History Of Homelessness Research Articles

“The great escape”: how an incident of elopement gave rise to trauma informed palliative care for a patient experiencing multiple disadvantage

BackgroundThis case report from Scotland, UK illustrates how unresolved traumatic experiences across the life course can affect a patient’s engagement with palliative care and offers insights into the flexibility and adaptations necessary for taking a trauma informed approach to care for an individual experiencing multiple disadvantage. Trauma informed care is a cornerstone in the pursuit of equitable palliative care, particularly for those facing multiple disadvantage, as it acknowledges the impact of past traumas on current healthcare experiences, and fosters an environment of understanding, acceptance, and tailored support to alleviate suffering in the final stages of life.Case presentation“M” was a veteran with a history of homelessness, living with end stage anal cancer and symptoms consistent with post-traumatic stress disorder, although he never received a formal diagnosis. M exhibited complex behaviours perceived to be related to his history of trauma, including his decision to elope from the hospice, reluctance to accept personal care from nurses, and unpredictability. These behaviours posed a significant challenge to his palliative care team, both in the hospice and at home. An individualised and flexible approach to care delivery was eventually adopted, which included a ‘safety-netting’ approach and care delivery outside of the hospice. M was ultimately supported to remain at home until a week before he died.ConclusionM’s case underscores the necessity of adopting a trauma informed approach to palliative care, particularly for patients with a history of trauma and multiple disadvantage. The case highlights the importance of understanding and respecting a patient’s past traumas, promoting safety and autonomy, and ensuring flexibility in care delivery.

The Promise of One-At-A-Time Therapy for Enhancing the Relevance and Accessibility of Psychological Interventions for Youth Experiencing Homelessness

This article describes a novel framework for the provision of individual psychotherapy for youth with histories of homelessness. We discuss the value of a one-at-a-time therapy approach in stepped care contexts through the Housing Outreach Project—Collaborative (HOPC), a comprehensive program for young people transitioning out of homelessness in Toronto, Canada.

Social and Metabolic Characteristics Associated With Multiple DKA Admissions at a Large County Hospital.

Diabetic ketoacidosis (DKA) is a preventable, deadly, and costly complication of type 1 diabetes mellitus (T1DM). Some individuals with T1DM have recurrent DKA admissions. We sought to characterize social factors that differ between patients with single vs multiple DKA admissions at an urban, safety-net hospital. We queried the electronic health records for T1DM patients admitted for DKA from 2019 to 2021. Admission laboratory values, demographic information, and detailed social histories were collected and analyzed statistically, including logistical regression. A total of 243 patients were admitted for DKA, 64 of whom had multiple DKA admissions. There was no significant difference between the groups in their admission laboratory values, hospital length of stay, health-care payer status, history of homelessness, current employment, living alone, independence of activities of daily living, and barriers to discharge. T1DM patients with multiple DKA admissions had greater rates of substance use disorder (33.0% vs 60.9%; P < .001), especially with cannabis (6.7% vs 25.0%; P < .001), tobacco (26.3% vs 46.3%; P = .002), and psychoactive substance use (1.1% vs 6.3%; P = .043). Regression models of substance use showed increased risk with any substance use (odds ratio [CI] 3.17 [1.78-5.73]; P < .001) and cannabis (3.70 [1.55-8.83]; P = .003). We identified substance use as a possible predictor of T1DM patients at risk for multiple DKA admissions. Our findings identify a group of T1DM patients for whom interventions may help to decrease recurrence of DKA episodes within similar community hospital populations.

Distal supports, capabilities, and growth-focused recovery: A comparison of Housing First and the staircase continuum of care.

Adults who have substantial histories of homelessness and complex support needs may feel ambivalent about integrating into their communities and find it difficult to do so. Being familiar to and recognized by others as a resident in a neighborhood or community are sources of "distal support"that provide individuals with feelings of belonging to their community and are important to recovery from homelessness. We hypothesized that individuals engaged with Housing First (HF) programs would report more distal support than individuals engaged with traditional homeless services (treatment as usual, TAU), and that distal support would predict more community integration, growth-related recovery, and achieved capabilities. We analyzed data collected from homeless services users (n = 445) engaged with either HF or TAU in eight European countries. Measures included achieved capabilities, growth-focused recovery, distal supports, and community integration. Serial mediation analyses confirmed our hypothesis that the effects of HF on growth-related recovery and achieved capabilities are indirect, mediated by distal supports and community integration. Findings are discussed in relation to the importance of modeling the effects of HF on social and psychological outcomes as indirect and identifying important mediators that translate the effects of HF components on social and psychological outcomes. We also note the importance of case management activities that encourage clients to develop and sustain distal supports with others who live and work in their neighborhoods.

