The Prevalence of Mental Illness in Homeless People in Germany

[Housing Situation of People with Severe Mental Illnesses]

OBJECTIVE

People with mental illness should live independently in the community. This study analyzed the housing situation and the use and need of psychiatric housing facilities of people with severe mental illness.

METHODS

Data from a cross-sectional study with 397 people with severe mental illness from two Bavarian districts were used and analyzed descriptively.

RESULTS

70% of the patients live independently. 6% use supported housing or residential care. 25% of the participants have housing needs, but 39% of them do not receive adequate help. Most of the patients are familiar with supported housing or residential care and find these helpful.

CONCLUSION

Most patients live in a housing situation that meets the social norm. However, some patients have an unresolved housing problem. The use of supported housing or residential care is helpful, but is rarely used.

Health Technology Access and Peer Support Among Digitally Engaged People Experiencing Homelessness: Qualitative Study

BACKGROUND

Although the effects of digital health are receiving wide scientific attention, very little is known about the characteristics of digitally engaged people experiencing homelessness, especially in Central and Eastern Europe. Our previous research revealed a considerable level of internet use in the homeless population of Budapest, Hungary, for general purposes (350/662, 52.9%) and medical purposes (229/664, 34.6%). Moreover, a digitally engaged subgroup was identified (129/662, 19.5%).

OBJECTIVE

The aim of this exploratory study was to map out the resources, attitudes, and behaviors of digitally engaged homeless individuals in relation to digital technology to set the basis for potential health policy interventions, which will enable better access to health services through strengthening of the digital components of the existing health care system.

METHODS

Between August 18, 2022, and October 27, 2022, a total of 12 in-depth semistructured interviews were conducted in 4 homeless shelters in Budapest, Hungary. Upon analysis by 3 independent evaluators, 2 interviews were excluded. The interviewees were chosen based on purposive sampling with predefined inclusion criteria. Thematic analysis of the transcripts was conducted.

RESULTS

In the thematic analysis, 4 main themes (attitude, access, usage patterns, and solutions for usage problems) emerged. Health-related technology use mostly appeared in health information-seeking behavior. Online search for prescribed medications (5 interviews), active ingredients of medications (4 interviews), medicinal herbs believed to replace certain pills (2 interviews) or foods, and natural materials (1 interview) were mentioned. Moreover, mobile health app use (3 interviews) was reported. The intention to circumvent or check on mainstream health care solutions was mainly associated with previous negative experiences in the health care system. Several gaps in the daily use of technology were identified by the interviewees; however, more than half of the interviewees (6/10) turned out to be contact points for their peers for digital problem-solving or basic digital literacy skill enhancement in the homeless shelters. Furthermore, a lack of institutional support or special programs targeting senior clients was noted.

CONCLUSIONS

Digitally engaged homeless individuals might become mediators between their peers and comprehensive digital health programs. They have the trust of their peers, can recognize and harness the benefits of digital technology, and are able to provide meaningful help in technology- and usage-related issues through experience. Digital health services have great promise in community shelters for managing and preventing health issues, and digitally engaged individuals might be important for the success of such services.

[Care trajectories of homeless or precariously housed mentally ill patients from two psychiatric-psychotherapeutic hospitals in North Rhine-Westphalia]

OBJECTIVES

Mental illness and homelessness are often associated with each other. The study aim was to describe the care trajectories of psychiatric inpatients admitted from precarious housing or homelessness.

METHODS

An anonymized data collection was performed at two psychiatric hospitals in North Rhine-Westphalia.

RESULTS

Of 76 identified patients, every other was discharged to unsecured housing or homelessness. An unresolved housing situation delayed discharge in almost every third case. Upon discharge outpatient somatic or psychiatric treatment was not secured in more than 30%, and in more than 40% of cases, resp.

CONCLUSION

Improvement of the housing situation is possible in a minority of cases for psychiatric inpatients admitted from unsecured housing. The unresolved housing situation was seen as an obstacle to discharge in every third case.

[Homelessness Among People with Mental Illness - Using the Example of a Growing German City]

OBJECTIVE

The present study investigated the development of homelessness among people with mental illness using the example of a growing German city.

METHODS

Eight psychosocial community centres estimated how many of their clients had become homeless in the previous year of care from 2008 to 2019. A random effects negative binominal (RENB) regression model was developed to investigate the change of homelessness over time.

RESULTS

The number of homeless, mentally ill clients of the psychosocial community centres increased significantly from 2008 to 2019 (IRR=1.26; 95-CI=1.16-1.36; p<.001). Every year, homelessness had an average increase of 26%.

CONCLUSION

The problem of homelessness among mentally ill people has worsened in the investigated region during the past few years. Existing support services must be assessed and community-based support services expanded.

Personality and attachment in the homeless: A systematic review

BACKGROUND

Homeless people present high rates of psychopathology, including personality disorders. Given the link between personality disorders and attachment, and the potential importance of these two traits for understanding homeless populations.

AIMS

Our aim was to review all studies focusing on attachment and on the full assessment of personality disorders in the homeless.

METHOD

Overall, 213 studies were screened through title and abstract. Of these, 63 articles were chosen for full-text assessment.

RESULTS

A total of 14 articles met eligibility criteria and were included in the present review. Six studies evaluated personality disorders and eight studies assessed attachment in the homeless. In general, reports suggested that personality disorders are highly common in the homeless, with frequencies ranging between 64% and 79% for any personality disorder. The most common personality diagnoses were paranoid (14%-74%), borderline (6%-62%), avoidant (14%-63%), and antisocial (4%-57%) personality disorders. Attachment reports differed in the methods used and presented diverse results and correlates. Even so, insecure types of attachment dominated in the homeless, accounting for 62% to 100% of the samples.

CONCLUSIONS

The high prevalence of personality disorders and insecure types of attachment in the homeless may impact intervention strategies for these people. The available literature evaluating attachment and the full assessment of personality disorders in the homeless is scarce, which supports the need for more research on these two topics.

