PreprintPDF Available

Homeless and Head Injured. Health Well being and Social Integration

Authors:
Preprints and early-stage research may not have been peer reviewed yet.

Abstract and Figures

This paper describes the setting up of a pilot community neurocase management service for homeless adults with a brain injury. Whilst homelessness is a major problem in the UK and elsewhere, to date few brain injury or homelessness services have considered the complex medical, psychological and social factors affecting this population specifically. Investment of resources in service provision should be based upon evidence of the presenting needs and best practice in meeting these. This paper addresses the first of these two requirements, focussing on the initial cohort referred into our service. More detail about the interventions received and outcomes achieved, along with a discussion of the challenges encountered in providing the service will be provided in a follow-up paper. The need for psychologically-informed services to promote social inclusion is supported by our data which revealed concerning levels of community estrangement. Our data also confirm that homelessness often occurs in the context of multiple comorbidities which traverse conventional boundaries across medical, social care and criminal justice systems, meaning that collaborative working is essential. The argument for neuropsychological input in designing and delivering support alongside other services is clear.
Content may be subject to copyright.
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
Homelessness and Head Injury:
Health, well-being and social integration in referrals to a neurocase management
service.
Andrew Worthington1,2, Lee Edwards3 and Lauren Joiner1
1Headwise, 2College of Medicine and College of Human and Health Sciences, Swansea
University, 3Headway Birmingham and Solihull
Abstract
This paper describes the setting up of a pilot community neurocase management service for
homeless adults with a brain injury. Whilst homelessness is a major problem in the UK and
elsewhere, to date few brain injury or homelessness services have considered the complex
medical, psychological and social factors affecting this population specifically. Investment of
resources in service provision should be based upon evidence of the presenting needs and best
practice in meeting these. This paper addresses the first of these two requirements, focussing
on the initial cohort referred into our service. More detail about the interventions received and
outcomes achieved, along with a discussion of the challenges encountered in providing the
service will be provided in a follow-up paper. The need for psychologically-informed services
to promote social inclusion is supported by our data which revealed concerning levels of
community estrangement. Our data also confirm that homelessness often occurs in the context
of multiple comorbidities which traverse conventional boundaries across medical, social care
and criminal justice systems, meaning that collaborative working is essential. The argument
for neuropsychological input in designing and delivering support alongside other services is
clear.
Introduction
Homelessness is an increasing societal problem which presents significant challenges to service
providers and is belatedly attracting the interest of neuropsychologists (Forrester et al., 2017).
According to research by Shelter
1
280,000 people in England alone are homeless on any given
1
This is England: A picture of homelessness in 2019. www.england/shelter.org.uk
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
night, an increase of 23,000 since 2016. Whilst definitions of homelessness vary and causes
are complex, one study of rough sleepers by Shelter (Rice et al, 2007) is typical in identifying
common contributory factors as: relationship breakdown (41%), drug problems (31%), alcohol
problems (28%), being asked to leave the family home (28%), leaving prison (25%) and mental
health problems (19%). In one study of 90 homeless men 80% were considered to have
possible cognitive impairment (Solliday-McRoy et al., 2004). Yet until recently little attention
was given to head injury or traumatic brain injury (TBI) as one of the major causes of all the
above factors and therefore of homelessness.
One systematic review identified only eight studies, with rates of TBI amongst homeless people
ranging from 8% to 53% and research was generally of poor quality (Topolovec-Vranic et al.,
2012). . Since then studies have demonstrated a strong association of head injury or traumatic
brain injury (TBI) and homelessness. The rate of head injury/TBI in homeless populations is
broadly about 50% having been reported recently as 43% (Mackelprang et al., 2014), 45%
(Topolovec-Vranic, 2014), 48% (Oddy et al., 2012), 53% (Hwang et al., 2008; Topolovec-
Vranic, 2017) and 64% (To et al., 2016).
Significantly the majority of people report a first head injury occurring prior to becoming
homeless, figures ranging from 51% (Mackelprang et al., 2014) to 70% (Hwang et al., 2008),
87% (Topolovec-Vranic et al., 2014) and 90% (Oddy et al., 2012). Head injury is also a risk
factor for mortality in the homeless (McMillan et al., 2015) and greater psychiatric morbidity
(Mackelprang et al., 2014). Mackelprang et al., (2014) reported that people with TBI became
homeless at a younger age and were more likely to suffer with mental health and substance
misuse and difficulties with daily activities. Similarly, amongst homeless veterans those with
a history of TBI were at greater risk of psychiatric morbidity (Brenner, 2017). The relationship
between head injury and homelessness was strongly endorsed in a recent systematic review
and meta-analysis which confirmed that a history of TBI was consistently associated with
younger age at first experience of homelessness and that the lifetime prevalence of moderate
or severe TBI in the homeless is almost ten times higher than in the general population (Stubbs
et al., 2020).
