Characteristics of persons who are homeless for the first time

Identifying a typology of homelessness based on self-sufficiency: Implications for rapid re-housing interventions

Limited research exists on the characteristics of individuals experiencing homelessness who achieve positive housing outcomes in rapid re-housing (RRH) interventions. We aimed to identify a typology of homelessness based on Self-Sufficiency Matrix (SSM) domains and examine its relation to sociodemographic characteristics and housing placement through RRH. Homeless Management Information System data, including sociodemographics, SSM domains, and housing outcomes, were obtained for 261 Homelessness Prevention and Rapid Re-housing Program participants in Indianapolis, Indiana, from 2009 to 2012. Latent class analysis (LCA) and latent class regression (LCR) were used to identify subgroups and predict associations between the identified typology and sociodemographic variables and housing placement outcome, respectively. LCA revealed three classes based on SSM domains: "High Self-Sufficiency," "Low Socioeconomic Self-Sufficiency," and "Low Psychosocial Self-Sufficiency." LCR revealed that race significantly predicted class membership such that Black individuals had a significantly higher probability of being in the High Self-Sufficiency class than the other two classes. Latent class membership significantly predicted immediate housing placement. The Low Psychosocial Self-Sufficiency group was the least likely to exit RRH to a permanent housing placement compared to the two other subgroups. Results affirm that individuals with greater psychosocial self-sufficiency have better housing outcomes through RRH than those with more complex support needs. Future research is needed to understand factors influencing differential self-sufficiency, as measured by the SSM, among Black and White individuals.

Direct and Indirect Associations between Family Residential Mobility, Parent Functioning, and Adolescent Behavioral Health

Residential mobility and caregiver social support are two key factors influencing adolescents' and their caregivers' health status. However, few studies have examined whether these factors vary across developmental periods. The present study therefore adopted a life course perspective to investigate the longitudinal effects of residential mobility and caregiver social support on a range of individual health outcomes (i.e., caregiver depression, adolescent internalizing problems, and adolescent externalizing problems) among families exposed to disadvantaged social and economic conditions. Data were obtained from the Longitudinal Studies in Child Abuse and Neglect, and 425 children and their caregivers who completed the age 12, 14, 16, and 18 interviews were included in this study. Structural equation modeling was conducted to test the measurement and structural models. The results showed that greater residential mobility was significantly associated with higher levels of caregiver depression, which in turn led to more adolescent internalizing and externalizing problems. Alternatively, higher levels of caregiver social support mitigated the levels of caregiver depression, which in turn resulted in fewer adolescent internalizing and externalizing problems. Highly mobile children and their caregivers were found to be vulnerable to several negative health outcomes and in high need of mental and behavioral health support and services. These findings inform important policy and practice implications on social support for mobile caregivers to address their children's behavioral problems.

Emergency department interventions for homelessness: a systematic review

BACKGROUND

The social determinants of health are economic and social conditions that contribute to health. Access to housing is a major social determinant of health and homeless patients often rely on emergency departments (EDs) for their healthcare. These patients are frequently discharged back to the street which further perpetuates the cycle of homelessness and negatively affects their health. Previous work has described the financial and systems implications of ED-housed interventions for homeless patients; this review summarizes ED-based interventions that seek to improve the social determinants of health of homeless patients.

METHODS

We conducted a search of multiple databases and gray literature for studies investigating interventions for homelessness that were initiated in the ED. Studies had to use a control group or use a pre/post-intervention design and measure outcomes that demonstrate an effect on health or the social determinants of health.

RESULTS

Thirteen studies were identified that met the inclusion criteria. Two studies were housing first interventions and were effective in providing housing and improving health. Seven studies used variations of case management and were able to address many of the social needs of people who are homeless.

CONCLUSION

This review demonstrated that ED interventions can be effective in improving the social determinants of health of homeless individuals and can be the place to initiate housing interventions. ED providers must advocate for the resources necessary to properly address the social needs of this marginalized population. Equipped with the proper resources, EDs can be one place where the cycle of homelessness is broken.

The effect of a Housing First intervention on primary care retention among homeless individuals with mental illness

Background

Primary care retention, defined as ongoing periodic contact with a consistent primary care provider, is beneficial for people with serious chronic illnesses. This study examined the effect of a Housing First intervention on primary care retention among homeless individuals with mental illness.

Methods

Two hundred individuals enrolled in the Toronto site of the At Home Project and randomized to Housing First or Treatment As Usual were studied. Medical records were reviewed to determine if participants were retained in primary care, defined as having at least one visit with the same primary care provider in each of two consecutive six-month periods during the 12 month period preceding and following randomization.

Results

Medical records were obtained for 47 individuals randomized to Housing First and 40 individuals randomized to Treatment As Usual. During the one year period following randomization, the proportion of Housing First and Treatment As Usual participants retained in primary care was not significantly different (38.3% vs. 47.5%, p = 0.39). The change in primary care retention rates from the year preceding randomization to the year following randomization was +10.6% in the Housing First group and -5.0% in the Treatment As Usual group.

Conclusion

Among homeless individuals with mental illness, Housing First did not significantly affect primary care retention over the follow-up period. These findings suggest Housing First interventions may need to place greater emphasis on connecting clients with primary care providers.

Correlates of Depressive Symptoms among Middle-Aged and Older Homeless Adults Using the 9-Item Patient Health Questionnaire

This study investigates the screening for depressive symptoms among middle-aged and older homeless adults based on Patient Health Questionnaire-9 (PHQ-9) and examines the possible factors associated with their major depressive symptoms. A cross-sectional survey was employed, and research subjects included 129 homeless people aged 45 years old and over in Taipei Wanhua District and Taipei Main Station. We used a structured questionnaire and face-to-face interview conducted by three social workers to collect data in the analyses. The content of the questionnaire included an informed consent form, demographic characteristics, enabling and need factors of healthcare, and PHQ-9 of homeless people. Results revealed that 15.5% respondents were free of depressive symptoms, 16.3% had mild level (score 5–9), 31.8% had moderate level (score 10–14), 26.4% had moderately severe level (score 15–19), and 10.1% had severe level of depressive symptoms (score 20–27). Adopting a PHQ-9 score 10 as a cut-off point for major depressive symptoms, 68.3% of middle-aged and older homeless adults were the cases needing to be referred to healthcare settings for further recheck in the near future. A multiple regression analysis found gender, age, and usage of psychiatric outpatient care were associated with major depressive symptom occurrence. The female participants were less likely to have major depressive symptoms than the male participants (OR = 0.29, 95% CI = 0.09–0.96). The elderly participants were more likely to have major depressive symptoms than the aged 45–54 years (OR = 5.29, 95% CI = 1.44–19.41). Those participants who have ever used psychiatric outpatient care were significantly more correlated with the occurrence of major depressive symptoms than their counterparts (OR = 3.65, 95% CI = 1.46–9.09). The present study suggests that in the future health policy should eliminate the risk factors of depressive symptoms and improve mental healthcare access, to improve the health and wellbeing of the homeless population.

