Homeless Adults Research Articles

Using the Capture–Recapture Technique to Supplement a Point-in-Time Count of Homeless Adults in Kittitas County, Washington

Abstract Capture–recapture (CRC) is a method of population estimation pioneered in biology that allows the surveyor to approximate the proportion of individuals who evaded sampling efforts (i.e., captures) based on repeated samples from the same population. The current national standard for estimating homelessness is a single-day enumeration called the point-in-time (PIT) count. By using a local community action agency’s homeless outreach program and a cold weather shelter as two distinct sampling sources to capture data using CRC methodology, the current study sought to estimate the homeless population in Kittitas County, Washington, and compare CRC with PIT count estimates. Four months of data collection for the two sampling sources yielded an estimate of 115 (95% CI [93, 137]) homeless individuals in the county using CRC methodology. The PIT count conducted in the same year sampled 61 individuals, supporting the idea that cross-sectional enumeration (i.e., PIT counts) underestimate the homeless population and could be supplemented by CRC methods, particularly in rural areas where resources to conduct PIT counts may be limited. Greater accuracy in homelessness enumeration may aid in advocacy efforts, provide baseline data for researching interventions designed to reduce homelessness, and yield statistics to better guide legislative and policy initiatives.

"I Have a Story to Tell Them": Qualitative Analsysis of Interviews with Formerly Homeless Adults

"I Have a Story to Tell Them": Qualitative Analsysis of Interviews with Formerly Homeless Adults

Pathways to social integration among homeless-experienced adults with serious mental illness: a qualitative perspective

BackgroundSocial integration (i.e., reciprocal interactions with peers and community members) is a notable challenge for many homeless-experienced adults with serious mental illness (SMI). In this study, we examine a range of housing services offered to homeless-experienced adults with SMI and identify the impacts of supportive services on participants’ social integration outcomes, with the goal of improving services in transitional and permanent housing settings for homeless-experienced adults with SMI.MethodsThrough semi-structured interviews with homeless-experienced adults with SMI (n = 30), we examine the impacts of housing and service settings on participants’ social integration. Participants received services in a variety of housing settings, including transitional housing with congregate/shared living (n = 10), transitional housing with individual quarters (n = 10), and permanent supportive housing (n = 10).ResultsParticipants expressed caution in developing social relationships, as these could pose barriers to recovery goals (e.g., substance use recovery). For many, social integration was secondary to mental and physical health and/or housing stability goals. Individual quarters gave individuals a place of respite and a sense of control regarding when and with whom they socialized. Meeting recovery goals was strongly related to connecting to and receiving a range of supportive services; interviews suggest that proximity to services was critical for engagement in these resources.ConclusionsPrograms serving homeless experienced adults with SMI should seek to understand how individuals conceptualize social integration, and how social relationships can either support or hinder participants’ recovery journey.

Framing family homelessness in the United States: media representations and the invisibility of families

Media coverage plays an important role in generating knowledge about and shaping understandings of homelessness. Although families make up about 35% of all those without housing in the United States, they remain relatively invisible in the media. We examine the amount of coverage and content of representations of homeless families in The New York Times and the Los Angeles Times in 2017 and 2022. Families receive little media coverage in comparison to single, homeless adults, especially men. When newspapers do address unhoused families, they mainly do so without reference to the race, gender, or sexuality of homeless families. As a result of limited and trivial coverage, it is difficult to find articles that provide extended discussion of family homelessness or explain the multi-layered structural factors that cause families to lose housing.

Homeless patients requiring haemodialysis: incidence, caseload characteristics, and implications for care

