Article

Migration to the Downtown Eastside neighbourhood of Vancouver and changes in service use in a cohort of mentally ill homeless adults: A 10-year retrospective study

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Abstract

Objectives Little research has investigated the role of migration as a potential contributor to the spatial concentration of homeless people with complex health and social needs. In addition, little is known concerning the relationship between possible migration and changes in levels of service use over time. We hypothesised that homeless, mentally ill individuals living in a concentrated urban setting had migrated from elsewhere over a 10-year period, in association with significant increases in the use of public services. Setting Recruitment was concentrated in the Downtown Eastside neighbourhood of Vancouver, Canada. Participants Participants (n=433) met criteria for chronic homelessness and serious mental illness, and provided consent to access administrative data. Methods Linked administrative data were used to retrospectively examine geographic relocation as well as rates of health, justice, and social welfare service utilisation in each of the 10 years prior to recruitment. Generalised estimating equations were used to estimate the effect of migration on service use. Results Over a 10-year period there was significant movement into Vancouver's Downtown Eastside neighbourhood (from 17% to 52% of the cohort). During the same period, there were significant annual increases in community medical services (adjusted rate ratio (ARR) per year=1.08; 95% CI 1.06 to 1.10), hospital admissions (ARR=1.08; 95% CI 1.04 to 1.11), criminal convictions (ARR=1.08; 95% CI 1.03 to 1.13), and financial assistance payments (ARR=1.04; 95% CI 1.03 to 1.06). Migration was significantly associated with financial assistance, but not with other types of services. Conclusions Significant increases in service use over a 10-year period coincided with significant migration into an urban area where relevant services were concentrated. These results highlight opportunities for early intervention in spatially diverse neighbourhoods to interrupt trajectories marked by worsening health and extremely high service involvement. Further research is urgently needed to investigate the causal relationships between physical migration, health and social welfare, and escalating use of public services. Trial registration numbers ISRCTN57595077 and ISRCTN66721740; Post-results.

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... Experts have argued that understanding homeless mobility in Canada is essential for successful policies, equitable service distribution, assisting recovery, and reducing homelessness (Tompkins et al. 2003;DeVerteuil 2004;Parker and Dykema 2013). Accordingly, researchers detail the movements of various subpopulations and different regional configurations (Cloke et al. 2003;Somers et al. 2015). They describe the mobilities of dispossessed and racialized populations disproportionately experiencing homelessness in Canada (Peters and Robillard 2009;Gray et al. 2011;Anderson and Collins 2014). ...
... These longer-distance moves are synonymously defined as migration. Canadian researchers examine rural-urban migration; First Nations, Métis, and Inuit (FNMI) peoples' mobilities; and service-induced migrations (Peters and Robillard 2009;Gray et al. 2011;Christensen 2012;Somers et al. 2015). However, the reasons why people experiencing homelessness move between places are not fully understood. ...
... Services can aid in people's transition from streets to homes, or they may contribute to homelessness. People move because of the loss of benefits; difficulties navigating bureaucratic systems; regional differences in service availability; and barriers to accessing social, health, and psychiatric services (Cloke et al. 2003;DeVerteuil 2003DeVerteuil , 2004Christensen 2012;Somers et al. 2015). Where Wolch et al. (1993) describe the survival circuits people take through cities to obtain resources, DeVerteuil (2003) describes how people are mobilized through institutions as a mechanism for managing poverty. ...
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en People experiencing homelessness are simultaneously socially and physically mobile. Individuals move through periods of housing stability and houselessness and varying degrees of financial (in)stability, and between different geographic spaces. Research concerning homeless mobilities emphasizes moves within cities and reveals seven factors deserving attention: housing; labour markets; social, health, and justice services; personal health; the attributes of different places; interpersonal networks; and how mobility is socially differentiated. However, the extent to which these factors shape homelessness and inter‐regional mobilities is unclear. Addressing this gap, I explore 612 people's moves using data collected from five Canadian cities. By analyzing participants' inter‐regional moves over ten years, I identify ten themes of homeless inter‐regional mobility in Canada including: interpersonal networks, the attributes of different places, labour markets and personal finances, the use of movement for personal growth, health and social services, residential mobilities, legal and health institutions, substance abuse and dependence, personal security, and travel. I find that the structures, institutions, resources, and personal experiences that produce homelessness simultaneously push people between places. Amidst an increasing emphasis aimed at understanding homeless experiences in Canada, this paper provides an overview of the inter‐regional mobilities of people experiencing homelessness in Canada. La mobilité des sans‐abri au Canada : les mouvements interrégionaux des participants au programme « At Home/Chez Soi » fr Les personnes sans domicile fixe ou sans‐abri sont à la fois socialement et physiquement en mouvement. Ces personnes traversent des périodes de stabilité et d'instabilité en matières de logement et de revenus, à des degrés divers. De plus, ils se déplacent entre différents espaces géographiques. Les recherches concernant la mobilité des sans‐abri mettent l'accent sur les déplacements à l'intérieur des villes et révèlent sept facteurs qui méritent l'attention : le logement ; le marché du travail ; les services sociaux, de santé et de justice ; la santé personnelle ; les attributs des différents lieux ; les réseaux interpersonnels et la manière dont la mobilité est socialement différenciée. Cependant, on ne sait pas exactement dans quelle mesure ces facteurs façonnent également la mobilité interrégionale des itinérants. Pour combler cette lacune, nous explorons les déplacements de 612 personnes à l'aide de données recueillies dans cinq villes canadiennes. En analysant les déplacements interrégionaux des participants au programme « At Home/Chez Soi » sur dix ans, nous avons identifié dix éléments influant sur la mobilité interrégionale des sans‐abri au Canada. De manière générale, il semble que les structures, les institutions, les ressources et les expériences personnelles qui produisent l'itinérance poussent simultanément les gens à se déplacer entre les lieux. Dans le contexte où l'on cherche à mieux saisir les expériences des sans‐abri au Canada, cette étude donne un aperçu des mobilités interrégionales des personnes sans domicile fixe à travers le pays.
... Elliot and Krivo 1991;Byrne et al. 2013;Lee et al. 2003;Wood et al. 2014;Fargo et al. 2013;Blid et al. 2008). Complementing these point-in-time studies are an increasing number of studies that account for spatiotemporal dynamics and variations by analysing, for example, the geographic movement of homeless people over a multiple wave survey (Alexander-Eitzman et al. 2013), the socioeconomic variables of the neighbourhoods people resided in before entering homeless shelters (Culhane et al. 1996), the previous migration histories of people experiencing homelessness at the time of survey (Somers et al. 2016) and the probabilities of entering and exiting homelessness by the socioeconomic characteristics of origin locations (Johnson et al. 2015). In the absence of longitudinal or retrospective data, spatial autocorrelation models may at least control for homelessness clusters and spatial dynamics that spill across neighbouring areal unitssomething that Iwata and Karato (2010) found to be the case in their study of the spatial pattern of homelessness in Osaka City, Japan. ...
... In particular, they suggest the importance of understanding the relationships between the structural causes of homelessness and the factors that drive the spatial patterns of different forms of homelessness. Street homelessness, for example, remains concentrated in inner city areas, perhaps because people in this situation gravitate to the inner city where accommodation and non-accommodation services and amenities are readily available and opportunities for earning money and maintaining social networks may be stronger (Iwata and Karato 2010;Lee and Price-Spratlen 2004;Somers et al. 2016). The spatial pattern of homeless shelters and boarding houses are likely to be driven less by the choices and experiences of people entering homelessness and more by various and often competing political, community, historical, theoretical and demand-driven influences as to how and where shelters and boarding houses should be located (Lee and Farrell 2005). ...
... There are some limitations associated with this study. First, is the reliance on Census point-in-time homelessness counts, despite emerging research demonstrating that homelessness is not fixed across time and space (Alexander-Eitzman et al. 2013;Somers et al. 2016). Secondly, the study is restricted by the Census areal units for which homelessness counts are made available. ...
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Homelessness in recent decades has been seen as highly spatially concentrated in the inner areas of large cities. Recent research suggests that homelessness remains spatially concentrated, though with some evidence of dispersion and the development of multiple clusters. This study analyses the spatial patterns of different types of homelessness under a relatively broad definition in Sydney, Australia using data from the national Censuses of 2001, 2006 and 2011. Convergence analysis is used to assess whether homelessness rates in different regions of the city have been converging or diverging. Homelessness in private dwellings, particularly in severely crowded dwellings, have indeed created clusters in Sydney’s western suburbs, while homelessness on the streets, in shelters and boarding houses remains concentrated in inner city areas. Growth in severe crowding in these suburban clusters and an increased concentration of boarding houses in inner city areas appears to have increased the spatial concentration of homelessness in Sydney over time. These findings are argued to be important for understanding the relationships between point-in-time homelessness distributions, the dynamics and processes that lead to these distributions and the underlying structural causes of homelessness.
... It has also been argued that more time spent homeless may increase the frequency of committing crimes as an adaptive survival strategy 2 . Additionally, most participants of VAH were recruited from a neighbourhood in Vancouver called the Downtown Eastside 49 . A prior analysis demonstrated that VAH participants had increasingly migrated to the Downtown Eastside in the ten-year period preceding study baseline, accompanied by substantial increases in criminal convictions 49 . ...
... Additionally, most participants of VAH were recruited from a neighbourhood in Vancouver called the Downtown Eastside 49 . A prior analysis demonstrated that VAH participants had increasingly migrated to the Downtown Eastside in the ten-year period preceding study baseline, accompanied by substantial increases in criminal convictions 49 . The finding of time being significantly associated with criminal convictions in the present study is consistent with those results. ...
... This is because prior analyses of VAH data using the IMRI have shown that, at most, about 12% of participants lived outside of BC 5 years before study baseline, and this proportion decreased to 3% in the year before baseline. On the other hand, at most, 20% of participants lived outside of BC 10 years prior to baseline 49 . To overcome this limitation, national administrative databases may be utilized, where permitted and in existence. ...