Mental and behavioral disorders in the population of homeless patients admitted to hospital emergency departments

The aim of the study is to identify the most common mental and behavioral disorders diagnosed in homeless patients admitted to hospital emergency departments and to identify performed medical procedures including diagnostic and therapeutic measures in this range.

Material and Method:Data from information systems of three hospitals concerning stays of homeless people in ED in Bydgoszcz in 2013-2015 were analyzed. As any as 3133 stays were identified. The data was compiled using the Microsoft Excel spreadsheet and Statistica 10 statistical software package.

Results: Diagnoses in the category of mental disorders and behavioral disorders constituted 23.3% of diagnoses made in the studied population, of which two thirds were psychiatric disorders and behavioral disorders caused by alcohol use. Specific personality disorders (5.84%), schizophrenia (3.82%), and mild mental retardation (2.24%) were diagnosed in patients. One tenth of all the ICD-9 procedures performed were the procedures of the category 94- Procedures related to mental condition

Conclusions: Mental and behavioral disorders are one of the main reasons for admission of homeless people to hospital emergency departments. Most diseases is diagnosed in facilities where psychiatric consultation is possible, as well as where the number of procedures related to mental condition performed is the highest. Homeless patients suffering from mental and behavioral disorders are rarely admitted to hospital wards for hospitalization. Psychiatric care for homeless patients admitted to emergency departments is an ad hoc intervention and depends on the availability of a psychiatrist. Providing homeless patients with access to a psychiatric diagnosis at ED level would affect the quality of psychiatric care and would contribute to the improvement of mental health of homeless people.

The entrepreneurship of survival among urban adults experiencing homelessness and mental illness

AIMS

Using an entrepreneurship lens, this study examined the narratives of urban adults experiencing homelessness and living with mental illness, to explore strategies used for day-to-day survival.

METHODS

Semi-structured qualitative interviews were conducted with 14 females, 30 males, and one individual identifying as "other," living in a mid-sized Canadian city. The average age was 39 years. Data were transcribed verbatim and analyzed using thematic analysis informed by grounded theory.

FINDINGS

Participants described creative and intentional strategies for managing life on the street without permanent shelter, including recognition of opportunities, mobilization of their own or acquired resources, and use of social connections and communication skills, and strategies that demonstrated entrepreneurial processes.

CONCLUSIONS

Findings suggest that participants used survival entrepreneurship strategies and processes to navigate daily life while experiencing homelessness. Recognition and validation of the propensity for enterprise and self-sufficiency are central for both individual recovery and ending homelessness within similar populations.

Health care of people in homelessness: a comparative study of mobile units in Portugal, United States and Brazil

This paper describes and analyzes the legal and normative framework guiding the use of mobile units in Portugal, United States and Brazil, which seek to improve access and continuity of care for people in homelessness. We used a comparative analysis through literature and documentary review relating three categories: context (demographic, socio-economic and epidemiological), services system (access, coverage, organization, management and financing) and, specifically, mobile units (design, care and financing model). The analysis was based on the theory of convergence/divergence between health systems from the perspective of equity in health. Improving access, addressing psychoactive substances abuse, outreach and multidisciplinary work proved to be common to all three countries, with the potential to reduce inequities. Relationships with primary healthcare, use of vehicles and the type of financing are considered differently in the three countries, influencing the greater or lesser extent of equity in the analyzed proposals.

Outcome Trajectories among Homeless Individuals with Mental Disorders in a Multisite Randomised Controlled Trial of Housing First

PURPOSE

Housing First (HF) has been shown to improve housing stability, on average, for formerly homeless adults with mental illness. However, little is known about patterns of change and characteristics that predict different outcome trajectories over time. This article reports on latent trajectories of housing stability among 2140 participants (84% followed 24 months) of a multisite randomised controlled trial of HF.

METHODS

Data were analyzed using generalised growth mixture modeling for the total cohort. Predictor variables were chosen based on the original program logic model and detailed reviews of other qualitative and quantitative findings. Treatment group assignment and level of need at baseline were included in the model.

RESULTS

In total, 73% of HF participants and 43% of treatment-as-usual (TAU) participants were in stable housing after 24 months of follow-up. Six trajectories of housing stability were identified for each of the HF and TAU groups. Variables that distinguished different trajectories included gender, age, prior month income, Aboriginal status, total time homeless, previous hospitalizations, overall health, psychiatric symptoms, and comorbidity, while others such as education, diagnosis, and substance use problems did not.

CONCLUSION

While the observed patterns and their predictors are of interest for further research and general service planning, no set of variables is yet known that can accurately predict the likelihood of particular individuals benefiting from HF programs at the outset.

Hospital Readmissions in a Community-based Sample of Homeless Adults: a Matched-cohort Study

BACKGROUND

Hospital readmission rates are a widely used quality indicator that may be elevated in disadvantaged populations.

OBJECTIVE

The objective of this study was to compare the hospital readmission rate among individuals experiencing homelessness with that of a low-income matched control group, and to identify risk factors associated with readmission within the group experiencing homelessness.

DESIGN

We conducted a 1:1 matched cohort study comparing 30-day hospital readmission rates between homeless patients and low-income controls matched on age, sex and primary reason for admission. Multivariate analyses using generalized estimating equations were used to assess risk factors associated with 30-day readmission in the homeless cohort.

PARTICIPANTS

This study examined a cohort of 1,165 homeless adults recruited at homeless shelters and meal programs in Toronto, Ontario, between 6 December 2004 and 20 December 2005.

MAIN MEASURES

The primary outcome was the occurrence of an unplanned medical or surgical readmission within 30 days of discharge from hospital.

KEY RESULTS

Between 6 December 2004 and 31 March 2009, homeless participants (N = 203) had 478 hospitalizations and a 30-day readmission rate of 22.2 %, compared to 300 hospitalizations and a readmission rate of 7.0 % among matched controls (OR = 3.79, 95 % CI 1.93-7.39). In the homeless cohort, having a primary care physician (OR = 2.65, 95 % CI 1.05-6.73) and leaving against medical advice (OR = 1.96, 95 % CI 0.99-3.86) were associated with an increased risk of 30-day readmission.

CONCLUSIONS

Homeless patients had nearly four times the odds of being readmitted within 30-days as compared to low-income controls matched on age, sex and primary reason for admission to hospital. Further research is needed to evaluate interventions to reduce readmissions among this patient population.