Background Homelessness is a recognized risk factor for the development of kidney failure. However, the risk of requiring renal replacement therapy (RRT) in homeless populations remains unknown. Furthermore, access to and provision of RRT for homeless populations have not been described. Methods We performed a retrospective study of all patients who newly commenced in-centre haemodialysis at St. James’s Hospital, Dublin, from January 2021 to December 2023. Housing status was captured using registered addresses and a review of social workers’ assessments. Homelessness was defined according to the European Typology on Homelessness and Housing Exclusion Criteria. Using publicly available census and homelessness data, we estimated the risk of commencing haemodialysis among homeless and non-homeless populations in the catchment area. Results The overall prevalence of homelessness among adults in the catchment area was approximately 2000/270,000 (0.74%). Of the 74 patients who commenced haemodialysis over the 3-year period, 13 (17.6%) were homeless. There was a significant difference in the incidence of commencing haemodialysis between non-homeless and homeless individuals in the catchment area (p<0.001, chi-square test). Among patients who commenced haemodialysis, the mean age was 53 years in homeless patients and 62 years in non-homeless patients (p<0.05, one-way ANOVA). 3/13 homeless patients (23%) had received nephrology healthcare at least 3 months prior to haemodialysis, compared with 39/61 non-homeless patients (64%) (p <0.05, chi-square). Of the three homeless patients who had received three months of nephrology healthcare prior to haemodialysis, all three patients commenced haemodialysis via an arteriovenous fistula. Mental health comorbidities were more frequent among homeless patients than among non-homeless patients (23% versus 8%) (not statistically significant), as were substance use disorders (38% versus 7%) (p<0.05, chi-squared test). Conclusion The incidence of kidney failure requiring haemodialysis was higher in homeless adults than in their non-homeless peers. Homeless patients were younger and started haemodialysis more urgently. There is an unmet need for nephrology healthcare for the homeless population.

Diverse Profiles of Homeless Young Adults: Implications for Tailored Prevention Strategies—Insights from Belgian Homelessness Counts

Young adults experiencing homelessness face multiple challenges and are often confronted with additional barriers stemming from adverse past experiences. Whereas youth homelessness rates appear to increase across Europe, our knowledge on its nature in Belgium remains limited. Based on recent local point-in-time counts on homelessness in Belgium (2020–2022) and a focus group (2022) to interpret these results, we examine the profiles of more than 2000 homeless young adults and distinguish between three distinct groups (youth care leavers, Belgians with no care history, and newcomers). Alongside the need for universal prevention, tailored interventions are crucial for each subgroup to address their unique needs.

The benefits of undergraduate medical students delivering free preparticipation physical evaluations in collaboration with a K-12 school district

BackgroundStudent-run free clinics are present at many medical schools throughout the United States. While many work with adult homeless or uninsured populations, few work with pediatric populations. We investigated the impact of volunteering at a free preparticipation sports physical clinic on medical students’ educational motivation, school engagement, confidence in their clinical skills, connectedness to community, and self-efficacy.MethodsFirst and second year undergraduate medical students who volunteered at a preparticipation sports physical clinic were eligible for the study. 30 students participated in the study, some volunteering multiple times, for a total of 55 post-volunteering surveys. Pre- and post-volunteering surveys were administered via REDCap. The surveys were designed using Likert scales and the General Self-Efficacy scale. Paired two tailed t-tests were used to analyze pre- and post-volunteering data.ResultsStudents had statistically significant increases in their confidence in working with pediatric populations, performing a standard physical exam, working in an interdisciplinary setting, and communicating with patients. They also demonstrated statistically significant increases in their feelings of connectedness to their reason for practicing medicine and to the greater local community.ConclusionsThis research demonstrated measurable increases in motivation and confidence in clinical skills for medical students that participated. This is a valuable experience for medical students and is a model that other medical schools can adopt to help diversify and strengthen their curriculum. In the future, we would like to collect more data to further evaluate the impact of this volunteering on medical students, patients, families, and other community stakeholders.

Destitute and dying: interventions and models of palliative and end of life care for homeless adults – a systematic review

BackgroundHomeless adults experience a significant symptom burden when living with a life-limiting illness and nearing the end of life. This increases the inequalities that homeless adults face while coping with...

Mixed methods on adverse childhood experiences predicting transitional and recurrent homelessness.

Research has associated lack of parental care, physical abuse, and parental substance abuse to homelessness, with the presence of two or more such factors dramatically increasing one's chances of becoming homeless as an adult. Less clear is which (cumulation of) factors may mediate the difference between transitional and recurrent homelessness. Quantitative analysis of four risk factors-addiction, weak social network, criminal activity, psychopathology-among 69 transitionally and recurrently homeless (RH) adults, followed by in-depth qualitative analysis of adverse childhood experiences (ACEs) among 30 selected participants. RH participants had higher cumulative risk and a higher prevalence and broader range of ACEs than transitionally homeless participants, with the prevalence of childhood physical abuse marking the greatest difference between the two groups. Recurrent homelessness was also correlated with addiction to hard drugs, criminal activity, and weak social networks. Longitudinal and intervention studies in larger groups are needed to assess causality.

