Attitudes of Physiotherapy Students toward People Experiencing Homelessness through a Musculoskeletal Health Program

Background: People experiencing homelessness (PEH) may be at particular risk for COVID19. We synthesised the evidence on SARS-Cov-2 infection, transmission, outcomes of disease, effects of non-pharmaceutical interventions (NPI), and the effectiveness of targeted strategies for infection prevention and control (IPC). Methods: Systematic review of articles, reports and grey-literature indexed in electronic databases (EMBASE, WHO-Covid19, Web of Science), pre-print repositories, institutional websites, and handsearching. Empirical papers of any study design addressing Covid-19 in PEH or homeless shelters’ staff in English were included. (PROSPERO 2020 CRD42020187033) Findings: Of 194 publications, 13 studies were included (two modelling, ten observational and one qualitative study). All were conducted in high-income countries. Random-effect meta-analysis of prevalence estimates yields a baseline SARS-Cov-2 prevalence of 2·14% (95% Confidence-Interval, 95%CI=1·02-3·27) in PEH and 1·72% (95%CI=0·31-3·12) in staff. In outbreaks, the pooled prevalence increases to 29·49% (95%CI=16·44-29·55) in PEH and 15·18% (95%CI=8·95-21·42) in staff. Main IPC strategies were universal and rapid testing, expansion of non-congregate housing support, and individual measures in shelters (bed spacing, limited staff rotation). Interpretation: Up to 30% PEH and 17% staff are infected during outbreaks of SARS-Cov-2 in homeless shelters. Most studies were conducted in the USA. No studies were found on health-related outcomes or health effects of NPI. An overview and evaluation of IPC strategies for PEH, including a better understanding of disease transmission, and reliable data on PEH within Covid-19 notification systems is needed. Qualitative studies may serve to voice PEH experiences and guide future evaluations and IPC strategies. Funding: No source of funding.Declaration of Interests: The review has been conducted in the scope of the German Competence Net Public Health Covid-19. JS is volunteering (without financial compensation) for a German NGO which provides medical services free of charge for - among others - individuals living in homeless shelters. He further reports membership of the German social democratic party (SPD). The other authors state that they have no competing interests.

ObjectivesAccess to healthcare and accurate health information is a persistent issue for people experiencing homelessness (PEH), one heightened by the COVID-19 pandemic and exacerbated by issues of health literacy and...

BackgroundThe COVID-19 pandemic has disproportionately affected people experiencing homelessness (PEH) residing in shelters. Initial and regular testing of PEH in communities with moderate or substantial SARS-CoV-2 transmission may limit spread in shelters. We analyzed factors associated with positive SARS-CoV-2 RNA and antibody tests for PEH staying in shelters or encampments in Denver, Colorado.MethodsIn May 2020, Denver Public Health collaborated with local leaders to identify 4 homeless shelters and 3 outdoor encampments for voluntary, universal SARS-CoV-2 testing. At each testing event, a short questionnaire including sociodemographic factors and symptoms was administered to PEH who consented to testing. SARS-CoV-2 RNA testing by reverse transcription polymerase chain reaction (RT-PCR) was performed on nasopharyngeal swabs; antibody testing was performed on venous blood samples. PEH reporting a prior positive RT-PCR test were not retested but were eligible for antibody testing. Statistical calculations were performed with an α of 0.05; all tests were two-sided.ResultsFrom June 2–July 28, 2020, 931 PEH were approached. A total of 863 RT-PCR tests were performed at 14 testing events, and 334 antibody tests were performed at 5 testing events. Overall, 604 and 259 RT-PCR tests were conducted in 4 shelters and 3 encampments, respectively; 189 and 145 antibody tests were conducted in 3 shelters and 2 encampments, respectively. PEH tested in shelters were older, more often men, less often Native American, and less likely to report COVID-19 symptoms than those tested at encampments (Table 1). Overall, 9% of PEH tested in shelters tested positive for SARS-CoV-2 compared to 3% of PEH tested in encampments (p=0.002); 8% of men had positive RT-PCR results compared to 2% of women (p=0.03) (Table 2). PEH tested at shelters had a higher percentage of detectable SARS-CoV-2 antibodies than those tested in encampments (24% vs 8%, p=0.0002; Table 3). Neither RT-PCR nor antibody test results differed significantly by race or ethnicity.Table 1. Demographics of participants residing in encampments compared with shelters in Denver, Colorado, May-July 2020 (n=931)Table 2. Comparison of participants testing positive or negative for SARS-CoV-2 RT-PCR* by location and demographics, in Denver, Colorado, May-July 2020Table 3. Comparison of participants testing positive or negative for antibodies against SARS-CoV-2 by location and demographics in Denver, Colorado, May-July 2020ConclusionA greater percentage of PEH tested positive for both SARS-CoV-2 RNA and antibodies at shelters than encampments, suggesting that continued assessment of mitigation strategies in shelters should be a priority.DisclosuresAll Authors: No reported disclosures