Construct Validity of the SF-12v2 for the Homeless Population with Mental Illness: An Instrument to Measure Self-Reported Mental and Physical Health

BACKGROUND

Self-reported health measures are important indicators used by clinicians and researchers for the evaluation of health interventions, outcome assessment of clinical studies, and identification of health needs to improve resource allocation. However, the application of self-reported health measures relies on developing reliable and valid instruments that are suitable across diverse populations. The main objective of this study is to evaluate the construct validity of the SF-12v.2, an instrument for measuring self-rated physical and mental health, for homeless adults with mental illness. Various interventions have been aimed at improving the health of homeless people with mental illness, and the development of valid instruments to evaluate these interventions is imperative.

STUDY DESIGN

We measured self-rated mental and physical health from a quota sample of 575 homeless people with mental illness using the SF-12v2, EQ-5D, Colorado Symptoms Index, and physical/mental health visual analogue scales. We examined the construct validity of the SF-12v2 through confirmatory factor analyses (CFA), and using ANOVA/correlation analyses to compare the SF-12v2 to the other instruments to ascertain discriminant/convergent validity.

RESULTS

Our CFA showed that the measurement properties of the original SF-12v2 model had a mediocre fit with our empirical data (χ2 = 193.6, df = 43, p < .0001, CFI = 0.85, NFI = 0.83, RMSEA = 0.08). We demonstrate that changes based on theoretical rationale and previous studies can significantly improve the model, achieving an excellent fit in our final model (χ2 = 160.6, df = 48, p < .0001, CFI = 0.95, NFI = 0.95, RMSEA = 0.06). Our CFA results suggest that an alternative scoring method based on the new model may optimize health status measurement of a homeless population. Despite these issues, convergent and discriminant validity of the SF-12v2 (scored based on the original model) was supported through multiple comparisons with other instruments.

CONCLUSION

Our study demonstrates for the first time that the SF-12v2 is generally appropriate as a measure of physical and mental health status for a homeless population with mental illness.

Profiles of criminal justice system involvement of mentally ill homeless adults

OBJECTIVES

This study aims to examine the rates of self-reported contacts with the criminal justice system among homeless adults with mental illness, to identify the characteristics of participants who have had contacts with the criminal justice system, to report the dimensional structure of criminal justice system involvement in this sample, and to identify typologies of justice-involved participants.

METHODS

Self-report data on criminal justice system involvement of 2221 adults participating in a Canadian Housing First trial were analyzed using multiple correspondence and cluster analysis.

RESULTS

Almost half of the participants had at least one contact with the criminal justice system in the 6months prior to study enrollment. Factors associated with justice involvement included age, gender, ethnic background, diagnosis, substance misuse, impulse control, compliance, victimization, service use, and duration of homelessness. A typology of criminal justice involvement was developed. Seven criminal justice system involvement profiles emerged; substance use and impulse control distinguished the clusters, whereas demographic and contextual variables did not.

CONCLUSIONS

The large number of profiles indicates the need for a diverse and flexible range of interventions that could be integrated within or in addition to current support of housing services, including integrated substance use and mental health interventions, risk management strategies, and trauma-oriented services.

Housing First for People With Severe Mental Illness Who Are Homeless: A Review of the Research and Findings From the At Home-Chez soi Demonstration Project

OBJECTIVE

To provide a review of the extant research literature on Housing First (HF) for people with severe mental illness (SMI) who are homeless and to describe the findings of the recently completed At Home (AH)-Chez soi (CS) demonstration project. HF represents a paradigm shift in the delivery of community mental health services, whereby people with SMI who are homeless are supported through assertive community treatment or intensive case management to move into regular housing.

METHOD

The AH-CS demonstration project entailed a randomized controlled trial conducted in 5 Canadian cities between 2009 and 2013. Mixed methods were used to examine the implementation of HF programs and participant outcomes, comparing 1158 people receiving HF to 990 people receiving standard care.

RESULTS

Initial research conducted in the United States shows HF to be a promising approach, yielding superior outcomes in helping people to rapidly exit homelessness and establish stable housing. Findings from the AH-CS demonstration project reveal that HF can be successfully adapted to different contexts and for different populations without losing its fidelity. People receiving HF achieved superior housing outcomes and showed more rapid improvements in community functioning and quality of life than those receiving treatment as usual.

CONCLUSIONS

Knowledge translation efforts have been undertaken to disseminate the positive findings and lessons learned from the AH-CS project and to scale up the HF approach across Canada.

Emergency department use and hospitalizations among homeless adults with substance dependence and mental disorders

Background

Homelessness, substance use, and mental disorders each have been associated with higher rates of emergency department (ED) use and hospitalization. We sought to understand the correlation between ED use, hospital admission, and substance dependence among homeless individuals with concurrent mental illness who participated in a ‘Housing First’ (HF) intervention trial.

Methods

The Vancouver At Home study consisted of two randomized controlled trials addressing homeless individuals with mental disorders who have “high” or “moderate” levels of need. Substance dependence was determined at baseline prior to randomization, using the Mini International Neuropsychiatric Interview diagnostic tool, version 6.0. To assess health service use, we reviewed the number of ED visits and the number of hospital admissions based on administrative data for six urban hospitals. Negative binomial regression modeling was used to test the independent association between substance dependence and health service use (ED use and hospitalization), adjusting for HF intervention, age, gender, ethnicity, education, duration of lifetime homelessness, mental disorders, chronic health conditions, and other variables that were selected a priori to be potentially associated with use of ED services and hospital admission.

Results

Of the 497 homeless adults with mental disorders who were recruited, we included 381 participants in our analyses who had at least 1 year of follow-up and had a personal health number that could be linked to administrative health data. Of this group, 59% (n = 223) met criteria for substance dependence. We found no independent association between substance dependence and ED visits or hospital admissions [rate ratio (RR) = 0.85; 95% CI 0.62–1.17 and RR = 1.21; 95% CI 0.83–1.77, respectively]. The most responsible diagnoses (defined as the diagnosis that accounts for the length of stay) for hospital admissions were schizo-affective disorder, schizophrenia-related disorder, or bipolar affective disorder; collectively reported in 48% (n = 263) of admissions. Fifteen percent (n = 84) of hospital admissions listed substance dependence as the most responsible diagnosis.

Conclusions

Substance dependence was not independently associated with ED use or hospital admission among homeless adults with mental disorders participating in an HF trial. Hospital admissions among this cohort were primarily associated with severe mental disorders.

Trial registration: ISRCTN57595077 and ISRCTN66721740

Homeless and incarcerated: an epidemiological study from Canada

BACKGROUND

Incarceration and homelessness are closely related yet studied rarely. This article aimed to study the incarcerated homeless and identify specific vulnerabilities, which rendered them different from the nonincarcerated homeless. It also aimed to describe the homeless population and its significant involvement with the criminal justice and enforcement system.

METHODS

Data were derived from the British Columbia Health of the Homeless Study (BCHOHS), carried out in three cities in British Columbia, Canada: the large urban center Vancouver (n = 250), Victoria (n = 150) and Prince George (n = 100). Measures included socio-demographic information, the Maudsley Addiction Profile (MAP), the Childhood Trauma Questionnaire (CTQ) and the Mini International Neuropsychiatric Interview (MINI) Plus.