Willingness to use and distribute HIV self-testing kits among people who inject drugs in the San Diego–Tijuana border region

BackgroundHIV self-testing (HIVST) could increase HIV testing access among people who inject drugs (PWID), and secondary distribution (i.e., peer-delivery) of HIVST kits in PWID social networks could further expand coverage. We assessed willingness to use and distribute HIVST kits among PWID in the San Diego–Tijuana border region.MethodsFrom 2020 to 2021, HIV-negative PWID in San Diego, USA, and Tijuana, Mexico, completed surveys and provided data on individual (N = 539) and social network (N = 366) characteristics. We used modified Poisson regression to examine the effects of individual and social network characteristics on willingness to use and distribute HIVST kits.ResultsMost participants were willing to use (81%) and distribute (81%) HIVST kits. At the individual level, prior HIV testing was positively associated with willingness to use (adjusted prevalence ratio [aPR] = 1.24, 95% confidence interval [CI] 1.10–1.40) and distribute (aPR = 1.27, 95% CI 1.12–1.43) HIVST kits, while perceiving oneself to be at higher HIV risk than others was negatively associated with willingness to use HIVST kits (aPR = 0.83, 95% CI 0.74–0.93). At the network level, willingness to distribute HIVST kits was positively associated with network size (aPR = 1.04 per member, 95% CI 1.01–1.08) and greater proportions of one’s network encouraging them to use drugs (aPR = 1.29, 95% CI 1.16–1.44) and having a history of homelessness (aPR = 1.51, 95% CI 1.31–1.74) or detention/arrest (aPR = 1.57, 95% CI 1.36–1.82), and negatively associated with a greater proportion of one’s network including “very close” persons (aPR = 0.80, 95% CI 0.69–0.94).ConclusionsWe found high potential for HIVST kits and their secondary distribution to increase HIV testing among PWID who face the greatest barriers to facility-based testing.

Who enrolls and why? Examining center-specific underlying patterns behind enrollment: a New York City-based traumatic brain injury model systems study

ABSTRACT Background To elucidate the sociodemographic and study factors involved in enrollment in the Traumatic Brain Injury Model System (TBIMS) database, this study examined the effect of a variety of variables on enrollment at a local TBIMS center. Methods A sample of 654 individuals from the local TBIMS center was studied examining enrollment by age, gender, race, ethnicity, homelessness status at date of injury, history of homelessness, health insurance status, presence of social support, primary language, consenting in hospital or after discharge, and the need for an interpreter. Binary logistic regression was conducted to identify variables that predict center-based enrollment into TBIMS. Results Results demonstrated that older age was associated with decreasing enrollment (OR = 0.99, p = 0.01), needing an interpreter made enrollment less likely (OR = 0.33, p < 0.01), being primarily Spanish speaking predicted enrollment (OR = 3.20, p = 0.02), Hispanic ethnicity predicted enrollment (OR = 7.31, p = 0.03), and approaching individuals in the hospital predicted enrollment (OR = 6.94, p < 0.01). Here, OR denotes the odds ratio estimate from a logistic regression model and P denotes the corresponding p-value. Conclusions These results can be useful in driving enrollment strategies at this center for other similar TBI research, and to contribute a representative TBI sample to the national database.

Epidemiological investigation of feline chronic gingivostomatitis and its relationship with oral microbiota in Xi'an, China.

