Foot Conditions among Homeless Persons: A Systematic Review

A Preliminary Assessment of Barriers and Facilitators to Accessing Foot Care in Homeless Shelters: A Scoping Review

BACKGROUND

This scoping review aims to explore the most common foot problems people experiencing homelessness (PEH) experience, as well as to explore the potential strategies for addressing foot problems in PEH, such as foot clinics, foot screening, and foot care for adults experiencing homelessness.

METHODS

A scoping review of the literature from MEDLINE (Ovid), CINAHL (EBSCOhost), Cochrane Register of Controlled Trials (Ovid), EMBASE (Ovid), PubMed, clinicaltrials.gov, Google Scholar, and Web of Science was conducted to identify relevant articles published from inception to April 14, 2023. Literature discussing foot problems, foot care, and intervention in PEH were included. Sixty-one articles were retained after screening by 2 independent reviewers. Data were extracted by 3 independent reviewers and disagreements were resolved by a fourth reviewer. Outcomes were determined after data extraction given the nature of the scoping review. Primary outcomes include foot problems, their severity, and their prevalence. The quality of studies included for data extraction was assessed using the Newcastle-Ottawa quality assessment scale and the National Institute of Health Quality Assessment Tool when applicable.

RESULTS

We present a summary of the prevalence of foot pain and foot problems along with gender differences when data was available. Frostbites, foot ulcers, peripheral arterial disease, foot infections (including diabetic foot infection), and related amputations were also found to be prevalent in PEH, with data suggesting that homelessness is an independent risk factor for these foot problems. Strategies and interventions to address foot health for PEH were divided into 1) direct interventions in the field, such as wound care, or education of PEH during clinical encounters and 2) organizational interventions, such as expanding outreach efforts, coordinating resources to avoid interfering with shelter hours, or improving the timeliness of interventions by first responders. The literature shows that foot exams, appropriate footwear, and education, which can be provided in the context of mobile clinics, play a critical role in the detection and prevention of foot pathologies. Barriers to care were broken down into 4 categories: accessing and receiving care, comorbid health issues or substance use, emotional barriers, and social inequalities.

CONCLUSIONS

Foot problems in PEH, which have been reported in the literature for decades, remain unchanged. Interventions and strategies to address this issue include provision of holistic care, enrollment in insurance programs, provision of supplies and education, and development of outreach services. Indeed, mobile clinics have been shown to eliminate multiple barriers to care for PEH. Although some screening tools were reported, their relevance and reliability have yet to be defined in further studies. While remaining gaps and barriers such as stigma, lack of follow-up care, and gratuity of services have been identified, alternative methods other than the aforementioned outreach efforts have yet to be described.

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

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

Social disparities in pulmonary embolism and deep vein thrombosis during the coronavirus disease 2019 pandemic from the Nationwide inpatient Sample

OBJECTIVES

Studies have shown that coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Studies have yet to examine the interconnectedness between COVID-19, hypercoagulability, and socioeconomics. The aim of this work was to investigate socioeconomic factors that may be associated with pulmonary embolism (PE), deep vein thrombosis (DVT), and COVID-19 in the United States.

METHODS

We performed a 1-year (2020) analysis of the National Inpatient Sample database. We identified all adult patients diagnosed with COVID-19, acute PE, or acute DVT using unweighted samples. We calculated the correlation and odds ratio (OR) between COVID-19 and (1) PE and (2) DVT. We executed a univariate analysis followed by a multivariate analysis to examine the effect of different factors on PE and DVT during the COVID-19 pandemic.

RESULTS

We identified 322,319 patients with COVID-19; 78,101 and 67,826 patients were identified with PE and DVT, respectively. PE and DVT, as well as inpatient mortality associated with both conditions, are significantly correlated with COVID-19. The OR between COVID-19 and PE was 2.04, while the OR between COVID-19 and DVT was 1.44. Using multivariate analysis, COVID-19 was associated with a higher incidence of PE (coefficient, 2.05) and DVT (coefficient, 1.42). Other factors that were significantly associated (P < .001) with increased incidence of PE and DVT along with their coefficients, respectively, include Black race (95% confidence interval [CI], 1.23-1.14), top quartile income (95% CI, 1.08-1.16), west region (95% CI, 1.10-1.04), urban teaching facilities (95% CI, 1.09-1.63), large bed size hospitals (95% CI, 1.08-1.29), insufficient insurance (95% CI, 1.88-2.19), hypertension (95% CI, 1.24-1.32), and obesity (95% CI, 1.41-1.25). Factors that were significantly associated (P < .001) with decreased incidence of PE and DVT along with their coefficients, respectively, include Asians/Pacific Islanders (95% CI, 0.52-0.53), female sex (95% CI, 0.79-0.74), homelessness (95% CI, 0.62-0.61), and diabetes mellitus (0.77-0.90).

CONCLUSIONS

In the Nationwide Inpatient Sample, COVID-19 is correlated positively with venous thromboembolism, including its subtypes, PE and DVT. Using a multivariate analysis, Black race, male sex, top quartile income, west region, urban teaching facilities, large bed size hospitals, and insufficient social insurance were associated significantly with an increased incidence of PE and DVT. Asians/Pacific Islanders, female sex, homelessness, and diabetes mellitus were significantly associated decreased incidence of PE and DVT.

Addressing dermatologic concerns and teledermatology in undomiciled and sheltered populations

Homelessness in the United States is a significant public health issue, with dermatologic disease being the most prevalent health concern among the undomiciled and sheltered populations. Despite a growing need for dermatologic care, the supply of dermatologists remains insufficient, contributing to disparities in healthcare access for this vulnerable group. This review aims to detail the spectrum of dermatologic conditions experienced by homeless individuals, identify barriers to adequate care, and explore teledermatology as a potential solution to bridge these gaps. A comprehensive literature review was conducted, analyzing studies and reports on dermatologic issues prevalent among the homeless population and the efficacy of teledermatology in addressing these concerns. Homeless individuals face a wide range of dermatologic problems, from common conditions like acne and eczema to severe issues such as cellulitis, leg ulcers, and skin cancer. Drug abuse, domestic and sexual abuse, and parasitic infestations further complicate the dermatologic health of this population. Teledermatology has emerged as a promising tool to enhance access to dermatologic care, showing significant improvements in clinical outcomes and accessibility, especially in underserved urban settings. However, challenges remain, such as the digital divide affecting the elderly and low-income populations, which could potentially exacerbate disparities. Addressing the dermatologic needs of the homeless population requires a multifaceted approach. Teledermatology offers a viable solution to improve care access and efficiency, but additional efforts are necessary to ensure inclusivity and avoid further marginalization. Volunteer-driven multidisciplinary clinics also play a crucial role in providing care, though they face challenges in continuity and resource availability. Future strategies should focus on integrating teledermatology with other supportive services to create a comprehensive care model for this underserved population.

