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Premature Mortality in Homeless Populations: A Review of the Literature

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... 1 Health outcomes for persons experiencing houselessness (PH) are worse than their housed counterparts and can lead to premature death, with unique needs at the end of life. [1][2][3] ''Double vulnerability'' occurs when a person suffers the negative consequences from the social/health vulnerabilities of houselessness 3 and are at a greater risk of serious illnesses such as cancer, cardiovascular disease, respiratory illness, infectious disease, and injury. 2 Further, life expectancy is reduced for PH with a mean age at death between 34 and 47 years, which is drastically lower than the 81.95 years that the general population expects. 4 In O'Connell's literature review on premature mortality in houseless populations, he explained that medical care for PH is challenging within our mainstream health care model. ...
... [1][2][3] ''Double vulnerability'' occurs when a person suffers the negative consequences from the social/health vulnerabilities of houselessness 3 and are at a greater risk of serious illnesses such as cancer, cardiovascular disease, respiratory illness, infectious disease, and injury. 2 Further, life expectancy is reduced for PH with a mean age at death between 34 and 47 years, which is drastically lower than the 81.95 years that the general population expects. 4 In O'Connell's literature review on premature mortality in houseless populations, he explained that medical care for PH is challenging within our mainstream health care model. ...
... 3 Many illnesses and premature deaths are preventable through the provision of stable housing and access to proper health care. 2,4 However, until long-term societallevel solutions are implemented, houselessness and health care barriers for PH remain social issues. In the meantime, health/social sector workers have responded with not-for-profit grassroots programs aiming at mitigating these hardships and preventing poorer health outcomes for PH. ...
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Background: People experiencing houselessness (PH) endure worse health outcomes than their housed counterparts and often have inadequate care when nearing end of life. Innovative palliative care approaches are necessary when considering socially vulnerable populations. Aim: Evaluate the implementation and early outcomes of the Calgary Allied Mobile Palliative Program (CAMPP) after the first four years of servicing people experiencing extreme social marginality. Setting/Participants: Participants include CAMPP clients and service providers (SPs) who work adjacently to CAMPP in the social services/health sectors. Design: This is a mixed-methods evaluation, including an SP survey (n = 31); client interviews (n = 5); collection of program metrics; and case note reviews. Results: The CAMPP has served 128 clients to date. The CAMPP supported clients by connecting them to 62 services, programs, agencies, and/or resources totaling 485 connections. The most referred-to resource was for social support in the community for PH at 61 referrals. The second was for transportation with 57 referrals, followed by referrals to palliative and Home Care programs (n = 53 referrals). Another common referral was for food assistance with 30 referrals. The survey showed that 97% of SPs agreed that CAMPP is “an essential service in the area of palliative care.” Twenty-six of 30 (87%) “Strongly Agreed” or “Agreed” that their knowledge in working with people with life-limiting illnesses has improved since working with CAMPP. The SPs suggested that the team should focus on referral clarity and improved communication with the wider health care team. Finally, clients reported high levels of satisfaction with CAMPP services. Clients also reported challenges navigating the complexity of care in the social/health services sector. Conclusions: The CAMPP bridges the gap in care between health/social services. The CAMPP connects clients to community resources and is effective in adapting to client needs. This evaluation provides four recommendations to improve and build on the existing program.
... 22,23 In 2005, O'Connell completed an international, narrative literature review of the association between homelessness and premature mortality. 24 Studies were included representing the countries of the United States, Canada, Sweden, and Denmark. The review calls attention to the complex interaction of health determinants with homelessness by discussing "death zones, " areas marked by poverty, unstable housing, homelessness, and overcrowding. ...
... The review concluded that people experiencing homelessness might be at a three to four times greater risk of death than the general population. 24 No peer-reviewed systematic review of the literature was found since O'Connell's review. 24 Historical research has consistently shown premature mortality among the homeless population. ...
... 24 No peer-reviewed systematic review of the literature was found since O'Connell's review. 24 Historical research has consistently shown premature mortality among the homeless population. Age-adjusted mortality rates for people experiencing homelessness in Philadelphia were shown to be four times the rate of the general population of the city. ...
Article
This systematic review assessed peer-reviewed research studies on mortality rates of the homeless population within the United States. Extrapolated data included definitions of homelessness, mortality data sources, findings on mortality rates, and causes of premature mortality. Results demonstrate that individuals experiencing homelessness die earlier than comparison groups not experiencing homelessness. Methodology and findings varied across studies. Subpopulations included veterans, families, youth, and unsheltered. Causes of death varied across subpopulations and changed over time. Top causes of death, predominantly determined by ICD codes, stemmed from neoplasms, heart disease, and substance use disorder. Sources used for mortality data included the National Death Index (NDI), the Social Security Death Index (SSDI), state death occurrence files, and city vital statistics. Important research foci include standardization, subpopulation variations, policy implications, and the influence of mortality risk factors, such as poverty and racism.
... Trauma, whether physical, mental, or psychosocial, that occurs during this timeframe can lead to changes in brain chemistry and neural connections, with consequential implications for future chronic illnesses. Furthermore, it is suggested that homelessness can increase all-cause mortality and decrease life expectancies by up to 30 years (average 42-52 years old) compared to those not experiencing homelessness [9][10][11]. ...
... Responses to the items were captured using a 4-point (0 to 3) scale, with higher scores indicating a greater number of days feeling bothered by the aforementioned problems. Responses for the four items were summed, with higher values indicating a greater severity of depression (normal [0-2], mild [3][4][5], moderate [6][7][8], and severe [9][10][11][12]) [52]. The PHQ-4 scale also has good internal consistency based on SDoH-HYA data, with an overall Cronbach's alpha of 0.80. ...
Article
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Homelessness is a pervasive issue in the United States that presents significant challenges to public health. Homeless young adults (HYAs) are at particular risk for increased incidence and severity of depression. Using primary survey data (n = 205) collected in the Phoenix Metropolitan Area, Arizona, from June to August 2022, this study aims to examine the relationship between adverse childhood experiences (ACEs) and depression among HYAs. We adopted the ACEs 10-item scale to measure childhood traumatic experiences, whereas depression was measured by using a PHQ-4 depression scale and diagnosed depression. Regression models were conducted to test the relationships between ACEs and depression outcomes while controlling for the covariates at the individual, interpersonal, and socioeconomic/living environment levels. The average PHQ-4 score was 5.01 (SD = 3.59), and 59.69% of HYAs reported being diagnosed previously with depression. The mean ACEs score was 5.22 out of 10. Other things being equal, for every one unit increase in ACEs scores, the odds of being diagnosed with depression increased by 11.5%, yet it was not statistically significant, while the PHQ-4 score increased by 0.445 (p < 0.001). Overall, HYAs were disproportionately affected by depression. This study elucidates the complex relationship between ACEs and depression among HYAs.
... Public health groups have called for more systematic data collection, as currently there is no federal count of unhoused deaths [7]. Most academic studies have focused on cause of death (COD) or risk factors for early death at the city or county level [12]. Factors involved in unhoused deaths include being unsheltered and having substance use issues [13]. ...
... Veterans, older adults, youths aged 15-25, and children under 18 who are unhoused are at greater risk of mortality than their housed counterparts [15][16][17][18]. Although the primary CODs vary by region, they often include deaths related to substance use, injuries, and illnesses including cancer and heart disease [7,12,19]. ...
Article
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Introduction The number of people dying while unhoused is increasing nationally. In Santa Clara County (SCC), deaths of unhoused people have almost tripled in 9 years. This is a retrospective cohort study examining mortality trends among unhoused people in SCC. The objective of the study is to characterize mortality outcomes in the unhoused population, and compare these to the SCC general population. Materials and methods We obtained data from the SCC Medical Examiner-Coroner’s Office on unhoused people’s deaths that occurred between 2011–2019. We analyzed demographic trends and cause of death, compared to mortality data on the SCC general population obtained from CDC databases. We also compared rates of deaths of despair. Results There were a total of 974 unhoused deaths in the SCC cohort. The unadjusted mortality rate among unhoused people is higher than the general population, and unhoused mortality has increased over time. The standardized mortality ratio for unhoused people is 3.8, compared to the general population in SCC. The most frequent age of death among unhoused people was between 55–64 years old (31.3%), followed by 45–54 (27.5%), compared to 85+ in the general population (38.3%). Over ninety percent of deaths in the general population were due to illness. In contrast, 38.2% of unhoused deaths were due to substance use, 32.0% illness, 19.0% injury, 4.2% homicide, and 4.1% suicide. The proportion of deaths of despair was 9-fold higher in the unhoused cohort compared to the housed cohort. Discussion Homelessness has profound impacts on health, as people who are unhoused are dying 20 years younger, with higher rates of injurious, treatable, and preventable causes, than people in the general population. System-level, inter-agency interventions are needed. Local governments need to systematically collect housing status at death to monitor mortality patterns among unhoused people, and adapt public health systems to prevent rising unhoused deaths.
... 4,10 Experiences while homeless (eg, exposures, stress, limited health care access) may contribute directly to premature mortality. 4,11 Little is known about how life-course and time-varying exposures and co-occurring conditions affect mortality risk among homeless older adults. ...
... The average age of death among homeless adults is 42 to 52 years. 11 In a retrospective cohort study of adults who received care at a homeless health care organization, mortality rates in individuals aged 25 to 44 years were 9-fold higher than the general population, while those in individuals aged 45 to 64 years were 4.5-fold higher. 5,6 Other US 6,32 and international studies show similar findings. ...
Article
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Importance: The population of homeless older adults is growing and experiences premature mortality. Little is known about factors associated with mortality among homeless older adults. Objective: To identify the prevalence and factors associated with mortality in a cohort of homeless adults 50 years and older. Design, setting, and participants: In this prospective cohort study (Health Outcomes in People Experiencing Homelessness in Older Middle Age [HOPE HOME]), 450 adults 50 years and older who were homeless at baseline were recruited via venue-based sampling in Oakland, California. Enrollment occurred in 2 phases, from July 2013 to June 2014 and from August 2017 to July 2018, and participants were interviewed at 6-month intervals. Exposures: Baseline and time-varying characteristics, including sociodemographic factors, social support, housing status, incarceration history, chronic medical conditions, substance use, and mental health problems. Main outcomes and measures: Mortality through December 31, 2021, based on state and local vital records information from contacts and death certificates. All-cause mortality rates were compared with those in the general population from 2014 to 2019 using age-specific standardized mortality ratios with 95% CIs. Results: Of the 450 included participants, median (IQR) age at baseline was 58.1 (54.5-61.6) years, 107 (24%) were women, and 360 (80%) were Black. Over a median (IQR) follow-up of 55 (38-93) months, 117 (26%) participants died. Median (IQR) age at death was 64.6 (60.3-67.5) years. In multivariable analyses, characteristics associated with mortality included a first episode of homelessness at 50 years and older (adjusted hazard ratio [aHR], 1.62; 95% CI, 1.13-2.32), homelessness (aHR, 1.82; 95% CI, 1.23-2.68) or institutionalization (aHR, 6.36; 95% CI, 3.42-11.82) at any follow-up compared with being housed, fair or poor self-rated health (aHR, 1.64; 95% CI, 1.13-2.40), and diabetes (aHR, 1.55; 95% CI, 1.06-2.26). Demographic characteristics, substance use problems, and mental health problems were not independently associated. All-cause standardized mortality was 3.5 times higher (95% CI, 2.5-4.4) compared with adults in Oakland. The most common causes of death were heart disease (n = 17 [14.5%]), cancer (n = 17 [14.5%]), and drug overdose (n = 14 [12.0%]). Conclusions and relevance: The cohort study found that premature mortality was common among homeless older adults and associated factors included late-life homelessness and ongoing homelessness. There is an urgent need for policy approaches to prevent and end homelessness among older adults in the US.
... Homelessness takes a dramatic toll on health, with life expectancies among the chronically homeless estimated to be as low as 42-52 years. 6 Weathering homelessness means that PEH develop age-related health problems decades earlier than their housed counterparts. 7,8 Many of these conditions may increase risk for severe COVID-19 illness and death. ...