Feline chronic gingivostomatitis (FCGS) is an ulcerative and/or proliferative disease that typically affects the palatoglossal folds. Because of its unknown pathogenesis and long disease course, it is difficult to treat and has a high recurrence rate. Most of the bacteria in the oral microbiota exist in the mouth symbiotically and maintain a dynamic balance, and when the balance is disrupted, they may cause disease. Disturbance of the oral microbiota may play an important role in the development of FCGS. In this study, the medical records of 3109 cats in three general pet hospitals in Xi 'an were collected. Sixty-one cats with FCGS were investigated via questionnaires, routine oral examinations and laboratory examinations. Oral microbiota samples were collected from 16 FCGS-affected cats, and microbial species were identified by 16S rDNA sequencing. The results showed that the incidence of FCGS had no significant correlation with age, sex or breed. However, the incidence of FCGS was associated with immunization, a history of homelessness and multicat rearing environments. The number of neutrophils and the serum amyloid A concentration were increased, and the percentage of cells positive for calicivirus antigen was high in all cases. All the cats had different degrees of dental calculus, and there were problems such as loss of alveolar bone or tooth resorption. Compared with those in healthy cats, the bacterial diversity and the abundance of anaerobic bacteria were significantly increased in cats with FCGS. Porphyromonas, Treponemas and Fusobacterium were abundant in the mouths of the affected cats and may be potential pathogens of FCGS. After tooth extraction, a shift could be seen in the composition of the oral microbiota in cats with FCGS. An isolated bacteria obtained from the mouths of the affected cats was homologous to P. gulae. Both the identified oral microbiota and the isolated strain of the cats with FCGS had high sensitivity to enrofloxacin and low sensitivity to metronidazole. This study provides support to current clinical criteria in diagnosing FCGS and proposes a more suitable antibiotic therapy.

COVID-19 Community Response Team for Toronto Homeless Services and Congregate Living Settings: an evaluation of Hospital-Community partnership through COVID-19 vaccine provision

Individuals experiencing homelessness face unique physical and mental health challenges, increased morbidity and premature mortality. In Canada, it is estimated that 235,000 individuals experience homelessness annually, and 180,000 use emergency shelters each night. (1) COVID -19 creates a significant heightened risk for those living in congregate sheltering spaces. Individuals with a recent history of homelessness and diagnosed with COVID-19, are at significantly higher risk of hospitalization and death than those housed in Ontario communities (2). &#x0D; Women’s College Hospital (WCH) is an ambulatory hospital situated in downtown Toronto. In March 2020, WCH set up one of Toronto’s 14 COVID-19 assessment centres to facilitate free testing for SARS-CoV-2. Formed by a group of health care providers at WCH, the goal of the COVID-19 Community Response Team (CRT) was to support Toronto shelters and congregate living sites to manage and prevent outbreaks of SARS-CoV-2 using a collaborative model through onsite mobile testing; supporting the management and prevention of outbreaks; and providing infection prevention and control training and guidance. (3) In total, CRT leveraged this model of care with 49 shelter and congregate living sites from April 2020 to April 2021. From this, the WCH COVID-19 vaccine program emerged, where 14 shelters were regionally identified to co-design and support the administration of vaccine clinics within each sheltering site. This research seeks to evaluate the impact and importance of this partnership model and its future potential in community-centered integrated care. In this study, three areas of inquiry are addressed: (1) Vaccine program evaluation and lessons learned (e.g., What were barriers, facilitators, and lessons throughout the process? How were shelter staff and clients impacted?); (2) Perceptions on hospital/community partnership (e.g., What were overall perceptions of this partnership and strategy?); (3) Opportunities forward (e.g., How can this partnership between hospitals and shelters be sustained in the future to fulfill needs beyond COVID-19). &#x0D; Constructivist grounded theory (CGT) is used in this project to explore perceptions and experiences of this partnership. (4) CGT data analysis revealed five main categories, 16 subcategories, and one core category. The core category is “access to healthcare is a human right; understand our communities”. The main categories are COVID-19 response capacity, outbreak identification and management, barriers to the vaccine program, community-centred immediate shelter needs, and avenues for intersectoral relationship strengthening. In conclusion, three key takeaways emerged for health(care) policy and practice:&#x0D; 1.‘Health as a human right’ framework is an organizing principle in shelters but not necessarily in hospitals. How can hospitals adopt and integrate this framework at the policy level to operationalize an equity-based approach to care? &#x0D; 2.For hospitals, there are gaps in knowledge about community and shelter realities. Ongoing formal partnering between hospitals and communities is one way to bridge this gap. &#x0D; 3.Empowering shelter staff is crucial to the success of hospital-partnered programs and clinical interventions. &#x0D; Finally, this project calls attention to the urgent context-specific exploration needed to advance official hospital-community partnerships, where there is an everlasting commitment and accountability. &#x0D;

