Stephen Wesley Hwang

St. Michael's Hospital | SMH · MAP Centre for Urban Health Solutions

Background Evidence is limited about healthcare cost disparities associated with homelessness, particularly in recent years after major policy and resource changes affecting people experiencing homelessness occurred after the onset of the COVID-19 pandemic. We estimated 1-year healthcare expenditures, overall and by type of service, among a represe...

Social isolation and loneliness (SIL) are public health challenges that disproportionally affect individuals who experience structural and socio-economic exclusion. The social and health outcomes of SIL for people with experiences of being unhoused have largely remained unexplored. Yet, there is limited synthesis of literature focused on SIL to app...

Objective We aimed to measure the change in proportion of opioid-related overdose deaths attributed to people experiencing homelessness and to compare the opioid-related fatalities between individuals experiencing homelessness and not experiencing homelessness at time of death. ApproachWe conducted a population-based, time-trend analysis using coro...

Conducting longitudinal research about the health of people experiencing homelessness poses unique challenges. In Canada, we previously demonstrated that identification through health administrative databases permits population-level studies, despite relatively low sensitivity. Since then, coding of homelessness became mandatory in hospitals nation...

People experiencing homelessness have historically had high mortality rates compared to housed individuals in Canada, a trend believed to have become exacerbated during the COVID-19 pandemic. In this matched cohort study conducted in Toronto, Canada, we investigated all-cause mortality over a one-year period by following a random sample of people e...

Social isolation and loneliness (SIL) are public health challenges that disproportionally affect individuals who experience structural and socio-economic exclusion. The social and health outcomes of SIL for people with experiences of being unhoused have largely remained unexplored. Yet, there is limited synthesis of literature that focused on SIL t...

Introduction Patients with major mental illness (MMI) and substance use disorders (SUD) face barriers in accessing healthcare. In this population-based retrospective cohort study, we investigated the uptake of COVID-19 vaccination in Ontario, Canada among community-dwelling individuals receiving healthcare for major mental illness (MMI) and/or subs...

Social capital is a collective asset important for individual and population wellbeing. Individuals who experience homelessness may face barriers in accessing social capital due to health challenges, small social networks, and social exclusion. Data from a 4‐year longitudinal study was used to determine if housing stability predicted greater social...

Recent anecdotal reports suggest increasing numbers of people experiencing homelessness are visiting emergency departments (EDs) during cold weather seasons due to inadequate shelter availability. We examined monthly ED visits among patients experiencing homelessness to determine whether there has been a significant increase in such visits in 2022/...

Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mappi...

Background Accurate estimation of SARS-CoV-2 re-infection is crucial to understanding the connection between infection burden and adverse outcomes. However, relying solely on PCR testing results in underreporting. We present a novel approach that includes longitudinal serologic data, and compared it against testing alone among people experiencing h...

Background: Accurate estimation of SARS-CoV-2 re-infection is crucial to understanding the connection between infection burden and adverse outcomes. However, relying solely on PCR testing results in underreporting. We present a novel approach that includes longitudinal serologic data, and compared it against testing alone among people experiencing...

Introduction/background summary: Twenty-four percent of Canada’s homeless shelter users are over the age of 50 years, a number that is predicted to rise [1]. Homeless older adults experience chronic health issues. They encounter barriers to accessing and utilizing healthcare and social services, such as stigma and misalignment between their needs a...

Purpose To characterize the availability of social determinants of health data in the electronic health record of pediatric ophthalmology patients and to examine the association of social determinants of health with attendance at scheduled operating room and clinic visits. Methods This was a retrospective cohort study of pediatric ophthalmology pa...

Aims: To measure the change in proportion of opioid-related overdose deaths attributed to people experiencing homelessness and to compare the opioid-related fatalities between individuals experiencing homelessness and not experiencing homelessness at time of death. Design, setting and participants: Population-based, time-trend analysis using cor...

Objectives: The overarching objective of this mixed methods longitudinal study was to understand whether and how rent subsidies and mentorship influenced socioeconomic inclusion outcomes for youth exiting homelessness. The focus of this paper is on the qualitative objectives, which evolved from a primary focus on exploring how study mentorship was...

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 Toront...

