Mortality among the homeless: Causes and meteorological relationships

Cardiovascular disease burden in the homeless population

INTRODUCTION

The burden of cardiovascular disease (CVD) among the homeless population has been rising, driven by factors such as lack of healthcare access, rising mental health disorders and substance use. This study aims to systematically analyse the CVD burden among homeless adults and characterise its prevalence and risk factors. Additionally, our literature review revealed a significant lack of cardiac-focused interventions in this population, thus we build on existing models to propose new CVD-specific interventions.

METHODS

A comprehensive systematic review and meta-analysis were performed on data collected from PubMed and Scopus until 22 October 2024. All observational studies that assessed homeless populations and met inclusion criteria were analysed. The primary outcomes reported were mortality, morbidity and hospitalisation due to CVD. These measures were collectively analysed to evaluate the overall CVD burden.

RESULTS

Our search strategy identified 22 studies, of which 12 were suitable for meta-analysis. We analysed data from 226 205 adults spanning more than 1 000 000 person-years and sought to characterise CVD distribution by demographic subgroups. Our findings indicate that homeless adults experience greater morbidity and mortality due to CVD than non-homeless adults (pooled OR 2.77; 95% CI 1.93 to 3.93; p<0.001; I2 =96.2%). Subgroup analyses by age, sex and geographic region were performed, but no significant differences in CVD morbidity and mortality were found.

CONCLUSION

Homeless adults have approximately three times greater odds of CVD than the general population. We found that the risk of CVD remains elevated regardless of demographic subgroup. Our findings emphasise the urgent need for targeted interventions within this population and highlight its associated risk factors, providing a foundation for the development of targeted interventions and policies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Health impacts of cold exposure among people experiencing homelessness: A narrative systematic review on risks and risk-reduction approaches

OBJECTIVE

To systematically review evidence from high income countries on health risks from cold weather exposure among people experiencing homelessness (PEH) and assess evidence on risk-reduction interventions and their effectiveness.

STUDY DESIGN

Narrative systematic review.

METHODS

Keyword-structured searches were performed in CINAHL, Emcare, Medline, SocINDEX, Scopus, OpenGrey, Social Policy and Practice and Web of Science, and supplemented by grey literature searches in a selection of other databases, from 1973 to 2024. Articles were double-screened on title/abstract and full text. Extracted data included information on study setting and population, health risks from cold exposure, intervention characteristics and effect sizes where reported. Studies were critically appraised using Joanna Briggs Institute checklists.

RESULTS

24 studies were included, predominantly from the UK and US. People sleeping rough were found to be at greater risk than the general population of mortality due to hypothermia, and of hypothermic injury. Studies assessing health service utilisation indicated higher than population average admission rates due to cold exposure among PEH. Studies on interventions to reduce health risks from cold exposure in these populations all addressed multi-component programmes including shelter provision as a central component. Evidence of effectiveness was very limited.

CONCLUSION

PEH are at greater risk of death from hypothermia, and of hypothermic injury due to cold exposure than the general population. The use of overnight shelters and severe weather emergency plans are established approaches in high income settings for reducing risks from cold exposure among those sleeping rough, but further evidence on effectiveness is needed.

Youth Homelessness in Denver, Colorado: 2017-2021

OBJECTIVES

Homelessness is a public health crisis in the United States, yet homelessness prevalence, especially among children and youth, is not well understood. In this study, we use an indirect estimation method known as multiple systems estimation to further evaluate prevalence of youth experiencing homelessness in Denver, Colorado.

METHODS

We performed a multiple systems estimation ("capture-recapture") analysis to estimate annual homelessness among youth aged 14 to 17 years in the city and county of Denver, Colorado from 2017 to 2021. We used 3 citywide datasets linked at the individual level and stratified by year, as follows: (1) Denver-Metro Homeless Management Information System, (2) Denver Public Schools McKinney-Vento data, and (3) Colorado's Statewide Automated Child Welfare Information System TRAILS. We identified "known" youth experiencing homelessness from the 3 datasets and developed log-linear models with calculated 95% CIs to estimate the unknown population. We combined these counts to estimate the total youth homeless population and stratified counts by race, ethnicity, and gender.

RESULTS

The known count of youth experiencing homelessness increased from 840 in 2017 to 1040 in 2021. We estimated the total number of youth experiencing homelessness increased from 2880 (95% CI, 2199-3290) in 2017 to 7084 (95% CI, 2826-9046) in 2021. This corresponds with an increase from 10.4% to 25.1% in the total prevalence of youth experiencing homelessness in Denver. We found 74.9% to 83.1% of youth experiencing homelessness were Black/African American or Hispanic.

CONCLUSIONS

The scope of youth homelessness increased notably and may be far greater than previously understood. Using multiple systems estimation may improve homelessness prevalence estimates and facilitate more effective resource allocation and service delivery.

Examining the risk of delirium in patients hospitalized with COVID-19: Insights from the homeless population

For patients hospitalized with COVID-19, delirium is a serious and under-recognized complication, and people experiencing homelessness (PEH) may be at greater risk. This retrospective cohort study compared delirium-associated risk factors and clinical outcomes between PEH and non-PEH. This study used patient records from 154 hospitals discharged from 2020-2021 from the Texas Inpatient Public Use Data file. Study subjects (n = 878) were patients, aged 18-69 years, who were hospitalized with COVID-19 and were identified as homeless. The baseline group included (n = 176,518) patients with COVID-19 aged 18-69 years who were not homeless. Logistic regression models were used to identify risk factors for delirium. Relevant risk factors included chronic comorbidities, substance use disorders, and traumatic brain injury (TBI). Seven of the delirium-associated risk factors were more prevalent among PEH compared to baseline. PEH had higher rates of TBI, alcohol, cannabis, and opioid use disorders. PEH had significantly higher rates of delirium (10.6% vs. 8.1%; P<0.01). However, PEH had fewer respiratory complications, including pneumonia (48.5% vs. 81.9%; P<0.001) and respiratory failure (28.7% vs. 61.9%; P<0.001), and lower in-hospital mortality (3.3% vs. 9.5%; P<0.001). The anti-viral Remdesivir had a protective effect against delirium (AOR = 0.63; CI: 0.60, 0.66). Mean hospital length of stay (LOS) was more than twice as long for delirious patients compared with non-delirious patients (18.4 days vs. 7.7 days; P<0.001). Delirium greatly increased the risk of in-hospital mortality (AOR = 3.8; CI: 3.6, 4.0). For PEH (n = 29) who died from COVID-19, delirium was present in more than half (52%) of cases. Hospitals should screen PEH for delirium and adopt nursing protocols to prevent delirium and reduce its severity.

Characterizing Violent Fatalities Among People Experiencing Homelessness Using the National Violent Death Reporting System, 2010 to 2021

Homelessness continues to be a serious public health problem in the United States. People experiencing homelessness (PEH) face stark health inequities, including high mortality rates and increased risk of violence victimization. Little is known about the risk factors around PEH dying violently. The objective of this study is to comprehensively describe these fatalities to inform future research and prevention efforts for this population. This retrospective study utilized data from the National Violent Death Reporting System from 2010 to 2021 to characterize and compare fatalities among PEH versus people who were not experiencing homelessness (PNEH). This study identified 7,231 PEH and 423,363 PNEH victims. Among PEH, the most common manners of death were suicide (44.9%) and homicide (31.0%), most were male (83.0%), and White, non-Hispanic (59.3%). Compared to PNEH, a significantly greater proportion of PEH had an alcohol problem (26.9% vs. 15.2%; p < .001) or other substance use problem (48.8% vs. 19.6%; p < .001). Among decedents who had a current mental health problem (PEH: 33.6% vs. PNEH: 36.7%), a smaller percentage of PEH were currently receiving treatment (PEH: 13.9% vs. PNEH: 20.7%; p<.001). Among those who died by suicide, more PEH had a recent eviction/loss of home that contributed to the death, compared to PNEH (21.0% vs. 2.8%; p < .001). Among individuals who died by homicide, PEH were significantly more likely to be killed by a random act of violence (PEH: 5.1% vs. PNEH: 2.6%; p < .001). These findings highlight unique characteristics of violent deaths among PEH, including circumstances involving mental health and substance use problems, and identify key intervention points for suicide prevention among this population. Future research to help prevent violence-related deaths among PEH would benefit by improved data collection methods to reduce missing data and linkages with other data sources.