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People experiencing homelessness and serious mental illness exhibit high rates of criminal justice system involvement. Researchers have debated the causes of such involvement among people experiencing serious mental illness, including what services to prioritize. Some, for example, have emphasized mental illness while others have emphasized poverty. We examined factors associated with criminal convictions among people experiencing homelessness and serious mental illness recruited to the Vancouver At Home study. Participants were recruited between October 2009 and June 2011. Comprehensive administrative data were examined over the five-year period preceding study baseline to identify risk and protective factors associated with criminal convictions among participants (n = 425). Eight variables were independently associated with criminal convictions, some of which included drug dependence (RR = 1.53; P = 0.009), psychiatric hospitalization (RR = 1.44; P = 0.030), an irregular frequency of social assistance payments (compared to regular payments; 1.75; P < 0.001), and prior conviction (RR = 3.56; P < 0.001). Collectively, findings of the present study implicate poverty, social marginalization, crises involving mental illness, and the need for long-term recovery-oriented services that address these conditions to reduce criminal convictions among people experiencing homelessness and serious mental illness.
... Research with homeless and vulnerably housed individuals living in these areas has found that experiences of being either homeless or housed tend to be transitory, rather than stable life contexts [6]. Moreover, prior work has found that distinctions between being homeless as opposed to housed are less salient among populations accessing low-quality, socially marginal housing [7]. Research has found that both homeless individuals and vulnerably housed individuals living in marginal housing (e.g., single room occupancy hotels and rooming houses) experience worse physical and mental health and increased mortality rates [4,[8][9][10]. ...
... The quality of living spaces may impact HRQoL through a number of pathways. Lower quality physical conditions of living spaces increase the likelihood of exposure to environmental hazards (e.g., poor ventilation, mold, and low heat) that are associated with ill health [7,19], which in turn is associated with lower HRQoL [13]. In addition, the social climate of a living space may positively benefit HRQoL through facilitating the development of supportive relationships and connections to health and social services [7,19]. ...
... Lower quality physical conditions of living spaces increase the likelihood of exposure to environmental hazards (e.g., poor ventilation, mold, and low heat) that are associated with ill health [7,19], which in turn is associated with lower HRQoL [13]. In addition, the social climate of a living space may positively benefit HRQoL through facilitating the development of supportive relationships and connections to health and social services [7,19]. Furthermore, individuals' experience of their living spaces as having positive qualities (e.g., privacy, safety, and friendliness) may benefit HRQoL by contributing to psychological well-being and reducing stress [7,19]. ...
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The objective of this study was to examine longitudinal associations between perceived quality of living spaces and mental and physical health-related quality of life (HRQoL) among homeless and vulnerably housed individuals living in three Canadian cities. The Health and Housing in Transition (HHiT) study was a prospective cohort study conducted between 2009 and 2013 of N = 1190 individuals who were homeless and vulnerably housed at baseline. Perceived quality of living spaces (based on rated comfort, safety, spaciousness, privacy, friendliness and overall quality) and both mental and physical HRQoL were assessed at baseline and at four annual follow up points. Generalized estimating equation (GEE) analyses were used to examine associations between perceived quality of living spaces and both mental and physical HRQoL over the four-year study period, controlling for time-varying housing status, health and socio-demographic variables. The results showed that higher perceived quality of living spaces was positively associated with mental (b = 0.42; 95% CI 0.38-0.47) and physical (b = 0.11; 95% CI 0.07-0.15) HRQoL over the four-year study period. Findings indicate that policies aimed at increasing HRQoL in this population should prioritize improving their experienced quality of living spaces.
... This cluster represents possible rural service deserts, where those entering homelessness must move to nearby counties to find services. Furthermore, Warren County has more services relative to its neighbors, leading to migration into the area (Somers, Moniruzzaman, and Rezansoff, 2015). To explore this cluster, the study examines service provider characteristics and news stories in conjunction with county-level characteristics obtained from the American Community Survey to provide a deeper picture of elements not offered by the HUD survey. ...
... A decrease in the homeless population of the county where people migrate to is also likely. Although the effect of targeting aid to counties where homelessness originates is not known (Somers, Moniruzzaman, and Rezansoff, 2015), further exploration on the topic may reveal more beneficial targets for aid provision. ...
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How do homeless service deserts in rural communities relate to people experiencing homelessness and migration to communities with services? This study explores this relationship using a mixed-methods case study of Kentucky and a rich dataset with county-level data. The data include information on unsheltered homelessness and typically underreported information like the number of people whose homelessness originated in each county. Combining that with data from the U.S. Department of Housing and Urban Development (HUD) on shelters and services shows that people experiencing homelessness migrate to counties with more shelters. Results show the importance of county-level data and data on originating homelessness for understanding homelessness and where to provide services to end it most effectively. Other states and homeless Continuums of Care, local jurisdictions for homeless services, where all service providers must coordinate to apply for and receive funding from HUD, can also provide public county-level data to clarify the geographic sources of homelessness and the relationship between services and migration.
... hospital, community [fee for service] primary care, home care, pharmaceutical and diagnostic databases) or population and health care utilization profiles (Local Health Area Profiles 2016; Primary and Community Care Profile: Your Community (Vancouver Downtown Eastside) 2017). This is due to factors related to significant health care access barriers facing transient and marginalized populations, intrinsic limitations of diseaseoriented medical record classification standards (e.g. the International Classification of Disease), inaccuracies associated with professional judgment, and poor standards of record keeping within health and social services sectors (Somers et al. 2015(Somers et al. , 2016Rosendal et al. 2015;Soler and Okkes 2012). Existing databases are often siloed, with significant data quality, completeness, accessibility, and analytics and reporting issues. ...
... Existing organizational reports and academic studies of the region's health and social services depict marginalized, multi-ethnic and transient populations with high incidence and prevalence rates of mental illness, substance use, trauma, and communicable and non-communicable illness and disease (Somers et al. 2015(Somers et al. , 2016Parpouchi et al. 2017; Carnegie Community Action Project 2018; Linden et al. 2013). Many clients (including a sizeable minority of frail seniors) are low-income, food-insecure, housinginsecure or homeless and face difficulties associated with access to social and health care services (Carnegie Community Action Project 2018; BC Non-Profit Housing Association & M.Thomson Consulting 2017). ...
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Operationalization of the fundamental building blocks of primary care (i.e. empanelment, team-based care and population management) within the context of Community Health Centers requires accurate and real-time measures of biopsychosocial complexity, at both client and population-levels. This article describes the conceptualization, design and development of a novel software tool (the VCAT-Complexity Module) that can calculate and report real-time person-oriented biopsychosocial complexity profiles, using multiple data sources. The tool aligns with a profile approach to conceptualizing health outcomes, and represents a potentially significant advance over disease-oriented complexity assessment tools. The results and face validity of the software’s complexity score outputs are discussed, along with their practical implications on functions related to the development of primary care within Vancouver Coastal Health, a Canadian Regional Health Authority.
... While reasons for moving into DTES need to be further examined, the finding that the availability of drugs or alcohol, having family or friends in the neighborhood, as well as health and social services were among the most commonly cited reasons for visiting the DTES (though they were not the reasons for moving into the DTES) reflects the concentration of both illicit drug markets and the availability of low-threshold public services in this neighborhood [33,34]. Our findings suggest that these factors may have acted as pull factors in some PWUD's decision to move into the DTES. ...
... For these PWUD, the proximity to illicit drug markets might have been a reason to relocate into the DTES, while the availability of some health and/or social services might have kept them in the neighborhood. Consistent with this interpretation, the escalating use of social services associated with moving into the DTES has also been found among individuals who were homeless and mentally ill [34]. However, it should be noted that only approximately 20% of participants reported coming to the DTES to access health and social services (10% for health services, and 10% for other services), with a greater number reporting that they came to the neighborhood for drugs/alcohol (30%) or to see family and friends (15.9%). ...
Article
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Background: Urban drug scenes are characterized by high prevalence of illicit drug dealing and use, violence and poverty, much of which is driven by the criminalization of people who use illicit drugs (PWUD) and the associated stigma. Despite significant public health needs, little is understood about patterns of moving into urban drug scenes among PWUD. Therefore, we sought to identify trajectories of residential mobility (hereafter 'mobility') among PWUD into the Downtown Eastside (DTES), an urban neighbourhood with an open drug scene in Vancouver, Canada, as well as characterize distinct trajectory groups among PWUD. Methods: Data were derived from three prospective cohort studies of community-recruited PWUD in Vancouver between 2005 and 2016. We used latent class growth analysis (LCGA) to identify distinct patterns of moving into the DTES among participants residing outside of DTES at baseline. Multivariable multinomial logistic regression was used to determine baseline factors associated with each trajectory group. Results: In total, 906 eligible participants (30.9% females) provided 9,317 observations. The LCGA assigned four trajectories: consistently living outside of DTES (52.8%); early move into DTES (11.9%); gradual move into DTES (19.5%); and move in then out (15.8%). Younger PWUD, those of Indigenous ancestry, those who were homeless or living in a single-room occupancy hotel (SRO), and those injecting drugs daily were more likely to move in then out of DTES (all p<0.05). Living in an SRO, daily injection drug use, and recent incarceration were also positively associated with early mobility (all p<0.05). Conclusions: Nearly half of the participants moved into the DTES. Younger PWUD and Indigenous peoples appeared to have particularly high mobility, as did those with markers of social-structural vulnerability and high intensity drug use. These findings indicate a need to tailor existing social and health services within the DTES and expand affordable housing options outside the DTES.
... for individuals with psychiatric disorders, including the exacerbation of mental health symptoms (Cantor-Graae & Pedersen, 2013). Research has supported relationships between an increased migration, poor mental health and wellbeing outcomes, especially among individuals with experiences of longstanding homelessness and severe psychiatric co-morbidities (Kauppi, Forchuk, et al., 2015;Somers, Moniruzzaman, & Rezansoff, 2016). Research studies that have explored differences concerning substance use, incarceration and homelessness among psychiatric survivors have exemplified relationships between migration and poor mental health (Fedock et al., 2013;Fries et al., 2014;Rich & Clark, 2005). ...