Support for brain-injured adults in this population has received less attention but evidence
indicates that case management-based services can minimise dependence on hospitals
(Sadowski et al., 2009) and reduce substance misuse and associated employment barriers (de
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
Vet et al., 2013). What is lacking, especially in the UK, is any evaluation of a similar approach
specifically for adults with brain injury who present as homeless.
Aims
In this article we review the inception of a novel neurocase management service designed to
provide assessment, support and signposting to address the complex social and health needs of
this population. The purpose of this paper is to report on the characteristics of the initial cohort
during the first year of operation. A subsequent paper will report on outcomes and
recommendations for developing future services.
Service organisation
The service was delivered primarily through a local brain injury charity in the UK, Headway
Birmingham and Solihull, funded by and in collaboration with Headwise, an independent
community neurorehabilitation provider. Conventionally, the usual care arrangements relied
on an office-based worker receiving a written/telephone referral and then having to follow up
whatever contact details were included which frequently lacked the usual means of personal
contact such as email, telephone number or home address. Unless the referred person attended
the initial assessment offered at Headway, the case worker would have no means of knowing
whether they received the appointment or why they did not attend. Anecdotally it was also
apparent that hospitals would often write-off homeless adults because of a host of comorbidities
and defer from referring on to community support providers. We also recognised that brain
injury charities receive numerous requests from hard-pressed statutory services to provide
front-line support often without the necessary clinical expertise or resources to manage
complex conditions.
We based our notion of homelessness on the legal definition in England as contained in the
Housing Act 1996 which includes anyone without a permanent home they had a legal right to
occupy and those at risk from residing in their home, for example due to violence or where it
was unreasonable to continue to occupy the premises. This also includes people threatened
with homelessness such as those being evicted or asked to leave by family and friends.
Our experience is that it is challenging to support homeless people due to the complexity of
their needs, their transient residence from place to place and a degree of ambivalence towards
professionals at times. With limited additional funds we wished to evaluate whether a more
proactive model centred on a dedicated brain injury case worker for homeless adults, with
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
clinical support, could provide a more timely and effective outreach. The service consisted of
one half-time brain injury case worker based at Headway and integrated within the wider
organisation, supported by a psychology graduate and with access to a consultant
neuropsychologist.
The unique feature of our service was the dedicated case worker able to engage proactively
with homeless adults and various agencies, providing neuropsychological and rehabilitative
inputs and signposting to other medical, social and legal support organisations where
appropriate. Their role was to identify and liaise with numerous potential referral sources
including hospital, social care, legal, police and other voluntary organisations that assist the
homeless and which could also help in meeting a range of needs. This meant the case worker
developing educational literature, making new contacts and having regular meetings with these
key stakeholders. It was anticipated that this ‘extra-care’ model would be compared with the
‘usual care’ approach that had been employed to date, with referrals randomly assigned to each
group. Participants were provided with information and given the choice to receive the usual
support or to opt-in to the evaluation which meant they would be randomly allocated to usual
care or extra care, and written consent was obtained. No person referred declined to participate
and all agreed for their data to be reported anonymously.
Measures
Upon referral the case worker would carry out an initial assessment within two weeks, either
in person or by telephone if this was not possible, using a neuropsychologically-informed
screening protocol. The main independent measures were presence of brain injury, using the
Brain Injury Screening Index (BISI) described by Ramos et al., (2018) and a number of key
demographic variables, including length of time homeless and whether this was preceded by a
first head injury, and the presence of other comorbid conditions. The principal dependant
measures were the EQ-5D-5L, Community Integration Measure (CIM) and the SF-12. The
EQ-5D-5L has been used in a variety of neurological conditions and incorporates a 5-point
rating scale of five basic dimensions of function: mobility, self-care, pain/discomfort,
anxiety/depression and usual activities. The CIM contains 10 self-statements with which a
respondent has to indicate their level of agreement on a 5-point scale. The CIM has been shown
to be a useful measure of integration for people with histories of TBI up to 15 years (Griffen et
al., 2010) and was felt to be relevant for our service with items such as ‘I know my way around
this community,’ ‘I have something useful and productive to do’ and ‘I feel like I belong here.’
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
The SF-12 has been widely used in homelessness research (Larson, 2002) and was scored using
the recommended Medical Outcomes Study software. This provides measures of physical
function, vitality, social function, pain and emotional health, and yields overall Mental Health
and Physical Health indices. Mental Health scores range from 10 to 70, Physical Health from
13 to 69, with US data giving a standardised mean of 50 (SD 10).