Daily heat and mortality among people experiencing homelessness in 2 urban US counties, 2015-2022

High and low daily ambient temperatures are associated with higher mortality in the general population. People experiencing homelessness (PEH) are thought to be particularly vulnerable, but there is almost no direct evidence available. We examined the temperature-mortality association among PEH in 2 populous, urban counties in hot-climate regions of the United States, focusing on heat effects. Study setting was Los Angeles County, CA, and Clark County, NV, which encompass the cities of Los Angeles and Las Vegas, respectively. Outcomes were 2015-2022 deaths among decedents categorized as homeless in county administrative records. We used quasi-Poisson distributed lag nonlinear models to estimate the association of mortality with daily temperatures and with 7-day lagged temperatures, adjusting for day of week, seasonality, and long-term trends. We estimated the minimum mortality temperature and fraction of mortality attributable to temperatures above and below minimum mortality temperature. The association between daily temperature and PEH mortality was skewed towards greater risk at higher temperatures, especially in Clark County. Temperature-attributable mortality equaled 50.1% of deaths in Clark County (95% CI, 29.0-62.8) and 7.0% in Los Angeles County (95% CI, 1.4-12.1). In both counties, most temperature-attributable deaths were attributable to heat rather than cold. In these hot-climate urban counties, our estimates of heat-attributable mortality among PEH were orders of magnitude greater than those reported in prior research on the general population. These results indicate that temperature vulnerability, particularly heat vulnerability, requires stronger public health and policy responses. This article is part of a Special Collection on Environmental Epidemiology.

Back on the Streets: Examining Emergency Department Return Rates for Unhoused Patients Discharged After Trauma

BACKGROUND

The unhoused population is at high risk for traumatic injuries and faces unique challenges in accessing follow-up care. However, there is scarce data regarding differences in Emergency Department (ED) return rates and reasons for return between unhoused and housed patients.

METHODS

We conducted a 3-year retrospective cohort study at a level-1 trauma center in a large metropolitan area. All patients who presented to the ED with traumatic injuries and were discharged without hospital admission were included in the study. The primary outcome was ED returns for trauma-related complications or new traumatic events <6 months after discharge. Patient characteristics and study outcomes were compared between housed and unhoused groups.

RESULTS

A total of 4184 patients were identified, of which 20.3% were unhoused. Compared to housed, unhoused patients were more likely to return to the ED (18.8% vs 13.9%, P < .001), more likely to return for trauma-related complications (4.6% vs 3.1%, P = .045), more likely to return with new trauma (7.1% vs 2.8%, P < .001), and less likely to return for scheduled wound checks (2.5% vs 4.3%, P = .012). Of the patients who returned with trauma-related complications, unhoused patients had a higher proportion of wound infection (20.5% vs 5.7%, P = .008). In the regression analysis, unhoused status was associated with increased odds of ED return with new trauma and decreased odds of return for scheduled wound checks.

CONCLUSIONS

This study observed significant disparities between unhoused and housed patients after trauma. Our results suggest that inadequate follow-up in unhoused patients may contribute to further ED return.

Comparison of Causes of Mortality Between Hospitalized Unsheltered Homeless Patients and Non-Homeless Sex and Age-Matched Controls: A Retrospective Case-Control Study

Objectives

Roofless individuals represent the most severe category of homelessness. Their clinical characteristics and mortality patterns in Central and Eastern Europe are little known.

Methods

A single-center retrospective case-control study at the internal medicine department in Bratislava, Slovakia was conducted. 5694 mortality records from 2010 to 2023 were screened, and 141 (118 men, 23 women) roofless individuals were identified. Patients were sex- and age-matched, with 141 patients from the cohort of non-homeless deceased patients.

Results

Compared to controls, roofless people had a higher incidence of immobility (p = 0.02) and hypothermia (p < 0.0001) at admission. 83% of the roofless people were men, and 59% of the roofless people died before reaching old age (60+). Homeless men died more often from infectious disease (p = 0.02), pneumonia being the most common one (60%). Men from the control group died more often from liver diseases (p = 0.03). There were no significant differences in the causes of mortality between women.

Conclusion

These findings could help to reduce the invisibility of the issue of massive premature mortality amongst homeless populations and roofless individuals, in particular.

Homelessness and mortality: gender, age, and housing status inequity in Korea

OBJECTIVES

We compared mortality rates among various housing statuses within the homeless population and investigated factors contributing to their deaths, including housing status, gender, and age.

METHODS

Using a comprehensive multi-year dataset (n=15,445) curated by the National Tuberculosis Screening and Case Management Programs, matched with the 2019-2021 Vital Statistics Death Database and National Health Insurance claims data, we calculated age-standardized mortality rates and conducted survival analysis to estimate differences in mortality rates based on housing status.

RESULTS

The mortality rate among the homeless population was twice as high as that of the general population, at 1,159.6 per 100,000 compared to 645.8 per 100,000, respectively. Cancer and cardiovascular diseases were the primary causes of death. Furthermore, individuals residing in shelter facilities faced a significantly higher risk of death than those who were rough sleeping, with an adjusted hazard ratio of 1.70 (95% confidence interval, 1.37 to 2.11). This increased risk was especially pronounced in older adults and women.

CONCLUSIONS

The study highlights the urgent need for targeted interventions, as the homeless population faces significantly higher mortality rates. Older adults and women in shelter facilities are at the highest risk.

The Role of Street Medicine and Mobile Clinics for Persons Experiencing Homelessness: A Scoping Review

INTRODUCTION

An estimated 5800 to 46,500 lives are lost due to homelessness each year. Experiencing homelessness and poor health are cyclically related, with one reinforcing the other. Mobile programs, which include vehicles that travel to deliver care, and street medicine, the act of bringing care to spaces where PEH live, may play a role in alleviating this burden by providing trusted, affordable, and accessible care to this community.

METHODS

We conducted a scoping review of peer-reviewed literature on the role of mobile clinics and street medicine in providing care for PEH by searching PubMed, Embase, and Web of Science on 10 August 2023. Articles from 2013 to 2023 specific to programs in the United States were included. The protocol was developed following the PRISMA-ScR guidelines. The primary outcome was the role of mobile programs for persons experiencing homelessness.

RESULTS

A total of 15 articles were included in this review. The descriptive findings emphasized that street medicine and mobile clinics provide primary care, behavioral health, and social services. The utilization findings indicate that street medicine programs positively impact the health system through their ability to defer emergency department and hospital visits, providing financial benefits. The comparative findings between mobile programs and office-based programs indicate current successes and areas for improvement.

DISCUSSION

Mobile clinics and street medicine programs that serve PEH provide a wide range of services. While more significant structural change is needed to address healthcare costs and housing policies in the United States, mobile clinics and street medicine teams can improve healthcare access and the healthcare system.

Improving the operational forecasts of outdoor Universal Thermal Climate Index with post-processing

The Universal Thermal Climate Index (UTCI) is a thermal comfort index that describes how the human body experiences ambient conditions. It has units of temperature and considers physiological aspects of the human body. It takes into account the effect of air temperature, humidity, wind, radiation, and clothes. It is increasingly used in many countries as a measure of thermal comfort for outdoor conditions, and its value is calculated as part of the operational meteorological forecast. At the same time, forecasts of outdoor UTCI tend to have a relatively large error caused by the error of meteorological forecasts. In Slovenia, there is a relatively dense network of meteorological stations. Crucially, at these stations, global solar radiation measurements are performed continuously, which makes estimating the actual value of the UTCI more accurate compared to the situation where no radiation measurements are available. We used seven years of measurements in hourly resolution from 42 stations to first verify the operational UTCI forecast for the first forecast day and, secondly, to try to improve the forecast via post-processing. We used two machine-learning methods, linear regression, and neural networks. Both methods have successfully reduced the error in the operational UTCI forecasts. Both methods reduced the daily mean error from about 2.6∘ C to almost zero, while the daily mean absolute error decreased from 5∘ C to 3∘ C for the neural network and 3.5∘ C for linear regression. Both methods, especially the neural network, also substantially reduced the dependence of the error on the time of the day.

Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness

BACKGROUND

This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group.

METHODS

Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months.

RESULTS

Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income.

DISCUSSION

This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).

[Homelessness as a determinant of health and its impact on quality of life]

OBJECTIVE

To determine the health status of the homeless population who spend the night on the streets and in shelters (extreme residential exclusion), with reference to their quality of life, self-perceived health, comorbidity and access to health resources.

METHOD

A cross-sectional descriptive study was carried out on a sample of 263 homeless people in the city of Valencia by means of a nocturnal count and using the EQ-5D-3L Health Related Quality of Life questionnaire and questions from the European Quality of Life Survey for Spain.

RESULTS

Of the people who participated in the study, 129 of them slept outdoors, 49% (62.79% men, 19.37% women and 17.84% unidentified), while 134 slept in hostels, i.e. 51% (67.16% men and 32.84% women) with an estimated average age of 41.53 years and 55% had been living on the street for less than 12 months. People staying overnight on the streets presented worse quality of life and more than a quarter of the sample lacked a health card.

CONCLUSIONS

There is a relationship between homelessness and poor health conditions in terms of quality of life, perceived health, comorbidity and accessibility to health to resources. The inverse care law is evidenced.

"Death Is a Possibility for Those without Shelter": A Thematic Analysis of News Coverage on Homelessness and the 2021 Heat Dome in Canada

Among the most vulnerable to the health-harming effects of heat are people experiencing homelessness. However, during the 2021 Heat Dome, the deadliest extreme heat event (EHE) recorded in Canada to date, people experiencing homelessness represented the smallest proportion of decedents (n = 3, 0.5%)-despite the impacted region (British Columbia) having some of the highest rates of homelessness in the country. Thus, we sought to explore the 2021 Heat Dome as a media-based case study to identify potential actions or targeted strategies that were initiated by community support agencies, individuals and groups, and communicated in the news during this EHE that may have aided in the protection of this group or helped minimize the mortality impacts. Using media articles collated for a more extensive investigation into the effects of the 2021 Heat Dome (n = 2909), we identified a subset which included content on people experiencing homelessness in Canada (n = 274, 9%). These articles were thematically analysed using NVivo. Three main themes were identified: (i) public warnings issued during the 2021 Heat Dome directly addressed people experiencing homelessness, (ii) community support services explicitly targeting this population were activated during the heat event, and (iii) challenges and barriers faced by people experiencing homelessness during extreme heat were communicated. These findings suggest that mass-media messaging and dedicated on-the-ground initiatives led by various organizations explicitly initiated to support individuals experiencing homelessness during the 2021 Heat Dome may have assisted in limiting the harmful impacts of the heat on this community.

In-hospital outcomes in unhoused patients with cardiogenic shock in the United States: Insights from The National Inpatient Sample 2011-2019

BACKGROUND

Unhoused patients face significant barriers to receiving health care in both the inpatient and outpatient settings. For unhoused patients with heart failure who are in extremis, there is a lack of data regarding in-hospital outcomes and resource utilization in the setting of cardiogenic shock (CS).

HYPOTHESIS

Unhoused patients hospitalized with CS have increased mortality and decreased use of invasive therapies as compared to housed patients.

METHODS

The National Inpatient Sample (NIS) database was queried from 2011 to 2019 for relevant ICD-9 and ICD-10 codes to identify unhoused patients with an admission diagnosis of CS. Baseline characteristics and in-hospital outcomes between patients were compared. Binary logistic regression was used to adjust outcomes for prespecified and significantly different baseline characteristics (p < .05).

RESULTS

We identified a weighted sample of 1 202 583 adult CS hospitalizations, of whom 4510 were unhoused (0.38%). There was no significant difference in the comorbidity adjusted odds of mortality between groups. Unhoused patients had lower odds of receiving mechanical circulatory support, left heart catheterization, percutaneous coronary intervention, or pulmonary artery catheterization. Unhoused patients had higher adjusted odds of infectious complications, undergoing intubation, or requiring restraints.

CONCLUSIONS

These data suggest that, despite having fewer traditional comorbidities, unhoused patients have similar mortality and less access to more aggressive care than housed patients. Unhoused patients may experience under-diuresis, or more conservative care strategies, as evidenced by the higher intubation rate in this population. Further studies are needed to elucidate long-term outcomes and investigate systemic methods to ameliorate barriers to care in unhoused populations.

Respiratory Syncytial Virus, Influenza and SARS-CoV-2 in Homeless People from Urban Shelters: A Systematic Review and Meta-Analysis (2023)

Homeless people (HP) are disproportionally affected by respiratory disorders, including pneumococcal and mycobacterial infections. On the contrary, more limited evidence has been previously gathered on influenza and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and very little is known about the occurrence of human respiratory syncytial virus (RSV), a common cause of respiratory tract infections among children and the elderly. The present systematic review was designed to collect available evidence about RSV, influenza and SARS-CoV-2 infections in HP, focusing on those from urban homeless shelters. Three medical databases (PubMed, Embase and Scopus) and the preprint repository medRxiv.org were therefore searched for eligible observational studies published up to 30 December 2023, and the collected cases were pooled in a random-effects model. Heterogeneity was assessed using the I2 statistics. Reporting bias was assessed by funnel plots and a regression analysis. Overall, 31 studies were retrieved, and of them, 17 reported on the point prevalence of respiratory pathogens, with pooled estimates of 4.91 cases per 1000 HP (95%CI: 2.46 to 9.80) for RSV, 3.47 per 1000 HP for influenza and 40.21 cases per 1000 HP (95%CI: 14.66 to 105.55) for SARS-CoV-2. Incidence estimates were calculated from 12 studies, and SARS-CoV-2 was characterized by the highest occurrence (9.58 diagnoses per 1000 persons-months, 95%CI: 3.00 to 16.16), followed by influenza (6.07, 95%CI: 0.00 to 15.06) and RSV (1.71, 95%CI: 0.00 to 4.13). Only four studies reported on the outcome of viral infections in HP: the assessed pathogens were associated with a high likelihood of hospitalization, while high rates of recurrence and eventual deaths were reported in cases of RSV infections. In summary, RSV, influenza and SARS-CoV-2 infections were documented in HP from urban shelters, and their potential outcomes stress the importance of specifically tailored preventive strategies.

Left out in the cold: Homicide amongst persons experiencing homelessness

BACKGROUND

There is no American population-level study comparing the characteristics of homicides involving victims who were vs were not experiencing homelessness at time of death. We aim to identify variables surrounding homeless homicide that are unique, and intervenable.

METHODS

In this retrospective cohort study, we reviewed the National Violent Death Reporting System (NVDRS) from 2003 to 2018 and compared the characteristics surrounding homicides of victims who were not-homeless (cohort 1) vs experiencing homelessness (cohort 2) at death. We utilized the available perpetrator data to characterize the average perpetrator for each cohort. We considered housing status to be our primary predictor and recorded NVDRS variables, such as age of victims and likelihood to know perpetrators, to be our primary outcomes.

RESULTS

81,212 Homicide Victims and 60,982 Homicide Perpetrators were included in analysis. Homeless cohort victims were more likely younger, White, male, and to have a known mental health or substance abuse disorder. PEH were also more likely to have co-morbid mental health and substance abuse disorders but were roughly half as likely to be getting treatment for said disorders. Circumstances surrounding incidents, including geographic location, mechanism of injury, and premeditation, varied; homeless cohort victims were more likely to die in random acts of violence, but were less likely to die via firearm.

CONCLUSIONS

There is room for targeted interventions against homeless homicides.

LEVEL OF EVIDENCE

Epidemiological, Level IV.