Stressful Life Events and Near-term Suicidal Risk in a Clinical Population

The present study examined 22 specific stressful life events (SLEs) in relation to recent and prospective suicidal thoughts and behaviors (STBs). The effect of assessment method (self-report vs. chart-based ratings) and inpatient/outpatient status was also investigated. Past 3-month STBs and SLEs were assessed for 1,058 psychiatric patients; 696 completed one-month follow-up assessments. SLEs were common, with 684 participants (64.7%) reporting at least one. Total number of SLEs correlated with recent and prospective STB. A higher incidence of SLE's was found with self-report vs. chart-based measures (on 20 SLEs) and inpatients vs. outpatients (on 7 SLEs). SLEs of interpersonal rejection and loss, homelessness and academic failure offered elevated risk. In sum, SLEs are common and associated with STBs in psychiatric patients. SLEs of interpersonal rejection and loss, homelessness and academic failure may merit increased clinical attention.

Socio-economic outcomes of COVID-19 on the marginalised: Who have taken the hardest hit?

This article aims to examine the socioeconomic outcomes of COVID-19 for socially marginalised people who are clients of social care organisations (e.g. people experiencing homelessness), and the factors influencing these outcomes. We tested the role of individual and socio-structural variables in determining socioeconomic outcomes based on a cross-sectional survey with 273 participants from eight European countries and 32 interviews and five workshops with managers and staff of social care organisations in ten European countries. 39% of the respondents agreed that the pandemic has had a negative effect on their income and access to shelter and food. The most common negative socio-economic outcome of the pandemic was loss of work (65% of respondents). According to multivariate regression analysis, variables such as being of a young age, being an immigrant/asylum seeker or residing in the country without documentation, living in your own home, and having (in)formal paid work as the main source of income are related to negative socio-economic outcomes following the COVID-19 pandemic. Factors such as individual psychological resilience and receiving social benefits as the main source of income tend to "protect" respondents from negative impacts. Qualitative results indicate that care organisations have been an important source of economic and psycho-social support, particularly significant in times of a huge surge in demand for services during the long-term crises of pandemic.

A COVID-19 isolation facility for people experiencing homelessness in Berlin, Germany: a retrospective patient record study

Introduction

People experiencing homelessness (PEH) are disproportionately affected by the COVID-19 pandemic. For many PEH it is impossible to isolate due to the lack of permanent housing. Therefore, an isolation facility for SARS-CoV-2 positive PEH was opened in Berlin, Germany, in May 2020, offering medical care, opioid and alcohol substitution therapy and social services. This study aimed to assess the needs of the admitted patients and requirements of the facility.

Materials and methods

This was a retrospective patient record study carried out in the isolation facility for PEH in Berlin, from December 2020 to June 2021. We extracted demographic and clinical data including observed psychological distress from records of all PEH tested positive for SARS-CoV-2 by RT-PCR. Data on duration and completion of isolation and the use of the facilities' services were analyzed. The association of patients' characteristics with the completion of isolation was assessed by Student's t-test or Fisher's exact test.

Results

A total of 139 patients were included in the study (89% male, mean age 45 years, 41% with comorbidities, 41% non-German speakers). 81% of patients were symptomatic (median duration 5 days, range 1-26). The median length of stay at the facility was 14 days (range 2-41). Among the patients, 80% had non-COVID-19 related medical conditions, 46% required alcohol substitution and 17% opioid substitution therapy. Three patients were hospitalized due to low oxygen saturation. No deaths occurred. Psychological distress was observed in 20%, and social support services were used by 65% of PEH. The majority (82%) completed the required isolation period according to the health authority's order. We did not observe a statistically significant association between completion of the isolation period and sociodemographic characteristics.

Conclusion

The specialized facility allowed PEH a high compliance with completion of the isolation period. Medical care, opioid and alcohol substitution, psychological care, language mediation and social support are essential components to address the specific needs of PEH. Besides contributing to infection prevention and control, isolation facilities may allow better access to medical care for SARS-CoV-2 infected PEH with possibly positive effects on the disease course.

Mental health of people with limited access to health services: a retrospective study of patients attending a humanitarian clinic network in Germany in 2021

BACKGROUND

Germany has a statutory health insurance system. However, a substantial part of the population still suffers from limited access to regular health services. While humanitarian organizations are partially filling this gap, people with limited access show a high prevalence of mental disorders. This study investigates the prevalence, and social determinants of mental disorders in patients attending the clinics of a humanitarian health network in three major cities in Germany, as well as perceived barriers to healthcare access in this population.

METHODS

We performed a descriptive, retrospective study of individuals attending the outpatient clinics of the humanitarian organization Ärzte der Welt, in Berlin, Hamburg and Munich, in 2021. Medico-administrative data was collected using a digital questionnaire at first presentation to the clinics. We report the prevalence of both perceived altered mental health and diagnosed mental disorders, as well as the perceived barriers to healthcare access in this population. We performed a logistic regression analysis to identify the socio-demographic factors associated with mental disorders.

RESULTS

Our study population consisted of 1,071 first presenters to the clinics in 2021. The median age at presentation was 32 years and 57.2% of the population were male. 81.8% experienced a form of homelessness, 40% originated from non-EU countries and only 12.4% had regular statutory health insurance. 101 (9.4%) patients had a diagnosed mental disorder. In addition, 128 (11.9%) patients reported feeling depressed, 99 (9.2%) reported a lack of interest in daily activities, and 134 (12.5%) lacked emotional support in situations of need on most days. The most reported barrier to accessing health services was high health expenses, reported by 61.3% of patients.In the bivariate logistic regression analysis age, insurance status and region of origin were significantly associated with mental disorders. In the multivariable analysis, only age groups 20-39 and 40-59 years remained significant.

CONCLUSIONS

People with limited access to regular health services have a high need for mental health services. As a chronic condition, this is even more difficult to manage outside of regular services, where humanitarian clinics are only filling the gap in serving basic health needs.

[On the Ideological Function of a Traditional Criticism of Psychiatry in Neoliberalism]

Social isolation and discrimination play a major role in the development and maintenance of mental disorders. This could motivate a critical public to demand improved treatment facilities for persons with mental illness. Instead, the media and a critical public tend to repeat a traditional critique of psychiatry, which was articulated before psychiatry reform in the 1970s and which tends to romanticize or neglect mental illness. The replication of this traditional critique of psychiatry today has an ideological function: it reassures a neoliberal public that it is emancipated from traditional authoritarian patterns of dominance, rejects demands for increased funding of mental health treatment facilities, and emphasizes individual autonomy at the price of blaming the victims for homelessness and social impoverishment.