Persons Experiencing Homelessness during Extreme Temperatures: Lessons for Promoting Socially Inclusive Adaptive Capacity

Climate change and increasing extreme temperatures present unique challenges to persons experiencing homelessness (PEH), including heightened physical and psychological harm. While green and urban infrastructure has emerged as one possible mitigation strategy, homeless populations are rarely included in municipal disaster planning or infrastructure research. This study used in-depth interviews with PEH (N = 42) during the summers of 2022 and 2023. Questions were designed around phenomenological methods to explore the individuals' firsthand descriptions of the lived experience of coping during extreme temperatures within a mid-size city in the Southeastern United States. Our findings highlight how social exclusion within the built environment reduces PEH's adaptive capacity and increases the physical and psychological risks of extreme temperatures, namely through limiting and policing scarce resources and restricting the mobility of PEH. In contrast, public transit provided relief from extreme temperatures. Implications from our findings include the need for attention on inclusive green urban infrastructure, including increased placement and access to shade, public water, mixed-use daytime sheltering models, and the installation of lockers to increase capacity to maintain supplies and gear necessary for enduring extreme temperatures. Findings also highlight the challenges of designing inclusive green infrastructure and the importance of de-stigmatizing homelessness and building more housing and income support to increase adaptive capacity for an entire community in the context of a rapidly warming climate.

Describing the development and implementation of a novel collaborative multidisciplinary approach to deliver foot health supports for individuals experiencing homelessness and its outcomes

Basic foot care is a real need of people experiencing homelessness. To improve access to foot health for this group, three services structured to provide healthcare support for people experiencing homelessness collaborated in metropolitan Melbourne, Australia: an established nurse-led Homeless Persons Program (HPP), a specialty community health podiatry clinic servicing people experiencing homelessness, and a charity supporting disadvantaged communities providing free socks, foot first aid kits and second-hand footwear for distribution by nurses and podiatrists of participating services. This paper outlines the implementation and evaluation of this collaboration. A four stage implementation approach was used, addressing: 1. Who needs to do what differently? 2. What are the barriers and enablers that need to be addressed? 3. Which intervention components could overcome the modifiable barriers and enhance the enablers? 4. How can the changes be measured? The evaluation prospectively collected information about how HPP nurses referred adults to podiatry, and whether the referred individuals accessed the podiatry clinic, the outcomes of the podiatry visit, and how many received footwear, socks and foot first aid kits provided by the non-profit organisation. Over 1st June 2019 and 31st December 2020, 52 individuals were identified as adults who could potentially benefit from podiatry by the HPP nurses, of which 33 accessed podiatry. Those who did not visit the podiatry clinic were more likely to be born outside of Australia, live in more precarious housing (crisis accommodation and rough sleeping), have slightly more predisposing factors for homelessness, but have fewer medical, psychological and cognitive conditions. A structured approach including processes, education, regular, outreach to youth refuges and formal outcome monitoring enabled foot health care access in people experiencing homelessness. Further research is needed to ascertain how to support participants at risk of foot problems to access podiatry before their foot health issue reaches crisis point.

Wound care in hard-to-reach populations: rough sleepers

People sleeping rough commonly develop wounds and other skin disorders. Wounds vary and develop for multiple reasons. They include acute wounds such as burns, infected injection sites, abscesses and cellulitis, as well as chronic wounds such as pressure ulcers; rough sleepers have a high prevalence of lower limb wounds. Skin and soft tissue infections are common, especially in people who inject drugs via subcutaneous or intramuscular routes. Emergency departments are often the pathways into healthcare for homeless people as traditional health and care systems often fail to meet their needs. Across England, initiatives have been developed to improve access to wound care for those who sleep rough. A case study illustrates the care of a homeless man presenting with a lower limb wound.

Chronic Cellulitis in the Unhoused: Case Study and Treatment Considerations

This report seeks to discuss sequelae of chronic cellulitis that is commonly treated in the ambulatory setting, as exacerbated by the conditions of living outside. Further we hope to identify etiologic factors that contribute to complication development. Additionally, this article will touch on unique treatment plan considerations for unhoused patients with the intention to educate providers and reduce mortality and morbidity relating to pedal skin and soft tissue infections in this population. This piece examines the case of a 52-year-old man with a history of chronic diseases, substance use disorder, and recurrent cellulitis. We highlight systemic issues in healthcare delivery for unhoused patients, including inadequate discharge planning, limited access to medication, and challenges in shelter placement. The discussion section emphasizes the importance of accurate diagnosis and tailored treatment plans for cellulitis in houseless individuals, the importance of a multidisciplinary approach incorporating social work services, and addressing chronic illnesses, substance use disorder, and housing issues. The report advocates for heightened awareness of bilateral cellulitis in unhoused populations, emphasizing the need for comprehensive, individualized treatment plans.

Dermatologic conditions and risk factors in people experiencing homelessness (PEH): systematic review

Limited data is present that characterizes dermatological conditions and their risk factors in people experiencing homelessness (PEH).We conducted a systematic review to investigate the types of dermatological conditions in PEH, their risk factors, and provide solutions when providing dermatological care to this patient population. We searched PubMed, EMBASE and Cochrane for articles written in English from 2012 to 2022. The last search was performed on December 27, 2022. Twelve studies met the inclusion criteria. Fifty-eight percent of the studies took place in the USA (n = 7) and 42% of studies took place in Canada (n = 5). Prevalent dermatological conditions included, skin cancer, cutaneous manifestations of malnutrition, cutaneous diphtheria, Group A Streptococcus infection (iGAS), lice, atopic dermatitis, acne, sexually transmitted infections (STIs), and Staphylococcus aureus infections. Risk factors included substance use disorder, skin trauma, not having access to sunscreen or hats, unstable housing, higher exposure to extreme weather, and higher mobility. Due to studies being conducted in the USA or Canada, results may not be generalizable. This systematic review strongly suggests that many dermatological conditions prevalent in PEH can be contributed to poor skin integrity. Better measures can significantly reduce certain dermatological conditions by improving access to dermatological care.