Hepatitis C virus (HCV) microelimination aims to detect and treat hidden infections, especially in at-risk groups, like people experiencing homelessness (PEH) with alcohol or drug use disorders. Point-of-care HCV RNA testing and peer support workers are crucial for identifying and preventing HCV infection among marginalized populations, contributing to overall elimination goals. To assess risk factors, prevalence, and trends of active HCV infection among PEH in Madrid, Spain (2019-2023). This cross-sectional study was conducted between 2019 and 2023 in PEH, defined as people who lacked a fixed, regular, and adequate night residence, screened on the street or in homeless shelters via mobile unit using rapid HCV antibody testing, followed by HCV-RNA testing in Madrid, Spain. Data were analyzed from January to June 2024. Active HCV infection among PEH was the main outcome. Risk factors analyzed included being born outside of Spain, alcohol misuse, lacking financial income, benzodiazepine use, injection drug use (IDU; including nonactive IDU and active IDU within the last year), opioid substitution therapy participation, and sexual behavior patterns. Data were analyzed using logistic regression. P values were adjusted for multiple testing using the false discovery rate (q-values). A total of 4741 individuals were screened for HCV infection, of whom 2709 (mean [SD] age, 42.2 [12.7]; 1953 [72.2%] men) were PEH and included in analysis. A total of 363 PEH (13.4%) had test results positive for HCV antibodies, of whom 172 (47.4%) had test results positive for HCV-RNA, and 148 of these (91.9%) started HCV treatment. Overall, active HCV infection prevalence was 6.3%, and the main risk factors associated with active HCV infection included IDU, encompassing both nonactive IDU (adjusted odds ratio [aOR], 10.9; 95% CI, 6.1-19.4; q < .001) and active IDU in the last year (aOR, 27.0; 95% CI, 15.2-48.0; q < .001); a lack of financial income (aOR, 1.8; 95% CI, 1.1-2.9; q = .03); and alcohol misuse (aOR, 1.8; 95% CI, 1.3-2.6; q = .008). There was a significant decrease between 2019 and 2023 in active HCV infection prevalence across the entire population, from 7.2% to 3.4% (P = .04). In this cross-sectional study of PEH in Madrid, IDU, lack of income, and alcohol misuse were primary risk factors associated with HCV infection. The significant decline in HCV rates observed across all risk groups during the study period suggests preventive policies were effective in reducing HCV prevalence among the homeless population.

Pet ownership among people experiencing homelessness (PEH) is common, but access to shelter, veterinary care, and flea-preventative products for PEH who own pets in the US is not well described. We sought to evaluate current knowledge of fleas and flea-borne diseases and characterize practices around pets and service animals among staff at homeless shelters and outreach organizations. In-person surveys were administered to staff at homeless shelters and on outreach teams in 7 states from August 2022 to April 2023 to evaluate knowledge, attitudes, and practices and to assess homeless shelter/organizational characteristics. Surveys were administered to 333 staff members at 60 homeless shelters and among 29 outreach teams. Seventy-eight percent of homeless shelters allowed pets or service animals. Only 2% of homeless shelters and 7% of outreach teams provided veterinary care; 15% of homeless shelters and 7% of outreach teams provided flea preventatives. Nearly three-quarters of surveyed homeless shelter staff responded that no steps were taken to treat fleas at their shelters. Veterinary care and availability of flea-preventative products are limited in homeless shelter and outreach organizations serving people experiencing homelessness. Pets of PEH might be at an increased risk of flea infestation and flea-borne diseases because of limited access to veterinary care and preventatives. Improving knowledge and access to flea prevention, screening, and treatment are critical to ensure PEH and their pets can consistently access homeless shelters or outreach services, and to prevent flea-borne disease transmission.