Invisible struggles: WASH insecurity and implications of extreme weather among urban homeless in high-income countries - A systematic scoping review

This paper aims to provide a deeper understanding of the water-, sanitation- and hygiene (WASH)-related insecurities that people experiencing homelessness in urban areas of high-income countries (HIC) are facing, and how these insecurities are further complicated during extreme weather events. While limited recent research has looked into WASH among people experiencing homelessness in HICs, and while some work has considering the implications of climate change on WASH and health, the nexus of WASH, extreme weather events and homelessness in HICs have not been studied thus far. We conducted the first systematic scoping review of peer-reviewed literature on this nexus, which is understudied and marked by complexity, involving a range of systems and forms of impact. A total of 50 publications were included in our analysis. We found that public facilities like drinking water fountains, toilets, handwashing facilities, and showers are scarce, frequently unavailable, often pose safety and cleanliness issues, and access to non-public facilities may be cost-prohibitive for homeless populations. Consequently, people experiencing homelessness, including those sleeping rough, in encampments, or shelters, are often forced to limit drinking water consumption, forego healthy hygiene behaviours, and resort to open urination and defecation, all of which carry health risks. Extreme weather events, like heatwaves, extreme cold, heavy rain and flooding exacerbate challenges for people experiencing homelessness, further complicating their access to WASH, and reducing the ability of service providers to deliver extra relief, creating a dual WASH and health burden. Our review highlights that the Human Right to Water and Sanitation is not met for people experiencing homelessness in urban areas of high-income countries, with women emerging as one of the most vulnerable subgroups. It reveals that the impact of certain WASH issues (e.g. drinking water) on homeless populations are better understood than others (e.g. waste), and, similarly, the effects of certain extreme weather events (e.g. heatwaves) on the health and WASH conditions of people experiencing homelessness are better understood than others (e.g. flooding). Data gaps and the lack of information on limited WASH access and health circumstances of people experiencing homelessness, further minimize their representation and consequently impose obstacles to improve their situation. Based on our analysis, we established a framework which operationalizes the nexus of WASH, extreme weather events and homelessness. This framework improves our understanding of the underlying complexities at the intersection of these three issues and provides a foundation for enhanced preparedness and health-oriented planning.

Nutritional needs, resources, and barriers among unhoused adults cared for by a street medicine organization in Chicago, Illinois: a cross-sectional study

BACKGROUND

Those experiencing houselessness rely on obtaining food from community organizers and donations. Simultaneously, the houseless face disproportionally high rates of medical conditions that may be affected by diet including diabetes, hypertension, and hyperlipidemia. There is limited literature on the resources and barriers of the houseless community regarding optimal nutrition from an actionable perspective. Further, less data is available on how street medicine organizations may best impact the nutrition of the unhoused they serve. Elucidating this information will inform how organizational efforts may best support the nutrition of the houseless community.

METHODS

In partnership with the medical student-run organization, Chicago Street Medicine, at Northwestern University Feinberg School of Medicine, twenty adults experiencing houselessness in Chicago, Illinois participated in the cross-sectional study. A 10-item survey was verbally administered to characterize the participants' daily food intake, food sources, barriers, resources, and nutritional preferences and needs. All data was directly transcribed into REDCap. Descriptive statistics were generated.

RESULTS

Individuals consumed a median of 2 snacks and meals per day (IQR: 1-3). No participant consumed adequate servings of every food group, with only one participant meeting the dietary intake requirements for one food group. Participants most often received their food from donations (n = 15), purchasing themselves (n = 11), food pantries (n = 4), and shelters (n = 3). Eleven of nineteen participants endorsed dental concerns as a major barrier to consuming certain foods. Twelve participants had access to a can opener and twelve could heat their meals on a stove or microwave. Seven had access to kitchen facilities where they may prepare a meal. Approximately half of participants had been counseled by a physician to maintain a particular diet, with most related to reducing sugar intake.

CONCLUSION

Most houseless participants were unable to acquire a balanced diet and often relied on organizational efforts to eat. Organizations should consider the chronic health conditions, dentition needs, and physical resources and barriers to optimal nutrition when obtaining food to distribute to the unhoused.

Sheltered from the heat? How tents and shade covers may unintentionally increase air temperature exposures to unsheltered communities

Objective

Heat vulnerability and homelessness are central public health concerns in cities globally, and public health implementation should address these two challenges in tandem to minimize preventable heat-related morbidity and mortality. Populations facing unsheltered homelessness use tents (or similar shelters) with shading features to minimize sun and heat exposure. This study evaluates the efficacy of different tent cover (shading) materials and how they moderate the in-tent air temperature (Tair) exposures of tent users during extreme summer conditions.

Study design

Within-tent Tair monitoring using Kestrel Drop devices occurred across three full typical summer days in Phoenix, Arizona in July 2022.

Methods

In-tent Tair were statistically compared between six small side-by-side identical tents with different cover materials (control (no cover), mylar, white bedsheet, tarp, sunbrella fabric, aluminum foil), as well as with ambient Tair.

Results

Using any tent resulted in higher daytime in-tent Tair than ambient Tair. Further, compared to a control tent, the Tair within tents shaded with sunbrella, tarp, and white bedsheet had significantly higher Tair at all times (2.36 °C, 2.46 °C, and 1.11 °C higher Tair, respectively), controlling for Tair and day/night.

Conclusion

Adding cover materials over tents may increase heat risk to an already vulnerable population at certain times of the day. Higher in-tent Tair is attributable to the reduced ability for heat and vapor to escape, largely due to reduced ventilation (mixing). Local authorities and welfare associations should reconsider using unventilated tents for shading and promote more widespread, ventilated tents and shade to ensure that prevention efforts do not further marginalize the most vulnerable. Future work should incorporate more comprehensive measurements of solar radiation to quantify overall heat stress for exposure reduction techniques.

Critical Windows of Maternal Exposure to Biothermal Stress and Birth Weight for Gestational Age in Western Australia

BACKGROUND

There is limited and inconsistent evidence on the risk of ambient temperature on small for gestational age (SGA) and there are no known related studies for large for gestational age (LGA). In addition, previous studies used temperature rather than a biothermal metric.

OBJECTIVES

Our aim was to examine the associations and critical susceptible windows of maternal exposure to a biothermal metric [Universal Thermal Climate Index (UTCI)] and the hazards of SGA and LGA.

METHODS

We linked 385,337 singleton term births between 1 January 2000 and 31 December 2015 in Western Australia to daily spatiotemporal UTCI. Distributed lag nonlinear models with Cox regression and multiple models were used to investigate maternal exposure to UTCI from 12 weeks preconception to birth and the adjusted hazard ratios (HRs) of SGA and LGA.

RESULTS

Relative to the median exposure, weekly and monthly specific exposures showed potential critical windows of susceptibility for SGA and LGA at extreme exposures, especially during late gestational periods. Monthly exposure showed strong positive associations from the 6th to the 10th gestational months with the highest hazard of 13% for SGA (HR = 1.13 ; 95% CI: 1.10, 1.14) and 7% for LGA (HR = 1.07 ; 95% CI: 1.03, 1.11) at the 10th month for the 1st UTCI centile. Entire pregnancy exposures showed the strongest hazards of 11% for SGA (HR = 1.11 ; 95% CI: 1.04, 1.18) and 3% for LGA (HR = 1.03 ; 95% CI: 0.95, 1.11) at the 99th UTCI centile. By trimesters, the highest hazards were found during the second and first trimesters for SGA and LGA, respectively, at the 99th UTCI centile. Based on estimated interaction effects, male births, mothers who were non-Caucasian, smokers, ≥ 35 years of age, and rural residents were most vulnerable.

CONCLUSIONS

Both weekly and monthly specific extreme biothermal stress exposures showed potential critical susceptible windows of SGA and LGA during late gestational periods with disproportionate sociodemographic vulnerabilities. https://doi.org/10.1289/EHP12660.

Call to Action: Academic Nursing's Role in Redesigning Health Care to Reduce the Human and Financial Cost of Health Inequities

Health equity is an aspirational goal for health outcomes that can be achieved when systemic inequalities are addressed. The human cost of health inequities is without number; we can and must ameliorate health inequities. This essay summarizes the impact of continued health disparities and inequities in the United States and outlines the ways in which increasing diversity in the nursing workforce and graduating equity-minded nurses can promote innovation and problem-solving to address these disparities and inequities. We then present multiple pathways for nurses in academia to advance health equity.