The Association of Homelessness With Rates of Diabetes Complications: A Population-Based Cohort Study

OBJECTIVE

To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless control subjects.

RESEARCH DESIGN AND METHODS

A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada. Inclusion criteria included a diagnosis of diabetes and at least one hospital encounter between April 2006 and March 2019. Homeless status was identified using a validated administrative data algorithm. Eligible people with a history of homelessness were matched to nonhomeless control subjects with similar sociodemographic and clinical characteristics. Rate ratios (RRs) for macrovascular complications, revascularization procedures, acute glycemic emergencies, skin/soft tissue infections, and amputation were calculated using generalized linear models with negative binomial distribution and robust SEs.

RESULTS

Of 1,076,437 people who were eligible for inclusion in the study, 6,944 were identified as homeless. A suitable nonhomeless match was found for 5,219 individuals. The rate of macrovascular complications was higher for people with a history of homelessness compared with nonhomeless control subjects (RR 1.85, 95% CI 1.64-2.07), as were rates of hospitalization for glycemia (RR 5.64, 95% CI 4.07-7.81) and skin/soft tissue infections (RR 3.78, 95% CI 3.31-4.32). By contrast, the rates of coronary revascularization procedures were lower for people with a history of homelessness (RR 0.76, 95% CI 0.62-0.94).

CONCLUSIONS

These findings contribute to our understanding of the impact of homelessness on long-term diabetes outcomes. The higher rates of complications among people with a history of homelessness present an opportunity for tailored interventions to mitigate these disparities.

Tinea pedis: an updated review

Background

Tinea pedis is one of the most common superficial fungal infections of the skin, with various clinical manifestations. This review aims to familiarize physicians with the clinical features, diagnosis and management of tinea pedis.

Methods

A search was conducted in April 2023 in PubMed Clinical Queries using the key terms 'tinea pedis' OR 'athlete's foot'. The search strategy included all clinical trials, observational studies and reviews published in English within the past 10 years.

Results

Tinea pedis is most often caused by Trichophyton rubrum and Trichophyton interdigitale. It is estimated that approximately 3% of the world population have tinea pedis. The prevalence is higher in adolescents and adults than in children. The peak age incidence is between 16 and 45 years of age. Tinea pedis is more common amongst males than females. Transmission amongst family members is the most common route, and transmission can also occur through indirect contact with contaminated belongings of the affected patient. Three main clinical forms of tinea pedis are recognized: interdigital, hyperkeratotic (moccasin-type) and vesiculobullous (inflammatory). The accuracy of clinical diagnosis of tinea pedis is low. A KOH wet-mount examination of skin scrapings of the active border of the lesion is recommended as a point-of-care testing. The diagnosis can be confirmed, if necessary, by fungal culture or culture-independent molecular tools of skin scrapings. Superficial or localized tinea pedis usually responds to topical antifungal therapy. Oral antifungal therapy should be reserved for severe disease, failed topical antifungal therapy, concomitant presence of onychomycosis or in immunocompromised patients.

Conclusion

Topical antifungal therapy (once to twice daily for 1-6 weeks) is the mainstay of treatment for superficial or localized tinea pedis. Examples of topical antifungal agents include allylamines (e.g. terbinafine), azoles (e.g. ketoconazole), benzylamine, ciclopirox, tolnaftate and amorolfine. Oral antifungal agents used for the treatment of tinea pedis include terbinafine, itraconazole and fluconazole. Combined therapy with topical and oral antifungals may increase the cure rate. The prognosis is good with appropriate antifungal treatment. Untreated, the lesions may persist and progress.

The importance of socio-economic determinants of health in the care of patients with peripheral artery disease: A narrative review from VAS

Socio-economic determinants of health (SDoH) include various nonmedical factors in the socio-economic sphere with a potentially significant impact on health outcomes. Their effects manifest through several mediators/moderators (behavioral characteristics, physical environment, psychosocial circumstances, access to care, and biological factors). Various critical covariates (age, gender/sex, race/ethnicity, culture/acculturation, and disability status) also interact. Analyzing the effects of these factors is challenging due to their enormous complexity. Although the significance of SDoH for cardiovascular diseases is well documented, research regarding their impact on peripheral artery disease (PAD) occurrence and care is less well documented. This narrative review explores to what extent SDoH are multifaceted in PAD and how they are associated with its occurrence and care. Additionally, methodological issues that may hamper this effort are addressed. Finally, the most important question, whether this association may contribute to reasonable interventions aimed at SDoH, is analyzed. This endeavor requires attention to the social context, a whole systems approach, multilevel-thinking, and a broader alliance that reaches out to more stakeholders outside the medical sphere. More research is needed to justify the power in this concept to improve PAD-related outcomes like lower extremity amputations. At the present time, some evidence, reasonable consideration, and intuitive reasoning support the implementation of various interventions in SDoH in this field.

Impact of neighborhood social disadvantage on the presentation and management of peripheral artery disease

OBJECTIVE

Studies examining the relationship between socioeconomic disparities and peripheral artery disease (PAD) often focus on individual social health determinants and fail to account for the complex interplay between factors that ultimately impact disease severity and outcomes. Area deprivation index (ADI), a validated measure of neighborhood adversity, provides a more comprehensive assessment of social disadvantage. Therefore, we examined the impact of ADI on PAD severity and its management.