Determinants of COVID-19 vaccine acceptance and access among people experiencing homelessness in Germany: A qualitative interview study

Introduction

People experiencing homelessness face lower life expectancy, higher prevalence of somatic and mental diseases and a more difficult access to healthcare compared to people in secure living. During the COVID-19 pandemic transmission rates were higher among people experiencing homelessness and preventive public health measures were not properly adapted to the specific needs of people experiencing homelessness. Thus, goal of our study was understanding the determinants of acceptability and access of the COVID-19 vaccine.

Materials and methods

We conducted a qualitative interview study with twenty guideline interviews with adult people currently experiencing homelessness in Berlin, Germany (August 2021 - April 2022). Participants were approached in a purposive sampling strategy. The interviews were analyzed with qualitative content analysis according to Mayring.

Results

Acceptance and attitude toward the COVID-19 vaccine is influenced by confidence in the vaccine as well as in the political and healthcare system, the individual COVID-19 risk perception and sense of collective responsibility. Overall, the acceptance of the vaccine was high among our participants. Facilities offering low threshold COVID-19 vaccines for people experiencing homelessness were perceived as helpful. Language barriers and the need for identity documents were major barriers to access the COVID 19 vaccine.

Discussion

People experiencing homelessness are a marginalized and vulnerable group often underrepresented in the public and scientific discourse. During the COVID-19 pandemic, preventive public health measures, including the COVID-19 vaccine, failed to consider specific needs of people experiencing homelessness. Multidimensional strategy to enhance inclusive healthcare are needed to improve access and to reduce discrimination and stigmatization.

Saúde dos indivíduos em situação de rua

Introdução: A população em situação de rua é vulnerabilizada por diversos fatores que determinam ou condicionam sua saúde e ocasionam aumento dos índices de comorbidades clínicas, entre elas as doenças mentais, crônicas e infectocontagiosas. A marginalização dos indivíduos que se encontram em situação de rua abre uma lacuna na assistência em saúde que, por vezes, é suprida por organizações sem fins lucrativos que exercem um papel social elementar. Objetivo: Mapear o perfil clínico da população em situação de rua de Curitiba (PR) atendida por iniciativa voluntária no período de um ano. Métodos: Trata-se de um estudo observacional descritivo de base documental realizado com fichas clínicas dos 509 pacientes maiores de 18 anos e que tiveram seu primeiro atendimento médico realizado pela Associação Médicos do Mundo, filial Curitiba (PR), no ano de 2019. Resultados: Indivíduos do sexo masculino, de etnia branca, faixa etária entre 36 e 45 anos, que cursaram o ensino fundamental e que se encontravam havia menos de um ano em situação de rua foram as condições sociodemográficas predominantes. As principais queixas motivadoras da procura pelo atendimento foram dor (45,19%), lesões cutâneas (15,71%) e queixas oftalmológicas (6,68%). Parte dos indivíduos mostrou acometimento crônico por hipertensão arterial sistêmica (9,03%), HIV/AIDS (3,53%) e diabetes mellitus (3,53%). Também foi identificada quantidade significativa de relatos de histórico de traumas físicos (59%). Encontrou-se correlação estatística entre hipertensão e medicamentos de uso contínuo (p=0,001). Menos que 10% dos indivíduos procuraram atendimento médico por queixas de saúde mental. Das mulheres que fizerem parte do estudo, 70% relataram fazer uso de substâncias e aproximadamente metade delas, uso regular de medicamentos. Já o uso de anticoncepcionais foi relatado por uma minoria delas (18,57%). Conclusões: As queixas de dor, as lesões cutâneas e as demandas oftalmológicas foram os principais motivadores da procura por ajuda médica pela população em situação de rua, além da prevalência de hipertensão arterial sistêmica como doença crônica. Os achados podem auxiliar e direcionar ações em saúde voltadas para essa população marginalizada.

[Health Service Utilization by Homeless Persons: Analysis of the Role of Enabling Factors, Pain and Gender using the Gelberg-Andersen Model]

The aim of the study was to find factors that influence health service utilization by homeless people. In a field study, a sample of 51 homeless men and 47 homeless women in the German county of Baden-Württemberg participated in face-to-face-interviews with a questionnaire designed for this study. Analyses were performed using multiple logistic regression models. Variables were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Satisfied subsistence needs (OR 1.33, 95%-CI [1.03-1.72] regarding utilization of vaccinations), a stable source of primary care (OR 12.2 [1.81-82] regarding utilization of early detection examinations; quasi-complete separation regarding use of GP services) social networks (OR 2.9 [1.13-7.5] regarding utilisation of early detection examinations; OR 0.63 [0.41-0.98] regarding emergency department visits) and technological ressources (OR 2.2 [1.13-4.4] regarding use of GP services) had a positive influence on the pattern of health service utilization. Pain was correlated with more emergency department visits (OR 1.72 [1.22-2.4]) and hospitalizations (OR 1.66 [1.19-2.3]). The results showed differences between homeless men and women. The factors of influence found in this study should be addressed in the care of homeless persons. Integration of social care into the regular health care system is necessary for early detection and treatment of complex social and medical needs of vulnerable populations. This requires interprofessional approaches in medical education and training focussing on the situation of vulnerable populations and on social determinants of health.

Self-imposed social isolation among clients of social care organisations in the COVID-19 pandemic

Although self-imposed social isolation is an important way of reducing the risk of COVID-19 infection, previous research indicates that this behaviour varies substantially between different groups and individuals. Socially marginalized people are generally less involved in protective health behaviours, but there are few studies of their COVID-19 protective behaviours. The aims of the paper are therefore to: 1) compare self-imposed social isolation to avoid COVID-19 among socially marginalized groups, and to 2) examine factors influencing this, focusing especially on the role of social capital, risk awareness and sources of information about COVID-19. The study is based on survey data (N = 173) from people who are clients of social care organisations in Estonia, Norway, Hungary and Portugal. The sample involves clients living: a) in their homes, b) in facilities, and c) on the street or under temporary arrangements. Results indicate that the level of social isolation among the marginalized groups is comparable to that of the general population in previous studies. As hypothesized, we find that respondents living on the street or under temporary arrangements engage in less self-imposed social isolation than e.g. the respondents living in their homes. We also find lower levels of risk awareness, social capital and trust in authorities' information about COVID-19 among people living on the street or under temporary arrangements. Only linking social capital and trust in authorities' information was significantly related to respondents' social isolation, and not worry for COVID-19 infection. Thus, it seems that respondents largely self-isolated because of "duty" and not worry for infection.

