'If I die, I die, I don't care about my health': Perspectives on self-care of people experiencing homelessness

Pharmacy Homeless Outreach Engagement Non-medical Independent Prescribing Rx (PHOENIx) Community Pharmacy-Based Pilot Randomized Controlled Trial

Randomized controlled trials (RCTs) aiming to address the multiple health and social challenges of people experiencing homelessness (PEH) are lacking. Here we report the findings from a multicenter, open, pilot RCT. The intervention involved independent prescriber pharmacist from the National Health Service working on outreach in partnership with dedicated workers from Homeless Voluntary Charity or Social Enterprises (HVCSEs) (Pharmacist and third sector charity worker integrated Homeless Outreach Engagement Non-medical Independent prescriber Rx'-PHOENIx) in low threshold HVCSE venues or temporary accommodation addressing PEH participants' health and wider needs through repeated outreach. The trial aimed to investigate whether sufficient numbers of participants could be recruited, retained, the intervention delivered as planned, and sufficient data collected to inform a subsequent definitive RCT. Clinical outcomes were also collected at follow-up (6 months). Participants were recruited from five community pharmacies and nearby venues in urban centers of Glasgow-Scotland and Birmingham-England, then randomized one-to-one into PHOENIx intervention in addition to usual care (UC) or UC only. A priori progression criteria were achieved: 55% of those assessed as eligible were recruited; at 6 months, 72% remained in the study, 91% had emergency department and mortality data available, and 72% completed questionnaire booklets. Fifty-three percent of participants received at least 50% of the planned PHOENIx intervention consultations (in-person or phone) at 6 months. Signs of improvement in clinical outcomes in the PHOENIx group included fewer ambulance call-outs, ED visits, and hospitalizations; higher outpatient attendances; and higher scores on self-reported health-related quality of life. A definitive RCT is merited.

Prevalence and risk factors of frailty in people experiencing homelessness: A systematic review and meta-analysis

BACKGROUND

The experience of homelessness has been associated with premature ageing and an earlier onset of geriatric syndromes. Identification of frailty and appropriate intervention, may help improve health outcomes for people experiencing homelessness (PEH). This review aimed to identify prevalence, use of screening tools and risk factors for frailty in PEH.

METHOD

A systematic review, conducted and reported following the PRISMA checklist, was undertaken investigating the prevalence and risk factors of frailty among PEH. Searches were conducted in Ovid MEDLINE, PsycInfo, Web of Science and CINAHL from inception to July 2024. A meta-analysis examining prevalence of frailty and pre-frailty was completed with a narrative synthesis of related risk factors.

RESULTS

A total of 1672 articles were screened for eligibility and 11 studies were included, containing 1017 participants from seven countries. Six different screening tools were employed to detect frailty in the included studies. The range of frailty prevalence was 16-70 % and pre-frailty prevalence was 18-60 %. The pooled frailty prevalence from studies employing the Fried Criteria was 39 % (95 % CI 15-66); the Clinical Frailty Scale: 37 % (95 % CI 24-51); the Edmonton Frailty Scale: 53 % (95 % CI 44-63); and the Tilburg Fraily Indicator: 31 % (95 % CI 8-60). High heterogeneity was observed between the studies. Identified risk factors for developing frailty in PEH included being female, increased years spent homeless, and drug addiction.

CONCLUSION

This study highlights a high prevalence of frailty and pre-frailty in PEH. The identified risk factors illustrate potential areas to target interventions to reverse frailty. Future research should focus on the role of screening for frailty in PEH and developing appropriate frailty detection tools in this group.

Formative Qualitative Research Informs Tailoring SNAP-Ed Curriculum for Transitional Housing Residents

OBJECTIVE

To modify the Supplemental Nutrition Assistance Program-Education curriculum based on formative research conducted at a homeless resource center.

METHODS

Researchers interviewed 4 administrators/staff and 5 transitional housing residents. We used a content analysis approach to independently code transcripts, reconcile differences, and identify themes. We adapted the Create Better Health curriculum using these data.

RESULTS

Curriculum adaptations included incorporating microwave-friendly recipes because of limited cooking facilities, providing strategies for making healthy food choices at facility-provided meals and convenience/dollar stores frequented by residents, and encouraging residents to exercise at their comfort levels because of common physical limitations. Classes located outside transitional housing units were planned for 60 minutes before and after mealtimes.

CONCLUSIONS AND IMPLICATIONS

Adapting the Supplemental Nutrition Assistance Program-Education curriculum to meet the unique needs of transitional housing residents may enable healthy behavioral changes. Further research is required to evaluate the feasibility and efficacy of this revised curriculum.

Patterns, circumstances and risk factors associated with non-fatal substance overdose in a cohort of homeless population: an observational study

BACKGROUND

Non-fatal overdoses frequently precede fatal overdoses, thus identifying risk factors for non-fatal overdoses could help develop strategies to prevent substance related deaths.

AIM

This study aimed to identify patterns, circumstances and risk factors leading to non-fatal substance overdose in people experiencing homelessness.

METHOD

All recorded cases of non-fatal substance overdose from a population of people experiencing homelessness registered at a specialist homelessness primary care centre in England were identified using electronic medical records. Overdose details and patient characteristics were extracted. The heterogeneity between variables in people with and without a recorded non-fatal overdose were tested and multivariable logistic regressions were used to identify the risk factors of non-fatal overdoses.