Before the COVID-19 pandemic, patients in Ontario who were uninsured due to immigration status faced barriers to hospital care that resulted in preventable illness and death. In March 2020, the Ontario Ministry of Health issued a memo indicating that it would pay for medically necessary hospital services for uninsured patients (Ontario Ministry of...

Objective: To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless control subjects. Research design and methods: A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada...

Importance: Few interventions are proven to reduce total health care costs, and addressing cost-related nonadherence has the potential to do so. Objective: To determine the effect of eliminating out-of-pocket medication fees on total health care costs. Design, setting, and participants: This secondary analysis of a multicenter randomized clini...

In response to the COVID-19 pandemic, the City of Toronto opened temporary shelter hotels with on-site supports for people previously living on the street, in encampments or in emergency shelters. The Beyond Housing program was created to enhance service offerings in the shelter hotel system and to support people not engaging with services. Using a...

We did a retrospective population-based study to estimate the relative hazard of mortality attributed to homelessness among a propensity-score-matched cohort of adults with diabetes who used hospital services from April 1, 2006, to March 31, 2019. We used a set of administrative databases to capture demographic and clinical information for people w...

Background Continuity of primary care (CPC) is associated with reduced mortality and improved health status. This study assessed the level of CPC and changes in CPC over 6 years among adults with experience of homelessness and mental illness who received a Housing First intervention. Methods Participants were adults (≥18 years old) with a serious...

Importance: People experiencing homelessness are at high risk of SARS-CoV-2 infection. Incident infection rates have yet to be established in these communities and are needed to inform infection prevention guidance and related interventions. Objective: To quantify the SARS-CoV-2 incident infection rate among people experiencing homelessness in T...

Objective: Financial incentives can facilitate behavior change and service engagement in health care settings, but research on their use with adults experiencing homelessness is limited. This study examined the effectiveness of financial incentives in improving service engagement and health outcomes among homeless adults with mental illness in Tor...

This study examined the characteristics of people who experienced housing instability and stability after 24 months of being enrolled in Housing First (HF). A companion study addresses the same objective using qualitative methods. A sequential logistic regression was conducted to determine predictors of unstable and stable housing at 24 months of e...

Homelessness results in barriers to effective diabetes self-management. Programs targeting individuals facing homelessness have refined strategies to address these barriers. We sought to develop a framework to characterize these strategies that could help multidisciplinary providers to better support these individuals. Semi-structured interviews we...

Introduction: People experiencing homelessness suffer from poor outcomes after hospitalisation due to systemic barriers to care, suboptimal transitions of care, and intersecting health and social burdens. Case management programmes have been shown to improve housing stability, but their effects on broad posthospital outcomes in this population have...

Objective We assessed the critical role of Housing First (HF) programs and frontline workers in responding to challenges faced during the first wave of the COVID-19 pandemic. Method Semi-structured interviews were conducted with nine HF frontline workers from three HF programs between May 2020 and July 2020, in Toronto, Canada. Information was col...

Objective: Homeless adults represent a marginalized group with numerous psychiatric and physical illness risk factors for poor functional outcomes. This study investigated bidirectional associations between housing stability and neurocognitive functioning in homeless adults using a longitudinal study design. Method: Participants were homeless adult...

Importance: There have been no published randomized clinical trials with a primary outcome of socioeconomic inclusion for young people who have experienced homelessness. Objective: To explore whether young people exiting homelessness who received rent subsidies and adult mentorship experienced more socioeconomic inclusion relative to young peopl...

Background People experiencing homelessness have diverse patterns of healthcare use. This study examined the distribution and determinants of healthcare encounters among adults with a history of homelessness. Methods Administrative healthcare records were linked with survey data for a general cohort of adults with a history of homelessness and a c...

Background: The lasting impact of colonization contributes to the disproportionate rates of homelessness experienced by Indigenous people in Canada. Methods: This study used participatory mixed methods to evaluate an urban, Indigenous-led Housing First program in Ontario to fill knowledge gaps on wise practices addressing the unique dimensions o...

Emergency shelters are a core component of homeless service systems that address immediate basic needs. Service bans, which refer to temporary or permanent disallowances from a program or organization, are an underresearched phenomenon that can leave people experiencing homelessness without needed supports. This exploratory study examined the facto...