In addition, we developed ad hoc 8-point category scales intended to group the sample in terms
of occupation status (e.g. voluntary work, cash in hand work, no constructive occupation) and
frequency and nature of homelessness (see Table 1). Whilst lacking known psychometric
properties, these provided important descriptive information to supplement the more formal
measures. We also recorded other potentially relevant information on degree of family contact,
finances, health service utilisation and involvement with the criminal justice system (see Table
4). Although participant numbers are modest, as far as we know these results provide the first
detailed characterisation of a brain injury homeless sample in the UK and it is hoped the
assessments employed can be used to inform future studies of this kind.
Results
In total there were 36 referrals, 25 of whom were possible to contact and assess. The majority
were male (22 of those assessed) and 24 were of working age. At least one TBI was reported
by 16 participants, and 5 reported two or more injuries. Of these 21 cases 19 were rated on the
BISI as moderate to severe, 9 being rated on the overall TBI Index score, which combines
frequency with severity, as very severe or extremely severe. In addition, 7 people reported non-
traumatic brain injuries such as stroke.
At initial assessment there was a wide range of homelessness experience, the most common
being nightly access to a shelter or sofa-surfing (Table 1) and unsurprisingly the majority (22
people) had no constructive occupation.
The number of people who reported a head injury prior to becoming homeless was 15 (60%)
with mean time from head injury to homelessness of 7.6 years (SD. 7.6) and 5 people reported
their head injury occurred subsequently (mean interval: 4.2 years [3.8]). In addition, 4 people
gave the same date (which could mean they became homeless upon sustaining a head injury)
and 1 respondent was unsure of the chronology, so the true figure may be 19-20 respondents
(76-80%) who became homeless following a head injury.
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
Homelessness Scale
Frequency
Sleeping on street ≥ 4 nights
2
Sleeping in shelter nightly
8
Sofa-surfing
8
B&B accommodation
3
Housing Association accommodation
0
Privately rented accommodation
3
At risk in own home
1
Table 1. Current experience of homelessness.
Table 2 shows the number of neuropsychological difficulties reported on the BISI by all 25
participants, with all but speech problems being reported by over half the sample.
Brain Injury Screening Index
Yes
Percentage
Problems with … Thinking
14
56
Memory
17
68
Concentration
13
52
Speech
11
44
Anxiety
15
60
Anger
17
68
Table 2. Neuropsychological problems reported on Brain Injury Screening index
There was a high rate of comorbid problems reported by participants during the assessment
(Table 3), especially substance misuse, with about one quarter also reporting serious mental
health problems and a fifth with some form of learning disability. In addition, one third had
been convicted of criminal behaviour in the past.
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
Comorbid conditions and /or
problems
Yes
Percentage
Learning Disability
5
20
ADHD
2
8
Substance misuse
10
40
Criminal behaviour
8
32
Mental health difficulties
6
24
Table 3. Prevalence of comorbidities reported by cohort.
In our cohort, 22 of the 25 adults had no constructive occupation, 1 had access to voluntary
work and 2 were undertaking some casual remunerative work. Additional data is summarised
in Table 4. One third did not have regular family contact, one third already received support
from an alcohol or drug service and a quarter had been involved with the police or court systems
in the previous three months. Overall 8 people had attended Accident and Emergency at least
once in the previous month, 3 of whom attended on at least four occasions. This represents a
third of our cohort. All but one were taking prescribed medication and reassuringly all were
registered with a GP but less than half had access to a dentist. Three-quarters had access to a
bank account but only one in five had a social worker they could call upon for assistance.
Frequency
Percentage
Registered with a GP
25
100
Registered with a dentist
12
48
Has a named social worker
5
20
Has a drug/alcohol team
8
32
Has own bank account
19
76
Is receiving support with debts
1
4
Has regular contact with family
17
68
Had police/courts contact in last 3 months
7
28
Taking regular medication
24
96
Table 4. Involvement with family, health, welfare and criminal justice systems.
Responses on the Community Integration Measure were informative. Approximately three-
quarters (19 respondents) agreed that at least sometimes they knew their way around the
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
community and knew people they could say hello to (20 respondents), but many felt they did
not belong in the community, most had nothing purposeful to occupy their time and the
majority disliked where they were living. Table 5 details these responses further.
Always
agree
Sometimes
agree
Neutral
Sometimes
disagree
Always
disagree
1. I feel like part of the community, like I belong
here
6
2
6
4
7
2. I know my way around this community
12
4
1
2
6
3. I know the rules in this community and can fit in
with them
18
1
2
1
3
4. I feel that I am accepted in this community
9
4
5
4
3
5. I can be independent in this community
10
6
2
3
4
6. I like where I am living now
3
3
4
1
14
7. There are people I feel close to in this community
9
5
3
5
3
8. I know a number of people well enough to say
hello and have them say hello back
13
5
1
1
5
9. There are things that I can do in the community
for fun in my free time
6
6
1
1
11
10. I have something to do in this community during
the main part of my day that is useful and
productive
2
6
4
2
11
Table 5. Initial responses on the Community Integration Measure.