RESULTS

From the 1221 registered patients, 194(16%) were identified as having had a non-fatal overdose with 428 overdoses between them. Half were polypharmacy events with the main substances of overdose being: heroin, paracetamol, benzodiazepines, cocaine, antipsychotics, SSRIs and synthetic cannabinoids. Risk of non-fatal overdose was greater in females, white ethnicity, ages 36-45, and in those with a recorded use of tobacco, alcohol or illicit substance use. Chronic physical and mental health conditions increased the risk of non-fatal overdose including respiratory conditions, blood borne viruses, migraines, anxiety and depression.

CONCLUSION

With a high number of non-fatal overdoses within this population, identifying individuals at risk based on the factors identified in this research could enable primary care providers to apply prevention actions such as overdose awareness and naloxone provision to avoid drug harm and deaths. Future work should explore the role of chronic physical conditions and their treatment on non-fatal overdose risks.

Health Deficits Among People Experiencing Homelessness in an Australian Capital City: An Observational Study

People experiencing, or at risk of, homelessness face challenges that result in poorer health outcomes compared to those in stable housing. This study provides the results of over 40 health measures that capture the health status of a group of people in temporary accommodation due to experiencing homelessness, aged 22 to 84 years, in an inner-city location, invited to participate in a comprehensive assessment of physical and psychological health. Evidence of accelerated ageing was found, with 44.2% of people being clinically frail, 63% having poor functional movement, and 36% having pain associated with oral health. Additionally, 90.6% of participants showed health risks due to nutritional deficiencies, over half reported poor sleep quality, 55.3% reported having psychological distress, and almost half reported fair or poor overall dental health. This study suggests a pathway to providing a relatively easily implemented series of health assessments to help respond to a group of underlying causes for accelerated ageing among a group of inner-city people experiencing homelessness. This work can be used to inform the prioritisation and development of community-based health services to address functional deficits that may contribute to accelerated ageing.

'The lights are on, and the doors are always open': a qualitative study to understand challenges underlying the need for emergency care in people experiencing homelessness in rural and coastal North East England

Introduction

People experiencing homelessness have high rates of emergency care attendance compared with the general population. This study explores the factors underlying the need for emergency care services among people experiencing homelessness in rural and coastal areas of North East England.

Methods

The study was conducted in Northumberland and North Tyneside (North East England). One-to-one semistructured interviews were conducted with people experiencing homelessness. Interviews and focus groups were undertaken with frontline staff from housing associations, police, ambulance services, emergency care, primary healthcare, mental health services and alcohol and drug recovery services. Discussions centred on emergency care experiences, reasons for access and underlying health and social needs.

Results

Participants included 20 people experiencing homelessness (aged 18-56, 70% male) and 18 service professionals (aged 20-56, 56% female). Emergency care was often viewed by participants as an accessible safe place. Four key themes were found in this rural and coastal context: accessibility challenges due to limited public transport and geographic isolation; fragmented support exacerbated by widely dispersed services; service restrictions and limited alternatives having particular impact where options are few and prioritisation of immediate needs influenced by limited local resources.

Conclusion

Challenges in accessing primary healthcare and social care, alongside varying levels of timely support and understanding of individual contexts, can contribute to the increased use of emergency care for people experiencing homelessness in rural and coastal areas. Integrating services with a focus on flexibility could be crucial for addressing the needs of these populations. This involves adapting to the unique circumstances of multiple deprived groups who lack access to community support.

Managing Health Without Stable Housing: Dimensions of Treatment Burden and Patient Capacity for People With Chronic Health Conditions Experiencing Homelessness

Although chronic health conditions and homelessness are prevalent problems in the United States and globally, little research has used the lens of burden of treatment theory to examine the experiences of people facing these challenges simultaneously. This study aimed to illuminate dimensions of treatment burden, which refers to the work of being a patient with chronic conditions, and patient capacity to manage this burden in a sample of people experiencing homelessness and chronic health problems in Buffalo, New York, United States. We completed in-depth interviews with men and women recruited from a homelessness services organization (N = 27) and applied core concepts from burden of treatment theory to our analysis to probe how participants navigated tasks related to treatment and self-care. Using codebook thematic analysis involving three coders, results revealed four interconnected themes of complex coordination, self-monitoring, obtaining and using prescriptions and medical supplies, and communication and explaining health issues, which were confirmed through member checking (N = 6). These dimensions of treatment burden were dynamically impacted by patient capacity factors-which included trauma, medical mistrust, health literacy, and social support-as well as by social determinants of health such as housing and income. Findings support the need for more formal collaboration mechanisms between healthcare providers and social service agencies, active involvement of patients in their health plans, and policies such as Housing First to improve access to stable and affordable housing and social services for people with complex health issues.

Homelessness and Organ Donor-Derived Bartonella quintana Infection

Louseborne Bartonella quintana infections in the United States occur almost exclusively among persons experiencing homelessness because of inadequate access to hygiene resources. Homelessness is increasing, and persons experiencing homelessness can be organ donors, despite barriers to receiving donated organs themselves. Recent reports have documented B. quintana transmission via organs transplanted from donors who had recently experienced homelessness. Those reports demonstrate the threat of severe bartonellosis in immunosuppressed organ transplant recipients after donor-derived B. quintana infection. Addressing the root causes of B. quintana transmission could improve the quality of life for persons experiencing homelessness and simultaneously mitigate risk for donor-derived B. quintana transmission. Interventions include improved access to housing, consistent access to hot water for showers and laundry, early treatment of body lice infestation and B. quintana infection, and B. quintana testing and prophylactic treatment of recipients of organs from donors who have experienced risk factors for B. quintana, including homelessness.

