George Tolomiczenko

Interventions to Improve the Health of the Homeless A Systematic Review

BACKGROUND Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people. METHODS MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria. RESULTS Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes. CONCLUSIONS Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.

Interventions to Improve the Health of the Homeless

BACKGROUND Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people. METHODS MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria. RESULTS Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes. CONCLUSIONS Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.

Universal Health Insurance and Health Care Access for Homeless Persons

OBJECTIVES We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system. METHODS We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs. RESULTS Unmet health care needs were reported by 17% of participants. Compared with Torontos general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey. CONCLUSIONS Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.

The effect of traumatic brain injury on the health of homeless people

Background: We sought to determine the lifetime prevalence of traumatic brain injury and its association with current health conditions in a representative sample of homeless people in Toronto, Ontario. Methods: We surveyed 601 men and 303 women at homeless shelters and meal programs in 2004–2005 (response rate 76%). We defined traumatic brain injury as any self-reported head injury that left the person dazed, confused, disoriented or unconscious. Injuries resulting in unconsciousness lasting 30 minutes or longer were defined as moderate or severe. We assessed mental health, alcohol and drug problems in the past 30 days using the Addiction Severity Index. Physical and mental health status was assessed using the SF-12 health survey. We examined associations between traumatic brain injury and health conditions. Results: The lifetime prevalence among homeless participants was 53% for any traumatic brain injury and 12% for moderate or severe traumatic brain injury. For 70% of respondents, their first traumatic brain injury occurred before the onset of homelessness. After adjustment for demographic characteristics and lifetime duration of homelessness, a history of moderate or severe traumatic brain injury was associated with significantly increased likelihood of seizures (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.8 to 5.6), mental health problems (OR 2.5, 95% CI 1.5 to 4.1), drug problems (OR 1.6, 95% CI 1.1 to 2.5), poorer physical health status (–8.3 points, 95% CI –11.1 to –5.5) and poorer mental health status (–6.0 points, 95% CI –8.3 to –3.7). Interpretation: Prior traumatic brain injury is very common among homeless people and is associated with poorer health.

Multidimensional Social Support and the Health of Homeless Individuals

Homeless individuals often suffer from serious health problems. It has been argued that the homeless are socially isolated, with low levels of social support and social functioning, and that this lack of social resources contributes to their ill health. These observations suggest the need to further explore the relationship between social networks, social support, and health among persons who are homeless. The purpose of this study was to examine the association between multidimensional (cognitive/perceived and behavioral/received) social support and health outcomes, including physical health status, mental health status, and recent victimization, among a representative sample of homeless individuals in Toronto, Canada. Multivariate regression analyses were performed on social support and health outcome data from a subsample of 544 homeless adults, recruited from shelters and meal programs through multistage cluster sampling procedures. Results indicated that participants perceived moderately high levels of access to financial, emotional, and instrumental social support in their social networks. These types of perceived social supports were related to better physical and mental health status and lower likelihood of victimization. These findings highlight a need for more services that encourage the integration of homeless individuals into social networks and the building of specific types of social support within networks, in addition to more research into social support and other social contextual factors (e.g., social capital) and their influence on the health of homeless individuals.

Self-report and observer measures of substance abuse among homeless mentally ill persons in the cross-section and over time

The comparability of self-report and observer measures of substance abuse among 118 homeless mentally ill persons was assessed using cross-sectional and longitudinal measures. Possible correlates of nondisclosure were identified from demographic variables and clinical indicators. Lifetime abuse reported at baseline was a sensitive predictor of subsequent abuse behavior in the project, but cross-sectional measures based only on self-report or observer ratings failed to identify many abusers. A total of 17% of the subjects never disclosed abuse that was observed during the project. The level of substance abuse is likely to be severely underestimated among homeless mentally ill persons when only one self-report measure is used at just one point in time. This problem can, however, largely be overcome by incorporating information from observers and from multiple follow-ups or by focusing on lifetime rather than current abuse. We also conclude that underreporting may bias estimates of some correlates of substance abuse.