... The study findings highlighted that both male and female participants who experienced ongoing homelessness continued to face social and mental health challenges. These findings are consistent with Somers et al. (2016), who indicated that the primary reason for migration was longstanding homelessness and severe psychiatric co-morbidities. Moreover, the study also identified that homeless female psychiatric survivors experienced stigma in the form of judgmental attitudes by members of their respective communities. ...
Article
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Globally, individuals with psychiatric disorders experience an increased risk for homelessness and frequent migration. The present qualitative study used intersectionality and thematic analysis to examine how male and female psychiatric survivors experienced the phenomenon of frequent migration in Canada. The study findings underscored aspects of frequent migration, including negative experiences associated with poverty, as well as increased risks for homelessness and mental health, stigma, and discrimination. The present findings call for bespoken services and programs to address male and female psychiatric survivors’ specific needs; thereby alleviating pathways to frequent migrations among psychiatric survivors.
... Studies detail how other social, spatial, political, and economic processes materially relate to homelessness (Bourlessas, 2018;DeVerteuil, 2003;Jocoy & Del Casino, 2010;Kerr, 2016;Peters & Robillard, 2009). Furthermore, researchers disrupt homogenizing narratives of homelessness by detailing the socially differentiated experiences of mobility for various populations (Bender et al., 2010;Jackson, 2012Jackson, , 2015Lankenau et al., 2008;Peters & Robillard, 2009;Preston et al., 2009;Somers et al., 2015;Takahashi et al., 2002;Tompkins et al., 2003). ...
... People use mobility as a resource to survive homelessness (Jackson, 2012;Wolch et al., 1993), often moving to find work, cope with houselessness, or access interpersonal networks (Cloke et al., 2003;Jackson, 2012;Kaufman, 2020;Lankenau et al., 2008;Peters & Robillard, 2009). Sometimes, mobility operates as a function of social and health services where people either move to access services (Christensen, 2012;Cloke et al., 2003;Somers et al., 2015) or when poverty management strategies cycle individuals through institutions (DeVerteuil, 2003). On the other hand, homelessness is associated with stasis and fixity. ...
Article
In the last 30 years, researchers have increasingly examined (im)mobility to understand why homelessness continues in the Global North. Studies consistently identify how people experiencing homelessness are excluded and displaced. However, the relationship between social and spatial marginalization is not well understood. In this article, I argue that a more complete understanding of mobility requires joint attention to social exclusion and spatial displacement. I develop the concept of expulsion to examine homeless mobilities. I draw on data from a longitudinal survey of homeless people’s inter-regional mobilities over ten years in Canada. I identify six modes of expulsion: residential expulsions, service exclusions, warehousing, racial banishments, violent expulsions, and ostracism. In each of these instances, people are mobilized to the social exterior while they are simultaneously displaced spatially. By developing a theory of expulsion, this paper contributes a new framework for understanding forced migration, coerced mobility, and involuntary displacement.
... As previously described, longer physical distances from services lead to reduced access and increased risk behaviours [46][47][48][49][50]. As one strategy to address distancerelated issues, other studies have highlighted a migratory element with relation to accessing services, with focus on people who use drugs [58,59,61,[86][87][88][89][90], as well as the interlinked field of mental health and homelessness services [91][92][93][94]. Perez Torruella [59] describes that such migration is encouraged by Puerto Rican authorities, on the basis of improved treatment access. ...
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Background The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access. Methods Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy. Results Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission. Conclusion Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.
... DTES is Canada's lowest income postal code that is at the epicenter of the national opioid crisis. [1][2][3][4] e DTES population of 18,500 includes some of the most complex (biopsychosocially), marginalized, and vulnerable people in Canada. 2 More than 80% of DTES residents self-identify as illicit drug users, 50% are on social assistance, 10% are homeless, and many more are housing and food insecure. 1,2 An estimated 2,181 people are homeless in the City of Vancouver (with a severe overrepresentation of Indigenous people), and over 7,000 people are housed in low-income, single-room-occupancy hotels. ...
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Background: Community health centers (CHCs) in British Columbia, Canada, are using a data-driven approach to enable functions related to the design, organization, management, delivery, and evaluation of primary health care services for complex populations. Methods: Descriptive study leveraging case studies from 4 CHCs in Vancouver, Canada, to provide an overview and examples of the functions and outputs of the Vancouver Community Analytics Tool (VCAT). Quantitative data were derived from electronic medical record data and regional emergency department data. Data were analyzed and reported by the VCAT software. Results: VCAT is a health system modeling, analytics, and reporting application suite that enables operationalization of the Ten Building Blocks of High-Performing Primary Care framework via 1) creation of a virtual patient record, 2) modeling and measurement of epidemiological profiles, 3) population management and quality improvement, 4) measurement and assessment of biopsychosocial complexity, 5) empanelment, and 6) design and optimization of team-based care. The software captures data on patient pathways and service operations for over 300 service sites, including community health centers, detox centers, and emergency departments. The software integrates data on service utilization and myriad other variables for over 750,000 individuals. Discussion: Using case studies, the article describes how the software helps solve practical clinical, organizational, and performance issues facing CHCs. Conclusions: VCAT models, analyzes, and visualizes the complexity profiles and service utilization patterns of complex populations, thereby enabling system administrators and clinicians to improve system performance and quality of care. The software represents a significant advance for health services research and is transforming the organization, delivery, and evaluation of primary health care services.
... Most Canadian SROs are located in urban centres, such as the impoverished Downtown Eastside (DTES) in Vancouver. Although located only a few blocks from the city's core business district, it is distinguished by high levels of poverty, drug activity, and poor health outcomes (Somers et al. 2016). Although all SRO tenants are covered by the Residential Tenancy Act (Province of British Columbia 2017), most SROs in the DTES are notorious for overall poor living conditions. ...
Article
Objective: Young adults living in single room occupancy (SRO) hotels, a form of low-income housing, are known to have complex health and substance problems compared to their peers in the general population. The objective of this study is to comprehensively describe the mental, physical, and social health profile of young adults living in SROs. Methods: This study reports baseline data from young adults aged 18-29 years, as part of a prospective cohort study of adults living in SROs in Vancouver, British Columbia, Canada. Baseline and follow-up data were collected from 101 young adults (median follow-up period 1.9 years [IQR 1.0-3.1]). The comprehensive assessment included laboratory tests, neuroimaging, and clinician- and patient-reported measures of mental, physical, and social health and functioning. Results: Three youth died during the preliminary follow-up period, translating into a higher than average mortality rate (18.6, 95% CI 6.0, 57.2) compared to age- and sex-matched Canadians. High prevalence of interactions with the health, social, and justice systems was reported. Participants were living with median two co-occurring illnesses, including mental, neurological, and infectious diseases. Greater number of multimorbid illnesses was associated with poorer real-world functioning (ρ = - 0.373, p < 0.001). All participants reported lifetime alcohol and cannabis use, with pervasive use of stimulants and opioids. Conclusion: This study reports high mortality rates, multimorbid illnesses, poor functioning, poverty, and ongoing unmet mental health needs among young adults living in SROs. Frequent interactions with the health, social, and justice systems suggest important points of intervention to improve health and functional trajectories of this vulnerable population.
... The over-representation of chronically homeless participants in our study, particularly among permanent housing residents, might also explain the high prevalence of participant health problems [53]. In terms of health and social service use, our sample had the high rates of service utilization typical for homeless populations [4,54,55]. The three groups reported twice as much use of emergency departments over a 12-month period relative to the general population, and had more hospitalizations, particularly emergency shelter users whose hospitalization rates were nearly four times the norm for the general population as shown in previous studies [23,56]. ...
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This study aimed to identify and compare major areas of met and unmet needs reported by 455 homeless or recently housed individuals recruited from emergency shelters, temporary housing, and permanent housing in Quebec (Canada). Mixed methods, guided by the Maslow framework, were used. Basic needs were the strongest needs category identified, followed by health and social services (an emergent category), and safety; very few participants expressed needs in the higher-order categories of love and belonging, self-esteem, and self-actualization. The only significant differences between the three housing groups occurred in basic needs met, which favored permanent housing residents. Safety was the only category where individuals reported more unmet than met needs. The study results suggested that increased overall access to and continuity of care with family physicians, MD or SUD clinicians and community organizations for social integration should be provided to help better these individuals. Case management, stigma prevention, supported employment programs, peer support and day centers should particularly be more widely implemented as interventions that may promote a higher incidence of met needs in specific needs categories.
... Previous literature has suggested that people experiencing homelessness may be categorized based on degree of geographical transience and that these subgroups may have differing health and service needs. 4,[35][36][37] Further analysis of ED visit data may provide information on patterns of migration between regions in Ontario. Lastly, transitions into and out of homelessness may be analyzed using ED visit data to assess the stability or precarity of homelessness in Ontario. ...
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Background: Data on people experiencing homelessness often come from time- and labour-intensive cross-sectional counts and surveys from selected samples. This study uses comprehensive administrative health data from emergency department (ED) visits to enumerate people experiencing homelessness and characterize demographic and geographic trends in the province of Ontario, Canada, from 2010 to 2017. Data and methods: People experiencing homelessness were identified by their postal code, designated as “XX.” Outcomes included the number of people experiencing homelessness stratified by year and week, gender and age plotted annually, the location of each ED visit, and composition changes in demographics and geographic distribution. Results: Over seven years, 39,408 individuals were identified as experiencing homelessness. The number of ED visits increased over the study period in all of Ontario. The average peak in the number of visits occurred annually in September, with the fewest visits in January. Rises in overall homelessness were secondary to increases in working-age homelessness. ED presentations were concentrated in urban centres. The total proportion of patients experiencing homelessness became less concentrated in Toronto, decreasing from 60% to 40% over the study period, with a shift toward EDs outside the city. Interpretation: This study shows that administrative health data can provide comprehensive information on demographics and other characteristics analyzed over time. Surveillance can be conducted cost-effectively, and changes can be tracked in real time to allow for services to be coordinated and implemented in a time-sensitive manner.
... All participants were homeless and mentally ill, with the majority diagnosed with Schizophrenia. This is in keeping with earlier studies in which schizophrenia, in addition to substance dependence, were identified as major psychiatric diagnosis [1,2,20,21]. It is noteworthy that the psychiatric diagnoses that might be changing the length for treatment and nature or specificity of cares given during hospitalization or ambulatory treatment, should not be over looked as has been proved in Vancouver population [22]. ...