Health Status of People Who Are and Are Not Experiencing Homelessness: Opportunities for Improvement

This study assessed the physical and psychological health parameters of adults experiencing homelessness to inform the development and delivery of health services by comparing with a housed population in the same South Australian city. Adults experiencing homelessness, known to existing support services, were invited to participate in a comprehensive assessment of their physical and mental health using questionnaires and objective assessments. Descriptive analyses using the percentage of participants failing to attain recommended published thresholds and accumulated health deficits for 16 health assessments were compared for the young group of people experiencing homelessness (18-40 years), the middle aged and older people experiencing homelessness (40-75 years), and a housed population of the middle aged and older people (40-75 years). Those experiencing homelessness had multiple and potentially inter-related health deficits compared with a population of people not experiencing homelessness in the same city. They were significantly less likely to meet healthy population norms for clinical frailty (p < 0.001), psychological distress (p < 0.001), grip strength (p < 0.001), lung function (p < 0.001), sleep quality (p < 0.001), and pelvic floor bother (p = 0.002). Significantly more accumulated health deficits were found for people experiencing homelessness when compared with the same ages for those who were not (mean 6.5 (SD 2.4) compared with 5.0 (SD 2.1)). This considerably increased for people experiencing homelessness aged less than 40 years (mean 8.7 (1.7)). Priorities for health service provision for people of different ages experiencing homelessness, when compared with housed community dwellers, have been described. The provision of targeted health assessments and service provision that specifically address healthcare needs among people experiencing homelessness are likely to have the biggest impacts across multiple health domains.

Barriers and facilitators to healthy eating in disadvantaged adults living in the UK: a scoping review

In the UK people living in disadvantaged communities are less likely than those with higher socio-economic status to have a healthy diet. To address this inequality, it is crucial scientists, practitioners and policy makers understand the factors that hinder and assist healthy food choice in these individuals. In this scoping review, we aimed to identify barriers and facilitators to healthy eating among disadvantaged individuals living in the UK. Additionally, we used the Theoretical Domains Framework (TDF) to synthesise results and provide a guide for the development of theory-informed behaviour change interventions. Five databases were searched, (CINAHL, Embase, MEDLINE, PsycINFO, and Web of Science) for articles assessing healthy dietary intake of disadvantaged adults living in the UK. A total of 50 papers (34 quantitative; 16 qualitative) were included in this review. Across all studies we identified 78 barriers and 49 facilitators found to either impede and/or encourage healthy eating. Both barriers and facilitators were more commonly classified under the Environmental, Context and Resources TDF domain, with 74% of studies assessing at least one factor pertaining to this domain. Results thus indicate that context related factors such as high cost and accessibility of healthy food, rather than personal factors, such as lack of efficiency in healthy lifestyle drive unhealthy eating in disadvantaged individuals in the UK. We discuss how such factors are largely overlooked in current interventions and propose that more effort should be directed towards implementing interventions that specifically target infrastructures rather than individuals.

Healthcare and housing provision for a UK homeless community: a qualitative service evaluation

OBJECTIVES

Homelessness is both a significant determinant and consequence of health and social inequalities. To better meet healthcare needs, dedicated mental health and general nurses were implemented to deliver outreach healthcare to people experiencing homelessness in one United Kingdom (UK) county. During COVID-19, the UK Government also instructed local authorities to accommodate individuals sleeping rough and have a national target to end rough sleeping. This qualitative study explored experiences of this nurse-let outreach service and housing journeys during and beyond COVID-19 among people experiencing homelessness.

STUDY DESIGN

Face-to-face, narrative storytelling interviews were conducted via opportunistic sampling in community settings. Individuals with recent or current experiences of homelessness were eligible.

METHODS

Participants were informed about the study via known professionals and introduced to the researcher. Eighteen narrative interviews were conducted, transcribed, and analysed using reflective thematic analysis.

RESULTS

Individuals described complex journeys in becoming and being homeless. The nurse-led outreach service provided integral support, with reported benefits to person-centred and accessible care and improved outcomes in health and well-being. After being housed, individuals valued housing necessities and described new responsibilities. However, some participants did not accept or stay in housing provisions where they perceived risks.

CONCLUSIONS

Interviewed participants perceived that the dedicated nurse-led outreach service improved their access to care and health outcomes. In the absence of dedicated provisions, mainstream healthcare should ensure flexible processes and collaborative professional working. Local authorities must also be afforded increased resources for housing, as well as integrated support, to reduce social and health inequalities.