INTERROGATING THE SKILLED NURSING STAYS OF HOMELESS AND SERIOUSLY ILL OLDER ADULTS

Abstract The culture change movement has fostered an intentional move away from restrictive ethos of care in hospitals, post-acute rehabilitation, and skilled nursing. However, for the millions in the United States who are uninsured, Medicaid-insured, or dual-eligible are less likely to access ‘deinstitutionalized’ healthcare environments. This presentation presents findings from a constructivist grounded theory study, Research and Supportive Care at Later-life for Unhoused People (RASCAL-UP), on the role of skilled nursing in the experiences of palliative care patients with histories of homelessness. Through provider interviews (n=30), field observations (n=12), and longitudinal chart documentation of a subset of homeless palliative care patients with stays in skilled nursing (n=13), this presentation will reflect on major findings: (1) barriers to skilled nursing entry; (2) successes and challenges in transitioning into skilled nursing residence; (3) acts of resistance to (re)institutionalization; and (4) discharge options and outcomes. Results showcase a need to fill the residential service gap between supportive housing and skilled nursing care and policy change that incentivizes consumer-directed practices for all.

PALLIATIVE AND END-OF-LIFE CARE FOR OLDER ADULTS WITH EXPERIENCES OF HOMELESSNESS

Abstract Although palliative and end-of-life (PEOL) care offers many benefits to those with life-limiting illness, unhoused older adults face significant barriers in accessing these types of care. This symposium examines disparities in PEOL care, emerging services for disadvantaged older adults, and recommendations for capacity-building within healthcare, housing, and aging services. The first paper is an exploratory study of programs serving the PEOL care needs of unhoused adults with serious illnesses. The second paper is a mixed methods study that explores provider perspectives on approaches and challenges to addressing the PEOL care needs among unhoused individuals. The third paper uses the CBPR method photovoice to highlight the experiences of terminally ill patients accessing social model hospice care, a free option to facilitate access to hospice for unhoused older adults. In addition to well-established disparities in the prevalence of serious illness and access to palliative care among people with experiences of homelessness, limits and barriers to holistic support remain once housed. The fourth paper uses secondary data analysis of the Research and Supportive Care at Later-life for Unhoused People (RASCAL-UP) study to describe current practices, perceived barriers, and recommendations in permanent supportive housing for older residents with complex comorbidities. The final paper, also using secondary data analysis of the RASCAL-UP study, addresses the role of skilled nursing for palliative care patients with histories of homelessness. Together, findings illuminate challenges to providing PEOL care for unhoused older adults and those with prior experiences of homelessness, as well as opportunities to improve access to care. This is a Hospice, Palliative and End-of-Life Care Interest Group Sponsored Symposium.

OPPORTUNITIES AND BARRIERS IN INTEGRATING PALLIATIVE CARE SERVICES INTO PERMANENT SUPPORTIVE HOUSING

Abstract Despite well-known inequities in rates of serious illness and premature mortality among people experiencing homelessness, as well as the unique biopsychosocial and spiritual care needs of people with homelessness histories, there is a lack of translational research focused on palliative care service delivery within permanent supportive housing. This presentation will present data from the Research, Action, &amp; Supportive Care at Later-life for Unhoused People (RASCAL-UP study) to describe the current practices, perceived barriers, and recommendations in providing support to older permanent supportive housing residents during serious illness and end-of-life. Through a thematic analysis of interviews with direct care providers (n=30) across multiple care settings, themes were identified: 1) the importance of on-site relationships; 2) cross-sector collaboration barriers; 3) interdisciplinary communication barriers within permanent supportive housing teams; 4) environmental and spatial considerations; and 5) missing levels of care between supportive housing and higher levels of medical care. From these results, we put forth recommendations for translational research, supportive housing policy, and capacity-building efforts for interdisciplinary and cross-sector healthcare and housing teams.