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MENTAL HEALTH CARE OF HOMELESS MENTALLY ILL PATIENTS IN AKWA IBOM STATE, NIGERIA: REHABILITATION MODEL, CHALLENGES AND STRATEGIES FOR IMPROVEMENT UCHE NWAOPARA1*, FESTUS ABASIUBONG2 AND OKOKON UMOH3 1State Psychiatric Hospital, Eket, Akwa Ibom State, Nigeria. 2Department of Psychiatry, Faculty of Clinical Sciences, University of Uyo, Nigeria. 3Department of Psychology, Faculty of Social Sciences, University of Uyo, Nigeria. Abstracts Background: The care of mentally ill in many developing countries suggests a marked coincidence of chronicity, with a sizeable number of apparently homeless mentally ill people, wandering about the cities and often neglected by the society. Aim: The purpose of this study was to assess the effectiveness of Transitional shelter-based treatment and rehabilitation model on homeless (vagrant) psychotic patients in Akwa Ibom State, Nigeria, evaluate its challenges and suggest strategies for improvement. Methods: This was a descriptive study of a purposive sample of 157 vagrant psychotic patients admitted and treated with psychotropic medications at the State Psychiatric hospital, Eket, in collaboration with the Akwa Ibom State Ministry of Social Welfare and Rehabilitation, in order to assess the effectiveness of Transitional shelter-based program for three months period. Results: One hundred and fifty seven (157) patients, were reviewed after three months stay in the hospital, and the results showed that 79% were males, and 21% females. The age range of the patients was from 16-65 years and majority of them, 79.6% were indigenes, while 20.4% were non-indigenes, 22.9% of the patients had substance-related problems. The most prevalent psychiatric diagnosis was Schizophrenia (37%). A total number of the patients 144 (91.7%) were successfully treated using psychotropic medications and re-integrated with their families; 5.7% were abandoned, 1.9% absconded while one (0.6%) died. Conclusion: Transitional or supportive housing and homeless shelters program can help stabilize people with chronic mental and/or substance use disorders that are homeless. There is need to strengthen and encourage this program in our environment so as to help this unfortunate group of people in our society. Keywords : Mental health; transitional shelter; vagrants; rehabilitation; collaboration; risk factors; challenges.
... Research has demonstrated that the COVID-19 pandemic has had a disproportionate effect on populations in which opioid usage is high, causing an increase in depression, anxiety, loneliness, and frustration (27). To help address these challenges, government and non-profit organizations make several social support services available in the area (28)(29)(30), such as food banks, harm reduction and education centers, and emergency shelters. However, many community services were greatly reduced due to physical distancing requirements. ...
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Previous research has focused on the benefits and difficulties of pet ownership in people, who are experiencing homelessness. However, many pet services, such as pet food banks, serve a more varied population of people. Furthermore, the effect of the COVID-19 pandemic has not been documented within the context of pet food banks. Vancouver's Downtown Eastside (DTES) population comprises a notable proportion of the city's overall population and has a high density of people who are experiencing financial hardships, but some of whom do not always experience homelessness. The purpose of this study was to gain an understanding of the number of clients and pets that are being serviced by a pet food bank, whether that has changed over time, and if it was impacted by the COVID-19 pandemic. We analyzed available attendance and service records from The British Columbia Society for the Prevention of Cruelty to Animals pet food bank between 2013 and 2020. We found that a median of 100 clients attended the food bank each week and that most of the companion animals serviced were cats (72.5%), then followed by dogs (25.2%), and rats (1.2%). Servicing was not consistent over time, with a weekly pattern of decreased attendance every fourth week of the month, which coincided with income assistance payments. This suggests that either servicing needs are decreased with income assistance or that the week of the month may present an access to care challenge. We also observed a decrease in the clientele attending in 2020 compared to previous years, suggesting an effect of COVID-19. Specifically, this trend was present for cats, rats, rabbits, and “other” companion animals, but not for dogs; the number of dog owners receiving services did not change in 2020, suggesting a difference between needed services in dog vs. other pet owners. The yearly trends shed light on the impact of COVID-19 on vulnerable populations, highlighting the need for additional support through times of crisis. Overall, the data show a complex relationship between pet service provision and other community issues and highlight the need to consider pet food banks within the greater social services networks.
... Significant differences in HQ between groups in Vancouver are likely attributable to the concentration of very low quality accommodations in the city's urban core, where homelessness is most visible. 24,25 After adjustment for other important variables, site was a significant predictor of HQ only for Winnipeg. There are important contextual differences with this city that can explain these findings. ...
Article
Housing quality (HQ) is associated with mental health, and may mediate outcomes in housing interventions. However, studies of housing interventions rarely report HQ. The purpose of this study was to describe HQ in a multi-site randomized controlled trial of Housing First (HF) in five Canadian cities and to examine possible differences by treatment group (HF recipients and treatment-as-usual (TAU) participants who were able to find housing through other programs or on their own). We also examined the association between HQ and the primary trial outcome: housing stability. The performance of a new multi-dimensional standardized observer-rated housing quality scale (the OHQS) in a relatively large cross-site sample was also of interest. HQ was rated by trained research assistants for 204 HF participants and 228 TAU participants using the OHQS. General linear regression models were used to examine unit/building quality scores by group and site adjusting for other group differences, and as a predictor of housing stability outcomes after 24 months of follow-up. The OHQS was found to have good reliability and validity, but because most of the neighborhood subscale items were negatively correlated with the overall scale, only unit and building items were included in the total HQ score (possible scores ranging from 13.5 to 135). Unit/building HQ was significantly better for the HF group overall (91.2 (95 % CI = 89.6–92.9) vs. 88.3 (95 % CI = 86.1–90.5); p = .036), and in one site. HQ in the TAU group was much more variable than the HF group overall (W (mean) = 24.7; p < .001) and in four of five sites. Unit/building HQ scores were positively associated with housing stability: (73.4 (95 % CI 68.3–78.5) for those housed none of the time; 91.1 (95 % CI 89.2–93.0) for those housed some of the time; and 93.1 (95 % CI 91.4–94.9)) for those housed all of the time (F = 43.9 p < .001). This association held after adjusting for site, housing characteristics, participant ethnocultural status, community functioning, and social support. This study demonstrates that HQ can be as good or better, and less variable, in HF programs in Canada that systematically and predominantly source housing stock from the private sector compared to housing procured outside of an HF program. HQ is also an important predictor of housing stability outcomes.
... 5 Pathways to homelessness integrate poverty, mental illness, addiction, lack of affordable housing and socioeconomic inequities. [6][7][8] The high prevalence of mental illness among the homeless 9 10 is related to sustained disinvestment in institutional models of care and insufficient attention to the design and implementation of community-based approaches to delivering housing and support. 11 Fragmentation between systems responsible for healthcare and social services amplifies the challenges faced by people who are mentally ill and homeless. ...
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Objectives Indigenous people in Canada are not only over-represented among the homeless population but their pathways to homelessness may differ from those of non-Indigenous people. This study investigated the history and current status of Indigenous and non-Indigenous people experiencing homelessness and mental illness. We hypothesised that compared with non-Indigenous people, those who are Indigenous would demonstrate histories of displacement earlier in life, higher rates of trauma and self-medication with alcohol and other substances. Design and setting Retrospective data were collected from a sample recruited through referral from diverse social and health agencies in Winnipeg and Vancouver. Participants Eligibility included being 19 years or older, current mental disorder and homelessness. Measures Data were collected via interviews, using questionnaires, on sociodemographics (eg, age, ethnicity, education), mental illness, substance use, physical health, service use and quality of life. Univariate and multivariable models were used to model the association between Indigenous ethnicity and dependent variables. Results A total of 1010 people met the inclusion criteria, of whom 439 self-identified as Indigenous. In adjusted models, Indigenous ethnicity was independently associated with being homeless at a younger age, having a lifetime duration of homelessness longer than 3 years, post-traumatic stress disorder, less severe mental disorder, alcohol dependence, more severe substance use in the past month and infectious disease. Indigenous participants were also nearly twice as likely as others (47% vs 25%) to have children younger than 18 years. Conclusions Among Canadians who are homeless and mentally ill, those who are Indigenous have distinct histories and current needs that are consistent with the legacy of colonisation. Responses to Indigenous homelessness must be developed within the context of reconciliation between Indigenous and non-Indigenous Canadians, addressing trauma, substance use and family separations. Trial registration number ISRCTN42520374 , ISRCTN57595077 , ISRCTN66721740 .
Article
Introduction and Aims People who use illicit drugs (PWUD) are vulnerable to an array of negative health outcomes, and increased hospital services utilisation. PWUD are also a transient population which poses challenges to the provision of optimal health care. The objective of this study was to identify out‐migration patterns from Vancouver's Downtown Eastside (DTES), a neighbourhood where services for PWUD are concentrated, and to estimate the impact of these patterns on hospitalisation events among PWUD. Design and Methods Data were collected through three prospective cohorts of PWUD in Vancouver, which were linked with health administrative data. Latent class growth analysis was used to define migration trajectory groups. Poisson regression was used to estimate the effect of migration patterns on hospitalisation events. Results A total of 1180 participants were included in the study. Four latent classes were identified: early migration out (243, 20.6%); frequent revisit (112, 9.5%); late migration out (219, 18.6%); and consistently living in the DTES (606, 51.4%). Compared with those who consistently lived in the DTES, participants in the early migration out group had lower hospitalisation events (adjusted rate ratio = 0.65; 95% confidence interval: 0.48–0.90). Discussion and Conclusion We found that PWUD who migrated out of the DTES early had lower hospitalisation events compared to those who consistently lived in the DTES, which may be a function of lesser addiction severity among this trajectory group. These findings underscore a need to provide transitional health and social service supports for other trajectory groups in an effort to minimise hospitalisation for preventable causes.