Overdose is the leading cause of death among people experiencing homelessness (PEH), but engagement in medication treatment is low in this population. Shelter-based buprenorphine may be a strategy for increasing initiation and retention on lifesaving medications. To estimate clinical outcomes and conduct an economic analysis of statewide shelter-based opioid treatment in Massachusetts. This economic evaluation study in Massachusetts used a cohort state-transition simulation model. Two cohorts were modeled starting in 2013, including (1) a closed cohort of a fixed population of PEH with history of high-risk opioid use over their lifetimes and (2) an open cohort in which membership could change over time, allowing assessment of population-level trends over a 10-year period. Data analysis occurred from January 2023 to April 2024. Model exposures included (1) no shelter-based buprenorphine (status quo) and (2) offering buprenorphine in shelters statewide. Outcomes included overdose deaths, quality-adjusted life-years (QALYs) gained, and health care and modified societal perspective costs. Sensitivity analyses were conducted on key parameters. In the closed cohort analysis of 13 800 PEH (mean [SD] age, 40.4 [13.1] years; 8749 male [63.4%]), shelter-based buprenorphine was associated with an additional 65.4 person-weeks taking buprenorphine over an individual's lifetime compared with status quo. Shelter-based buprenorphine was cost saving when compared with the status quo, with a discounted lifetime cost savings from the health sector perspective of $1300 per person, and 0.2 additional discounted QALYs per person and 0.9 additional life-years per person. In the population-level simulation, 254 overdose deaths were averted over the 10-year period with the shelter-based buprenorphine strategy compared with the status quo (a 9.2% reduction of overdose deaths among PEH in Massachusetts). Overdose-related and other health care utilization undiscounted costs decreased by $3.0 million and $66.4 million, respectively. Shelter-based opioid treatment generated $44.7 million in additional medication and clinical costs, but saved $69.4 million in overdose and other health costs. In this economic evaluation of clinical and economic outcomes among PEH, shelter-based buprenorphine was associated with fewer overdose deaths and was cost saving. These findings suggest that broad rollout of shelter-based buprenorphine may be an important tool in addressing the overdose crisis.

Purpose The Frailty, and Holistic Care Needs Assessment (FHCNA) questionnaire was designed for use by non-clinical staff to assess the health and social care needs among people residing in homeless hostels. This study aims to refine the FHCNA to enable use in practice. The authors explored the views of mainstream health and social care professionals (HSCPs) regarding necessary questions, formatting and potential utility and then modified the questionnaire so it can be used to respond to identified needs in line with health reviews and Care Act assessments. Design/methodology/approach Semi-structured interviews with HSCPs practising in mainstream services were carried out and analysed thematically to explore their views of how they could be supported to respond to the frailty needs of people experiencing homelessness (PEH). Modifications to the FHCNA were made, and focus groups were carried out to check for usability with hostel staff and people with lived experience of homelessness. Findings Multiple uses of the modified FHCNA were identified including guiding consultations, supporting multi-disciplinary decision making and education/advocacy for both mainstream professionals and homelessness services. To optimise its utility in the face of systemic barriers, adaptations were suggested, including a shift towards the social care paradigm to support professionals’ understanding of identified needs within the context of the Care Act, the addition of information to combat the normalisation of frailty in PEH and prompts to streamline responses from GPs. Feedback from PEH and hostel staff was positive, and acceptability of the questionnaire remained following adaptations. Practical implications Multiple uses of the modified FHCNA were identified, including guiding consultations, supporting multidisciplinary decision-making and education/advocacy for both mainstream professionals and homelessness services. Social implications Findings supported adaptations of the FHCNA to combat the normalisation of frailty in PEH and prompts to streamline responses from GPs. Originality/value To the best of the authors’ knowledge, this is the first study to explore how information regarding the health and care needs of PEH can be gathered in a way that facilitates a timely and individualised response from mainstream HSCPs.