Continued Homelessness and Depressive Symptoms in Older Adults

Depression is common in adults experiencing homelessness. It is unclear whether continued homelessness is associated with more depressive symptoms. To examine the association between residential status and depressive symptoms in adults aged 50 years or older experiencing homelessness at study entry. This cohort study analyzed results from the Health Outcomes of People Experiencing Homelessness in Older Middle Age (HOPE HOME) project, which in 2013 began enrolling adults aged 50 years or older experiencing homelessness in Oakland, California, and conducted structured interviews every 6 months for a mean duration of 5.5 years through 2023 (for this cohort study). Eligible participants included those aged 50 years or older, able to speak English, and experiencing homelessness at enrollment. We analyzed data collected from 2013 to 2023. The exposure of interest was residential status. At follow-up visits, residential status was categorized as (1) homelessness (meeting the HEARTH [Homeless Emergency Assistance and Rapid Transition to Housing] Act definition) or (2) housed (living in a noninstitutional environment and not meeting the HEARTH Act definition). The primary outcome was moderate to severe depressive symptoms (with Center for Epidemiologic Studies-Depression [CES-D] scale score ≥22). The augmented inverse probability of treatment weighting (AIPTW) approach was used to examine the association between continued homelessness and depressive symptoms. The AIPTW adjusted for the following variables: number of chronic health conditions, age, sex, visiting a health care practitioner, receiving outpatient mental health treatment, receiving mental health medication, exposure to abuse, substance use disorder, and binge drinking. The cohort was composed of 450 participants, of whom 343 (76.2%) were males, and the mean (SD) age was 58.5 (5.2) years. Participants completed a median (IQR) of 8.9 (8-11) follow-up visits. With 1640 person-years of observation time, participants continued homelessness for 880 person-years (57.1%) and experienced being housed for 715 person-years (44.3%). Many participants (304 [78.0%]) were housed during at least 1 follow-up visit. The odds of a CES-D scale score of 22 or higher was significantly higher among participants who continued experiencing homelessness than among housed participants (marginal causal odds ratio, 1.08; 95% CI, 1.04-1.11; P < .001). This cohort study found that continued homelessness was associated independently with increased odds of depressive symptoms. Obtaining housing may have a favorable role in depression and overall well-being of older adults experiencing homelessness and may be considered as a mental health intervention.

Assessing anxiety and depression trajectories among single homeless adults receiving rapid rehousing following placement in housing

Despite growing international interest in using rapid rehousing (RRH) to address homelessness, there is little information about the mental health outcomes of RRH participants. We examined changes in anxiety and depression symptoms over time following placement in housing among a cohort of 98 single homeless adults receiving RRH services from a major city in the United States. We also assessed the extent to which sociodemographic characteristics, and factors related to RRH participants’ ability to maintain independent housing, were associated with the trajectory of change in anxiety and depression symptoms. We found statistically significant linear decreases in both anxiety and depression symptoms. Factors identified as having the strongest association with changes in anxiety and depression symptoms over time included age, race, monthly income, having a poor credit history as a barrier to housing and reporting that a mental health problem made it difficult to live on one’s own. Our findings suggest that the benefits of RRH may extend beyond improved housing stability and point to the need for additional and more rigorous research to test the impact of RRH on mental health outcomes.