Article
The objective of this study was to identify migration patterns from an open illicit drug scene (the Downtown Eastside [DTES] neighborhood) and describe factors associated with these migration patterns. Data were derived from three cohorts of people who use illicit drugs in Vancouver, Canada. Defined using latent class growth analysis, we identified four distinct migration trajectory groups: 1) consistently living in the DTES (47.8%); 2) early migration out, with a median time of migrating out of DTES of 5.3 months (21.5%); 3) late migration out, with a median time of migrating out of DTES of 38.0 months (20.1%); and 4) frequent revisit back-and-forth to DTES (10.6%). In a multivariable model, compared to the "consistently living in the DTES" group, factors associated with the "frequent revisit" group included being enrolled in non-pharmacological addiction treatment and having an HCV-positive serostatus. Factors associated with the "early migration out" group included being enrolled in detoxification or in other non-pharmacological addiction treatment, later calendar year, being on income assistance, living in a single room occupancy hotel, and having an HCV-positive serostatus. These findings point to the need for appropriate distribution of services in order to meet the needs of this population.
Article
Background: People who use illicit drugs (PWUD) experience various adverse health outcomes leading to increased healthcare service utilization. PWUD are also a highly mobile population which poses challenges to healthcare delivery. The objective of this study was to identify migration patterns from the Downtown Eastside (DTES), an urban illicit drug scene in Vancouver and to estimate the impact of different migration patterns on two outcomes: a) emergency department (ED) visits and b) ED visits resulting in inpatient admission among PWUD. Methods: Three prospective cohorts of PWUD in Vancouver were linked with regional ED data. We defined the optimal number of trajectory groups that best represented distinct patterns of migration from Vancouver's DTES using a latent class growth analysis. Then, generalized estimating equations were used to estimate the effect of migration patterns on the two ED outcomes. Results: Four distinct migration trajectory patterns were identified among the 1210 included participants: PWUD who consistently lived in the DTES, those who migrated out of DTES early, those who migrated out of DTES late, and those who frequently revisited the DTES. Participants who frequently revisited the DTES had higher odds of an ED visit (adjusted odds ratio = 1.62; 95% confidence interval: 1.28-2.06). There was no significant association between migration patterns and inpatient admission. Conclusions: We found that PWUD who frequently revisited the DTES were more likely to have utilized the ED, suggesting that there may be a subgroup of PWUD who are at increased risk of experiencing negative health outcomes.Supplemental data for this article is available online at 10.1080/10826084.2021.1958849.
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Objective: Deinstitutionalization is an ongoing process, as many jurisdictions continue to struggle with redesigning their psychiatric systems. Historically, reducing psychiatric beds and closing hospitals have resulted in deleterious outcomes for people with severe and persistent mental illness. More recent evidence suggests that careful implementation of deinstitutionalization policies can thwart potential adverse consequences and may even foster favorable outcomes. This study evaluated the extent to which the recent devolution of the only tertiary psychiatric hospital in British Columbia resulted in a direct shift of individuals to other institutional sectors, such as criminal justice and health sectors. Methods: Admission rates to general hospitals, continuing care facilities, correctional institutions, and forensic psychiatric facilities were compared among two patient groups: those discharged before the realignment of the tertiary psychiatric hospital system (prerealignment cohort) (N=164) and those discharged after initiation of the system reforms (postrealignment cohort) (N=171). Results: Most of the patients in the postrealignment cohort have remained in the tertiary care settings to which they were originally discharged. For patients in the postrealignment cohort, contact with other institutional sectors was rare and shorter in duration than it was for patients in the prerealignment cohort. Conclusions: This study provides preliminary evidence that recent efforts to realign British Columbia's provincial tertiary psychiatric hospital system have not resulted in a significant shift of the relocated patients to institutions in other sectors.
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Housing First (HF) is an established intervention for people experiencing homelessness and mental illness. We compared daily substance use (DSU) between HF and treatment as usual (TAU). Two concurrent randomized controlled trials with 24-month follow up. Market rental apartments with support provided by Assertive Community Treatment (ACT) or Intensive Case Management (ICM); a single building with on site supports (CONG); TAU- in Vancouver Canada. Inclusion criteria were current homelessness and mental illness. Participants were assessed as having either "high needs" (HN; n = 297) or "moderate needs" (MN; n = 200). MN participants were randomized to ICM (n = 100) or MN-TAU (n = 100). HN participants were randomized to ACT (n = 90), CONG (n = 107), or HN-TAU (n = 100). All HF interventions included independent housing with support services, with an emphasis on promoting client choice and harm reduction in relation to substance use. TAU included existing services and support available to homeless adults with mental illness. DSU over 24 months and 12 months was derived from Maudsley Addiction Profile. Also measured were demographics, homelessness history, psychiatric diagnoses, symptom severity, comorbid illnesses, and duration of stable housing. Compared with HN-TAU, neither CONG (adjusted odds (AOR) ratio = 0.73, 95% confidence interval (CI) = 0.39-1.37) nor ACT (AOR = 1.22, 95% CI = 0.61-2.45) differed on DSU at 24 months, and MN-TAU did not differ from ICM (AOR = 0.78, 95% CI = 0.37-1.63). There were no differences: at 12 months, when analyses were restricted to participants who indicated substance use at baseline, or when considering the duration of stable housing. Housing First, an intervention to support recovery for homeless people who have co-occurring mental illness and substance use disorders, did not reduce daily substance use compared with treatment as usual after 12 or 24 months. This article is protected by copyright. All rights reserved.
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The Downtown Eastside of Vancouver, British Columbia, remains one of the poorest neighborhoods in Canada, yet is also a site of rapid gentrification. Both new and revitalized restaurants have created new spaces of consumption, transforming the neighborhood into a dining destination. Site visits and an analysis of the discourses used in newspaper articles and magazine features, as well as on blogs and in other online spaces, indicate that the presence of poor and marginalized residents of the Downtown Eastside is one of the reasons for some consumers’ decisions to visit new upscale establishments in the area. Analysis of advertisements and other primary documents indicates that the presence of poor and marginalized residents has become a competitive niche for the promotion of distinctive and authentic culinary adventures. This trend toward poverty tourism signals a shift from the simple displacement of low-income residents to a more complex form of gentrification in which residents face spatial management and control while their poverty is commodified.
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Individuals with mental illnesses are overrepresented among the homeless. Housing First (HF) has been shown to promote positive outcomes in this population. However, key questions remain unresolved, including: how to match support services to client needs, the benefits of housing in scattered sites versus single congregate building, and the effectiveness of HF with individuals actively using substances. The present study aimed to recruit two samples of homeless mentally ill participants who differed in the complexity of their needs. Study details, including recruitment, randomization, and follow-up, are presented. Eligibility was based on homeless status and current mental disorder. Participants were classified as either moderate needs (MN) or high needs (HN). Those with MN were randomized to HF with Intensive Case Management (HF-ICM) or usual care. Those with HN were randomized to HF with Assertive Community Treatment (HF-ACT), congregate housing with support, or usual care. Participants were interviewed every 3 months for 2 years. Separate consent was sought to access administrative data. Participants met eligibility for either MN (n = 200) or HN (n = 297) and were randomized accordingly. Both samples were primarily male and white. Compared to participants designated MN, HN participants had higher rates of hospitalization for psychiatric reasons prior to randomization, were younger at the time of recruitment, younger when first homeless, more likely to meet criteria for substance dependence, and less likely to have completed high school. Across all study arms, between 92% and 100% of participants were followed over 24 months post-randomization. Minimal significant differences were found between study arms following randomization. 438 participants (88%) provided consent to access administrative data. The study successfully recruited participants meeting criteria for homelessness and current mental disorder. Both MN and HN groups had high rates of substance dependence, suicidality, and physical illness. Randomization resulted in no meaningful detectable differences between study arms.Trial registration: Current Controlled Trials: ISRCTN57595077 (Vancouver at Home study: Housing First plus Assertive Community Treatment versus congregate housing plus supports versus treatment as usual) and ISRCTN66721740 (Vancouver At Home study: Housing First plus Intensive Case Management versus treatment as usual).
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The benefits of Pathways Housing First in addressing chronic homelessness for persons with severe mental illness have been well established. However, the implementation and effectiveness of such programs in rural areas has yet to be examined. We described the model's adaptations in Vermont, including the use of hybrid assertive community treatment-intensive case management teams, which consisted of service coordinators with geographically based caseloads (staff/client ratio of 1:20) and regional multidisciplinary specialists. The program's innovative and widespread inclusion of technology into operations facilitated efficiency and responsiveness, and a pilot telehealth initiative supplemented in-person client visits. The program achieved a housing retention rate of 85% over approximately 3 years, and consumers reported decreased time spent homeless, demonstrating that program adaptations and technological enhancements were successful. (Am J Public Health. Published online ahead of print October 22, 2013; e1-e4. doi: 10.2105/AJPH.2013.301606).
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Objectives: We examined the relationship between substance dependence and residential stability in homeless adults with current mental disorders 12 months after randomization to Housing First programs or treatment as usual (no housing or support through the study). Methods: The Vancouver At Home study in Canada included 2 randomized controlled trials of Housing First interventions. Eligible participants met the criteria for homelessness or precarious housing, as well as a current mental disorder. Residential stability was defined as the number of days in stable residences 12 months after randomization. We used negative binomial regression modeling to examine the independent association between residential stability and substance dependence. Results: We recruited 497 participants, and 58% (n = 288) met the criteria for substance dependence. We found no significant association between substance dependence and residential stability (adjusted incidence rate ratio = 0.97; 95% confidence interval = 0.69, 1.35) after adjusting for housing intervention, employment, sociodemographics, chronic health conditions, mental disorder severity, psychiatric symptoms, and lifetime duration of homelessness. Conclusions: People with mental disorders might achieve similar levels of housing stability from Housing First regardless of whether they experience concurrent substance dependence.