PROTOCOL: Group-based community interventions to support the social reintegration of marginalised adults with mental illness

This is the protocol for a Campbell systematic review. The main objective is to explore the general efficacy of group-based community interventions aimed at supporting marginalised adults with mental illness and related problems on outcomes such as problem behaviour, subjective well-being, homelessness, poverty and employment. Furthermore, the objective is to explore the potential advantages/disadvantages of using a group-based versus an individual intervention when targeting specific problems or when using specific types of interventions.

Chronic diseases and multi-morbidity in persons experiencing homelessness: results from a cross-sectional study conducted at three humanitarian clinics in Germany in 2020

BACKGROUND

Persons experiencing homelessness (PEH) suffer a high burden of chronic diseases and multi-morbidity, yet face significant barriers in accessing healthcare services. These health inequalities were further aggravated during the COVID-19 pandemic. While there is a lack of comprehensive health data on PEH, even less is known about populations experiencing housing exclusion, a hidden form of homelessness. This study examines and compares chronic diseases and multi-morbidity in PEH, persons experiencing housing exclusion, and persons with secure housing who lacked access to regular healthcare services in the wake of the COVID-19 pandemic in Germany.

METHODS

Study participants were adults who sought medical care at clinics of the humanitarian organisation "Ärzte der Welt" in Munich, Hamburg and Berlin in 2020. The patients were categorised into three housing groups according to the ETHOS classification of homelessness and housing exclusion. Socio-demographic characteristics, self-rated health, chronic diseases and multi-morbidity were described in each group. Logistic regression analysis was used to identify socio-demographic factors associated with higher odds of chronic diseases and multi-morbidity in each housing group.

RESULTS

Of the 695 study participants, 333 experienced homelessness, 292 experienced housing exclusion and 70 had secure housing. 92.3% of all patients had either no or limited health coverage, and 96.7% were below the poverty line. Males and EU/EEA citizens were highly represented among PEH (74.2% and 56.8% respectively). PEH had lower self-rated health (47.8%, p = 0.04), and a higher prevalence of psychiatric illness (20.9%, p = 0.04). In adjusted analyses, belonging to the age group 35-49 and ≥ 50 years were associated with greater odds of chronic disease (AOR = 2.33, 95% CI = 1.68-3.24; AOR = 3.57, 95% CI = 2.55-5.01, respectively) while being ≥ 50 years old was associated with multi-morbidity (AOR = 2.01, 95% CI = 1.21, 3.33). Of the 18 participants tested for SARS-COV-2, 15 were PEH, 1 of whom tested positive.

CONCLUSIONS

Housing status was not an independent risk factor for chronic disease and multi-morbidity in our study population. However, PEH reported poorer self-rated and psychiatric health. Strategies to improve access to healthcare services amongst persons experiencing homelessness and housing exclusion are needed in Germany.

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.

Health Status and Access to Healthcare for Uninsured Migrants in Germany: A Qualitative Study on the Involvement of Public Authorities in Nine Cities

Non-governmental organisations (NGOs) regularly report data on their work with uninsured migrants (UM) within a (so-called) parallel health care system. The role and involvement of public authorities therein have yet been underrepresented in research. Our aim was to gain a better understanding of public authorities’ role in the parallel health care system and their view of the health situation of UM. We conducted qualitative semi-structured interviews with 12 experts recruited by purposive sampling from local public health authorities (LPHAs), state-level public health authorities (SPHAs), and social services offices (SSO) in nine cities, recorded, transcribed, and subjected the data to qualitative content analysis. LPHAs are more often directly involved in providing medical services, while SSOs and SPHAs function as gatekeepers for access to social benefits, including health insurance, and in grant-funded projects. NGOs keep substituting for the lack of access to regular health care from public institutions, but even in settings with extended services, public authorities and NGOs have not been able to provide sufficient care through the parallel health care system: Experts report gaps in the provision of health care with respect to the depth and height of coverage, due to the fragmentation of services and (ostensible) resource scarcity. Our study highlights the necessity for universal access to regular health care to overcome the fragmentation of services and improve access to needed health care for UM in Germany.

[Associations of mental illness and homelessness: results of a secondary data analysis at a Berlin health center for the homeless]

Hintergrund

Wohnungslosigkeit ist Ausdruck und Folge einer komplexen Problemlage, die die medizinischen und sozialen Versorgungssysteme in Deutschland vor große Herausforderungen stellt. Etwa 3 Viertel der wohnungslosen Menschen leiden an psychischen Erkrankungen. Ziel dieser Studie war es, Assoziationen zwischen psychischen Erkrankungen und Wohnungslosigkeit zu untersuchen.

Material und Methoden

Es wurde eine Sekundärdatenanalyse von Patient*innendokumentationen eines Berliner Gesundheitszentrums für Obdachlose durchgeführt. In die explorative Studie eingeschlossen wurden Daten von 112 wohnungslosen Patient*innen, die dort zwischen den Jahren 2006 und 2020 versorgt wurden.

Ergebnisse

Bei 84,9 % der Patient*innen lagen psychische Erkrankungen bereits vor dem Beginn der Wohnungslosigkeit vor. Assoziiert mit einem frühen Beginn der Wohnungslosigkeit waren die Faktoren niedrige Schulbildung sowie Drogenabusus. Eine lange Dauer der Wohnungslosigkeit war mit den Faktoren Alkoholabusus sowie Haftaufenthalte assoziiert. Jede erneute Episode der Straßenobdachlosigkeit war mit einer durchschnittlichen Verlängerung der Dauer der Wohnungslosigkeit um 7,9 Monate assoziiert.

Diskussion

Da psychische Erkrankungen wichtige Einflussfaktoren für die Entstehung und Aufrechterhaltung von Wohnungslosigkeit sind, sollten vermehrt präventive Strategien sowie spezialisierte Angebote für diese vulnerable Gruppe geschaffen werden. Insbesondere wiederkehrende Episoden der Straßenobdachlosigkeit sollten so weit wie möglich verhindert werden. Der Zusammenhang zwischen Inhaftierungen und Wohnungslosigkeit legt nahe, dass eine intensivere Begleitung bei der Wiedereingliederung nach Haftentlassung erforderlich ist.