Adverse childhood experiences in a pathway to single adult homelessness in Hamilton, New Zealand

Adverse childhood experiences (ACEs) can contribute to housing instability and risk of homelessness, featuring disproportionately in the life histories of many people experiencing homelessness. However, little is known about the prevalence and lifelong impact of ACEs among people experiencing homelessness in New Zealand, a country experiencing increasing homelessness levels amid a housing affordability crisis. Drawing on data from 100 questionnaire surveys and 11 interviews with participants registered with The People’s Project, a Housing First homeless service in Hamilton, we explore the prevalence and role of ACEs in homeless journeys, identifying a common pathway to homelessness among participants. Some varying factors contributing additionally for Māori (indigenous people) were identified. Our findings showed ACEs were commonly reported by participants, often preceding a series of disruptive events across participants’ lives. Accumulations of adverse events, coupled with structural and other constraints, contributed to housing insecurity across lifespans. Results highlight the importance of trauma-informed homelessness initiatives, such as Housing First, as well as measures aimed at reducing upstream drivers of homelessness such as poverty, structural racism, and the ongoing impacts of colonisation in New Zealand.

Performance of the Elixhauser Comorbidity Index in Predicting Mortality Among a National US Sample of Hospitalized Homeless Adults.

The Elixhauser Comorbidity Index (ECI) is widely used, but its performance in homeless populations has not been evaluated. Using a national sample of inpatients, this study compared homeless and nonhomeless inpatients on common clinical diagnoses and evaluated ECI performance in predicting mortality among homeless inpatients. A retrospective study was conducted using 2019 National Inpatient Sample (NIS) data, the largest publicly available all-payer inpatient health care database in the United States. Among 4,347,959 hospitalizations, 78,819 (weighted 1.8%) were identified as homeless. The ECI consists of 38 medical conditions; homelessness was defined using the International Classification of Diseases Tenth Revision Clinical Modification (ICD-10-CM) diagnostic code, and clinical conditions were based on the Clinical Classifications Software Refined (CCSR) for ICD-10-CM. Leading clinical diagnoses for homeless inpatients included schizophrenia and other psychotic disorders (13.3%), depressive disorders (9.4%), and alcohol-related disorders (7.2%); leading diagnoses for nonhomeless inpatients were septicemia (10.2%), heart failure (5.2%), and acute myocardial infarction (3.0%). Metastatic cancer and liver disease were the most common ECI diagnoses for both homeless and nonhomeless inpatients. ECI indicators and summary scores were predictive of in-hospital mortality for homeless and nonhomeless inpatients, with all models yielding concordance statistics above 0.80, with better performance found among homeless inpatients. These findings underlie the high rates of behavioral health conditions among homeless inpatients and the strong performance of the ECI in predicting in-hospital mortality among homeless inpatients, supporting its continued use as a case-mix control method and predictor of hospital readmissions.

Perspectives on Aging and Illness by Homeless Adults Receiving Street Medicine

Perspectives on Aging and Illness by Homeless Adults Receiving Street Medicine

Epidemiological features of depression and anxiety among homeless adults with healthcare access problems in London, UK: descriptive cross-sectional analysis.

In England in 2021, an estimated 274 000 people were homeless on a given night. It has long been recognised that physical and mental health of people who are homeless is poorer than for people who are housed. There are few peer-reviewed studies to inform health and social care for depression or anxiety among homeless adults in this setting. To measure the symptoms of depression and anxiety among adults who are homeless and who have difficulty accessing healthcare, and to describe distribution of symptoms across sociodemographic, social vulnerability and health-related characteristics. We completed structured questionnaires with 311 adults who were homeless and who had difficulty accessing healthcare in London, UK, between August and December 2021. We measured anxiety and depression symptoms using the 4-item Patient Health Questionnaire (PHQ-4) score. We compared median PHQ-4 scores across strata of the sociodemographic, social vulnerability and health-related characteristics, and tested for associations using the Kruskal-Wallis test. The median PHQ-4 score was 8 out of 12, and 40.2% had scores suggesting high clinical need. Although PHQ-4 scores were consistently high across a range of socioeconomic, social vulnerability and health-related characteristics, they were positively associated with: young age; food insecurity; recent and historic abuse; joint, bone or muscle problems; and frequency of marijuana use. The most common (60%) barrier to accessing healthcare related to transportation. Adults who are homeless and have difficulty accessing healthcare have high levels of depression and anxiety symptoms. Our findings support consideration of population-level, multisectoral intervention.