RESULTS

Incarcerated homeless were more often male (66.6%), were in foster care (56.4%) and had greater substance use especially of crack cocaine (69.6%) and crystal methamphetamine (78.7%). They also had greater scores on emotional and sexual abuse domains of CTQ, indicating greater abuse. A higher prevalence of depression (57%) and psychotic disorders (55.3%) was also observed. Risk factors identified which had a positive predictor value were male gender (p < .001; odds ratio (OR) = 2.8; 95% confidence interval (CI): 1.7-4.4), a diagnosis of depression (p = .02; 95% CI: 1.1-4.4) and severe emotional neglect (p = .02; 95% CI: 1.1-3.2) in the childhood.

CONCLUSION

Homeless individuals may be traumatized at an early age, put into foster care, rendered homeless, initiated into substance use and re-traumatized on repeated occasions in adult life, rendering them vulnerable to incarceration and mental illness.

Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: a mixed methods approach

This research sought to determine whether the implementation of Housing First in a large-scale, multi-site Canadian project for homeless participants with mental illness shows high fidelity to the Pathways Housing First model, and what factors help or hinder implementation. Fidelity ratings for 10 Housing First programs in five cities were made by an external quality assurance team along five key dimensions of Housing First based on 84 key informant interviews, 10 consumer focus groups, and 100 chart reviews. An additional 72 key informant interviews and 35 focus groups yielded qualitative data on factors that helped or hindered implementation. Overall, the findings show a high degree of fidelity to the model with more than 71% of the fidelity items being scored higher than 3 on a 4-point scale. The qualitative research found that both delivery system factors, including community and organizational capacity, and support system factors, training and technical assistance, facilitated implementation. Fidelity challenges include the availability of housing, consumer representation in program operations, and limitations to the array of services offered. Factors that accounted for these challenges include low vacancy rates, challenges of involving recently homeless people in program operations, and a lack of services in some of the communities. The study demonstrates how the combined use of fidelity assessment and qualitative methods can be used in implementation evaluation to develop and improve a program.

I built my house of hope: abused women and pathways into homelessness

Violence from intimate partners is a serious reality for a number of women. For some abused women, leaving becomes a path to homelessness. In fact, when abused women and their children leave their homes because of partner abuse, they become homeless even if they subsequently seek residence in a shelter for woman abuse. This project interviewed 62 women from across Canada who had been abused by partners and were homeless at some point. The women were asked about their experiences with both partner abuse and homelessness and the effects on themselves and their children, which suggest important policy shifts.

A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance

OBJECTIVES

We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system.

METHODS

We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs).

RESULTS

Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations.

CONCLUSIONS

In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.

Mental disorder, service use, and barriers to care among 500 homeless people in 3 different urban settings

OBJECTIVE

To determine the standardized rates of mental disorder, health service use and barriers to care in a representatively diverse sample of homeless adults in three different sized urban centers in British Columbia, Canada.

METHOD

Five hundred homeless adults from Vancouver, Victoria and Prince George were recruited. The MINI-International Neuropsychiatric Interview PLUS was used to determine current and lifetime rates of mental disorder, mental disorder episodes and suicidality. Health service use and barriers to care were recorded.

RESULTS

Overall, 92.8 % of participants met criteria for a current mental disorder: 82.6 % for alcohol or drug dependence, 57.3 % anxiety disorder, 31.5 % mood disorder. Over half (53.4 %) met criteria for a concurrent disorder. Only 14.9 % had seen a psychiatrist and 12.7 % a mental health team in the year prior to the survey. Most common barriers included being poorly connected to the system of care and issues related to homelessness. Mental disorder rates across sites were high, however, differences were found that reflected the composition of the samples.

CONCLUSION

Improving the mental health state of the homeless will require significant capacity for mental health and concurrent disorder programming that is tailored to the community it intends to serve. Demographic features of the population may help in directing assessments of need.

Moving ahead: evaluation of a work-skills training program for homeless adults

This study examines the impact of a work-skills program grounded in an integrated services approach on both employment and related life domains among homeless individuals. Six hundred thirty-eight participants in a 14-week work-skills program at a large day center in New England completed assessments at intake between 1999 and 2007; a subsample of 333 also completed assessments at graduation from the program; a smaller subsample of 55 participants were re-assessed 6 months after graduation. These assessments measured work and related life skills, employment, housing status, general health status, substance use, self-esteem and self-efficacy, and legal involvement. Results revealed improvement in all types of work and related life skills, employment and income, and multiple other life domains from baseline to graduation and follow-up. Exploratory analyses suggested that improvements in work and related life skills were associated with improvement in self-esteem and self-efficacy, and that these improvements predicted stable housing situations at follow-up. Overall, these findings indicate that, for individuals struggling with the challenges of homelessness, completion of a work-skills program has a positive impact on skills and employment, and on a diverse set of life domains.

Recommendations for improving the end-of-life care system for homeless populations: A qualitative study of the views of Canadian health and social services professionals

Background

Homeless populations have complex and diverse end-of-life care needs. However, they typically die outside of the end-of-life care system. To date, few studies have explored barriers to the end-of-life care system for homeless populations. This qualitative study involving health and social services professionals from across Canada sought to identify barriers to the end-of-life care system for homeless populations and generate recommendations to improve their access to end-of-life care.

Methods

Semi-structured qualitative interviews were conducted with 54 health and social services professionals involved in end-of-life care services delivery to homeless persons in six Canadian cities (Halifax, Hamilton, Ottawa, Thunder Bay, Toronto and Winnipeg). Participants included health administrators, physicians, nurses, social workers, harm reduction specialists, and outreach workers. Interviews were audio-recorded, transcribed verbatim and analysed thematically.

Results

Participants identified key barriers to end-of-life care services for homeless persons, including: (1) insufficient availability of end-of-life care services; (2) exclusionary operating procedures; and, (3) poor continuity of care. Participants identified recommendations that they felt had the potential to minimize these barriers, including: (1) adopting low-threshold strategies (e.g. flexible behavioural policies and harm reduction strategies); (2) linking with population-specific health and social care providers (e.g. emergency shelters); and, (3) strengthening population-specific training.

Conclusions

Homeless persons may be underserved by the end-of-life care system as a result of barriers that they face to accessing end-of-life care services. Changes in the rules and regulations that reflect the health needs and circumstances of homeless persons and measures to improve continuity of care have the potential to increase equity in the end-of-life care system for this underserved population.

Ending homelessness among people with mental illness: the At Home/Chez Soi randomized trial of a Housing First intervention in Toronto

Background

The At Home/Chez Soi (AH/CS) Project is a randomized controlled trial of a Housing First intervention to meet the needs of homeless individuals with mental illness in five cities across Canada. The objectives of this paper are to examine the approach to participant recruitment and community engagement at the Toronto site of the AH/CS Project, and to describe the baseline demographics of participants in Toronto.

