Matthew J. To

How did a Housing First intervention improve health and social outcomes among homeless adults with mental illness in Toronto? Two-year outcomes from a randomised trial

Objectives We studied the impact of a Housing First (HF) intervention on housing, contact with the justice system, healthcare usage and health outcomes among At Home/Chez Soi randomised trial participants in Toronto, a city with an extensive service network for social and health services for individuals who are experiencing homelessness and mental illness. Methods Participants identified as high needs were randomised to receive either the intervention which provided them with housing and supports by an assertive community treatment team (HF+ACT) or treatment as usual (TAU). Participants (N=197) had in-person interviews every 3 months for 2 years. Results The HF+ACT group spent more time stably housed compared to the TAU group with the mean difference between the groups of 45.8% (95% CI 37.1% to 54.4%, p<0.0001). Accounting for baseline differences, HF+ACT group showed significant improvements over TAU group for community functioning, selected quality-of-life subscales and arrests at some time points during follow-up. No differences between HF+ACT and TAU groups over the follow-up were observed for health service usage, community integration and substance use. Conclusions HF for individuals with high levels of need increased housing stability and selected health and justice outcomes over 2 years in a city with many social and health services. Trial registration number ISRCTN42520374.

Healthcare Utilization, Legal Incidents, and Victimization Following Traumatic Brain Injury in Homeless and Vulnerably Housed Individuals: A Prospective Cohort Study.

Objective:To characterize the associations between a history of traumatic brain injury (TBI) and subsequent healthcare utilization, legal involvement, and victimization. Setting:Three major Canadian cities. Participants:A total of 1181 homeless and vulnerably housed adults who were single and 18 years or older. Data for 968 participants (82%) were available at 1-year follow-up. Design:Prospective cohort study. Data were collected using structured, in-person interviews at baseline in 2009 and approximately 1 year after baseline. Main Measures:Self-reported TBI, 12-item Short Form Health Survey, healthcare, and criminal justice use questionnaires. Results:The lifetime prevalence of TBI was 61%. A history of TBI was independently associated with emergency department (ED) use [adjusted odds ratio (AOR) = 1.5, 95% confidence interval (CI): 1.11–1.96], being arrested or incarcerated (AOR = 1.79, 95% CI: 1.3–2.48) and being a victim of physical assault (AOR = 2.81, 95% CI: 1.96–4.03) during the 1-year follow-up period. Conclusions:Homeless and vulnerably housed individuals with a lifetime history of TBI are more likely to be ED users, arrested or incarcerated, and victims of physical assault over a 1-year follow-up period even after adjustment for health status and other confounders. These findings have public health and criminal justice implications and highlight the need for effective screening, treatment, and rehabilitation for TBI in this population.

Housing First for older homeless adults with mental illness: a subgroup analysis of the At Home/Chez Soi randomized controlled trial

This study compares the effect of Housing First on older (≥50 years old) and younger (18–49 years old) homeless adults with mental illness participating in At Home/Chez Soi, a 24‐month multisite randomized controlled trial of Housing First.

Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School

Abstract Phenomenon: Homelessness is a major public health concern. Given that homeless individuals have high rates of mortality and morbidity, are more likely to be users of the healthcare system, and often report unmet health needs, it is important to examine how homelessness is addressed in medical education. We wanted to examine content and framing of issues related to homelessness in the case-based learning (CBL) curriculum and provide insights about whether medical students are being adequately trained to meet the health needs of homeless individuals through CBL. Approach: CBL content at a Canadian medical school that featured content related to homelessness was analyzed. Data were extracted from cases for the following variables: curriculum unit (e.g., professionalism/ethics curriculum or biomedical/clinical curriculum), patient characteristics (e.g., age, sex), and medical and social conditions. A thematic analysis was performed on cases related to homelessness. Discrepancies in analysis were resolved by consensus. Findings: Homelessness was mentioned in five (2.6%) of 191 CBL cases in the medical curriculum. Homelessness was significantly more likely to be featured in professionalism/ethics cases than in biomedical/clinical cases (p = .03). Homeless patients were portrayed as socially disadvantaged individuals, and medical learners were prompted to discuss ethical issues related to homeless patients in cases. However, homeless individuals were largely voiceless in cases. Homelessness was associated with serious physical and mental health concerns, but students were rarely prompted to address these concerns. Insights: The health and social needs of homeless individuals are often overlooked in CBL cases in the medical curriculum. Moreover, stereotypes of homelessness may be reinforced through medical training. There are opportunities for growth in addressing the needs of homeless individuals through medical education.