Health literacy and its association with mental and spiritual well-being among women experiencing homelessness

Low health literacy (HL) has been linked to low self-rated health, reduced efficacy of behaviour change, and challenges in preventing, treating, or managing health conditions. People experiencing homelessness are at risk of poor HL; however, few studies have investigated HL in relation to mental and spiritual well-being among people experiencing homelessness in general, or women experiencing homelessness specifically. This cross-sectional study of 46 women experiencing homelessness in Stockholm, Sweden, recruited during the period October 2019-December 2020, aimed to examine how HL was associated with mental and spiritual well-being among women experiencing homelessness. Participants answered questions about socio-demographic characteristics (age, length of homelessness, education) and digital technology (mobile phone/the Internet) use, in addition to Swedish language versions of three questionnaires administered through structured, face-to-face interviews: the Communicative and Critical Health Literacy Scale, the General Health Questionnaire 12 and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being. Data were analysed using linear regression, which revealed statistically significant associations between HL and mental well-being (p = .009), and between HL and spiritual well-being (p = .022). However, neither socio-demographic characteristics nor digital technology use were significantly associated with HL. In conclusion, promoting HL may improve mental and spiritual well-being in this vulnerable population. An advisory board of women with lived experiences of homelessness (n = 5) supported the interpretation of the findings and emphasised the need to consider HL in relation to basic needs such as 'housing first'. Moreover, health information and services should be accessible to people with different degrees of HL.

The experience of food insecurity during and following homelessness in high-income countries: A systematic review and meta-aggregation

Homelessness is a pervasive challenge caused by poverty which continues to grow in economically developed countries, posing significant health impacts (Fazel et al., Lancet, 384: 1529-1540, 2014). While food security related to poverty and low income has been investigated, this review specifically explores the experience of food security during and following homelessness. Given the fact that the health of individuals who experience homelessness is known to be poor and the importance of nutrition, this is a necessary contribution. Informed by a health equity lens, this review synthesises the findings and quality of the literature regarding experiences of food security during and following homelessness in high-income countries. We used the Joanna Briggs Institute methodology, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Qualitative studies published to date were obtained from six databases. We conducted a meta-aggregation of existing qualitative findings. Twenty-four studies on 462 participants were included in the review. Through meta-aggregation four themes were created: (1) imposed food options as a determinant of health out of my control; (2) obtaining food for survival despite stigma or other consequences; (3) situated within a system that maintains food insecurity; and (4) surviving hardships. Persons during and following homelessness in high-income countries face multiple challenges when securing food while situated in an oppressive system that lacks choice. Despite this, persons who have experienced homelessness demonstrate resilience by finding ways to meet their basic needs in the face of imposed barriers. Implications for research, policy and practice are offered.

Provision of services to persons experiencing homelessness during the COVID-19 pandemic: A qualitative study on the perspectives of homelessness service providers

This study aimed to explore the perspectives of homelessness service providers on the impact of the COVID-19 pandemic on service provision, barriers encountered and learning for the future. Semi-structured online interviews were conducted with homelessness service providers (n = 15) identified through the network of homelessness services operating within the United Kingdom. Data were transcribed verbatim and analysed thematically using framework technique. Six key themes were identified including the impact of the pandemic on health and well-being of persons experiencing homelessness (PEH); the changing needs of service users during the pandemic; impact of emergency provision of housing support on services offered; service adaptations; sustainability of services and learnings from the pandemic. Participants described that being able to offer accommodation through government schemes provided protection to PEH through 'wrap-around support'. The pandemic was deemed to have precipitated change and developed resilience in some services. However, lack of resources, donations and sponsors during the pandemic constrained the services forcing many to close or offer reduced services. Reduced face-to-face contact with PEH and lack of ability to offer skills sessions led to the exacerbation of mental health concerns amongst clients. The pandemic was also identified to have encouraged positive relationship building between clients and service providers, better communications between service providers and effective housing of PEH. There is a need to address the barriers, sustain the positive learnings and enable organisations and PEH to adapt to the transition when transient and emergency support from the government and local councils ends.

Medicines prescribing for homeless persons: analysis of prescription data from specialist homelessness general practices

Background

Specialist homelessness practices remain the main primary care access point for many persons experiencing homelessness. Prescribing practices are poorly understood in this population.

Objective

This study aims to investigate prescribing of medicines to homeless persons who present to specialist homelessness primary care practices and compares the data with the general population.

Setting

Analyses of publicly available prescribing and demographics data pertaining to primary care in England.

Methods

Prescribing data from 15 specialist homelessness practices in England were extracted for the period 04/2019-03/2020 and compared with data from (a) general populations, (b) the most deprived populations, and (c) the least deprived populations in England.

Main outcome measure

Prescribing rates, measured as the number of items/1000 population in key disease areas.

Results

Data corresponding to 20,572 homeless persons was included. Marked disparity were observed in regards to prescribing rates of drugs for Central Nervous System disorders. For example, prescribing rates were 83-fold (mean (SD) 1296.7(1447.6) vs. 15.7(9.2) p = 0.033) items), and 12-fold (p = 0.018) higher amongst homeless populations for opioid dependence and psychosis disorders respectively compared to the general populations. Differences with populations in the least deprived populations were even higher. Prescribing medicines for other long-term conditions other than mental health and substance misuse was lower in the homeless than in the general population.

Conclusions

Most of the prescribing activities in the homeless population relate to mental health conditions and substance misuse. It is possible that other long-term conditions that overlap with homelessness are under-diagnosed and under-managed. Wide variations in data across practices needs investigation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11096-022-01399-3.