Homelessness among psychiatric inpatients in North Rhine-Westphalia: a retrospective routine data analysis

BACKGROUND

Within the last five years the number of homeless persons in Germany has more than doubled, with many suffering from mental illnesses that require treatment. Whether the mental illness itself led to losing shelter or whether the state of being homeless increased the likelihood of developing symptoms of a mental disorder remains unclear. The current study assessed the interaction of homelessness and mental illness from a care provider perspective.

METHODS

We conducted a retrospective analysis of inpatient routine data from 20 psychiatric hospitals in North Rhine-Westphalia (NRW), Germany, over a period of four years (N = 366,767 inpatient treatment cases). Patients were considered "homeless" if they had no fixed unique address.

RESULTS

About 2.4% of the analyzed cohort was classified as homeless, with increasing tendency over the study period (+14% from 2016 to 2019). The percentage of homeless patients varied broadly between the hospitals (0.2-6.3%). Homeless patients were more often male and on average eight years younger than patients with a fixed address. Homeless patients experienced more involuntary measures (admission and restraint), had a shorter course of treatment and were more often discharged within one day. Every second homeless case was diagnosed with a substance use disorder and every third homeless case with a psychotic disorder, whereas affective disorders were diagnosed less frequently in this group. Psychiatric comorbidity occurred more often in homeless patients whereas somatic diseases did not.

CONCLUSIONS

Multiple patient-related sociodemographic and local factors are associated with homelessness of psychiatric inpatients. In addition, clinical factors differ between homeless and non-homeless patients, pointing to more severe mental illness and treatment complications (e.g., coercive measures) in homeless persons. Thus, homelessness of psychiatric inpatients can imply special challenges that need to be considered by healthcare providers and politicians, with the goal of optimizing mental and social care and the mental health outcomes of homeless persons.

Online therapy: an added value for inpatient routine care? Perspectives from mental health care professionals

Internet-delivered interventions can be effective in treating mental disorders. However, their rate of use in German psychiatric inpatient routine care is low. The current study aimed to investigate the attitude of mental health care professionals working in inpatient care regarding internet-delivered interventions, including presumed benefits, barriers and facilitators. In total, 176 health professionals from ten inpatient psychiatric hospitals throughout Germany were surveyed on site. The professionals' attitude towards internet-delivered interventions in inpatient care was assessed by an adapted version of the 'Attitude toward Telemedicine in Psychiatry and Psychotherapy' (ATTiP) questionnaire. To identify benefits, barriers and facilitators, we developed open-response questions that were based on the 'Unified Theory of Acceptance and Use of Technology' (UTAUT) and analyzed by a qualitative content analysis. Professionals reported little experience or knowledge about internet-delivered interventions. Their attitude towards internet-delivered interventions in psychiatric inpatient care was rather indifferent. The most frequently mentioned potential benefits were an optimised treatment structure and patient empowerment; the most frequently anticipated barriers were too severe symptoms of patients, the feared neglect of face-to-face contacts and insufficient technical equipment; and the most frequently mentioned facilitators were high usability of the internet-based intervention, a sufficient functional level of the patient and further education of staff. For successful implementation in the inpatient sector, internet-delivered interventions must be adapted to the special needs of severely mentally ill patients and to the hospital management systems and workflow. In addition, technical preconditions (internet access, devices) must be met. Last, further education of mental health care professionals is needed.

The prevalence of mental disorders among homeless people in high-income countries: An updated systematic review and meta-regression analysis

BACKGROUND

Homelessness continues to be a pressing public health concern in many countries, and mental disorders in homeless persons contribute to their high rates of morbidity and mortality. Many primary studies have estimated prevalence rates for mental disorders in homeless individuals. We conducted a systematic review and meta-analysis of studies on the prevalence of any mental disorder and major psychiatric diagnoses in clearly defined homeless populations in any high-income country.

METHODS AND FINDINGS

We systematically searched for observational studies that estimated prevalence rates of mental disorders in samples of homeless individuals, using Medline, Embase, PsycInfo, and Google Scholar. We updated a previous systematic review and meta-analysis conducted in 2007, and searched until 1 April 2021. Studies were included if they sampled exclusively homeless persons, diagnosed mental disorders by standardized criteria using validated methods, provided point or up to 12-month prevalence rates, and were conducted in high-income countries. We identified 39 publications with a total of 8,049 participants. Study quality was assessed using the JBI critical appraisal tool for prevalence studies and a risk of bias tool. Random effects meta-analyses of prevalence rates were conducted, and heterogeneity was assessed by meta-regression analyses. The mean prevalence of any current mental disorder was estimated at 76.2% (95% CI 64.0% to 86.6%). The most common diagnostic categories were alcohol use disorders, at 36.7% (95% CI 27.7% to 46.2%), and drug use disorders, at 21.7% (95% CI 13.1% to 31.7%), followed by schizophrenia spectrum disorders (12.4% [95% CI 9.5% to 15.7%]) and major depression (12.6% [95% CI 8.0% to 18.2%]). We found substantial heterogeneity in prevalence rates between studies, which was partially explained by sampling method, study location, and the sex distribution of participants. Limitations included lack of information on certain subpopulations (e.g., women and immigrants) and unmet healthcare needs.

CONCLUSIONS

Public health and policy interventions to improve the health of homeless persons should consider the pattern and extent of psychiatric morbidity. Our findings suggest that the burden of psychiatric morbidity in homeless persons is substantial, and should lead to regular reviews of how healthcare services assess, treat, and follow up homeless people. The high burden of substance use disorders and schizophrenia spectrum disorders need particular attention in service development. This systematic review and meta-analysis has been registered with PROSPERO (CRD42018085216).

TRIAL REGISTRATION

PROSPERO CRD42018085216.

A Comprehensive Assessment to Enable Recovery of the Homeless: The HOP-TR Study

Background: Homelessness is an increasing problem in Western European countries. In the Netherlands, policy reforms and austerity measures induced an urgent need for management information on local homeless citizens. Municipal authorities initiated cross-sectional reviews of Homeless Service (HS) users. The resulting Homeless People Treatment and Recovery (HOP-TR) study developed a health and needs assessment strategy over different domains to comprehensively assess individuals and care networks with the perspective on recovery.