... Given low life expectancy among PEH, 6 we also hypothesize differing age distributions, with fewer PEH aged ≥80. Importantly, however, older PEH remained at substantially elevated mortality risk compared with younger PEH. ...
Article
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We reviewed publicly available data from major U.S. health jurisdictions to compare SARS-CoV-2 case fatality rates in people experiencing homelessness to the general population. Case fatality among people experiencing homelessness was 1.3 times (95% CI 1.1, 1.5) that of the general population, suggesting that PEH should be prioritized for vaccination.
... Given women veterans' unique needs-for example, they are more likely to experience shorter periods of homelessness, 7 are often homeless with children, 5,19 and more frequently have needs related to mental health rather than substance use 5,6,7,20 -it is important to understand intervention points to prevent transitions from stable to unstable housing. Preventing women's transitions into homelessness will likely reduce their experience of poor health outcomes (eg, premature mortality, 21 higher rates of comorbid conditions), 22 which are often associated with housing instability. This is particularly relevant as the US Department of Veterans Affairs provides resources through Supportive Services for Veteran Families (SSVF) and other programs to prevent and end homelessness among veterans. ...
... This screen was administered nationally during the study period to veterans accessing primary care through VHA who were not already engaged with VHA Homeless Programs or receiving long-term or palliative care. 21 We conducted a logistic regression identifying correlates of transition to unstable housing; correlates of interest included marital status; discharge status from the military; military service during Operations Enduring Freedom, Iraqi Freedom or New Dawn (OEF/OIF/ OND); service-connected disability; combat exposure; experience of MST; and diagnosis of a chronic medical, mental health, or substance use condition. We controlled for race and age in the model. ...
Article
Introduction: Preventing and ending homelessness for women veterans, a priority of the Department of Veterans Affairs (VA), can be aided by identifying factors that increase their risk for housing instability. Methods: This study relied on data from the Veterans Health Administration's universal screen for housing instability from Fiscal Year 2013 to 2016, and administrative data from electronic medical records. Using logistic regression, we compared 2 groups of women veterans: those who consistently had stable housing and those who transitioned to unstable housing after a period of housing stability. Results: We found that a history of military sexual trauma, lack of access to VA benefits and other financial resources, and single or divorced marital status were significant risk factors for women veterans' housing instability. These findings are consistent with an existing theoretical model of housing instability and homelessness among women veterans, which highlights the importance of traumatic and adverse events and isolation as risk factors. Conclusions: These risk factors and their effect on women veterans' housing instability can be mitigated by new and increased supportive interventions, targeted to those at highest risk.
... Researchers have estimated life expectancies among the chronically homeless to be as low as 42-52 years. 8 Weathering homelessness means that PEH develop age-related health problems decades earlier than their housed counterparts. 9,10 Many of these conditions may increase risk for severe illness and death from COVID-19. ...
... The most likely explanation for this finding is survivor bias: on average, PEH who survive to age 65 without shelter may be less frail than older adults in the general population. Given low life expectancy among PEH, 8 we also hypothesize differing age distributions within this stratum, with fewer PEH aged 80 and over. Importantly, however, older PEH remained at substantially elevated mortality risk compared with younger PEH. ...
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We reviewed publicly available data from major U.S. health jurisdictions to compare case fatality rates in people experiencing homelessness (PEH) to the general population. Case fatality among PEH was 1.3 times (95% CI 1.1, 1.5) that of the general population, suggesting that PEH should be prioritized for vaccination.
... Research demonstrates that PEH face higher mortality rates compared to people not experiencing homelessness (PNEH) (Aldridge et al., 2018;Chang et al., 2023;Funk et al., 2022;Hwang, 2000;O'Connell, 2005;Roncarati et al., 2018). Prior studies not only suggest that the high prevalence of morbidity among PEH partly explains this excessive mortality but also underscore the ways that housing independently impacts one's health and risk of death (Fazel et al., 2014;Morrison, 2009;Romaszko et al., 2017). ...
Article
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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.
... Homeless patients have a hard time accessing healthcare and end up utilizing the emergency department (ED) more than housed patients [14]. Unfortunately, the ED is often the only resource a homeless patient can access when presenting with critical health issues. ...
Article
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Patients who are homeless regularly must overcome tremendous barriers to obtain health care post discharge from hospitalizations, surgeries, emergency departments, and urgent care clinics. Lack of health insurance and financial hardship are commonly experienced by many people in the United States living below the poverty line. Often, basic needs such as food and shelter outweigh obtaining proper healthcare. An aspect of healthcare that frequently burdens individuals who are homeless is proper wound care. With many homeless individuals experiencing multiple health comorbidities leading to chronic wounds (diabetic ulcers, chronic ulcers, venous insufficiency, lack of properly fitting shoes, needle injuries, injuries from the environment, mental illness, post-surgical incisions), it appears imperative that we must do a better job at implementing effective wound care strategies when working with this specific population. This review prompts a current analysis of what the standard for wound care is in our homeless population in addition to what means this population has to obtain proper materials and education for wound healing. We propose a call to action for emergency departments, free clinics, and shelters to offer additional education and supplies for chronic wounds seen in patients experiencing homelessness.
... arly scholarly literature on homeless mortality from the 1970s to the 1990s and early 2000s showed a consistent relationship between homelessness and increased mortality. 1 During this period, leading causes of death shifted over time. In the 1980s, 40 percent of deaths in a homeless cohort in Philadelphia, Pennsylvania, were attributed to injury or heart disease. 2 During the 1990s, HIV/AIDS, homicide, heart disease, and cancer were leading causes of death in people experiencing homelessness in Boston, Massachusetts. 3 By the 2000s, chronic substance use and drug overdose, along with cancer and heart disease, became the major causes of death among Boston's homeless population. ...
Article
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The number and percentage of people in the US dying while homeless has increased in recent years. However, information about the causes of death most prevalent among this population, and about how cause-specific mortality rates may be shifting over time, has been limited to locally specific data. Using a unique data set of 22,143 homeless decedents in twenty-two localities across ten states and Washington, D.C., from the period 2011-20, we found large increases in all-cause and cause-specific homeless mortality rates. The largest increases in cause-specific homeless mortality rates in the ten-year period were for deaths related to drug and alcohol overdose, diabetes, infection, cancer, homicide, and traffic injury. We discuss implications of these results and posit that people experiencing homelessness are systematically excluded from the life-affirming institutions of housing and health care, in an example of mortal systemic exclusion. The findings have important implications for existing local and federal policy approaches to homelessness.
... Premature mortality research shows that the experience of homelessness 1 is deadly and that people affected by homelessness have mortality rates three to four times greater than the general population (O'Connell 2005;Nicholas et al. 2021). Research has found that people affected by homelessness who are unsheltered have greater rates of early mortality (Chang et al. 2023;Roncarati et al. 2018) and that leading causes of death currently include drug overdose, exposure to the elements, and violence (Cawley et al. 2022;Stanley et al. 2016). ...
Article
Services play a crucial role in responding to homelessness, facilitating stable housing, and improving health outcomes. Yet people in need do not always access services and little is known about such individuals and groups. Using mortality data from the New Mexico Office of the Medical Investigator (OMI) that was cross-referenced with services records from Homelessness Management Information Systems (HMIS), this study identified and compared people affected by homelessness ( N = 1196) who died between 2014 and 2019 based on whether they had engaged with homelessness services ( n = 841) or who were unhoused without a record services engagement ( n = 355). Groups were compared by age, race, gender, region of the state, and leading causes of death. Approximately 30 percent of individuals found to be homeless were not engaged in homelessness services. There were statistically greater numbers of Native Americans among those who were unhoused without a record of homelessness services. There were also inequities across regions of the state. This supports the need for increased outreach in rural areas and removing barriers to service engagement. The leading causes of death were drug overdose, alcohol, and heart disease, thus reinforcing the need for harm reduction education and practices both within and outside of services.
... PWUD are overrepresented in homeless populations [91][92][93]. Homelessness was identified as a risk factor in three (6%) studies in the review, two of which were longitudinal cohort studies. Arnautovska et al. [53] compared all suicide deaths in homeless and non-homeless people over a 20-year period, and found that homelessness significantly increased the risk of death by suicide in PWUD, in comparison to PWUD in the non-homeless population (42.4% vs. 20.4%). ...
Article
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Background Suicide is a significant contributor to global mortality. People who use drugs (PWUD) are at increased risk of death by suicide relative to the general population, but there is a lack of information on associated candidate factors for suicide in this group. The aim of this study was to provide a comprehensive overview of existing evidence on potential factors for death by suicide in PWUD. Methods A scoping review was conducted according to the Arksey and O’Malley framework. Articles were identified using Medline, CINAHL, PsycINFO, SOCIndex, the Cochrane Database of Systematic Reviews and the Campbell Collaboration Database of Systematic Reviews; supplemented by grey literature, technical reports, and consultation with experts. No limitations were placed on study design. Publications in English from January 2000 to December 2021 were included. Two reviewers independently screened full-text publications for inclusion. Extracted data were collated using tables and accompanying narrative descriptive summaries. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. Results The initial search identified 12,389 individual publications, of which 53 met the inclusion criteria. The majority (87%) of included publications were primary research, with an uncontrolled, retrospective study design. The most common data sources were drug treatment databases or national death indexes. Eleven potential factors associated with death by suicide among PWUD were identified: sex; mental health conditions; periods of heightened vulnerability; age profile; use of stimulants, cannabis, or new psychoactive substances; specific medical conditions; lack of dual diagnosis service provision; homelessness; incarceration; intravenous drug use; and race or ethnicity. Opioids, followed by cannabis and stimulant drugs were the most prevalent drugs of use in PWUD who died by suicide. A large proportion of evidence was related to opioid use; therefore, more primary research on suicide and explicit risk factors is required. Conclusions The majority of studies exploring factors associated with death by suicide among PWUD involved descriptive epidemiological data, with limited in-depth analyses of explicit risk factors. To prevent suicide in PWUD, it is important to consider potential risk factors and type of drug use, and to tailor policies and practices accordingly.
... La littérature spécialisée considère que les personnes sans domicile fixe ont souvent, dès la cinquantaine, un état de santé équivalent à celui d'une personne de 65 ou 70 ans qui serait demeurée mieux logée tout au long de sa vie (Denoncourt et al. 2005;McDonald et al. 2007;O'Connel, 2005). Autrement dit, l'espérance de vie de la personne itinérante est de 15 à 25 années de moins que celle de la population générale (Frances, 2011;Marpsat, 2002;Shibusawa & Padgett, 2009 (Fournier, 2001). ...
Article
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Vivre à la rue n’est pas une sinécure pour qui que ce soit, mais cela devient très ardu à un âge avancé alors que l’état de santé de l’individu se fragilise et que son réseau social tend à s’étioler. Tenant compte du vieillissement global de la population mondiale, cette sombre perspective menace un nombre grandissant de personnes ici comme ailleurs. À Montréal spécifiquement, le phénomène est partiellement connu des chercheurs et des intervenants sociaux du réseau public et des organismes communautaires du centre-ville (Agence de la santé et des services sociaux de Montréal (ASSSM), 2008; Réseau d’aide aux personnes seules et itinérantes de Montréal (RAPSIM), 2011; Ville de Montréal, 2011). Cette situation pose un certain nombre d’enjeux pour l’adaptation conséquente de leurs pratiques à de nouvelles demandes en termes de réadaptation, de soins de santé ou de types d’hébergement et de logement. Ces problématiques nous ont incités à initier un programme de recherche dont nous présentons ici la première étape d’exploration suivie de nos conclusions préliminaires. L’objectif final est de rencontrer les acteurs du terrain (personnes âgées en situation d’itinérance et intervenants) afin de mieux comprendre ce phénomène et de proposer des pistes d’intervention.
