in the greater Paris region

Context

Homeless individuals face exacerbated risks of infectious diseases, including sexually transmitted infections (STIs). Programs led by Community Health Workers (CHWs) have demonstrated potential to enhance healthcare access for marginalized groups such as homeless families. This study aims to evaluate the feasibility and effectiveness of a novel CHW-based outreach program addressing sexual health issues among individuals residing in homeless hostels.

Methods

Twelve social homeless hostels in the greater Paris region were selected as program implementation sites. An outreach program was developed consisting of two interventions: sexual health workshops and STI screening sessions (HIV and hepatitis B and C) accompanied by individual interviews, both conducted by CHWs within each hostel over an 8-week period and scheduled weekly. Feasibility, participation and engagement were evaluated using complementary methods including qualitative field observations, semi-structured interviews and focus groups with CHWs, satisfaction questionnaires for participants, and quantitative outcome data collection of each intervention.

Results

A total of 80 program activities (workshops and screening sessions) were conducted. Among the participants, 542 women and 30 men engaged in workshops. During the 30 Rapid Diagnostic Testing sessions, 150 individuals underwent testing for HIV, hepatitis B, and/or hepatitis C. Positivity rates were 6.7% for hepatitis B and 0.9% for hepatitis C. No HIV infections were detected. Participant satisfaction rates were consistently high (>76%) across workshops. Qualitative analysis unveiled two critical axes influencing program feasibility and effectiveness: program organization and CHW involvement.

Discussion

This assessment of the program highlights its feasibility among a population that is difficult to reach through conventional healthcare efforts. The intervention's potential effectiveness is suggested by self- and CHW-reported improvements in sexual health literacy and high rates of referral to the healthcare system, as well as holistic well-being considerations. CHW involvement is a vital determinant of program success, as are robust coordination among stakeholders, deep understanding of the target population, and strong partner engagement.

Conclusion

This outreach program amplifies the voices of often-overlooked populations while empowering them to navigate health and social challenges. Although these workshops serve as lifelines for those frequently excluded from mainstream services, long-term improvements to the health and wellbeing of homeless populations will necessitate systemic governmental intervention.

Social patterning of childhood overweight in the French national ELFE cohort

An inverse social gradient in early childhood overweight has been consistently described in high-income countries; however, less is known about the role of migration status. We studied the social patterning of overweight in preschool children according to the mother's socio-economic and migration background. For 9250 children of the French ELFE birth cohort with body mass index collected at age 3.5 years, we used nested logistic regression to investigate the association of overweight status in children with maternal educational level, occupation, household income and migration status. Overall, 8.3% (95%CI [7.7-9.0]) of children were classified as overweight. The odds of overweight was increased for children from immigrant mothers (OR 2.22 [95% CI 1.75-2.78]) and descendants of immigrant mothers (OR 1.35 [1.04-2.78]) versus non-immigrant mothers. The highest odds of overweight was also observed in children whose mothers had low education, were unemployed or students, or were from households in the lowest income quintile. Our findings confirm that socio-economic disadvantage and migration status are risk factors for childhood overweight. However, the social patterning of overweight did not apply uniformly to all variables. These new and comprehensive insights should inform future public health interventions aimed at tackling social inequalities in childhood overweight.

Evaluating a Public Health Information Service According to Users' Socioeconomic Position and Health Status: Protocol for a Cross-Sectional Study

BACKGROUND

The increasing use of information technology in the field of health is supposed to promote users' empowerment but can also reinforce social inequalities. Some health authorities in various countries have developed mechanisms to offer accurate and relevant information to health care system users, often through health websites. However, the evaluation of these sociotechnical tools is inadequate, particularly with respect to differences and inequalities in use by social groups.

OBJECTIVE

Our study aims to evaluate the access, understanding, appraisal, and use of the French website Santé.fr by users according to their socioeconomic position and perceived health status.

METHODS

This cross-sectional study involves the entire French population to which Santé.fr is offered. Data will be collected through mixed methods, including a web-based questionnaire for quantitative data and interviews and focus groups for qualitative data. Collected data will cover users' access, understanding, appraisal, and use of Santé.fr, as well as sociodemographic and socioeconomic characteristics, health status, and digital health literacy. A validation of the dimensions of access, understanding, appraisal, and use of Santé.fr will be conducted, followed by principal component analysis and ascendant hierarchical classification based on the 2 main components of principal component analysis to characterize homogeneous users' profiles. Regression models will be used to investigate the relationships between each dimension and socioeconomic position and health status variables. NVivo 11 software (Lumivero) will be used to categorize interviewees' comments into preidentified themes or themes emerging from the discourse and compare them with the comments of various types of interviewees to understand the factors influencing people's access, understanding, appraisal, and use of Santé.fr.

RESULTS

Recruitment is scheduled to begin in January 2024 and will conclude when the required number of participants is reached. Data collection is expected to be finalized approximately 7 months after recruitment, with the final data analysis programmed to be completed around December 2024.

CONCLUSIONS

This study would be the first in France and in Europe to evaluate a public health information service, in this case the Santé.fr website (the official website of the French Ministry of Health), according to users' socioeconomic position and health status. The study could discover issues related to inequalities in access to, and the use of, digital technologies for obtaining health information on the internet. Given that access to health information on the internet is crucial for health decision-making and empowerment, inequalities in access may have subsequent consequences on health inequalities among social categories. Therefore, it is important to ensure that all social categories have access to Santé.fr.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/51123.

Is breastfeeding duration related to the health of migrant mother-child dyads experiencing homelessness? The ENFAMS cross-sectional survey

BACKGROUND

Literature from the general population shows a consensus about the health benefits associated with breastfeeding for both mothers and children. However, studies investigating these issues in the context of homelessness and migration are rare. This research aimed to examine the relations of any breastfeeding duration with health outcomes among migrant mother-child dyads experiencing homelessness.

METHODS

Data were collected among sheltered and mainly foreign-born mothers experiencing homelessness, and their children aged 6 months to 5 years, from the ENFAMS cross-sectional survey (n = 481, 2013-Great Paris area). Any breastfeeding duration, along with various health outcomes of both the mother and her child, was ascertained by face-to-face questionnaires administered by trained interviewers to mothers (perceived physical and emotional health and maternal depression) or by trained psychologists to children (adaptive behaviours). Nurses measured weight and height [thus allowing them to calculate body mass index (BMI)] and haemoglobin concentration (mother-child dyad) and maternal blood pressure. Multivariable linear and modified Poisson regression analyses were performed to examine outcome-wide associations between any breastfeeding duration ≥6 months and the various mother-child outcomes.

RESULTS

Any breastfeeding ≥6 months was associated with lower systolic blood pressure in mothers (B = -0.40, 95% confidence interval = -0.68 to -0.12). No association was observed with the other outcomes.

CONCLUSIONS

The relevance of supporting breastfeeding to improve mothers' physical health holds true in the context of migration and homelessness. It is therefore important to support breastfeeding in these settings. Moreover, given the documented social complexity of breastfeeding practices, interventions should take mothers' socio-cultural heritage and the structural barriers they face into account.