On the SF-12 our sample yielded a mean Mental Health score of 35.2 (SD 13.6) and mean
Physical Health score of 37.1 (10.7), both of which are lower than reported by Grinman et al.,
(2010) for homeless adults with drug problems in Toronto. These authors did not record the
presence of brain injury but assuming from other studies that 50% did not have a brain injury,
then brain injury should be considered an additional complicating factor in our sample.
Significantly, around three quarters of our cohort were rated as ‘far below average’ for Mental
Health (19 respondents) and Physical Health (18 respondents).
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
On the EQ-5D general health ratings from 1 to 100 on the health thermometer were clustered
around the middle with wide variability (mean: 46.5; SD: 27.4) which is well below the UK
population mean of 82.5 (SD 17) reported by Kind et al., (1993) in a study of almost 4000
adults (excluding the homeless). It is also lower than the values reported by Argintaru et al.,
(2013) for homeless adults in Canada. Again, assuming a base rate of 50% brain injury in the
homeless population, it suggests brain injury confers additional health burden, possibly through
impact on physical as well as mental function.
Based on mean ratings for each EQ-5D dimension within the range 1 to 5, the greatest
difficulties were reported in terms of anxiety/depression (2.92) and pain/discomfort (2.80),
closely followed by problems with mobility (2.56) and usual activities (2.48) whereas self-care
was rated the least problematic (1.56). Taking the average score for each dimension yields a
profile of 32233 which, based on the EQ-5D-5L UK value set published by Devlin et al. (2016),
equates to a health state of 0.6 where 1 represents the highest health status possible and 0
represents death. This figure allows for comparison with other health conditions, with change
over time and in cost-utility analysis. For example, the result from our sample is lower than
Argintaru et al., (2013) reported for homeless adults with no unmet needs (0.8) and those with
residual unmet needs (0.7).
Discussion
Homelessness is a problem that neuropsychologists cannot afford to ignore if services are to
reach some of the most vulnerable members of society. Our service analysis that at least 60%
of people sustained a head injury prior to becoming homeless is consistent with data from
elsewhere, though the process by which this occurs is likely to be complex, often taking place
over many years, suggesting there may be numerous opportunities to intervene.
To date there are very few dedicated services to assist those currently homeless or at risk of
homelessness despite, or perhaps because of, their complex medical, psychological, social and
housing needs. Reliance on collaborative working across agencies is challenging and whether
that is sufficient or even practical at present, or whether a dedicated service is the way forward
remains to be determined
Homelessness takes many forms as illustrated in the variety of responses in Table 1 in our
modest sample. Our data supports the importance of an initial screening process broad enough
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
to encompass multiple needs and sufficiently detailed to be sensitive to the lived experience of
each person. This means being able to prioritise different inputs for different people, such as
support to contact their family, advice about money, help to find a dentist or to abstain from
drugs. It also means embracing community psychology as person-specific solutions are
unlikely to reside in individually-focused interventions alone. The need for psychologically-
informed services to promote social inclusions (Seager, 2011) is supported by our data which
reveal concerning levels of community estrangement.
Services must recognise that brain injury is a significant risk factor for homelessness and there
is now a strong argument for neuropsychological input in designing and delivering support
alongside other psychological approaches. Andersen et al (2014) for example reported attention
impairment on the RBANS in 11 homeless men reporting a TBI compared to a control group
of 19 non-TBI homeless males. RBANS scores were not associated with mental health or
substance misuse per se. Neuropsychologists should also be aware that the Homelessness
Reduction Act 2017 places a duty on local housing authorities to ensure provision of advisory
services which must be designed to meet the needs of persons suffering from a mental illness
or impairment, or any other group identified as being at particular risk of homelessness in the
authority’s district (emphasis ours). With brain injury being recognised as a key risk factor for
homelessness the stage is now set for the neuropsychological needs of homeless adults to given
due recognition and for neuropsychologists to be at the forefront of service delivery.
References
Andersen J, Kot N, Ennis N, Colantonio A, Ouchterlony D, Cusimano MD, Topolovec-Vranic
J (2014) Traumatic brain injury and cognitive impairment in men who are homeless. Disability
and Rehabilitation 36: 2210-2215.
Argintaru N, Chambers C, Gogosis E, Farrell S, Palepu S, Klodawsky F, Hwang S. (2013) A
cross-sectional observational study of unmet health needs among homeless and vulnerably
housed adults in three Canadian cities. BMC Public Health 13: 577.
Brenner LA, Hostetter TA, Barnes SM, Stearns-Yoder KA, Soberay KA, Forster JE (2017)
Traumatic brain injury, psychiatric diagnoses and suicide risk amongst Veterans seeing
services related to homelessness. Brain Injury 31: 1731-1735.