Methods: Dutch HS users were selected using a naturalistic meta-snowball sampling. Semi-structured interviews provided the primary data source. The interview content was partly derived from the InterRAI Community Mental Health questionnaire and the “Homelessness Supplement.” Using the raw interview data, algorithmic summary scores were computed and integrating clinical parameters assessed. The data describe health and needs in a rights-based, recovery-oriented frame of reference. The mental health approach is transdiagnostic. The positive health framework is used for structuring health and needs aspects in relation to the symptomatic (physical and mental health), social (daily living, social participation), and personal (quality of life, meaning) dimensions of recovery.

Results: Recruitment (between 2015 and 2017) resulted in a saturated sample of 436 HS users in 16 facilities and seven cities. Most participants were long-term or intermittently homeless. The sample characteristics reveal the multi domain character of needs and the relevance of a broad, comprehensive approach. Local authorities used the reports to reflect and discuss needs, care provision, access, and network cooperation. These dialogs incited to improve the quality of care at various ecosystem levels.

Discussion: This paper describes new recruitment strategies and data collections of comprehensive data domains, to improve our knowledge in the field of homelessness. Traditional epidemiological literature on homelessness is often domain specific and relies on administrative sources. The HOP-TR study uses an analytical epidemiological approach. It shifts the assessment focus from problem-centered marginalization processes toward a comprehensive, three-dimensional recovery-oriented vision of health. Different perspectives are integrated to explore the interaction of homeless people with care networks.

Suicide by homeless patients in England and Wales: national clinical survey

BACKGROUND

Homelessness in England and Wales is on the rise together with the mortality rate among homeless people. Many homeless people have a mental illness, which is a risk factor for suicide.

AIMS

This study used data from the National Confidential Inquiry into Suicide and Safety in Mental Health to examine demographic and clinical characteristics of homeless people who died by suicide and were in recent contact with mental health services.

METHOD

We have compared 514 patients (2% of the total sample) who died by suicide and who were reported as being homeless or having no fixed abode by their clinicians with patients in stable accommodation between 2000 and 2016 to identify differences in sociodemographic characteristics and clinical care.

RESULTS

Our analysis suggests that homeless patients who died by suicide had more acute (alcohol: 47% v. 25%, P < 0.01, drug: 39% v. 15%, P < 0.01) and chronic (alcohol: 72% v. 44%, P > 0.01, drug: 64% v. 31%) substance misuse issues than patients in stable accommodation. Homeless patients were also more likely to die as in-patients (21% v. 10%, P < 0.01) or within 3 months of discharge (32% v. 19%, P < 0.01).

CONCLUSIONS

Homeless patients who died by suicide more often had known risk factors for suicide than patients in stable accommodation. As a result of the higher percentages of post-discharge and in-patient suicides in homeless patients as well as the high prevalence of substance misuse, this study recommends closer integration of services as well as awareness of risks during in-patient admission and in the weeks immediately after discharge.

A retrospective analysis of the health and social situation of homeless people in Berlin: study protocol

BACKGROUND

Homelessness is often described as both a driver and a consequence of poor health, social exclusion and economic marginalisation. The present protocol provides a detailed description of the study Examining the health situation of homeless people in Berlin: a retrospective analysis of data from the health centre for the homeless of the Jenny De la Torre Foundation from 2006 to 2020 (GIG study). The primary objective of the GIG study is to describe and analyse the social and health situation of homeless people in Berlin.

METHODS

A retrospective secondary data analysis of an anonymous full census of medical records for the years 2006 until 2020 from a health centre for homeless people will be carried out. The main outcome is the description and analysis of the social and health situation of homeless people in Berlin. Total and cross-sectional sample characteristics will be presented in a descriptive analysis using Chi-Square Test, Mann-Whitney-U-Test or independent t-Test as appropriate to test (sub) group differences. Further, outcomes will be analysed using finite mixture modelling in order to distinguish different types of social and health conditions. Latent variable regressions will be applied in order to identify sociodemographic and disease-related factors associated with decreasing health conditions.

DISCUSSION

Given the high number of homeless individuals in Germany, it is of great importance to examine their social and health situation in order to gain a better understanding of challenges and needs of homeless people and work on new approaches and solutions to effectively address these.

TRAIL REGISTRATION

The study was prospectively registered with the German Clinical Trials Register (trial registration number: DRKS00021172 ). Registered 26 June 2020.

Health Patterns Reveal Interdependent Needs of Dutch Homeless Service Users

Background: Homelessness is an increasing problem in Western European countries. Dutch local authorities initiated cross-sectional reviews to obtain accurate health and needs information on Homeless Service (HS) users. Methods: The Homeless People Treatment and Recovery (HOP-TR) study uses a comprehensive assessment strategy to obtain health data. Using a naturalistic meta-snowball sampling in 2015-2017, 436 Dutch HS users were assessed. The lived experience of HS users was the primary data source and was enriched with professional assessments. The InterRAI Community Mental Health questionnaire and "Homelessness Supplement" provided information in different areas of life. The approach for mental health assessments was transdiagnostic. Raw interview data were recoded to assess health and needs. The positive health framework structured symptomatic, social, and personal health domains relevant to recovery. Results: Most subjects were males, low educated, with a migration background. The majority were long-term or intermittently homeless. Concurrent health problems were present in two domains or more in most (95.0%) subjects. Almost all participants showed mental health problems (98.6%); for a significant share severe (72.5%). Frequent comorbid conditions were addiction (78%), chronic physical conditions (59.2%), and intellectual impairments (39.9%). Conclusion: The HOP-TR study reveals significant concurrent health problems among Dutch HS users. The interdependent character of different needs requires an integrated 3-D public health approach to comprehensively serve symptomatic, social, and personal dimensions, required to facilitate recovery.

Housing Satisfaction of Psychiatric Patients in Different Forms of Housing-A Cross-Sectional Study in Berlin, Germany

The growing social problem of homelessness and precarious housing situations has negative effects on psychological outcomes and quality of life (QoL) for mentally ill people. Despite a large body of research on QoL among homeless mentally ill people, research on housing satisfaction as a specific QoL domain and important outcome variable for treatment interventions is scarce. The purpose of this cross-sectional study is to investigate housing satisfaction among psychiatric patients in various housing situations. Out of 1,251 patients that were treated in the targeted facilities during the admission period, 540 agreed to participate (43.2%). 123 participants were excluded from the analysis due to missing data, resulting in a sample of N = 417. Housing satisfaction data was assessed in a subjective screening and differences in satisfaction levels between housing status groups were analyzed. As hypothesized, more normative housing situations reported higher housing satisfaction. Homeless participants and those living in socio-therapeutic facilities were associated with more psychological and physical distress resulting from their housing situation than domiciled and flat-sharing participants. Problems of reducing homelessness and improving housing support are highlighted, as well as opportunities for improving support, particularly in therapeutic facilities.