METHODS

We identified all patients who underwent infrainguinal revascularization (open or endovascular) or amputation for symptomatic PAD in the Vascular Quality Initiative registry between 2003 and 2020. An ADI score of 1 to 100 was assigned to each patient based on their residential zip code, with higher ADI scores corresponding with increasing adversity. Patients were categorized by ADI quintiles (Q1-Q5). The outcomes of interest included indication for procedure (claudication, rest pain, or tissue loss) and rates of revascularization (vs primary amputation). Multinomial logistic regression was used to evaluate for an independent association between ADI quintile and these outcomes.

RESULTS

Among the 79,973 patients identified, 9604 (12%) were in the lowest ADI quintile (Q1), 14,961 (18.7%) in Q2, 19,800 (24.8%) in Q3, 21,735 (27.2%) in Q4, and 13,873 (17.4%) in Q5. There were significant trends toward lower rates of claudication (Q1: 39% vs Q5: 34%, P < .001), higher rates of rest pain (Q1: 12.4% vs Q5: 17.8%, P < .001) as the indication for intervention, and lower rates of revascularization (Q1: 80% vs Q5: 69%, P < .001) with increasing ADI quintiles. In adjusted analyses, there was a progressively higher likelihood of presenting with rest pain vs claudication, with patients in Q5 having the highest probability when compared with those in Q1 (relative risk: 2.0; 95% confidence interval: 1.8-2.2; P < .001). Patients in Q5, when compared with those in Q1, also had a higher likelihood of presenting with tissue loss vs claudication (relative risk: 1.4; 95% confidence interval: 1.3-1.6; P < .001). Compared with patients in Q1, patients in Q2-Q5 had a lower likelihood of undergoing any revascularization procedure.

CONCLUSIONS

Among patients who underwent infrainguinal revascularization or amputation in the Vascular Quality Initiative, those with higher neighborhood adversity had more advanced disease at presentation and lower rates of revascularization. Further work is needed to better understand neighborhood factors that are contributing to these disparities in order to identify community-level targets for improvement.

Using the National Institute on Minority Health and Health Disparities framework to better understand disparities in major amputations

Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twice as likely to lose a limb as those identifying as non-Hispanic White. Those identifying as Latino face a 30% increase. Rural patients are also more likely to undergo major amputations, and the rural-urban disparity is widening. We used the National Institute on Minority Health and Health Disparities framework to better understand these disparities and identify common factors contributing to them. Common factors were abundant and included increased prevalence of diabetes, possible lower rates of foot self-care, transportation barriers to medical appointments, living in disadvantaged neighborhoods, and lack of insurance. Solutions within and outside the health care realm are needed. Health care-specific interventions that embed preventative and ambulatory care services within communities may be particularly high yield.

Antifungal Nail Lacquer for Enhanced Transungual Delivery of Econazole Nitrate

The fungal disease of the nail, onychomycosis, which is also the most prevalent nail disturbance, demands effective topical treatment options considering the possible adverse effects of systemic antifungal therapy. The current work is focused on development of an adhesive and resistant, drug-delivering and permeation-enhancing polymeric film containing econazole nitrate (ECN) for topical antifungal treatment. The development of the lacquer formulation was guided by the Quality by Design approach to achieve the critical quality attributes needed to obtain the product of desired quality. Eudragit RSPO at 10% w/w was found to be the ideal adhesive polymer for the application and an optimal permeation-enhancing lacquer formulation was achieved by the optimization of other formulation excipients, such as plasticizer and the solvent system. Additionally, novel experimental enhancements introduced to the research included refined D₅₀ drying time and drying rate tests for lacquer characterization as well as a multi-mechanism permeation-enhancing pre-treatment. Moreover, a practical implication was provided by a handwashing simulation designed to test the performance of the lacquer during actual use. In vitro drug release testing and ex vivo nail permeation testing demonstrated that the optimized nail lacquer performed better than control lacquer lacking the permeation enhancer by achieving a faster and sustained delivery of ECN. It can be concluded that this is a promising drug delivery system for topical antifungal treatment of onychomycotic nails, and the novel characterization techniques may be adapted for similar formulations in the future.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

BACKGROUND

Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population.

METHODS

Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted.

RESULTS

Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant.

CONCLUSION

While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

Allied health professionals: A promising ally in the work against health inequalities- A rapid review

Objectives

Allied Health Professionals (AHPs) have a crucial role in reducing health inequalities. However, there is a lack of evidence regarding the ways they can fulfil this role. This rapid review explores the ways in which AHPs can decrease health care or health outcome inequalities; address inequalities in the social determinants of health; and support disadvantaged groups at an individual, organisational and system level.

Study design

Rapid review following Cochrane criteria and narrative synthesis.

Methods

MEDLINE, EMBASE, CINAHL, Web of Science and AMED were searched combined with grey literature, to identify quantitative or qualitative review articles published between January 2010 and February 2021.

Results

From 8727 references, 36 met the inclusion criteria. The methodological quality of the studies was assessed with the AMSTAR tool and was generally low. Meta-analysis was not possible due to the heterogeneity of the studies, and a narrative synthesis was produced. Three themes emerged at patient and organisational level: 1) access to AHP services; 2) quality of care; and 3) social determinants of health. Two themes emerged at system level: 1) unequal workforce distribution and 2) lack of inclusive clinical guidelines.

Conclusions

This rapid review offers a broad range of evidence on the ways AHPs can contribute to the reduction of inequalities in health care, both in terms of access and quality of care and in health outcomes. More research is needed to further understand the impact of AHPs on inequalities affecting specific groups and their contribution to equitable distribution of social determinants of health.

Responding to foot health needs of people experiencing homelessness: the role of a publicly funded community-based podiatry service

Background

People experiencing homelessness are known to suffer from poor health and can be reluctant to seek healthcare except in crisis. Foot and ankle problems are a concern; as well as causing discomfort and pain, they may escalate from a minor problem to a very serious one without timely and appropriate treatment. Little is known about the foot and ankle problems of people experiencing homelessness.

This paper describes a podiatric service specifically for people experiencing homelessness, which includes a fixed site as well as outreach services. The service operates as part of the Homelessness Team program at Cohealth, a large community health service in Melbourne.