Methods

Homeless individuals (n = 575) with either high needs (n = 197) or moderate needs (n = 378) for mental health support were recruited through service providers in the city of Toronto. Participants were randomized to Housing First interventions or Treatment as Usual (control) groups. Housing First interventions were offered at two different mental health service delivery levels: Assertive Community Treatment for high needs participants and Intensive Case Management for moderate needs participants. Demographic data were collected via quantitative questionnaires at baseline interviews.

Results

The effectiveness of the recruitment strategy was influenced by a carefully designed referral system, targeted recruitment of specific groups, and an extensive network of pre-existing services. Community members, potential participants, service providers, and other stakeholders were engaged through active outreach and information sessions. Challenges related to the need for different sectors to work together were resolved through team building strategies. Randomization produced similar demographic, mental health, cognitive and functional impairment characteristics in the intervention and control groups for both the high needs and moderate needs groups. The majority of participants were male (69%), aged >40 years (53%), single/never married (69%), without dependent children (71%), born in Canada (54%), and non-white (64%). Many participants had substance dependence (38%), psychotic disorder (37%), major depressive episode (36%), alcohol dependence (29%), post-traumatic stress disorder (PTSD) (23%), and mood disorder with psychotic features (21%). More than two-thirds of the participants (65%) indicated some level of suicidality.

Conclusions

Recruitment at the Toronto site of AH/CS project produced a sample of participants that reflects the diverse demographics of the target population. This study will provide much needed data on how to best address the issue of homelessness and mental illness in Canada.

The mediating roles of stress and maladaptive behaviors on self-harm and suicide attempts among runaway and homeless youth

Runaway and homeless youth often have a constellation of background behavioral, emotional, and familial problems that contribute to stress and maladaptive behaviors, which, in turn, can lead to self-harming and suicidal behaviors. The current study examined the roles of stress and maladaptive behaviors as mediators between demographic and psychosocial background characteristics and self-injurious outcomes through the lens of the stress process paradigm. The model was tested in a sample of runaway and homeless youth from Los Angeles County (N = 474, age 12-24, 41 % female, 17 % White, 32.5 % African American, 21.5 % Hispanic/Latino). Background variables (gender, age, sexual minority status, parental drug use history, and emotional distress) predicted hypothesized mediators of maladaptive behaviors and recent stress. In turn, it was hypothesized that the mediators would predict self-harming behaviors and suicide attempts in the last 3 months. Females and LGBT (lesbian, gay, bisexual, transgender) youth were more likely to have self-harmed and attempted suicide; younger participants reported more self-harming. The mediating constructs were associated more highly with self-harming than suicide attempts bivariately, although differences were modest. Maladaptive behaviors and recent stress were significant predictors of self-harm, whereas only recent stress was a significant predictor of suicide attempts. All background factors were significant predictors of recent stress. Older age, a history of parental drug use, and greater emotional distress predicted problem drug use. Males, younger participants, and participants with emotional distress reported more delinquent behaviors. Significant indirect effects on self-harming behaviors were mediated through stress and maladaptive behaviors. The hypothesized paradigm was useful in explaining the associations among background factors and self-injurious outcomes and the influence of mediating factors on these associations.

Cognitive interviewing methods for questionnaire pre-testing in homeless persons with mental disorders

In this study, cognitive interviewing methods were used to test targeted questionnaire items from a battery of quantitative instruments selected for a large multisite trial of supported housing interventions for homeless individuals with mental disorders. Most of the instruments had no published psychometrics in this population. Participants were 30 homeless adults with mental disorders (including substance use disorders) recruited from service agencies in Vancouver, Winnipeg, and Toronto, Canada. Six interviewers, trained in cognitive interviewing methods and using standard interview schedules, conducted the interviews. Questions and, in some cases, instructions, for testing were selected from existing instruments according to a priori criteria. Items on physical and mental health status, housing quality and living situation, substance use, health and justice system service use, and community integration were tested. The focus of testing was on relevance, comprehension, and recall, and on sensitivity/acceptability for this population. Findings were collated across items by site and conclusions validated by interviewers. There was both variation and similarity of responses for identified topics of interest. With respect to relevance, many items on the questionnaires were not applicable to homeless people. Comprehension varied considerably; thus, both checks on understanding and methods to assist comprehension and recall are recommended, particularly for participants with acute symptoms of mental illness and those with cognitive impairment. The acceptability of items ranged widely across the sample, but findings were consistent with previous literature, which indicates that "how you ask" is as important as "what you ask." Cognitive interviewing methods worked well and elicited information crucial to effective measurement in this unique population. Pretesting study instruments, including standard instruments, for use in special populations such as homeless individuals with mental disorders is important for training interviewers and improving measurement, as well as interpreting findings.

Health status, quality of life, residential stability, substance use, and health care utilization among adults applying to a supportive housing program

Supportive housing, defined as subsidized housing in conjunction with site-based social services, may help improve the health and residential stability of highly disadvantaged individuals. This study examined changes in health status, quality of life, substance use, health care utilization, and residential stability among 112 homeless and vulnerably housed individuals who applied to a supportive housing program in Toronto, Canada, from December 2005 to June 2007. Follow-up interviews were conducted every 6 months for 18 months. Comparisons were made between individuals who were accepted into the program (intervention) and those who were wait-listed (usual care) using repeated-measures analyses. Individuals who were accepted into the housing program experienced significantly greater improvements in satisfaction with living situation compared with individuals in the usual care group (time, F(3,3,261) = 47.68, p < 0.01; group × time, F(3,3,261) = 14.60, p < 0.01). There were no significant differences in other quality of life measures, health status, health care utilization, or substance use between the two groups over time. Significant improvement in residential stability occurred over time, independent of assigned housing group (time, F(3,3,261) = 9.96, p < 0.01; group × time, F(3,3,261) = 1.74, p = 0.17). The ability to examine the effects of supportive housing on homeless individuals was limited by the small number of participants who were literally homeless at baseline and by the large number of participants who gained stable housing during the study period regardless of their assigned housing status. Nonetheless, this study shows that highly disadvantaged individuals with a high prevalence of poor physical and mental health and substance use can achieve stable housing.

Housing status as an independent predictor of functional capacity in patients with schizophrenia

This study compared the functional capacity and neurocognitive status of homeless and housed adults with schizophrenia or schizoaffective disorder and examined whether housing status is an independent predictor of functional capacity. We examined 30 homeless individuals and 21 housed controls and matched for diagnosis, sex, and age. The participants, recruited from an acute psychiatric inpatient unit, completed a measure of psychiatric symptom severity, a neuropsychological test battery, and a measure of functional capacity, the University of California-San Diego performance-based skills assessment (UPSA). There were no significant differences in performance on the neuropsychological test battery or the UPSA between housed and homeless participants. In a multivariate model, however, cognitive status and housing status were independent predictors of functional capacity, and homelessness was associated with an approximately 9-point lower score on the UPSA. This finding highlights the importance of neuropsychological screening and interventions that promote housing stability for patients with schizophrenia.