Technology Access and Perceptions of Telehealth Services Among Young Adults Involved in the Court System

PurposeThis study examined access to technology and telehealth among young adults (ages 18–24) who were court-involved and were recruited from an alternative sentencing program in New York City. MethodsUsing sequential mixed methods design, we examined demographic factors linked with access to technology and perceived usefulness of the Internet among n = 321 young adults who were court-involved (75% male, 65% African American, 35% Latinx). We then conducted in-depth interviews with 27 young adults to elicit first-person account of their access to, interest in, and experience with technology and telehealth. ResultsAlthough most participants had access to a phone with a data plan, a substantial proportion reported inconsistent access to the technology critical to telehealth. Certain young adults were more likely to lack consistent access to the technology needed for telehealth, including Black young adults, males, those with less than a high school diploma, those with a history of homelessness, and those who had difficulties paying for basic necessities. Qualitative interviews revealed that most had a strong self-efficacy using technology, while distrust of technology, inexperience with and skepticism of telehealth, low perceived need for care, and medical mistrust were common significant barriers in this underserved population. DiscussionFindings underscored the critical need to address medical mistrust and increase access to and utilization of care among young adults who are court-involved. Results can inform the development and implementation of interventions designed to improve accessibility and acceptability of telehealth.

A Qualitative Study of the Delivery of Tele-Mental Health Services to People with Severe and Persistent Mental Illness with a History of Homelessness

Covid-19 has presented challenges to community mental health organizations that have historically almost exclusively delivered in-person services. This study uses qualitative methods to examine the launch of tele-mental health case management delivery in response to the Covid-19 pandemic in a community mental health organization, from the perspectives of case managers and clients. Tele-mental health challenges included access to and use of technology, and limitations of technology. Our findings suggest that tele-mental health case management delivered via the phone and videoconferencing is viewed, for the most part, positively by both clients and case managers, although it cannot fully replicate in-person services.

Cancer risk behavior and healthcare utilization among people experiencing homelessness in Europe

Abstract Background People experiencing homelessness (PEH) are a vulnerable population, having higher cancer morbidity and mortality compared to the housed population. Reasons for this may be due to higher prevalence of risky health behaviors but also owning to barrier to access and utilize healthcare services. This study aimed to show the prevalence of risky health behavior and utilization of healthcare services in PEH in Austria, Greece, Spain and the UK. Methods Data from 262 PEH participating in an ongoing longitudinal study on cancer prevention and early detection were included in a preliminary analysis (03/2023). Participants were adults, with no history of cancer recruited during their visits to social and healthcare services. Demographic data, high-risk health behaviors and visits to healthcare services were collected via questionnaires. Results Mean age of participants was 47.6 years (SD = 12.9) with 56.2% identifying themselves as male. The majority (50.4%) were homeless for up to 3 years and 61.6% had no history of homelessness. On average, 13.6 (SD = 10.2) cigarettes per day were reported by 62% of active smokers, 51% reported regular alcohol intake and 20.6% reported use of illicit drugs. Multimorbidity (co-occurrence of two or more chronic illnesses) was prevalent in 20.2% of participants. Half of participants reported having health insurance and 55% reported utilizing health care services in the past 12 months. The average number of visits to general practitioners and medical specialists was 3.9 (SD = 5.5) and 2.1 (SD = 5.1), respectively with an average of 2.2 (SD = 7.3) nights spent in hospital. Conclusions The proportion of PHE engaging in high-risk health behaviors is higher and utilization of health services is lower compared to the housed population. PEH may benefit from improved access to preventive and community health services, which is currently assessed by implementing the Health Navigator Model as part of the Horizon 2020 CANCERLESS project (GA965351). Key messages • High prevalence of risky health behaviors and multimorbidity in PEH was observed. • The reported low health care utilization among PEH may be due to structural barriers.