... Homelessness is not only associated with a higher prevalence of somatic and mental illness, but also with higher mortality rates. According to a literature review comparing data on mortality from the United States, Canada, Europe, Asia, and Australia, PEH are three to four times more likely to die prematurely than the general population and their life expectancy is reduced by 30 years (7). ...
Article
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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.
... and other factors, the average life expectancy in the homeless population has been estimated to be between 42 and 52 years, compared with 78 years in the housed population [7]. ...
Article
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People who are homeless disproportionately experience the burdens of chronic disease, have limited access to preventive care, and may be less trusting of healthcare agencies. The Collective Impact Project created and evaluated an innovative model designed to increase chronic disease screening and referral to healthcare and public health services. Trained Peer Navigators (PNs), who were paid staff with lived experiences similar to the clients served, were embedded in five agencies serving people experiencing homelessness or at risk for homelessness. Over two years, PNs engaged 1071 individuals. Of those, 823 were screened for chronic diseases and 429 were referred to healthcare services. Alongside screening and referrals, the project demonstrated the value of convening a coalition of community stakeholders, experts, and resources to identify service gaps and how PN functions might complement existing staffing roles. Project findings add to a growing literature documenting unique PN roles that potentially reduce health inequities.
... Older age was the largest factor associated with any incidence of cancer which is not surprising. However, this may be worth noting because some studies suggest homeless populations experience "premature aging" as they have been found to die at earlier ages, are more likely to have chronic health conditions, and experience earlier onset of physical and cognitive decline than stably housed populations (24)(25)(26)(27). This premature aging may not directly translate to cancer risk, but it may translate to greater difficulties in managing, seeking, and adhering to cancer treatment and care. ...
Article
Background: This study examined the incidence and correlates of cancer among homeless and unstably housed (HUH) veterans as compared to stably housed (SH) veterans. Methods: Using VA administrative data from 564,563 HUH and 5,213,820 SH veterans in 2013 and 2014, we examined the types and stages of 69 different types of cancer diagnosed among HUH and SH veterans. Sociodemographic and psychiatric characteristics associated with cancer were also examined. Results: The one-year incidence rate of cancer was 21.5% lower among HUH veterans than SH veterans (0.68% and 0.86% respectively). There was no difference in the most common stages and types of cancer among HUH and SH veterans. The most common primary sites of cancer were in the prostate, lung, and bronchus. HUH veterans were more likely than SH veterans to have cancer of the liver and intrahepatic bile ducts (∆4.79%). Among HUH veterans, older age and alcohol use disorder were associated with greater risk for any incident cancer while suicidal ideation/behaviors were associated with lower risk. Psychiatric conditions were often diagnosed before cancer diagnosis for SH and HUH veterans; rates of substance use disorders and suicidal ideation/behaviors decreased in HUH veterans after cancer diagnosis. Conclusions: The VA healthcare system serves many HUH veterans with cancer. Mental health and substance use disorders are important to treat in veterans at risk of cancer and as potential sequalae of cancer. Impact: The high prevalence of psychiatric disorders in HUH populations is important to consider in the diagnosis and treatment of cancer in these populations.
... While this article focuses on the British context, looking at English and Welsh jurisdictions in particular, it is important to note from the outset that the high rate of mortality amongst homeless populations is a global issue. Globally, homeless populations are three to four times more likely to die than the general population (O'Connell, 2005), and while the cause of death may play out differently across national and global contexts and across demographic trends, there is 'a remarkable consistency that transcends borders, cultures and oceans' (O'connell, 2005, p. 13). Public health and epidemiological studies show that homeless adults and children are more likely to be afflicted with underlying health conditions than the general population (Romaszko et al., 2017). ...
Article
In this article we explore the vicissitudes of extraordinariness in relation to homelessness and mortality in Britain. Death and its threat are a constant presence in the lives of people experiencing homelessness, but despite the established fact that homeless populations have a far lower life expectancy than the general population, mortality is rarely considered as part of the homelessness plight, nor is it fully acknowledged or understood in official spheres. This article explores the ways in which homelessness and mortality are constructed as an unpreventable phenomenon, not deserving of any meaningful political intervention. Drawing on the conceptual framework of ‘organised abandonment’, we argue that the invisibility of homeless people in death can be linked to their invisibility in life. In so doing, we underline the minimalist policy frameworks and the expansion of anti-homeless campaigns, which, to different extents, result in the exclusion of homeless individuals and families. Since the COVID-19 pandemic, however, the risk of death affecting homeless groups was responded to as an extraordinary social and political problem, requiring maximum political intervention. While remaining cognisant of the limitations of the extraordinary homelessness and housing policy measures brought in during this time, we argue that there are key possibilities to be explored within those policy responses.
... We named this factor 'Optimism' because the item content reflects an optimistic future orientation, feeling able to live long and well, and to sustain a sense of self-confidence and equanimity. Life expectancies for individuals in homeless situations are lower than for the general population, and life in homelessness is characterized by multiple morbidities for a significant portion of the population [104]. Confidence in one's own health, well-being, and longevity are springboards for the kinds of life tasks identified by positive psychologists as contributing to happiness and well-being. ...
Article
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Abstract Background Purposeful participation in personally meaningful life tasks, enjoyment of positive reciprocal relationships, and opportunities to realize one’s potential are growth-related aspects of a meaningful life that should be considered important dimensions of recovery from homelessness. The extent to which homeless services support individuals to achieve the capabilities they need to become who they want to be and do what they want to do is, in turn, an important indicator of their effectiveness. In this study, we developed a measure of achieved capabilities (MACHS) for use in homeless services settings, and assessed its construct and concurrent validity. Methods We analysed data collected from homeless services users at two time points in eight European countries to assess the factor structure and psychometric properties of the new measure. Participants were adults engaged with either Housing First (n = 245) or treatment as usual (n = 320). Results Exploratory and confirmatory factor analyses yielded a four-factor structure of the capabilities measure: community integration, optimism, safety, and self-determination. We obtained evidence for construct validity through observed correlations between achieved capabilities and recovery, working alliance and satisfaction with services. Moreover, we obtained evidence of the measure’s concurrent validity from its positive association between HF and personal recovery, which was fully mediated by achieved capabilities. Conclusions Findings demonstrate that the MACHS is a valid and reliable measure that may be used to assess the extent to which homeless services support their clients to develop capabilities needed for growth-related recovery. Implications for practice and future research directions are discussed. Keywords Capabilities approach, Housing First, Homelessness, Recovery
... In the last 20 years, studies have shown that veterans, older adults, youths aged 15-25, and children under 18 who are unhoused are at greater risk of mortality than their housed counterparts (16)(17)(18)(19). The primary causes of death vary by region, and they often include deaths related to substance use, injuries, and illnesses including cancer and heart disease (20)(21)(22). ...
Article
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Introduction Asians and Pacific Islanders (APIs) who are experiencing homelessness are situated in a social intersection that has rendered them unrecognized and therefore vulnerable. There has been increasing attention to racial disparities in homelessness, but research into API homelessness is exceedingly rare, despite rapidly growing populations. The purpose of this study is to examine the causes of death among APIs who died while homeless in Santa Clara County (SCC) and compare these causes to other racial groups. Materials and methods We report on data obtained from the SCC Medical Examiner-Coroner's Office on unhoused people's deaths that occurred between 2011 and 2021 (n = 1,394), including data on deaths of APIs experiencing homelessness (n = 87). Results APIs comprised 6.2% of total deaths of unhoused people. APIs died less often of causes related to drug/alcohol use than all other racial groups (24.1, compared to 39.3%), and there was a trend toward more API deaths from injuries or illnesses. When APIs were disaggregated into sub-groups (East/Southeast Asian, South Asian, Pacific Islander), there were notable mortality differences in cause of death, age, and sex. Discussion We argue that invisibility is a structural determinant of health that homeless APIs face. Though relatively small in numbers, APIs who are invisible may experience increased social isolation and, subsequently, specific increased mortality risks. To understand the health outcomes of unhoused APIs, it is essential that researchers and policymakers recognize API homelessness and gather and report disaggregated races and ethnicities.
... PEH individuals' primary mode of transportation is usually by foot, and thus any trauma, injury, or disease affecting the feet can greatly affect their wellbeing, especially their abilities to nd food and shelter. These individuals, particularly those who are unsheltered, have an average life expectancy of 55 years which is more than 20 years below the national average [20]. This is often due to a combination of chronic illnesses, substance dependence, and suboptimal mental health. ...
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Patients experiencing homelessness (PEH) are a patient group with high levels of morbidity and mortality. PEH have high rates of dermatophyte infections, although the exact incidence and prevalence compared to the general population has not been determined. This study characterizes tinea pedis in homeless individuals across geographic locations and offers recommendations for treatment in low-resource settings. A total of 58 PubMed articles were analyzed with inclusion criteria containing ‘tinea pedis’ and ‘homeless’. Cohort studies, cross-sectional studies, and case-control studies published from 1979–2022 were evaluated. In North America, among sheltered homeless individuals the prevalence of tinea pedis ranged from 3.2–13.5% whereas it occurs at roughly a 10% frequency in the general population. European studies showed a tinea pedis frequency of 4.4–34.9% in the general population compared to 3.2% in a homeless patient cohort. There is incomplete data on tinea pedis infections in homeless populations in Africa, Asia, and South America. There are statistically significant differences in disease burden and healthcare utilization between sheltered and unsheltered homeless patients. This study raises questions about the status of dermatophytosis among homeless populations in high-risk areas such as the Southern United States. Pre-emptive treatment of tinea pedis is vital for PEH due to the potential for severe complications such as cellulitis and osteomyelitis. Longitudinal treatment in low-resource settings with simple interventions such as antifungal powder, socks, and hygiene supplies, can potentially prevent the progression of tinea pedis and improve disease burden.
... The psychosocial and structural stressors of homelessness also contribute to the poor health of this population. People who are homeless suffer from mortality rates three to six times those of the general population, and homelessness is an independent risk factor for mortality [38,[57][58][59]. People who are homeless also experience higher rates of chronic illness, injury, infectious disease (e.g., tuberculosis, HIV, hepatitis A, and hepatitis C), substance use, and mental illness than their low-income housed counterparts [60]. ...
Chapter
Nearly 568,000 people are homeless (living in homeless shelters, on the streets, or in other places not meant for human habitation) on any given night in the US. The majority of people who experience homelessness do so for limited periods of time, though some people experience chronic homelessness. Homelessness has profoundly negative health effects and is associated with premature mortality. Research across settings has found that homelessness is common among emergency department (ED) patients. Homelessness is therefore an important consideration in the management of ED patients. This chapter provides guidance for emergency providers (EPs) on assessing and responding to patients’ homelessness in the ED and beyond.
... For example, in the USA, which is one of the wealthiest countries in the world, an estimated 600 000 individuals are homeless on any given night. 1 Homelessness is defined as the lack of 'a fixed, regular, and adequate night time residence' by the US Department of Housing and Urban Development. 2 Studies have found that homeless individuals are more likely to encounter barriers to accessing medical care, including poverty, family problems, poor health literacy and a lack of social support. 3 Homelessness is an especially important issue among young women, as pregnancy among homeless women is common and, due to the lack of resources available for homeless women, the health and lives of both mother and baby could be affected if appropriate care cannot be delivered. 4 Due to the intersection of homelessness, poverty, drug use and limited access to effective contraception, homeless female adolescents are more likely to report a pregnancy in a lifetime than their housed counterparts. ...
... Prior studies have shown that compared with the general population, homeless persons have higher rates of physical and mental illness and substance abuse, 2 higher hospitalization rates, 3,4 increased length of hospitalization, 5 and are more likely to die at a younger age. [6][7][8][9] Homeless people also face barriers that impair access to healthcare, such as lack of health insurance, 10 inadequate treatment for those with mental health or substance abuse, 11,12, and daily struggles for essentials of life. 13 To understand the social, mental, and healthcare needs of the homeless population in the community and ways that the health care system can better adapt to help these populations, Hemet Global Medical Center (HGMC) California Social Services department in association with the Internal Medicine residency program organized a four-week outreach to the homeless population. ...
