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1.  Harm reduction services as a point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs: a qualitative analysis 
BMC Public Health  2012;12:312.
Background
Homeless and marginally housed persons who use alcohol and/or illicit drugs often have end-of-life care needs that go unmet due to barriers that they face to accessing end-of-life care services. Many homeless and marginally housed persons who use these substances must therefore rely upon alternate sources of end-of-life care and support. This article explores the role of harm reduction services in end-of-life care services delivery to homeless and marginally housed persons who use alcohol and/or illicit drugs.
Methods
A qualitative case study design was used to explore end-of-life care services delivery to homeless and marginally housed persons in six Canadian cities. A key objective was to explore the role of harm reduction services. 54 health and social services professionals participated in semi-structured qualitative interviews. All participants reported that they provided care and support to this population at end-of-life.
Results
Harm reduction services (e.g., syringe exchange programs, managed alcohol programs, etc.) were identified as a critical point-of-entry to and source of end-of-life care and support for homeless and marginally housed persons who use alcohol and/or illicit drugs. Where possible, harm reduction services facilitated referrals to end-of-life care services for this population. Harm reduction services also provided end-of-life care and support when members of this population were unable or unwilling to access end-of-life care services, thereby improving quality-of-life and increasing self-determination regarding place-of-death.
Conclusions
While partnerships between harm reduction programs and end-of-life care services are identified as one way to improve access, it is noted that more comprehensive harm reduction services might be needed in end-of-life care settings if they are to engage this underserved population.
doi:10.1186/1471-2458-12-312
PMCID: PMC3355019  PMID: 22545586
2.  Experiences With and Attitudes Toward Death and Dying Among Homeless Persons 
Background
Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population.
Objective
To explore the experiences and attitudes toward death and dying among homeless persons.
Design
Qualitative study utilizing focus groups.
Participants
Fifty-three homeless persons recruited from homeless service agencies.
Measurements
In-depth interviews, which were audiotaped and transcribed.
Results
We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants’ attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL.
Conclusions
Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised.
doi:10.1007/s11606-006-0045-8
PMCID: PMC1829422  PMID: 17372788
homelessness; death; end-of-life care; focus groups; poverty
3.  Experiences With and Attitudes Toward Death and Dying Among Homeless Persons 
Background
Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population.
Objective
To explore the experiences and attitudes toward death and dying among homeless persons.
Design
Qualitative study utilizing focus groups.
Participants
Fifty-three homeless persons recruited from homeless service agencies.
Measurements
In-depth interviews, which were audiotaped and transcribed.
Results
We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants’ attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL.
Conclusions
Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised.
doi:10.1007/s11606-006-0045-8
PMCID: PMC1829422  PMID: 17372788
homelessness; death; end-of-life care; focus groups; poverty
4.  Dying on the Streets: Homeless Persons’ Concerns and Desires about End of Life Care 
Background
There is little understanding about the experiences and preferences at the end of life (EOL) for people from unique cultural and socioeconomic backgrounds. Homeless individuals are extreme examples of these overlooked populations; they have the greatest risk of death, encounter barriers to health care, and lack the resources and relationships assumed necessary for appropriate EOL care. Exploring their desires and concerns will provide insight for the care of this vulnerable and disenfranchised population, as well as others who are underserved.
Objective
Explore the concerns and desires for EOL care among homeless persons.
Design
Qualitative study utilizing focus groups.
Participants
Fifty-three homeless persons recruited from agencies providing homeless services.
Measurements
In-depth interviews, which were audiotaped and transcribed.
Results
We present 3 domains encompassing 11 themes arising from our investigation, some of which are previously unreported. Homeless persons worried about dying and EOL care; had frequent encounters with death; voiced many unique fears, such as dying anonymously and undiscovered; favored EOL documentation, such as advance directives; and demonstrated ambivalence towards contacting family. They also spoke of barriers to EOL care and shared interventions to improve dying among the very poor and estranged.
Conclusions
Homeless persons have significant personal experience and feelings about death, dying, and EOL care, much of which is different from those previously described in the EOL literature about other populations. These findings have implications not only for homeless persons, but for others who are poor and disenfranchised.
doi:10.1007/s11606-006-0046-7
PMCID: PMC1829423  PMID: 17372789
bioethics; homelessness; end-of-life care; focus groups; poverty
5.  Dying on the Streets: Homeless Persons’ Concerns and Desires about End of Life Care 
Background
There is little understanding about the experiences and preferences at the end of life (EOL) for people from unique cultural and socioeconomic backgrounds. Homeless individuals are extreme examples of these overlooked populations; they have the greatest risk of death, encounter barriers to health care, and lack the resources and relationships assumed necessary for appropriate EOL care. Exploring their desires and concerns will provide insight for the care of this vulnerable and disenfranchised population, as well as others who are underserved.
