Homeless persons' experiences of health- and social care: A systematic integrative review

The Experiences of Adults Experiencing Homelessness When Accessing and Using Psychosocial Interventions: A Systematic Review and Qualitative Evidence Synthesis

Background

Adults experiencing homelessness in high-income countries are more likely to have mental ill-health and engage in problematic substance use. They are also more likely to experience challenges when accessing services. Psychosocial interventions are increasingly used with this group. Most of the evidence around these interventions is not specific to their use with adults experiencing homelessness.

Objectives

To summarise the best available evidence of the views and experiences of adults experiencing homelessness in high-income countries about psychosocial interventions.

Search Methods

This review is based on evidence identified in an Evidence and Gap Map (EGM) on interventions for people experiencing homelessness. The EGM searches were conducted in September 2021. Additionally, we undertook a call for evidence and hand searches of key journals.

Selection Criteria

We included qualitative data from studies of psychosocial interventions. Participants were adults aged 18+ experiencing homelessness in high-income countries. Only studies that reported the views, opinions, perceptions, and experiences of participants were included.

Data Collection and Analysis

Of the 468 studies originally screened, 17 were eligible for full-text review, which was undertaken independently by two reviewers. Ten were excluded at this stage, and seven were identified as meeting the inclusion criteria. Analysis was undertaken using thematic synthesis in three stages: (1) findings data were extracted from studies. Two reviewers independently extracted findings from included studies. These were compared and agreed on which findings to include for analysis; (2) two reviewers gave each line of extracted data a descriptive code (a short descriptive summary). These were compared and a set of codes for inclusion in the next stage of analysis was agreed; (3) the reviewers iteratively examined the descriptive themes, inferring from these themes the experiences of participants and their perceptions of how the intervention worked for them. These analytical themes were discussed with a panel of people with experience of homelessness.

Main Results

Seven studies were included in this review, covering several intervention types. A total of 84 adults experiencing homelessness were included in these studies. Three studies were conducted in Canada, three in the United States, and one in Scotland. All were published after 2009. The studies used various qualitative methods of data collection and analysis. None of the included studies were assessed as high quality. The most significant area of concern across the included studies concerned relationships between researchers and research participants, where five included studies were assessed as low quality. Areas of higher quality were clarity of research questions and methods. Overall, 368 lines of findings were extracted and coded under 118 descriptive codes. Of these, 55 related to direct quotes of participants' views and experiences. The remainder were the study authors' interpretations of the research participants' experiences. The 118 descriptive codes were grouped into 14 descriptive themes. The themes are descriptions of patterns in the data (the findings extracted from the included studies). These 14 descriptive themes (and the 118 descriptive codes underpinning them) summarise data from the primary studies. The final analysis stage was interpretation of the descriptive themes and development of analytical themes to answer the review questions. The reviewers were able to answer two of the four review questions: the experiences of participants when using psychosocial interventions, and whether they felt the interventions worked for them. The question concerning underlying theories of how the interventions are intended to work was addressed through a separate analysis. The question of differences between interventions could not be answered because of the small number of included studies. The final analysis stage identified three analytical themes. These are: (1) the individual plays a pivotal role in their recovery and change journey; (2) accessibility is a key component of intervention success; and (3) relationships are an important intervention ingredient.

Author's Conclusions

The reviewers draw two broad conclusions from this analysis: (1) it is important to place adults experiencing homelessness at the centre of the design of psychosocial interventions; and (2) it is important to treat adults experiencing homelessness as individuals.

Understanding root causes of homelessness in Marin County, CA and prevention strategies through semi-structured interviews and constant comparative analysis

INTRODUCTION

Even with the increased prevalence of homelessness in the US, there is limited research that investigates circumstances that can lead to homelessness, especially in affluent communities in California. This lack of understanding, even when resources are available, perpetuates the inequities in health and wellbeing statewide, connection to basic necessities, effective prevention strategies, and meaningful policy changes.

METHODS

This qualitative analysis consisted of a total of 24, semi-structured interviews conducted in the Spring of 2023 by public health researchers. Participants (18 and older) who were seeking support from a local community partner (the Ritter Center) were interviewed. Interviews consisted of a verbal consent in English and a set of IRB approved questions about the participants life circumstances and background that may have led to homelessness. Transcribed interviews were coded, and several themes emerged.

RESULTS

Thematic analysis supports three main themes: lack of resources, mental health struggles and past trauma, and safety and health issues. Lack of resources draws attention for more access to sustainable housing opportunities to prevent homeless in the first place. Struggles with mental health stemmed from extreme childhood trauma including stories of abandonment. Substance use and misuse were reported both before and after experiencing homelessness. Many participants expressed current concerns about their relationship with safety and overall health for many years.

CONCLUSIONS

Common themes suggest that there are recurrent circumstances that lead to individuals experiencing homelessness. Understanding the root causes of homelessness can help public health departments, local government and organizations implement upstream interventions to prevent the perpetuation of homelessness.

Barriers and delays to healthcare at time of death: qualitative analysis of Los Angeles County death records of people experiencing homelessness

BACKGROUND

Human health and homelessness are incompatible with one another. People experiencing homelessness (PEH) experience extreme health and social inequities, including a significantly higher mortality rate and lower life expectancy compared to the general adult population. While many studies have attempted to identify the most common causes of death, no study to our knowledge has sought to contextualize these deaths using death records. The objective of this study was to conduct a qualitative analysis of the Los Angeles County medical examiner records of people experiencing homelessness from 2018 in order to identify modifiable barriers and delays in accessing health care services.

METHODS

This study was a qualitative analysis of medical examiner records produced by the Los Angeles County Department of the Medical Examiner (DME). In 2019, the study's senior author (EC) entered into a data use agreement with DME to provide records of deaths (n = 998) among people experiencing homelessness in 2018. The DME dataset was entered into a single file for coding using NVivo 12. Using thematic analysis as outlined by Braun and Clarke, the authors iteratively identified themes related to barriers and delays in healthcare to create a codebook.

RESULTS

A strength of this study was its identification of barriers and delays to care themes (in italics) proximal to the deaths of PEH, an outcome that community and healthcare organizations aim to reduce. PEH are often suffering from extreme states of death due to advanced disease and have significant difficulty managing their health conditions, which manifests as medication non-adherence, missed dialysis, and a lack of preventative care. These factors, as well as disengagement and early termination of care and a lack of a bystander response to PEH distress may have contributed to these deaths.

CONCLUSIONS

People experiencing homelessness experience many barriers and delays to care which may be linked to untimely deaths. This study highlights the importance of healthcare and community organizations serving PEH to foster social cohesion, understand reasons for PEH's early termination and/or non-acceptance of care, and adopt equity-oriented care approaches, which aim to improve individuals' ability to engage in outpatient services and treatment.

Complementary medicine among individuals experiencing homelessness in Switzerland: a quantitative and qualitative descriptive study

BACKGROUND

People experiencing homelessness (PEH) are disproportionately affected by health issues yet remain underserved by the health care system. Emerging findings suggest that complementary medicine (CM) approaches might help address the low access to earlier treatment and the complex needs of this population. Very little research has explored this topic in Europe. Thus, this study aimed to explore perceptions, experiences, and interests in CM among PEH in Switzerland.

METHODS

Participants (N = 123) were PEH in French-speaking Switzerland who completed a questionnaire assessing their use of and interest in CM. A subsample of the survey participants (n = 18) and 14 professionals working in the homeless-serving sector participated in semi-structured interviews exploring perceived utility of CM for PEH. Descriptive statistics and conventional content analysis were used to analyze quantitative and qualitative data, respectively.

RESULTS

Quantitative findings showed that despite high levels of interest in CM, less than 30% of participants reported using CM at least once in the previous 6 months. The five CM modalities with the highest interest were osteopathy (61.5% interested or very interested), therapeutic massage (59.2%), nutritional supplements (57.1%), music therapy (50.8%), and acupuncture (49.1%). The qualitative findings reinforced the substantial interest in CM. They revealed that CM approaches were perceived as useful to mitigate some health and social issues frequently encountered in this population, ultimately contributing to improved health and well-being. Participants made recommendations for practices that would help engage and retain PEH in a CM program, such as making it accessible and equitable, and following certain steps to earn the trust of PEH. Finally, a minority of participants questioned the relevance of a CM program for this population, arguing instead that more urgent social and conventional medical needs must be addressed first.

CONCLUSIONS

Taken together, these findings suggest that integrative medicine, which incorporates conventional and complementary approaches to medical and social services may represent a suitable offering for PEH to address their competing bio-psycho-social needs. Using a community-based participatory approach to co-develop such a program might help to ensure effectiveness and thereby increase health equity.