Article
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Objective: To understand the social, mental, and healthcare needs of the homeless population in the community and ways that the health care system can better adapt to help this population Method: Physicians and social workers from a hospital in California had a one-hour per week interaction for four weeks with 23 homeless people in the community. We discussed the medical and social needs of the homeless, substance use, mental health, and housing. Results: We identified three main themes from the discussions: first, participants faced challenges and barriers to accessing healthcare, such as competing personal needs, lack of identification documents, and lack of health insurance. Second, participants gained new knowledge of available resources in the community, and third, participants felt supported and socially connected with physicians and other attendees during the meetings. Conclusion: The opportunity for service providers and homeless people to interact in an informal environment was reported as helpful by participants. There is a need for more research on the influence of such social interactions on the health and wellbeing of homeless individuals.
... Auch ist Drogenmissbrauch recht häufig [8]. Zudem ist die Lebenserwartung bei obdachlosen Menschen im Ver gleich zur Allgemeinbevölkerung merklich reduziert [9]. Da die Zahl obdachloser Mensch fortwährend ansteigt [1], muss die Relevanz dieser vulnerablen Gruppe hervorgehoben werden. ...
Article
Zusammenfassung Ziel der Studie Bisher mangelt es an Studie zur Inanspruchnahme von Gesundheitsleistungen bei Obdachlosen. Deshalb zielt diese Arbeit darauf ab, die Inanspruchnahme von Gesundheitsleistungen bei Obdachlosen zu beschreiben. Methodik Die Daten für diese Arbeit stammen aus der Hamburger Obdachlosenbefragung (n=150, mittleres Alter 44,6 Jahre (SD: 12,5 Jahre)), die zwischen dem 25. Mai und dem 3. Juni 2020 in Hamburg durchgeführt wurde. Die Inanspruchnahme von Gesundheitsleistungen wurde im Detail erfasst (u. a., Krankenversichertenstatus, Inanspruchnahme ambulanter und stationärer Leistungen, Medikamenteneinnahme, Gründe für fehlende Inanspruchnahme von Gesundheitsleistungen). Ergebnisse Insgesamt hatten 61,2% der Obdachlosen eine Gesundheitskarte. Ungefähr zwei Drittel (65,9%) der Obdachlosen hatten in den letzten 12 Monaten irgendeine medizinische Leistung in Anspruch genommen. Wesentlicher Grund für eine Nicht-Inanspruchnahme war der fehlende Bedarf (74,6%). Insgesamt waren 39,8% in den letzten 12 Monaten mindestens einmal im Krankenhaus. Mobile Hilfen haben in den letzten 12 Monaten gut ein Drittel der Obdachlosen (34,2%) in Anspruch genommen (primär das Krankenmobil, weniger das Zahnmobil sowie das ArztMobil Hamburg). Insgesamt haben ca. 37,7% der Obdachlosen Medikamente regelmäßig eingenommen. Schwierigkeiten bei dem Zugang zu Medikamenten begründeten sich primär über zu hohe Preise (63,6%). Knapp die Hälfte der Obdachlosen (47,0%) hatte in den letzten 3 Monaten keinen Arzt in Anspruch genommen. Schlussfolgerung Unsere Arbeit hat die Inanspruchnahme von Gesundheitsleistungen bei Obdachlosen beschrieben. Es bedarf weiterer Anstrengungen, um die sich daraus ergebenden Herausforderungen (z. B. im Zugang zu medizinischen Leistungen) anzugehen. Weitere Forschungen in diesem Bereich sind daher unerlässlich.
... People who are homeless also have a higher risk of developing health problems that are relatively rare within the general population, such as those caused by blood-borne viruses (BBVs) including hepatitis and human immunodeficiency virus (HIV) [17,18]. Moreover, the longer a person is homeless, the higher their risk of ill health and premature death [19], with mortality rates estimated to be between three to four times higher than in the general population [14,20]. ...
Article
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Background People who experience homelessness and those vulnerably housed experience disproportionately high rates of drug use and associated harms, yet barriers to services and support are common. We undertook a systematic ‘review of reviews’ to investigate the effects of interventions for this population on substance use, housing, and related outcomes, as well as on treatment engagement, retention and successful completion. Methods and findings We searched ten electronic databases from inception to October 2020 for reviews and syntheses, conducted a grey literature search, and hand searched reference lists of included studies. We selected reviews that synthesised evidence on any type of treatment or intervention that reported substance use outcomes for people who reported being homeless. We appraised the quality of included reviews using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews and Research Syntheses and the Scale for the Assessment of Narrative Review Articles. Our search identified 843 citations, and 25 reviews met the inclusion criteria. Regarding substance use outcomes, there was evidence that harm reduction approaches lead to decreases in drug-related risk behaviour and fatal overdoses, and reduce mortality, morbidity, and substance use. Case management interventions were significantly better than treatment as usual in reducing substance use among people who are homeless. The evidence indicates that Housing First does not lead to significant changes in substance use. Evidence regarding housing and other outcomes is mixed. Conclusions People who are homeless and use drugs experience many barriers to accessing healthcare and treatment. Evidence regarding interventions designed specifically for this population is limited, but harm reduction and case management approaches can lead to improvements in substance use outcomes, whilst some housing interventions improve housing outcomes and may provide more stability. More research is needed regarding optimal treatment length as well as qualitative insights from people experiencing or at risk of homelessness.
... These include being at greater risk of suffering from poorer physical health, including infectious diseases (Beijer et al., 2012), as well as using alcohol, drugs and tobacco (Fazel et al., 2008), and being at increased risk of premature fraility and ageing (Rogans-Watson et al., 2020) and death (Bean et al., 2013;Kerman et al., 2020). Mortality rates among people who are homeless have been estimated to be between three to four times higher than the general population (Fazel et al., 2014;O'Connell, 2005). Moreover, those who experience homelessness tend to report disproportionately high rates of co-occurring problem substance use, poor mental health and physical health (Hewett & Halligan, 2010;Levitt et al., 2009). ...
Article
Full-text available
Housing First (HF) represents a significant shift in the way that the problem of homelessness and co-occuring challenges including problem substance use, is addressed. HF interventions have been the focus of much research. Quantitative studies have consistently shown positive findings regarding housing outcomes, with results regarding health and well-being outcomes more mixed. To date, limited attention has been paid to the experiences and perspectives of HF service providers, and few studies have explored the views of those HF recipients. In enabling providers and recipients to share their professional and personal experiences of HF, qualitative insights can help inform, and improve, service provision and practice. Semi-structured interviews were conducted with seven HF staff members and 11 clients in a single third sector service in Scotland. Overall, clients experienced HF positively and described how involvement in HF had enabled positive changes in their lives. Service providers reported positive views on HF alongside ways to maximize the effectiveness of the model. While our findings provide support for current efforts to promote HF as an approach to help end homelessness, a number of challenges exist. To address these, we propose a set of recommendations for those planning and implementing HF services.
... First, we assume that COVID-19 spreads at the same rate within the PEH community as it does in the general population and that social distancing interventions are equally effective at reducing transmission within this community. However, considering that PEH generally reside in densely packed shelters or encampments with limited access to sanitation that make it difficult to self-isolate, congregate in facilities that deliver essential services, have higher rates of underlying medical conditions and are more likely to fall ill, it is highly probable that PEH have higher levels of transmission and susceptibility to COVID-19 [4,29,30] than the general population. While public health officials in Austin have enacted various efforts to protect this vulnerable population, like acquiring five protective lodging facilities to help high risk individuals socially distance, it is currently unknown whether these measures have successfully counterbalanced these risks. ...
Article
Full-text available
As COVID-19 spreads across the United States, people experiencing homelessness (PEH) are among the most vulnerable to the virus. To mitigate transmission, municipal governments are procuring isolation facilities for PEH to utilize following possible exposure to the virus. Here we describe the framework for anticipating isolation bed demand in PEH communities that we developed to support public health planning in Austin, Texas during March 2020. Using a mathematical model of COVID-19 transmission, we projected that, under no social distancing orders, a maximum of 299 (95% Confidence Interval: 223, 321) PEH may require isolation rooms in the same week. Based on these analyses, Austin Public Health finalized a lease agreement for 205 isolation rooms on March 27th 2020. As of October 7th 2020, a maximum of 130 rooms have been used on a single day, and a total of 602 PEH have used the facility. As a general rule of thumb, we expect the peak proportion of the PEH population that will require isolation to be roughly triple the projected peak daily incidence in the city. This framework can guide the provisioning of COVID-19 isolation and post-acute care facilities for high risk communities throughout the United States.
... There are several health disparities among homeless individuals when compared to domiciled counterparts, most concerning of which is an increased mortality rate [7][8][9][10][11]. Homeless patients have been found to have nearly twice the mortality rate compared with nonhomeless cohorts after adjustment for age, sex, and prior hospitalization [8]. ...
Article
Full-text available
Background Annually 1.5 million Americans face housing insecurity, and compared to their domiciled counterparts are three times more likely to utilize the Emergency Department (ED). Community Based Participatory Research (CBPR) methods have been employed in underserved populations, but use in the ED has been limited. We employed CBPR in an urban American hospital with a primary goal of improved linkage to care, reduced ED recidivism, and improved homeless health care. Methods A needs analysis was performed using semi-structured individual interviews with participants experiencing homelessness as well as with stakeholders. Results were analyzed using principles of grounded theory. At the end of the interviews, respondents were invited to join the “CBPR team”. At CBPR team meetings, results from interviews were expounded upon and discussions on intervention development were conducted. Results Twenty-five stakeholders were interviewed including people experiencing housing insecurity, ED staff, inpatient staff, and community shelters and services. Three themes emerged from the interviews. First, the homeless population lack access to basic needs, thus management of medical needs must be managed alongside social ones. Second, specific challenges to address homeless needs in the ED include episodic care, inability to recognize housing insecurity, timely involvement of ancillary staff, and provider attitudes towards homeless patients affecting quality of care. Lastly, improved discharge planning and communication with outside resources is essential to improving homeless health and decreasing ED overutilization. A limitation of results is difficulty for participants experiencing homelessness to commit to regular CBPR meetings, as well as possible bias towards social networks influencing included stakeholders. Conclusion CBPR is a promising approach to address gaps in homeless health care as it provides a comprehensive view incorporating various critical perspectives. Key ED-based interventions addressing recidivism include improved identification of housing insecurity, reinforced relationships between ED and community resources, and better discharge planning.
... Homeless individuals suffer high levels of medical and psychiatric illnesses 4 5 and face substantial barriers to meeting basic social and healthcare needs, leading to high rates of premature disability and death. 6 Cardiovascular disease-a leading cause of death and disability for all populations-is particularly burdensome for homeless individuals, 7 who have less access to the preventive and routine care needed to effectively manage these conditions and tend to have more cardiovascular risk factors. 5 8 Compared with the general population, homeless individuals have higher rates of hypertension, Strengths and limitations of this study ► To investigate disparities in cardiovascular care and outcomes for homeless versus non-homeless patients by the hospital safety-net status, we analysed the combined data, including all hospital admissions and the hospital characteristics in four US states. ...