Methods

The study used routinely collected data. Every person who was seen by the podiatrist in the Cohealth Homelessness Team in 2019, whether on site or on outreach, was included in the study (n = 295). Of these, 156 were attending for the first time and 139 were returning clients. People who used the service were predominantly rough sleeping (45.2%), with 32.2% in unstable or insecure housing and 22.6% recently housed.

Results

Skin and nail pathologies (68.1%), inadequate footwear (51.9%) and biomechanical issues (44.1%) were the most common presentations. People sleeping rough were particularly likely to present with biomechanical issues (50.8%), acute wound care needs (17.4%) or traumatic injury (10.6%). Most people presented with more than one issue (mean = 2.4), and new clients (mean = 2.53) and those rough sleeping (mean = 2.69) had more issues than others.

Outreach was the most effective way to reach clients in the most difficult circumstances (48.9% of those in unstable housing, 34.8% of rough sleepers). Most of the clients (81.4%) had connections with other services offered by Cohealth, such as social work or physiotherapy.

Conclusions

This study demonstrated that reaching and intervening on foot and ankle problems of people experiencing homelessness who may not seek care on their own could be achieved through a publicly funded health service, using simplified pathways to care including outreach. In addition to the long- and short- term benefits of the immediate podiatric treatment, building trust and connections through footcare may provide an entry point into accepting other health and welfare services.

Exploring Foot Care Conditions for People Experiencing Homelessness: A Community Participatory Approach

Introduction:

People experiencing homelessness are faced with complex challenges and are at high risk of illness due to inequities and disparities in access to health care services.

Objective:

To explore the health and foot care problems related to people experiencing homelessness in British Columbia.

Methods:

A community participatory research approach was used with a sample of 65 people experiencing homelessness. Data were collected using a survey questionnaire and face-to-face semistructured interviews.

Results:

Thematic findings shows risk of foot injuries, lack of foot care resources, and absence of family support. Barriers to equitable access to services for most participants experiencing homelessness were lack of housing (76.92%), inability to work (72.31%), and inability to afford the cost of living on their own (63.08%).

Conclusions:

There is a pressing need for early screening and detection by health care professionals and enhanced foot care services to reduce foot problems and improve foot care wellness of homeless people. Addressing foot-related care are necessary steps in promoting health, preventing illness, and improving access to health services among people experiencing homelessness.

Assessment of a Hotel-Based Protective Housing Program for Incidence of SARS-CoV-2 Infection and Management of Chronic Illness Among Persons Experiencing Homelessness

IMPORTANCE

Persons experiencing homelessness (PEH) are at higher risk for SARS-CoV-2 infection and severe illness due to COVID-19 because of a limited ability to physically distance and a higher burden of underlying health conditions.

OBJECTIVE

To describe and assess a hotel-based protective housing intervention to reduce incidence of SARS-CoV-2 infection among PEH in Chicago, Illinois, with increased risk of severe illness due to COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study analyzed PEH who were provided protective housing in individual hotel rooms in downtown Chicago during the COVID-19 pandemic from April 2 through September 3, 2020. Participants were PEH at increased risk for severe COVID-19, defined as (1) aged at least 60 years regardless of health conditions, (2) aged at least 55 years with any underlying health condition posing increased risk, or (3) aged less than 55 years with any underlying health condition posing substantially increased risk (eg, HIV/AIDS).

EXPOSURES

Participants were housed in individual hotel rooms to reduce the risk of SARS-CoV-2 infection; on-site health care workers provided daily symptom monitoring, regular SARS-CoV-2 testing, and care for chronic health conditions. Additional on-site services included treatment of mental health and substance use disorders and social services.

MAIN OUTCOMES AND MEASURES

The main outcome measured was SARS-CoV-2 incidence, with SARS-Cov2 infection defined as a positive upper respiratory specimen using any polymerase chain reaction diagnostic assay authorized for emergency use by the Food and Drug Administration. Secondary outcomes were blood pressure control, glycemic control as measured by hemoglobin A1c, and housing placements at departure.

RESULTS

Of 259 participants from 16 homeless shelters in Chicago, 104 (40.2%) were aged at least 65 years, 190 (73.4%) were male, 185 (71.4%) were non-Hispanic Black, and 49 (18.9%) were non-Hispanic White. There was an observed reduction in SARS-CoV-2 incidence during the study period among the protective housing cohort (54.7 per 1000 people [95% CI, 22.4-87.1 per 1000 people]) compared with citywide rates for PEH residing in shelters (137.1 per 1000 people [95% CI, 125.1-149.1 per 1000 people]; P = .001). There was also an adjusted change in systolic blood pressure at a rate of -5.7 mm Hg (95% CI, -9.3 to -2.1 mm Hg) and hemoglobin A1c at a rate of -1.4% (95% CI, -2.4% to -0.4%) compared with baseline. More than half of participants (51% [n = 132]) departed from the intervention to housing of some kind (eg, supportive housing).

CONCLUSIONS AND RELEVANCE

This cohort study found that protective housing was associated with a reduction in SARS-CoV-2 infection among high-risk PEH during the first wave of the COVID-19 pandemic in Chicago. These findings suggest that with appropriate wraparound supports (ie, multisector services to address complex needs), such housing interventions may reduce the risk of SARS-CoV-2 infection, improve noncommunicable disease control, and provide a pathway to permanent housing.

Understanding Dermatologic Concerns Among Persons Experiencing Homelessness: A Scoping Review and Discussion for Improved Delivery of Care

There is a paucity of information surrounding dermatologic care for persons experiencing homelessness (PEH). This scoping review aims to map existing literature and provide a summary of the most common cutaneous manifestations among PEH, risk factors for dermatologic disease, describe any reported interventions, as well as identify research gaps for future studies. Search strategies developed for MEDLINE and hand searching yielded 486 articles. Out of the 486 articles screened, 93 articles met the inclusion criteria. The majority were cohort studies, cross-sectional studies, and case-control studies concentrated in North America and Europe. Excluding the pediatric population, the prevalence of dermatologic conditions ranged from 16.6% to 53.5%. Common skin conditions described in PEH were: acne, psoriasis, seborrheic dermatitis, atopic dermatitis, and lichen simplex chronicus. There were no studies comparing the extent or severity of these cutaneous diseases in PEH and the general population. PEH have a higher prevalence of skin infections and non-melanoma skin cancers. This scoping review has direct implications on public health interventions for PEH and highlights the need for evidence-based interventions to provide optimum and safe dermatologic healthcare for PEH. We propose several recommendations for improved care delivery, including addressing upstream factors and comorbidities impacting skin health, providing trauma informed care, reducing barriers to care, preventing and managing skin conditions, as well as including PEH in the planning and implementation of any proposed intervention.