An investigation of predictors of mental health in single men and women experiencing homelessness in three Canadian cities

ABSTRACT Homelessness is related to poorer mental health, yet, there is limited understanding of the predictors of mental health of men and women experiencing homelessness. To support service providers in identifying individuals who might be at particular risk of poor mental health, this study investigated the predictors of mental health in 501 single men and women experiencing homelessness in Vancouver, Toronto, and Ottawa, Canada. Data were obtained via in-person, structured interviews. In order to identify whether predictors differ by gender, multiple linear regressions were conducted separately for men and women. Mental health status was measured by the Mental Component Summary score of the 12-item Short-Form Health Survey. Better mental health for men and women was associated with the presence of fewer chronic health conditions and a higher level of social support. An older age, not having experienced a recent physical attack, and absence of a mental health diagnosis were related to better mental health for women. The absence of unmet mental health needs within the past 12 months was associated with better mental health for men. The study highlights differences in factors associated with mental health for men and women. Service providers should be aware of the association of these factors with mental health to guide assessment and service planning.

Twelve tips for medical students to facilitate a Photovoice project

Abstract Participatory action projects, such as Photovoice, can provide medical trainees with a unique opportunity for community engagement. Through Photovoice, participants with lived experience engage in dialog and capture photographs of community issues. Participants subsequently develop narratives that accompany photos to raise awareness about community needs. In this paper, we describe twelve tips to develop a Photovoice project and discuss how medical students can engage communities through a participatory action lens. Such an approach not only serves as a method for medical students to learn about social determinants of health through the perspective of lived experience, but also has the capacity of building advocacy and community collaboration skills. Through providing a voice to marginalized individuals using Photovoice, medical students can partner with communities to work toward social change. Photovoice participants also benefit from the project as it provides them with a platform to highlight strengths and weaknesses in their community.

Concurrent Disorders and Health Care Utilization Among Homeless and Vulnerably Housed Persons in Canada

ABSTRACT Objective: Individuals who are homeless or vulnerably housed have a higher prevalence of concurrent disorders, defined as having a mental health diagnosis and problematic substance use, compared to the general housed population. The study objective was to investigate the effect of having concurrent disorders on health care utilization among homeless or vulnerably housed individuals, using longitudinal data from the Health and Housing in Transition Study. Methods: In 2009, 1190 homeless or vulnerably housed adults were recruited in Ottawa, Toronto, and Vancouver, Canada. Participants completed baseline interviews and four annual follow-up interviews, providing data on sociodemographics, housing history, mental health diagnoses, problematic drug use with the Drug Abuse Screening Test (DAST-10), problematic alcohol use with the Alcohol Use Disorders Identification Test (AUDIT), chronic health conditions, and utilization of the following health care services: emergency department (ED), hospitalization, and primary care. Concurrent disorders were defined as the participant having ever received a mental health diagnosis at baseline and having problematic substance use (i.e., DAST-10 ≥ 6 and/or AUDIT ≥ 20) at any time during the study period. Three generalized mixed effects logistic regression models were used to examine the independent association of having concurrent disorders and reporting ED use, hospitalization, or primary care visits in the past 12 months. Results: Among our sample of adults who were homeless or vulnerably housed, 22.6% (n = 261) reported having concurrent disorders at baseline. Individuals with concurrent disorders had significantly higher odds of ED use (adjusted odds ratio [AOR] = 1.71; 95% confidence interval [CI], 1.4–2.11), hospitalization (AOR = 1.45; 95% CI, 1.16–1.81), and primary care visits (AOR = 1.34; 95% CI, 1.05–1.71) in the past 12 months over the four-year follow-up period, after adjusting for potential confounders. Conclusions: Concurrent disorders were associated with higher rates of health care utilization when compared to those without concurrent disorders among homeless and vulnerably housed individuals. Comprehensive programs that integrate mental health and addiction services with primary care as well as community-based outreach may better address the unmet health care needs of individuals living with concurrent disorders who are vulnerable to poor health outcomes.

Incidence and Associated Risk Factors of Traumatic Brain Injury in a Cohort of Homeless and Vulnerably Housed Adults in 3 Canadian Cities

Objective:To examine the factors associated with incident traumatic brain injury (TBI) among homeless and vulnerably housed persons over a 3-year follow-up period. Setting and participants:Data were obtained from the Health and Housing in Transition study, which tracked the health and housing status of 1190 homeless or vulnerably housed individuals in 3 Canadian cities for 3 years. Design and Main Measures:Main measure was self-reported incident TBI during the follow-up period. Factors associated with TBI were ascertained using mixed-effects logistic regression. Results:During first, second, and third years of follow-up, 187 (19.4%), 166 (17.1%), and 172 (17.9%) participants reported a minimum of 1 incident TBI, respectively. Among 825 participants with available data for all 3 years of follow-up, 307 (37.2%) reported at least 1 incident TBI during the 3-year follow-up period. Lifetime prevalence of TBI, endorsing a history of mental health diagnoses at baseline, problematic alcohol and drug use, younger age, poorer mental health, and residential instability were associated with increased risk of incident TBI during follow-up period. Conclusion:Mental health support and addressing residential instability and problematic substance use may reduce further risk of TBI and its associated poor health and social outcomes in this population.

Social equity in health care

Wong and colleagues observe two interesting and unfortunate findings in their study.[1][1] Individuals at higher risk of poor outcomes, including those with more comorbidities, are less likely to receive follow-up care, and those who visited a physician in the preceding year were more likely to