Article
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Objectives Evidence suggests that homeless patients experience worse quality of care and poorer health outcomes across a range of medical conditions. It remains unclear, however, whether differences in care delivery at safety-net versus non-safety-net hospitals explain these disparities. We aimed to investigate whether homeless versus non-homeless adults hospitalised for cardiovascular conditions (acute myocardial infarction (AMI) and stroke) experience differences in care delivery and health outcomes at safety-net versus non-safety-net hospitals. Design Cross-sectional study. Setting Data including all hospital admissions in four states (Florida, Massachusetts, Maryland, and New York) in 2014. Participants We analysed 167 105 adults aged 18 years or older hospitalised for cardiovascular conditions (age mean=64.5 years; 75 361 (45.1%) women; 2123 (1.3%) homeless hospitalisations) discharged from 348 hospitals. Outcome measures Risk-adjusted diagnostic and therapeutic procedure and in-hospital mortality, after adjusting for patient characteristics and state and quarter fixed effects. Results At safety-net hospitals, homeless adults hospitalised for AMI were less likely to receive coronary angiogram (adjusted OR (aOR), 0.42; 95% CI, 0.36 to 0.50; p<0.001), percutaneous coronary intervention (aOR, 0.52; 95% CI, 0.44 to 0.62; p<0.001) and coronary artery bypass graft (aOR, 0.43; 95% CI, 0.26 to 0.71; p<0.01) compared with non-homeless adults. Homeless patients treated for strokes at safety-net hospitals were less likely to receive cerebral arteriography (aOR, 0.23; 95% CI, 0.16 to 0.34; p<0.001), but were as likely to receive thrombolysis therapy. At non-safety-net hospitals, we found no evidence that the probability of receiving these procedures differed between homeless and non-homeless adults hospitalised for AMI or stroke. Finally, there were no differences in in-hospital mortality rates for homeless versus non-homeless patients at either safety-net or non-safety-net hospitals. Conclusion Disparities in receipt of diagnostic and therapeutic procedures for homeless patients with cardiovascular conditions were observed only at safety-net hospitals. However, we found no evidence that these differences influenced in-hospital mortality markedly.
... Moreover, they have a high prevalence of substance use disorders [5]. Premature death is frequent in this group [6]. ...
Article
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Background To identify the determinants of health care use among homeless individuals. Methods Data were taken from the Hamburg survey of homeless individuals ( n = 100 individuals in the here used model, mean age 44.8 years, SD 12.5) focusing on homeless individuals in Hamburg, Germany. The number of physician visits in the past 3 months and hospitalization in the preceding 12 months were used as outcome measures. Drawing on the Andersen model of health care use as a conceptual framework, predisposing characteristics, enabling resources and need factors as well as psychosocial variables were included as correlates. Results Negative binomial regressions showed that increased physician visits were associated with being female (IRR: 4.02 [95% CI: 1.60–10.11]), absence of chronic alcohol consume (IRR: 0.26 [95% CI: 0.12–0.57]) and lower health-related quality of life (IRR: 0.97 [95% CI: 0.96–0.98]). Furthermore, logistic regressions showed that the likelihood of hospitalization was positively associated with lower age (OR: 0.93 [95% CI: 0.89–0.98]), having health insurance (OR: 8.11 [2.11–30.80]) and lower health-related quality of life (OR: 0.97 [95% CI: 0.94–0.99]). Conclusions Our study showed that predisposing characteristics (both age and sex), enabling resources (i.e., health insurance) and need factors in terms of health-related quality of life are main drivers of health care use among homeless individuals. This knowledge may assist in managing health care use.
... This initiative is aimed at underprivileged populations in general, but especially the homeless, those engaged in prostitution and undocumented immigrants, and the results are significant. Several other studies [60][61][62][63][64][65][66] also underscore the existence of a strong relationship between the lack of adequate housing and increased mortality among homeless individuals, which is three to four times higher than that of the general population. They also report a life expectancy of 42 to 52 years for homeless individuals, which is approximately 30 years lower than that of the general population [67]. ...
Article
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Background In Spain, homeless individuals have lower perceived quality of health than the rest of the population and their life expectancy is 30 years lower than the national average. While the Spanish health system provides universal access and coverage, homeless individuals do not access or use public care enough to maintain their health. The objective of this study is to determine if homeless individuals can access public health services in conditions of equality with the rest of the population, as established in healthcare legislation, and to better understand the causes of observed inequalities or inequities of access. Methods A detailed qualitative study was carried out in the city of Barcelona (Spain) from October 2019 to February 2020. A total of nine open and in-depth interviews were done with homeless individuals along with seven semi-structured interviews with key informants and two focus groups. One group was composed of eight individuals who were living on the street at the time and the other consisted of eight individuals working in healthcare and social assistance. Results The participants indicated that homeless individuals tend to only access healthcare services when they are seriously ill or have suffered some kind of injury. Once there, they tend to encounter significant barriers that might be 1) administrative; 2) personal, based on belief that that will be poorly attended, discriminated against, or unable to afford treatment; or 3) medical-professional, when health professionals, who understand the lifestyle of this population and their low follow-through with treatments, tend towards minimalist interventions that lack the dedication they would apply to other groups of patients. Conclusions The conclusions derived from this study convey the infrequent use of health services by homeless individuals for reasons attributable to the population itself, to healthcare workers and to the entire healthcare system. Accordingly, to reduce inequities of access to these services, recommendations to healthcare service providers include adapting facilities to provide more adequate care for this population; increasing sensitivity/awareness among healthcare workers; developing in situ care systems in places where the homeless population is most concentrated; and establishing healthcare collaboration agreements with entities that work with this population.
... 6,[12][13] Th is confl uence of factors has led to homeless individuals being at three to four times increased risk of death compared with the general population. [14][15][16][17] Th eir life expectancy is also signifi cantly lower than their housed counterparts-as low as 64.2 years for single adult males, which amounts to almost 12 years less than the average lifespan for the general U.S. male population. 14,18 At the same time that the number of people experiencing homelessness continues to increase, the nation is experiencing an epidemic of drug-induced overdoses that claimed over 67,000 lives in 2019, and over 70,000 in 2017. ...
Article
People experiencing homelessness suffer from a risk of mortality three to four times that of the general population, with drug-induced overdose replacing HIV as the emerging epidemic. This study assessed markers of mortality among people experiencing homelessness (N=157) in Orange County, CA during the Fall of 2016. We utilized the Vulnerability Index, an eight-question survey, to identify factors that may affect mortality risk among individuals experiencing homelessness and included two additional questions to identify potential risk of drug-induced overdose. Eighty-three percent of participants reported more than one heightened mortality risk marker and 64% may be at higher risk of drug-induced overdose. Given the state of the opioid epidemic, there is pressing need to couple public health interventions targeting people experiencing homelessness with harm reduction efforts including naloxone distribution (opioid-induced overdose reversal medication) and syringe exchange programs.
... Existing evidence indicates that people experiencing homelessness are disproportionately vulnerable to premature death, and experience ill health at greater rates and at an earlier age than is true of the general population [2][3][4]. Higher mortality rates are generally attributed to acute and chronic medical conditions, substance misuse, violence, suicide or unintentional injury [3,[5][6][7]. The prevalence of tuberculosis, HIV, and hepatitis C is also higher amongst people experiencing homelessness [8,9]. ...
Article
Full-text available
Background Severely and multiply disadvantaged members of the homeless population are disproportionately vulnerable to exceptionally high levels of multi-morbidity and premature death. Given widespread calls for the development of interventions that might improve the uptake and effectiveness of healthcare for this population, this study investigated patient and other stakeholder perspectives regarding an outreach service, delivered by prescribing pharmacists in collaboration with a local voluntary sector provider, within homelessness services and on the street in Glasgow (UK). Methods The qualitative study involved semi-structured face-to-face interviews with 40 purposively sampled individuals with current or recent experience of homelessness (32 of whom had direct experience of the service and 8 of whom did not), all ( n = 4) staff involved in frontline delivery of the service, and 10 representatives of stakeholder agencies working in partnership with the service and/or with the same client group. Pseudonymised verbatim interview transcriptions were analysed systematically via thematic and framework analysis. Results The service was effective at case finding and engaging with patients who were reluctant to utilise or physically unable to access existing (mainstream or specialist ‘homeless’) healthcare provision. It helped patients overcome many of the barriers that homeless people commonly face when attempting to access healthcare, enabled immediate diagnosis and prescription of medication, and catalysed and capitalised on windows of opportunity when patients were motivated to address healthcare needs. A number of improvements in health outcomes, including but not limited to medication adherence, were also reported. Conclusions A proactive, informal, flexible, holistic and person-centred outreach service delivered within homelessness service settings and on the street can act as a valuable bridge to both primary and secondary healthcare for people experiencing homelessness who would otherwise ‘fall through the gaps’ of provision. Prescribing pharmacist input coupled with third sector involvement into healthcare for this vulnerable population allows for the prompt treatment of and/or prescription for a range of conditions, and offers substantial potential for improving health-related outcomes.
... Among people experiencing homelessness, the prevalence of alcohol use has been estimated at 80% (Velasquez et al., 2000), with over third reporting symptoms congruent with alcohol use disorder (AUD; Fazel et al., 2008;Krausz et al., 2013) This group is at increased risk for alcohol-related harm (WHO, 2004;World Health Organization, 2014), including alcohol-related mortality (Hawke et al., 2007;O'Connell, 2005). In fact, studies have shown that people experiencing homelessness are 6-10 times more likely to die of alcohol-attributable causes than the general population (Baggett et al., 2015;Hwang et al., 2009). ...
Article
Aims This secondary study characterized components of and engagement in the life‐enhancing alcohol‐management program (LEAP), which is resident‐driven housing first programming. Methods We used a process akin to conventional content analysis to operationalize the LEAP according to its component activities. We used generalized linear modeling to identify predictors of LEAP activity participation and to predict alcohol and quality‐of‐life outcomes from participation in specific LEAP activities categories. Results Overall, 86% of participants attended at least one LEAP activity, which comprised three categories: administrative leadership opportunities, meaningful activities, and pathways to recovery. Employment status alone predicted LEAP activity attendance: Employed residents attended 88% fewer LEAP activities than unemployed residents. Participants who sought out more pathways to recovery activities were more likely daily drinkers and more impacted by alcohol‐related harm. Those engaging in administrative leadership opportunities were overall less impacted by alcohol use and had a higher quality of life generally, and their alcohol outcomes further improved over time. Conclusions Programming developed with Housing First residents was well‐attended but could be made more inclusive by including evening programming to accommodate residents employed full time and engaging more severely impacted participants in administrative leadership activities, where the greatest benefits of programming were seen.
... Individuals who lack stable housing are at greater risk for morbidity and mortality when compared to housed individuals of the same age or gender. Common preventable ailments, such as hypertension, are exacerbated and can lead to chronic health problems when an individual lacks a safe place to rest, adequate nutrition, or a place to store medications (Fazel et al., 2014;Hwang et al., 2011;O'Connell, 2005). When an unhoused individual is hospitalized or has an illness requiring a period of recuperation, the lack of a place to recover hinders the healing process and the ability to convalesce. ...
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Objective A program evaluation to demonstrate the feasibility of a recuperative care pilot project to address the needs of unhoused individuals. Design The study is a descriptive postprogram evaluation. Sample A total of 73 referrals were made to the project with 23 admissions. Measure Data regarding number and type of referrals for admission, cost of respite care per guest and per day, hospital costs avoided, referrals to community services, and discharge destination were collected. Intervention A case management care model was used. The project staff included a public health nurse and an outreach worker. Results One local hospital accounted for 65% of all admissions. Admitting diagnoses were abscess/wound care (44%) followed by postsurgery recovery (17%). Housing resources (65%) was a common referral with 22% of guests discharged to stable housing. Actual length of stay exceeded the planned length by an average of 24 days. Total cost per guest per day was 157.45whichisanestimatedsavingstoreferringacutecarefacilitiesofbetween157.45 which is an estimated savings to referring acute care facilities of between 18,000 and $48,000 per day. Conclusions The project demonstrated an ability to provide unhoused individuals a place to recuperate following hospitalization in a cost‐effective manner. Challenges and recommendations of the program going forward were identified.
... Dr. Llorente is a professor of psychiatry at Georgetown University School of Medicine and Dr. Crawford is adjunct clinical professor of nursing at George Washington University, all in Washington, DC. outcomes; higher medical costs for emergency department visits and hospital admissions; longer stays (often for conditions that could be treated in ambulatory settings); and increased mortality. [4][5][6][7] From a societal perspective, homelessness is associated with costs for shelters and other forms of temporary housing and with higher justice system costs stemming from police, court, and jail involvement. 8 The higher justice system costs are in part attributable to significantly longer incarcerations for homeless persons than for demographically similar inmates who have been similarly charged but have housing. ...