Objective
Explore the concerns and desires for EOL care among homeless persons.
Design
Qualitative study utilizing focus groups.
Participants
Fifty-three homeless persons recruited from agencies providing homeless services.
Measurements
In-depth interviews, which were audiotaped and transcribed.
Results
We present 3 domains encompassing 11 themes arising from our investigation, some of which are previously unreported. Homeless persons worried about dying and EOL care; had frequent encounters with death; voiced many unique fears, such as dying anonymously and undiscovered; favored EOL documentation, such as advance directives; and demonstrated ambivalence towards contacting family. They also spoke of barriers to EOL care and shared interventions to improve dying among the very poor and estranged.
Conclusions
Homeless persons have significant personal experience and feelings about death, dying, and EOL care, much of which is different from those previously described in the EOL literature about other populations. These findings have implications not only for homeless persons, but for others who are poor and disenfranchised.
doi:10.1007/s11606-006-0046-7
PMCID: PMC1829423  PMID: 17372789
bioethics; homelessness; end-of-life care; focus groups; poverty
6.  Unique health care utilization patterns in a homeless population in Ghent 
Background
Existing studies concerning the health care use of homeless people describe higher utilisation rates for hospital-based care and emergency care, and lower rates for primary care by homeless people compared to the general population. Homeless people are importantly hindered and/or steered in their health care use by barriers directly related to the organisation of care. Our goal is to describe the accessibility of primary health care services, secondary care and emergency care for homeless people living in an area with a universal primary health care system and active guidance towards this unique system.
Methods
Observational, cross-sectional study design. Data from the Belgian National health survey were merged with comparable data collected by means of a face-to-face interview from homeless people in Ghent. 122 homeless people who made use of homeless centres and shelters in Ghent were interviewed using a reduced version of the Belgian National Health survey over a period of 5 months. 2-dimensional crosstabs were built in order to study the bivariate relationship between health care use (primary health care, secondary and emergency care) and being homeless. To determine the independent association, a logistic model was constructed adjusting for age and sex.
Results and Discussion
Homeless people have a higher likelihood to consult a GP than the non-homeless people in Ghent, even after adjusting for age and sex. The same trend is demonstrated for secondary and emergency care.
Conclusions
Homeless people in Ghent do find the way to primary health care and make use of it. It seems that the universal primary health care system in Ghent with an active guidance by social workers contributes to easier GP access.
doi:10.1186/1472-6963-10-242
PMCID: PMC2933678  PMID: 20723222
7.  A cross-sectional observational study of unmet health needs among homeless and vulnerably housed adults in three Canadian cities 
BMC Public Health  2013;13:577.
Background
Homeless persons experience a high burden of health problems; yet, they face significant barriers in accessing health care. Less is known about unmet needs for care among vulnerably housed persons who live in poor-quality or temporary housing and are at high risk of becoming homeless. The objectives of this study were to examine the prevalence of and factors associated with unmet needs for health care in a population-based sample of homeless and vulnerably housed adults in three major cities within a universal health insurance system.
Methods
Participants were recruited at shelters, meal programs, community health centers, drop-in centers, rooming houses, and single room occupancy hotels in Vancouver, Toronto, and Ottawa, Canada, throughout 2009. Baseline interviews elicited demographic characteristics, health status, and barriers to health care. Logistic regression was used to identify factors associated with self-reported unmet needs for health care in the past 12 months.
Results
Of the 1,181 participants included in the analysis, 445 (37%) reported unmet needs. In adjusted analyses, factors associated with a greater odds of reporting unmet needs were having employment in the past 12 months (AOR = 1.40, 95% CI = 1.03–1.91) and having ≥3 chronic health conditions (AOR = 2.17, 95% CI = 1.24–3.79). Having higher health-related quality of life (AOR = 0.21, 95% CI = 0.09–0.53), improved mental (AOR = 0.97, 95% CI = 0.96–0.98) or physical health (AOR = 0.98, 95% CI = 0.96–0.99), and having a primary care provider (AOR = 0.63, 95% CI = 0.46–0.85) decreased the odds of reporting unmet needs.
Conclusions
Homeless and vulnerably housed adults have a similar likelihood of experiencing unmet health care needs. Strategies to improve access to primary care and reduce barriers to accessing care in these populations are needed.
doi:10.1186/1471-2458-13-577
PMCID: PMC3691921  PMID: 23764199
Access to care; Homelessness; Housing; Primary care; Public health policy
8.  Homeless People’s Perceptions of Welcomeness and Unwelcomeness in Healthcare Encounters 
Journal of General Internal Medicine  2007;22(7):1011-1017.