Cold-related injuries among patients experiencing homelessness in Toronto: a descriptive analysis of emergency department visits

PURPOSE

Homelessness increases the risk of cold-related injuries. We examined emergency department visits for cold-related injuries in Toronto over a 4-year period, comparing visits for patients identified as homeless to visits for patients not identified as homeless.

METHODS

This descriptive analysis of visits to emergency departments in Toronto between July 2018 and June 2022 used linked health administrative data. We measured emergency department visits with cold-related injury diagnoses among patients experiencing homelessness and those not identified as homeless. Rates were expressed as a number of visits for cold-related injury per 100,000 visits overall. Rate ratios were used to compare rates between homeless vs. not homeless groups.

RESULTS

We identified 333 visits for cold-related injuries among patients experiencing homelessness and 1126 visits among non-homeless patients. In each of the 4 years of observation, rate ratios ranged between 13.6 and 17.6 for cold-related injuries overall, 13.7 and 17.8 for hypothermia, and 10.3 and 18.3 for frostbite. Rates per 100,000 visits in the fourth year (July 2021 to June 2022) were significantly higher than in the pre-pandemic period. Male patients had higher rates, regardless of homelessness status; female patients experiencing homelessness had higher rate ratios than male patients experiencing homelessness.

CONCLUSION

Patients experiencing homelessness visiting the emergency department are much more likely to be seen for cold-related injuries than non-homeless patients. Additional efforts are needed to prevent cold-related exposure and consequent injury among people experiencing homelessness.

Prenatal exposure to long-term heat stress and stillbirth in Ghana: A within-space time-series analysis

INTRODUCTION

Few studies examined the association between prenatal long-term ambient temperature exposure and stillbirth and fewer still from developing countries. Rather than ambient temperature, we used a human thermophysiological index, Universal Thermal Climate Index (UTCI) to investigate the role of long-term heat stress exposure on stillbirth in Ghana.

METHODS

District-level monthly UTCI was linked with 90,532 stillbirths of 5,961,328 births across all 260 local districts between 1^st January 2012 and 31^st December 2020. A within-space time-series design was applied with distributed lag nonlinear models and conditional quasi-Poisson regression.

RESULTS

The mean (28.5 ± 2.1 °C) and median UTCI (28.8 °C) indicated moderate heat stress. The Relative Risks (RRs) and 95% Confidence Intervals (CIs) for exposure to lower-moderate heat (1st to 25th percentiles of UTCI) and strong heat (99th percentile) stresses showed lower risks, relative to the median UTCI. The higher-moderate heat stress exposures (75th and 90th percentiles) showed greater risks which increased with the duration of heat stress exposures and were stronger in the 90th percentile. The risk ranged from 2% (RR = 1.02, 95% CI 0.99, 1.05) to 18% (RR = 1.18, 95% CI 1.02, 1.36) for the 90th percentile, relative to the median UTCI. Assuming causality, 19 (95% CI 3, 37) and 27 (95% CI 3, 54) excess stillbirths per 10,000 births were attributable to long-term exposure to the 90th percentile relative to median UTCI for the past six and nine months, respectively. Districts with low population density, low gross domestic product, and low air pollution which collectively defined rural districts were at higher risk as compared to those in the high level (urban districts).

DISCUSSION

Maternal exposure to long-term heat stress was associated with a greater risk of stillbirth. Climate change-resilient interventional measures to reduce maternal exposure to heat stress, particularly in rural areas may help lower the risk of stillbirth.

Suicide Among Persons Experiencing Homelessness

INTRODUCTION

This study aims to characterize suicide and associated disparities among persons experiencing homelessness (PEH).

MATERIALS AND METHODS

We reviewed suicide victims in the National Violent Death Reporting System (NVDRS) from 2003 to 2018 and compared factors surrounding suicides of PEH to factors of housed victims. We also utilized the Point-in-Time (PIT) survey (2010-2018), and census population estimates, to estimate suicide rates among PEH and the wider population.

RESULTS

1.1% of suicide victims were described as experiencing homelessness at the time of their deaths, a value that is disproportional given the overall homeless rates of 0.2% in the past decade. Compared to nonhomeless victims, PEH were more likely to be younger, Black, male, and nonveterans. PEH were significantly more likely to have an identified alcohol/substance use disorder. PEH were half as likely to die via firearm and were more likely to die in natural areas, motels, and the streets. PEH were significantly more likely to have a history of suicidal thoughts, a history of suicide attempts, and a history of disclosure of intent, particularly to health care workers.

CONCLUSIONS

PEH are disproportionately overrepresented among all suicide victims, but the circumstances surrounding their deaths create opportunity for targeted interventions.

Cancer Diagnoses and Use of Radiation Therapy Among Persons Experiencing Homelessness

PURPOSE

Persons experiencing homelessness (PEH) have low rates of cancer screening and worse cancer mortality compared with persons not experiencing homelessness. Data regarding cancer diagnosis and treatment in PEH are limited. We investigated cancer prevalence and use of radiation therapy (RT) in PEH.

METHODS AND MATERIALS

Patients presenting between January 1, 2014, and September 27, 2021, at a large metropolitan hospital system were assessed for homelessness via intake screening or chart search. PEH data were cross-referenced with the institution's cancer database to identify PEH with cancer diagnoses. Demographic, clinical, and treatment variables were abstracted.

RESULTS

Of a total of 9654 (9250 evaluable) PEH with a median age of 42 years, 81 patients (0.88%) had at least 1 cancer diagnosis and 5 had multiple diagnoses, for a total of 87 PEH with at least 1 cancer diagnosis. The median age at diagnosis was 60 years. In total, 43% were female and 51% were Black, and 43% presented with advanced or metastatic disease. Lung (17%), prostate (15%), leukemia/lymphoma (13%), and head/neck (9%) were the most common diagnoses. In total, 17% of patients underwent surgery alone, 13% received chemotherapy alone, 14% received RT alone, and 6% received hormone therapy alone. A total of 8% of patients underwent no treatment, and 43% underwent multimodality therapy. In total, 58% of treated patients never achieved disease-free status. Of the 31 patients who received RT, 87% received external beam RT. Most patients (70%) received hypofractionated regimens. For patients who had multifraction treatment, the treatment completion rate was 85%, significantly lower than the departmental completion rate of 98% (P < .00001).

CONCLUSIONS

In a large cohort of PEH in a metropolitan setting, cancer diagnoses were uncommon and were frequently in advanced stages. Most patients underwent single-modality treatment or no treatment at all. Despite the use of hypofractionation, the RT completion rate was low, likely reflecting complex barriers to care. Further interventions to optimize cancer diagnosis and treatment in PEH are urgently needed.

Individuals Experiencing Homelessness: A Systematic Review of Otolaryngology-Related Health Needs and Community-Based Interventions

OBJECTIVE

Access to and use of physician services is limited for those experiencing homelessness. Homelessness may predispose patients to several Otolaryngology-Head and Neck Surgery (OHNS) health conditions and barriers to care may leave these unaddressed. The aim of this review was to synthesize the literature on OHNS health needs and community-based interventions for patients experiencing homelessness.

DATA SOURCES

English literature was searched in MEDLINE, EMBASE, and CINAHL.

REVIEW METHODS

Studies were included if they reported on OHNS-related conditions in patients experiencing homelessness and/or interventions related to providing OHNS care to this patient population.

RESULTS

Twelve hundred and one articles were screened, and 12 articles were included. Most studies reported on otologic conditions (n = 8) and head and neck-related conditions (n = 6). Nasal trauma, chronic rhinosinusitis, dysphonia, hearing loss, and cancerous/precancerous head and neck lesions were common OHNS conditions reported in this patient population. Identified barriers to care included lack of transportation, financial considerations, and lower health literacy. Three articles on community-based interventions were included. Most of these interventions were single visits to shelters, and ensuring adequate follow-up was identified as a challenge.

CONCLUSION

The current literature brings attention to certain OHNS diseases that are prevalent in this unique patient population and identifies unique barriers these patients experience when accessing care. Future studies should focus on further delineating the impact of OHNS diseases in patients experiencing homelessness and screening interventions that can be employed to mitigate the impact of diseases of the head and neck.