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Ending homelessness in Washington, DC, involves the collaboration of government and community partners who can identify and address risk factors for homelessness.
... Furthermore, there is evidence internationally to suggest that homelessness is also a risk factor for premature mortality. 6,7,9,10,[16][17][18][19] Studies indicate that homeless individuals have an increased mortality rate throughout their lifetime, being most marked in younger age groups. 9,17-21 Deaths among younger homeless individuals are commonly related to accidental and/or drug/alcohol causes, while deaths among older homeless individuals are most often related to cardiovascular disease and cancer. ...
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Objective: To examine the effect of homelessness on mortality. Methods: This 15-year retrospective longitudinal cohort study compared mortality outcomes of homeless and non-homeless adults attending the emergency department of an inner-city public hospital in Melbourne, Victoria between 1 January 2003 and 31 December 2004. Homeless individuals had ≥1 recorded episodes of homelessness within the recruitment period, categorised by type: primary, secondary, tertiary, marginally housed. Non-homeless individuals were stably housed throughout. Results: Over 15 years, homeless individuals had a higher mortality rate (11.89 vs. 8.10 per 1,000 person-years), significantly increased mortality risk (rate ratio 1.47, 95% confidence interval [CI] 1.26-1.71) and younger median age at death (66.60 vs. 78.19 years) compared to non-homeless individuals. Using adjusted Cox proportional hazards models, primary (hazard ratio [HR] 2.05, 95%CI 1.67-2.50), secondary (HR 1.60, 95%CI 1.23-2.10) and tertiary (HR 1.72, 95%CI 1.16-2.56) homelessness were independent risk factors for premature mortality. Conclusion: At least one recorded episode of primary, secondary, or tertiary homelessness was associated with premature mortality and younger age at death over a 15-year period. Implications for public health: Accurately identifying individuals experiencing primary, secondary or tertiary homelessness at the emergency department may enable targeted interventions that could potentially reduce their risk of premature mortality.
... In the United States in 2018, 554,000 people were estimated to be homeless (Ngo & Turbow, 2019). Homeless individuals are at an increased risk for a variety of problems, including extreme poverty and poor general health (Fischer & Breakey, 1991), unemployment (Acuna, & Erlenbusch, 2009), alcohol use disorder (Breakey et al., 1989;Fazel et al., 2008;Toro et al., 1995), and premature death (O'Connell, 2005). Given the size of the homeless population in the United States, and severity of the problems faced by homeless individuals, the Institute of Medicine identified this population as a group in need of specialized interventions that are tailored to their unique characteristics and needs (IOM, 1990), including housing, income, and employment (Zerger, 2002). ...
Article
Unemployment, homelessness, and substance use are interrelated. The present study took place as part of a clinical trial intended to promote employment and abstinence from alcohol among unemployed, homeless adults with alcohol use disorders. Participants earned abstinence-contingent financial incentives for completing employment-seeking activities and hourly stipends for working with an employment specialist. In the initial condition, participants were paid all earnings on bimonthly intervals. Despite the availability of incentives for completing employment-seeking activities, participants completed activities at low rates. A multiple baseline across participants was used to evaluate the effect of providing pay every day for completing employment-seeking activities. Daily pay increased rates of completing activities for all three participants. Results suggest that reinforcer immediacy can be an important parameter in the control of employment-seeking activities.
... . People who are homeless already face higher risk of mortality (O'Connell, 2005), chronic medical conditions (Koh et al., 2020), mental health and substance use problems (Lebrun-Harris et al., 2013), and poor health care access (Moore & Rosenheck, 2016). All these factors and comorbidities increase the risk of exposure of severe complications from coronavirus (Lewis, 2020) for people living with behavioral health conditions. ...
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Far from being an equalizer, as some have claimed, the COVID‐19 pandemic has exposed just how vulnerable many of our social, health, and political systems are in the face of major public health shocks. Rapid responses by health systems to meet increased demand for hospital beds while continuing to provide health services, largely via a shift to telehealth services, are critical adaptations. However, these actions are not sufficient to mitigate the impact of coronavirus for people from marginalized communities, particularly those with behavioral health conditions, who are experiencing disproportional health, economic, and social impacts from the evolving pandemic. Helping these communities weather this storm requires partnering with existing community‐based organizations and local governments to rapidly and flexibly meet the needs of vulnerable populations.
... Over a half a million people are houseless (also referred to as homeless) on any given night in the United States [1]. People who are houseless are three to four times more likely to die than the average population, and the average life expectancy for a person who is houseless in the United States is between 42 and 52 years, whereas average life expectancy is nearly 35 years longer for the general population [2]. To address these disparities, much research has supported "housing as health", citing emerging areas of research that have identified links between housing and health outcomes, including decreasing health utilization and improving self-reported mental and physical health [3,4]. ...
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Background: People who are houseless (also referred to as homeless) perceive high stigma in healthcare settings, and face disproportionate disparities in morbidity and mortality versus people who are housed. Medical students and the training institutions they are a part of play important roles in advocating for the needs of this community. The objective of this study was to understand perceptions of how medical students and institutions can meet needs of the self-identified needs of the houseless community. Methods: Between February and May 2018, medical students conducted mixed-methods surveys with semi-structured qualitative interview guides at two community-based organizations that serve people who are houseless in Portland, Oregon. Medical students approach guests at both locations to ascertain interest in participating in the study. Qualitative data were analyzed using thematic analysis rooted in an inductive process. Results: We enrolled 38 participants in this study. Most participants were male (73.7%), white (78.9%), and had been houseless for over a year at the time of interview (65.8%). Qualitative themes describe care experiences among people with mental health and substance use disorders, and roles for medical students and health-care institutions. Specifically, people who are houseless want medical students to 1) listen to and believe them, 2) work to destigmatize houselessness, 3) engage in diverse clinical experiences, and 4) advocate for change at the institutional level. Participants asked healthcare institutions to use their power to change laws that criminalize substance use and houselessness, and build healthcare systems that take better care of people with addiction and mental health conditions. Conclusions: Medical students, and the institutions they are a part of, should seek to reduce stigma against people who are houseless in medical systems. Additionally, institutions should change their approaches to healthcare delivery and advocacy to better support the health of people who are houseless.
Article
Objectives London has the highest proportion of people experiencing homelessness (PEH) living in temporary accommodation in the United Kingdom. PEH have poorer health outcomes, greater dietary inequalities, and die younger than the general population. Despite this, little is known about the nutrition status of PEH. This study aimed to examine the dietary health inequalities experienced by PEH in London, specifically assessing malnutrition among PEH living in temporary accommodation. Methods This was a prospective cross‐sectional study in 18 hostels in London. Participants were recruited from the temporary accommodation in which they resided through a combination of purposive, snowballing and convenience sampling. Demographic information was gathered, including age, gender, ethnicity and hostel of residence. The primary outcome was malnutrition risk assessed by the Malnutrition Universal Screening Tool (MUST), other outcomes included body composition, dietary intake and quality, mental health and food insecurity. Ethical approval was obtained from the University College London Ethics Committee (16191/006). Findings Two hundred participants were recruited between July and December 2023. The majority were male (84.5%), were of White ethnicity (61%), with a mean (SD) age of 45.7 years (11.6) and a BMI of 23.4 kg/m ² (4.7). The median MUST score was 2 (interquartile range [IQR]: 0.0, 3.0), and 60% had a risk of malnutrition. The median mental health score was 6 (3.0, 10.0), with 55% having moderate to severe depression/anxiety. Median food security score was low (4.5 [(0.0, 8.0]), with 44% experiencing very low food security. The median dietary quality score was low (8.0 [6.0, 9.0]) with low intakes of energy, fibre, and micronutrients, including vitamin D, iron, folate, and calcium, with a higher intake of free sugars compared with UK dietary recommendations and intakes. Conclusion This is the first study to show that PEH living in temporary residences had a high risk of malnutrition and experienced dietary inequalities related to poor diet quality and severe food insecurity. There is an urgent need for improved food environments, dietary quality of donated foods and improved nutrition screening and nutrition support provision for PEH in temporary accommodation. Findings could help inform policymakers, health services and food aid charities to set nutrition standards for temporary accommodation to promote the dietary health of PEH.
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In the last decade, a movement known as "street medicine" has emerged. It is a relatively new medical field in which healthcare providers deliver medical care to homeless populations outside of traditional healthcare facilities, on the streets, and in various settings where unsheltered people live. Physicians essentially visit people living in camps, along riverbanks, in alleys, and abandoned buildings to provide medical care. During the pandemic, street medicine in the U.S. was often the first line of defense for people living on the streets. As the practice of street medicine continues to grow and expand across the country, there is an increasing demand to standardize patient care delivered outside traditional healthcare facilities.
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Background: Access to water and sanitation is a basic human right; however, in many parts of the world, communities experience water, sanitation, and hygiene (WaSH) insecurity. While WaSH insecurity is prevalent in many low and middle-income countries, it is also a problem in high-income countries, like the United States, as is evident in vulnerable populations, including people experiencing homelessness. Limited knowledge exists about the coping strategies unhoused people use to access WaSH services. This study, therefore, examines WaSH access among unhoused communities in Los Angeles, California, a city with the second-highest count of unhoused people across the nation. Methods: We conducted a cross-sectional study using a snowball sampling technique with 263 unhoused people living in Skid Row, Los Angeles. We calculated frequencies and multivariate analyses to describe (1) How unhoused communities cope and gain access to WaSH services in different places? Moreover, (2) What individual-level factors contribute to unhoused people’s ability to access WaSH services? Results: Our findings reveal that access to WaSH services in Los Angeles is most difficult at night. Reduced access to overnight sanitation resulted in 19% of the sample population using buckets inside their tents and 28% openly defecating in public spaces. Bottled water and public taps are the primary drinking water source, but 6% of the sample reported obtaining water from fire hydrants, and 50% of the population stores water for night use. Unhoused people also had limited access to water and soap for hand hygiene throughout the day, with 17% of the sample relying on hand sanitizer to clean their hands. Shower and laundry access was also among the most limited services reducing people’s ability to maintain body hygiene practices and limiting employment opportunities. Our regression models suggest that access to WaSH is not homogenous. Community differences exist, with the odds of having difficulty accessing sanitation services being two times greater for those living outside of Skid Row (95% CI: 1.08-6.37) and three times greater for people who have been unhoused for more than six years compared to people who have been unhoused for less than a year (95% CI: 1.36-8.07). Conclusion: Overall, this study suggests a need for more permanent and 24-hour accessible WaSH services for unhoused communities living in Skid Row, including restrooms, drinking water, water and soap for hand hygiene, showers, and laundry services.
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This study discusses the activities of cooperative societies in meeting the challenges of housing provision in the face of rapid urbanization. The study made an exposition of housing and related services, loan seeking and repayment processes. The cooperative societies in formal and informal settings were studied. Cooperative societies in 2 tertiary institutions in Nigeria were used as cases for formal setting. Informal setting was represented by the oldest Coordinating Cooperative Union in Ibadan, Nigeria. A total of 330 respondents took part in the study. Questionnaire and interviews were utilized to collect data for the study. The findings revealed that all the cooperative societies ran multipurpose services with housing loan services being equally included. These services included mass purchasing of land (b) acquisition of fixed assets (c) housing loans to members who are about to complete their personal houses or in the process of having one. Cooperative societies were seen as the easiest channels of securing access to affordable housing due to absence of bureaucratic bottleneck and insurmountable conditions. The general feeling was that decision making on how, when and to whom the loan should be given was faster, reliable and enhancing social, mental and physical stability for better productivity.