Background
Homeless people face many barriers to obtaining health care, and their attitudes toward seeking health care services may be shaped in part by previous encounters with health care providers.
Objective
To examine how homeless persons experienced “welcomeness” and “unwelcomeness” in past encounters with health care providers and to characterize their perceptions of these interactions.
Design
Qualitative content analysis of 17 in-depth interviews.
Participants
Seventeen homeless men and women, aged 29–62 years, residing at 5 shelters in Toronto, Canada.
Approach
Interpretive content analysis was performed using iterative stages of inductive coding. Interview transcripts were analyzed using Buber’s philosophical conceptualization of ways of relating as “I–It” (the way persons relate to objects) and “I–You” (the way persons relate to dynamic beings).
Results
Most participants perceived their experiences of unwelcomeness as acts of discrimination. Homelessness and low social class were most commonly cited as the perceived basis for discriminatory treatment. Many participants reported intense emotional responses to unwelcoming experiences, which negatively influenced their desire to seek health care in the future. Participants’ descriptions of unwelcoming health care encounters were consistent with “I–It” ways of relating in that they felt dehumanized, not listened to, or disempowered. Welcoming experiences were consistent with “I–You” ways of relating, in that patients felt valued as a person, truly listened to, or empowered.
Conclusions
Homeless people’s perceptions of welcomeness and unwelcomeness are an important aspect of their encounters with health care providers. Buber’s “I–It” and “I–You” concepts are potentially useful aids to health care providers who wish to understand how welcoming and unwelcoming interactions are fostered.
doi:10.1007/s11606-007-0183-7
PMCID: PMC2219712  PMID: 17415619
homeless persons; professional-patient relations; trust; welcomeness; unwelcomeness
9.  Health-Seeking Challenges Among Homeless Youth 
Nursing research  2010;59(3):212-218.
Background
Approximately 1.5 to 2 million homeless young persons live on the streets in the United States. With the current economic situation, research is needed on quality of services geared toward homeless young adults.
Objectives
The objective of this study was to explore homeless young adults' perspectives on barriers and facilitators of health-care-seeking behavior and their perspectives on improving existing programs for homeless persons.
Methods
This article is a descriptive qualitative study using focus groups, with a purposeful sample of 24 homeless drug-using young adults.
Results
Identified themes were failing access to care based on perceived structural barriers (limited clinic sites, limited hours of operation, priority health conditions, and long wait times) and social barriers (perception of discrimination by uncaring professionals, law enforcement, and society in general).
Discussion
Results provide insight into programmatic and agency resources that facilitate health-seeking behaviors among homeless young adults and include implications for more research with providers of homeless health and social services.
doi:10.1097/NNR.0b013e3181d1a8a9
PMCID: PMC2949422  PMID: 20404776
health care; health-seeking behaviors; homeless; young adults
10.  Challenges to immunization: the experiences of homeless youth 
BMC Public Health  2012;12:338.
Background
Homelessness is a critical social issue, both a product of, and contributing to, poor mental and physical health. Over 150,000 young Canadians live on the streets. Homeless youth experience a high incidence of infectious diseases, many of which are vaccine preventable. Early departure from school and limited access to public health services makes them a particularly vulnerable high-risk group. This study explores challenges to obtaining essential vaccines experienced by homeless youth.
Methods
A qualitative research study to explore knowledge, attitudes, beliefs, and experiences surrounding immunization of hard-to-reach homeless youth was designed. Participants were recruited for focus groups from Phoenix House and Shelter, a non-profit, community-based organization assisting homeless youth in Halifax, Nova Scotia, Canada. An experienced facilitator guided the recorded discussions. Transcripts of audiotapes were analyzed using a constant comparative method until data revealed a set of exemplars and themes that best captured participants’ knowledge, attitudes, beliefs and experiences surrounding immunization and infectious diseases.
Results
Important themes emerged from our analysis. Considerable variability in knowledge about immunization and vaccine preventable diseases was found. The homeless youth in the study had limited awareness of meningitis in contrast to a greater knowledge about sexually transmitted infections and influenza, gained during the H1N1/09 public health campaign. They recognized their poverty as a risk for contracting infectious diseases, along with their inability to always employ known strategies to prevent infectious diseases, due to circumstances. They showed considerable insight into the detrimental effects of poor hygiene, sleeping locations and risk behaviour. Interviewed homeless youth regarded themselves as good compliers of health professional advice and offered valuable suggestions to improve immunization in their population.