Mothers with mental illness experiencing homelessness: a critical analysis

The experiences of homeless mothers with mental illness were examined from the critical perspective of feminist intersectionality. The purpose of this study was to unveil experiences of oppression and resistance in the lives of homeless mothers with mental illness, while learning from them what is conducive to their health. A qualitative secondary analysis was done using focus group transcripts from a study examining issues related to diversity and homelessness for psychiatric survivors and a study on mental health and housing. A purposive sample of 7 focus groups comprised of 67 participants was used for this study. Findings revealed three overarching themes: (1) discrimination based on intersecting social identities; (2) being stuck: the cycle of oppression; and (3) we're not giving up: resistance through perseverance. The contextual influences of mothering while homeless with a mental illness were emphasized in the results. The findings illuminate the need for increased on ongoing advocacy at individual and structural levels.

Factors Associated with Motivation to Change HIV Risk and Substance Use Behaviors among Homeless Youth

This study sought to identify and compare variables associated with motivation to change alcohol, drug use, and HIV risk behaviors among a sample of homeless youths. More frequent alcohol use, older age, and childhood sexual abuse was associated with greater motivation to change alcohol use; higher reported negative consequences of substance use was associated with higher motivation to reduce illicit drug use. Shorter periods of current homelessness predicted higher motivation to change HIV risk behaviors. Findings suggest these areas might be fruitful targets of intervention efforts to enhance motivation to reduce alcohol and illicit drug use and HIV risk behaviors.

Rethinking research on forming typologies of homelessness

In homelessness research and policymaking, it seems to be axiomatic that single adults experience 3 temporally based types of homelessness: chronic, episodic, and transitional. We discuss problems with the theorization of this typology and with the research design, data analysis, and time-aggregated conceptualization and measurement of temporality in the empirical work supporting the typology. To address the latter, we suggest a time-patterned approach to temporality and report a 10-group typology that differs significantly from the more familiar 3-group typology. We argue that which approach is used-and how typologies are developed more generally-should be based on theory and the uses to which typologies are put rather than on claims to being more true.

Addiction treatment and stable housing among a cohort of injection drug users

Background

Unstable housing and homelessness is prevalent among injection drug users (IDU). We sought to examine whether accessing addiction treatment was associated with attaining stable housing in a prospective cohort of IDU in Vancouver, Canada.

Methods

We used data collected via the Vancouver Injection Drug User Study (VIDUS) between December 2005 and April 2010. Attaining stable housing was defined as two consecutive “stable housing” designations (i.e., living in an apartment or house) during the follow-up period. We assessed exposure to addiction treatment in the interview prior to the attainment of stable housing among participants who were homeless or living in single room occupancy (SRO) hotels at baseline. Bivariate and multivariate associations between the baseline and time-updated characteristics and attaining stable housing were examined using Cox proportional hazard regression models.

Principal Findings

Of the 992 IDU eligible for this analysis, 495 (49.9%) reported being homeless, 497 (50.1%) resided in SRO hotels, and 380 (38.3%) were enrolled in addiction treatment at the baseline interview. Only 211 (21.3%) attained stable housing during the follow-up period and of this group, 69 (32.7%) had addiction treatment exposure prior to achieving stable housing. Addiction treatment was inversely associated with attaining stable housing in a multivariate model (adjusted hazard ratio [AHR]  = 0.71; 95% CI: 0.52–0.96). Being in a partnered relationship was positively associated with the primary outcome (AHR  = 1.39; 95% CI: 1.02–1.88). Receipt of income assistance (AHR  = 0.65; 95% CI: 0.44–0.96), daily crack use (AHR  = 0.69; 95% CI: 0.51–0.93) and daily heroin use (AHR  = 0.63; 95% CI: 0.43–0.92) were negatively associated with attaining stable housing.

Conclusions

Exposure to addiction treatment in our study was negatively associated with attaining stable housing and may have represented a marker of instability among this sample of IDU. Efforts to stably house this vulnerable group may be occurring in contexts outside of addiction treatment.

Community-based services for homeless adults experiencing concurrent mental health and substance use disorders: a realist approach to synthesizing evidence

Consultations with community-based service providers in Toronto identified a lack of strong research evidence about successful community-based interventions that address the needs of homeless clients experiencing concurrent mental health and substance use disorders. We undertook a collaborative research effort between academic-based and community-based partners to conduct a systematic evidence synthesis drawing heavily from Pawson's realist review methodology to focus on both whether programs are successful and why and how they lead to improved outcomes. We examined scholarly and nonscholarly literature to explore program approaches and program elements that lead to improvements in mental health and substance use disorders among homeless individuals with concurrent disorders (CD). Information related to program contexts, elements, and successes and failures were extracted and further supplemented by key informant interviews and author communication regarding reviewed published studies. From the ten programs that we reviewed, we identified six important and promising program strategies that reduce mental health and, to a far lesser degree, substance use problems: client choice in treatment decision-making, positive interpersonal relationships between client and provider, assertive community treatment approaches, providing supportive housing, providing supports for instrumental needs, and nonrestrictive program approaches. These promising program strategies function, in part, by promoting and supporting autonomy among homeless adults experiencing CD. Our realist informed review is a useful methodology for synthesizing complex programming information on community-based interventions.

Age differences among homeless individuals: adolescence through adulthood

The present study examines differences between homeless adolescents, young adults, and older adults served by homeless shelters or food programs to inform service provision. Four homeless studies using the same sampling and measurement methods were pooled to permit comparisons across age groups. Results showed that homeless adolescents demonstrated greater resilience than younger and older adults. Adolescents reported the shortest duration of homelessness, lowest number of life stressors, fewest physical symptoms, largest social networks, and fewest clinically significant mental health problems. Adolescents also received fewer alcohol and drug abuse diagnoses than younger and older adults. Younger adults reported less time homeless and fewer physical symptoms than older adults, but more life stressors. Younger adults also endorsed higher levels of hostile and paranoid psychological symptoms. Implications for service provision and policy are discussed.

High rates of homelessness among a cohort of street-involved youth

Using multivariate logistic regression, we examined the prevalence and correlates of homelessness among youth enrolled in a community-recruited prospective cohort known as the At-Risk Youth Study (ARYS), between September 2005 and October 2006. Of 478 individuals included in this analysis, 132 (27.6%) were female and 120 (25.1%) self-identified as Aboriginal. The median age was 22 (IQR: 20-24). In total, 284 (56.9%) participants reported baseline homelessness, with most living either at no fixed address, on the street, or in a hostel or shelter. Factors associated with homelessness included public injecting, frequent crack use, experienced violence, having less than a high-school education, and not having been in any addiction treatment. Homeless individuals were at-risk for various adverse health outcomes. These findings indicate the need for additional interventions, including residential addiction treatment, to address homelessness and drug use among youth.