Assessing the reentry needs of incarcerated individuals with co-occurring opioid use and mental health concerns

Individuals with co-occurring mental health concerns and opioid use disorder (COD) are at high risk of mortality and poor social and health outcomes upon release, and there is a need to better understand the unique reentry needs of this population. The high level of need experienced by individuals with COD will demonstrate a necessity for comprehensive reentry support which includes mental health treatment, Medications for Opioid Use Disorder (MOUD), social services such as education, employment, Medicaid, and housing. This sample included 490 adults from a targeted jail/prison reentry program for individuals experiencing COD in a Midwestern state. Program participants had histories of trauma (90%), homelessness (62%), and inpatient psychiatric care (38%). Further, most participants reported needing medical attention for a physical problem (70%) at baseline. Finally, participants had extensive criminal-legal system exposures, with an average of 10 lifetime arrests outside of their current incarceration (M = 9.91, SD = 8.74). The findings have important implications for expanding reentry services to support individuals with COD. This includes the need to begin services prior to release and ensuring the coordination and continuity of care with community-based treatment providers.

Prevalence and Clinical Characteristics of Recreational and At-Risk/Problematic Gambling Among Low-Income U.S. Veterans: Results from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) Study.

This study examined associations between recreational gambling (RG) and at-risk/problem gambling (ARPG), and clinical measures of mental illness and substance use, functionality, homelessness, in a nationally representative sample of U.S. military veterans. Data were analyzed from 781 veterans who participated National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study conducted in 2021. Chi-square tests, analyses of variance (ANOVAs) and logistic regressions analyses were conducted to examine unadjusted and adjusted associations between gambling group status and sociodemographic, psychiatric, substance use, functioning, and homelessness measures. A significant minority of low-income U.S. veterans reported gambling, with 24.9% (95% confidence interval [CI] 95% CI 21.12-28.76%) exhibiting RG and 6.7% (95% CI 3.88-9.42%) screening positive for ARPG. The prevalence of ARPG was higher among younger, non-White veterans. ARPG was associated with greater symptoms of substance use and anxiety; poorer physical functioning; history of any mental illness; lifetime history of homelessness; and having any student or car loans relative to NG. Veterans who had RG were more likely to screen positive for drug use disorders relative to NG. Results of the current study provide an up-to-date estimate of the current prevalence of RG and ARPG among low-income U.S. veterans and underscore the importance of routine screening, monitoring, and development of interventions for problematic gambling severity, as well as interventions for ARPG in this population. These findings may inform targeted intervention strategies for this vulnerable subpopulation.

A Grounded Theory of Provider Perspectives Regarding Resident Moves from Permanent Supportive Housing

To address the ongoing supply-demand gap for permanent supportive housing (PSH), Moving On initiatives (MOIs) provide linkage to affordable housing without embedded support services and rental subsidies, as well as short-term transitional case management to support transitions to independent housing. PSH providers mediate outcomes for individuals moving on from PSH by providing appropriate supports and assistance. Yet, little is known about how providers view these moves. This study explores how providers perceive moves from PSH. Individual interviews were completed with PSH providers from seven U.S. agencies. Data was analyzed via a modified grounded theory approach. The data show that organizational support and prior experience with moving on shape providers’ perceptions of resident capacity. These perceptions were associated with gatekeeping and recovery-oriented approaches, which informed providers’ self-perceived role as following or leading residents towards moving on. System-level support and pressure to adopt a moving on mindset may lead more providers to promote independence and autonomy among individuals with histories of homelessness.

Examining the Potential Impact of Restricting Low-Income Housing Tax Credit Housing for Individuals With Certain Criminal Convictions in Texas

Because housing is central to the recovery of individuals with experiences of homelessness and incarceration, it is important to consider how U.S. policies denying housing to residents with criminal histories can adversely affect racial and ethnic minorities and individuals with a history of homelessness. The state of Texas passed a rule specifying certain criteria that Low-Income Housing Tax Credit (LIHTC) supportive housing providers must use to screen tenants using criminal history. A retrospective cohort of 600 LIHTC supportive housing residents was used to estimate the potential impact of the rule. Based on this sample, the rule would have resulted in significantly higher proportions of Black and chronically homeless individuals being denied housing compared to the proportions of White and low-income individuals, respectively, who would have been denied housing. With the exception of drug convictions, there was no significant difference in recidivism between residents who would have been affected by the rule and unaffected residents who also had criminal justice involvement within a comparable time frame before move-in.

Insurance Status is Associated With Recurrence in Cutaneous Head and Neck Squamous Cell Carcinoma.