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Homelessness and mental illness have a strong association with public disorder and criminality. Experimental evidence indicates that Housing First (HF) increases housing stability and perceived choice among those experiencing chronic homelessness and mental disorders. HF is also associated with lower residential costs than common alternative approaches. Few studies have examined the effect of HF on criminal behavior. Individuals meeting criteria for homelessness and a current mental disorder were randomized to one of three conditions treatment as usual (reference); scattered site HF; and congregate HF. Administrative data concerning justice system events were linked in order to study prior histories of offending and to test the relationship between housing status and offending following randomization for up to two years. The majority of the sample (67%) was involved with the justice system, with a mean of 8.07 convictions per person in the ten years prior to recruitment. The most common category of crime was "property offences" (mean = 4.09). Following randomization, the scattered site HF condition was associated with significantly lower numbers of sentences than treatment as usual (Adjusted IRR = 0.29; 95% CI 0.12-0.72). Congregate HF was associated with a marginally significant reduction in sentences compared to treatment as usual (Adjusted IRR = 0.55; 95% CI: 0.26-1.14). This study is the first randomized controlled trial to demonstrate benefits of HF among a homeless sample with mental illness in the domain of public safety and crime. Our sample was frequently involved with the justice system, with great personal and societal costs. Further implementation of HF is strongly indicated, particularly in the scattered site format. Research examining interdependencies between housing, health, and the justice system is indicated. ISRCTN57595077.
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Purpose: This study used an experimental design to examine longitudinal changes in subjective quality of life (QoL) among homeless adults with mental illness after assignment to different types of supported housing or to treatment as usual (TAU, no housing or supports through the study). We hypothesized that subjective QoL would improve over time among participants assigned to supported housing as compared to TAU, regardless of the type of supported housing received or participants' level of need. Methods: Participants (n = 497) were stratified by level of need ("high" or "moderate") and randomly assigned to Housing First (HF) in scattered-site apartments, HF in a congregate setting (high needs only), or TAU. Linear mixed-effects regression was used to model the association between study arm and self-reported QoL at baseline and at 6 and 12 months post-baseline by need level. Results: Based on the adjusted overall score on the QoL measure, participants randomized to HF reported significantly greater overall QoL as compared to TAU, regardless of need level or type of supported housing at both 6 and 12 months post-baseline. Scores on the safety and living situation subscales were significantly greater for both high and moderate need participants assigned to supported housing regardless of type at both 6 and 12 months post-baseline as compared to TAU. Conclusions: Despite multiple health and social challenges faced by homeless individuals with mental illness, HF in both scattered-site and congregate models results in significantly greater perceived QoL as compared to individuals who do not receive HF even after a relatively short period of time.
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People with histories of homelessness and serious mental illness experience profound health disparities. Housing First is an evidenced-based practice that is working to end homelessness for these individuals through a combination of permanent housing and community-based supports. The Jefferson Department of Family and Community Medicine and a Housing First agency, Pathways to Housing-PA, has formed a partnership to address multiple levels of health care needs for this group. We present a preliminary program evaluation of this partnership using the framework of the patient-centered medical home and the "10 Essential Public Health Services." Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system. The Pathways to Housing-PA/Jefferson Department of Family and Community Medicine partnership represents a community of solution, and multiple measures provide preliminary evidence that this model is feasible and can address the "grand challenges" of integrated community health services.
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In December of 2000, the City of Vancouver released its Four Pillars Drug Strategy in response to a serious public health crisis driven by illicit drug use in Vancouver. Following initial actions in the area of harm reduction and enforcement, in June 2005 the City of Vancouver developed its draft prevention plan titled "Preventing Harm from Psychoactive Substance Use". The plan is based on a synthesis of international research and evaluation, examples of successful programs from other jurisdictions, and a community dialogue process. Its recommendations fall under five key prevention priorities, including reducing risk factors and increasing protective factors across the life course, community centred interventions, addressing impacts on communities, legislative and public policy change and regulated markets. Together, these prevention priorities form an integrated plan to prevent harm from substance use. This article provides a description of the process leading to the development of the plan and seeks to articulate its key strategies. © 2006 Published by Elsevier B.V.
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Pathways Housing First provides access to housing, support, and treatment services to clients having the most complex needs-persons who have been homeless for at least 5 years and have both a psychiatric disability and substance dependency. In a 2-year Housing and Urban Development-funded demonstration project in Washington, DC, in 2007 and 2008, we observed promising outcomes in housing retention and reductions in psychiatric symptoms, alcohol use, and demand for intensive support services. The program is designed to be fiscally self-sustaining through extant public disability benefits for housing, treatment, and support services. This approach shows strong support for first providing a permanently supported housing solution for chronically homeless and severely disabled individuals in need of housing and treatment of co-occurring disorders.
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This study investigates hypotheses regarding the association of census tract variables with the risk for homelessness. We used prior address information reported by families entering emergency shelters in two large U.S. cities to characterize the nature of that distribution. Three dense clusters of homeless origins were found in Philadelphia and three in New York City, accounting for 67 percent and 61 percent of shelter admissions and revealing that homeless families’ prior addresses are more highly concentrated than the poverty distribution in both cities. The rate of shelter admission is strongly and positively related to the concentration of poor, African-American, and female-headed households with young children in a neighborhood. It is also correlated with fewer youth, elderly, and immigrants. Such areas have higher rates of unemployment and labor force nonparticipation, more housing crowding, more abandonment, higher rates of vacancy, and higher rent-to-income ratios than other areas.
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This study identified characteristics and experiences of arrestees and jail inmates with a serious mental illness that were associated with misdemeanor and felony arrests and additional days in jail. County and statewide criminal justice records and health and social service archival data sets were used to identify inmates with serious mental illness who were in the Pinellas County, Florida, jail between July 1, 2003, and June 30, 2004, and their health and social service contacts from July 1, 2002, to June 10, 2006. Criminal justice and mental health services were recorded longitudinally across 16 quarters, or 90-day periods. Generalized estimating equations for count data were used to describe the associations between individual characteristics and experiences and the risks of misdemeanor and felony arrests and additional days in jail. A total of 3,769 jail inmates (10.1% of all jail inmates) were diagnosed as having a serious mental illness. Participants experienced a mean+/-SD of .90+/-.60 arrest for every three quarters and 10.9+/-23.6 days in jail per quarter that they resided in the county. Being male, being homeless, not having outpatient mental health treatment, and having an involuntary psychiatric evaluation in the previous quarter were independently associated with significantly increased odds of misdemeanor arrests and additional days in jail. On the other hand, being black, being younger than 21 years, having a nonpsychotic diagnosis, and a co-occurring substance use disorder diagnosis were all independently associated with significantly increased odds of felony arrests, and with the exception of having a nonpsychotic diagnosis, they were also significantly associated with additional days in jail. Findings suggest that there are subgroups of individuals with a serious mental illness in the criminal justice system that may require different policy and programmatic responses.
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There are well over a million homeless people in Western Europe and North America, but reliable estimates of the prevalence of major mental disorders among this population are lacking. We undertook a systematic review of surveys of such disorders in homeless people. We searched for surveys of the prevalence of psychotic illness, major depression, alcohol and drug dependence, and personality disorder that were based on interviews of samples of unselected homeless people. We searched bibliographic indexes, scanned reference lists, and corresponded with authors. We explored potential sources of any observed heterogeneity in the estimates by meta-regression analysis, including geographical region, sample size, and diagnostic method. Twenty-nine eligible surveys provided estimates obtained from 5,684 homeless individuals from seven countries. Substantial heterogeneity was observed in prevalence estimates for mental disorders among the studies (all Cochran's chi(2) significant at p < 0.001 and all I(2) > 85%). The most common mental disorders were alcohol dependence, which ranged from 8.1% to 58.5%, and drug dependence, which ranged from 4.5% to 54.2%. For psychotic illness, the prevalence ranged from 2.8% to 42.3%, with similar findings for major depression. The prevalence of alcohol dependence was found to have increased over recent decades. Homeless people in Western countries are substantially more likely to have alcohol and drug dependence than the age-matched general population in those countries, and the prevalences of psychotic illnesses and personality disorders are higher. Models of psychiatric and social care that can best meet these mental health needs requires further investigation.
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A number of legal, social, and political factors over the past 40 years have led to the current epidemic of psychiatric disorders in the U.S. prison system. Although numerous investigations have reported substantially elevated rates of psychiatric disorders among prison inmates compared with the general population, it is unclear whether mental illness is a risk factor for multiple episodes of incarceration. The authors examined this association in a retrospective cohort study of the nation's largest state prison system. The study population included 79,211 inmates who began serving a sentence between September 1, 2006, and August 31, 2007. Data on psychiatric disorders, demographic characteristics, and history of incarceration for the preceding 6-year period were obtained from statewide medical information systems and analyzed. Inmates with major psychiatric disorders (major depressive disorder, bipolar disorders, schizophrenia, and nonschizophrenic psychotic disorders) had substantially increased risks of multiple incarcerations over the 6-year study period. The greatest increase in risk was observed among inmates with bipolar disorders, who were 3.3 times more likely to have had four or more previous incarcerations compared with inmates who had no major psychiatric disorder. Prison inmates with major psychiatric disorders are more likely than those without to have had previous incarcerations. The authors recommend expanding interventions to reduce recidivism among mentally ill inmates. They discuss the potential benefits of continuity of care reentry programs to help mentally ill inmates connect with community-based mental health programs at the time of their release, as well as a greater role for mental health courts and other diversion strategies.
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This study tests a typology of homelessness using administrative data on public shelter use in New York City (1988-1995) and Philadelphia (1991-1995). Cluster analysis is used to produce three groups (transitionally, episodically, and chronically homeless) by number of shelter days and number of shelter episodes. Results show that the transitionally homeless, who constitute approximately 80% of shelter users in both cities, are younger, less likely to have mental health, substance abuse, or medical problems, and to overrepresent Whites relative to the other clusters. The episodically homeless, who constitute 10% of shelter users, are also comparatively young, but are more likely to be non-White, and to have mental health, substance abuse, and medical problems. The chronically homeless, who account for 10% of shelter users, tend to be older, non-White, and to have higher levels of mental health, substance abuse, and medical problems. Differences in health status between the episodically and chronically homeless are smaller, and in some cases the chronically homeless have lower rates (substance abuse in New York; serious mental illness in Philadelphia). Despite their relatively small number, the chronically homeless consume half of the total shelter days. Results suggest that program planning would benefit from application of this typology, possibly targeting the transitionally homeless with preventive and resettlement assistance, the episodically homeless with transitional housing and residential treatment, and the chronically homeless with supported housing and long-term care programs.