Conclusions
To provide effective public health interventions, it is necessary to consider the knowledge, attitudes, beliefs, and experiences of hard to reach, high risk groups. Our study shows that homeless youth are interested and capable in discussing immunization. Active targeting of homeless youth for public health immunization programs is needed. Working collaboratively with non-profit organizations that assist homeless youth provides an opportunity to increase their knowledge of infectious risks and to improve immunization strategies in this vulnerable group.
doi:10.1186/1471-2458-12-338
PMCID: PMC3390266  PMID: 22568937
Homeless youth; Hard to reach population; Vaccines; Immunization programs; Infectious diseases; Invasive meningococcal disease
11.  Homelessness and the Response to Emerging Infectious Disease Outbreaks: Lessons from SARS 
Journal of Urban Health   2008;85(3):402-410.
During the 2003 severe acute respiratory syndrome (SARS) outbreak in Toronto, the potential introduction of SARS into the homeless population was a serious concern. Although no homeless individual in Toronto contracted SARS, the outbreak highlighted the need to develop an outbreak preparedness plan that accounts for unique issues related to homeless people. We conducted key informant interviews with homeless service providers and public health officials (n = 17) and identified challenges specific to the homeless population in the areas of communication, infection control, isolation and quarantine, and resource allocation. Planning for future outbreaks should take into account the need to (1) develop systems that enable rapid two-way communication between public health officials and homeless service providers, (2) ensure that homeless service providers have access to infection control supplies and staff training, (3) prepare for possible homeless shelter closures due to staff shortages or high attack rates among clients, and (4) plan for where and how clinically ill homeless individuals will be isolated and treated. The Toronto SARS experience provided insights that are relevant to response planning for future outbreaks in cities with substantial numbers of homeless individuals.
doi:10.1007/s11524-008-9270-2
PMCID: PMC2329752  PMID: 18347991
Contact tracing; Disease outbreaks; Homeless persons; Human; Influenza; Patient isolation; Quarantine; Severe acute respiratory syndrome.
12.  Homeless youth’s overwhelming health burden: A review of the literature 
Paediatrics & Child Health  2011;16(6):e43-e47.
Homelessness has reached epidemic proportions in Canada. Canadian children and adolescents are the most vulnerable because youth comprise the fastest growing segment of the homeless population. A systematic literature review was undertaken using MEDLINE, Web of Science and the Homeless Hub (www.homelesshub.ca) to encompass the time frame from January 1990 to June 2009. The following terms were used as key words: ‘homelessness’, ‘homeless youth’, ‘poverty’, ‘street youth’ and ‘runaway’. The present review identified an intersection among education deficits, social service insufficiencies, and poor mental and physical health in homeless youth. Health care delivery to homeless youth was often nonanticipatory, inconsistent and perceived as discriminatory. However, street youth were identified as requiring health care for pregnancy, mental health concerns, sexually transmitted illnesses, respiratory conditions, substance abuse and a myriad of other illnesses. Plenty of work is still required to reduce health inequalities and improve the daily living conditions of Canadian youth living in poverty.
PMCID: PMC3328221  PMID: 22654549
Homeless; Homelessness; Poverty; Street youth; Youth
13.  Health Care for Homeless Women 
OBJECTIVE
Homelessness is a significant and growing problem in the United States. Women and families are the fastest growing segments of the homeless population. Homelessness increases the risk of having health problems and encountering barriers to care. This study determines how much perceived unmet need for medical care there is among homeless women, what homeless women perceive to be barriers to health care, and how barriers and other factors are associated with unmet needs.
DESIGN
Cross-sectional study of homeless women, utilizing structured interviews.
SETTING AND PARTICIPANTS
Community-based probability sample of 974 homeless women aged 15 to 44 years.
MAIN OUTCOME MEASURES
Perceived unmet need for medical care in the past 60 days. Relationship between unmet need and demographic variables, place of stay, source of health care, insurance, and perceived barriers to care.
RESULTS
Of the 974 women, 37% reported unmet need for medical care. Controlling for other factors, the odds of unmet need were lower among those with a regular source of care (odds ratio [OR] to .35, 95% confidence interval [CI], .21 to 58), while having health insurance was not significantly associated. The odds of unmet need were higher among those who experienced the barriers: not knowing where to go (OR 2.27, 95% CI, 1.40 to 3.69), long office waiting times (OR 1.89, 95% CI 1.27 to 2.83) and being too sick to seek care (OR 2.03, 95% CI, 1.14 to 3.62).
CONCLUSIONS
There is significant unmet need for medical care among homeless women. Having a regular source of care was more important than health insurance in lowering the odds of unmet need. Homeless women must be educated regarding sources of care, and clinics serving the homeless must decrease waiting times.
doi:10.1046/j.1525-1497.2003.20909.x
PMCID: PMC1494940  PMID: 14687278
barriers; homeless; unmet need; vulnerable population; women
14.  Quality of life themes in Canadian adults and street youth who are homeless or hard-to-house: A multi-site focus group study 
Background
The aim of this study was to identify what is most important to the quality of life (QoL) of those who experience homelessness by directly soliciting the views of homeless and hard-to-house Canadians themselves. These individuals live within a unique social context that differs considerably from that of the general population. To understand the life areas that are most important to them, it is critical to have direct input from target populations of homeless and hard-to-house persons.