Health Care Access and Use Among Adults Experiencing Homelessness

Importance

Demographic and policy changes have occurred since the last large, representative study of homeless adults in the 1990s, which may affect health care access and use.

Objective

To describe the prevalence of poor health care access and short-term health care and use the Gelberg-Andersen Behavioral Model for Vulnerable Populations to assess the association between changes in homelessness with health care access and short-term care use.

Design, Setting, and Participants

This representative survey of adults experiencing homelessness in California from October 2021 to November 2022 used multistage, venue-based, and respondent-driven sampling. Data were analyzed from May 2023 to December 2024.

Exposures

Shelter status (predisposing vulnerable), insurance (enabling), impairment with activities of daily living (ADL; need), and illicit substance use during the previous 6 months (need).

Main Outcomes and Measures

The study assessed self-reported no prior-year ambulatory care use and prior 6-month unmet health care need, unmet medication need, emergency department (ED) use, and hospitalization. Population prevalence estimates with Wald 95% CIs and multivariable Poisson regressions were calculated to compute prevalence ratios (PRs).

Results

Thirty-two hundred adults completed the survey (mean age, 46.1 [95% CI, 45.3-46.9] years; 1965 cisgender men [67.2%], 1148 cisgender women [31.2%], and 57 transgender and gender queer individuals [1.6%]), of whom 2016 (77.6%) were unsheltered, 2609 (82.6%) were insured, 1056 (34.4%) had an ADL impairment, and 911 (37.1%) reported illicit substance use 3 or more times a week. A total of 1121 (39.1%) reported no ambulatory care use; 765 (24.3%) reported an unmet health care need and 714 (23.3%) an unmet medication need; 1252 (38.9%) used the ED; and 668 (22.0%) were hospitalized. Lack of ambulatory care use (PR, 1.71; 95% CI, 1.51-1.94) and unmet health care needs (PR, 1.19; 95% CI, 1.02-1.40) were more prevalent for those who were unsheltered. Lack of ambulatory care use (PR, 0.63; 95% CI, 0.57-0.70) and unmet health care needs (PR, 0.80; 95% CI, 0.67-0.95) were less prevalent for those with insurance. Unmet health care needs (PR, 2.13; 95% CI, 1.79-2.55), ED use (PR, 1.15; 95% CI, 1.02-1.30), and hospitalization (PR, 1.74; 95% CI, 1.40-2.17) were more prevalent for those with an ADL impairment. Lack of ambulatory care use (PR, 1.46; 95% CI, 1.19-1.79) and unmet health care needs (PR, 1.30; 95% CI, 1.08-1.55) were more prevalent for those who used illicit substances 3 or more times a week.

Conclusions and Relevance

This cross-sectional study found that adults experiencing homelessness reported poor access to ambulatory care and a high prevalence of short-term care use, despite high rates of insurance. Changes in homelessness during the past 30 years were associated with worsened health care access and use.

Barriers, facilitators and solutions to the care of people experiencing homelessness with traumatic brain injury in Quebec, Canada: clinicians' and concerned parties' perspectives

PURPOSE

People experiencing homelessness have disproportionately high rates of traumatic brain injury (TBI), yet services remain inaccessible or poorly adapted to their needs. Limited research has explored the barriers, facilitators and potential solutions to improve healthcare for this population. The objectives were to identify the individual- and environment-level barriers to healthcare for people experiencing homelessness who have sustained a TBI, identify the environment-level facilitators to care for this population, and identify potential solutions to improve care.

MATERIAL AND METHODS

A qualitative descriptive study was conducted and four focus groups were held (n = 20), consisting of healthcare professionals (n = 10), community workers (n = 6), and managers from both sectors (n = 4). Data were analyzed using Braun and Clarke's thematic analysis approach.

RESULTS

Participants reported: (1) healthcare structures misaligned with the realities of people experiencing homelessness; (2) reduced trust in health services by people experiencing homelessness; (3) reliance on overburdened community organizations lacking TBI expertise; and (4) transforming care requires cross-sector collaborations and rethinking current healthcare delivery to provide more flexible TBI services.

CONCLUSION

Healthcare for this population is not optimal and fails to meet their needs. Implementing low-threshold service models, fostering collaboration, and providing targeted training could significantly improve TBI care for this population.

Trends in Homelessness and Social Sustainability: Veterans vs. Non-Veterans in the US

Introduction: Social sustainability is deeply connected to the well-being of marginalized groups, and it is important to highlight how mental health impacts the social inclusion of homeless individuals, particularly veterans. Homelessness is a growing global issue, disproportionately affecting U.S. veterans, with mental health challenges playing a significant role in its onset and perpetuation. Purpose: This study aims to compare the sociodemographic and clinical characteristics of homeless veterans and non-veterans in the U.S. Method: Using public data (N = 6295), this quantitative study applies descriptive and inferential statistical analyses. Results: Homeless veterans are more likely than non-veterans to be older, male, and identify as Caucasian or African American. They are more frequently high school graduates or have higher education, and report being divorced, widowed, married, or in varied employment statuses (full-time, part-time, or unemployed). Veterans exhibit higher rates of severe mental illnesses, schizophrenia, trauma- and stressor-related disorders, ADHD, bipolar disorder, personality disorders, depression, anxiety, and substance or alcohol use disorders. However, they are less likely than non-veterans to report substance-induced disorders, intoxication, dependence, or abuse involving cocaine, cannabis, opioids, and other substances. Conclusions: Psychosocial interventions for homeless veterans should prioritize mental health-related concerns, whereas efforts for homeless non-veterans should focus on addressing substance use. Future research should develop tailored interventions, explore the sociodemographic factors influencing homelessness, and investigate the interplay between trauma, mental health, and substance use. Addressing these issues can contribute to a more resilient, inclusive, and sustainable society by providing long-term support and integration opportunities for those most affected. The novelty of this study lies in distinguishing between mental health issues prevalent in veterans and substance use disorders more common in non-veterans, offering insights for tailored interventions. It also connects these findings to social sustainability, suggesting that addressing these issues can promote a more inclusive and resilient society.

Lifetime homelessness among young transgender women in Lima, Peru is associated with HIV vulnerability: Results from a cross-sectional survey

Transgender youth face disproportionately high rates of homelessness, which can increase vulnerability to HIV. In Peru, the incidence of HIV among transgender women has increased 19% since 2010 and young transgender women are a priority population for HIV prevention. We sought to estimate the proportion of young transgender women experiencing homelessness and associations between homelessness and HIV vulnerabilities. We recruited transgender women ages 16-24 years (N = 209) to participate in a biobehavioural survey and HIV and STI testing (chlamydia, syphilis, gonorrhea). Poisson regression models with robust standard errors were fit to estimate the association between past homelessness and past 6-month condomless sex, adjusted for potential confounding by age, education, sex work, non-injection drug use, post-traumatic stress disorder (PTSD), and violence. Among participants (median age 23 years), 68 (32.5%) had ever been homeless and 19 (9.1%) reported homelessness in the past 3 months. Overall, 51.5% of those who had been homeless reported past 6-month condomless sex compared to 29.1% of those who had never been homeless (p < 0.001). HIV prevalence was 44.6% among those with a history of homelessness and 39.6% among those who had never been homeless (p = 0.65); lifetime homelessness was significantly associated with increased sex work (p < 0.001), violence (p < 0.01), and PTSD (p < 0.001). In the model adjusting for age, education, and behavioural risk (sex work, non-injection drug use), participants who had been homeless had 1.43 times higher prevalence of past 6-month condomless sex (95% CI = 1.05-1.96); results were attenuated when adjusting for violence and PTSD. The high prevalence of homelessness among young transgender women sampled underscores the compounding HIV vulnerabilities faced by this population. Efforts to prevent homelessness and improve access to housing are urgently needed alongside healthcare services, including HIV prevention and treatment, to address the disproportionate HIV epidemic among young Peruvian transgender women.

Drop-In Wound Care: Calgary's Wound Care Model Centred Around People Experiencing Homelessness

People experiencing housing insecurities or homelessness face significant barriers to equitable healthcare. A drop-in wound care service was established to mitigate social barriers and improve accessibility. This model facilitates direct access to a multidisciplinary team of trauma-informed medical staff on a walk-in basis. A retrospective chart review was performed on patients seen at the drop-in clinic from January 2021 to December 2021. A total of 119 patients were serviced over 798 visits, with 254 unique wounds managed. 82.8% of patients were living unsheltered, in emergency shelters or in provisional accommodation at the time of assessment. Trauma wounds, lower leg ulcers and frostbites represented the top three complaints. 69.7% of all patients returned to service for at least a second visit, with a median of 4 visits per patient over 42.5 days. Unsheltered patients were most likely to return to service (87.5%) but were most likely to be lost prior to wound closure (68.8%). Timely access to care with consistent follow-up is essential for quality wound care. Our drop-in service presents a working model for providing equitable wound care to socially disadvantaged patient populations. The effectiveness of this model is highlighted by the continual expansion serving 909 and 1029 visits in subsequent years.