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
de Vet R, van Luijtelaar MJA, Brilleslijper-Katwer SN, Vanderplasschen W, Beijersbergen
MD, Wolf JRLM (2013) Effectiveness of case management for homeless persons: A systematic
review. American Journal of Public Health 103: e13 - e26.
Devlin NJ, Shah KK, Feng Y, Mulhern B, van Hout B (2017) Valuing health-related quality of
life: An EQ-5D-5L value set for England. Health Economics 27: 7-22.
Forrester RL, Weatherhead S, Rosbert C, Hewett N, Worthington A (2017) Homelessness and
brain injury: What role do we play as socially-conscious service providers? The
Neuropsychologist 4: 19 24.
Griffen JA, Hanks RA, Meachen S (2010) The reliability and validity of the Community
Integration Measure in persons with traumatic brain injury. Rehabilitation Psychology 55: 292-
297.
Grinman MN, Chiu S, Redelmeier DA, Levinson W, Kiss A, Tolomiczenko G, Cowan L,
Hwang S. (2010) Drug problems among homeless individuals in Toronto, Canada: prevalence,
drugs of choice and relation to health status. BMC Public Health 10:94
Hwang S Colantonio A, Levinson W (2008) The effect of traumatic brain injury on the
health of homeless people. Canadian Medical Association Journal: 179: 779-784.
Kind P, Dolan P, Gudex C, Williams A (1993) Variations in population health status: results
from a United Kingdom national questionnaire survey. British Medical Journal 316: 736-741.
Larson CO (2002) Use of the SF-12 instrument for measuring the health of homeless persons.
Health Services Research 37: 733 750.
Mackelprang JL, Harpin SB, Grubenhoff JA, Rivara FP (2014) Adverse outcomes among
homeless adolescents and young adults who report a history of traumatic brain injury.
American Journal of Public Health 104: 1986-1992.
McMillan TM, Laurie M, Oddy M, Menzies M, Stewart E, Wainman-Lefley J (2015) Head
injury and mortality in the homeless. Journal of Neurotrauma 32: 116-119.
Oddy M, Moir JF, Fortescue D, Chadwick S (2012) The prevalence of traumatic brain injury
in the homeless community in a UK city. Brain Injury 26: 1058-1064.
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
Ramos SDS, Liddement J, Addicott C, Fortescue D, Oddy M (2018) The development of the
Brain Injury Screening Index (BISI): a self-report measure. Neuropsychological Rehabilitation
28:
Rice B, Hough J, Smith J, Francis M (2007) Reaching Out. A consultation with street homeless
people 10 years after the launch of the Rough Sleepers Unit. London: Shelter in partnership
with Broadway.
Sadowski SS, Kee RA, VanderWeele TJ, Buchannan D (2009) Effect of a housing and case
management program on emergency department visits and hospitalisations among chronically
ill homeless adults. Journal of the American Medical Association 301: 1771-1778.
Seager M (2011) Homelessness is more than Houselessness: a psychologically-minded
approach to inclusion and rough sleeping. Mental Health and Social Inclusion 15: 183-189.
Solliday-Mcroay C, Campbell TC, Melcgert TP, Young TJ, Cisler RA (2004)
Neuropsychological functioning of homeless men. Journal of Nervous and Mental Disease 192:
471-478.
Stubbs JL, Thornton AE, Sevick JM, Silverberg ND, Barr AM, Honer WG, Panenka WJ (2020)
Traumatic brain innnnjury in homeless and marginally housed individuals: a systematic review
and meta-analysis. Lancet Public Health 5:e19-32.
To MJ, Palepu A, Aubry T, Nisenbaum R, Gogosis E, Gademann A, Cherner R, Farrell S, Misir
V, Hwang S (2016) Predictors of homelessness among vulnerably housed adults in 3 Canadian
cities: a prospective cohort study. BMC Public Health 16: 1041.
Topolovec-Vranic J, Ennis N, Colantonio A, Cusimano MD, Hwang SW, Kontos P,
Ouchterlony D, Stergiopoulos V. (2012) Traumatic brain injury among people who are
homeless: a systematic review. BMC Public Health 12:1059.
Topolovec-Vranic J, Ennis N, Howatt M, Ouchterlony D, Michalak A, Masanic C, Colantonio
A, Hwang S, Kontos P, Stergiopoulos V, Cusimano MD. (2014) Traumatic brain injury among
men in an urban homeless shelter: observational study of rates and mechanisms of injury.
Canadian Medical Association Journal Open 2: E69 E76.
Final accepted version. Please cite this article as: Worthington, A., Edwards, L., & Joiner, L. (2020). Homelessness and Head Injury: Health,
well-being and social integration in referrals to a neurocase management service. The Neuropsychologist, 9, xx-xx.
https://shop.bps.org.uk/publications/publication-by-series/the-neuropsychologist.html
Topolovec-Vranic J, Schuler A, Gozdzik A, Somers J, Bourque P, Frankish J, Jbilou J, Pakzad
S, Lazgare LIP, Hwang SW (2017) The high burden of traumatic brain injury and comorbidities
amongst homeless adults with mental illness. Journal of Psychiatric Research 87: 53-60.