[Relevance of the transcultural approach to improve the care relationship in the perinatal period]

The international literature review highlights higher neonatal morbimortality in migrant patients and their babies. The explanatory hypotheses include late pregnancy follow-up with difficulty accessing care, language barriers, and different cultural representation in pregnancy support. On the one hand, we propose to explain the cultural factors that can impact the caring relationship during the perinatal period. On the other hand, we set out tools for anthropological and psychological understanding to enhance the sharing of cultural representations around pregnancy follow-up, the needs of a baby, and obstetrical or postnatal complications. The request for a specialised transcultural opinion needs to be more systematic; the transcultural posture is adaptable to each care professional. This requires the professional to address explicitly the impact of culture in care and consider their own cultural distance. Specialised advice is recommended in certain situations of cumulative vulnerability (complex trauma, perinatal depression with cultural coding of symptoms), blockage or refusal of care for cultural reasons and to avoid cultural misunderstandings. We detail two modalities: mediation and a discussion group around cultural issues set up in the maternity ward. The institutional work we propose within the multidisciplinary team in the maternity ward also allows the acquisition of transcultural competencies.

Voices of women in homelessness during the outbreak of the COVID-19 pandemic: a co-created qualitative study

BACKGROUND

Women in homelessness face extreme health- and social inequities. It could be postulated that during societal crises, they become even more vulnerable. Thus, the aim was to explore experiences related to the COVID-19 pandemic among women in homelessness.

METHODS

Ten interviews were conducted with women in homelessness, in Stockholm, Sweden, using researcher-driven photo elicitation. The data analysis was guided by the DEPICT model for collaborative data analysis and a qualitative content analysis was performed. A collaborative reference group of women with lived experience of homelessness contributed to the research process through designing the data collection, performing the data analysis, and providing feedback during report writing.

RESULTS

For women in homelessness, the COVID-19 pandemic was adding insult to injury, as it significantly affected everyday life and permeated most aspects of existence, leading to diminished interactions with others and reduced societal support. Thus, in an already dire situation, the virus amplified health- and social issues to another level. The women strived to find their balance on the shifting sands of guidelines and restrictions due to the pandemic. Adhering to the new social distancing rules and guidelines in line with the rest of society, was simply impossible when experiencing homelessness. However, for some women the pandemic was nothing but a storm in a teacup. The harsh reality continued irrespectively, living one day at a time and prioritizing provision for basic human needs.

CONCLUSIONS

The COVID-19 pandemic and homelessness can be viewed as two intersecting crises. However, the women's aggregated experiences were greater than the sum of experiencing homelessness and meeting the threat of the virus. Gender, exposure to violence, poverty, social isolation, and substance use were additional factors that further marginalized the women during the pandemic. To rebuild a better and more sustainable post-pandemic future for all, global commitment to ending homelessness is crucial. In addition, addressing social determinants of health must be the number one health intervention.

Transcultural skills for early childhood professionals

Context

Transcultural skills are especially useful for those involved in the perinatal period, when parents and babies must adapt to one another in a setting of migration a long a focus of transcultural clinical practice.

Objective

The aim of this article is to provide useful transcultural skills for any health care worker (e.g., psychologists, child psychiatrists, midwives, family doctors, pediatricians, specialized child-care attendants, and social workers) who provide care or support to families during the perinatal period. It highlights the cultural aspects requiring attention in relation to representations of pregnancy, children's needs, obstetric complications, and postnatal problems. Taking into account the impact of culture on clinical evaluation and treatment can enable professionals to distinguish what involves cultural representations of pregnancy, babies, and sometimes of disease from what is associated with interaction disorders or maternal psychopathology.

Methods

After explaining the relevance of transcultural clinical practices to provide migrant mothers with better support, we describe 9 themes useful to explore from a transcultural perspective. This choice is based on the transcultural clinical practice in our specialized department.

Results

The description of these 9 themes is intended to aid in their pragmatic application and is illustrated with short clinical vignettes for specific concepts. We describe situations that are extreme but often encountered in liaison transcultural clinical practice for maternity wards: perinatal mourning with cultural coding, mediation in refusal of care, cultural misunderstandings, situations of complex trauma and of multiple contextual vulnerabilities, and difficulties associated with acculturation.

Discussion

The transcultural levers described here make it possible to limit cultural misunderstandings and to promote the therapeutic alliance. It presupposes the professionals will concomitantly analyze their cultural countertransference and acquire both the knowledge and know-how needed to understand the elements of cultural, political, and social issues needed to develop clinical finesse.

Conclusion

This combined theoretical-clinical article is intended to be pedagogical. It provides guidelines for conducting transcultural child psychiatry/psychological interviews in the perinatal period aimed at both assessment and therapy.

Social determinants of inadequate prenatal care utilization in sheltered homeless mothers in the Greater Paris area in France

Background

Sheltered homeless families suffer from deleterious living conditions such as housing instability (i.e., moving from one shelter to another) that could be an additional barrier to healthcare utilization. Few studies have specifically examined perinatal health in homeless mothers and their utilization of prenatal healthcare. This study aimed to identify social determinants such as living conditions (i.e., housing instability) associated with inadequate prenatal care utilization (PCU) in sheltered homeless mothers in the Greater Paris area in France.

Methods

The homeless children and families cross-sectional survey [ENFAMS: (Enfants et familles sans logement)] was performed on a random representative sample of homeless families living in shelters in the greater Paris area in 2013. Following French guidelines, PCU was deemed inadequate if one or more of the following criteria was met: attending fewer than 50% of recommended prenatal visits, PCU initiation after the first trimester of pregnancy, and fewer than three ultrasounds during the entire pregnancy. Families were interviewed in 17 languages by trained peer interviewers in face-to-face interviews. Structural equation modeling was used to identify factors associated with inadequate PCU and to estimate correlations between them.

Results

This study analyzed data on 121 homeless sheltered mothers who had at least one child less than one year old. They were socially disadvantaged and most were born outside France. One in five (19.3%) had inadequate PCU. Associated factors were socio-demographic characteristics (young age, primiparous), health status (dissatisfaction with self-perceived general health), and living conditions (housing instability in the second and third trimesters).

Conclusion

It is essential to reduce housing instability to help sheltered mothers to benefit from social, territorial and medical support and healthcare utilization. Housing stability for pregnant sheltered homeless mothers should be a priority to ensure better PCU and guarantee the newborn's health as much as possible.

Lifestyle Patterns of Children Experiencing Homelessness: Family Socio-Ecological Correlates and Links with Physical and Mental Health

Diet, screen time, physical activity, and sleep combine into lifestyle patterns with synergistic effects on health. This study aimed to identify lifestyle patterns in children without housing and assess their associations with physical and mental health and family socio-ecological factors. In the 2013 ENFAMS cross-sectional survey (children aged 6-12 experiencing homelessness, Greater Paris area, n = 235), parents reported socio-ecological factors, children's behaviours, and mental health (the latter was also child-reported). Nurses measured children's haemoglobin concentrations and body mass index. Principal component analysis was used to derive sex-specific lifestyle patterns. Hierarchical linear regressions and "outcome-wide" analyses assessed, respectively, these patterns' relations to health and family socio-ecological factors. A rather healthy lifestyle pattern-similarly characterized by diverse diet and high sleep time-was identified, with slight differences by sex. Scores for this pattern were higher for children in food-secure or higher-income households, whose parents were proficient in French, who slept longer, or who received more social support compared to their counterparts, with some nuances by sex. Higher scores for this pattern were associated with higher prosocial behaviour scores (girls) and lower anxiety and hyperactivity-inattention symptoms scores (boys), but not with physical health. For this underserved and understudied population, the results highlight the importance of family socio-ecological factors in shaping the lifestyles and mental health of children.