Associations between Homelessness and Alzheimer's Disease and Related Dementia: A Systematic Review

The homeless population in the United States is rapidly aging, with a parallel increase in Alzheimer's disease and related dementia (ADRD). During an evolving pandemic that jeopardizes employment and housing, assessing the relationship between ADRD and homelessness is critical since the latter is potentially intervenable. The objective of this study is to review the literature and determine whether there is an association between homelessness and dementia risk. A systematic review of existing studies was conducted through PubMED, SCOPUS, and EMBASE among others. Of the 228 results found, nine met inclusion criteria. Homeless studies mainly centered on veteran populations (n = 6/9). There is a complex relationship suggesting homelessness as a risk for and consequence of ADRD but also co-occurrence with psychiatric disorders, substance abuse, and traumatic injuries. Future studies should employ enumeration surveys with modular longitudinal tracking and measure social determinants of health, discrimination, chronic stress, and mood disorders.

COVID-19 Mortality Rates in Los Angeles County Among People Experiencing Homelessness, March 2020-February 2021

OBJECTIVE

Understanding COVID-19-related mortality among the large population of people experiencing homelessness (PEH) in Los Angeles County (LA County) may inform public health policies to protect this vulnerable group. We investigated the impact of COVID-19 on PEH compared with the general population in LA County.

METHODS

We calculated crude COVID-19 mortality rates per 100 000 population and mortality rates adjusted for age, race, and sex/gender among PEH and compared them with the general population in LA County from March 1, 2020, through February 28, 2021.

RESULTS

Among adults aged ≥18 years, the crude mortality rate per 100 000 population among PEH was 20% higher than among the general LA County population (348.7 vs 287.6). After adjusting for age, the mortality rate among PEH was 570.7 per 100 000 population. PEH had nearly twice the risk of dying from COVID-19 as people in the general LA County population; PEH aged 18-29 years had almost 8 times the risk of dying compared with their peers in the general LA County population. PEH had a higher risk of mortality than the general population after adjusting for race (standardized mortality ratio [SMR] = 1.4; 95% CI, 1.2-1.6) and sex/gender (SMR = 1.3; 95% CI, 1.1-1.5).

CONCLUSIONS

A higher risk of COVID-19-related death among PEH compared with the general population indicates the need for public health policies and interventions to protect this vulnerable group.

Mental health needs of homeless and recently housed individuals in Canada: A meta-ethnography

Homeless individuals are disproportionately likely to experience mental health conditions, and typically face many systemic barriers to access mental health services. This study sought to determine the mental health needs of homeless and recently housed individuals in Canada. A meta-ethnography was conducted to synthesise existing qualitative data and translate themes across a broader context. Thirty-five studies on the experiences of 1511 individuals with a history of homelessness were included. Themes were interpreted by comparing and contrasting findings across multiple contexts. Distinct, yet highly interrelated, unmet mental health needs were revealed through personal narratives of trauma, stigmatisation, victimisation, and a lack of basic necessities. Six themes that characterised this population's mental health needs were ontological security, autonomy, hope and purpose, empowerment, social connection and belonging, and access to services. This study revealed homeless individuals' unmet mental health needs to inform social and policy change and improve psychological well-being.

Factors Associated With Hospital Readmission Among Patients Experiencing Homelessness

INTRODUCTION

Homelessness is associated with increased acute care utilization and poor healthcare outcomes. This study aims to compare hospital readmission rates among patients experiencing homelessness and patients who are not homeless and assess the impact of different clinical and demographic characteristics on acute care utilization among patients experiencing homelessness.

METHODS

This was a retrospective study of patients encountered in 2018 and 2019 at ChristianaCare Health Systems. The analysis was done in August 2021. The prevalence of major chronic conditions among patients experiencing homelessness (n=1,329) and those not experiencing it (n=143,360) was evaluated. Patients experiencing homelessness were matched with nonhomeless patients using 1:1 propensity score matching. Time-to-event analysis approaches were used to analyze time-to-readmission and 30-day readmission rates.

RESULTS

The 30-day readmission rates were 42.8% among patients experiencing homelessness and 19.9% among matched patients not experiencing homelessness. The hazard of 30-day readmission among patients experiencing homelessness was 2.6 (95% CI=1.93, 3.53) times higher than that among the matched nonhomeless cohort. In patients experiencing homelessness, drug use disorder, major depressive disorder, chronic kidney disease, obesity, arthritis, HIV/AIDS, and epilepsy were associated with shortened time to readmission. Moreover, Black racial identity was associated with shortened time to readmission.

CONCLUSIONS

Patients experiencing homelessness had higher acute care utilization than those not experiencing homelessness. Black racial identity and several comorbidities were associated with increased acute care utilization among patients experiencing homelessness. Efforts to address upstream social determinants of health, destigmatization, and healthcare management accounting for the whole spectrum of clinical comorbidities might be important in promoting the health of people experiencing homelessness.

Universal Climate Thermal Index as a prognostic tool in medical science in the context of climate change: A systematic review

The assessment of the impact of meteorological factors on the epidemiology of various diseases and on human pathophysiology and physiology requires a comprehensive approach and new tools independent of currently occurring climate change. The thermal comfort index, i.e., Universal Climate Thermal Index (UTCI), is gaining more and more recognition from researchers interested in such assessments. This index facilitates the evaluation of the impact of cold stress and heat stress on the human organism and the assessment of the incidence of weather-related diseases. This work aims at identifying those areas of medical science for which the UTCI was applied for scientific research as well as its popularization among clinicians, epidemiologists, and specialists in public health management. This is a systematic review of literature found in Pubmed, Sciencedirect and Web of Science databases from which, consistent with PRISMA guidelines, original papers employing the UTCI in studies related to health, physiological parameters, and epidemiologic applications were extracted. Out of the total number of 367 papers identified in the databases, 33 original works were included in the analysis. The selected publications were analyzed in terms of determining the areas of medical science in which the UTCI was applied. The majority of studies were devoted to the broadly understood mortality, cardiac events, and emergency medicine. A significant disproportion between publications discussing heat stress and those utilizing the UTCI for its assessment was revealed.

Onychotillomania in the Setting of Homelessness

Onychotillomania is a psychodermatosis that involves repetitive, self-induced trauma to the nail and sometimes the periungual skin. It is generally seen as an overlapping psychiatric and dermatologic disorder, although there have not been any statistically significant associations with psychiatric illness. Some studies have noted an association with obsessive-compulsive disorder (OCD). Due to the relative lack of empirical data on this condition, treatments are often not evidence-based. As a result, there is no standardized method of treating onychotillomania, and patients suffering from this disease are susceptible to relapse. This report presents the case of a 32-year-old male experiencing homelessness and suffering from major depressive disorder and methamphetamine use disorder who developed onychotillomania two months after becoming homeless. He regularly used various instruments such as nail cutters, tweezers, and nail files to constantly pick at his nails, a few of which were noted to be bleeding with signs of infection. He was evaluated jointly by dermatology and psychiatry providers who confirmed the diagnosis. By thorough examination of the patient’s history, he was provided tactile sensory equipment to reduce his repetitive picking behavior. A direct referral for substance use counseling was also provided. At follow-up, he was noted to have a subjective improvement in his picking symptoms, although there was no significant difference in the size of his nails. This case represents the twofold challenge of managing a difficult condition, onychotillomania, in the setting of the severe socio-personal stressor of homelessness.

Social support and quality of life among chronically homeless patients with schizophrenia

This study aimed to describe the sociodemographic characteristics, social support received, and quality of life of chronically homeless patients with schizophrenia in China. A self-prepared sociodemographic questionnaire, the Social Support Rating Scale (SSRS), European Five-dimensional Health Scale (EQ-5D), and Eysenck Personality were administrated to 3,967 chronically homeless and 3,724 non-homeless patients from the Department of Xiangtan Fifth People's Hospital, Hunan, China, between April 2011 and October 2016. Results indicated that the homeless patients were more likely to live outside the city and be ethnic minorities compared with non-homeless patients. Although the married proportion was higher among homeless patients, they had a higher rate of being divorced or widowed. Notably, the homeless patients had higher employment rates before illness, despite significantly lower education (P < 0.001). Chronically homeless patients with schizophrenia showed a lower score in the SSRS (30.29 ± 7.34 vs. 26.16 ± 10.04, p < 0.001); they had significantly lower objective support, subject support, social support, and EQ-Visual Analog Scale, Eysenck Personality Questionnaire-Psychoticism, and Eysenck Personality-Neuroticism scores (p < 0.001). Homeless patients may be worse off, and could be assisted by providing accommodation, family intervention, medical services (such as pain medication), and other comprehensive measures.