A Scoping Review of the Health Impact of the COVID-19 Pandemic on Persons Experiencing Homelessness in North America and Europe

Persons experiencing homelessness (PEH) are at heightened risk for infection, morbidity, and mortality from COVID-19. However, health consequences of the pandemic extend far beyond those directly caused by the virus. This scoping review aimed to explore the impacts of the COVID-19 pandemic on the health and well-being of PEH in North America and Europe. A systematic search of academic and grey literature was conducted in September 2021. To be included, studies had to include primary data related to the impact of the pandemic on health or well-being of PEH and be written in English. All potentially relevant references were independently screened by two reviewers, and minor conflicts were settled with input of a third reviewer. A total of 96 articles met criteria for inclusion. Data extraction was completed for all included studies, and findings synthesised and presented thematically. Numerous health impacts of the pandemic on PEH were identified, including SARS-CoV-2 infection, morbidity, mortality, and hospitalisation, fear of infection, access to housing, hygiene, PPE, food, as well as mental health, substance use, other health-related outcomes and treatment services. Gaps in the literature relating to persons using alcohol, access to mental health support, and violence were also identified. Implications for future research are discussed.

Gambling and homelessness: A systematic review and meta-analysis of prevalence

INTRODUCTION

There is growing concern internationally about co-occurring gambling and homelessness. We systematically review prevalence estimates in help-seeking and community samples.

METHODS

Adopting PRISMA guidelines, we searched CINAHL Plus, Cochrane Library, Embase, Ovid MEDLINE, PsychINFO, Proquest Central, PubMed, Scopus, Web of Science, and Google Scholar for relevant peer-reviewed articles in English. Primary outcomes examined in narrative and quantitative syntheses included prevalence of: (i) gambling in persons experiencing homelessness; (ii) harmful gambling in persons experiencing homelessness; and, (iii) homelessness in persons experiencing harmful gambling.

RESULTS

Searches identified 917 records after removing duplicates. After screening, 45 articles providing 54 prevalence estimates across 12 countries were included, with help-seeking (k = 37) and community based sample (k = 8) estimates pooled separately. Gambling prevalence (all timeframes) in help-seeking samples of persons experiencing homelessness is low (28.7%, 95% CI: 17.3-41.7, k = 14) compared to the general population (approximately 60-80%). However, harmful gambling prevalence (including problem, pathological, and disordered gambling) in help-seeking samples of persons experiencing homelessness is high (16.5%, 95% CI: 10.2-24.2, k = 20) compared to the general population (approximately 1-7%). Additionally, homelessness prevalence is high in help-seeking samples of persons experiencing harmful gambling (23.6%, 95% CI: 18.4-29.2, k = 4) compared to the general population (<1%). Meta-analysis found high between-study heterogeneity and risk of bias from small samples sizes.

CONCLUSIONS

There are high rates of harmful gambling in persons experiencing homelessness and, concurrently, high rates of homelessness in persons experiencing harmful gambling. Improvements in sampling and measurement are needed to strengthen robustness and generalizability of prevalence estimates, which can potentially inform the scale and targeting of clinical interventions, support services, and policy responses.

Validação de álbum seriado sobre redução de danos para pessoas em situação de rua

Resumo Este estudo buscou construir e validar um álbum seriado sobre redução de danos para pessoas em situação de rua. Foi desenvolvida pesquisa metodológica para a construção e validação do álbum seriado por 22 juízes especialistas. Foi considerado índice de concordância de, no mínimo, 80% para se garantir a validação do material. Houve nível de concordância de 100% quanto aos objetivos do material, assim como sua relevância para prática clínica. A estrutura e apresentação obteve concordância de 95,5%. Assim, o índice de validade de conteúdo global na validação com juízes foi igual a 0,99, o que confirma a validação de conteúdo e aparência junto aos especialistas da área. A tecnologia foi considerada válida quanto ao conteúdo, podendo ser utilizada como ferramenta educativa sobre redução de danos, e como meio de aproximação e construção de vínculo do profissional com pessoas em situação de rua nos serviços de saúde e assistência social.

Representation of persons experiencing homelessness and coding of homelessness in general practices: descriptive evaluation using healthcare utilisation data

Background

Epidemiological studies focused on primary healthcare needs of persons experiencing homelessness (PEH) are often based on data from specialist homeless healthcare services.

Aim

To explore the presentation of PEH, coding of homelessness, and associated health conditions in mainstream primary care general practices in England.

Design & setting

EMIS electronic database search of medical records was conducted across 48 general practices in a clinical commissioning group (CCG), representing one of the most socioeconomically deprived regions in England, which also lacks a specialist primary healthcare service for PEH.

Method

Key terms and codes were used to identify PEH, their respective diagnoses across 22 health conditions, and prescribed medications over the past 4 years.

Results

From a population of approximately 321 000, 43 (0.013%) people were coded as PEH, compared with a homelessness prevalence of 0.5% in the English general population. Mental health conditions were the most prevalent diagnoses among the PEH registrants (56.6%); the recorded prevalence of other common long-term conditions in PEH was lower than the levels observed in PEH registered with specialist homelessness health services.

Conclusion

In a population with approximately four times higher rate of statutory homelessness, PEH representation in mainstream general practices was under-represented by several folds. As homelessness overlaps with mental health, substance misuse, and long-term health conditions, consistent coding of homelessness in medical records is imperative in order to offer tailored support and prevention actions when patients present for services.