Rethinking interventions for dementia through a nonpharmaceutical lens: An analysis of five interventions

ABSTRACT The future welfare of older adults is a worldwide concern. By 2034, it is estimated that individuals 65 and older in the U.S. will be 77 million. Consequently, this reality will impact healthcare facilities and increase Medicare and Medicaid costs, resulting in higher incidents of homeless older adults, children caring for parents, the need for more caregivers, and an increased number of older individuals experiencing various forms of dementia. To address these concerns, the current trend for treating the onset of dementia and Alzheimer’s disease has been moving toward nonpharmaceutical interventions. Even though researchers have tapped into the benefits of several nonpharmaceutical treatments, there appears to be a constant debate on establishing which method is most effective. Deciding on best practices and methods to slow down and/or halt the progression of dementia is the gap this research needs to fill. To provide clarity on the topic, an analysis of alternative interventions to treat the onset of dementia is what this paper strived to achieve. The analysis involved comparing and contrasting the benefits of each intervention as well as illustrating the implications of the findings. In this regard, a systematic review was conducted examining the benefits of five nonpharmaceutical strategies; mental training, music therapy, technology usage, physical activity, and social interaction. Although findings revealed some form of improvement in each of the nonpharmacological interventions examined, the overarching theme appeared to lean toward providing mental stimulation. It was also not conclusive that physical activity prevented cognitive decline. More research is recommended.

IJCM_174A: Lifestyle risk factors among homeless adults in Chennai- A Cross Sectional Study

Background: India defines ‘homeless’ as those who do not live in Census houses, but rather stay on pavements, roadsides, railway platforms, staircases, temples, streets, in pipes, or other open spaces. According to 2018 GCC enumeration of urban homeless, there are 3764 men and 2962 women, in total 6726 adult population. As they have a relatively different lifestyle, it is essential to know about their lifestyle risk factors and their accessibility to healthcare. In order to attain our Sustainable Development goals, in particular SDG 3- it is essential to target the well being of the homeless population. Objective: To estimate the lifestyle risk factors among homeless population in Chennai. Methodology: All adults who were 18 years and above and who fit in the criteria for homeless where taken for the study and an Interviewer administered pre-designed questionnaire, under the following Socio Demographic Details, Behavioural Measurements which included tobacco use, alcohol consumption, diet, lifestyle advice and physical activity was used to ascertain the lifestyle risk factors among the homeless. Data was entered in MS excel and analyzed using SPSS-21. Results: Out of 341 participants, 70.7% were females,27.3% males and 2.1% transgender. 27.6% had a habit of smoking daily and among that 24.9% were using smokeless tobacco. 15% had a habit of drinking alcohol. In the past one year 57.2% had visited the hospital and 44% had visited a government facility. 27.3% did moderate work and 14.4% vigorious work. 1.5% had a habit of doing moderate exercise on a daily basis.76.8% and 54.8% had undergone screening for hypertension and diabetes mellitus respectively. Conclusion: Spreading awareness to the homeless population on lifestyle risk factors is essential to ensure their healthy living.

Homelessness: challenges and opportunities in the “new normal”

Purpose This paper – the final paper of a series of three – aims to discuss the implications of the findings from a service user needs assessment of people experiencing homelessness in the Northwest of England. It will expand on the previous paper by offering a more detailed analysis and discussion of the identified key themes and issues. The service user needs assessment was completed as part of a review of local service provision in the Northwest of England against the backdrop of the COVID-19 pandemic. Design/methodology/approach Semi-structured questionnaires were administered and used by health-care professionals to collect data from individuals accessing the Homeless and Vulnerable Adults Service (HVAS) in Bolton. The questionnaires included a section exploring Adverse Childhood Experiences. Data from 100 completed questionnaires were analysed to better understand the needs of those accessing the HVAS. Findings Multiple deprivations including extensive health and social care needs were identified within the cohort. Meeting these complex needs was challenging for both service users and service providers. This paper will explore key themes identified by the needs assessment and draw upon further comments from those who participated in the data-gathering process. The paper discusses the practicalities of responding to the complex needs of those with lived experience of homelessness. It highlights how a coordinated partnership approach, using an integrated service delivery model can be both cost-effective and responsive to the needs of those often on the margins of our society. Research limitations/implications Data collection during the COVID-19 pandemic presented a number of challenges. The collection period had to be extended whilst patient care was prioritised. Quantitative methods were used, however, this limited the opportunity for service user involvement and feedback. Future research could use qualitative methods to address this balance and use a more inclusive approach. Practical implications This study illustrates that the needs of the homeless population are broad and varied. Although the population themselves have developed different responses to their situations, their needs can only be fully met by a co-ordinated, multi-agency, partnership response. An integrated service model can help identify, understand, and meet the needs of the whole population and individuals within it to improve healthcare for a vulnerable population. Social implications This study highlighted new and important findings around the resilience of the homeless population and the significance of building protective factors to help combat the multiplicity of social isolation with both physical and mental health problems. Originality/value The discussion provides an opportunity to reflect on established views in relation to the nature and scope of homelessness. The paper describes a contemporary approach to tackling current issues faced by those experiencing homelessness in the current context of the COVID-19 pandemic. Recommendations for service improvements will include highlighting established good practices including embedding a more inclusive/participatory approach.