Contact details:
Professor Andrew Worthington
Headwise
Claremont House
Claremont Bank
Shrewsbury
SY1 1RW
aworthington@headwise.org.uk
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Background: Homelessness is a global public health concern, and traumatic brain injury (TBI) could represent an underappreciated factor in the health trajectories of homeless and marginally housed individuals. We aimed to evaluate the lifetime prevalence of TBI in this population, and to summarise findings on TBI incidence and the association between TBI and health-related or functioning-related outcomes. Methods: For this systematic review and meta-analysis, we searched without date restrictions for original research studies in English that reported data on the prevalence or incidence of TBI, or the association between TBI and one or more health-related or function-related outcome measures. Studies were included if they had a group or clearly identifiable subgroup of individuals who were homeless, marginally housed, or seeking services for homeless people. With use of random-effects models, we calculated pooled estimates of the lifetime prevalence of any severity of TBI and the lifetime prevalence of moderate or severe TBI. We used meta-regression and subgroup analysis to evaluate potential moderators of prevalence estimates and the leave-one-out method for sensitivity analyses. We then summarised findings from all studies that evaluated TBI incidence and the association between TBI and health- related or functioning-related outcomes. All statistical analyses were done using R version 3.5.1. The study is registered with PROSPERO, number CRD42019119678. Findings: Of 463 potentially eligible studies identified by the search, 38 studies were included in the systematic review and 22 studies were included in the meta-analysis. The lifetime prevalence of any severity of TBI in homeless and marginally housed individuals (18 studies, n=9702 individuals) was 53·1% (95% CI 46·4–59·7; I2=97%) and the lifetime prevalence of moderate or severe TBI (nine studies, n=5787) was 22·5% (13·5–35·0; I2=99%). The method used to ascertain TBI history, the age of the sample, and the sample size significantly moderated estimated lifetime prevalence of any severity of TBI. TBI was consistently associated with poorer self-reported physical and mental health, higher suicidality and suicide risk, memory concerns, and increased health service use and criminal justice system involvement. Interpretation: The lifetime prevalence of TBI is high among homeless and marginally housed individuals, and a history of TBI is associated with poorer health and general functioning. Health-care providers and public health officials should have an increased awareness of the burden of TBI in this population. Prospective and longitudinal studies are needed to better understand how the health of this population is affected by TBI. Funding: Canadian Institutes of Health Research.
Article
Full-text available
Background Homelessness is a major concern in many urban communities across North America. Since vulnerably housed individuals are at risk of experiencing homelessness, it is important to identify predictive factors linked to subsequent homelessness in this population. The objectives of this study were to determine the probability of experiencing homelessness among vulnerably housed adults over three years and factors associated with higher risk of homelessness. Methods Vulnerably housed adults were recruited in three Canadian cities. Data on demographic characteristics, chronic health conditions, and drug use problems were collected through structured interviews. Housing history was obtained at baseline and annual follow-up interviews. Generalized estimating equations were used to characterize associations between candidate predictors and subsequent experiences of homelessness during each follow-up year. Results Among 561 participants, the prevalence of homelessness was 29.2 % over three years. Male gender (AOR = 1.59, 95 % CI: 1.14–2.21) and severe drug use problems (AOR = 1.98, 95 % CI: 1.22–3.20) were independently associated with experiencing homelessness during the follow-up period. Having ≥3 chronic conditions (AOR = 0.55, 95 % CI: 0.33–0.94) and reporting higher housing quality (AOR = 0.99, 95 % CI: 0.97–1.00) were protective against homelessness. Conclusions Vulnerably housed individuals are at high risk for experiencing homelessness. The study has public health implications, highlighting the need for enhanced access to addiction treatment and improved housing quality for this population.
Article
Full-text available
Objectives: Measures of patient-reported health are increasingly used in clinical and health system decisions, and the EQ-5D is one of the most widely used questionnaires. It is recommended by NICE and is widely used in clinical trials, as well as in population health surveys and the NHS PROMs programme. A new version, the EQ-5D-5L, is now available. The objective of this study is to establish how important different sorts of health problems are to overall quality of life, and to produce the set of scores (‘value set’) required to use EQ-5D-5L data in decision-making and priority setting in the English NHS. Design: The study design followed an international research protocol. Each participant valued 10 health states using a time trade-off approach and completed seven discrete choice tasks. The data are used to model values for all 3,125 states described by the EQ-5D-5L. Setting: England general population. Participants: Data were collected in face-to-face interviews with 996 adult members of the general public, selected at random from residential postcodes. The sample is broadly representative of the general population. Results: The data obtained from participants had good face validity. Problems with pain/discomfort and anxiety/depression were the most important factor in overall quality of life. Values ranged from -0.281 (for extreme problems on all dimensions) to 0.951. Conclusions: The value set reported here will have important implications for public decisions made using EQ-5D-5L data. There are considerably fewer states judged to be ‘worse than dead’ compared to the current EQ-5D value set (4.93%, compared with over one-third) and the minimum value is higher (-0.281 compared to -0.594). The results imply that QALY gains for interventions seeking to improve very poor health will be smaller using the EQ-5D-5L tariff, and may previously have been overestimated.