Clinical characteristics, attendance outcomes and deaths of homeless persons in the emergency department: implications for primary health care and community prevention programmes

OBJECTIVES

Persons experiencing homelessness (PEH) are known to be often excluded from primary health care and community prevention programmes leading to high use of hospital emergency departments (EDs). This study aimed to identify demographic features, clinical characteristics and attendance outcomes of PEH presenting to ED.

STUDY DESIGN

Analysis of routinely collected data set.

METHODS

Clinical presentations and drug prescription data of PEH who presented a major ED in the West Midlands region of England from 2014 to 2019 were extracted and analysed using descriptive and inferential statistics.

RESULTS

During the study period, 3271 of 596,198 presentations were made by PEH; 74% PEH attendees were male. Drug- and alcohol-related conditions, as well as pain and injury constituted the most frequent reasons for presentation, contributing to over half of all presentations. A significantly higher proportion of males (n = 481, 20.3%) presented with drug and alcohol problems than females (n = 93, 11.2%) (P ≤ 0.001). However, pain was the primary reason for presentation for twice as many female patients (n = 189, 22.8%) compared with males (n = 305, 12.9%) (P < 0.001). Nearly one in five left the ED before being assessed and a total of 39 patients (1.2%) died in the ED and 785 (24.0%) required in-patient admissions to the same hospital.

CONCLUSIONS

Drug, alcohol and pain including the need of opioid analgesics constituted the majority of presentations made by PEH in ED. The observed rate of death of PEH in ED is 12 times higher than the general population. A very high proportion of PEH also leave the ED before being treated. Future research should focus on strengthening community interventions, particularly to improve access to those at risk of dual diagnoses of substance misuse and mental health problems. Interventions involving multisector collaborations are needed to improve seamless discharge from ED and minimise repeat attendance. Gender differences in the nature of presentations and ED outcomes needs to be investigated further.

Scope, quality and inclusivity of international clinical guidelines on mental health and substance abuse in relation to dual diagnosis, social and community outcomes: a systematic review

OBJECTIVE

It is estimated that up to 75% of patients with severe mental illness (SMI) also have substance use disorder (SUD). The aim of this systematic review was to explore the scope, quality and inclusivity of international clinical guidelines on mental health and/or substance abuse in relation to diagnosis and treatment of co-existing disorders and considerations for wider social and contextual factors in treatment recommendations.

METHOD

A protocol (PROSPERO CRD42020187094) driven systematic review was conducted. A systematic search was undertaken using six databases including MEDLINE, Cochrane Library, EMBASE, PsychInfo from 2010 till June 2020; and webpages of guideline bodies and professional societies. Guideline quality was assessed based on 'Appraisal of Guidelines for Research & Evaluation II' (AGREE II) tool. Data was extracted using a pre-piloted structured data extraction form and synthesized narratively. Reporting was based on PRISMA guideline.

RESULT

A total of 12,644 records were identified. Of these, 21 guidelines were included in this review. Three of the included guidelines were related to coexisting disorders, 11 related to SMI, and 7 guidelines were related to SUD. Seven (out of 18) single disorder guidelines did not adequately recommend the importance of diagnosis or treatment of concurrent disorders despite their high co-prevalence. The majority of the guidelines (n = 15) lacked recommendations for medicines optimisation in accordance with concurrent disorders (SMI or SUD) such as in the context of drug interactions. Social cause and consequence of dual diagnosis such as homelessness and safeguarding and associated referral pathways were sparsely mentioned.

CONCLUSION

Despite very high co-prevalence, clinical guidelines for SUD or SMI tend to have limited considerations for coexisting disorders in diagnosis, treatment and management. There is a need to improve the scope, quality and inclusivity of guidelines to offer person-centred and integrated care.

Perceived barriers and facilitators to uptake of non-traditional roles by pharmacists in Saudi Arabia and implications for COVID-19 pandemic and beyond: a qualitative study using Theoretical Domain Framework

Background

The COVID-19 pandemic has further strengthened the need for pharmacists to uptake non-traditional roles. Pharmacy practice in Saudi Arabia is emerging in recent years with greater policy emphasis on pharmacists taking new clinical roles. This study aimed to explore the experiences, perceptions and barriers of Saudi pharmacists about their uptake of non-traditional roles using Theoretical Domains Framework (TDF).

Methods

A qualitative semi-structured study using face-to-face or telephone interviews were conducted. Eligible participants included qualified pharmacists from Saudi Arabia. Interviews focused on pharmacist’s perceptions, current opportunities and key challenges towards the uptake of non-traditional roles. Interviews were audiotaped and transcribed verbatim. Results were analysed through the framework analysis method and were later mapped with respective domains of TDF.

Results

A total of 14 pharmacists completed the interview (9 females and 5 males). Participants showed an overall positive attitude towards the uptake of non-traditional roles. Participants felt that there was wider support available for pharmacists at the policy level to uptake non-traditional roles. However, a need for greater recognition of roles by other healthcare professionals and patients were identified. Participants alluded to reluctance of some physicians to take on board the suggestions from a pharmacist. Key barriers to uptake of non-traditional roles were related to environmental context and resources domain of TDF. For example, participants discussed the need for even further practical experiences during their undergraduate degree to become ready to adopt non-traditional roles in clinical practice.