Exploring the complexity of homelessness in emergency medicine: Dissecting myths, evidence, and solutions

Background

Emergency departments serve as critical-access points for people experiencing homelessness (PEH). These patients face significant health disparities and are subject to stigmatization and misconceptions, often contributing to suboptimal care and moral distress among providers. Structural competency, a framework that addresses the social, political, and economic determinants of health, is crucial in rethinking the care of PEH in emergency medicine (EM).

Methods

This paper is based on the proceedings of the SAEM24 didactic session, which utilized a structural competency framework to address common misconceptions about unhoused patients. The session was developed through comprehensive literature reviews conducted by a multidisciplinary team and focused on integrating structural competency into EM practice.

Results

To confront the bias and stigma surrounding PEH, the didactic session provided evidence throughout four key areas: the diversity and changing demographics of homelessness, understanding the structural and infrastructural drivers of homelessness, identifying the impact of homelessness on health and health care access, and implementing practical interventions aimed at improving health outcomes for unhoused individuals. These areas are critical in educating EM providers on the complexities of caring for unhoused patients and the systemic issues that exacerbate their health crises.

Conclusions

Addressing homelessness within EM through a structural competency framework is imperative for researching and delivering effective health care. Continuous education and policy advocacy are vital to confront the underlying structural determinants of health and enhance emergency care for unhoused populations.

Homelessness and Birth Outcomes in the Pregnancy Risk Assessment Monitoring System, 2016-2020

OBJECTIVES

This study aimed to estimate the prevalence of homelessness shortly before or during pregnancy and describe differences in maternal characteristics and adverse birth outcomes between people reporting homelessness and not reporting homelessness.

METHODS

We used 2016-2020 Pregnancy Risk Assessment Monitoring System (PRAMS) data from 31 sites to estimate the prevalence of self-reported homelessness during the 12 months before giving birth. We used logistic regression models to evaluate the association between homelessness and adverse birth outcomes, specifically small for gestational age (SGA), low birth weight (LBW), and preterm birth (PTB).

RESULTS

Of 138,603 respondents, 4,045 reported homelessness, representing 2.4% of weighted respondents. Respondents reporting homelessness differed from respondents who did not report homelessness in maternal demographic characteristics, health conditions, behavioral and environmental risk factors, and adequacy of prenatal care. In unadjusted models, homelessness was associated with higher prevalences of SGA, LBW, and PTB (PR 1.38, 95% CI 1.21-1.57; PR 1.73, 95% CI 1.56-1.91; PR 1.42, 95% CI 1.25-1.61; respectively). After adjusting for maternal age, race and ethnicity, education, BMI, and cigarette smoking, prevalence ratios were attenuated and no longer significant.

CONCLUSIONS FOR PRACTICE

Although homelessness was not independently associated with adverse birth outcomes in adjusted models, people reporting homelessness before or during pregnancy represent a group at increased risk of inadequate health care utilization and adverse birth outcomes due to other underlying demographic and social factors. Health care providers can play a critical role in identifying if patients may be experiencing homelessness and facilitating connections to social support.

Factors influencing satisfaction with medical services in medically underserved populations: an analytical cross-sectional study at a free medical clinic in the Republic of Korea

BACKGROUND

This study aimed to explore factors influencing satisfaction with medical services among medically underserved populations at the free medical clinic, providing data to improve free medical services for these populations.

METHODS

We employed a descriptive correlational study design involving 112 individuals (aged 19 years and older) from medically underserved populations who visited the clinic. Data were collected through face-to-face surveys from September to October 2023, and statistical analyses (t-tests, analysis of variance, Pearson correlation, and hierarchical multiple regression) were used to identify key predictors of satisfaction.

RESULTS

Perceived support from healthcare providers emerged as the strongest predictor of satisfaction with medical services, demonstrating a significant positive association. While social support was positively correlated with perceived support from healthcare providers, it did not independently predict satisfaction.

CONCLUSION

These findings underscore the importance of healthcare provider and social support in increasing satisfaction with medical services among medically underserved populations. Developing tailored healthcare programs and specialized healthcare provider training are essential strategies to improve healthcare access and outcomes for these vulnerable groups.

Barriers and Delays to Healthcare at Time of Death: Qualitative Analysis of Los Angeles County Death Records of People Experiencing Homelessness

Background

Human health and homelessness are incompatible with one another. People experiencing homelessness (PEH) experience extreme health and social inequities, including a significantly higher mortality rate and lower life expectancy compared to the general adult population. While many studies have attempted to identify the most common causes of death, no study to our knowledge has sought to contextualize these deaths using death records. The objective of this study was to conduct a qualitative analysis of the Los Angeles County medical examiner records of people experiencing homelessness from 2018 in order to identify modifiable barriers and delays in accessing health care services.

Methods

This study was a qualitative analysis of medical examiner records produced by the Los Angeles County Department of the Medical Examiner (DME). In 2019, the study's senior author (EC) entered into a data use agreement with DME to provide records of deaths (n = 998) among people experiencing homelessness in 2018. The DME dataset was entered into a single file for coding using NVivo 12. Using thematic analysis as outlined by Braun and Clarke, the authors iteratively identified themes related to barriers and delays in healthcare to create a codebook.

Results

A strength of this study was its identification of barriers and delays to care themes (in italics) proximal to the deaths of PEH, an outcome that community and healthcare organizations aim to reduce. PEH are often suffering from extreme states of death due to advanced disease and have significant difficulty managing their health conditions, which manifests as medication non-adherence, missed dialysis, and a lack of preventative care. These factors, as well as disengagement and early termination of care (declining EMS services, AMA discharges) and a lack of a bystander response to PEH distress may have contributed to these deaths.

Conclusions

People experiencing homelessness experience many barriers and delays to care which may be linked to untimely deaths. This study highlights the importance of healthcare and community organizations serving PEH to foster social cohesion, understand reasons for PEH's early termination and/or non-acceptance of care, and adopt equity-oriented care approaches, which aim to improve individuals' ability to engage in outpatient services and treatment.

Collaborative networks in community-based health and social care services: insights from Blackpool and the Fylde Coast (United Kingdom)

BACKGROUND

Globally, health and social care systems have been responding to the demand for better integrated service delivery to tackle complex public health and socioeconomic challenges. Similarly, services in the United Kingdom strive for comprehensive, person-centred care to support health equity and improved quality of life. This study took place in Blackpool and the Fylde Coast, United Kingdom, where socioeconomic deprivation and health inequalities persist and effective collaboration among health and social care providers offers an opportunity to tackle such complex challenges. The study used social network analysis (SNA) to investigate collaboration patterns between organizations to identify key characteristics and areas for improved integration.

METHODS

Data were collected from March to June 2023. First, a comprehensive mapping exercise identified a total of 453 community-based providers who were invited to participate via email. Data on service provision were collected using an adapted version of the Template for Intervention Description and Replication (TIDieR) form from organizations' websites. Service descriptions were thematically categorized into 11 domains. A total of 44 organizations provided information on their collaborations through an online survey, reporting on collaborations across 321 organizations. SNA examined collaboration patterns via visualization and multivariate network regressions (MRQAP).

RESULTS

The mapping identified a great range of community-based support. The network density indicated relatively low overall collaboration (2.2%) among 321 organizations. Within the subset of 44 organizations who completed the questionnaire, collaborations were more frequent (15%). Collaboration ties were unevenly distributed, where some organizations had more connections. MRQAP showed that organizations within the same domain were more likely to collaborate. Some combinations, such as collaborations between housing, shelter and nutritional support with child and family support and mental health were significantly overrepresented.

DISCUSSION

The network had low density, highlighting the potential for more collaborations. The network appears fragmented, probably owing to a tendency for organizations to collaborate with others operating in the same service domain. The frequent collaborations between certain domains highlight the complex needs of local communities. Effective integrated care initiatives, data sharing and place-based partnership/voluntary, community, faith, social enterprise sector capacity-building programmes could build more resilient and interconnected networks that meet community needs.