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People experiencing homelessness (PEH) suffer higher burdens of chronic illnesses, have higher rates of emergency medicine (ED) use and hospitalization, and ultimately are at increased risk for premature death compared to housed counterparts. Structural racism contributes to a disproportionate burden of homelessness among people of color. PEH experience not only significant medical concerns but also complex social needs that need to be addressed concurrently for effective healing, issues that have been magnified by the COVID‐19 pandemic. As health disparities and structural racism intersect among PEH, it is critically important to develop PEH‐centered interventions to improve care and health outcomes as part of an effort to dismantle racism. One opportunity to address these disparities in care for PEH is through training ED physicians on methods for identifying and intervening on the unique needs of vulnerable patient groups. The Accreditation Council for Graduate Medical Education has outlined health quality pathways in the clinical learning environment to address health disparities. Community‐based participatory research (CBPR) is particularly well suited for this scenario as it allows experiential learning for trainees to work with and understand a diverse group of stakeholders, to deepen their knowledge of local health disparities, and to lead research and measure outcomes of interventions to tackle health disparities. In this paper, we highlight the utility of CBPR in fostering experiential learning for EM residents on tackling health disparities and the importance of community collaboration in trainee‐led interventions for comprehensive ED care.
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Although existing scholarship notes that homelessness thrives in concentrated poverty, models estimating the association between the intensity of residential poverty segregation and local homelessness rates across communities remain absent from the literature. To fill this gap, the author considers this relationship for 272 homelessness Continuums of Care covering urban and suburban spaces spanning 43 states and the District of Columbia. Models suggest that poverty segregation is positively associated with the expected homelessness rate of a Continuum of Care, a relationship that remains significant when controlling for a range of established drivers of the condition. The author discusses this finding within a framework qualifying residential poverty segregation as both a cause and a consequence of the local prevalence of economic disadvantage that predicts homelessness via its relationship with disadvantage and unique spatial effects.
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Homelessness may be both a cause of and one of the more extreme outcomes of poverty. Governments at all levels and private organizations have a variety of tools to combat homelessness, and these strategies have changed dramatically over the past quarter century. In this paper, we catalog the policy responses and the existing literature on the effectiveness of these strategies, focusing on studies of individual‐level effects from randomized controlled trial evaluations and the best quasi‐experimental designs. We conclude by discussing outstanding questions that can be addressed with these same methods.
Article
Background: The average age of the homeless population is and will continue to rise. Although women comprise a significant and growing percentage of this vulnerable population, their age- and sex-specific health characteristics are poorly understood. Materials and Methods: This integrative review appraises published research addressing the physical and behavioral health characteristics of aging homeless women (≥50 years) in the United States (2000-2019). The authors searched six electronic databases to identify eligible studies. Studies were screened for methodological quality by using the Johns Hopkins Nursing Evidence-Based Practice model. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: Ten primary studies met the review eligibility criteria. All were level III (non-experimental); nine appraised as "good" quality (level B), and one as "lower" quality (level C). Aging homeless women demonstrate elevated rates of physical health conditions, related to suboptimal nutrition, lower than expected preventive health screening uptake, and geriatric concerns. Disproportionate rates of mental health conditions are compounded by substance use and interpersonal trauma. Familial and social dynamics and socioeconomic disadvantage contribute to social health concerns. Spiritual health is a critically important yet underexplored protective factor. Conclusions: Studies are limited, though collective findings suggest that aging homeless women endure a disproportionate physical, behavioral, and social health burden compared with aging non-homeless women and aging homeless men. Implications for research on early aging, preventative health strategies, and homelessness among women, and clinical practice in the context of geriatric and women's health are described.
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Homeless persons have high mortality rates. To ascertain causes of death in a group of homeless persons. Cohort study. 17,292 adults seen by the Boston Health Care for the Homeless Program from 1988 to 1993. Cause-specific mortality rates adjusted for race and rate ratios that compare mortality rates in homeless persons with those in the general population of Boston. Homicide was the leading cause of death among men who were 18 to 24 years of age (mortality rate, 242.7 per 100000 person-years; rate ratio, 4.1). The acquired immunodeficiency syndrome was the major cause of death in men (mortality rate, 336.5 per 100000 person-years; rate ratio, 2.0) and women (mortality rate, 116.0 per 100000 person-years; rate ratio, 5.0) who were 25 to 44 years of age. Heart disease and cancer were the leading causes of death in persons who were 45 to 64 years of age. The most common causes of death among homeless adults who have contact with clinicians vary by age group. Efforts to reduce the rate of death among homeless persons should focus on these causes.
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Homeless individuals experience high mortality rates. Males, whites, and substance abusers are more likely to die, but other high-risk characteristics are unknown. To identify demographic and clinical factors associated with an increased risk of death in homeless individuals. We conducted a case-control study of 558 adults who were seen by a health care program for the homeless in Boston, Mass, and who died in 1988 to 1993. Age-matched paired controls were selected from among individuals seen by the program who were alive at the end of 1993. Predictive data were obtained by blinded review of medical records. Odds ratios (ORs) for death were calculated using logistic regression analysis models. In a multivariate analysis, the strongest risk factors for death were acquired immunodeficiency syndrome (OR, 55.8), symptomatic human immunodeficiency virus infection (OR, 17.7), asymptomatic human immunodeficiency virus infection (OR, 4.1), renal disease (OR, 18.4), a history of cold-related injury (OR, 8.0), liver disease (OR, 3.8), and arrhythmia (OR, 3.3). A history of substance abuse involving injection drugs (OR, 1.6) or alcohol (OR, 1.5) also increased the risk of mortality. Nonfluency in English was associated with a decreased risk of death (OR, 0.4). In a group of adults seen by a health care program for the homeless, specific medical illnesses were associated with the greatest risk of death. Substance abuse alone was less strongly associated with death. Interventions to reduce mortality among the homeless should focus on individuals with high-risk characteristics.
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This study examined the rates and predictors of mortality among sheltered homeless men and women in New York City. Identifying data on a representative sample of shelter residents surveyed in 1987 were matched against national mortality records for 1987 through 1994. Standardized mortality ratios were computed to compare death rates among homeless people with those of the general US and New York City populations. Logistic regression analysis was used to examine predictors of mortality within the homeless sample. Age-adjusted death rates of homeless men and women were 4 times those of the general US population and 2 to 3 times those of the general population of New York City. Among homeless men, prior use of injectable drugs, incarceration, and chronic homelessness increased the likelihood of death. For homeless shelter users, chronic homelessness itself compounds the high risk of death associated with disease/disability and intravenous drug use. Interventions must address not only the health conditions of the homeless but also the societal conditions that perpetuate homelessness.
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Homeless persons in US cities have high mortality rates. However, few comparison data exist for death rates among homeless persons in other developed countries. To compare mortality rates among men using homeless shelters and the general population in Toronto, Ontario, and to determine whether mortality rates differ significantly among men using homeless shelters in Canadian and US cities. Cohort study conducted from 1995 through 1997, with a mean follow-up of 2.6 years. Men aged 18 years or older who used homeless shelters in Toronto in 1995 (n=8933). Mortality rate ratios comparing age-specific mortality rates among men using homeless shelters in Toronto with those of men in the general population of Toronto and of men using homeless shelters in New York, NY; Boston, Mass; and Philadelphia, Pa. Men using homeless shelters in Toronto were more likely to die than men in the city's general population. Mortality rate ratios were 8.3 (95% confidence interval [CI], 4.4-15.6) for men aged 18 to 24 years, 3.7 (95% CI, 3.0-4.6) for men aged 25 to 44 years, and 2.3 (95% CI, 1.8-3.0) for men aged 45 to 64 years. In most cases, however, the risk of death was significantly lower for men using homeless shelters in Toronto than for those in US cities. For men aged 25 to 44 years using homeless shelters, mortality rate ratios were 0.52 (95% CI, 0.41-0.65) for Toronto compared with Boston and 0.61 (95% CI, 0.44-0.85) for Toronto compared with New York City. For men aged 35 to 54 years using homeless shelters, the mortality rate ratio was 0.42 (95% CI, 0.27-0.66) for Toronto compared with Philadelphia. Mortality rates among men who use homeless shelters in Toronto, while higher than in the general population of Toronto, are much lower than mortality rates observed among men using homeless shelters in 3 major US cities. Further study is needed to identify the reasons for this disparity.
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Homeless people suffer from high levels of morbidity and mortality, but there is surprisingly little empiric evidence that homelessness has a direct adverse effect on health. This study examined the relationship between shelter use and risk of death using longitudinal data in a cohort of 8,769 homeless men in Toronto, Ontario. Shelter use was modelled as a time-dependent covariate in a Cox regression analysis. In a model adjusted for age and previous pattern of homelessness, the risk of death during months in which homeless shelters were used was significantly increased (hazard ratio, 1.84; 95% confidence interval, 1.27-2.67). Among men, periods of homeless shelter use are associated with higher mortality. There are three reasons why this finding does not necessarily mean that homelessness itself increases the risk of death. First, the hazard of death associated with shelter use compared to non-shelter use may be significantly different from that associated with homelessness compared to non-homelessness. Second, the association between shelter use and risk of death may be confounded by other variables such as alcohol and drug use. Finally, because the mechanism and time-course of the putative effect of homelessness on health is uncertain, appropriate modelling of the time-dependent covariate is difficult to ensure. Further research into the possible adverse effects of homelessness on health is needed and would have important implications for public policy.
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To investigate mortality among users of hostels for homeless people in Copenhagen, and to identify predictors of death such as conditions during upbringing, mental illness, and misuse of alcohol and drugs. Register based follow up study. Two hostels for homeless people in Copenhagen, Denmark 579 people who stayed in one hostel in Copenhagen in 1991, and a representative sample of 185 people who stayed in the original hostel and one other in Copenhagen. Cause specific mortality. The age and sex standardised mortality ratio for both sexes was 3.8 (95% confidence interval 3.5 to 4.1); 2.8 (2.6 to 3.1) for men and 5.6 (4.3 to 6.9) for women. The age and sex standardised mortality ratio for suicide for both sexes was 6.0 (3.9 to 8.1), for death from natural causes 2.6 (2.3 to 2.9), for unintentional injuries 14.6 (11.4 to 17.8), and for unknown cause of death 62.9 (52.7 to 73.2). Mortality was comparatively higher in the younger age groups. It was also significantly higher among homeless people who had stayed in a hostel more than once and stayed fewer than 11 days, compared with the rest of the study group. Risk factors for early death were premature death of the father and misuse of alcohol and sedatives. Homeless people staying in hostels, particularly young women, are more likely to die early than the general population. Other predictors of early death include adverse experiences in childhood, such as death of the father, and misuse of alcohol and sedatives.
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Homeless people are at high risk for illness and have higher death rates than the general population. Patterns of mortality among homeless men have been investigated, but less attention has been given to mortality rates among homeless women. We report mortality rates and causes of death in a cohort of women who used homeless shelters in Toronto. We also compare our results with those of other published studies of homeless women and with data for women in the general population. A cohort of 1981 women not accompanied by dependent children who used homeless shelters in Toronto in 1995 was observed for death over a mean of 2.6 years. In addition, we analyzed data from published studies of mortality rates among homeless women in 6 other cities (Montreal, Copenhagen, Boston, New York, Philadelphia and Brighton, UK). In Toronto, mortality rates were 515 per 100,000 person-years among homeless women 18-44 years of age and 438 per 100,000 person-years among those 45-64 years of age. Homeless women 18-44 years of age were 10 times more likely to die than women in the general population of Toronto. In studies from a total of 7 cities, the risk of death among homeless women was greater than that among women in the general population by a factor of 4.6 to 31.2 in the younger age group and 1.0 to 2.0 in the older age group. In 6 of the 7 cities, the mortality rates among younger homeless women and younger homeless men were not significantly different. In contrast, in 4 of the 6 cities, the mortality rates were significantly lower among older homeless women than among older homeless men. Excess mortality is far greater among homeless women under age 45 years than among older homeless women. Mortality rates among younger homeless women often approach or equal those of younger homeless men. Efforts to reduce deaths of homeless women should focus on those under age 45.