Comparison of COVID-19 mitigation and decompression strategies among homeless shelters: a prospective cohort study

PURPOSE

To compare the effectiveness of COVID-19 mitigation strategies in two homeless shelters in Massachusetts during the pandemic.

METHODS

We conducted a prospective cohort study that followed guests in two Massachusetts homeless shelters between March 30 and May 13, 2020, which adopted different depopulation strategies. One set up temporary tents in its parking lot, while the other decompressed its guests to a gym and a hotel. The outcome was assessed by comparing the odds ratios of positive SARS-CoV-2 RT-PCR assays.

RESULTS

Guests residing at the shelter that used temporary tents had 6.21 times (95% CI = 1.86, 20.77) higher odds of testing positive for SARS-CoV-2 at follow-up after adjusting for loss to follow up, age, gender, and race. The daily COVID-19 symptoms checklist performed poorly in detecting positive infection.

CONCLUSIONS

The study highlights the importance of depopulating shelter guests with stable and adequate indoor space to prevent SARS-CoV-2 transmission. Daily temperature and symptom checks should be combined with routine testing. With the rising homelessness due to mass unemployment and eviction crisis, our study supports further governmental assistance in decompressing homeless shelters during this pandemic.

A Scoping Review on Access and Use of Technology in Youth Experiencing Homelessness: Implications for Healthcare

Introduction: Youth are among the fastest growing subset of the homeless population. Youth experiencing homelessness (YEH) face multiple barriers in accessing health information and health care services. As such, they may best be reached through information and communication technologies (ICTs); however, limited efforts have been made to synthesize literature on this topic. In this paper, we review studies on access and use of ICTs among YEH. We also discuss the implications of the review for healthcare. Methods: Using scoping review methodology, we searched four databases (Medline, Embase, PsycInfo, and CINAHL) for studies published between 2005 and 2019, screening 1,927 titles and abstracts. Results: We identified 19 articles reporting on studies with YEH between the ages of 12-30, the majority of which were published in the USA. On average, more than half of the samples owned smartphones, used social media, and accessed the internet weekly to search for housing, employment, health information, and to communicate with family, peers, and health workers; however, many youths faced barriers to sustaining their access to technology. Benefits of using ICTs were connecting with home-based peers, family, and case workers, which was associated with a reduction in substance use, risky sexual health behaviors, and severity of mental health symptoms. Connecting with negative, street-based social ties was identified as the most common risk factor to using ICTs due to its association with engaging in risky sex behaviors and substance abuse. Discussion: This review supports the advancement of research and practice on using ICTs to deliver public health information and health services to YEH, while also considering the health-related risks, benefits, and barriers that YEH face when accessing ICTs.

Health status of women affected by homelessness: A cluster of in concreto human rights violations and a time for action

Health problems of women experiencing homelessness are driven either from the usual background characteristics of this population, or from the homeless lifestyle. Apart from poverty and unemployment, transition to homelessness is often associated with substance abuse, history of victimization, stress, poor mental health and human immunodeficiency virus (HIV). Water insecurity can undermine bodily hygiene and dental health, posing a greater risk of dehydration and opportunistic infections. Exposure to extreme environmental conditions like heat waves and natural disasters increases morbidity, accelerates aging, and reduces life expectancy. Nutrition-wise, a high prevalence of food insecurity, obesity, and micronutrient deficiencies are apparent due to low diet quality and food waste. Poor hygiene, violence, and overcrowding increase the susceptibility of these women to communicable diseases, including sexually transmitted ones and COVID-19. Furthermore, established cardiovascular disease and diabetes mellitus are often either undertreated or neglected, and their complications are more widespread than in the general population. In addition, lack of medical screening and contraception non-use induce a variety of reproductive health issues. All these health conditions are tightly related to violations of human rights in this population, including the rights to housing, water, food, reproduction, health, work, and no discrimination. Thus, the care provided to women experiencing homelessness should be optimized at a multidimensional level, spanning beyond the provision of a warm bed, to include access to clean water and sanitation, psychological support and stress-coping strategies, disease management and acute health care, food of adequate quality, opportunities for employment and support for any minor dependants.

The Ecology of Unsheltered Homelessness: Environmental and Social-Network Predictors of Well-Being among an Unsheltered Homeless Population

People experiencing homelessness (PEH) face extreme weather exposure and limited social support. However, few studies have empirically assessed biophysical and social drivers of health outcomes among unsheltered PEH. Social network, health, and outdoor exposure data were collected from a convenience sample of unsheltered PEH (n = 246) in Nashville, TN, from August 2018–June 2019. Using multivariate fixed-effects linear regression models, we examined associations between biophysical and social environments and self-reported general health and emotional well-being. We found that study participants reported the lowest general health scores during winter months—Nashville’s coldest season. We also found a positive association between the number of nights participants spent indoors during the previous week and general health. Participants who spent even one night indoors during the past week had 1.8-point higher general health scores than participants who spent zero nights indoors (p < 0.01). Additionally, participants who experienced a conflict with a social contact in the past 30 days had lower emotional well-being scores than participants who experienced no conflict. Finally, women had worse general health and emotional well-being than men. Ecologically framed research about health and well-being among PEH is critically needed, especially as climate change threatens to increase the danger of many homeless environments.

Impact of the COVID-19 pandemic on the homeless: results from a retrospective closed cohort in France (March-May 2020)

Objectives

To evaluate severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, hospitalization and fatality rates in residents of homeless shelters run by Samusocial of Paris.

Methods

We conducted a retrospective serological study between July and August 2020 on all residents and staff members of three homeless shelters run by Samusocial of Paris: two centres providing healthcare accommodation (HCA) and one a women's dormitory. We included all adults present in the shelters or who died of a proven SARS-CoV-2 infection during the first wave (March–May). SARS-CoV-2 antibodies were detected in serum samples using the SARS-CoV-2 IgG Architect (Abbott) test. Any participant with a positive PCR or serology was defined as a confirmed SARS-CoV-2 case.

Results

We included 100 residents and 83 staff members. The confirmed SARS-CoV-2 rate by PCR or serology was 72/100 (72.0%) for residents and 17/83 (20.5%) for staff members. Women accommodated in the dormitory had the highest infection rate (90.6%). The hospitalization rate in residents was 17/72 (23.6%) and the death rate 4/72 (5.6%). All hospitalizations and deaths occurred among HCA residents. Among the residents of HCA shelters, 34/68 (50%) presented at least two comorbidity factors associated with being at high risk for severe SARS-CoV-2 infection.

Conclusion

The SARS-CoV-2 infection rate was high in residents of these homeless shelters (10.6% seroprevalence in the Île-de-France region during the first wave). Severe SARS-CoV-2 infection was highly associated with the prevalence of comorbidities. This population should be considered as a priority in vaccination campaigns and in access to individual housing units when at risk.

The benefits and challenges of embedding specialist palliative care teams within homeless hostels to enhance support and learning: Perspectives from palliative care teams and hostel staff

BACKGROUND

People residing in UK homeless hostels experience extremely high rates of multi-morbidity, frailty and age-related conditions at a young age. However, they seldom receive palliative care with the burden of support falling to hostel staff.

AIM

To evaluate a model embedding palliative specialists, trained as 'homelessness champions', into hostels for two half-days a month to provide support to staff and residents and facilitate a multidisciplinary approach to care.

DESIGN

An exploratory qualitative design.

SETTING/PARTICIPANTS

Four homeless hostels in London, UK, including nine hostel managers/support staff and seven palliative care specialists (five nurses and two social workers).

RESULTS

Benefits to introducing the model included: developing partnership working between hostel staff and palliative care specialists, developing a holistic palliative ethos within the hostels and improving how hostel staff seek support and connect with local external services. Challenges to implementation included limited time and resources, and barriers related to primary care.