Burn Care in the Street: A Survey of the Current Landscape of Burn Care Provided by Street Medicine Teams

People experiencing homelessness are at increased risk for serious burn injuries and face additional barriers to care such as inability to perform wound care and difficulty with follow-up. Although not burn-specific, street medicine (SM) programs provide direct medical care to people experiencing unsheltered homelessness in their own environment and may be well positioned to bridge this gap in burn care for this population. We conducted a cross-sectional survey to characterize the burn care experience of SM teams with providing burn care for people experiencing homelessness. The 60 respondents included 18 (30%) physicians, 15 (25%) nurse practitioners or physician assistants, 15 (25%) registered nurses, 6 (10%) medical students, and 6 (10%) other team members. The most common reported barriers to care were prior negative experiences with emergency departments, and transportation to burn centers. There was regional variability in frequency of providing burn care, which was reflected in respondent comfort with assessing and treating burns. Burns were most often dressed with daily dressings such as a non-adherent dressing over silver sulfadiazine or bacitracin. Silver-based contact dressings were rarely used. Street medicine teams in the United States are treating burn injuries among people experiencing homelessness, though management practices and experience treating burns was variable. As SM programs continue to grow, burn-related education, training, and connections to local burn centers for team members is important. Through strengthened partnerships between burn centers and street medicine teams, these programs may be well positioned to bridge the gap in burn care for people experiencing homelessness.

Late discovery of bodies in indoor settings: A forensic practitioner's view on recognizing cases of social isolation in eastern Attica, Greece

The late discovery of a deceased is an observable phenomenon in urban centers and is highly associated with unaccompanied deaths. The aim of this study is to investigate the socio-demographic patterns and circumstances surrounding the late discovery of deceased individuals in indoor settings within urban areas, in Greece. The studied sample included 217 decomposing individuals discovered indoors in eastern Attica between the years 2012-2021. The majority of cases involved Greek males aged above 65, single, childless, and living alone. A history of illegal substance and alcohol abuse, psychiatric disorders and atypical behavior was recorded in some cases, however these represented the minority of the sample. The majority of bodies were discovered inside their permanent homes by relatives or neighbors at the stage of early decomposition within a month of their death. Manner of death was in most cases natural. Statistically significant associations between the examined variables were noted. Differences in the death circumstances between individuals with and without socially reprehensible behaviors were illuminated. Ultimately, the study seeks to identify risk factors leading to social disengagement and contribute to the development of protective measures against this phenomenon.

Healthcare needs, expectations and experiences of people experiencing homelessness in Western Switzerland: a qualitative and quantitative descriptive study

AIMS

The literature from Canada, the UK and the USA reports health inequities among people experiencing homelessness; however little is known about this population's health in Switzerland. Our study is the first to comprehensively assess health needs, expectations and experiences of people experiencing homelessness in Switzerland.

METHODS

We describe the health needs, expectations and experiences of people experiencing homelessness in French-speaking Switzerland, using both quantitative and qualitative methods. From May to August 2022, 123 people experiencing homelessness completed quantitative questionnaires about health needs, expectations and experiences. Recruitment took place in 10 homeless-serving institutions across four cities in the Canton of Vaud. A total of 18 people experiencing homelessness and 13 professionals involved in the homeless-serving sector completed qualitative interviews. For the qualitative strand, we selected people experiencing homelessness using quota sampling based on health insurance, residency status and sex representativeness according to the study population. For homeless-serving sector professionals, we used quota sampling by professions (i.e. night watcher in shelters; social/healthcare workers) ensuring balance. In addition, we aimed to recruit at least one homeless-serving sector professional from each of the ten institutions included in the parent research project.

RESULTS

The most common health issues reported were musculoskeletal, dental and psychiatric. Thirty-one percent of people experiencing homelessness had visited emergency rooms and 27% a community health centre in the prior 6 months. People experiencing homelessness reported low quality of life according to the WHOQOL, especially in social and environmental domains; 33% reported moderate and 17% high grade of psychological distress. Findings indicated that up to 32% of participants reported facing difficulties in reaching out to the healthcare system. In qualitative interviews, people experiencing homelessness described positive perceptions about the Swiss healthcare system. However, people experiencing homelessness reported various barriers encountered while seeking healthcare (e.g., health insurance, financial barriers, appointment delays, hesitancy in accessing care, prioritising other needs). Both groups commonly reported that social situations impacted the health and healthcare use of people experiencing homelessness.

CONCLUSION

People experiencing homelessness in Switzerland are not spared by the common health inequities reported in Canada, the USA and the UK. Our results provide interesting foundations on which to build public health actions towards health equity for people experiencing homelessness in Switzerland and suggest that they could benefit from additional medical follow-up and tailored interventions.

'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.

Health and healthcare use of homeless population: Evaluation study of joint social work and healthcare provision

BACKGROUND

Homelessness as an extreme form of poverty perpetuates and exacerbates health inequalities. People experiencing homelessness face a mortality rate 10 times higher than that of the general population, with an average age of death at 45. There is a significant disconnect between the mainstream healthcare system and the specific health needs of people experiencing homelessness, leading to substantial human and economic costs.

OBJECTIVE

The objective of this evaluation study is to assess the impact of an intervention in nurse-led healthcare outreach services to people experiencing homelessness on their utilization of healthcare services.

DESIGN

This study is a part of research program aimed at assuring health equity of most vulnerable members of a society. Detailed understanding of barriers to care is a necessary precondition for improvements in healthcare use.

DATA

The study analyzes data on hospitalization and emergency department visits by people experiencing homelessness across three cities in Czechia from 2014 to 2021.

METHODS

A quantitative difference-in-differences approach is complemented by insights from field studies in these three cities.

RESULTS

The intervention in people experiencing homelessness outreach led to a reduction in both hospital admissions and the emergency visits by people experiencing homelessness, alleviating pressure on health service capacity and reducing associated healthcare costs. Enhanced primary nurse-led healthcare outreach, along with cross-sectoral integration and activation, has lowered the barriers to accessing essential healthcare services.

CONCLUSION

A pivotal policy outcome of this study is the establishment of an insurance provision that allows medical doctors to claim additional costs incurred in treating people experiencing homelessness from a public insurance system.

Implementation of a Mental Health Nursing Practicum in an Urban Homeless Shelter

BACKGROUND

People experiencing homelessness suffer from deficient access to health care and disproportionately poor health outcomes. The American Association of Colleges of Nursing (AACN) maintains learning competencies for prelicensure nursing students. Shelters are rich environments for students to garner experiences with the inequities plaguing our health care system and to fulfill AACN competencies.

METHOD

We established a psychiatric and mental health nursing practicum at a homeless shelter. Following a retrospective pretest methodology, we evaluated student learning with the Health Care Professional's Attitudes Toward the Homeless Inventory (HPATHI). Students, faculty, and shelter staff provided qualitative feedback postpracticum.

RESULTS

Students' median HPATHI scores increased on 16 of 19 survey items. Qualitative feedback was largely positive and reinforced HPATHI data.

CONCLUSION

The practicum provided rich learning experiences for students. Educators establishing shelter-based practica should prioritize continuity, develop referral pathways for residents with illness, maintain a flexible mindset, administer prospective student surveys, and solicit feedback from shelter residents. [J Nurs Educ. 2025;64(1):56-59.].

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.

Cancer Prevention for Women Experiencing Homelessness: Onsite Mammography, Navigation, and Education

PURPOSE

Persons experiencing homelessness (PEHs) represent a medically underserved population with a disproportionately high rate of late-stage cancer diagnoses and cancer mortality. During mobile onsite mammography and breast health education events, we studied PEH's barriers to and uptake of cancer screenings.

METHODS

This study used patient surveys and review of the electronic health record. The main outcome measures included mammogram and diagnostic imaging (as needed) results. A questionnaire assessed patient's views and barriers related to social determinants of health. The study included women accessing community organization resources who were 40 years or older or who met criteria for screening mammography.

RESULTS

Forty-six individuals completed mammograms and 41 individuals participated in the survey, for a response rate of 89%. Thirty-five participants (85%) held health insurance provided by a Medicaid managed plan. Thirty-six participants (87%) received a negative mammogram result, and five participants (12%) required follow-up for abnormal results. Of these five, two participants completed diagnostic follow-up with negative results, and three did not complete diagnostic follow-up. In addition to barriers related to housing insecurity, five patients (12%) reported transportation barriers. A majority (n = 28, 68%) disagreed or strongly disagreed with the statement, "I'm afraid the mammogram will be painful." A majority (n = 31, 76%) disagreed or strongly disagreed with the statement, "I'm busy and do not have time." Nearly all participants (n = 37, 90%) responded yes to the statement, "I believe in preventative care screenings." Eight participants (20%) completed at least one additional cancer screening.

CONCLUSION

By creating enduring programs offering screening, navigation, and education, academic-community partnerships may begin to address the increased cancer mortality among PEHs by improving screening adherence.