Development of a foot care model to determine the risk of foot problems among homeless adults in Canada

Foot care is a common problem for homeless adults in cities, who often receive fragmented foot care services, resulting in increased foot problems, health complications, hospitalisation, limb removal and disabilities. Among the health factors that negatively affect the homeless, foot health is essential, but often neglected. This study employed a descriptive, cross-sectional research design to assess the foot care of homeless people and develop recommendations for clinical practice. Using Inlow's 60-s foot screening method, the foot conditions of a purposive sample of 65 homeless adults were examined in British Columbia, Canada, in 2019-2020. Descriptive and inferential statistics were used to analyse the data. Determinants, such as sex and years of homelessness significantly contributed to homeless individuals' risk of developing foot problems. Differences in perceived and observed foot problems were influenced by equitable access to social health and healthcare services. Foot assessment is not well-covered by homeless health services and should be implemented as part of the standard medical review of homeless patients. Furthermore, foot assessment should be conducted by healthcare professionals, rather than relying on the standard practice of service users' self-report. Finally, foot care should be based on tailoring assessments and interventions for the individualised needs of homeless service users. Future research must seek ways to integrate homeless individuals' voices in the development, implementation and evaluation of foot care services.

Towards Equitable Health Care Access: Community Participatory Research Exploring Unmet Health Care Needs of Homeless Individuals

Community and health services often overlook health care needs of persons experiencing homelessness, which leads to deterioration in health and increased utilization of emergency services. Since homeless people are underrepresented in health service research, little is known about their unmet health care needs, particularly in smaller cities where resources are limited. This community-based participatory research explored the experiences of small-city homeless service users (HSUs) with unmet health care needs and community service providers (CSPs) who work with them to determine barriers to health care access affecting them. Structured interviews were conducted with 65 HSUs and 15 CSPs in interior British Columbia, Canada. These interviews were audio-recorded, and the retrieved data were analyzed thematically. The three themes uncovered included: a lack of access to health care and risk of stigma, a lack of trust and fear of discrimination, and a need for community navigation and social support. The findings indicate that HSUs do not receive equitable care and face challenges in accessing appropriate and timely foot care, which contributes to increased foot-related emergency visits, loss of trust in the health care system, and disabilities due to worsening foot conditions. Various social determinants of health also impact HSUs, such as low socioeconomic status, lack of housing, decreased social support, unhealthy behaviors, and inequitable access to health services. By collaborating with HSUs, community and health services need to develop innovative outreach programs that provide better community resources as the first step toward equitable access to health care.

Variability in comorbidites and health services use across homeless typologies: multicenter data linkage between healthcare and homeless systems

BACKGROUND

Homelessness is associated with substantial morbidity. Data linkages between homeless and health systems are important to understand unique needs across homeless populations, identify homeless individuals not registered in homeless databases, quantify the impact of housing services on health-system use, and motivate health systems and payers to contribute to housing solutions.

METHODS

We performed a cross-sectional survey including six health systems and two Homeless Management Information Systems (HMIS) in Cook County, Illinois. We performed privacy-preserving record linkage to identify homelessness through HMIS or ICD-10 codes captured in electronic medical records. We measured the prevalence of health conditions and health-services use across the following typologies: housing-service utilizers stratified by service provided (stable, stable plus unstable, unstable) and non-utilizers (i.e., homelessness identified through diagnosis codes-without receipt of housing services).

RESULTS

Among 11,447 homeless recipients of healthcare, nearly 1 in 5 were identified by ICD10 code alone without recorded homeless services (n = 2177; 19%). Almost half received homeless services that did not include stable housing (n = 5444; 48%), followed by stable housing (n = 3017; 26%), then receipt of both stable and unstable services (n = 809; 7%). Setting stable housing recipients as the referent group, we found a stepwise increase in behavioral-health conditions from stable housing to those known as homeless solely by health systems. Compared to those in stable housing, prevalence rate ratios (PRR) for those without homeless services were as follows: depression (PRR = 2.2; 95% CI 1.9 to 2.5), anxiety (PRR = 2.5; 95% CI 2.1 to 3.0), schizophrenia (PRR = 3.3; 95% CI 2.7 to 4.0), and alcohol-use disorder (PRR = 4.4; 95% CI 3.6 to 5.3). Homeless individuals who had not received housing services relied on emergency departments for healthcare-nearly 3 of 4 visited at least one and many (24%) visited multiple.

CONCLUSIONS

Differences in behavioral-health conditions and health-system use across homeless typologies highlight the particularly high burden among homeless who are disconnected from homeless services. Fragmented and high use of emergency departments for care should motivate health systems and payers to promote housing solutions, especially those that incorporate substance use and mental health treatment.

Foot Health Assessment and Problem Identification in a Dominican Batey Community: A Descriptive Study

PURPOSE

Foot problems can adversely impact foot function and quality of life. Foot problems are often overlooked, particularly in populations with limited health care access. Little is known about the foot health of Haitian immigrants who live and work in the bateyes (rural sugarcane villages) of the Dominican Republic. These immigrant workers may experience foot problems that could affect foot function and the ability to work and provide for their families.

DESIGN

Cross-sectional, exploratory, descriptive study design.

SUBJECTS AND SETTING

A convenience sample of adults was recruited from an ongoing community-based participatory research project evaluating a mobile hypertension screening and treatment clinic program in 11 Dominican batey communities.

METHODS

Foot health was assessed using the Foot Problems Checklist, a 24-item survey instrument developed for this study based on a review of the literature and foot clinician expertise. A certified foot care nurse recorded foot health data on the Foot Problems Checklist via visual and physical inspection.