Therapeutic alliance impact on analgesic outcomes in a real-world clinical setting: An observational study

A good therapeutic alliance is relevant for healthcare providers exposed to patients' suffering, especially since patients and physicians may understand the painful experience differently. Our aim was to explore the impact of therapeutic alliance on analgesic outcomes in a real-world interdisciplinary pain unit (PU). A cross-sectional observational study was conducted on outpatients (n = 69) using opioids on a long-term basis for the treatment of chronic non-cancer pain, where clinical pharmacologists and pharmacists advised patients about their opioid treatment. Responses to the patient-doctor relationship questionnaire (PDRQ), sociodemographic and clinical information (pain level, quality of life and hospital use) were collected, whereas pharmacology data (analgesic prescription, adverse events, and compliance) were obtained from electronic health records. Patients were predominantly middle-aged (75 % women, 72 % retired), experiencing moderate pain (VAS 40-70 mm) on average, and under a high morphine equianalgesic dosage (95 ± 88 mg per day, mainly tapentadol or fentanyl). Patients with better PDRQ outcomes, and therefore better therapeutic alliance, showed lower pain intensity than patients with worse PDRQ outcomes (pain intensity: high scores 60 ± 47 mm and medium scores 60 ± 45 mm vs. low scores 80 ± 75 mm, p < 0.01). Along with this, pain intensity was lower when patients affirmed that, thanks to the health-care providers, they "gained new insight", "felt better", or "felt content with their doctor's treatment". What´s more, patients who affirmed "I benefit from the treatment" experienced increased pain relief (benefit 40 ± 30 vs. non-benefit 19 ± 26 mm, p = 0.010) and improved quality of life (benefit 33 ± 25 vs. non-benefit 18 ± 16 mm, p = 0.031). However, there was a percentage of patients who did not fully understand the provided information, which is something to be taken into account to improve in clinical routine. Therapeutic alliance supported by pharmacist experts on pain management can be an effective strategy to improve analgesic outcomes. Further efforts are needed to improve communication strategies for pain management. Future directions of research should include the analysis of the role of the pharmacist in poly-professional consultations as related to the advice of patients about their medication, and the mutual trust with the patients.

Heterogeneity among Homeless Australian Women and Their Reasons for Homelessness Entry

Many women become homeless each year, both women who are alone and women with children. Both groups face substantial risks to their physical and mental health, as do the children of homeless mothers. Little is known about the similarities and differences between these two groups in terms of their demographic characteristics, their circumstances on presentation to specialist homelessness services, and the factors that have contributed to their homelessness. The current study analysed data from 163 single mothers with children and 126 lone women who presented to a specialist homelessness service in Australia. It found some similarities between groups, but also considerable heterogeneity. Single mothers were more likely to be younger, to have been born overseas, and to have been homeless in the past 12 months. Lone women were more likely to have medical issues, a mental health condition, addiction issues, admission to a psychiatric ward in the past 12 months, and to not be in the labour force. Implications for service delivery are discussed.

Emergency department utilisation by homeless children in Dublin, Ireland: a retrospective review

INTRODUCTION

Despite increasing prevalence, European family homelessness remains under-researched.

METHODS

A retrospective review was performed of homeless children attending a paediatric emergency department in Dublin, Ireland, from 1 January 2017 to 31 December 2020. Comparison was made with a random cohort of 1500 non-homeless paediatric attendances in 2019. Homelessness was defined using the European Typology of Homelessness and Housing Exclusion, including those with addresses of no fixed abode, government homeless accommodation and certain residential settings. The objectives were to compare presentations between homeless and non-homeless children. We were interested in determining differences regarding demographics, healthcare utilisation, clinical presentation and outcomes.

RESULTS

Of 197 437 attendances 3138 (1.59%) were homeless. Compared with the non homeless, homeless children were less likely to be ethnically Irish (37.4% vs 74.6%, p<0.001) or have been born in Ireland (82.3% vs 96.2%, p<0.001). Irish Travellers (3% vs 0.8%), Roma (22.5% vs 2.4%) and black (21.1% vs 4.2%) ethnicities were over-represented (p<0.001) in the homeless cohort.Homeless children were younger (age <12 months: 26% vs 16%; p<0.001), less likely to be fully vaccinated (73.6% vs 81.9%, p<0.001) and have registered general practitioners (89.7% vs 95.8%, p<0.001). They were more likely to represent within 2 weeks (15.9% vs 10.5%, p<0.001), and use ambulance transportation (13.2% vs 6.7%, p<0.001). Homeless children had lower acuity presentations (triage category 4-5: 47.2% vs 40.7%, p<0.001) and fewer admissions (5.9% vs 8.4%, p<0.001) than non-homeless children.

DISCUSSION

Infants, Irish Travellers, Roma and black ethnicities were over-represented in homeless presentations. Homeless children had increased reliance on emergency services for primary healthcare needs.

Impact of the COVID-19 pandemic on vulnerable groups, including homeless persons and migrants, in France: a qualitative study

•

Social inequalities in health increased especially during lockdown.

•

Homeless persons felt neglected as lockdown was designed for those with stable housing.

•

Access to an emergency shelter had positive impacts on homeless persons.

•

Sudden implementation of lockdown reminded prior violent or traumatic circumstances.

•

Crisis communication should be adapted to improve adherence to preventive measures.

Social inequalities tended to increase in the context of the pandemic, particularly in relation to the measures taken to manage and reduce the risk of COVID-19. When lockdown measures required the general population “to stay home”, what were homeless people expected to do? The ECHO study is a cross-sectional, descriptive study with a convergent mixed-method design. Data were collected across shelters in France both during and immediately following the lockdown (April – June 2020). This article presents the study’s qualitative findings, with a focus on understanding both the experiences and perceptions among these populations of the measures taken to limit the COVID-19 infection. A total of 26 semi-directed individual interviews were conducted across seven shelters in both Lyon (42%) and Paris (58%). Data were analysed using thematic content analysis with partial blinded coding. Four key themes were identified: 1- Reactions to the introduction of lockdown: a sudden implementation reminiscent of prior violent or traumatic circumstances amongst participants, 2- Accommodation during lockdown: participants’ conflicting visions of the shelter, 3- Influence of the media and public communication: an abundant flow of information impacting participant’s wellbeing and representations on the pandemic, and 4- The individual impact of lockdown: perceived health and limitations to daily life activities. The most vulnerable populations have borne the heaviest burden during the pandemic. It is therefore crucial that we improve both the availability of information, and the health literacy of, all groups within the national population.

Depression during the COVID-19 pandemic amongst residents of homeless shelters in France

Background

Accumulating evidence suggests that the COVID-19 pandemic has negatively affected global mental health and well-being. However, the impact amongst homeless persons has not been fully evaluated. The ECHO study reports factors associated with depression amongst the homeless population living in shelters in France during the spring of 2020.

Methods

Interview data were collected from 527 participants living in temporary and/or emergency accommodation following France's first lockdown (02/05/20 – 07/06/20), in the metropolitan regions of Paris (74%), Lyon (19%) and Strasbourg (7%). Interviews were conducted in French, English, or with interpreters (33% of participants, ∼20 languages). Presence of depression was ascertained using the Patient Health Questionnaire (PHQ-9).