Methods
Focus groups were conducted with 140 individuals aged 15 to 73 years who were homeless or hard-to-house to explore the circumstances in which they were living and to capture what they find to be important and relevant domains of QoL. Participants were recruited in Toronto, Ottawa, Montreal, and Vancouver. Content analysis was used to analyze the data.
Results
Six major content themes emerged: Health/health care; Living conditions; Financial situation; Employment situation; Relationships; and Recreational and leisure activities. These themes were linked to broader concepts that included having choices, stability, respect, and the same rights as other members of society.
Conclusions
These findings not only aid our understanding of QoL in this group, but may be used to develop measures that capture QoL in this population and help programs and policies become more effective in improving the life situation for persons who are homeless and hard-to-house.
Quality of life themes in Canadian adults and street youth who are homeless or hard-to-house: A multi-site focus group study.
doi:10.1186/1477-7525-10-93
PMCID: PMC3462681  PMID: 22894551
Homeless; Quality of life; Hard-to-house
15.  Elderly Homeless Veterans in Los Angeles: Chronicity and precipitants of homelessness 
American journal of public health  2013;103(0 2):10.2105/AJPH.2013.301309.
We interviewed 33 chronically and 26 acutely homeless veterans aged 65 and over about their health and mental health, education and employment experience, social support, service needs and other precipitants of homelessness. Chronically homeless elderly veterans were more likely to have lower levels of education, had greater numbers and longer durations of prior homelessness, fewer social contacts providing instrumental support, and were more likely to report financial barriers to procuring housing. In response to open-ended questioning, elderly homeless veterans revealed how health and substance use issues interacted with loss of social support and eviction. The results suggest the importance of healthcare access and substance disorder treatment among elderly veterans and informs service delivery. Further research with larger samples is needed to confirm the characteristics and needs of the elderly homeless veteran population.
doi:10.2105/AJPH.2013.301309
PMCID: PMC3838488  PMID: 24148059
elderly homeless veterans; homeless chronicity; precipitants of homelessness
16.  Service provision and barriers to care for homeless people with mental health problems across 14 European capital cities 
Background
Mental health problems are disproportionately higher amongst homeless people. Many barriers exist for homeless people with mental health problems in accessing treatment yet little research has been done on service provision and quality of care for this group. The aim of this paper is to assess current service provision and identify barriers to care for homeless people with mental health problems in 14 European capital cities.
Method
Two methods of data collection were employed; (i) In two highly deprived areas in each of the 14 European capital cities, homeless-specific services providing mental health, social care or general health services were assessed. Data were obtained on service characteristics, staff and programmes provided. (ii) Semi-structured interviews were conducted in each area with experts in mental health care provision for homeless people in order to determine the barriers to care and ways to overcome them.
Results
Across the 14 capital cities, 111 homeless-specific services were assessed. Input from professionally qualified mental health staff was reported as low, as were levels of active outreach and case finding. Out-of-hours service provision appears inadequate and high levels of service exclusion criteria were evident. Prejudice in the services towards homeless people, a lack of co-ordination amongst services, and the difficulties homeless people face in obtaining health insurance were identified as major barriers to service provision.
Conclusions
While there is variability in service provision across European capital cities, the reported barriers to service accessibility are common. Homeless-specific services are more responsive to the initial needs of homeless people with mental health problems, while generic services tend to be more conducive to long term care. Further research is needed to determine the effectiveness of different service delivery models, including the most effective coordination of homeless specific and generic services.
doi:10.1186/1472-6963-12-222
PMCID: PMC3441802  PMID: 22838503
17.  Cognitive Interviewing Methods for Questionnaire Pre-Testing in Homeless Persons with Mental Disorders 
In this study, cognitive interviewing methods were used to test targeted questionnaire items from a battery of quantitative instruments selected for a large multisite trial of supported housing interventions for homeless individuals with mental disorders. Most of the instruments had no published psychometrics in this population. Participants were 30 homeless adults with mental disorders (including substance use disorders) recruited from service agencies in Vancouver, Winnipeg, and Toronto, Canada. Six interviewers, trained in cognitive interviewing methods and using standard interview schedules, conducted the interviews. Questions and, in some cases, instructions, for testing were selected from existing instruments according to a priori criteria. Items on physical and mental health status, housing quality and living situation, substance use, health and justice system service use, and community integration were tested. The focus of testing was on relevance, comprehension, and recall, and on sensitivity/acceptability for this population. Findings were collated across items by site and conclusions validated by interviewers. There was both variation and similarity of responses for identified topics of interest. With respect to relevance, many items on the questionnaires were not applicable to homeless people. Comprehension varied considerably; thus, both checks on understanding and methods to assist comprehension and recall are recommended, particularly for participants with acute symptoms of mental illness and those with cognitive impairment. The acceptability of items ranged widely across the sample, but findings were consistent with previous literature, which indicates that “how you ask” is as important as “what you ask.” Cognitive interviewing methods worked well and elicited information crucial to effective measurement in this unique population. Pretesting study instruments, including standard instruments, for use in special populations such as homeless individuals with mental disorders is important for training interviewers and improving measurement, as well as interpreting findings.