A conceptual framework to model social determinants of COVID-19 vaccination uptake among underserved homeless populations

BackgroundHomeless people have a higher risk of COVID-19 infection, linked to several social, economic and environmental determinants, frequent comorbidities, obstacles to exercising their constitutional social and health rights, poor medical cover, and insufficient use of the healthcare system. Data on COVID-19 vaccine uptake and its main determinants are lacking for this underserved population. ObjectivesTo construct and testa conceptual framework to model structural social determinants of COVID-19 vaccine uptake among underserved homeless populations, and to test this model to identify the determinants of COVID-19 vaccine uptake on the homeless population living in two metropolitan areas in France. MethodsWe implemented a multicenter cross-sectional survey from 15/11/2021 to 22/12/2021 in homeless adults in the city of Marseille and in the greater Paris area.Persons sheltered in migrant worker hostels or in emergency social shelters, members of the COVID HOMELESS cohort study in Marseille, and Travelers living in traditional housing were all eligible. A standardized face-to-face questionnaire was administered to the participants where they lived in various languages by trained interviewers. We used structural equation modeling to analyze the structural social determinants of COVID-19 vaccine uptake, the latter defined as receiving at least one dose. ResultsThe participation rate was 64 %, accounting for 3811 participants. There were three main factors associated with greater vaccine uptake: i) opportunity, which included having a personal general practitioner (β = 0.05, p < 0.05), healthcare cover (β = 0.05, p < 0.05), and somebody to accompany the participant for medical appointments (β = -0.04, p < 0.05); ii) motivation, which included attitudes towards vaccination (β = 0.55, p < 0.05), press- and poster-based information (β = 0.03, p < 0.05), and vaccination history (β = 0.03, p < 0.05); iii) type of housing (β = 0.13, p < 0.05) and housing stability (β = 0.04, p < 0.05). ConclusionOur results highlight that housing exclusion is a structural social determinant of COVID-19 vaccine uptake in homeless people in France. They also underline the role which opportunity and motivation play in improving uptake in this underserved homeless population.

Examining the Role of Self-Harm in the Relationship between Emergency Department Service Utilization and Trauma-Induced Homelessness among Homeless Individuals in Texas.

Homelessness is a complex public health problem in the United States. Current or ongoing history of trauma among individuals adds to the complexity and challenges of homelessness. Our study assessed the moderating role of self-harm in the association between emergency department (ED) service utilization and trauma-induced homelessness (TIH) among adults in Texas. Homeless adults (N = 282) who completed their baseline Vulnerability Index Service Prioritization Decision Assistance Prescreen Tool survey between February 2021 and February 2022 at a Local Mental Health Authority in Texas were selected. The outcome variable, TIH, was assessed by current period of homelessness due to experiencing trauma or abuse. The main independent variable was ED utilization, while self-harm in the past year was assessed as the moderating variable. A multivariate logistic regression with a moderation analysis was conducted while adjusting for the covariates. Individuals who utilized ED services and engaged in self-harm and risky behaviors had greater odds of experiencing current period of TIH. Male respondents were less likely to experience TIH. Finally, engaging in self-harm significantly moderated the association between ED service use and TIH. This study may help inform efforts to develop tailored interventions and promote resilience-based approaches to improve health outcomes among individuals experiencing homelessness due to TIH.