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The authors discuss what can be learned from our experience with deinstitutionalization. The deinstitutionalization of mentally ill persons has three components: the release of these individuals from hospitals into the community, their diversion from hospital admission, and the development of alternative community services. The greatest problems have been in creating adequate and accessible community resources. Where community services have been available and comprehensive, most persons with severe mental illness have significantly benefited. On the other hand, there have been unintended consequences of deinstitutionalization-a new generation of uninstitutionalized persons who have severe mental illness, who are homeless, or who have been criminalized and who present significant challenges to service systems. Among the lessons learned from deinstitutionalization are that successful deinstitutionalization involves more than simply changing the locus of care; that service planning must be tailored to the needs of each individual; that hospital care must be available for those who need it; that services must be culturally relevant; that severely mentally ill persons must be involved in their service planning; that service systems must not be restricted by preconceived ideology; and that continuity of care must be achieved.
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This study examined factors associated with emergency department use among homeless and marginally housed persons. Interviews were conducted with 2578 homeless and marginally housed persons, and factors associated with different patterns of emergency department use were assessed in multivariate models. Findings showed that 40.4% of respondents had 1 or more emergency department encounters in the previous year; 7.9% exhibited high rates of use (more than 3 visits) and accounted for 54.5% of all visits. Factors associated with high use rates included less stable housing, victimization, arrests, physical and mental illness, and substance abuse. Predisposing and need factors appeared to drive emergency department use. Efforts to reduce emergency department use among the homeless should be targeted toward addressing underlying risk factors among those exhibiting high rates of use.
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The method of generalized estimating equations (GEE) is often used to analyze longitudinal and other correlated response data, particularly if responses are binary. However, few descriptions of the method are accessible to epidemiologists. In this paper, the authors use small worked examples and one real data set, involving both binary and quantitative response data, to help end-users appreciate the essence of the method. The examples are simple enough to see the behind-the-scenes calculations and the essential role of weighted observations, and they allow nonstatisticians to imagine the calculations involved when the GEE method is applied to more complex multivariate data.
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We examined the longitudinal effects of a Housing First program for homeless, mentally ill individuals' on those individuals' consumer choice, housing stability, substance use, treatment utilization, and psychiatric symptoms. Two hundred twenty-five participants were randomly assigned to receive housing contingent on treatment and sobriety (control) or to receive immediate housing without treatment prerequisites (experimental). Interviews were conducted every 6 months for 24 months. The experimental group obtained housing earlier, remained stably housed, and reported higher perceived choice. Utilization of substance abuse treatment was significantly higher for the control group, but no differences were found in substance use or psychiatric symptoms. Participants in the Housing First program were able to obtain and maintain independent housing without compromising psychiatric or substance abuse symptoms.
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While several studies have reported on sexual risk behaviours and the prevalence of sexually transmitted infections (STIs) among injection drug users (IDUs), there are fewer prospective studies that have been able to examine populations of IDUs with no history of STIs. Therefore, the authors examined prevalence, correlates and factors associated with time to first STI infection in a prospective cohort of IDUs in Vancouver, British Columbia. METHODS: The authors examined the prevalence and correlates of STIs among IDUs at the time of recruitment into a prospective cohort study. The authors also evaluated the cumulative rate of time to first STI among IDUs with no history of STIs at baseline using the Kaplan-Meier method, and modelled factors independently associated with first STI using Cox regression. RESULTS: Between May 1996 and November 2003, 1560 individuals were recruited into the cohort; of these individuals, 745 reported a history of STI at baseline. Among the 815 who did not report an STI at baseline, 671 (82%) had at least one follow-up visit and were eligible for the analysis of time to first STI. After 36 months of follow-up, the cumulative rate of first STI was 8.2% for men and 15.9% for women (log-rank P
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Research Summary Police officials across the United States are increasingly relying on place-based approaches for crime prevention. In this article, we examine the Safer Cities Initiative, a widely publicized place-based policing intervention implemented in Los Angeles's “Skid Row” that focused on crime and disorder associated with homeless encampments. Crime reduction was the goal. The police division in which the program was undertaken provides 8 years of time-series data serving as the observations for the treatment condition. Four adjacent police divisions in which the program was not undertaken provide 8 years of time-series data serving as the observations for the comparison condition. The data are analyzed using a generalized additive model. On balance, we find that this place-based intervention is associated with meaningful reductions in violent, property, and nuisance street crimes. There is no evidence of crime displacement. Policy Implications This study provides further evidence that geographically targeted police interventions can lead to significant crime prevention benefits, with no evidence that crime is simply displaced to other areas. Criminologists and the media have given the Los Angeles Police Department (LAPD) little credit for major reductions in crime that have occurred during the past 5 years following a number of major policy reforms. We suggest that researchers should look more closely at the targeted interventions the LAPD has undertaken for evidence-based examples of effective policing. Importantly, this work suggests that crime associated with homeless encampments can be meaningfully reduced with targeted police actions. However, law enforcement actions do not address the roots of homelessness nor most of its consequences. Getting tough on the homeless should not be confused with policies or programs that respond fundamentally to the social and personal problems that homelessness presents.
Conference Paper
Housing First Reduces Re-offending among Formerly Homeless Adults with Mental Disorders: Results of a Randomized Controlled Trial Stefanie N Rezansoff, Akm Moniruzzaman & Julian M Somers Background: People who are both homeless and mentally ill are at very high risk of being arrested and involved with the criminal justice system. Considerable public costs have been associated with service use among this subgroup, especially those related to justice system involvement. Healthcare and housing interventions have been shown to produce multiple benefits among the homeless mentally ill, particularly the model known as Housing First (HF). HF is characterized by rapid rehousing in permanent, market accommodations without requirements around sobriety/treatment adherence, and facilitating access to specific resources (e.g., health, social, vocational) to support the attainment of client centered goals. Experimental evidence indicates that HF increases housing stability within this population. It is also associated with lower residential costs than common alternative approaches. Few studies, however, have examined the effect of HF on crime or public safety. Methods: Individuals meeting criteria for homelessness and a current mental disorder were randomized to one of three conditions: treatment as usual (reference); scattered site HF (in which participants are dispersed in market accommodations); and congregate HF (where participants are supported together in a single building). Administrative data representing all convictions extending from at least ten years prior to recruitment and up to two years post-randomization were linked in order to study prior histories of offending and to test the relationship between housing status and offending following randomization for up to two years. Intent-to-treat analysis was conducted to evaluate the effect of HF interventions using negative binomial regression. Results: Of the 297 study participants, 67% (n=198) was involved with the justice system, with a mean of 8.07 convictions per person in the ten years prior to recruitment. The most common category of crime was "property offences" (mean=4.09). Following randomization, the scattered site HF condition was associated with significantly fewer sentences than treatment as usual (Adjusted IRR = 0.29; p = 0.07). Congregate HF was associated with a marginally significant reduction in sentences compared to treatment as usual (Adjusted IRR = 0.55; p=0.108). Offending history was predictive of convictions, while concurrent substance use was not. Conclusions: This study is the first randomized controlled trial to demonstrate benefits of HF among a homeless sample with mental illness in the domain of public safety and crime. Our results are consistent with broader social policy programs that have experimentally demonstrated improvements in physical and mental health among the poor through reductions in economic segregation. Our sample was frequently involved with the justice system, with great personal and societal costs, and findings confirm that HF programs – particularly those using the scattered site format – promote reductions in offending and reconviction. Our findings also suggest that non-abstinence based HF for people with concurrent disorders can effectively improve public safety. This underscores the importance of addressing criminogenic risks among the homeless and mentally ill, such as poverty and exposure to crime, rather than triaging offence risk on the basis of specific symptoms. Further implementation of HF is strongly indicated. Research examining interdependencies between housing, health, and the justice system is indicated. 5 keywords: Intra-urban dynamics; social and territorial health inequities; determinants of health; public health; urban planning
Article
Homeless individuals represent a disadvantaged and marginalised group who experience increased rates of physical illness as well as mental and substance use disorders. Compared to stably housed individuals, homeless adults with mental disorders use hospital emergency departments and other acute health care services at a higher frequency. Housing First integrates housing and support services in a client-centred model and has been shown to reduce acute health care among homeless populations. The present analysis is based on participants enrolled in the Vancouver At Home Study (n = 297) randomised to one of three intervention arms (Housing First in a ‘congregate setting’, in ‘scattered site’ [SS] apartments in the private rental market, or to ‘treatment as usual’ [TAU] where individuals continue to use existing services available to homeless adults with mental illness), and incorporates linked data from a regional database representing six urban emergency departments. Compared to TAU, significantly lower numbers of emergency visits were observed during the post-randomisation period in the SS group (adjusted rate ratio 0.55 [0.35,0.86]). Our results suggest that Housing First, particularly the SS model, produces significantly lower hospital emergency department visits among homeless adults with a mental disorder. These findings demonstrate the potential effectiveness of Housing First to reduce acute health care use among homeless individuals and have implications for future health and housing policy initiatives.
Article
Abundant research confirms a high prevalence of substance use and mental disorders in correctional samples. It is unclear, however, how these contribute to the risk of repeat offending. The present study examined offense trajectories within a Canadian Provincial offender population (N = 31,014), and observed that offenders with non–substance-related mental disorders were at no greater risk of recidivism than those with no diagnosis. In contrast, odds of recidivism were significantly higher among those with substance use and/or co-occurring disorders. These findings add strength to the emerging conclusion that non–substance-related mental disorders are, as a group, less likely to predict recidivism than substance use disorders. Notably, nearly 50% of repeat offenders had a physician-diagnosed substance use disorder in the 5 years prior to their index offense. Results are discussed in relation to the necessity for targeted evidence-based partnerships between health and corrections sectors that are responsive to both public health and safety. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
Article
Silent killer diseases produce minimum or no symptoms and if not treated are capable of causing death. Heart disease, hypertension and diabetes are examples of silent diseases. There are other less known diseases such as renal cell cancer. Homelessness is another less known silent killer, but is not a disease or illness, it is a product of society. It does, however, produce signs and symptoms that nurses should be aware of. When homelessness is ignored or not treated, death at an early age is often the outcome.