CONCLUSION

This is the first evaluation of embedding palliative care specialists within homeless hostels. Inequity in health and social care access was highlighted with evidence of benefit of this additional support for both hostel staff and residents. Considering COVID-19, future research should explore remote ways of working including providing in-reach support to homelessness services from a range of services and organisations.

Global Climate Implications for Homelessness: A Scoping Review

Homelessness is a persistent global challenge with significant health impacts on those affected. Homeless people are by definition the most exposed to weather conditions and the social and economic problems caused by extreme weather and climate change and variability. This systematic review was designed to synthesize the academic literature that addresses the health and social implications of global climate change for homelessness. The question examined in this systematic scoping review is the following: What is the current state of knowledge in the scientific literature on the health and social implications of global climate change for homelessness? A systematic scoping review method was used to identify and synthesize the peer-reviewed literature relevant to this question. The databases searched were PsycINFO, Medline, Scopus, and Google Scholar. Of the 26 papers identified in this review, 20 employed original data analyses with conclusions largely inferred from cross-sectional associations. Themes included the potential influence of climate change on homelessness prevalence, climate impacts that exacerbate specific vulnerabilities of homeless populations (e.g., chronic illness, exposure, stigmatization), and health and social outcomes. Service use and design implications were also addressed. Given the scale of the impacts of climate change on homelessness, the literature on this topic poses promising directions but is under-developed in its current state to adequately inform risk mitigation and response planning. A systems framework is proposed here to inform future research and service design.

Severe Psychopathology and Substance Use Disorder Modify the Association Between Housing Trajectories and Food Security Among Homeless Adults

Purpose: We examined the housing trajectories of homeless people with mental illness over a follow-up period of 6 years and the association of these trajectories with food security. We then examined the modifying role of psychopathology and alcohol and substance use disorders in this association. Materials and Methods: We followed 487 homeless adults with mental illness at the Toronto site of the At Home/Chez-Soi project-a randomized trial of Housing First. Food security data were collected seven times during the follow-up period. Psychopathology (Colorado Symptom Index score) and alcohol and substance use disorders were assessed at baseline. Housing trajectories were identified using group-based trajectory modeling. Logistic regression was used to estimate the association between housing trajectory groups and food security. Results: Three housing trajectory groups were identified: rapid move to consistent stable housing (34.7%), slow and inconsistent housing (52.1%), and never moved to stable housing (13.2%). Individuals included in the rapid move to consistent housing trajectory group had higher odds of remaining food secure compared with those in the never moved to stable housing trajectory group over the follow-up period [AOR 2.9, 95% CI: 1.3-6.6, P-value: 0.009]. However, when interactions were considered, this association was significant among those with moderate psychopathology but not severe psychopathology. Individuals with substance use disorder and in the never moved to stable housing group had the lowest food security status. Discussion: Severe psychopathology and substance use disorders modified the association between housing trajectories and food security. International Standard Randomized Control Trial Number Register (ISRCTN42520374).

Advocates Make a Difference in Duration of Homelessness and Quality of Life

Social support is known to protect against homelessness and improve the wellbeing of people experiencing homelessness, but the role of professional versus informal advocates has not been studied in relation to the duration of homelessness and quality of life. We measured the effect of the presence and quality of formal (professional) and informal (family or friend) advocates on these outcomes. Our team interviewed 67 adults experiencing homelessness at tiny house villages and self-organized encampments in Seattle/King County, Washington in 2018-2019. The duration of homelessness was 19.6 months shorter for those with a high-quality informal advocate, compared to those without, while controlling for race, age, gender, and sexuality. However, this difference did not reach statistical significance at the alpha 0.05 level (p = .069). Additionally, those with high-quality informal advocates had 5.3 times the odds (p = .010) of reporting high quality of life compared to those without. The effect of at least one high-quality, professional advocate was insignificant in our model. Our results suggest social workers and other professional advocates integrate methods that strengthen clients' informal relationships into their practice.

Increases in social support co-occur with decreases in depressive symptoms and substance use problems among adults in permanent supportive housing: an 18-month longitudinal study

BACKGROUND

Social support is a well-known protective factor against depressive symptoms and substance use problems, but very few studies have examined its protective effects among residents of permanent supportive housing (PSH), a housing program for people with a history of chronic homelessness. We utilized unconditional latent growth curve models (LGCMs) and parallel process growth models to describe univariate trajectories of social support, depressive symptoms, and substance use problems and to examine their longitudinal associations in a large sample of adults residing in PSH.

METHODS

Participants were 653 adult PSH residents in North Texas (56% female; 57% Black; mean age: 51 years) who participated in a monthly health coaching program from 2014 to 2017. Their health behaviors were assessed at baseline and tracked every six months at three follow-up visits.

RESULTS

Unconditional LGCMs indicated that over time, social support increased, whereas depressive symptoms and substance use problems decreased. However, their rates of change slowed over time. Further, in parallel process growth models, we found that at baseline, individuals with greater social support tended to have less severe depressive symptoms and substance use problems (coefficients: - 0.67, p < 0.01; - 0.52, p < 0.01, respectively). Individuals with a faster increase in social support tended to have steeper rates of reduction in both depressive symptoms (coefficient: - 0.99, p < 0.01) and substance use problems (coefficient: - 0.98, p < 0.01), respectively.

CONCLUSIONS

This study suggests that plausibly, increases in social support, though slowing over time, still positively impact depressive symptoms and substance use problems among PSH residents. Future PSH programs could emphasize social support as an early component as it may contribute to clients' overall health.

Primary care services tailored for adult and adolescent homeless persons: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to explore existing literature on primary care services for adult and adolescent homeless persons, map the evidence and identify gaps in the literature.

INTRODUCTION

Homeless adults and adolescents have complicated health needs, increased need for services, and more barriers to care. Recipients of primary care services use less emergency and urgent care resources. More information is needed in order to tailor primary care services for this vulnerable population.

INCLUSION CRITERIA

This review will consider studies with participants aged 13 years or older who are currently or previously homeless. Studies will be included regardless of type of primary care service, country of origin, healthcare delivery system, geographic location or cultural setting.

METHODS

The proposed review will be conducted in accordance with the JBI methodology for scoping reviews. The search strategy aims to locate published and unpublished studies and will be adapted for each information source. The reference lists of selected studies will be screened for additional citations. The search will be limited to the English language, but not by date of publication. Databases to be searched include MEDLINE (PubMed), CINAHL, Scopus, Embase, PsycINFO, PsychArticles, PsycEXTRA, Academic Search Premier and Web of Science. Gray literature and unpublished studies will be searched. After screening titles and abstracts, two independent reviewers will retrieve potentially relevant, full-text studies and extract data. Data will be presented in diagrammatic form, accompanied by a narrative summary.

Health Literacy and Self-Rated Health among Homeless Adults

Poor health literacy reduces the efficacy of behavior change interventions, hampers management of health conditions, and attenuates understanding of the prevention and treatment of diseases. Poor health literacy has also been linked to fair/poor self-rated health in domiciled samples; however, there is a paucity of studies on the relation amongst homeless adults, who bear a disproportionate burden of disease and disability and require high level of care and access to health services. Here, we examined the association between health literacy and self-rated health among a convenience sample of homeless adults. Participants were recruited from six homeless-serving agencies in Oklahoma City (N = 575; 63% men, Mage = 43.6±12.3). Logistic regression was used to assess the association between health literacy (confidence completing medical forms: extremely/quite a bit vs somewhat/little bit/not at all) and self-rated health (poor/fair vs good/very good/excellent) controlling for age, subjective social status, education, race, sex, income, health insurance, employment, social security recipient status, diabetes diagnosis, high blood pressure diagnosis, and high cholesterol diagnosis. In the adjusted model, health literate homeless individuals had greater odds of endorsing good/very good/excellent self-rated health compared to those somewhat/a little bit/not at all confident completing medical forms (AOR = 2.02, [CI95% = 1.35-3.02]). Interventions targeted at adjusting reading level and comprehensibility of health information are needed for homeless individuals with poor/limited health literacy, which may ultimately impact their self-rated health. Shelters and homeless-serving agencies could host classes focused on practical skills for enhancing health literacy and/or provide navigation services.