Results

Amongst ECHO study participants, 30% had symptoms of moderate to severe depression (PHQ-9 ≥ 10). Multivariate analysis revealed depression to be associated with being female (aOR: 2.15; CI: 1.26–3.69), single (aOR: 1.60; CI: 1.01–2.52), chronically ill (aOR: 2.32; CI: 1.43: 3.78), facing food insecurity (aOR: 2.12; CI: 1.40–3.22) and participants’ region of origin. Persons born African and Eastern Mediterranean regions showed higher levels of depression (30–33% of participants) than those migrating from other European countries (14%). Reduced rates of depression were observed amongst participants aged 30–49 (aOR: 0.60; CI: 0.38–0.95) and over 50 (aOR: 0.28; CI: 0.13–0.64), compared to 18–29-year-olds.

Limitations

These data are cross-sectional, only providing information on a given moment in time.

Conclusions

Our results indicate high levels of depression amongst homeless persons during the COVID-19 pandemic. Predicted future instability and economic repercussions could particularly impact the mental health of this vulnerable group.

"Stripped of dignity" - Women in homelessness and their perspectives of healthcare services: A qualitative study

BACKGROUND

A much more substantial European evidence base on the accessibility of healthcare services among women experiencing homelessness across healthcare systems in Europe is warranted.

OBJECTIVE

To give voice to women with experiences of homelessness, and to explore their perspectives of healthcare services in an EU country with universal healthcare.

DESIGN

The study is part of a research program striving to promote equal healthcare through co-production with women in homelessness. An advisory board of women with lived experience of homelessness was established and a qualitative, interpretive and exploratory design was employed.

PARTICIPANTS

26 women with experience of homelessness were interviewed. Their median age was 46 years (range 42) and 70% were roofless/houseless.

METHODS

Data were analyzed with content analysis. Co-production and joint analyses were conducted by researchers and three women with experience of homelessness, using the DEPICT model for collaborative analysis.

RESULTS

The analysis resulted in one overall theme: Visiting healthcare from the outskirts of society, comprising three sub-themes: Demand for a life in order - Exclusion in action; Unwell, unsafe and a woman - Multifaceted needs challenge healthcare; and Abuse versus humanity - power of healthcare encounters to raise or reduce. Women's experiences of care encounters were disparate, with prevalent control, mistrust and stigma, yet healthcare professionals that demonstrated respect for the woman's human dignity was described both as life-altering and lifesaving.

CONCLUSIONS

Women in homelessness live on the outskirts of society and have multiple experiences of exclusion and loss of dignity within healthcare services. The multifaceted care needs challenge healthcare, leading to women feeling alienated, invisible, disconnected and worthless. We urge registered nurses to take actions for inclusion health, i.e. focusing health efforts of people experiencing extreme health inequities. We can lead the way by speaking up and confronting discriminating behaviors, protecting and restoring human dignity in caring relationships, and framing healthcare services for all citizens. Tweetable abstract: Women in homelessness have multiple experiences of exclusion and loss of dignity within healthcare services. Nurses must frame healthcare to include all citizens.

Characteristics associated with the risk of psychosis among immigrants and their descendants in France

OBJECTIVE

To explore the sociodemographic characteristics that might explain the increased incidence of psychosis among immigrants and their descendants in France.

METHODS

Data were collected for all subjects with first contact for psychosis aged between 18 and 64 years, in two catchment areas in the Paris region. Incidence rates (IR) and incidence rate ratios (IRR) were adjusted for gender and age.

RESULTS

During 805,396 persons-year at risk, we identified 321 cases of first-episode psychosis, of which 129 were immigrants and 78 descendants of immigrants. We found that the geographic origin was associated with the risk of psychosis although generation has little impact. Sub-Saharan African immigrants and their descendants showed the highest risk (IRR = 3.1 and IRR = 2.9, respectively). We observed that living in deprived areas increased the incidence of psychosis (IRR = 1.3, 95CI%: 1.0-1.6), particularly among immigrants (IRR = 1.6; 95% CI: 1.1-2.5). Finally, our study showed that subjects having unstable housing (a proxy for "hard to count population") could inflate the incidence rates among immigrants.

CONCLUSION

The current study shows that the increased risk of psychosis in groups with an immigration background in France is associated with their origin and highlights the importance of socioeconomic factors in modulating this risk.

Demographic, socioeconomic, and sociocultural factors associated with any breastfeeding in homeless mothers

In high-income countries, breastfeeding has been shown to be positively associated with socioeconomic position. However, less is known about breastfeeding practices and their associated factors among extremely disadvantaged populations. We aimed to assess the associations of cultural origins and socioeconomic factors with any breastfeeding initiation and duration in homeless families. We analyzed data from 456 children aged 6 months to 5 years from the cross-sectional ENFAMS survey, conducted in 2013 among a random sample of homeless families in shelters in the Greater Paris area. Data were collected by bilingual interviewers in 17 languages. Four nested multivariable robust Poisson regression models were run in a hierarchical framework to determine the factors associated with breastfeeding initiation and with any breastfeeding for 6 months or more. Most of the children (86.0%) had previously been or were currently being breastfed at the time of the survey; 58.9% were fed with breast milk ≥6 months. A higher maternal age and African origin were positively associated with breastfeeding ≥6 months, although the relation to the region of origin was moderated by education level. Migration to escape war, unrest or other violence and the child's birth in France were inversely associated with breastfeeding ≥6 months. Any breastfeeding by these homeless mothers seems influenced predominantly by their cultural origin and complicated by a difficult migration trajectory. The possible influence of poor material circumstances and cumulative hardship should encourage interventions targeted at homeless mothers that emphasize social/family support with a commitment to improving the family's living conditions.

Mental Health and Service Use of Migrants in Contact with the Public Psychiatry System in Paris

BACKGROUND

Migrants, and particularly asylum seekers, are at increased risk of psychiatric disorders in comparison with natives. At the same time, inequalities in access to mental health care are observed.

METHODS

In order to evaluate whether the Parisian public psychiatric system is optimally structured to meet the needs of this population, we examined data on mental health and service use considering three different levels: the global system treatment level, a psychiatric reception center, and mobile teams specializing in access to psychiatric care for asylum seekers.

RESULTS

We found higher treatment rates among migrants than among natives (p < 0.001) but inequalities in pathways to care: more mandatory admissions (OR = 1.36, 95% CI: 1.02-1.80) and fewer specialized consultations (OR = 0.56, 95% CI: 0.38-0.81). We observed a mismatch between increased need and provision of care among migrants without stable housing or seeking asylum.

CONCLUSIONS

Inequalities in the provision of care for migrants are observed in the Parisian public psychiatric system, particularly for those experiencing poor social and economic conditions. There is a need to facilitate access to mental health care and develop more tailored interventions to reduce discontinuity of care.

Post-Traumatic Stress Disorder in Homeless Migrant Mothers of the Paris Region Shelters

Migrant women are disproportionately more likely to experience traumatic events in their country of origin, during migration and after arriving in the host country. Homeless women are more likely to be exposed to multiple victimizations in childhood (emotional or physical maltreatment) and in adulthood (sexual abuse, street victimization). This study’s objective was to describe the factors associated with the likelihood of post-traumatic stress disorder (PTSD) among homeless migrant mothers in the Paris region. Face-to-face interviews were conducted by bilingual psychologists and interviewers in a representative sample of homeless families in the Paris region. PTSD was ascertained using the Mini International Neuropsychiatric Interview (MINI) (n = 691 mothers). We studied PTSD in mothers using weighted Poisson regression. Homeless migrant mothers had high levels of PTSD (18.9%) in the 12 months preceding the study. In multivariate analysis, PTSD was associated with departure from the country of origin because of violence (PR = 1.45 95% CI 1.03; 2.04), depression in the preceding 12 months (PR = 1.82 95% CI 1.20; 2.76), and residential instability (PR = 1.93 95% CI 1.27; 2.93). Homeless migrant mothers have high levels of traumatic events and PTSD. Improvements in screening for depression and PTSD and access to appropriate medical care are essential for this vulnerable group.