Pathways into homelessness: recently homeless adults problems and service use before and after becoming homeless in Amsterdam

Background

To improve homelessness prevention practice, we met with recently homeless adults, to explore their pathways into homelessness, problems and service use, before and after becoming homeless.

Methods

Recently homeless adults (last housing lost up to two years ago and legally staying in the Netherlands) were sampled in the streets, day centres and overnight shelters in Amsterdam. In April and May 2004, students conducted interviews and collected data on demographics, self reported pathways into homelessness, social and medical problems, and service use, before and after becoming homeless.

Results

among 120 recently homeless adults, (male 88%, Dutch 50%, average age 38 years, mean duration of homelessness 23 weeks), the main reported pathways into homelessness were evictions 38%, relationship problems 35%, prison 6% and other reasons 22%. Compared to the relationship group, the eviction group was slightly older (average age 39.6 versus 35.5 years; p = 0.08), belonged more often to a migrant group (p = 0.025), and reported more living single (p < 0,001), more financial debts (p = 0.009), more alcohol problems (p = 0.048) and more contacts with debt control services (p = 0.009). The relationship group reported more domestic conflicts (p < 0.001) and tended to report more drug (cocaine) problems. Before homelessness, in the total group, contacts with any social service were 38% and with any medical service 27%. Despite these contacts they did not keep their house. During homelessness only contacts with social work and benefit agencies increased, contacts with medical services remained low.

Conclusion

the recently homeless fit the overall profile of the homeless population in Amsterdam: single (Dutch) men, around 40 years, with a mix of financial debts, addiction, mental and/or physical health problems. Contacts with services were fragmented and did not prevent homelessness. For homelessness prevention, systematic and outreach social medical care before and during homelessness should be provided.

Effects of housing circumstances on health, quality of life and healthcare use for people with severe mental illness: a review

Individuals with severe and persistent mental illness (SPMI) identify housing as an important factor in achieving and maintaining their health. However, many live in substandard accommodations that are physically inadequate, crowded, noisy and located in undesirable neighbourhoods. In much of the research on housing for persons with SPMI, the central outcome of interest is remaining housed; however, it is worth investigating whether housing has other benefits. This paper is a systematic review of studies that investigated the relationship between housing-related independent variables and health-related dependent variables. Ten online databases were searched for studies published since 1980 that had study populations of adults with SPMI, analysed primary or secondary empirical data, and measured housing-related independent variables and health-related dependent variables. Clearly defined epidemiological criteria were used to assess the strength of evidence of the selected studies. Twenty-nine studies met the suitability criteria, of which 14 reported healthcare utilisation outcomes; 12 examined mental status outcomes; and 9 reported quality-of-life outcomes. The findings of the review suggest that there is good evidence that housing interventions benefit the homeless population; however more research is needed about housing solutions for individuals with SPMI who are housed, but in precarious or inappropriate housing situations. Study methodologies could be improved by emphasising longitudinal designs that focus on participant retention and by implementing matched control groups or randomised interventions to strengthen internal validity. Ensuring that a person is adequately housed upon discharge from hospital should be a treatment priority. When housing eligibility is not dependent on psychiatric treatment compliance and sobriety, providing permanent housing minimises harm and may free people to voluntarily seek treatment. Housing that offers an unlimited length of stay is recommended because SPMI is a chronic and fluctuating condition that requires stable surroundings to maintain health.

From psychiatric ward to the streets and shelters

The issue of discharge from hospital ward to the streets is seldom explored in the literature, but all too commonly experienced by individuals experiencing psychiatric disorders. The Community University Research Alliance on Housing and Mental Health sought to determine how frequently people were discharged from psychiatric wards to shelters or the street in London, Ontario, Canada. A number of data sources were accessed to determine instances of discharges to shelters or the street. Data were analysed to determine the number of moves occurring between hospital and shelter or no fixed address. All datasets revealed the problem of discharge to shelters or the street occurred regularly. All data sources used have the difficulty of likely underestimating the extent of the problem. This type of discharge occurred at least 194 times in 2002 in London, Ontario, Canada. Policies that contribute to this problem include income-support policies, the reduction in psychiatric hospital beds and the lack of community supports. Without recognition, this problem is at risk of remaining invisible with no further improvements to the situation.

Dyspepsia in homeless adults

GOALS

To determine the prevalence of and risk factors for dyspepsia in a representative sample of homeless persons using shelters in Toronto, Canada.

BACKGROUND

Homeless people have many risk factors for dyspepsia, but little information is available on gastrointestinal symptoms in this population.

STUDY

Cross-sectional survey of a representative sample of 100 homeless adults, with serologic testing for Helicobacter pylori infection.

RESULTS

The prevalence of moderate, severe, or very severe symptoms within the past 3 months was 18% for upper stomach pain and 59% for any dyspeptic symptom. Nonwhite ethnicity (odds ratio, 3.5; 95% confidence interval, 1.1-10.9) and a history of gastrointestinal disease (odds ratio, 8.6; 95% confidence interval, 2.5-29.6) were significantly associated with moderate to very severe upper stomach pain. H. pylori infection was identified in 31% of participants but was not significantly associated with dyspepsia.

CONCLUSIONS

Dyspepsia is a common problem among homeless adults in Toronto. The presence of upper stomach pain is most strongly associated with a history of gastrointestinal disease.

Episodic homelessness and health care utilization in a prospective cohort of HIV-infected persons with alcohol problems

BACKGROUND

Because individuals with HIV/AIDS often have complex medical and social needs, the impact of housing status on medical service utilization is difficult to isolate from the impact of conditions that may worsen during periods of homelessness such as depression and substance abuse. We examine whether episodes of homelessness are independently associated with suboptimal medical utilization even when accounting for concurrent addiction severity and depression.

METHODS

We used data from a 30-month cohort of patients with HIV/AIDS and alcohol problems. Housing status, utilization (ambulatory visits, emergency department (ED) visits, and hospitalizations) and other features were assessed with standardized research interviews at 6-month intervals. Multivariable longitudinal regression models calculated incidence rate ratios (IRR) comparing utilization rates during 6-month intervals (homeless versus housed). Additional models assessed whether addiction severity and depressive symptoms could account for utilization differences.

RESULTS

Of the 349 subjects, 139 (39%) reported homelessness at least once during the study period; among these subjects, the median number of nights homeless per 6-month interview period was 30. Homelessness was associated with higher ED utilization (IRR = 2.17; 95% CI = 1.72-2.74) and hospitalizations (IRR = 2.30; 1.70-3.12), despite no difference in ambulatory care utilization (IRR = 1.09; 0.89-1.33). These associations were attenuated but remained significant when adjusting for addiction severity and depressive symptoms.