RESULTS

Study participants were 25 females and 16 males, aged 18 to 90 years, and all had at least one foot health problem. The most common foot problems were calluses (78%), dry skin (76%), thick nails (59%), jagged nails (29%), long/overgrown nails (17%), and skin fissures (12%).

CONCLUSIONS

While the foot problems we observed were not considered serious, they could become progressively debilitating and be prevented with proper self-management guided by appropriate knowledge and skills and available supplies. We recommend the development and testing of foot care self-management interventions deliverable via mobile clinics to increase access and improve foot health outcomes.

Diabetes management interventions for homeless adults: a systematic review

OBJECTIVES

Recent studies investigating diabetes show that inequalities to access appropriate care still persists. Whilst most of the general population are able to access a suitable quality of care, there are a number of groups who fail to receive the same standard. The objective of this review was to identify existing diabetes management interventions for homeless adults.

METHODS

A literature search was conducted in February 2017, and repeated in September 2020.

RESULTS

Of the 223 potentially relevant articles identified, only 26 were retrieved for detailed evaluation, and 6 met the inclusion criteria. Papers focusing on the management of diabetes in homeless people were included. The studies used interventions including diabetes education; medication support and supplies for blood monitoring; improvements in self-care behaviours; improvements in diabetes control; patient empowerment/engagement; and community engagement/partnerships.

CONCLUSIONS

Effective strategies for addressing the challenges and obstacles that the homeless population face, requires innovative, multi-sectored, flexible and well-coordinated models of care. Without appropriate support, these groups of people are prone to experience poor control of their diabetes; resulting in an increased risk of developing major health complications.

A Multilevel Intervention Framework for Supporting People Experiencing Homelessness with Pets

Simple Summary

Approximately one in 10 people experiencing homelessness have pets. Despite pets having psychosocial benefits for their owners, pets can also present challenges for people experiencing homelessness related to meeting their basic needs and obtaining housing. This article proposes a framework of policy, public, and service interventions for improving the health and well-being of pet owners experiencing homelessness. At the policy level, the framework proposes an increase of pet-friendly emergency shelters, access to market rental housing and veterinary medicine, and the use of a Housing First approach. At the public level, educational interventions are needed to improve knowledge and reduce stigma about the relationship between homelessness and pet ownership. At the service delivery level, direct service providers can support pet owners experiencing homelessness by recognizing their strengths, connecting them to community services, being aware of the risks associated with pet loss, providing harm reduction strategies, documenting animals as emotional support animals, and engaging in advocacy. By targeting policies and service approaches that exacerbate the hardships faced by pet owners experiencing homelessness, the framework is a set of deliberate actions to better support this vulnerable group.

Abstract

Approximately one in 10 people experiencing homelessness have pets. Despite the psychosocial benefits derived from pet ownership, systemic and structural barriers can prevent this group from meeting their basic needs and exiting homelessness. A multilevel framework is proposed for improving the health and well-being of pet owners experiencing homelessness. Informed by a One Health approach, the framework identifies interventions at the policy, public, and direct service delivery levels. Policy interventions are proposed to increase the supply of pet-friendly emergency shelters, access to market rental housing and veterinary medicine, and the use of a Housing First approach. At the public level, educational interventions are needed to improve knowledge and reduce stigma about the relationship between homelessness and pet ownership. Direct service providers can support pet owners experiencing homelessness by recognizing their strengths, connecting them to community services, being aware of the risks associated with pet loss, providing harm reduction strategies, documenting animals as emotional support animals, and engaging in advocacy. By targeting policies and service approaches that exacerbate the hardships faced by pet owners experiencing homelessness, the framework is a set of deliberate actions to better support a group that is often overlooked or unaccommodated in efforts to end homelessness.

Homeless Hope: a voluntary, nurse-led organisation working to educate and support people sleeping rough

This article describes the development of a nurse-led voluntary organisation that provides basic foot care to the homeless at street level in three Welsh cities. There is a large percentage of street sleepers who choose not to access professional health and care services for various reasons, and many of these individuals have foot health problems, such as sore, painful, swollen feet from continuous walking, calluses, dried skin, blisters that are often de-roofed and trench foot. Through support and education, however, several of these people have been able to take ownership of their identified problems, by building trusting relationships with Homeless Hope nurses. Through collaborative communication with professional services, Homeless Hope nurses provide an informal link between non-engaging rough sleepers and the services in place to help support them.

Religious Faith and Diabetes Health Beliefs in a Homeless Population: A Qualitative Study

This participatory action research project explored the perspectives and challenges of homeless persons living with, or at risk for, type 2 diabetes. Because these persons were sheltered in and served by a church, their perspectives provide understanding about how religious faith may influence diabetes self-management.

The Effect of Place of Service on Diabetic Screening Adherence in the Homeless Population

This study examined the association between place of service and adherence to select diabetes screening measures in a homeless population. At a Midwestern metropolitan federally qualified health center (FQHC), 508 participants with diabetes and also experiencing homelessness were studied throughout calendar year 2018. Diabetes measures included controlled blood pressure, diabetic foot exam and hemoglobin A1C screening. Patients were seen at one of three locations: FQHC only, shelter only and both shelter and FQHC. After controlling for primary insurance, insurance status, homeless status, age group, ethnicity, primary language, race, sex and poverty level, a stepwise binary logistic regression demonstrated significant model improvement in A1c screening (p ≤ 0.001) and controlled blood pressure (p = 0.009) when place of service was added as a predictor. Specifically, results showed significant negative associations in screening adherence for shelter as compared to FQHC for both controlled blood pressure (OR = 0.40; 95% CI = 0.20-0.79; p = 0.009) and A1c screening (OR = 0.06; 95% CI = 0.03-0.16; p ≤ 0.001). Our results support the hypothesis that FQHC care results in higher rates of adherence than shelter only or FQHC and shelter combined care. The study addresses the gap in literature surrounding place of service and patient adherence. Recommendations for future research are included.