The psychological impact of childhood homelessness-a literature review

In August 2019, 3848 children in Ireland were faced with emergency homelessness [1]. In recent years, lack of affordable housing, unemployment and shortage of rental properties have been the primary driving factors for the potentially devastating impact of familial homelessness in our society [1]. Our aim was to evaluate current knowledge on the psychological impact of homelessness in children. Using the PRISMA model, we performed a review of the currently available literature on the psychological impact of homelessness on children. This concept was explored under two different categories-'transgenerational' and 'new-onset homelessness'. Hidden homelessness was also explored. Our literature review revealed several psychological morbidities which were unique to children. This includes developmental and learning delays, behavioural difficulties and increased levels of anxiety and depression [66, 77, 40, 81, 42]. This has been demonstrated by poorer performance in school testing and increased levels of aggression. Anxiety in children within this cohort has been shown to peak at time of dispersion from their stable home environment [67]. Our study highlights violence, aggression and poor academic learning outcomes to be just some of the key findings in our review of homelessness in childhood, worldwide. Unfortunately, there has been minimum research to date on paediatric homelessness within the context of the Irish population. We anticipate this review to be the first chapter in a multipart series investigation to evaluate the psychological morbidity of paediatric homelessness within the Irish Society.

Physical illnesses associated with childhood homelessness: a literature review

BACKGROUND

Childhood homelessness is a growing concern in Ireland [1] creating a paediatric subpopulation at increased risk of physical illnesses, many with life-long consequences [2].

AIM

Our aim was to identify and categorize the physical morbidities prevalent in homeless children.

METHODS

A review of the English-language literature on physical morbidities affecting homeless children (defined as ≤ 18 years of age) published from 1999 to 2019 was conducted.

RESULTS

Respiratory issues were the most commonly cited illnesses affecting homeless children, including asthma, upper respiratory tract infections, and chronic cough [3]. Homeless children were described as being at increased risk for contracting infectious diseases, with many studies placing emphasis on the risks of sexually transmitted infections (STIs) and HIV/AIDS transmission [4, 5]. Dermatologic concerns for this population comprised of scabies and head lice infestation, dermatitis, and abrasions [3, 6]. Malnutrition manifested as a range of physical morbidities, including childhood obesity [7], iron deficiency anemia [4], and stunted growth [8]. Studies demonstrated a higher prevalence of poor dental [7] and ocular health [9] in this population as well. Many articles also commented on the risk factors predisposing homeless children to these physical health concerns, which can broadly be categorized as limited access to health care, poor living conditions, and lack of education [3, 10].

CONCLUSION

This literature review summarized the physical illnesses prevalent among homeless children and the contributing factors leading to them. Gaps in the literature were also identified and included a dearth of studies focusing on younger children compared with adolescents. Further research into prevention and intervention programs for this vulnerable population is urgently needed.

Diphtheria-Tetanus-Polio, Measles-Mumps-Rubella, and Hepatitis B Vaccination Coverage and Associated Factors among Homeless Children in the Paris Region in 2013: Results from the ENFAMS Survey

Background: The number of homeless families has increased considerably since the 1990s in France. We aimed to estimate the homeless children vaccination coverage (VC) for diphtheria, tetanus, polio, measles-mumps-rubella and hepatitis B and identify factors associated with insufficient VC according to birthplace. Methods: A cross-sectional survey was conducted among homeless shelter families in the greater Paris area. A nurse conducted face-to-face interviews and collected vaccination records. We analyzed factors associated with insufficient VC, stratified by birthplace and vaccine, using robust Poisson regression. Results: The study included 214 children born in France and 236 born outside France. VC in French-born homeless children was high (>90% at 24 months for most vaccinations) and similar to levels observed in the general population, whereas VC in those born outside France was low (<50% at 24 months for all vaccines). Factors significantly associated with insufficient VC among children born outside France were age, parents with French-language difficulties, and changing residence at least twice in the previous year. Children in contact with the healthcare system at least once in the previous year had significantly higher VC, irrespective of vaccine and birthplace. Conclusion: Special attention should be paid to homeless children born outside France, with recent European and French recommendations confirming the need for catch-up vaccination in children with undocumented VC.

Non-communicable Disease among Homeless Men in Nagoya, Japan: Relationship between Metabolic Abnormalities and Sociodemographic Backgrounds

Objective To examine the degree of metabolic abnormalities and their association with the sociodemographic background or mental illness/cognitive disability among homeless men in Nagoya, Japan. Methods We interviewed 106 homeless men (aged 54.2±12.7 years) and measured their metabolic parameters. Mental illness and cognitive disability were diagnosed using the Mini-International Neuropsychiatric Interview and Wechsler Adult Intelligence Scale-III test, respectively. Associations between metabolic abnormalities and the sociodemographic background or mental illness/cognitive disability were analyzed. Results There were significant correlations of liver dysfunction (AST≥35 IU, ALT≥35 IU, γ-GTP≥75 IU), hypertension [systolic/diastolic blood pressure (BP) ≥140/90 mmHg], and dyslipidemia (HDL <40 mg/dL) with the history/duration of homelessness (over 2 times/year) and residence status (living on the streets). Although the mean body mass index (BMI), BP, HbA1c, and LDL in participants living in temporary residences were similar to those obtained from the general population data from National Health Nutrition Survey (NHNS) 2016, the systolic/diastolic BP in those living on the street was significantly higher than in the general population, and the HDL in those living in temporary residences was significantly lower than in those reported in the NHNS 2016 data. In the group with cognitive disability, the ALT, TG, and BMI values were significantly higher and the HDL level significantly lower in those living in temporary residences than in those living on the streets. Conclusion Stressful conditions while living on the streets may exacerbate hypertension and liver dysfunction, and unhealthy food habits when living in a temporary residence may exacerbate low HDL levels. In addition, an inability to self-manage due to cognitive disability may increase the ALT, TG, and BMI values. The provision of homeless people with the skills to sustain independent living conditions and ensure a healthy diet is required.

Self-Perceived Health among Migrants Seen in Médecins du Monde Free Clinics in Europe: Impact of Length of Stay and Wealth of Country of Origin on Migrants' Health

Health of migrants is a widely studied topic. It has been argued that migrant health may deteriorate over time. Though migrants are a “hard to reach” population in survey data, this paper builds on a unique dataset provided by Médecins du Monde from five countries. We study self-perceived health (SPH) in connection with socio-economic and demographic factors and length of stay. Results differ for men and women. Compared to other documented migrants, asylum seekers have a 50–70% greater chance of having worse health. Migrants with better living conditions have a 57–78% chance of being in better health. Male migrants with a job have between a 82–116% chance of being in good health. The probability for women from poorer countries to have a better physical SPH after three months of residing in the host country is six-fold that of women from richer countries. This paper contributes widely to the knowledge of health of migrants. Contrary to other evidence, health of women migrants from poorer countries tends to improve with length of stay.