CONCLUSION

In patients with HIV/AIDS and alcohol problems, efforts to improve housing stability may help to mitigate intensive medical utilization patterns.

"It's important to be proud of the place you live in": housing problems and preferences of psychiatric survivors

TOPIC

It is important to understand housing and mental health issues from the perspective of psychiatric survivors. This paper reports findings from a series of focus group meetings held with survivors of mental illness to address issues concerning housing preferences and housing needs.

METHODS

The discussions were recorded, transcribed, and analyzed using an ethnographic method of analysis. The themes that emerged related to oppression, social networks and social supports, housing conditions, poverty and finances, and accessing services. Participants described the ongoing stigma, discrimination, and poverty that reduced their access to safe, adequate housing.

FINDINGS

They preferred independent housing where supports would be available as needed. Participants described the dilemma of having to choose between the housing they wanted and the supports they needed, since supports were often contingent upon living in a less desirable housing situation.

CONCLUSIONS

Nurses and other mental healthcare workers need to be aware of these issues for discharge planning, community support, and ongoing advocacy. The survivor voices need to be heard by decision-makers at various levels of government in order for housing policy to become more receptive to their realities.

Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness

Despite the increase in consumer-driven interventions for homeless and mentally ill individuals, there is little evidence that these programs enhance psychological outcomes. This study followed 197 homeless and mentally ill adults who were randomized into one of two conditions: a consumer-driven "Housing First" program or "treatment as usual" requiring psychiatric treatment and sobriety before housing. Proportion of time homeless, perceived choice, mastery, and psychiatric symptoms were measured at six time points. Results indicate a direct relationship between Housing First and decreased homelessness and increased perceived choice; the effect of choice on psychiatric symptoms was partially mediated by mastery. The strong and inverse relationship between perceived choice and psychiatric symptoms supports expansion of programs that increase consumer choice, thereby enhancing mastery and decreasing psychiatric symptoms.

Homelessness and health in Canada: research lessons and priorities

This article was for prepared for an international think-tank on reducing health disparities and promoting equity for vulnerable populations. Its purposes are to provide an overview of homelessness research and to stimulate discussion on strategic directions for research. We identified studies on homelessness, with an emphasis on Canadian research. Studies were grouped by focus and design under the following topics: the scope of homelessness, the health status of homeless persons, interventions to reduce homelessness and improve health, and strategic directions for future research. Key issues include the definition of homelessness, the scope of homelessness, its heterogeneity, and competing explanations of homelessness. Homeless people suffer from higher levels of disease and the causal pathways linking homelessness and poor health are complex. Efforts to reduce homelessness and improve health have included biomedical, educational, environmental, and policy strategies. Significant research gaps and opportunities exist in these areas. Strategic research will require stakeholder and community engagement, and more rigorous methods. Priorities include achievement of consensus on measuring homelessness, health status of the homeless, development of research infrastructure, and ensuring that future initiatives can be evaluated for effectiveness.

Predictors of screening results for depressive symptoms among homeless adults in Los Angeles with latent tuberculosis

The purpose of this study was to examine predictors of screening results for depressive symptoms in a Los Angeles homeless population with latent tuberculosis (TB). Four hundred and fifteen homeless adults participating in a nurse case managed intervention were included in this analysis. Logistic regression results indicated that those who reported a physical health limitation, multiple sex partners, daily drug use, alcohol dependence, or not having completed high school, were more likely to screen positive. Social support from non-drug users was protective. Given the importance of adherence to TB treatment regimens, the high prevalence of a positive screening for depressive symptoms in the homeless and the potential for depression to reduce adherence rates, routine screening and treatment for depression in high risk homeless adults being treated for TB may be warranted.

Pathways to youth homelessness

Research documents high levels of psychopathology among homeless youth. Most research, however, has not distinguished between disorders that are present prior to homelessness and those that develop following homelessness. Hence whether psychological disorders are the cause or consequence of homelessness has not been established. The aim of this study is to investigate causal pathways to homelessness amongst currently homeless youth in Australia. The study uses a quasi-qualitative methodology to generate hypotheses for larger-scale research. High rates of psychological disorders were confirmed in the sample 35 homeless youth aged 14-25. The rates of psychological disorders at the point of homelessness were greater than in normative samples, but the rates of clinical disorder increased further once homeless. Further in-depth analyses were conducted to identify the temporal sequence for each individual with a view to establishing a set of causal pathways to homelessness and trajectories following homelessness that characterised the people in the sample. Five pathways to homelessness and five trajectories following homelessness were identified that accounted for the entire sample. Each pathway constituted a series of interactions between different factors similar to that described by Craig and Hodson (1998. Psychological Medicine, 28, 1379-1388) as "complex subsidiary pathways". The major findings were that (1) trauma is a common experience amongst homeless youth prior to homelessness and figured in the causal pathways to homelessness for over half of the sample; (2) once homeless, for the majority of youth there is an increase in the number of psychological diagnoses including drug and alcohol diagnoses; and (3) crime did not precede homelessness for all but one youth; however, following homelessness, involvement in criminal activity was common and became a distinguishing factor amongst youth. The implications of these findings for future research and service development are discussed.

Risk factors for cardiovascular disease in homeless adults

BACKGROUND

Homeless people represent an extremely disadvantaged group in North America. Among older homeless men, cardiovascular disease (CVD) is the leading cause of death. The objective of this study was to examine cardiovascular risk factors in a representative sample of homeless adults and identify opportunities for improved risk factor modification.

METHODS AND RESULTS

Homeless persons were randomly selected at shelters for single adults in Toronto. Response rate was 79%. Participants (n=202) underwent interviews, physical measurements, and blood sampling. The mean age of participants was 42 years, and 89% were men. The prevalence of smoking among homeless subjects (78%; 95% confidence interval [CI], 72% to 84%) was significantly higher than in the general population (standardized morbidity ratio [SMR], 254; 95% CI, 216 to 297). Hypertension, high cholesterol, and diabetes were not more prevalent than in the general population but were often poorly controlled. Homeless men were significantly less likely to be overweight or obese than men in the general population (SMR, 79; 95% CI, 63 to 98). Cocaine use in the last year was reported by 29% of subjects (95% CI, 23% to 36%). CVD was reported by 15% of subjects, fewer than one third of whom reported taking aspirin or cholesterol-lowering medication. According to multiple-risk-factor equations, the median estimated 10-year absolute risk of myocardial infarction or coronary death among homeless men aged 30 to 74 years was 5% (interquartile range, 3% to 9%).

CONCLUSIONS

Cardiovascular risk factor modification is suboptimal among homeless adults in Toronto, despite universal health insurance. Multiple risk factor equations may underestimate true risk in this population because of inadequate accounting for factors such as cocaine use and heavy smoking.