Article
The mortality in a series of 6,032 homeless men in Stockholm was investigated. The observation period was up to 3 years. The observed number of deaths amounted to 327 compared to the expected 86·7, corresponding to an excess mortality ratio of about 4. Mortality was raised for all the causes of death studied. Most striking, however, was excess mortality from accidents and diseases of the digestive and respiratory systems. Accidental deaths were remarkably numerous, indicating that these are largely correlated to the social consequences of abuse. The same applies to deaths from pulmonary tuberculosis. Excess mortality from suicide was lower than that found in some earlier studies. This discrepancy is discussed. In comparison with the general population the high mortality from diseases such as cirrhosis of the liver and pancreatitis shows that many medically serious cases of alcoholism are included in the “Homeless Men” group.
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In brief, a composite picture of the social ecology of MHC Area 602 is one of severe economic deprivation, poor housing, a mixture of overcrowding and loneliness, family breakdown, personal disability and social instability. Much of the population is in a 'minority status,' in terms either of racial-ethnic background, marital status, occupation and extremes of age or of living arrangements. To respond to the question of whether this is merely an exceptional coincidence or part of an orderly relation, we calculated rank-order correlation coefficients (Kendall's tau) between the rankings of the 39 MHC areas on total mortality and their rankings on the sociodemographic indicators. In essence, this procedure asks whether the 'line-up' of the areas on sociodemographic indicators is predictive of their 'line-up' in terms of excess mortality in 1972-1973. Seventy-six of 131 correlations were statistically significant at or beyond P = 0.05. The significant social indicators reflect primarily the characteristics of economic deprivation and social disorganization wherein Area 602 is extreme. These findings suggest that the extreme mortality rates in the areas described are unlikely to be the result of chance, but are part of a biosocial gradient, with lesser degrees of social deprivation tending to be accompanied by lesser rates of mortality.
Article
We wanted to compare demographics, risk behaviors, AIDS-defining diagnoses, and survival between homeless and housed persons with AIDS in Boston from 1983 to 1991. Our retrospective cohort study used chart review to identify homeless AIDS cases and data from the Massachusetts AIDS Surveillance Program for comparison of homeless and nonhomeless cases. Seventy-two homeless and 1,536 nonhomeless Boston residents were reported to have AIDS between Jan. 1, 1983, and July 1, 1991. Homeless persons with AIDS were more likely to be African American or Latino (81 vs. 39%, p < 0.0001) and have i.v. drug use as a risk behavior (75 vs. 19%, p < 0.0001). The AIDS-defining diagnoses among the homeless were more commonly disseminated Mycobacterium tuberculosis (9 vs. 2%, p < 0.0001) and esophageal candidiasis (17 vs. 9%, p < 0.01). These differences were not seen when the populations were stratified by i.v. drug use. No significant difference in survival between the homeless and nonhomeless cohorts was found. Homeless individuals with human immunodeficiency virus are significantly different than housed persons, and at greater risk of invasive opportunistic infections. Appropriate clinical strategies can be developed to provide needed care to homeless persons with HIV.
Article
Homeless people are at high risk for death from many causes, but age-adjusted death rates for well-defined homeless populations have not been determined. We identified 6308 homeless persons 15 to 74 years of age who were served by one or both of two agencies for the homeless in Philadelphia between January 1, 1985, and December 31, 1988. Using a data base that contained all deaths in Philadelphia and listings of all Philadelphia residents during the same period, we compared the mortality rate for this homeless population with the rate in the general population of Philadelphia. The age-adjusted mortality rate among the homeless was 3.5 times that of Philadelphia's general population (95 percent confidence interval, 2.8 to 4.5). The age-adjusted number of years of potential life lost before the age of 75 years was 3.6 times higher for the homeless people than for the general population (345 vs. 97 years lost per 1000 person-years of observation). Fifty-one of the 96 deaths of homeless persons (53 percent) occurred during the summer months. Mortality rates were higher among the homeless than in the general population for nonwhites, whites, women, and men. Within the homeless cohort, white men and substance abusers had higher mortality rates than other subgroups, but even homeless people not known to be substance abusers had a threefold higher risk of death than members of the general population. Injuries, heart disease, liver disease, poisoning, and ill-defined conditions accounted for 73 percent of all the deaths among the homeless. Homeless adults in Philadelphia have an age-adjusted mortality rate nearly four times that of Philadelphia's general population. White men and substance abusers are at particularly high risk. Matching cohorts of homeless people to death records is a useful way to monitor mortality rates over time, evaluate interventions, and identify subgroups with an increased risk of death.
Article
The circumstances surrounding the deaths of 128 homeless persons investigated by the Fulton County, GA, Medical Examiner's Office during the period 1988-90 and the demographic characteristics of the deceased were studied and analyzed. Emphasis was placed on cause and manner of death, unintentional injuries, and alcohol-related mortality. Ninety-eight percent of those who died were men, 55 percent occurred outdoors, 55 percent were due to natural causes, and 42 percent resulted from injuries, most of which were unintentional. The average age at death was 46 years, and 80 percent of those who died were found dead. Nearly half of the deaths (47 percent) were related to the acute or chronic effects of alcohol; the blood of 45 percent tested positive for ethanol; of that 45 percent, 75 percent had a blood ethanol concentration that exceeded 0.1 grams per deciliter. Mortality patterns among the homeless persons in the study were similar to those previously reported in Fulton County and in San Francisco, CA. Available data indicate that mortality prevention strategies for the homeless in Fulton County should target alcohol abuse and unintentional injuries. Further studies are needed to document regional mortality patterns of the homeless.
Article
This study directly compared mortality risk in homeless and nonhomeless mentally ill veterans and compared mortality rates in these groups with the general U.S. population. The study used a retrospective cohort design to assess mortality over a 9-year period in homeless (N = 6,714) and nonhomeless (N = 1,715) male veterans who were treated by Department of Veterans Affairs specialized mental health programs. The study showed that mortality rates in all homeless members of the cohort were significantly higher than the general U.S. population. Relative to nonhomeless cohort members, significant increases in mortality risk were observed in cohort members who at baseline were age 45 to 54 and had been homeless 1 year or less (RR = 1.55, 95% CI = 1.02, 2.36) and those age 55 and older who had been homeless 1 year or less (RR = 1.83, 95% CI = 1.33, 2.52). Similar, but nonsignificant trends were observed in cohort members who had been homeless more than 1 year at baseline. Additionally, medical problems at baseline and history of prior hospitalization for alcohol problems elevated mortality risk. Employment at baseline and minority group membership reduced mortality risk. The study suggests that mentally ill veterans served by specialized VA mental health programs are at elevated risk of mortality, relative to the general population. Homelessness increases this risk, particularly in older veterans, and this difference does not abate after entry into a health care system.
Article
The aims were first, to describe deaths in a cohort of homeless people compared to the general population and secondly, to compare deaths among the individuals with schizophrenia to those without schizophrenia. Mortality was assessed in a cohort of 708 homeless subjects, 506 with schizophrenia who were referred 10 years previously to psychiatric outreach clinics. Standardized mortality ratios (SMRs) were calculated. Eighty-three people (12%) had died, 19 from suicide. The SMR was 3.76 for homeless men and 3.14 for homeless women. There was a non-significant trend for higher excess mortality among men without schizophrenia compared to men with schizophrenia. SMRs for suicide were significantly elevated among homeless men. Homeless people in inner Sydney have death rates three to four times higher than people in the general population of New South Wales. Excess mortality was greatest for younger age groups.
Article
Many studies have shown a high prevalence of sexually transmitted diseases, human immunodeficiency virus (HIV) infection, viral hepatitis, drug dependence, and mental health problems among street youth. However, data on mortality among these youth are sparse. To estimate mortality rate among street youth in Montreal and to identify causes of death and factors increasing the risk of death. From January 1995 to September 2000, 1013 street youth 14 to 25 years of age were recruited in a prospective cohort with semi-annual follow-ups. Original study objectives were to determine the incidence and risk factors for HIV infection in that population; however, several participants died during the first months of follow-up, prompting investigators to add mortality to the study objectives. Mortality data were obtained from the coroner's office and the Institut de la Statistique du Québec. Mortality rate among participants and factors increasing the risk of death. Twenty-six youth died during follow-up for a mortality rate of 921 per 100 000 person-years (95% confidence interval [CI], 602-1350); this represented a standardized mortality ratio of 11.4. The observed causes of death were as follows: suicide (13), overdose (8), unintentional injury (2), fulminant hepatitis A (1), heart disease (1); 1 was unidentified. In multivariate Cox regression analyses, HIV infection (adjusted hazard ratio [AHR] = 5.6; 95% CI, 1.9-16.8), daily alcohol use in the last month (AHR = 3.2; 95% CI, 1.3-7.7), homelessness in the last 6 months (AHR = 3.0; 95% CI, 1.1-7.6), drug injection in the last 6 months (AHR = 2.7; 95% CI, 1.2-6.2), and male sex (AHR = 2.6; 95% CI, 0.9-7.7) were identified as independent predictors of mortality. Current heavy substance use and homelessness were factors associated with death among street youth. HIV infection was also identified as an important predictor of mortality; however, its role remains to be clarified. These findings should be taken into account when developing interventions to prevent mortality among street youth.
Article
Mortality has declined in most HIV-infected populations yet remains high among those with barriers to accessing antiretroviral (ARV) therapy. We sought to determine predictors of death in a group of HIV-infected homeless persons in San Francisco. Between 1996 and 2002, quarterly interviews and blood draws were conducted. Hazards of death were compared by number of months of the prior 6 months that an individual took any ARV, drug use, hepatitis C virus (HCV) status, and housing status. Among 330 participants, 65% were HCV-seropositive at baseline, 85% received ARV during the study period, and there were 57 deaths (5.3 per 100 person-years). Compared with 0 of the prior 6 months on therapy, the risk of death was not significantly reduced for individuals on 1 to 5 months of therapy (hazard ratio [HR]=0.82, 95% confidence interval [CI]: 0.43-1.57), but the risk of death was reduced 62% for those on ARV therapy for 6 months (HR=0.38, CI: 0.19-0.76). Housing status and HCV status were not significant predictors of death. HIV is the major cause of death in this population, whereas the impact of HCV infection seems to be minimal. Sustained ARV treatment significantly reduces the risk of death among the homeless.
Article
Urban homeless populations suffer disproportionately high rates of premature death. In response to a wave of highly publicized deaths on the streets of Boston during the winter of 1998-1999, the Massachusetts Department of Public Health (MDPH) convened a task force to investigate these deaths and implement an integrated response to this public health crisis. Comprised of a broad coalition of public and private agencies as well as homeless persons and advocacy groups, the MDPH Task Force reviewed the circumstances surrounding the 13 deaths, monitored subsequent deaths among homeless persons in Boston, and implemented a comprehensive plan to address critical needs and prevent further deaths. Contrary to the task force's initial assumption, the 13 decedents had multiple recent contacts with the medical, psychiatric, and substance abuse systems. In response to this finding, the MDPH Task Force sought to improve continuity of care and prevent future deaths among Boston's street population. Coordination of needed services was achieved through the creation of new, and often unconventional, partnerships. This case study exemplifies a public health practice response to the vexing health care challenges confronting homeless people who must struggle to survive on the streets and in shelters.
Article
Older individuals living on the streets of our urban cities are a unique sub-group of the homeless population. No studies have been published about these elderly "rough sleepers" who face daunting obstacles to health care while facing a litany of health risks on the streets that are magnified by the physical and mental limitations of advancing years. To improve our understanding of this itinerant group, the Street Team of the Boston Health Care for the Homeless Program prospectively followed 30 individuals aged 60 or older living on Boston's streets for the four-year period from 2000 through 2003. This cohort included 8 (27%) women and 22 (73%) men ranging in age from 60 to 82 years. The average age was 67 years old At the end of the four year study period, 9 (30%) had died and 6 (20%) were in nursing homes. Despite intense efforts, only 5 (17%) found housing. Seven (23%) were still on Boston's streets after four years, and one was lost to follow-up. We conclude that elderly rough sleepers have high morbidity and mortality and pose significant challenges to programs seeking to provide housing and supportive health care services for this vulnerable sub-group of elderly homeless persons. New and creative housing options are needed, and the delicate issues of competency and guardianship must be addressed.
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