Conclusions

Participants of this theoretically informed qualitative study showed an overall positive attitude towards the way pharmacy practice is progressing in Saudi Arabia and their uptake of non-traditional roles. However, there is a need to improve interdisciplinary working, patient awareness of pharmacist competencies and their educational preparedness in furthering their uptake of non-traditional roles. Addressing such barriers and promoting uptake of novel roles by pharmacists is imperative in the context of emerging COVID-19 and future pandemics.

Barriers to monitoring and management of cardiovascular and metabolic health of patients prescribed antipsychotic drugs: a systematic review

BACKGROUND

The use of atypical antipsychotics which currently form the primary choice pharmacotherapy for several mental health conditions have been linked to cardiovascular and metabolic side effects. This systematic review aimed to investigate the barriers to monitoring and management of cardiovascular co-morbidities in patients prescribed antipsychotic medicines.

METHODS

A protocol-led (CRD-42018106002) systematic literature review was conducted by searching Medline, Embase, and PsycINFO databases 2003 until October 2019. Cochrane, Centre for Review and Dissemination (CRD) and PRISMA guidelines were followed. Studies investigating barriers to monitoring and management of cardiovascular co-morbidities in patients prescribed antipsychotic medicines were included.

RESULTS

A total of 23 records were included. Key barriers included a) health-care system-related factors such as lack of knowledge and expertise amongst care providers, available resources, confusion around remit and roles, fragmentation of care such as across general practitioners and psychiatrists, and time constraints and b) patient-related factors such as disability resulting from mental health conditions, knowledge and skills of the patients.

CONCLUSION

Barriers to monitoring and management of cardiovascular and metabolic health of patients taking antipsychotic medicines are multidimensional. Apart from educational interventions directed to both patients and health-care professionals, the results suggest a need for the improvement of wider system-related factors to improve physical health of patients prescribed antipsychotic medicines. Clearer guidelines, clarity of remit and roles amongst service providers are necessary in addition to educational interventions directed at patients and health-care professionals in improving physical health monitoring, counselling and management of patients prescribed antipsychotic medicines.

TRIAL REGISTRATION

A protocol was developed and registered with PROSPERO as per PRISMA-P guidelines ( CRD 42018106002 ).

Current status of opioid epidemic in the United Kingdom and strategies for treatment optimisation in chronic pain

The increase in opioid prescriptions in the United States has been accompanied by an increase in misuse as well as overdose and toxicity related morbidity and mortality. However, the extent of the increased opioid use, including misuse in the United Kingdom, currently remains less debated. Recent studies in the United Kingdom have shown a rise in opioid use and attributed deaths, particularly in areas with higher deprivation. There are also large variations amongst the devolved nations; Scotland has the highest drug-related deaths and year-on-year increase within Europe. Better clinical guidelines that can enable person-centred management of chronic pain, medicines optimisation, and early diagnosis and treatment of opioid use disorder are crucial to addressing opioid-related morbidity and mortality in the United Kingdom.

Air Pollution-Related Health Impacts on Individuals Experiencing Homelessness: Environmental Justice and Health Vulnerability in Salt Lake County, Utah

Experiences of homelessness, although widely varied, are characterized by extensive time in public spaces, often outdoors. However, there has been little empirical research about the ways in which environmental factors affect individuals experiencing homelessness (IEHs). Therefore, the purpose of this study was to use an environmental justice approach to understand how cardiopulmonary health of IEHs is affected by episodic poor air quality in Salt Lake County. It was hypothesized that people who had experienced unsheltered homelessness and those who had been experiencing homelessness for longer periods of time would report greater health difficulties from poor air quality exposure. Through a combination of in-person semistructured interviews with IEHs (n = 138) and access to corresponding state-based service provider databases, researchers examined both overall descriptives of and relationships between types (sheltered and unsheltered) and duration (chronic and nonchronic) of homelessness. More than 61% of IEHs reported physical reactions to air pollution, 37% reported air pollution-related emotional stress, and more than 89% had sought medical attention for a condition related to air pollution. Findings indicate that while IEHs report a number of health effects related to poor air quality, there were no significant differences between individuals based on either sheltered status or duration of their experiences of homelessness. This study provides an initial empirical inquiry to understand how environmental disamenities negatively influence IEHs, as well as noting that sheltered status and duration of homelessness are less impactful than originally hypothesized.

Health, illness and healthcare-seeking behaviour of the street dwellers of Dhaka City, Bangladesh: qualitative exploratory study

OBJECTIVE

This study explored the illness experiences and healthcare-seeking behaviour of a cross-section of street dwellers of Dhaka City for designing a customised intervention.

DESIGN

A qualitative exploratory study of a sample of street dwellers of Dhaka City.

SETTING

Samples were taken from three purposively selected spots of Dhaka City with a high concentration of the target population.

PARTICIPANTS

Fifteen in-depth interviews and six informal group discussions with 40 street dwellers (≥18 years), and key informant interviews with service providers (n=6) and policymakers (n=3) were conducted during January-June 2019 to elicit necessary data.

PRIMARY OUTCOME MEASURES

Qualitative narrative of illness experiences of the sampled street dwellers, relevant healthcare-seeking behaviour and experiences of interactions with health systems.