Article
Full-text available
Background: Little empiric research has investigated the interrelationship between homelessness and traumatic brain injury. The objectives of this study were to determine the rate, mechanisms and associated outcomes of traumatic brain injury among men in an urban homeless shelter. Methods: We recruited participants from an urban men's shelter in Toronto, Ontario. Researchers administered the Brain Injury Screening Questionnaire, a semistructured interview screening tool for brain injury. Demographic information and detailed histories of brain injuries were obtained. Participants with positive and negative screening results were compared, and the rates and mechanisms of injury were analyzed by age group. Results: A total of 111 men (mean age 54.2 ± standard deviation 11.5 yr; range 27-81 yr) participated. Nearly half (50 [45%]) of the respondents had a positive screening result for traumatic brain injury. Of these, 73% (35/48) reported experiencing their first injury before adulthood (< 18 yr), and 87% (40/46) reported a first injury before the onset of homelessness. Among those with a positive screening result, 33 (66%) reported sustaining at least one traumatic brain injury by assault, 22 (44%) by sports or another recreational activity, 21 (42%) by motor vehicle collision and 21 (42%) by a fall. A positive screening result was significantly associated with a lifetime history of arrest or mental illness and a parental history of substance abuse. Interpretation: Multiple mechanisms contributed to high rates of traumatic brain injury within a sample of homeless men. Assault was the most common mechanism, with sports and recreation, motor vehicle collisions and falls also being reported frequently by the participants. Injury commonly predated the onset of homelessness, with most participants experiencing their first injury in childhood. Additional research is needed to understand the complex interactions among homelessness, traumatic brain injury, mental illness and substance use.
Article
Full-text available
Risk factors for head injury are also risk factors for becoming homeless, but there is little research on this vulnerable group, who can be neglected by health services who specialise in acquired brain injury. This study investigates the prevalence of admissions to hospital with a head injury in the homeless and associations with later mortality. It compares homeless people with and without a record of hospitalised head injury (HHI) and the Glasgow population. Data were obtained from a UK National Health Service strategy to enhance care of the homeless. This included development and production of local registers of homeless people. In Glasgow the initiative took place over a seven year (2004-2010) period and comprised 40 general practitioner (family practice) services in the locality of 55 homeless hostels. The register was linked to hospital admissions with head injury recorded in Scottish Medical Records and to the General Register of Scotland which records deaths. 1590 homeless people were registered in general practitioner (family doctor) returns. The prevalence of admission to hospital with head injury in the homeless over a thirty year period (13.5%) was 5.4 times higher than in the Glasgow population. In the homeless with HHI, 33.6% died in the seven year census period, compared to 13.9% in the homeless with no hospitalised HI (NHHI). The standardised mortality ratio for HHI (4.51) was more than twice that for NHHI (2.08). The SMR for HHI aged 15-34 (17.54) was particularly high. These findings suggest that HHI is common in the homeless relative to the general population and is a risk factor for late mortality in the homeless population.
Article
Full-text available
Purpose: To examine cognitive performance among a sample of men in a residential unit of an urban homeless shelter and to compare cognitive performance between those with and without a history of traumatic brain injury (TBI). Methods: An exploratory, quantitative study of participants recruited through convenience sampling. Participants were screened for TBI using the Brain Injury Screening Questionnaire, and cognitive function using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Data were analyzed to examine associations between TBI status and cognitive performance. Results: Thirty-four participants were recruited for the study: n = 12 with a positive and n = 22 with a negative screen for TBI. Both groups performed below norms in all cognitive domains measured by the RBANS. Those with a positive screen for TBI performed significantly worse on attention tasks than those with a negative screen for TBI (p = 0.026). RBANS scores were not associated with either mental health or substance abuse status. Conclusions: A history of TBI was associated with generally poorer cognitive performance in the study sample. An improved awareness of TBI and cognitive dysfunction among service providers and routine TBI screening could improve treatment and service delivery for this population.