Intersectional Structural Stigma: A Qualitative Study With Persons Experiencing Homelessness in the Southwest United States

This study explored the manifestations of intersectional structural stigma and stigma-reducing strategies in the context of health among a diverse group of persons experiencing homelessness in the southwest United States. Purposive sampling was used to recruit youth (ages 12-17), young adults (ages 18-24), adults (ages 25 years old or older), women with children, veterans, and males over 60 years old who self-identified as homeless. Grounded theory was applied, and thematic analysis was conducted using data collected from seven focus groups (n = 76 participants). A model of intersectional stigma was adapted from the Health Stigma and Discrimination Framework. This adaptation depicts pathways for addressing intersectional stigmatization experienced by individuals with multiple intersecting identities across the interpersonal, organization, and community levels not explicitly addressed in the Health Stigma and Discrimination Framework. At the interpersonal level, participants indicated they experienced stigmatizing behaviors and practices by service providers due primarily to their identities related to economic or unhoused statuses, gender, age, and mental health. Facilitators of intersectional stigma were identified through organization practices and processes. Multiple stigmatized identities due to social beliefs also facilitated stigmatization at the community level. Health outcomes influenced by stigmatization were also identified. Despite the stigmatization they experienced, participants discussed stigma-reducing strategies related to community assets, medical care, and destigmatizing practices by service providers.

Perceived Higher Unmet Care Needs among Adults in Permanent Supportive Housing

This study is original in that it assesses various types of care needs, barriers to care, and factors associated with higher unmet needs among 308 permanent supportive housing (PSH) residents in Quebec (Canada). Data from structured interviews that featured the Perceived Need for Care Questionnaire were collected from 2020 to 2022, controlling for the COVID-19 pandemic period. Eight types of care (e.g., information, counseling) were accounted for. Based on the Behavioral Model for Vulnerable Populations, predisposing, need, and enabling factors associated with higher unmet care needs were assessed using a negative binomial regression model. The study found that 56% of adult PSH residents, even those who had lived in PSH for 5 + years, had unmet care needs. Twice as many unmet needs were due to structural (e.g., care access) rather than motivational barriers. Living in single-site PSH, in healthier neighborhoods, having better quality of life and self-esteem, and being more satisfied with housing and outpatient care were associated with fewer unmet care needs. PSH residents with co-occurring mental disorders (MD) and substance use disorders (SUD), and with moderate or severe psychological distress were likely to have more unmet needs. Better access to care, counseling and integrated treatment for co-occurring MD-SUD might be improved, as well as access to information on user rights, health and available support. Welfare benefits could be increased, with more peer support and meaningful activities, especially in single-site PSH. The quality of the neighborhoods where PSH are located might also be better monitored.

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

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

Hostel support workers' experiences navigating healthcare alongside people experiencing homelessness: a qualitative study in the UK

OBJECTIVES

This study aimed to explore how hostel support workers (HSWs) experience navigating healthcare alongside people experiencing homelessness (PEH). PEH experience poor health outcomes, increased mortality and face many barriers when accessing healthcare. HSWs have a dynamic and holistic role, working with PEH to navigate access to health and social care, whilst facilitating independence. HSWs have been described as important in addressing barriers to access and linking healthcare and PEH. However, HSWs' experiences navigating this role across sectors remains underexplored.

DESIGN

In this qualitative study, semistructured interviews were conducted, and phenomenological thematic analysis was performed.

SETTING

Interviews were conducted with participants from 13 hostels across four UK counties.

PARTICIPANTS

17 HSWs were interviewed, with experience in their role ranging from 3 months to over 10 years.

RESULTS

Three themes were identified.HSWs feeling stigmatised by healthcare staff (HCS), including power inequalities between HSWs and HCS, and the impact of stigma against PEH in healthcare on HSWs.Working across sectors, including both collaborative and disconnected experiences.In-reach and its role in linking PEH and healthcare. This included the contrasting subthemes of in-reach as an effective link versus in-reach being an impractical and unsustainable solution.

CONCLUSIONS

Cross-sector collaboration has been recognised as an effective way to increase healthcare access and improve outcomes for Inclusion Health Groups, including PEH. This has been further highlighted by the formation of Integrated Care Systems, which strive to bring sectors together to tackle inequalities in outcomes, experience and access. Collaborative relationships between sectors, that is, hostels and healthcare, are vital for increasing healthcare access for PEH. We explored the experiences of HSWs navigating healthcare access for this marginalised population. Recognising and understanding these experiences are the first steps in building collaborative cross-sector relationships to improve healthcare accessibility, experiences and outcomes for PEH.

Hassan N, Abu Said AM, Bachik B. Desired support system to eradicate urban homelessness: an exploratory descriptive study

Background - The new increasing homeless lately consist of women, children, youth, the elderly and marginalized ethnic or migrant groups. Some of them are working and earn salaries, however, the income is not sufficient to live modestly. Purpose - The purpose of this research is to establish a desired support system to eradicate urban homelessness in the country. Design/methodology/approach - This is an exploratory descriptive method study which employed quantitative techniques.  The study employed a social ecological model to investigate behavior of homeless via multiple levels of influences including intrapersonal, interpersonal, organizational, community and public policy. Surveys have been conducted on sixty-five homeless individuals.  Findings - It was found that support systems and structures should be derived from the whole streams from families, communities, organizations and government. Employment opportunities, long-term shelters within the community places and highly demanded skills are needed to improve their living condition. Research limitations - This study is only focused on the socio-economic structures of the homeless in a capital city. Originality/value - This is an empirical research using a social ecological model for the homeless in the Kuala Lumpur area. Research on homeless study has received little attention and has yet to be fully explored.

Exploring the inflammatory profile of homelessness population: a comprehensive analysis of individuals in two temporary shelters in Lisbon

Background

Homeless people are continuously facing adverse living conditions as poor access to basic nutrition, hygiene conditions and healthcare services, being at increased risk of severe infectious diseases as HIV and hepatitis as well as cardiovascular diseases and mental disorders. The characterization of homeless people's health is fundamental to identify their health care needs. Considering that the aforementioned diseases are associated with chronic inflammatory processes, the main goal of this study was to characterize the inflammatory profile of a homeless population through quantification in saliva of a panel of inflammatory cytokines.

Methods

The inflammatory profile was assessed in 114 individuals residing in two temporary shelters located in Lisbon and that accepted to participated in the study. Inflammatory proteins were quantified using a Multiplex Immunoassay approach. Data analysis was performed using the GraphPad Prism software and statistical significance among the groups was assessed using the nonparametric Mann-Whitney test.

Results

Even though some protein levels might be masked by drug treatment, data analysis showed high levels of INF-ϒ, IL-10 and TNF-α in the infectious disease group, critical cytokines for the immune response against viruses and bacteria. Also, cytokines like IL-1β and IL-6 were detected at statistically significant levels in the cardiovascular disease group and all cytokines included in this study were quantified in the mental disorders group.

Conclusion

These findings may help the healthcare services in the evaluation of treatment efficacy and disease monitoring, and in the development of effective public healthcare strategies and policy interventions to improve quality of life of the homeless population.

Health status and self-perception of health among homeless people in Spain: a mixed-methods study

Introduction

Homelessness is a phenomenon of social exclusion and poverty that has increased alarmingly during recent years. Homeless people (HP) experience violations of several basic human rights or needs that impact their well-being. Therefore, the aim of this research was to assess the health status and self-perceived health of HP and examining the impact of homelessness on their health.

Methods

We used an explanatory sequential mixed-methods approach that integrated a quantitative cross-sectional study within critical social and ethno-sociological qualitative frameworks. Data were collected in Palma, Spain, from December 1, 2020, to January 1, 2023. A total of 198 HP were recruited from the streets and public areas. Basic human needs (Virginia Henderson model), medical diagnoses, substance abuse (DAST-10), diet quality (IASE), depression (PHQ-9), and social support (SSQ-6) were assessed. Then, 17 semi-structured interviews were conducted and were analyzed using thematic content and discourse analysis. Quantitative and qualitative data were integrated and jointly analyzed.

Results

The 79.3% of the participants were men, mean age of 47.8 ± 12.2 years. The 76.4% were Spanish. The participants reported severe difficulties in accessing the labor market, and that this greatly affected their self-esteem and mental health. The 48.9% of the participants suffered from one or more chronic diseases, and 50.3% were diagnosed with a mental health disorder. The participants generally did not consider health problems as a central concern. The health needs that most affected the participants were related to food, safety, and social support. HP frequently felt unsafe, fearfully, and anxious.