doi:10.1007/s11524-011-9632-z
PMCID: PMC3284589  PMID: 22109879
Mental disorders; Homelessness; Survey methods; Cognitive interviewing; Pretesting
18.  Barriers to appropriate diabetes management among homeless people in Toronto 
Background
Homeless people are more likely to have chronic medical conditions and to encounter barriers to health care than the general population. In this study we identify barriers to appropriate disease management among homeless adults with diabetes mellitus in Toronto.
Methods
People with diabetes were surveyed at homeless shelters in Toronto. Information was obtained on demographic characteristics, diabetes history, access to health care, substance abuse and mental illness. Participants‚ descriptions of the difficulties they experienced in managing their diabetes were analysed qualitatively. Hemoglobin A1c levels were used to assess adequacy of glycemic control.
Results
Fifty people completed the survey (response rate 83%). Of the respondents 82% were male and 64% were white. Type 2 diabetes had been diagnosed in 86%, with 62% of all participants taking oral agents alone and 28% taking insulin alone. Overall, 72% of the participants reported experiencing difficulties managing their diabetes: the most common were related to diet (type of food at shelters and inability to make dietary choices, reported by 64%) and scheduling and logistics (inability to get insulin and diabetic supplies when needed and inability to coordinate medications with meals, reported by 18%). Although alcohol use, cocaine use and mental health problems were common, few respondents cited these issues as barriers to diabetes management. According to Canadian Diabetes Association guidelines, glycemic control was inadequate in 44% of the people tested.
Interpretation
In Toronto, most homeless adults with diabetes report difficulties managing their disease, and poor glycemic control is common.
PMCID: PMC80205  PMID: 10934977
19.  Homelessness and drug abuse among young men who have sex with men in New York city: A preliminary epidemiological trajectory 
Journal of adolescence  2005;28(2):201-214.
The objective of this paper is to profile the role of homelessness in drug and sexual risk in a population of young men who have sex with men (YMSM). Data are from a cross-sectional survey collected between 2000 and 2001 in New York City (N = 569). With the goal of examining the import of homelessness in increased risk for the onset of drug and sexual risk, we compare and contrast three subgroups: (1) YMSM with no history of homelessness, (2) YMSM with a past history of homelessness but who were not homeless at the time of the interview, and (3) YMSM who were currently homeless. For each group, we describe the prevalence of a broad range of stressful life events (including foster care and runaway episodes, involvement in the criminal justice system, etc.), as well as selected mental health problems (including past suicide attempts, current depression, and selected help-seeking variables). Additionally, we examine the prevalence of selected drug and sexual risk, including exposure to a broad range of illegal substances, current use of illegal drugs, and prevalence of lifetime exposure to sex work. Finally, we use an event history analysis approach (time–event displays and paired t-test analysis) to examine the timing of negative life experiences and homelessness relative to the onset of drug and sexual risk. High levels of background negative life experiences and manifest mental health distress are seen in all three groups. Both a prior experience of homelessness and currently being homeless are both strongly associated with both higher levels of lifetime exposure to drug and sexual risk as well as higher levels of current drug and sexual risk. Onset of these risks occur earlier in both groups that have had an experience of housing instability (e.g., runaway, foster care, etc.) but are delayed or not present among YMSM with no history of housing instability. Few YMSM had used drug prior to becoming homeless. While causal inferences are subject to the limitations of a cross-sectional design, the findings pose an empirical challenge to the prevailing assumption that prior drug use is a dominant causal factor in YMSM becoming homeless. More broadly, the data illustrate the complexity of factors that must be accounted for, both in advancing our epidemiological understanding of the complexity of homelessness and its relationship to the onset of drug and sexual risk among high risk youth populations.