Initial Effectiveness Evaluation of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders for Homeless Women

The purpose of this study is to evaluate the effectiveness of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders adapted for homeless women (UPHW). Eighty-one homeless women participated in this single-blinded quasi-experimental clinical trial, involving up to 12 sessions of group treatment, and 3-and 6-month follow-ups. The participants received either immediate treatment with the UPHW (n = 46) or delayed treatment, following a 12-week wait-list control period (WLC; n = 35). Primary outcomes included depression and anxiety. Secondary measures comprised positive and negative affect, psychological well-being, health perception, and social support. The UPHW resulted in significant improvement on measures of anxiety, depression and negative affect. Improvements in anxiety and depression were maintained over a 3-month follow-up period, but not at 6-month. The reliability of the clinical changes showed significant differences between UPHW and WLC for depression. Moreover, the inter-session assessment in the UPHW group showed a linear trend reduction for depression and anxiety scores along the 12 sessions. The clinical implications on the UPHW in social settings are also discussed.

[Homelessness and mental illnesses]

Wohnungslosigkeit ist Ausdruck ausgeprägter sozialer Exklusionsphänomene und trifft besonders häufig Menschen mit seelischen Erkrankungen. Hierbei gehen die Erkrankungen meist der Wohnungslosigkeit vorweg, wobei einige seelische Störungen erst infolge der Wohnungslosigkeit auftreten. International wurde eine Vielzahl therapeutischer Unterstützungsformen für wohnungslose Menschen mit seelischen Erkrankungen evaluiert mit vorwiegend aufsuchenden Behandlungsstrategien. Dies wird häufig kombiniert mit niedrigschwelliger Zurverfügungstellung von Wohnraum. Hierbei zeigen sich gute Effekte auf die Zeit des Verbleibs in Wohnungen und auf die Verbesserung psychiatrischer Symptome, allerdings keine ausreichenden Effekte auf Substanzgebrauchsstörungen. Möglichkeiten zukünftiger Projekte liegen am ehesten im Einbezug ehemals Betroffener und in der Verwendung digitaler Medien.

[Somatic diseases of homeless people in Germany. A narrative literature review for the years 2009-2019]

BACKGROUND

According to estimates, between 337,000 and 650,000 people in Germany live without a permanent residence. They are highly deprived in terms of health. Studies on the health situation are rare and methodologically heterogeneous. Previous reviews have focused on mental illness.

OBJECTIVES

The aim of this paper is to provide an overview of current research on somatic diseases of homeless people in Germany.

METHODS

Based on a systematic literature review for the years 2009-2019, the methodological approaches, sample access, recruitment, and health aspects reported in the studies are compared.

RESULTS

By means of a systematic literature search, eight peer-reviewed journal articles were identified. Often the term "homelessness" was not operationalised. The average age of homeless participants was between 40.9 years and 67 years, and the proportion of women was between 0 and 35.3%. Frequently the sample was taken from accommodation and medical services for homeless people. One recruitment strategy was "respondent-driven sampling" in conjunction with incentives. The respondents most frequently reported cardiovascular diseases (17%-37.2%), musculoskeletal diseases (≥20%), and respiratory diseases (7%-24%). Depending on the recruitment site, infectious diseases were common (tuberculosis, hepatitis B and C).

CONCLUSION

Somatic health studies of homeless people are often selective. Older men with lower educational backgrounds living in large German cities appear to be overrepresented, and there is no uniform use of the term "homelessness." Compared with representative population data for Germany, increased risks of somatic illness were observed; cohort characteristics can explain these to a limited extent. Biographical and intersectional approaches are needed to capture multiple and cumulative exposure situations in homelessness.

Correlates of depression and anxiety among homeless adults with latent tuberculosis infection

Homeless persons have disproportionate rates of latent tuberculosis infection (LTBI). LTBI treatment can prevent and reduce active tuberculosis spread. We examined associations between mental health, social support, and perceptions of general health in 50 LTBI-positive, homeless adults enrolled in LTBI treatment. Depression and anxiety prevalence were 40% and 48%, respectively. Depression was negatively associated with general health, positive social interaction, and tangible, emotional/informational, and total social support, and positively associated with severe substance use (ps < 0.05). Anxiety was negatively associated with emotional/informational, tangible and total social support, and positively associated with severe substance use (ps < 0.05). Mental health services may help improve LTBI interventions.

Prevalence of mental disorders among people who are homeless: An umbrella review

BACKGROUND

Homelessness is a major problem that critically impacts the mental health and well-being of the affected individuals. This umbrella review aimed to evaluate the current evidence on the prevalence of mental disorders among homeless people from evidence-based systematic reviews and meta-analyses.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Joanna Briggs Institute (JBI) methodology for umbrella reviews. We searched 12 major databases and additional sources to identify systematically conducted reviews and meta-analyses reporting the prevalence of mental disorders among homeless populations.

RESULTS

We evaluated 1,277 citations and found 15 reviews meeting our criteria. Most studies were conducted among high-income countries with samples from different age groups. Studies reported high prevalence rates of depressive and anxiety disorders, schizophrenia spectrum and psychotic disorders, substance use disorders, suicidal behavior, bipolar and mood disorders, neurocognitive disorders and other mental disorders among homeless people. Moreover, studies also reported a high burden of co-occurring mental and physical health problems among the homeless experiencing mental disorders.

CONCLUSION

This umbrella review synthesized the current evidence on the epidemiological burden of mental disorders in homelessness. This evidence necessitates advanced research to explore psychosocial and epidemiological correlates and adopt multipronged interventions to prevent, identify and treat mental disorders among homeless populations.

Bank Account Ownership and Access Among In-Patients in Psychiatric Care in Berlin, Germany-A Cross-Sectional Patient Survey

BACKGROUND

Access to a bank account is critical for overall participation in social life and an indicator for social integration. Worldwide about 1.7 billion people remain with no access to banking facilities as a form of financial exclusion which represents 31% of the world's general population. In contrast, in Western countries like Germany, 99% of the general population use bank accounts.