Objectives To describe COVID-19 vaccine coverage (i.e., the estimated percentage of people who have received a vaccine) and determinants of vaccine receipt among individuals with a recent experience of homelessness in Ontario, Canada. ApproachWe conducted a retrospective, population-based cohort study of 23,247 individuals (≥18 years) with a recent...

Introduction People experiencing homelessness are at high risk for COVID-19 and poor outcomes if infected. Vaccination offers protection against serious illness, and people experiencing homelessness have been prioritised in the vaccine roll-out in Toronto, Canada. Yet, current COVID-19 vaccination rates among people experiencing homelessness are lo...

Introduction Homelessness poses unique barriers to diabetes management. Population-level data on the risks of diabetes outcomes among people experiencing homelessness are needed to inform resource investment. The aim of this study was to create a population cohort of people with diabetes with a history of homelessness to understand their unique dem...

People experiencing homelessness were prioritized for COVID-19 vaccination in Toronto, Canada, due to the high risk of infection and associated complications relative to the general population. We aimed to ascertain COVID-19 vaccine coverage in this population and explore factors associated with the receipt of at least one dose. We collected survey...

Introduction: Initial reports suggest people experiencing homelessness (PEH) are at high risk for SARS-CoV-2 infection and associated morbidity and mortality. However, there have been few longitudinal evaluations of the spread and impact of COVID-19 among PEH. This study will estimate the prevalence and incidence of COVID-19 infections in a cohort...

Background: People experiencing homelessness are vulnerable to SARS-CoV-2 infection and its consequences. We aimed to understand the perspectives of people experiencing homelessness, and of the health care and shelter workers who cared for them, during the COVID-19 pandemic. Methods: We conducted an interpretivist qualitative study in Toronto, C...

Homelessness is associated with excess cardiovascular morbidity and mortality. This study reports on the long-term effects of a Canadian housing first initiative, compared to treatment as usual, on major cardiovascular events among adults experiencing homelessness and mental illness. Over the 7-year follow-up period, 34 of 527 participants (6.5%) e...

Coordinated access and coordinated entry systems have become central features in community responses to homelessness in Canada and the United States. Coordinated systems assess individuals and families experiencing homelessness on their needs, prioritize them based upon these needs, and then match them to appropriate housing. Despite the widespread...

This study uses data from the state-level Youth Risk Behavioral Survey to evaluate mental health and substance use outcomes among homeless and nonhomeless adolescents in 2019.

People experiencing homelessness are often considered frequent healthcare users. Although their service use is not uniform, it can be difficult to identify the highest-cost users without access to comprehensive cost data. This study validated a set of algorithms that apply healthcare encounter data to identify high-cost users among adults with a hi...

The effects of the coronavirus disease‐2019 (COVID‐19) pandemic on the lives of underserved populations are underexplored. This study aimed to identify the impacts of the COVID‐19 pandemic and associated public health responses on the health and social well‐being, and food security of users of Housing First (HF) services in Toronto (Canada) during...

Equity-Mobilizing Partnerships in Community (EMPaCT) is a novel approach to patient engagement that centres diverse lived experiences and promotes equity-oriented and inclusive partnerships. As an independent community table, EMPaCT is made up primarily of patients/diverse members of community. Researchers and other decision makers come to this tab...

Background: Hospitalizations fell precipitously among the general population during the COVID-19 pandemic. It remains unclear whether individuals experiencing homelessness experienced similar reductions. Objective: To examine how overall and cause-specific hospitalizations changed among individuals with a recent history of homelessness (IRHH) an...

Plain English summary Lung cancer is the most commonly diagnosed cancer in Canada and is responsible for a quarter of all cancer-related deaths in the country. Screening for lung cancer using tools such as a CT scan can allow us to find lung cancers when they are still small and curable. People can receive a lung CT scan depending on how old they a...

Background People experiencing homelessness face a high risk of SARS-CoV-2 infection and transmission, as well as health complications and death due to COVID-19. Despite being prioritised for receiving the COVID-19 vaccine in many regions, little data are available on vaccine uptake in this vulnerable population. Using population-based health-care...