Article
Full-text available
Background Homeless persons experience a high burden of health problems; yet, they face significant barriers in accessing health care. Less is known about unmet needs for care among vulnerably housed persons who live in poor-quality or temporary housing and are at high risk of becoming homeless. The objectives of this study were to examine the prevalence of and factors associated with unmet needs for health care in a population-based sample of homeless and vulnerably housed adults in three major cities within a universal health insurance system. Methods Participants were recruited at shelters, meal programs, community health centers, drop-in centers, rooming houses, and single room occupancy hotels in Vancouver, Toronto, and Ottawa, Canada, throughout 2009. Baseline interviews elicited demographic characteristics, health status, and barriers to health care. Logistic regression was used to identify factors associated with self-reported unmet needs for health care in the past 12 months. Results Of the 1,181 participants included in the analysis, 445 (37%) reported unmet needs. In adjusted analyses, factors associated with a greater odds of reporting unmet needs were having employment in the past 12 months (AOR = 1.40, 95% CI = 1.03–1.91) and having ≥3 chronic health conditions (AOR = 2.17, 95% CI = 1.24–3.79). Having higher health-related quality of life (AOR = 0.21, 95% CI = 0.09–0.53), improved mental (AOR = 0.97, 95% CI = 0.96–0.98) or physical health (AOR = 0.98, 95% CI = 0.96–0.99), and having a primary care provider (AOR = 0.63, 95% CI = 0.46–0.85) decreased the odds of reporting unmet needs. Conclusions Homeless and vulnerably housed adults have a similar likelihood of experiencing unmet health care needs. Strategies to improve access to primary care and reduce barriers to accessing care in these populations are needed.
Article
The aim of this study was to investigate the psychometric properties and screening accuracy of the Brain Injury Screening Index (BISI), a self-report questionnaire designed to identify a history of acquired brain injury. The study was conducted in a closed male prison in the UK. The purposive sample comprised 55 male prisoners who arrived at the establishment during the study. A repeated measures design was used, where the Brain Injury Screening Index (BISI) was administered on three occasions. Inter-rater reliability was poor to moderate, but test retest reliability was moderate to good. Medical records were not available for all participants, but the limited number obtained resulted in a sensitivity of .38 to .71 and specificity of .47 to .70 across the three screening administrations of the BISI. The limitations of the present findings are discussed in the context of the use of the tool in custodial environments. It is argued that these results suggest that, when used as recommended, the BISI has acceptable reliability and validity as an initial screen for identifying individuals who should receive support and a comprehensive neuropsychological assessment, and it merits further investigation and development.
Article
Objective: characterize the prevalence of self-reported head injury with loss of consciousness (LOC) and associated demographic, clinical and service use factors in a sample of homeless adults with mental illness. Method: Participants in the At Home/Chez Soi study were interviewed at the time of study enrollment regarding their history of head injuries, mental and physical health diagnoses and justice system and healthcare interactions. Sociodemographic and clinical data were also collected. Results: Over half of the 2088 study respondents (52.6%, n = 1098) reported a history of head injury with a LOC, which was associated with several demographic, clinical and service use variables in this population. With respect to specific mental health conditions, a history of head injury with LOC was associated with higher odds of current depression (OR = 2.18, CI: 1.83-2.60), manic episode or hypomanic episode (OR = 1.91, CI: 1.45-2.50), PTSD (OR = 2.98, CI: 2.44-3.65), panic disorder (OR = 2.37, CI:1.91-2.93), mood disorder (OR = 1.78, CI: 1.40-2.26) and alcohol (OR = 2.09, CI: 1.75-2.49) and drug (OR = 1.73, CI: 1.46-2.06) misuse disorders, but reduced odds of having diagnosis of a psychotic disorder (OR = 0.63, CI: 0.53-0.76). A history of head injury with LOC was also associated with increased use of variety of services, including family medicine (OR = 1.33, CI: 1.12-1.59), criminal justice system (OR = 1.50, CI: 1.25-1.80) and the emergency department (OR = 1.03, CI: 1.01-1.05). Conclusions: Amongst homeless adults with mental illness having a history of head injuries with LOC was independently associated with various adverse outcomes. These individuals constitute a high-risk group who may benefit from specialized services.
Article
Purpose – This paper seeks to identify and remedy a fundamental absence of psychological thinking in the current conceptual framework underpinning services for homeless people. Design/methodology/approach – After describing the psychological limitations of current approaches to homelessness, an attempt is made to define what a psychologically‐minded service culture would look like and the concept of “re‐homing” is introduced. The concept of “psychologically informed environment” is explored as one important practical development in this direction. A brief case study is used to illustrate the power of re‐homing. Findings – Findings and observations relating to the lack of psychologically‐informed practice within current approaches to homelessness and mental health are reported. Originality/value – The originality of this paper lies in its identification of a clear psychological basis for limitations within the current service paradigm for homelessness people and its provision of a new and pragmatic concept of “re‐homing” based on the psychological‐mindedness that is already to be found in other aspects of human society and culture.