RESULTS

We focused on three main themes, namely, reported illnesses, relevant healthcare-seeking behaviour and health system experiences of the street dwellers. Findings reveal that most of the street dwellers suffered from fever and respiratory illnesses in the last 6 months; however, a majority did not visit formal facilities. They preferred visiting retail drug shops for advice and treatment or waited for self-recovery. Formal facilities were visited only when treatment from drug shops failed to cure them or they suffered serious illnesses or traumatic injury. The reproductive-age women did not seek pregnancy care and most deliveries took place in the street dwellings. Lack of awareness, financial constraints and fear of visiting formal facilities were some of the reasons mentioned. Those who visited formal facilities faced barriers like the cost of medicines and diagnostic tests, long waiting time and opportunity cost.

CONCLUSIONS

The street dwellers lacked access to formal health systems for needed services as the latter lags far behind to outreach this extremely vulnerable population. What they need is explicit targeting with a customised package of services based on their illness profile, at a time and place convenient to them with minimum or no cost implications.

'Genuine doctor care': Perspectives on general practice and community-based care of Australian men experiencing homelessness

People with complex health and social needs, including tri-morbidity and homelessness, are challenging for modern healthcare systems. These clients have poor health and social outcomes. They tend to use available health resources inefficiently, with fragmented, uncoordinated use of multiple health and social care services. Increasing access for these clients to well-supported general practice care may be an effective response to these challenges. The aim of this study was to explore client experiences of, and attitudes to, community-based healthcare, and general practice in particular, to identify opportunities to improve healthcare provision. Five focus groups with a total of 20 men currently experiencing homelessness were facilitated by the corresponding author in an inner-city homeless hostel. Discussions were transcribed, coded and analysed thematically. The analysis was informed by earlier focus group discussions with community-based homeless healthcare providers. Participants reported reluctance to engage with healthcare providers outside times of perceived crisis, and experiences of stigma and dismissive care. Some participants were sceptical of the motivations of health and social care providers, including general practitioners. Presentations with physical and psychological pain featured prominently in participant accounts. Three key themes identified important aspects of client experiences of community-based healthcare which indicate potential areas for improvement. These themes were as follows: the relative invisibility and low salience of general practice compared to hospital-based emergency and inpatient services; discontinuity within community-based healthcare and across transitions between community-based and other healthcare; and inconsistent and unsatisfactory general practitioner responses to physical and psychological pain. These responses included apparent over-prescribing, under-prescribing and short-term 'band-aid' responses. Generalist medical expertise was valued in general practitioners, but not consistently experienced. A number of challenges and opportunities exist, at both individual and system levels, for general practice to realise its potential to deliver effective, compassionate and efficient care to clients experiencing homelessness.

Research priorities in healthcare of persons experiencing homelessness: outcomes of a national multi-disciplinary stakeholder discussion in the United Kingdom

Background

Persons experiencing homelessness (PEH) face up to twelve times higher mortality rates compared to the general population. There is a need to develop, evaluate and implement novel interventions to minimise such inequalities. This paper aims to present outcomes of a national stakeholder engagement event that was conducted to discuss research priorities around healthcare of PEH in the United Kingdom (UK).

Main body

A national stakeholder event was organised in Birmingham, UK. This workshop aimed to engage diverse stakeholders from a variety of background including representations from clinical practice, substance misuse, anti-slavery network, public health practice, local authority, homelessness charities, drugs and alcohol services, Public Health England and academia.

A total of five key priority areas for research were identified which included: a) interventions to improve access to health services and preventative services; b) interventions to prevent drug and alcohol related deaths; c) improving existing services through quality improvement; d) identifying PEH’s preferences of services; and e) interventions to break the link between vulnerabilities, particularly- modern day slavery and homelessness. Effective partnerships across diverse stakeholder groups were deemed to be imperative in developing, testing and implementing novel interventions.

Conclusions

Maximising access to services, prevention of early deaths linked to drugs and alcohol, and identifying effective and ineffective policies and programmes were identified as priority research areas in relation to healthcare of PEH. The outcomes of this discussion will enable design and conduct of interdisciplinary research programmes to address the syndemics of homelessness and linked adverse health outcomes. Priorities identified here are likely to be applicable internationally.

Clinical Pharmacy Intervention for Persons Experiencing Homelessness: Evaluation of Patient Perspectives in Service Design and Development

Persons experiencing homelessness have a high prevalence of severe mental health problems, alcohol dependence, substance misuse and infectious hepatitis C, and face up to twelve times higher mortality rates compared to the general population. They also face barriers to accessing healthcare. However, clinical pharmacy services are currently not available to homeless populations in England. The aim of this study was to conduct public involvement sessions with persons experiencing homelessness with a view to inform the design of patient-centred clinical pharmacy healthcare services. Qualitative methodology was used, using a focus group with homeless persons from emergency shelters and one to one engagement with those sleeping rough, using a topic guide. A total of nine homeless persons took part—seven males and two females. The participants of the sessions said that patient-centred clinical pharmacy services delivered for homeless persons would address many of their unmet needs around access to medicines, their understanding of prescribed medicines and holistic management of their health. The service would be able to make a positive impact on their health outcomes by screening for health conditions, facilitating better integration across services, referral and liaison with other services, and minimising misuse of prescribed medicines. The findings of this study will be used to inform the development, implementation and evaluation of a patient-centred clinical pharmacy service tailored to meet the specific needs of the homeless population.