Article
Data from the First Census of Homeless People in the City of São Paulo, carried out in 2000, show that the spatial distribution of this population is not random and points to a number of high-incidence districts. The authors estimated a regression model that related this distribution to a series of indicators. The values found appear to confirm, initially, the relationship between the spatial distribution of street people and the presence of verticalized premises for use by commercial establishments and services, the presence of people not living in the districts, and the per capita income of families living in the districts.
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IntroductionSingle room occupancy (SRO) hotel units represent the most basic shelter provided for low-income individuals living in Vancouver's Downtown Eastside (DTES). While homelessness and marginalized housing in general, have been identified as environments that facilitate HIV risk behaviours, less attention has been paid to the specific context of living in SRO hotels. This analysis was therefore undertaken to describe the characteristics of individuals living in SRO hotels and to explore the association between living in SRO hotels and health status.
Article
This article investigates the spatial dimension of automotive theft, break and enter, and violent crime in Vancouver, British Columbia in 1996. The article uses and synthesizes social disorganization theory and routine activity theory as a theoretical backcloth and employs a spatial autoregressive regression procedure that accounts for spatial autocorrelation between crime rates and socio-economic characteristics at the census tract level. Strong support is found for synthesizing these two most common spatial theories of crime. In particular, high unemployment (social disorganization theory) and the presence of young populations (routine activity theory) are the strongest predictors of criminal activity.Le présent article examine la dimension spatiale du vol automobile, du cambriolage et de crimes violents recensés en 1996 dans la ville de Vancouver, Colombie-Britannique. L'article s'appuie sur des théories de la désorganisation sociale et des activités courantes et en fait une synthèse servant de base théorique. Il utilise une méthode de régression spatiale autorégressive qui permet d'expliquer l'autocorrélation spatiale entre les taux de criminalité et les caractéristiques socio-économiques selon les secteurs de recensement. La synthèse de ces deux théories spatiales les plus répandues en matière de criminologie est validée. Le taux de chômage élevé (la théorie de la désorganisation sociale) et la présence de jeunes (théorie des activités courantes) constituent les facteurs les plus importants pour prédire la criminalité.
Article
The Collaborative Initiative to Help End Chronic Homelessness was a coordinated effort by the US Departments of Health and Human Services (HHS), Housing and Urban Development (HUD), and Veterans Affairs (VA), and the US Interagency Council on Homelessness to house and provide comprehensive supportive services to individuals with serious psychiatric, substance use, health, and related disabilities who were experiencing long-term chronic homelessness. Eleven communities received 3-year grants from HHS and VA (2003–2006) and up to 5-year grants from HUD (2003–2008) to implement the initiative. This article provides background on chronic homelessness, describes the federal collaboration to comprehensively address chronic homelessness, and introduces the seven articles in this special issue that describe the findings and lessons learned from the participating communities in addressing chronic homelessness. Collectively, these articles offer insight into the challenges and benefits of providing housing and services to individuals experiencing chronic homelessness. Keywordshomelessness-chronic-housing-supportive services-mental health services-substance use disorders
Article
Deinstitutionalization is an ongoing process, as many jurisdictions continue to struggle with redesigning their psychiatric systems. Historically, reducing psychiatric beds and closing hospitals have resulted in deleterious outcomes for people with severe and persistent mental illness. More recent evidence suggests that careful implementation of deinstitutionalization policies can thwart potential adverse consequences and may even foster favorable outcomes. This study evaluated the extent to which the recent devolution of the only tertiary psychiatric hospital in British Columbia resulted in a direct shift of individuals to other institutional sectors, such as criminal justice and health sectors. Admission rates to general hospitals, continuing care facilities, correctional institutions, and forensic psychiatric facilities were compared among two patient groups: those discharged before the realignment of the tertiary psychiatric hospital system (prerealignment cohort) (N=164) and those discharged after initiation of the system reforms (postrealignment cohort) (N=171). Most of the patients in the postrealignment cohort have remained in the tertiary care settings to which they were originally discharged. For patients in the postrealignment cohort, contact with other institutional sectors was rare and shorter in duration than it was for patients in the prerealignment cohort. This study provides preliminary evidence that recent efforts to realign British Columbia's provincial tertiary psychiatric hospital system have not resulted in a significant shift of the relocated patients to institutions in other sectors.
Article
While recent research suggests that policing interventions can reduce crime through the spatial deconcentration of street homelessness in Skid Row, such efforts will not succeed on a sustained basis. The city and county need a more comprehensive plan that includes targeted housing development for people who are chronically homeless, along with the spatial deconcentration and repurposing of existing homeless programs.
Article
Two modeling approaches are commonly used to estimate the associations between neighborhood characteristics and individual-level health outcomes in multilevel studies (subjects within neighborhoods). Random effects models (or mixed models) use maximum likelihood estimation. Population average models typically use a generalized estimating equation (GEE) approach. These methods are used in place of basic regression approaches because the health of residents in the same neighborhood may be correlated, thus violating independence assumptions made by traditional regression procedures. This violation is particularly relevant to estimates of the variability of estimates. Though the literature appears to favor the mixed-model approach, little theoretical guidance has been offered to justify this choice. In this paper, we review the assumptions behind the estimates and inference provided by these 2 approaches. We propose a perspective that treats regression models for what they are in most circumstances: reasonable approximations of some true underlying relationship. We argue in general that mixed models involve unverifiable assumptions on the data-generating distribution, which lead to potentially misleading estimates and biased inference. We conclude that the estimation-equation approach of population average models provides a more useful approximation of the truth.
Article
Homeless people in Osaka City are geographically concentrated. The purpose of this paper is to empirically test the hypothesis that the geographic concentration arises from the benefits of homeless networks. A spatial regression model is estimated using data on Osaka City's homeless population by census blocks. The positive coefficient of the spatially lagged dependent variable enables us to explore how a homeless network across census blocks, outweighs a negative competition effect. The estimated results indicate that homeless networks exist in homeless societies.
Article
Longitudinal data sets are comprised of repeated observations of an outcome and a set of covariates for each of many subjects. One objective of statistical analysis is to describe the marginal expectation of the outcome variable as a function of the covariates while accounting for the correlation among the repeated observations for a given subject. This paper proposes a unifying approach to such analysis for a variety of discrete and continuous outcomes. A class of generalized estimating equations (GEEs) for the regression parameters is proposed. The equations are extensions of those used in quasi-likelihood (Wedderburn, 1974, Biometrika 61, 439-447) methods. The GEEs have solutions which are consistent and asymptotically Gaussian even when the time dependence is misspecified as we often expect. A consistent variance estimate is presented. We illustrate the use of the GEE approach with longitudinal data from a study of the effect of mothers' stress on children's morbidity.
Article
To develop a brief, multi-dimensional instrument for assessing treatment outcome for people with drug and/or alcohol problems. The Maudsley Addiction Profile (MAP) is the first instrument to be developed in the United Kingdom for this purpose. Field testing with quota-recruitment of problem drug users and problem alcohol users in treatment with researcher and clinician-administered test-retest interviews. Two community and two inpatient services at the Bethlem Royal and Maudsley Hospital, London. Subjects (160 drug users and 80 alcohol users) interviewed by eight interviews (four researchers and four clinicians), each of whom interviewed 30 subjects on two occasions. Sixty items across substance use, health risk, physical/psychological health and personal/social functioning domains. Average completion time of the MAP was 12 minutes. The questionnaire was acceptable to a majority of subjects and performed well with both researcher and clinician interviewers. Internal reliability and feasible concurrent validity assessments of the scales and items were highly satisfactory. Test-retest reliability was good, average intraclass correlation coefficients across eight substances were 0.94 and 0.81 across health risk, health problems, relationship conflict, employment and crime measures. The MAP can serve as a core research instrument with additional outcome measures added as required. The collection of a set of reliable quantitative measures of problems among drug and alcohol users by research or treatment personnel for outcome evaluation purposes need not be time-consuming.
Article
There is currently great concern over the demands on psychiatric services in metropolitan areas in most developed countries, and this is exemplified in capital cities. These greater demands were not anticipated by those planning psychiatric services and the consequences have led to insufficient beds in many areas. We investigated the geographical mobility (the number of changes of address in the past 2 years) of patients presenting to services in greater London, to determine whether this might be a possible factor in the increased demand. The geographical mobility of the severely mentally ill was determined by taking a random sample of all psychiatric admissions to hospitals serving residents in the London area over the calendar year of 1994 (n = 156) and an equivalent sample of patients in an established community mental health team (n = 74) in one area (Paddington). The extent of geographical movement was determined for the 2 years prior to interview. Greater geographical movement in the in-patient group was found for those living in inner London compared with outer London and for patients admitted to hospitals outside their catchment area. Twenty-eight percent of the in-patient sample had changed address in the year before admission (including 13% more than once) and 39% had changed address in the 2 years prior to admission. By contrast, the patients seen by the community psychiatric team were less than half as likely to have changed address over the previous year as the in-patients, and none of the community team's patients had changed address more than once over the previous year. The geographically mobile patients had significantly longer periods in hospital than geographically stable patients. Geographical mobility of psychiatric patients in London is high and is particularly marked for those presenting for in-patient treatment. These findings suggest that greater mobility could be one of the most important reasons for the higher than expected demands on psychiatric services and the difficulties in maintaining contact with patients in London in general and inner London in particular. More attention should be paid to geographical mobility as a predictor of psychiatric service use, and it is recommended that it is recorded regularly in information systems.
Tackling homelessness in Los Angeles’ skid row
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Culhane DP. Tackling homelessness in Los Angeles' skid row. Criminol Public Policy 2010;9:851–7.
Baseline personal story interviews from the Vancouver at home study. Mental Health Commission of Canada
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Patterson M, Markey M, Eiboff F. Baseline personal story interviews from the Vancouver at home study. Mental Health Commission of Canada, 2011.
A thousand dreams: Vancouver's downtown eastside and the fight of its future
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Culbert L, Boyd N, Campbell L. A thousand dreams: Vancouver's downtown eastside and the fight of its future. Vancouver: D&M, 2010.
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