People with histories of homelessness often have difficulties obtaining and maintaining adequate housing. This qualitative study examined the residential transitions of people with histories of residential instability and homelessness to understand factors contributing to the instability they experience. Interviews were conducted with 64 participan...

Among those visiting a testing centre in Toronto, ON, between March and April 2020, people experiencing homelessness (n = 214) were more likely to test positive for COVID-19 compared with those not experiencing homelessness (n = 1,836) even after adjustment for age, sex and medical co-morbidity (15.4% vs. 6.7%, p < 0.001; odds ratio [OR] 2.41, 95%...

Aims: To examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre-pandemic, peak, and re-opening periods of the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. D...

Aims: To examine how weekly rates of emergency department (ED) visits for drug overdoses changed among individuals with a recent history of homelessness (IRHH) and their housed counterparts during the pre-pandemic, peak, and reopening periods of the first wave of the COVID-19 pandemic, using corresponding weeks in 2019 as a historical control. Desi...

Hospital discharge is a key transition in a patient's care pathway, providing an effective point of intervention to address a patient's ongoing health and social care needs. Addressing these needs may prevent hospital readmissions. The hospital discharge process for people experiencing homelessness who have been admitted for medical conditions has...

Background: Benzodiazepines are considered first-line treatment for patients experiencing severe acute alcohol withdrawal syndrome (sAAWS). Although several medications have been evaluated as potential adjuvant treatments for sAAWS, barbiturates show particular promise. Objective: In the PHENOMANAL trial, we will assess the feasibility of conduc...

Purpose To conduct a multi-dimensional and time-patterned analysis to identify distinct well-being trajectory profiles over a 6-year follow-up period among adults experiencing homelessness and mental illness. Methods Data from 543 participants of the At Home Chez Soi study’s Toronto site were examined over a 6-year follow-up period, including meas...

Chronic pain and substance use disorders are serious conditions that are prevalent among homeless populations. The aim of this study was to examine the association between chronic pain and substance use among individuals experiencing homelessness and mental illness. We analyzed cross-sectional data from two sites of the At Home/Chez Soi study (Vanc...

Objectives People experiencing homelessness are at increased risk of SARS-CoV-2 infection. This study reports the point prevalence of SARS-CoV-2 infection during testing conducted at sites serving people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic. We also explored the association between site characteristics...

Background: Timely access to primary care and adequate disease management are necessary to mitigate severe consequences of diabetes, such as cardiovascular disease complications and premature mortality. People experiencing homelessness face unique challenges to diabetes care and self-management including limited access to medical resources and lack...

Background: Screening for lung cancer with low dose CT can facilitate the detection of early-stage lung cancers that are amenable to treatment, reducing mortality related to lung cancer. Individuals are considered eligible for lung cancer screening if they meet specific high-risk criteria, such as age and smoking history. Population groups that are...

Objective To evaluate the effect of a one-time cash transfer of $C1000 in people who are unable to physically distance due to insufficient income. Design Open-label, multi-centre, randomised superiority trial. Setting Seven primary care sites in Ontario, Canada; six urban sites associated with St. Michael’s Hospital in Toronto and one in Manitoul...

Chronic pain and its role in homelessness is an under-researched but critical issue. This chapter aims to summarize the scant evidence on this topic. It examines underlying factors for the association of homelessness with chronic pain, which occurs much more often in homeless individuals than in the general population. Chronic pain impacts a variet...

Objective: Grounded in principles of adult education, Recovery Education Centres (RECs) hold promise in promoting recovery for adults with mental health challenges, but research on recovery outcomes for hard-to-reach populations participating in RECs is scant. This quasi-experimental study compares 12-month recovery outcomes of adults with historie...

Background Adverse childhood experiences (ACEs) are strong risk factors for homelessness and poor health and functioning. We aimed to evaluate the lifetime prevalence of ACEs and their associations with health-related and functioning-related outcomes among homeless adults. Methods In this systematic review and meta-analysis, we searched from datab...

Background: People experiencing homelessness are at increased risk of SARS-CoV-2 infection. This study reports the point prevalence of SARS-CoV-2 infection during testing conducted at sites serving people experiencing homelessness in Toronto during the first wave of the COVID-19 pandemic. We also explored the association between site characteristic...