To identify socioeconomic factors influencing the presentation and outcomes of cutaneous head and neck squamous cell carcinoma (cHNSCC). Retrospective cohort study. Tertiary academic medical center with comprehensive cancer center. Patients treated for cHNSCC at a single institution between 2008 and 2022 were included. Demographic, socioeconomic data and disease characteristics were obtained from medical record abstraction. Outcome measures included tumor stage, number of distinct primaries, recurrence, and disease-related death. χ2 and Mann-Whitney tests were implemented to evaluate clinicopathologic distributions across disease stages. Survival analyses were performed using Cox regression and Kaplan-Meier analysis. A total of 346 patients met the inclusion criteria. The median age at presentation and length of follow-up was 70.8 and 3.1 years, respectively. The majority of the cohort was white, male, and English-speaking. 13.3% of patients were underinsured and 27.5% were immunosuppressed. Patients who presented with advanced disease were more likely to be underinsured (21.7% vs 9.6%, P = .006) and have a history of homelessness (8.5% vs 2.1%, P = .014). Immunosuppressed patients were more likely to be underinsured (P = .009). Insurance status (1.97 [1.06-3.66],P = .032) and immune status (2.35 [1.30-4.26],P = .005) were independently associated with worse recurrence-free survival. Socioeconomic factors that influence access to care, such as insurance status, are associated with cHNSCC disease stage and disease recurrence. These factors may impose barriers that delay diagnosis and treatment. This may result in worse disease-related outcomes and greater treatment-associated morbidity for certain patients.

Risk of homelessness after prison release and recidivism in Denmark: a nationwide, register-based cohort study

Transitional periods between and across services have been linked to homelessness. We aimed to investigate the association of previous history of homelessness and psychiatric disorders with risk of homelessness after release from prison. Additionally, we examined the association between homelessness after release and risk of recidivism. We did a nationwide, register-based cohort study of people aged 15 years or older who were released from prison for the first time in Denmark between Jan 1, 2001, and Dec 31, 2021. We obtained data using the Danish Civil Registration System with data linked across other registries (the Danish Central Criminal Register, the Danish Homeless Register, the Danish National Patient Register, and the Danish Psychiatric Central Research Register) on release date, homeless shelter contacts, psychiatric disorders, and new convictions. Outcomes were homelessness after release from prison, defined as first homeless shelter contact following release from first imprisonment, and recidivism within 2 years of release, defined as the first police-recorded criminal conviction after prison release. We calculated incidence rates per 1000 person-years, incidence rate ratios (IRRs) using Poisson regression analysis, and probability of homelessness and recidivism after release. Sex, age, calendar year, country of origin, highest educational level, relationship status, and length of index imprisonment were included as confounders. The study cohort included 37 382 individuals (34 792 males [93·1%] and 2590 females [6·9%]) aged 15-41 years, who were released from prison between Jan 1, 2001, and Dec 31, 2021, contributing 202 197 person-years at risk. Mean follow-up duration was 5·4 person-years (SD 5·6). Overall, 1843 (4·9%) of 37 382 individuals became homeless. 1 year after release from prison, 788 (2·1%) of 37 382 individuals had at least one homeless shelter contact, and among 1761 individuals with previous history of homelessness before index imprisonment, 357 (20·7%) became homeless. The incidence of homelessness after release was 102·5 cases per 1000 person-years for individuals with previous history of homelessness and 6·7 cases per 1000 person-years in individuals without (IRR 16·4, 95% CI 14·8-18·2; adjusted for sex, age, and calendar year). Individuals who additionally had a mental illness had a higher risk of homelessness (IRR 22·6, 19·7-25·9) compared with those without either previous homelessness or mental illness, and a substantially higher risk was observed for those with previous homelessness and drug use disorder (25·0, 21·6-28·9) compared with those without. Within 2 years of release from prison, the probability of recidivism was 73·2% (95% CI 72·8-73·7). The risk of recidivism was higher among people experiencing homelessness after release from prison than those who did not experience homelessness after release (IRR 1·5, 95% CI 1·3-1·7), adjusted for sex, age, and calendar year. Criminal justice services should review approaches to reduce risk of homelessness, and consider improving liaison with mental health and substance misuse services to prevent adverse outcomes on release from prison. Clinical guidelines applied to criminal justice settings should address the health of individuals who experience homelessness. Lundbeck Foundation.