Conclusion

Homelessness, unemployment, and social exclusion have significant negative impacts on the health and wellbeing of HP. Precarious work conditions and deficiencies in the welfare system contribute significantly to homelessness. These results highlight the need for systemic solutions that extend beyond short-term housing initiatives.

Sex differences in houselessness, injection drug use, and mental health conditions among people newly diagnosed with HIV in Manitoba, Canada from 2018 to 2021: a retrospective cohort study

Background

Manitoba saw the highest number of new HIV diagnoses in the province's history in 2021 and is the only Canadian province not meeting any of the previous UNAIDS 90-90-90 targets. Our goal was to describe sex differences and syndemic conditions within an incident HIV cohort in Manitoba, and the HIV treatment initiation and undetectable viral load outcomes.

Methods

This was a retrospective cohort study of all people 18 years and older newly diagnosed with HIV in Manitoba, Canada between January 1st, 2018 and December 31st, 2021. Data was collected as follows: before HIV diagnosis: chlamydia, gonorrhoea, syphilis, and/or hepatitis C antibodies. At the time of HIV diagnosis: age, sex, gender, race/ethnicity, sexual orientation. During follow-up: CD4 counts, viral load, HIV treatment, hospitalizations, and number of visits to HIV care. Main exposures evaluated: methamphetamine use, injection drug use, houselessness, and mental health conditions. Outcomes: started antiretroviral treatment and achieved an undetectable viral load. A descriptive statistical analysis was used.

Findings

There were 404 new HIV diagnoses in Manitoba from 2018 to 2021; 44.8% were female, 55.2% male; 76.% self-identified as Indigenous, 13.4% white/European, 4.7% African/black; 86.6% cis-gender; 60.9% heterosexual, 13.4% gay, bisexual and men who have sex with men, and 1.7% lesbian. Injection drug use was reported by 71.8% and 43.5% of females and males respectively. Methamphetamine was the most frequently injected drug (62.4%). Amongst females, 81.8% experienced at least one of the following: houselessness (43.1%), mental health comorbidities (46.4%), and injection drug use (71.8%). Only 64.9% of all individuals had an undetectable viral load (61.1% females and 67.9% males), 56.5% among people experiencing houselessness, 59% among young people (≤29 years), and 60.1% among people who inject drugs.

Interpretation

People newly diagnosed with HIV in Manitoba are disproportionately experiencing houselessness, mental illness, and injection drug use (mostly methamphetamine). This pattern is more pronounced for female individuals. These findings highlight the need for syndemic and gender-specific approaches, simultaneously addressing social and health conditions, to treat HIV.

Funding

This work was supported by the Canadian Institutes of Health Research, The Manitoba Medical Service Foundation, The James Farley Memorial Fund and the Canada Research Chairs Program.

"Just a knife wound this week, nothing too painful": An ethnographic exploration of how primary care patients experiencing homelessness view their own health and healthcare

Community health needs assessments (CHNA) involving qualitative techniques help tailor health services to the specific needs of the population groups for whom they are designed. In light of increasing health disparities amongst people experiencing homelessness (PEH)-and to ensure the integration of their voices into a larger CHNA-this study used an ethnographic approach grounded in a social constructivist research paradigm to explore the perspectives of PEH attending a primary care and addiction service in Ireland on their priority health and healthcare needs. Participant observations and informal interviews were conducted with clients experiencing homelessness attending the service for three hours every Monday morning between October 2022 and April 2023. Field note data from active participant observation and informal conversations were collected, anonymised, and analysed using inductive thematic analysis in accordance with the Declaration of Helsinki and the researchers' institutional Research Ethics Committee. Three main themes emerged from the analysis: self-identified priorities, satisfaction with health services, and migrant health. Clients' priority concerns relate to their mental health and personal safety, strengthening ties with children and families, finding a sense of purpose, and feeling better physically. These challenges differ from those of the general population in terms of their severity observed both prior to and during experiences of homelessness, coupled with disproportionately high levels of loss, fear, pain, fatigue, social stigma and other barriers to accessing satisfactory housing. In terms of services, clients are satisfied with their ability to access primary care and harm reduction in a social environment where positive exchanges with friends and providers take place. Conversely, barriers to accessing mental health and addiction services persist including the internalised belief that one is beyond help, lack of access to information on available services and their entry requirements, and lingering stigma within a health system that treats addiction as separate to health. Moving forward, health practitioners may consider holding more regular and open conversations with clients experiencing homelessness about the care they are receiving, its rationale, and whether or not changes are desired that can be safely made. The health needs of migrants and asylum seekers entering homelessness in Ireland are urgent and should be prioritised in future research.

Health inequalities among people experiencing food insecurity. An intersectional approach

The study examines the socioeconomic determinants of physical health among populations experiencing food insecurity and receiving free meals in soup kitchens in the Prefecture of Attica, Greece. Data were collected from the same six soup kitchens in 2012, 2017 and 2021, resulting in a dataset of 1533 observations. The study revealed that periods characterised by an economic recession are associated with deteriorated physical health of food-insecure people. Moreover, the study found that physical health deteriorations among food-insecure people are associated with older age, female gender, immigration status, disability and/or long-term health conditions, LGBT status, unemployment, economic inactivity, homelessness, living below the poverty threshold, long-term food dependency, illicit drug consumption and residing in lower- and middle-class areas. The study proposes the Intersectional Model of Health Inequalities, which integrates multiple factors involved in shaping the health inequalities of people experiencing food insecurity, from macro-level factors such as a country's economic performance to individual-level factors like education, employment status and demographic characteristics. The model emphasises that low-income populations should not be treated as a homogeneous entity. Its goal is to inform policymakers about the diverse health inequalities experienced by people with low incomes.

Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

Asking about violence and abuse among patients experiencing homelessness: a focus group study with healthcare professionals

BACKGROUND

People experiencing homelessness are at increased risk of violence and abuse, however, there is insufficient knowledge about rates of inquiry or readiness of healthcare professionals to address violence and abuse among this population. This study aimed to explore healthcare professionals' experiences and perceptions of asking about violence and abuse among patients experiencing homelessness.

METHODS

This study used a qualitative, interpretive, and exploratory design. We performed focus group discussions with healthcare professionals (n = 22) working at an integrative healthcare unit for people experiencing homelessness. Data were analysed using reflexive thematic analysis, following Braun and Clarke's six-phase approach. Findings are reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

The overarching theme of the analysis is that addressing violence and abuse is at risk of "falling through the cracks". The theme is supported by three sub-themes: Hesitance to address violence and abuse, The complex dynamics of violence and abuse in homelessness, and Challenges in addressing violence and abuse amidst competing priorities and collaborative efforts. The normalisation of violence and abuse within the context of homelessness perpetuates a "cycle" where the severity and urgency of addressing violence and abuse are overlooked or minimised, hindering effective interventions. Moreover, healthcare professionals themselves may inadvertently contribute to this normalisation. The hesitance expressed by healthcare professionals in addressing the issue further reinforces the prevailing belief that violence and abuse are inherent aspects of homelessness. This normalisation within the healthcare system adds another layer of complexity to addressing these issues effectively.

CONCLUSIONS

The findings underscore the need for targeted interventions and coordinated efforts that not only address the immediate physical needs of people experiencing homelessness but also challenge and reshape the normalised perceptions surrounding violence and abuse. By prioritising awareness, education, and supportive interventions, we can begin to "break the cycle" and provide a safer environment where violence and abuse are not accepted or overlooked.

Physical therapy interventions for people experiencing homelessness to improve pain and self-perceived health status

BACKGROUND

Homeless shelters have emerged as components of the social services network, playing an important role in providing health care to the homeless population. The aim of this study was to evaluate an individualized physical therapy intervention for people experiencing homelessness and to determine the relationship between self-perceived variables.

METHODS

Pre and post study, setting at the "Santa y Real Hermandad de Nuestra Señora del Refugio y Piedad" homeless shelter in Zaragoza, Spain. Participants were people experiencing homelessness with musculoskeletal disorders who attended a physical therapy service at shelter facilities. A physical therapy program was implemented including health education, exercise and manual therapy, electrotherapy, thermotherapy and bandaging. Demographic variables (age and gender), nationality, employment situation, educational level, pain location, number of painful areas, feeling of loneliness (3-Item Loneliness Scale; values from 3 to 9), pain intensity (Numerical Pain Rating Scale [NPRS]; from 0 to 10) and self-perceived health (Clinical Global Impression [CGI]; from 1 to 7).