Relationship between non-communicable diseases and background characteristics among homeless people in Nagoya City, Japan

Background

There are few reports that objectively show actual health conditions among the homeless or diagnoses of non-communicable diseases based on blood tests. This report discloses the actual data from blood tests and non-communicable diseases among the participants. Furthermore, associations between the test values for lifestyle-related disease and mental disorder/intellectual disability, as well as personal backgrounds of homeless people, were analyzed from the data gathered in the survey.

Methods

This study was performed in a rented meeting room close to Nagoya Station on November 2, 2014. Blood samples, physical measurements, blood pressure measurements intellectual faculties were measured. Physical/mental diseases were diagnosed by doctors. Fisher’s exact test was performed to compare between subgroups (by participants’ socio-demographic data or the presence of mental illness/cognitive disability) according to non-communicable disease test values, and to calculate the odds ratio.

Results

Abnormalities among participants in test values for non-communicable disease were as follows: hypoalbuminemia in one participant (0.9%), abnormalities in liver function in 22 participants (19.3%), decreased renal function in two participants (1.8%), dyslipidemia in 67 participants (58.8%), "a person whose impaired glucose tolerance cannot be ruled out" in 20 participants (17.5%), obesity in 33 participants (28.9%), thinness in five participants (4.3%), and hypertension in 60 participants (52.6%). Compared to the National health and nutrition survey 2015, non-communicable diseases of the homeless people were similar or slightly better than in the general population in Japan. Participants aged 20–39 years had a significant positive tendency of having liver function abnormality compared to ≥60 years old participants. There was no significant tendency with socio-demographic characteristics in dyslipidemia and “impaired glucose tolerance”.

Conclusion

It was found that the percentage of homeless people in Nagoya who showed abnormalities of lifestyle-related disease was similar or better than that of general population in Japan.

Anaemia and associated factors in homeless children in the Paris region: the ENFAMS survey

Background

Food insecurity is a major concern in homeless population, however nutritional consequences remain poorly documented, especially for children. The objective of this study was to assess the prevalence of anaemia and to investigate the relation between both food insecurity and dietary intake to moderate-to-severe anaemia (MSA) in homeless sheltered children.

Methods

In 2013, a cross-sectional survey was conducted on a random sample of 801 sheltered homeless families in the Paris region. Haemoglobin concentration was measured in 630 mother/child dyads and questionnaires administrated to mothers collected socio-demographic, socioeconomic, health and dietary data. Factors associated with MSA were analysed in two stratified child age groups; 0.5-5 and 6-12 years old.

Results

Anaemia was detected in 39.9% of the children and 50.6% of the mothers, and MSA in 22.3% and 25.6%, respectively. In both age groups, MSA was positively associated with maternal MSA. In the 0.5-5 years group, it was also positively associated with child food insecurity, no cooking facilities and household monthly income. In the 6-12 years group, it was positively associated with household food insecurity and children's age.

Conclusion

A higher food insecurity score was associated with greater prevalence of moderate-to-severe anaemia in children. Considering the high prevalence of anaemia among homeless mothers and their children, these findings highlight the need for reducing food insecurity in shelters so as to prevent anaemia in this vulnerable population.

Impact of fruits and vegetables vouchers on food insecurity in disadvantaged families from a Paris suburb

BACKGROUND

Social inequalities in nutrition lead a high number of families to struggle with food insecurity, even in developed countries. We aimed to assess the impact of fruits and vegetables vouchers on food security among disadvantaged households from a Paris suburb.

METHODS

We used a pre-post assessment design. Families answered face-to-face questionnaires on food consumption and food security status before and after a randomly assigned intervention. Households in the intervention group received vouchers to buy exclusively fruits and vegetables over one year. Both intervention and control groups benefitted from nutritional education through workshops performed by dieticians during the study period. The Household Food Security Module (HFSM) was used to assess food security status of households at inclusion. Food Insufficiency Indicator (FSI) was used to assess food security at inclusion and follow-up. Evolution of FSI on both groups was evaluated using McNemar test.

RESULTS

Among the 91 families included between May 2015 and May 2016, 64 completed the post assessment questionnaire. At inclusion, 68.3% of families were experiencing food insecurity and 78.1% were experiencing food insufficiency. No association was found between food consumptions and food security status. After one-year follow-up, the prevalence of food insufficiency was significantly decreased in the intervention group (61.8%, with p value = 0.03), and unchanged in the control group.

CONCLUSION

In this pilot study, food insufficiency was significantly decreased in families receiving vouchers for fruits and vegetables over a one-year period.

TRIAL REGISTRATION

NCT02461238, registered 3 June 2015 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02461238.

Hair concentration of trace elements and growth in homeless children aged <6years: Results from the ENFAMS study

BACKGROUND

Growth is an important indicator of health in early childhood. This is a critical developmental period, during which a number of factors, including exposure to metals, might play a role in later physical and metabolic functions.

OBJECTIVE

To study the association between exposure to arsenic (As), cadmium (Cd), mercury (Hg), lead (Pb) and selenium (Se), and physical growth of children from homeless families aged <6years.

METHODS

This study was based on data of the cross-sectional survey (ENFAMS), which was conducted by the Observatoire du Samu Social on a random sample of homeless sheltered families in the Paris region during winter 2013. Families with children under 6years (N=324) were interviewed in 17 languages using face-to-face questionnaires. A nurse took anthropometric measures and collected hair samples where As, Cd, Hg, Pb and Se levels were measured. We calculated weight-for-age Z-score (WAZ), height-for-age Z-score (HAZ) and BMI-for-age Z-score (BMIZ) of children, using the 2006 WHO Child Growth Standards as a reference. Associations between ln-transformed metal exposures and growth outcomes were tested by multivariable linear regression models with adjustment for potential confounders (including maternal anthropometrical and socio-demographical characteristics, gestational age, child birthweight, breastfeeding, food insecurity of the child). Due to missing data (1.6% to 14.2% depending on the variables), we used multiple imputation by chained equations.

RESULTS

A strong positive correlation was found between Pb and Cd levels (r=0.65; p<0.001). Positive associations between Se level and HAZ (β=0.61; p=0.05) and between Cd and BMIZ (β=0.21; p=0.03) and negative associations between As and HAZ (β=-0.18; p=0.05) were no more significant after multiple imputation. A weak negative trend was observed between Cd and HAZ (β=-0.14; p=0.14), while positive trends were found between Se and both WAZ (β=0.55; p=0.10) and HAZ (β=0.51; p=0.06) after multiple imputation.

CONCLUSION

Overall, our results found no strong association between exposure to metals and physical growth of homeless children but we observed some trends that were consistent with previous studies. More research is required studying these associations longitudinally, along with higher sample sizes, for better understanding the sources of exposure in homeless population and the potential effects on growth.

Factors associated with depression among homeless mothers. Results of the ENFAMS survey

PURPOSE

Women are disproportionately likely to suffer from depression. This is especially true for those who experience socioeconomic hardship, such as homelessness. In France, among homeless mothers many are migrant. However, it is not clear whether risk factors associated with depression are specific for this group or the same as in the general population. Our objective was to describe socio-demographic, relational, living and housing conditions and health factors associated with depression among homeless mothers.