doi:10.1016/j.adolescence.2005.02.003
PMCID: PMC2755549  PMID: 15878043
20.  Homelessness: a problem for primary care? 
Homelessness is a social problem that affects all facets of contemporary society. This paper discusses the concept of homelessness in terms of its historical context and the dominance of the pervasive 'victim blaming' ideologies, which, together with the worldwide economic changes that have contributed to a fiscal crisis of the state, and the resultant policies and circumstances, have led to an increase in the number of 'new homeless' people. This paper attempts to challenge the dominant political discourse on homelessness. The widespread healthcare problems and heterogeneity of homeless people have a particular impact on health services, with many homeless people inappropriately accessing local accident and emergency (A&E) departments because of barriers inhibiting adequate access to primary care. A number of primary care schemes have been successfully implemented to enable the homeless to have better access to appropriate care. However, there is no consistency in the level of services around the United Kingdom (UK), and innovations in service are not widespread and by their nature they are ad hoc. Despite the successes of such schemes, many homeless people still access health care inappropriately. Until homeless people are fully integrated into primary care the situation will not change. The question remains, how can appropriate access be established? A start can be made by building on some of the positive work that is already being done in primary care, but in reality general practitioners (GPs) will be 'swimming against the tide' unless a more integrated policy approach is adopted to tackle homelessness.
PMCID: PMC1314623  PMID: 12939894
21.  Access to primary health care among homeless adults in Toronto, Canada: results from the Street Health survey 
Open Medicine  2011;5(2):e94-e103.
Background
Despite experiencing a disproportionate burden of acute and chronic health issues, many homeless people face barriers to primary health care. Most studies on health care access among homeless populations have been conducted in the United States, and relatively few are available from countries such as Canada that have a system of universal health insurance. We investigated access to primary health care among a representative sample of homeless adults in Toronto, Canada.
Methods
Homeless adults were recruited from shelter and meal programs in downtown Toronto between November 2006 and February 2007. Cross-sectional data were collected on demographic characteristics, health status, health determinants and access to health care. We used multivariable logistic regression analysis to investigate the association between having a family doctor as the usual source of health care (an indicator of access to primary care) and health status, proof of health insurance, and substance use after adjustment for demographic characteristics.
Results
Of the 366 participants included in our study, 156 (43%) reported having a family doctor. After adjustment for potential confounders and covariates, we found that the odds of having a family doctor significantly decreased with every additional year spent homeless in the participant’s lifetime (adjusted odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86–0.97). Having a family doctor was significantly associated with being lesbian, gay, bisexual or transgendered (adjusted OR 2.70, 95% CI 1.04–7.00), having a health card (proof of health insurance coverage in the province of Ontario) (adjusted OR 2.80, 95% CI 1.61–4.89) and having a chronic medical condition (adjusted OR 1.91, 95% CI 1.03–3.53).
Interpretation
Less than half of the homeless people in Toronto who participated in our study reported having a family doctor. Not having a family doctor was associated with key indicators of health care access and health status, including increasing duration of homelessness, lack of proof of health insurance coverage and having a chronic medical condition. Increased efforts are needed to address the barriers to appropriate health care and good health that persist in this population despite the provision of health insurance.
PMCID: PMC3148004  PMID: 21915240
22.  Audit of work at a medical centre for the homeless over one year 
An audit of one years' work at a voluntary health care service for the homeless involving doctors, a chiropodist, nurses and social workers was carried out. It was found that although certain health problems are more common among the homeless than in the general population, the range resembles that in any general practice. However, registration with general practitioners was much less common among the homeless than in the general population, and a high proportion of referrals to hospital did not lead to appropriate treatment. The value of a special primary health care service for the homeless is discussed.
PMCID: PMC1710758  PMID: 3681848
23.  Homing in on the homeless: assessing the physical health of homeless adults in Los Angeles County using an original method to obtain physical examination data in a survey. 
Health Services Research  1996;31(5):533-549.