RESULTS

Sixty-four homeless people (age of 46.4 ± 10.9 years) participated in the study. Musculoskeletal pain was reported by 98.4% of subjects, with moderate pain intensities (6.1), and 48.4% presenting with pain at multiple sites. Perceptions of loneliness were low (3.7 ± 2.5) and self-perceived health status was moderately ill (3.5 ± 1.7). Positive significant correlations were identified between pain intensity and self-perceived health. The average number of sessions was 1.5 (± 0.8), with manual therapy (35.6%) followed by health education (23.5%) being the most frequently used techniques. Both pain and self-perceived health improved after treatment, even following a brief intervention.

CONCLUSIONS

This study demonstrates the potentially negative impact of untreated pain on the self-perceived health of homeless individuals with musculoskeletal disorders that should be targeted for consideration. The findings suggest that a paradigm shift in pain management, including a physical therapy service in shelters, is needed to address the rehabilitation demands of these individuals in a real-life context. This study was approved by the Aragon Ethics Committee (PI19/438) and performed according to the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement.

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.

Critical Success Factors for Intersectoral Collaboration: Homelessness and COVID-19 - Case Studies and Learnings from an Australian City

Introduction

The COVID-19 pandemic disproportionally impacted people experiencing homelessness, including people sleeping rough, people in temporary accommodation and those living in boarding houses. This paper reports on intersectoral responses across six health and social care agencies in Inner Sydney, New South Wales, Australia. Prior to the pandemic the six agencies had established an Intersectoral Homelessness Health Strategy (IHHS), in recognition of the need for intersectoral collaboration to address the complex health needs of people experiencing homelessness.

Description

The governance structure of the IHHS provided a platform for several innovative intersectoral responses to the pandemic. A realist informed framework was used to select, describe, and analyse case studies of intersectoral collaboration.

Discussion

The resultant six critical success factors (trust, shared ways of working, agile collaboration, communication mechanisms, authorising environment, and sustained momentum), align with the existing literature that explores effective intersectoral collaboration in complex health or social care settings. This paper goes further by describing intersectoral collaboration 'in action', setting a strong foundation for future collaborative initiatives.

Conclusion

While there is no single right approach to undertaking intersectoral collaboration, which is highly context specific, the six critical success factors identified could be applied to other health issues where dynamic collaboration and integration of healthcare is needed.

Lessons Learned from Implementation of a Post-opioid Overdose Outreach Program in a Rural Massachusetts Community

Post-overdose outreach programs can play a key role in reducing opioid overdose deaths and increasing access to healthcare services. The design and implementation of these programs, especially in rural communities, remains a gap in knowledge. We aimed to understand the lessons learned from the implementation experiences of the Community, Opportunity, Network, Navigation, Exploration, and Connection Team (CONNECT), a post-overdose outreach program based in a rural community in Massachusetts. We conducted semi-structured focus groups and interviews with 21 community partners after the first year of implementation in 2022. Participants included behavioral health, medical, public health, and public safety personnel involved in the design and implementation of CONNECT. Using a combination of thematic and rapid qualitative analysis methods, we inductively coded transcripts for salient themes. Themes were mapped onto the Health Equity Implementation Framework to better understand implementation and health-equity factors. Facilitators to implementation of this innovation included efficient inter-partner data sharing and coordination, and ability to offer numerous health services to clients to meet their needs. Key partners identified that CONNECT serves clients who use opioids, have previous involvement with the legal system, and reside in low-income areas within this rural region. Unhoused individuals and individuals who do not call 9-11 after an overdose were identified as populations of need that CONNECT was missing due to structural barriers. Partners shared how the context of this rural community came with challenges related to limited access to health services and pervasive stigma towards substance use, while it was also perceived to foster a culture of collaboration and unity among multidisciplinary key partners. Post overdose outreach programs serve clients with complex health needs. The ability to access services for these health needs is shaped by the post overdose outreach program and its key partners, and by the broader community context. As post-overdose outreach programs continue to expand as a promising strategy to address the opioid overdose crisis, there exists a need to contextualize implementation strategies to inform adaptations and develop best-practices.

Meeting the Health and Social Needs of America's Unhoused and Housing-Unstable Populations: A Position Paper From the American College of Physicians

Access to safe and stable housing has both a direct and indirect effect on health. Experiencing homelessness and housing instability can induce stress and trauma, worsening behavioral health and substance use. The absence of safe and stable living conditions can make it challenging to rest, recuperate, and recover from health ailments and can pose barriers to treatment adherence. Homelessness and housing instability is associated with high rates of numerous diseases and chronic conditions. Its cyclical relationship with other social drivers of health can exacerbate health disparities. As a result, unhoused persons experience unique health challenges and require a health care system and professionals designed to meet their distinct needs. Physicians and other health professionals have a role in educating themselves about the needs of unhoused patients as well as making themselves aware of community and government resources available to these populations. Policymakers must support health professionals in these efforts by supporting the data infrastructure needed to facilitate these referrals to resources, supporting research into best practices for caring for these populations, and investing in community-based organization capacity. Policy action is needed to address the underlying drivers of homelessness, including a dearth of affordable housing, while also addressing the short-term need for safe shelter now. In this position paper, the American College of Physicians (ACP) recognizes the need to address universal access to housing to fulfill one's right to health. ACP offers several recommendations to prevent homelessness and promote the necessary health care and social needs of unhoused populations.

Access, Outcomes, and Costs Associated with Surgery for Malignancy Among People Experiencing Homelessness

BACKGROUND

Little is known about surgery for malignancy among people experiencing homelessness (PEH). Poor healthcare access may lead to delayed diagnosis and need for unplanned surgery. This study aimed to (1) characterize access to care among PEH, (2) evaluate postoperative outcomes, and (3) assess costs associated with surgery for malignancy among PEH.

METHODS

This was a retrospective cohort study of patients in the Healthcare Cost and Utilization Project (HCUP) who underwent surgery in Florida, New York, or Massachusetts for gastrointestinal or lung cancer from 2016 to 2017. PEH were identified using HCUP's "Homeless" variable and ICD-10 code Z59. Multivariable regression models controlling patient and hospital variables evaluated associations between homelessness and postoperative morbidity, length of stay (LOS), 30-day readmission, and hospitalization costs.

RESULTS

Of 67,034 patients at 566 hospitals, 98 (0.2%) were PEH. Most PEH (44.9%) underwent surgery for colorectal cancer. PEH more frequently underwent unplanned surgery than housed patients (65.3% vs 23.7%, odds ratio (OR) 5.17, 95% confidence interval (CI) 3.00-8.92) and less often were treated at cancer centers (66.0% vs 76.2%, p=0.02). Morbidity rates were similar between groups (20.4% vs 14.5%, p=0.10). However, PEH demonstrated higher odds of facility discharge (OR 5.89, 95% CI 3.50-9.78) and readmission (OR 1.81, 95% CI 1.07-3.05) as well as 67.7% longer adjusted LOS (95% CI 42.0-98.2%). Adjusted costs were 32.7% higher (95% CI 14.5-53.9%) among PEH.

CONCLUSIONS

PEH demonstrated increased odds of unplanned surgery, longer LOS, and increased costs. These results underscore a need for improved access to oncologic care for PEH.

Using Photovoice to Explore Determinants of Health among Homeless and Unstably Housed Women

The lived experiences of homeless and unstably housed women, including their health-related priorities, are understudied in smaller metropolitan and rural communities. In this study, we partnered with a day center for women who experience homelessness in Spokane, Washington. We used Photovoice, a community-based participatory action research method, to explore the health-related concerns, needs, and behavior of women who are homeless or unstably housed. Participant-generated photographs and group interview data were analyzed using thematic analysis. Three themes were generated: "These are my supports", "I'm trying to make my health better", and "[My] choices are very limited". The themes illustrated individual, interpersonal, community, and societal strengths and vulnerabilities aligned with the social ecological model. Participants demonstrated resourcefulness, creativity, and hope as they strived toward health improvement. Trauma-informed, strengths-based approaches that respect the autonomy of homeless and unstably housed women and that amplify their voices are needed to minimize power imbalances in research, policy, and practice. This includes an imperative for healthcare and social work programs to ready graduates to deliver effective, empathic services by increasing their knowledge of social determinants of health and of the stigma faced by marginalized communities. Moreover, collaborating with these communities when designing, implementing, and evaluating services is critical.

Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California

The impacts of homelessness on health and health care access are detrimental. Intervention and efforts to improve outcomes and increase availability of affordable housing have mainly originated from the public health sector and government. The role that large community-based health systems may play has yet to be established. This study characterizes patients self-identified as homeless in acute care facilities in a large integrated health care system in Northern California to inform the development of collaborative interventions addressing unmet needs of this vulnerable population. The authors compared sociodemographic characteristics, clinical conditions, and health care utilization of individuals who did and did not self-identify as homeless and characterized their geographical distribution in relation to Sutter hospitals and homeless resources. Between July 1, 2019 and June 30, 2020, 5% (N = 20,259) of the acute care settings patients had evidence of homelessness, among which 51.1% age <45 years, 66.4% males, and 24% non-Hispanic Black. Patients experiencing homelessness had higher emergency department utilization and lower utilization of outpatient and urgent care services. Mental health conditions were more common among patients experiencing homelessness. More than half of the hospitals had >5% of patients who identified as homeless. Some hospitals with higher proportions of patients experiencing homelessness are not located near many shelter resources. By understanding patients who self-identify as homeless, it is possible to assess the role of the health system in addressing their unmet needs. Accurate identification is the first step for the health systems to develop and deliver better solutions through collaborations with nonprofit organizations, community partners, and government agencies.

Variables Associated with Quality of Life Among Individuals Living in Permanent Supportive Housing

This study identified individual sociodemographic and clinical characteristics and service use patterns associated with quality of life (QoL) among 308 individuals living in permanent supportive housing (PSH) in Québec (Canada). Data were collected between 2020 and 2022, and linear multivariate analyses produced. Results demonstrated that better individual psychosocial conditions were positively associated with higher QoL. As well, living in PSH located in good neighborhoods for at least 5 years, higher self-esteem and community integration were positively associated with greater QoL. Met needs, satisfaction with housing support services, and no use of acute care were also linked with positive QoL. Comprehensive efforts to improve treatment for mental health disabilities responsive to the needs of PSH residents, and sustained long-term housing may reinforce QoL. Encouraging active participation in community-based activities, incorporating biophilic design into the neighborhoods around PSH, and promoting satisfaction with care may also enhance QoL.

A systematic review of macro-, meso, and micro-level harm reduction interventions addressing the U.S. opioid overdose epidemic

Background

This systematic review aimed to 1) identify the range of opioid harm reduction interventions implemented at macro-, meso-, and micro-levels in the United States, and 2) summarize the outcomes of these interventions.

Methods

We conducted a systematic review of academic literature published between 2011-2023 following PRISMA guidelines. Articles were excluded if they reported on research that was not specific to opioids, did not report the effects of an intervention, or focused on a medical treatment for opioid use disorder. Two coders independently extracted data and reconciled discrepancies prior to narrative synthesis.

Results

Of 6,198 articles initially identified, 36 met inclusion criteria across macro (n=7), meso (n=8), and micro (n=21) domains. Positive evidence for micro- and meso-level interventions is largely consistent, whereas evidence for macro-level interventions is mixed. Among micro- and meso-level interventions, supply distribution interventions were most effective in increasing safe use knowledge and behaviors among people who use drugs.

Discussion

Most harm reduction interventions demonstrate moderate to strong evidence of effectiveness for addressing the opioid overdose epidemic across domains. Findings revealed a lack of multi-level interventions and a lack of culturally relevant interventions that prioritize Black and Brown communities disproportionately impacted during the opioid overdose epidemic's latter phases.

REDCap as a Platform for Cutaneous Disease Management in Street Medicine: Descriptive Study

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Exploring Frontline Shelter Staff Perspectives on the Healthcare Needs of Clients Experiencing Homelessness

PURPOSE

To examine healthcare service development needs for persons experiencing homelessness from the perspective of frontline staff at a homeless shelter in Montreal, Quebec.

DESIGN

Qualitative descriptive design.

METHODS

Purposive sampling, semi-structured interviews with frontline shelter staff (n = 8), and thematic analysis.

FINDINGS

Themes included: 1) Challenges meeting healthcare service needs in a shelter environment. 2) Visions for improving healthcare services while accounting for health issues and barriers to care. 3) Participants' own knowledge gaps around health and healthcare services.

CONCLUSIONS

Future research should emphasize this group's crucial role in homelessness healthcare services development.

"Homeless Life to Hopeful Life of Elderly Beggars"-: Before and After Rehabilitation: A Qualitative Approach

This qualitative study explores the experiences of elderly beggars who transitioned from a life of homelessness to a hopeful life through rehabilitation programs. The aim is to gain insights into their lived experiences, challenges faced during their homeless phase, and the transformative effects of rehabilitation interventions. The study employs Case study approach applying thematic analysis to capture the narratives of elderly individuals who have undergone rehabilitation. The data was collected directly from the elderly using purposive sampling method. The in-depth interview guide was used to collect data from 30 elderly people in Atchayam Beggars Rehabilitation centre at Erode. From the findings, it was clear that homeless phase is characterized by extreme poverty, social exclusion, health issues, and a lack of basic necessities. The elderly beggars face numerous challenges, including stigma, discrimination, and a sense of hopelessness. The study documents the transformative journey of the elderly beggars, highlighting the positive changes they experience after rehabilitation. These changes include improved physical and mental well-being, restored self-esteem, regained social connections, and the acquisition of new skills. The elderly experience a renewed sense of hope, dignity, and empowerment as they move from vulnerability to independence and self-sufficiency. The study also highlights the significance of destigmatization efforts and community involvement in fostering the successful reintegration of elderly beggars into society. The study also contributes to the existing literature by shedding light on the possibilities for positive change and the journey from homeless life to a hopeful life among this vulnerable population.

Increasing Primary Care Engagement Among Homeless-Experienced Veterans Following an Emergency Department Visit: Qualitative Insights From Los Angeles County

BACKGROUND

Homeless-experienced persons that present in the Emergency Department (ED) often fail to receive follow-up primary care. To inform implementation of a post-ED patient navigation model, we engaged homeless-experienced Veterans to identify barriers to primary care and the acceptability of a peer-led intervention within the ED.

METHODS

Between August and November 2023, 3 focus groups (n = 14) and 2 interviews were held (total n = 16) with homeless-experienced Veterans who sought care in the Department of Veterans Affairs' (VA) Greater Los Angeles (GLA) ED. We inquired about barriers to primary care post-ED visit, ways to improve connection, and the acceptability of a peer-led intervention. Fieldnotes were taken and coded using rapid qualitative methods.

RESULTS

Participants noted challenges receiving adequate information about and support connecting with primary care; challenges included lengthy appointment wait times, lack of knowledge regarding clinic walk-ins, and challenges with social needs. Recommendations for facilitating connection comprised support with patient navigation, including obtaining timely appointments, addressing social needs, and identifying healthcare priorities. Participants noted numerous benefits to having peers in the ED to assist with healthcare and resource connection.

CONCLUSIONS

Data will inform future work to adapt and pilot a peer-led patient navigation model for homeless-experienced Veterans in VA GLA's ED.

Analysis of older adult blood pressure readings and hypertension treatment rates among the unsheltered population of Miami-Dade County

Objective

To assess prevalence of elevated blood pressure readings, rates of established hypertension diagnosis, and blood pressure control medication prescription rates in a cohort of older people experiencing unsheltered homelessness presenting to a Street Medicine clinic in Miami-Dade County, Florida. In addition, we will compare outcomes found in the study cohort to that of the general population.

Methods

Demographic information, clinical history, blood pressure control medication prescription, and blood pressure measurements were taken by a Street Medicine team of medical providers. The team routinely provides medical evaluations and care for people experiencing unsheltered homelessness who reside in rough sleeper tent encampments located on the street. Clinical information and vitals were recorded in REDCap. De-identified data from patients 65 years and above were downloaded and compared to a general population data set-the Centers for Disease Control National Health and Nutrition Examination Survey (CDC NHANES) 2017-2020 Pre-pandemic cohort. Data analysis was performed using R Studio version 4.3.2.

Results

Blood pressure was reported in 120 distinct interactions with older people experiencing homelessness. Compared to the age-matched NHANES data, older people experiencing unsheltered homelessness were at significantly increased relative risk for elevated blood pressure within the range of Stage 1 Hypertension (RR: 3.914, 95% CI: 2.560-5.892, P < 0.001), and within range of Stage 2 Hypertension (RR: 5.550, 95% CI: 4.272-7.210, P < 0.001). According to NHANES, 49.6% of adults over 60 with diagnosed hypertension receive treatment. Of study participants, 69% of those with elevated blood pressure had previously received a diagnosis of hypertension and 15.9% on medication to control blood pressure.

Conclusion

Our cohort of older people experiencing unsheltered homelessness had higher rates of elevated blood pressure and reduced rates of hypertension diagnosis and treatment as compared to the general population. Older people experiencing unsheltered homelessness are a growing population, and future research should seek to evaluate and understand older adult care vulnerabilities, including chronic disease management, to improve health outcomes for those who are aging, hypertensive, and unhoused.