Health supports needed for homeless persons transitioning from hospitals

Being homeless has a negative effect on health and the health needs of individuals experiencing homelessness are complex and challenging to address. As a result of limited access to and use of primary healthcare, the main point of entry into the healthcare system for individuals experiencing homelessness is often hospitals and emergency departments. Persons experiencing homelessness are commonly discharged from hospital settings to locations that do not support recovery or access to follow-up care (e.g. shelters or the street). This can be costly to both the healthcare system and to individuals' health and quality of life. We conducted a scoping review of the literature published between 2007 and 2017 to identify the types of health supports needed for persons experiencing homelessness who are discharged from the hospital. Thirteen literature sources met inclusion criteria and thematic data analyses by two researchers resulted in the identification of six themes related to the types of health supports needed for persons experiencing homelessness who are transitioning (i.e. being discharged) from the hospital. Using a community consultation approach, the scoping review themes were validated with 23 health and shelter service providers and included in our integrated findings. Themes included: (a) a respectful and understanding approach to care, (b) housing assessments, (c) communication/coordination/navigation, (d) supports for after-care, (e) complex medical care and medication management, and (f) basic needs and transportation. These themes were found to resonate with participants of the community consultation workshop. Recommendations for trauma-informed care and patient- or client-centred care approaches are discussed.

Diabetes Care for Patients Experiencing Homelessness: Beyond Metformin and Sulfonylureas

On any given night in the United States, an estimated 553,742 people are homeless. Applying a broader definition of homelessness that includes unstably housed people, an estimated 1.5% of Americans experience homelessness in a given year. Rates of diabetes are increasing among individuals experiencing homelessness. The social, psychological, and physical challenges of homelessness not only contribute to the rate of diabetes, but also complicate management. Unstable housing, limited medical resources, food insecurity, and competing priorities are barriers to diabetes care among patients experiencing homelessness. Homeless patients with diabetes more frequently develop specific comorbidities that require special attention, such as cardiovascular disease, substance abuse, depression, and foot wounds. The Affordable Care Act gave states the option to expand Medicaid to those earning up to 138% of the federal poverty level. This addressed a gap in coverage for low-income individuals not eligible for Medicaid or employer-sponsored insurance. With increased insurance coverage, this has increased the variety of medications available to treat hyperglycemia from type 2 diabetes beyond metformin, sulfonylureas, and insulin. Several of the newer classes of medications have advantages for patients experiencing homelessness, but also have special considerations in this vulnerable patient population. This narrative review will provide a review of dipeptidyl peptidase-4 inhibitors, glucagon-like peptide agonists, sodium glucose cotransporter-2 inhibitors, and thiazolidinediones in individuals experiencing homelessness.

Proper fitting shoes: Reducing pain, increasing activity, and improving foot health among adults experiencing homelessness

INTRODUCTION

Foot and lower limb pain reported by many adults experiencing homelessness may be due to improper shoes and may contribute to decreased activity and physical functioning.

OBJECTIVE

The purpose of this study was to characterize the effects of proper fitting shoes on pain, activity, and foot health in adults experiencing homelessness.

DESIGN

A pretest-posttest quasi-experimental pilot study design was used.

SAMPLE

Twenty-three out of 30 enrolled participants completed the study and were mostly female, non-Hispanic, black individuals with high school education or higher.

MEASUREMENTS

Eligible participants completed surveys related to pain, foot health, and foot conditions, and a 10-meter walking test prior to (BASELINE) and after (FINAL) the intervention.

INTERVENTION

Participants wore properly fitted shoes for 6 weeks and were encouraged to maintain activity levels consistent with activity levels prior to receiving new shoes.

RESULTS

Pain scores were lower at FINAL versus BASELINE. Participants reported reductions in knee, back and ankle/feet pain. Participants had significant improvements on almost all areas of foot health and had faster gait speed at FINAL versus BASELINE. Minimal changes in foot conditions were observed.

CONCLUSION

Proper fitting shoes improve pain, walking speed, and foot health in adults experiencing homelessness with moderate to severe pain.

Reaching out to diabetic soles: Outreach foot care pilot project

Objectives:

To assess the effectiveness of outreach foot care services as a tool for engagement with isolated vulnerable seniors. To improve foot health of diabetic seniors, thus avoiding expensive and potentially life-threatening diabetic complications.

Methods:

Four validated tools are used to gather data: InLow 60-second Diabetic Foot Screen©, Short Diabetes Knowledge Instrument for Older and Minority Adults, Brief Healthcare Questionnaire (Patient Health Questionnaire-9), and the Health-Related Quality of Life Questionnaire.

Results:

Five monthly visits to 20 participants resulted in multiple co-morbidities being identified, improvements in foot status and diabetic knowledge realized, and determinants of health addressed. Seniors needed support and resources to engage in diabetes self-management.

Conclusion:

The importance of regular foot care as a key element of any self-management plan for diabetes cannot be understated, nor can increasing social services spending to include coverage for foot care thereby avoiding expensive healthcare. Using foot care as a tool for engagement conferred access to vulnerable seniors who ultimately benefited from healthcare and social interactions with a provider.

Musculoskeletal Flexibility and Quality of Life: A Feasibility Study of Homeless Young Adults in Los Angeles County

Proper musculoskeletal health is dependent on the efficient inner workings of muscles, tendons, ligaments, joints, and bones. The homeless experience can be physically debilitating to these tissues and anatomical structures. This feasibility study aims to explore how to answer the overarching question: do the lived experiences of homeless young adults negatively affect their musculoskeletal health? Questionnaires were distributed to assess the demographic characteristics, physical activity, health behaviors, and sleep patterns of 40 homeless young adults and 45 university students in Los Angeles County. Participants also completed supervised stretch tests to assess musculoskeletal flexibility. Findings indicate that homeless young adults were less flexible in all four stretch assessments compared to university students. Noteworthy differences were noted with the sit and reach (p=0.050), butterfly (p=0.036), right shoulder (p=0.005), and left trunk twist tests (p=0.041). Analyses of physical activity levels and sleep location within the homeless subgroup suggest a deleterious impact on flexibility. Flexibility assessments are a low cost and sensitive method for measuring degree of musculoskeletal dysfunction of homeless young adults. Preliminary data suggests that the musculoskeletal health of this subgroup is adversely affected by their lived experience. Health services such as yoga or Pilates, in addition to existing case management and mental health services at homeless drop-in centers, may reduce the likelihood of long-term physical disability.