METHODS

The ENFAMS survey, conducted via face-to-face bilingual interviews with a representative sample of homeless families in the Paris region (January-May 2013, n = 733 mothers). Mothers reported their socio-demographic characteristics, housing conditions including residential mobility, as well as physical and mental health. Depression was ascertained using the Composite International Diagnostic Interview (CIDI). Factors associated with mother's depression were studied in weighted Poisson regression models with robust error variance.

RESULTS

The prevalence of depression among participating mothers was 28.8%. In multivariate analyses, depression was associated with fluency in French (PR = 1.88 95% CI 1.40; 2.51), suicide risk (PR = 2.26, 95% CI 1.82; 2.82), post-traumatic stress disorder (PR = 1.97, 95% CI 1.50; 2.60), and unmet health needs (PR = 1.68, 95% CI 1.09; 2.57).

CONCLUSIONS

Homeless mothers have high levels of depression and associated psychiatric comorbidities. Associated risk factors appear to be both specific for this group and shared with mothers in the general population. Improvements in the monitoring of mental health difficulties as well as access to appropriate medical care in this vulnerable population may help improve health and social outcomes.

Food Insecurity in Homeless Families in the Paris Region (France): Results from the ENFAMS Survey

The number of families living in shelters in the Paris region (France) has increased by a factor of three in 10 years. In 2013, a survey was performed on homeless families in order to characterize their living conditions, their health needs, and the developmental problems in children. This probability survey was conducted in 17 languages among 801 homeless families sheltered in emergency centers for asylum-seekers, emergency housing centers, social rehabilitation centers, and social hotels in the Paris region. Among the 772 families that provided data on food security only 14.0% were with food security, whereas 43.3% were with low food security and 9.8% with very low food security (a situation where children are also affected). Stratified multivariate robust Poisson models showed that some characteristics are associated with a higher risk of food insecurity and/or of falling into very low food security, such as residential instability, single parenthood, having more than three children, depressive symptoms, housing in social hostels, and difficult access to cheap or free food locally. Given the wealth of the Paris region, resources and programs should be concentrated on improving the living situation of this vulnerable population. It needs better detection of these families, a closer social follow-up, and an increase in food aid.

Adaptive Behavior of Sheltered Homeless Children in the French ENFAMS Survey

OBJECTIVES

To describe the adaptive behaviors in a large sample of homeless children and identify factors associated with developmental delay.

METHODS

Data were from a cross-sectional survey of 557 children younger than 6 years randomly sampled among homeless sheltered families in the Paris region, France (January-May 2013). An interviewer and a psychologist conducted face-to-face interviews to collect information on sociodemographic and health characteristics. We assessed adaptive behaviors using the Vineland Adaptive Behavior Scales, second edition (VABS-II).

RESULTS

The mean VABS-II composite score (SD) was 75.4 (12.0), and most participating children (80.9%) were considered developmentally delayed. Characteristics negatively associated with children's developmental score were age, birth in a country other than France, low birth weight, and past-year hospitalization.

CONCLUSIONS

There is a high prevalence of developmental delays among children growing up homeless. Public Health Implications. Long-term integrated programs improving parenting and children's opportunities for stimulation and socialization should be developed in daycare centers, schools, shelters, and medical practices to minimize negative effects of early living conditions on children's development.

Food Insecurity Is Associated with Low Adherence to the Mediterranean Diet and Adverse Health Conditions in Portuguese Adults

Background

Food insecurity is a limited or uncertain access to the adequate food and is a significant public health problem. We aimed to assess determinants of food insecurity and the corresponding health impact in Portugal, a southern European country that faced a severe economic crisis.

Methods

Data were derived from the Epidemiology of Chronic Diseases Cohort Study (EpiDoC), a population-based cohort of 10,661 individuals that were representative of the Portuguese adult population and followed since 2011. A cross-sectional analysis of the third wave of evaluation (EpiDoC 3) was performed between 2015 and 2016. Food insecurity was assessed with the household food insecurity psychometric scale. Socioeconomic, demographic, lifestyle, adherence to Mediterranean diet (MD), self-reported non-communicable disease, health-related quality of life (HRQoL) (EQ-5D-3L), physical function (HAQ score), and health resource consumption information was also collected.

Results

The estimated proportion of food insecurity was 19.3% among a total of 5,653 participants. Food insecure households had low adherence to the MD (OR = 0.44; 95% IC 0.31–0.62). In addition, diabetes (OR = 1.69; 95% IC 1.20–2.40), rheumatic disease (OR = 1.67; 95% IC 1.07–2.60), and depression symptoms (OR = 1.50; 95% IC 1.09–2.06) were independently associated with food insecurity. On average, food insecure households had a lower HRQoL (OR = 0.18; 95% IC 0.11–0.31) and a higher disability (OR = 2.59; 95% IC 2.04–3.29). A significantly higher proportion of food insecure households reported being hospitalized (OR = 1.57; 95% IC 1.18–2.07) and had more public hospital medical appointments (OR = 1.48; 95% IC 1.12–1.94) in the previous 12 months.

Conclusion

We found that food insecurity is highly prevalent in Portugal. Food insecurity was associated with low adherence to the MD, non-communicable chronic diseases, lower quality of life, and higher health resource consumption. Therefore, this study provides valuable insight into the relationship between food security and the diet and health of the population during an economic crisis.

[Characteristics and health status of homeless women born in France and abroad: Results of Insee-Ined 2012 survey]

BACKGROUND

French national surveys among the homeless population in 2001 and 2012 provided a general description of the homeless beneficiaries of medical and social aids. However, given the increasing number of women in this population, mostly born abroad and accompanied by their children, a descriptive study of homeless women according to the fact of being born in France or abroad was conducted.

METHODS

A probability sample of 1470 French-speaking homeless women was recruited for the Insee-Ined 2012 survey. Socio-demographic characteristics, life trajectories, work and employment over the last 12 months, perceived health, reported morbidity, use of care and medical coverage have been described, comparing homeless women born abroad with those born in France.

RESULTS

Homeless women are young (median age=34 y.), often single (55%), without a partner (71%) and often accompanied by children (52%). The vast majority (60%) reported no salary during the previous 12 months. Housing conditions were less precarious in women born in France, but these women had a more difficult life history, a more unfavorable perception of their health status, and a higher frequency of chronic health problems. Homeless women born abroad seemed to have more precarious conditions of life and more difficulties to access aids and medical coverage. Overall, despite a relatively good availability of medical insurance, homeless women, regardless of the place of birth, often reported health problems, which were not treated.

CONCLUSION

This study suggests that homeless women often have to deal with chronic health problems that are not treated. Homeless women born abroad are characterized by more precarious living conditions that women born in France. Although younger, with an overall favorable perception of their health and declaring less often an addiction, their general state of health appears to be as fragile as for women born in France. Actions towards homeless women should be implemented to promote their access to care.

Prevalence of Mental Disorders and Addictions among Homeless People in the Greater Paris Area, France

The Samenta study was conducted in 2009 in the Greater Paris area to estimate the prevalence of psychiatric disorders in homeless people. A cross-sectional survey was performed with a three-stage random sample of homeless people (n = 859), including users of day services, emergency shelters, hot meal distribution, long-term rehabilitation centres, and social hotels. Information was collected by a lay interviewer, using the Mini International Neuropsychiatric Interview, and completed by a psychologist through an open clinical interview. In the end, a psychiatrist assessed the psychiatric diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD, 10th revision). One third of homeless people in the Paris area had at least one severe psychiatric disorder (SPD): psychotic disorders (13%), anxiety disorders (12%), or severe mood disorders (7%). One in five was alcohol-dependent and 18% were drug users. Homeless women had significantly higher prevalence of anxiety disorders and depression compared to men, who were more likely to suffer from psychotic disorders. Homeless people of French origin were at higher risk of SPD, as well as people who experienced various adverse life events before the age of 18 (running away, sexual violence, parental disputes, and/or addictions) and those who experienced homelessness for the first time before the age of 26. The prevalence rates of the main psychiatric disorders within the homeless population of our study are consistent with those reported in other Western cities. Our results advocate for an improvement in the detection, housing, and care of psychiatric homeless people.