Introduction: People over age 50 comprise 30% of people experiencing homelessness (PEH) in the United States and are predicted to increase exponentially in the next ten years. Few studies have documented PEH hypertension (HTN) prevalence, and treatment protocols rarely test their efficacy specifically when treating older PEH. The few geriatric PEH HTN studies that have been conducted are based out of homeless shelters, with even less known about the HTN rates of people experiencing unsheltered homelessness (PEUH) who constitute one-third of PEH nationally. Our objective is to assess prevalence of elevated blood pressure (BP) and HTN treatment rates among geriatric PEUH presenting at a free clinic in Miami-Dade County. Methods: Clinical information and BP measurements of 105 PEUH over 50 were documented as part of care by a street outreach medical team. Clinical information was recorded in a REDCap electronic database. De-identified data was compared to the Centers for Disease Control National Health and Nutrition Examination Survey 2017-2019 pre-pandemic cohort (CDC NHANES) and analyzed in R studio version 4.3.2. Results: PEUH were at significantly increased relative risk (RR) for Stage 1 HTN (RR 3.97, Confidence Interval (CI) 2.68-5.89, p&lt;0.0001) when compared to age- matched NHANES dataset. After 10-year age cohort stratification the small PEH sample size (N=11) lacked enough power to reach significance. PEUH were also found to be at significantly increased risk of Stage 2 HTN (RR 6.17, CI 4.93-7.73, p&lt;0.0001). Here findings remained significant after 10-year age cohort stratification (N=41). NHANES reports medication use by 20-year age groups: 50.8% of people aged 40-59, and 49.4% of people over 60 with diagnosed HTN were on BP control medication. PEUH were at significantly increased risk of untreated HTN (RR 1.67, CI 1.50-1.87, p&lt;0.0001). Only 15.9% were prescribed medication. Conclusion: Increased risk of elevated BP and untreated HTN among geriatric PEUH likely reflect barriers of access to chronic disease management. There are likely also unidentified confounding factors preventing proper care for this vulnerable population. Further investigation should critically assess gaps in the care to devise protocols for improving treatment outcomes.

Factors related to medication adherence among people experiencing homelessness.

The provision and siting of homeless emergency shelters have community-wide implications for addressing the needs of people experiencing homelessness (PEH). In Utah, Salt Lake County’s transition from a large, centralized emergency shelter sited in a free transit zone to a decentralized scattered-site model outside of a no-cost transit zone provided the context to evaluate how transportation access and mobility patterns of PEH were affected as they were displaced from a centralized service network in a downtown core. We conducted 19 in-depth, semi-structured interviews with PEH aged 18 + who were staying in one of three distributed resource centers who had also previously stayed at the former centralized shelter. Thematic analysis of the interviews resulted in three categories, each with distinct sub-categories: 1) Pre-decentralization transportation and mobility, 2) Post-decentralization transportation and mobility, and 3) Recommendations to improve transportation access for PEH, including lowering or eliminating financial barriers to transportation and expanding transit and shuttle van frequency and route radius. Study findings demonstrate that there is a significant need for community planners to collaborate on the siting of homeless shelters to provide more affordable, flexible, and equitable access to transportation networks.

People experiencing homelessness (PEH) are at disproportionate risk of becoming infected and having severe illness from coronavirus disease 2019 (COVID-19), especially when residing in congregate settings like homeless shelters. Behavioral health problems related to substance use disorder (SUD) and severe mental illness (SMI) may have created additional challenges for PEH to practice prevention measures like mask wearing, physical distancing, handwashing, and quarantine and isolation. The study objective was to understand the perceived barriers PEH face regarding COVID-19 non-pharmaceutical prevention strategies and identify recommendations for overcoming barriers. From August-October 2020, qualitative phone interviews with 50 purposively selected behavioral health professionals across the United States serving PEH with SUD or SMI were conducted. Professionals described that PEH faced barriers to prevention that were structural (e.g., access to necessary resources), behavioral (related to SUD or SMI), or related to the priority of other needs. Recommendations to overcome these barriers included providing free prevention resources (e.g., masks and hand sanitizer), providing education about importance of prevention strategies, and prioritizing access to stable housing. Interviews took place before COVID-19 vaccines were available, so barriers to vaccination are not included in this paper. Findings can help support tailored approaches during COVID-19 and future public health threats.