METHODS

We conducted an exploratory cross-sectional survey on bank account ownership and bank account access among psychiatric in-patients in a psychiatric hospital in Berlin. Out of 540 participants who were reached for an interview, 486 shared information about bank account ownership and 469 on access.

RESULTS

Out of 486 participants 49 (10.1%) did not own a bank account. Among the remaining 420 participants owning a bank account, 36 (8.3%) did not have direct access to their bank account, but only, e.g., their legal guardian. Regression results found psychosis, intellectual disabilities, a longer treatment duration, as well as being of male gender and a more instable housing status to be significantly associated with a missing bank account or a missing access to one's bank account.

CONCLUSIONS

The lack of bank account ownership and access among this population of psychiatric patients is concerning. The interrelationship between factors of financial exclusion and mental health should be further explored in longitudinal studies. More attention is needed to support people with severe mental illness to be able to access resources associated with financial inclusion.

Housing situation and healthcare for patients in a psychiatric centre in Berlin, Germany: a cross-sectional patient survey

OBJECTIVE

To determine the housing situation among people seeking psychiatric treatment in relation to morbidity and service utilisation.

DESIGN

Cross-sectional patient survey.

SETTING

Psychiatric centre with a defined catchment area in Berlin, Germany, March-September 2016.

PARTICIPANTS

540 psychiatric inpatients including day clinics (43.2% of all admitted patients in the study period (n=1251)).

MAIN OUTCOME MEASURES

Housing status 30 days prior the interview as well as influencing variables including service use, psychiatric morbidity and sociodemographic variables.

RESULTS

In our survey, 327 participants (68.7%) currently rented or owned an own apartment; 62 (13.0%) reported to be homeless (living on the street or in shelters for homeless or refugees); 87 (18.3%) were accommodated in sociotherapeutic facilities. Participants without an own apartment were more likely to be male and younger and to have a lower level of education. Homeless participants were diagnosed with a substance use disorder significantly more often (74.2%). Psychotic disorders were the highest among homeless participants (29.0%). Concerning service use, we did neither find a lower utilisation of ambulatory services nor a higher utilisation of hospital-based care among homeless participants.

CONCLUSIONS

Our findings underline the need for effective housing for people with mental illness. Despite many sociotherapeutic facilities, a concerning number of people with mental illness is living in homelessness. Especially early interventions addressing substance use might prevent future homelessness.

[Social inequality and mental health]

Social inequality refers to the inequitable distribution of social prosperity including the resource of health. The relationship between social inequality and mental health can be established by means of indicators of social inequality throughout all age groups in Germany. There are social gradients of mental health on the population level, i.e. the linear relationship between social classes or status and state of health. Fundamental determinants of health disparity are cultural, social, political, and geographical conditions, which interact with the genetic make-up and epigenetic processes. These determinants also influence the management of developmental tasks during the life course and are of utmost importance for the development of mental disorders. The maladaptation to chronic stress is at the core of health disparity. Interventions at the individual behavioral level should comprise the development of stress management and coping strategies.

The Medical Treatment of Homeless People

BACKGROUND

The homeless are often in poor health, and their risk of premature death is three to four times that of the general population. This article is intended to provide an overview of the medical care of the homeless in Germany.

METHODS

We selectively reviewed pertinent scientific and non-scientific publications from the years 2000-2017 that were retrieved from PubMed, from the reports of the German Homeless Aid Society (Bundesarbeitsgemeinschaft Wohnungslosenhilfe), from the websites of homeless aid organizations, and from Google Scholar.

RESULTS

At least 75% of the homeless currently suffer from a mental illness requiring treatment. Common somatic problems include respiratory (6-14%) and cardiovascular disorders (7-20%), injuries and intoxications (5-15%), and infectious and parasitic diseases (10-16%). To circumvent the multiple barriers impeding homeless people's access to standard medical care (lack of health insurance, a feeling of being unwelcome, lack of disease awareness, impaired capacity for compliance), medical help is offered to them outside the system in a number of ways, embedded in an overall scheme of social and practical assistance with daily living. These medical resources differ from region to region. They are often underfinanced and tend to focus on acute general medical care, with limited access to specialists.

CONCLUSION

More heath care resources need to be made available to the homeless beyond standard medical care. Concrete suggestions are discussed in the text.

Using Facebook for Improving the Psychological Well-Being of Individuals Experiencing Homelessness: Experimental and Longitudinal Study

BACKGROUND

Web-based social networks are a powerful communicative element and their use is increasingly widespread. Persons living in extreme social exclusion such as individuals experiencing homelessness can benefit from the positive elements of communication and relationship associated with social networking sites.

OBJECTIVE

This study aimed to suggest the comparison of a Facebook training course and an office software course and their effect on psychological well-being in a group of individuals experiencing homelessness.

METHODS

An experimental and longitudinal study was designed. Individuals experiencing homelessness were randomly assigned to either the Facebook group or the office software group, and their social skills, self-esteem, self-efficacy, and satisfaction with life were measured on 4 occasions: pretest, at the end of the training course, 1 month later, and 3 months later. A mixed analysis of variance of repeated measures (2×4) was performed.

RESULTS

A total of 92 individuals experiencing homelessness participated in the study. The number of cases in which the 4 measurements were completed was 71 (35 in the intervention group and 36 in the control group). The mixed analysis of variance of repeated measures and the multiple regression analysis indicated a significant increase of the 4 analyzed parameters, with greater significance in the areas of social skills and self-esteem. The critical levels associated to the interaction Time×Program were significant in all variables and levels. Therefore, the scores in the 4 analyzed constructs were not equal according to the program carried out throughout the work. The effect size associated to the interaction Time×Program in the social skills scores was large (η²=0.32); in the self-esteem and self-efficacy scores, it was medium, (η²=0.13); and in the satisfaction with life scores, it was small (η²=0.09). The results of the adjustment of the different models of multiple linear regression indicate that the number of hours devoted weekly to the use of Facebook was a predictor of the increase in the scores of social skills (B=3.43, r²=.405) and self-esteem (B=.382). Age (B=.175) and self-efficacy (B=.09) were also variables, which with independence and in equal conditions, predicted self-esteem (r²=.29). Finally, self-esteem (B=.69) was also a predictor variable of the increase of satisfaction with life (r²=.195).

CONCLUSIONS

These findings suggest that Facebook could be a key element in homeless psychological well-being and socialization.