Drug problems among homeless individuals in Toronto, Canada: prevalence, drugs of choice, and relation to health status

BackgroundDrug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals. The objective of this study was to determine the prevalence and characteristics of drug use among a representative sample of homeless individuals and to examine the association between drug problems and physical and mental health status.MethodsRecruitment of 603 single men, 304 single women, and 284 adults with dependent children occurred at homeless shelters and meal programs in Toronto, Canada. Information was collected on demographic characteristics and patterns of drug use. The Addiction Severity Index was used to assess whether participants suffered from drug problems. Associations of drug problems with physical and mental health status (measured by the SF-12 scale) were examined using regression analyses.ResultsForty percent of the study sample had drug problems in the last 30 days. These individuals were more likely to be single men and less educated than those without drug problems. They were also more likely to have become homeless at a younger age (mean 24.8 vs. 30.9 years) and for a longer duration (mean 4.8 vs. 2.9 years). Marijuana and cocaine were the most frequently used drugs in the past two years (40% and 27%, respectively). Drug problems within the last 30 days were associated with significantly poorer mental health status (-4.9 points, 95% CI -6.5 to -3.2) but not with poorer physical health status (-0.03 points, 95% CI -1.3 to 1.3)).ConclusionsDrug use is common among homeless individuals in Toronto. Current drug problems are associated with poorer mental health status but not with poorer physical health status.

Neuropsychological Function in Homeless Mentally Ill Individuals

Because little data are available on the neuropsychological functioning of severely and persistently mentally ill (SPMI) persons who are homeless, our primary goal was to describe accurately and extensively the general neuropsychological functioning of a large group of such homeless individuals. In addition, we have sought to examine the relationship between some neuropsychological functions and demographic, illness, and clinical state measures in this population. A 5-hour neuropsychological test battery was administered to 116 SPMI homeless individuals. Neuropsychological, diagnostic, substance abuse, clinical, and psychopathology data were obtained in a standardized manner. SPMI homeless individuals were significantly impaired on a wide range of neuropsychological functions. Specific test performances were most significantly related to precursor variables (level of education and parental socioeconomic status) and state variables (level of psychosis and anticholinergic medication dose). Gender and substance abuse had significant effects limited to sustained attention. Neuropsychological performance was impaired in this sample of homeless SPMI persons. Further research, using profile analysis to directly compare groups composed of homeless persons without psychiatric illness or demographically matched persons of comparable psychiatric status who are not homeless will help clarify the role of homelessness and psychosis on neuropsychological function.

The health of homeless immigrants

Background: This study examined the association between immigrant status and current health in a representative sample of 1189 homeless people in Toronto, Canada. Methods: Multivariate regression analyses were performed to examine the relationship between immigrant status and current health status (assessed using the SF-12) among homeless recent immigrants (⩽10 years since immigration), non-recent immigrants (>10 years since immigration) and Canadian-born individuals recruited at shelters and meal programmes (response rate 73%). Results: After adjusting for demographic characteristics and lifetime duration of homelessness, recent immigrants were significantly less likely to have chronic conditions (RR 0.7, 95% CI 0.5 to 0.9), mental health problems (OR 0.4, 95% CI 0.2 to 0.7), alcohol problems (OR 0.2, 95% CI 0.1 to 0.5) and drug problems (OR 0.2, 95% CI 0.1 to 0.4) than non-recent immigrants and Canadian-born individuals. Recent immigrants were also more likely to have better mental health status (+3.4 points, SE ±1.6) and physical health status (+2.2 points, SE ±1.3) on scales with a mean of 50 and a SD of 10 in the general population. Conclusion: Homeless recent immigrants are a distinct group who are generally healthier and may have very different service needs from other homeless people.

Educating the Public About Mental Illness and Homelessness: A Cautionary Note

Objective: To determine whether the viewing of a video depicting the successful struggles of homeless persons with mental illness in finding and maintaining housing can have a positive impact on attitudes toward homeless persons with mental illness. Method: Five hundred and seventy-five high school students attending a brief educational session on mental illness participated in 1 of 3 comparison versions of the 2-hour program (control, video, video plus discussion). All completed an “Attitudes toward Homelessness and Mental Illness Questionnaire.” Demographic and prior exposure variables were entered as covariates in between-group analyses of variance. Results: Females and subjects who had more prior encounters with homeless persons were found to have the most positive attitudes. After controlling for these effects, the video alone had a negative impact on attitudes relative to the other groups, while the video followed by a discussion with one of the people featured in it had a largely positive impact. Conclusions: The apparent immediacy and the evocative power of video presentations cannot substitute for direct contact for the purpose of promoting positive attitude change. The findings are consistent with prior research emphasizing the importance of direct interaction with members of stigmatized groups to reduce negative attitudes. Education programs trying to destigmatize mental illness and homelessness using videos should proceed with caution.