OBJECTIVE: Public policy that decreases the finding for social services may combine with the ascendancy of corporate managed care to increase the health care deficit. Assessing the health impact of these policy changes on various populations is a fundamental challenge for health services research. Disadvantaged populations, such as the homeless, are likely to be affected disproportionately. Research quality data on the physical health of such populations are difficult and expensive to obtain. In particular, physical examination data have not been available and self-reports are insufficient. Our objective: to develop and utilize a structured physical exam system enabling lay survey researchers to report reliably physical findings related to six tracer conditions in a disadvantaged population. STUDY SETTING: A field survey of homeless adults in Los Angeles County, California. Respondents were 363 homeless adults representing a subsample of a probability sample of the county's homeless adult population. STUDY DESIGN: We integrated existing measures with expert clinical opinion and original means of data collection into a structured physical exam enabling lay interviewers to identify the prevalence of vision problems, significant skin disorders, peripheral vascular disease of the lower extremities, selected podiatric disorders, hypertension, and tuberculosis in a sample of homeless adults. PRINCIPAL MEASURES: We describe lay interviewer performance in terms of mastery of the necessary material based on written and practical exams and in terms of the number of respondents successfully followed. We base our description of the instrument on the time necessary to complete it, and on the proportion of each component successfully completed during the field survey, as well as on interrater reliability. We report the prevalence of the various clinical conditions according to self-report and according to the structured limited physical exam, as well as the marginal proportion of respondents who were identified by the physical exam and not by self-report. PRINCIPAL FINDINGS: Interviewers performed the exam successfully under field conditions. Respondent acceptance of the instrument was high. Interrater agreement was 100 percent regarding the need for referral on the basis of blood pressure and vision. Kappa statistics for skin, foot, and edema findings were .67,.71, and .81, respectively. Adjusted for sampling weights, 60 percent of this population required referral for at least one of the specified conditions. For those portions of the survey for which both self-report and physical exam data were available, lay interviewers made significant percentages of referrals on the basis of physical findings alone. CONCLUSIONS: High blood pressure, poor vision, peripheral vascular diseases of the feet and legs, and significant skin conditions are prevalent among the homeless in Los Angeles County. Without physical exam data, estimates of the prevalence of these conditions will be incorrect. Researchers can use laypersons to collect reliable and valid physical exam data on disadvantaged populations. This represents a new tool for assessing and monitoring the health of these populations.
PMCID: PMC1070140  PMID: 8943989
24.  The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities 
BMJ Open  2011;1(2):e000323.
Introduction
Housing First is a complex housing and support intervention for homeless individuals with mental health problems. It has a sufficient knowledge base and interest to warrant a test of wide-scale implementation in various settings. This protocol describes the quantitative design of a Canadian five city, $110 million demonstration project and provides the rationale for key scientific decisions.
Methods
A pragmatic, mixed methods, multi-site field trial of the effectiveness of Housing First in Vancouver, Winnipeg, Toronto, Montreal and Moncton, is randomising approximately 2500 participants, stratified by high and moderate need levels, into intervention and treatment as usual groups. Quantitative outcome measures are being collected over a 2-year period and a qualitative process evaluation is being completed. Primary outcomes are housing stability, social functioning and, for the economic analyses, quality of life. Hierarchical linear modelling is the primary data analytic strategy.
Ethics and dissemination
Research ethics board approval has been obtained from 11 institutions and a safety and adverse events committee is in place. The results of the multi-site analyses of outcomes at 12 months and 2 years will be reported in a series of core scientific journal papers. Extensive knowledge exchange activities with non-academic audiences will occur throughout the duration of the project.
Trial registration number
This study has been registered with the International Standard Randomised Control Trial Number Register and assigned ISRCTN42520374.
Article summary
Article focus
An evaluation of the cost-effectiveness of Housing First in comparison to treatment as usual for homeless adults with mental illness in five Canadian cities with a 2-year follow-up.
Primary outcomes include housing stability, quality of life and social functioning.
The correlates of different trajectories and the critical ingredients of the intervention for sub-populations will also be investigated.
Key messages
The first and largest multi-site trial of this complex housing and support intervention will provide information about implementation and outcomes.
The addition of site specific intervention arms to a core common protocol will allow investigation of innovative adaptations that are tailored to local context.
The inclusion of a broader homeless population receiving a less intensive service model will increase the policy relevance of findings.
Strengths and limitations of this study
A larger sample size (n=2500) and a wider range of outcome variables than in previous trials are strengths of this study.
This study utilises a concomitant mixed methods process evaluation that includes fidelity assessments.
Variation in sample characteristics and in treatment as usual across five cities may limit opportunities for aggregate analyses.
doi:10.1136/bmjopen-2011-000323
PMCID: PMC3221290  PMID: 22102645
25.  Housing issues of persons with AIDS 
The housing status of persons with HIV/AIDS is a central issue in their care and prognosis. We conducted eight focus groups to explore the housing needs of special populations of persons with HIV/AIDS in New York State; these populations included substance users, ex-offenders, persons with documented histories of homelessness, and rural dwellers/migrant workers. For the focus groups, 52 participants were recruited from the clientele of health and social service agencies. A major theme was the potent effect that housing situations had on participants’ health. Participants frequently attributed lowered T-cell counts and increased lethargy to the stress associated with governmental rules and paperwork. Lack of money, inadequacy of entitlements, and high costs of housing were the major barriers to securing stable and appropriate housing. Furthermore, participants experienced housing discrimination based on HIV status and experience with the criminal justice system or drugs.
doi:10.1007/BF02344937
PMCID: PMC3456293  PMID: 9663975
Housing; HIV/AIDS; Health; Discrimination; Health Services

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