Unmet healthcare needs in homeless women with children in the Greater Paris area in France

BACKGROUND

Despite their poor health status, homeless women encounter many barriers to care. The objectives of our study were to estimate the prevalence of unmet healthcare needs in homeless women and to analyse associated relationships with the following factors: financial and spatial access to care, housing history, migration status, healthcare utilisation, victimization history, caring for children, social network and self-perceived health status.

METHODS

We used data from 656 homeless women interviewed during the ENFAMS representative survey of sheltered homeless families, conducted in the Paris region in 2013. Structural equation models (SEM) were used to estimate the impact of various factors on homeless women's unmet healthcare needs.

RESULTS

Among those interviewed, 25.1% (95%CI[21.3-29.0]) had at least one unmet healthcare need over the previous year. Most had given up on visiting general practitioners and medical specialists. No association with factors related to financial access or to health insurance status was found. However, food insecurity, poor spatial health access and poor self-perceived health were associated with unmet healthcare needs. Self-perceived health appeared to be affected by victimization and depression.

DISCUSSION

The lower prevalence of unmet healthcare needs in homeless women compared with women in stable housing situations suggests that homeless women have lower needs perceptions and/or lower expectations of the healthcare system. This hypothesis is supported by the results from SEM. Strategies to provide better access to care for this population should not only focus on financial interventions but also more broadly on spatial healthcare access, cultural norms, and perceptions of health. Reducing their unmet needs and improving their access to healthcare and prevention must include an improvement in their living, financial and housing conditions.

Socio-economic disparities in the diet of French children and adolescents: a multidimensional issue

OBJECTIVE

The present research aimed to study the multidimensionality of the link between dietary intake and socio-economic position (SEP) in a representative sample of French children and adolescents, using a variety of SEP indicators.

DESIGN

Data from the second French national food consumption survey (INCA2) were used. Information on food consumption was collected using a 7d food record and SEP data (occupation, education, income, household wealth indices) using questionnaires. Multivariable linear regression analyses were performed separately in children and adolescents to assess the relationships between dietary components (food groups and macronutrients) and each dimension of SEP.

SETTING

The INCA2 survey, France.

SUBJECTS

A representative sample of French children (3-10 years of age; n 574) and adolescents (11-17 years of age; n 881).

RESULTS

Compared with children from a higher SEP, those from a lower SEP had lower intakes of fruit and vegetables, yoghurts and confectionery and higher intakes of starchy foods, meat, milk, sugar-sweetened beverages and pizzas/sandwiches. Similar results were observed in adolescents for fruit and vegetables, yoghurts and sugar-sweetened beverages. Adolescents also had lower intakes of cakes/pastries and higher intakes of processed meat and dairy desserts. Neither energy nor protein intake was associated with SEP. Adolescents from a lower SEP had higher carbohydrate and lower lipid intakes. Overall, these findings were consistent across the various dimensions of SEP, but the gradient was steeper depending on the caregiver's educational level.

CONCLUSIONS

This research highlights the need for specific messages to help poorly educated families adopt good eating habits.

The role of food insecurity in developmental psychopathology

Food security is a condition achieved when all members of a household have access to adequate food at all times for a healthy, active lifestyle. As of 2014, 14% of households in the United States were food insecure. Previous research has suggested that household food insecurity is associated with numerous adverse medical and psychosocial outcomes across the lifespan. In this narrative review, we examine current research on food insecurity, specifically as it relates to child psychopathology and risk factors thereof: namely, parental mental illness and poor diet and metabolic health. Moreover, we begin to speculate about behavioral and physiological mechanisms by which these conditions may influence one another, and discuss possible interventions through enhanced screening and treatment, parent training, and provision of high quality foods to vulnerable households. Further research is needed to the effects of child and parental mental health on metabolic outcomes in families with food insecurity.

Emotional and behavioral difficulties in children growing up homeless in Paris. Results of the ENFAMS survey

PURPOSE

Children growing up in homeless families are disproportionately more likely to experience health and psychological problems. Our objective was to describe social, environmental, individual and family characteristics associated with emotional and behavioral difficulties among homeless children living in the Paris region.

METHODS

Face-to-face interviews with a representative sample of homeless families were conducted by bilingual psychologists and interviewers between January and May 2013 (n=343 children ages 4-13 years). Mothers reported children's emotional and behavioral difficulties (Strength and Difficulties Questionnaire [SDQ]), family socio-demographic characteristics, residential mobility, and parents' and children's physical and mental health. Children were interviewed regarding their perception of their living arrangements, friendships and school experiences. We studied children's SDQ total score in a linear regression framework.

RESULTS

Homeless children had higher SDQ total scores than children in the general population of France, (mean total score=11.3 vs 8.9, P<0,001). In multivariate analyses, children's difficulties were associated with parents' region of birth (beta=1.74 for Sub-Saharan Africa, beta=0.60 for Eastern Europe, beta=3.22 for other countries, P=0.020), residential mobility (beta=0.22, P=0.012), children's health (beta=3.49, P<0.001) and overweight (beta=2.14, P=0.007), the child's sleeping habits (beta=2.82, P=0.002), the mother's suicide risk (beta=4.13, P<0.001), the child's dislike of the family's accommodation (beta=3.59, P<0.001) and the child's experience of bullying (beta=3.21, P=0.002).

CONCLUSIONS

Children growing up homeless experience high levels of psychological difficulties which can put them at risk for poor mental health and educational outcomes long-term. Access to appropriate screening and medical care for this vulnerable yet underserved group are greatly needed.

Asthma-Like Symptoms in Homeless Children in the Greater Paris Area in 2013: Prevalence, Associated Factors and Utilization of Healthcare Services in the ENFAMS Survey

INTRODUCTION

Asthma remains poorly studied in homeless children. We sought to estimate the prevalence of asthma-like symptoms (ALS) and to identify the factors associated with ALS and healthcare service utilisation.

MATERIALS AND METHODS

A cross-sectional survey of a random sample of sheltered homeless families was conducted by interviewing 801 parents of children (0-12 years) in 17 languages. ALS were defined as wheezing or night cough without fever during the previous year. Poisson regression models with robust error variance were used to compute prevalence ratios (PR) for factors associated with ALS and healthcare service utilisation for ALS.

RESULTS

The prevalence of ALS among the children was 19.9%. Poor housing sanitation was significantly associated with ALS, as being born in the European Union. Most of the children with ALS had used healthcare services (85.4%). The main barriers to accessing such services were having lived in France for less than 49 months, having difficulties in French and living in poor housing conditions.

CONCLUSION

ALS prevalence seemed lower than in the general child population, possibly because of the children's origins. Environmental factors associated with ALS point to the need to improve the indoor environment of family shelters. The relatively high rate of healthcare service utilisation should not overshadow existing barriers.