Multifarious barriers to accessing healthcare services among people experiencing homelessness (PEH) lead to delays in seeking care for acute infections, including those caused by respiratory viruses. PEH are at high risk of acute respiratory illness (ARI)-related complications, especially in shelter settings that may facilitate virus spread, yet data characterizing healthcare utilization for ARI episodes among sheltered PEH remained limited. We conducted a cross-sectional study of viral respiratory infection among adult residents at two homeless shelters in Seattle, Washington between January and May 2019. We assessed factors associated with seeking medical care for ARI via self-report. We collected illness questionnaires and nasal swabs were tested for respiratory viruses by reverse transcription quantitative real-time PCR (RT-qPCR). We observed 825 encounters from 649 unique participants; 241 (29.2%) encounters reported seeking healthcare for their ARI episode. Seasonal influenza vaccine receipt (adjusted prevalence ratio [aPR] 1.39, 95% CI 1.02-1.88), having health insurance (aPR 2.77, 95% CI 1.27-6.02), chronic lung conditions (aPR 1.55, 95% CI 1.12-2.15), and experiencing influenza-like-illness symptoms (aPR 1.63, 95% CI 1.20 - 2.20) were associated with increased likelihood of seeking care. Smoking (aPR 0.65, 95% CI 0.45-0.92) was associated with decreased likelihood of seeking care. Findings suggest that care seeking for viral respiratory illness among PEH may be supported by prior engagement with primary healthcare services. Strategies to increase healthcare utilization may lead to earlier detection of respiratory viruses.

People experiencing homelessness (PEH) are disproportionately diagnosed with active tuberculosis. While promoting latent tuberculosis infection (LTBI) treatment has been a call to action, PEH engaging in substance use often experience challenges in completing LTBI treatment. In this non-randomized single arm study, we tested an innovative, community-based, nurse-led community health worker (RN-CHW) model, on reducing drug use among 50 PEH, residing in homeless shelters or living on the streets in Los Angeles. Follow-up was at 3- and 6- months. Findings revealed significant and ongoing decrease in any drug use (odds ratio [OR]=0.30; 95% confidence interval [CI]=0.14-0.68);p=.004), amphetamine use (OR=0.14; 95% CI=0.02-0.81;p=.029), cannabis use (OR=0.26; 95% CI=0.12-0.57;p=.001) and methamphetamine use (OR=0.30; 95% CI=0.10-0.90;p=.031) at 6-month follow-up. To our knowledge, this pilot study is the first to evaluate the impact a RN-CHW delivered intervention on reduction in drug use among PEH enrolled in a LTBI intervention. LTBI interventions may serve as an entryway into reduction in drug use among this underserved population.

People experiencing homelessness (PEH) have an increased risk of all-cause mortality, higher rates of vaccine-preventable diseases (VPDs), and poorer related health outcomes compared to the general population. At the same time, delivering vaccinations within this vulnerable group is complex, and there is limited evidence to inform practice in this field. This study aims to explore the key determinants influencing vaccination willingness among PEH. Cross-sectional survey of PEH at shelters, night shelters, and free-meal sites in Warsaw (Sep 2024-Aug 2025; convenience sampling). Analyses used ETHOS-weighted descriptives (95%CIs) and logistic regression comparing reluctant (unsure or unwilling) vs. willing (secondary: unwilling vs. willing), adjusted for prespecified sociodemographic and homelessness characteristics. Of 275 PEH surveyed, 215 (78.2%) were male, and 60 (21.8%) were female. Based on FEANTSA (European Federation of National Organisations Working with the Homeless) categories, 162 (58.9%) were classified as Roofless, 85 (30.9%) as Houseless, and 11 (4.0%) as Insecure. Weighted mean age was 52.6 years (95% CI: 50.9-54.2). The majority of the surveyed individuals have completed secondary education (37.1%), followed by vocational (31.6%), primary (20.7%), and higher (9.8%); two participants (0.7%) had not completed primary school. Overall vaccination willingness was 69.9% (95%CI 63.1-76.0). Unwillingness and uncertainty were 24.0% (95%CI 18.5-30.5) and 6.1% (95%CI 3.4-10.6), respectively. Lower odds of reluctance were observed for secondary/higher education (vs. primary; OR 0.40, 95%CI 0.22-0.76), Roofless individuals (OR 0.46, 95% CI 0.24-0.89), and those experiencing homelessness for a prolonged period of time (per 1-SD, OR 0.59, 95%CI 0.40-0.86). Sex, age, and chronic illness were not significant. Across attitude items, lower perceived effectiveness and lower personal benefit showed the strongest associations with reluctance; safety concerns were modest. As compared to the full sample, reluctant respondents were about two times more likely to endorse low-benefit/low-effectiveness statements, while safety concerns were common in both groups. About two-thirds of respondents were willing to vaccinate. Reluctance was most strongly associated with lower perceived vaccine effectiveness and personal benefit. Interventions should address these beliefs and prospectively evaluate whether changes to them translate into greater willingness and, ultimately, higher uptake.

"Without my medication, I'm a wreck": Photo-elicitation to explore medication use among people experiencing homelessness.