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1.  Infectious Disease Exposures and Contact Tracing in Homeless Shelters 
An outbreak among homeless shelter users of a communicable disease with a short generation time would pose serious public health challenges. Data from Toronto were used to examine the number of shelter residents potentially exposed in the event of such an outbreak. A shelter user had contact with a mean of 97 other residents (range, 1–292) in one day and a mean of 120 (range, 2–624) in eight days. After a single week, contact tracing becomes difficult due to the challenge of locating homeless people who have left the shelter system. Over an 8-day period, individuals who used more than one shelter had contact with an average of 98 more other shelter residents than those who stayed in a single shelter had. At the onset of a serious outbreak, it may be desirable to institute policies that strongly encourage individuals to remain at their current shelter for the duration of the outbreak.
doi:10.1353/hpu.0.0070
PMCID: PMC4465825  PMID: 19029743 CAMSID: cams4738
Homeless people; disease outbreaks; contact tracing
2.  A Comprehensive Assessment of Health Care Utilization among Homeless Adults under a System of Universal Health Insurance 
American journal of public health  2013;103(0 2):S294-S301.
Objective
To comprehensively assess health care utilization in a population-based sample of homeless adults compared to matched controls under a system of universal health insurance.
Methods
Health care utilization was assessed for 1,165 homeless single adult men, single adult women, and adults in families and their age- and sex-matched low-income controls in Toronto, Canada from 2005-2009. Repeated measures general linear models (GLM) were used to calculate risk ratios and 95% confidence intervals.
Results
Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum=141.1), 2.0 emergency department encounters (maximum=104.9), 0.2 medical/surgical hospitalizations (maximum=14.9), and 0.1 psychiatric hospitalizations per person-year (maximum=4.8). Rate ratios comparing homeless participants to matched controls were 1.76 (95% CI: 1.58-1.96) for ambulatory care encounters, 8.48 (95% CI: 6.72-10.70) for emergency department encounters, 4.22 (95% CI: 2.99-5.94) for medical/surgical hospitalizations, and 9.27 (95% CI: 4.42-19.43) for psychiatric hospitalizations.
Conclusions
Within a system of universal health insurance, homeless people have substantially higher rates of emergency department and hospital use compared to general population controls. These differences are largely driven by the subset of homeless persons who are extremely high-intensity users of health services.
doi:10.2105/AJPH.2013.301369
PMCID: PMC3969141  PMID: 24148051
Health care utilization; Homeless persons; Matched controls; Ambulatory care; Hospitalization
3.  Predictors of Medical/surgical and Psychiatric Hospitalizations among a Population-based Cohort of Homeless Adults 
American journal of public health  2013;103(0 2):S380-S388.
Objectives
To identify factors associated with inpatient hospitalizations among a population-based cohort of homeless adults in Toronto, Canada.
Methods
Participants were linked to administrative databases to capture hospital admissions during the study period (2005–2009). Logistic regression was used to identify predictors of medical/surgical and psychiatric hospitalizations.
Results
Among 1,165 homeless adults, 20% had a medical/surgical hospitalization and 12% had a psychiatric hospitalization during the study period. These individuals contributed a total of 921 hospitalizations, of which 548 were medical/surgical and 373 were psychiatric. Independent predictors of medical/surgical hospitalization included birth in Canada, having a primary care provider, higher perceived external health locus of control, and lower health status. Independent predictors of psychiatric hospitalization included being a current smoker, having a recent mental health problem, and having a lower perceived internal health locus of control. Being accompanied by a partner or dependent children was protective for hospitalization.
Conclusions
Health care need was a strong predictor of medical/surgical and psychiatric hospitalizations. Some hospitalizations among homeless adults are potentially avoidable, while others represent an unavoidable use of health services.
doi:10.2105/AJPH.2013.301646
PMCID: PMC3969145  PMID: 24148040
Hospitalization; Homeless persons; Health care utilization
4.  High Utilizers of Emergency Health Services in a Population-based Cohort of Homeless Adults 
American journal of public health  2013;103(0 2):S302-S310.
Objectives
To identify predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Canada.
Methods
ED visit rates were assessed using administrative data (2005-2009). Logistic regression was used to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥4.7 visits per person-year).
Results
Among 1,165 homeless adults, 892 (77%) had at least one ED visit during the study period. The average rate of ED visits was 2.0 visits/person-year, while frequent users averaged 12.1 visits/person-year. Frequent users accounted for 10% of the sample but contributed over 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner and/or dependent children had a protective effect on frequent use.
Conclusions
Among homeless adults with universal health insurance, a small subgroup accounts for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors.
doi:10.2105/AJPH.2013.301397
PMCID: PMC3969147  PMID: 24148033
Health care utilization; Emergency department; Homeless persons
5.  Traumatic brain injury among men in an urban homeless shelter: observational study of rates and mechanisms of injury 
CMAJ Open  2014;2(2):E69-E76.
Background
Little empiric research has investigated the interrelationship between homelessness and traumatic brain injury. The objectives of this study were to determine the rate, mechanisms and associated outcomes of traumatic brain injury among men in an urban homeless shelter.
Methods
We recruited participants from an urban men’s shelter in Toronto, Ontario. Researchers administered the Brain Injury Screening Questionnaire, a semistructured interview screening tool for brain injury. Demographic information and detailed histories of brain injuries were obtained. Participants with positive and negative screening results were compared, and the rates and mechanisms of injury were analyzed by age group.
Results
A total of 111 men (mean age 54.2 ± standard deviation 11.5 yr; range 27–81 yr) participated. Nearly half (50 [45%]) of the respondents had a positive screening result for traumatic brain injury. Of these, 73% (35/48) reported experiencing their first injury before adulthood (< 18 yr), and 87% (40/46) reported a first injury before the onset of homelessness. Among those with a positive screening result, 33 (66%) reported sustaining at least one traumatic brain injury by assault, 22 (44%) by sports or another recreational activity, 21 (42%) by motor vehicle collision and 21 (42%) by a fall. A positive screening result was significantly associated with a lifetime history of arrest or mental illness and a parental history of substance abuse.
Interpretation
Multiple mechanisms contributed to high rates of traumatic brain injury within a sample of homeless men. Assault was the most common mechanism, with sports and recreation, motor vehicle collisions and falls also being reported frequently by the participants. Injury commonly predated the onset of homelessness, with most participants experiencing their first injury in childhood. Additional research is needed to understand the complex interactions among homelessness, traumatic brain injury, mental illness and substance use.
doi:10.9778/cmajo.20130046
PMCID: PMC4084748  PMID: 25077132
6.  Effectiveness of Housing First with Intensive Case Management in an Ethnically Diverse Sample of Homeless Adults with Mental Illness: A Randomized Controlled Trial 
PLoS ONE  2015;10(7):e0130281.
Housing First (HF) is being widely disseminated in efforts to end homelessness among homeless adults with psychiatric disabilities. This study evaluates the effectiveness of HF with Intensive Case Management (ICM) among ethnically diverse homeless adults in an urban setting. 378 participants were randomized to HF with ICM or treatment-as-usual (TAU) in Toronto (Canada), and followed for 24 months. Measures of effectiveness included housing stability, physical (EQ5D-VAS) and mental (CSI, GAIN-SS) health, social functioning (MCAS), quality of life (QoLI20), and health service use. Two-thirds of the sample (63%) was from racialized groups and half (50%) were born outside Canada. Over the 24 months of follow-up, HF participants spent a significantly greater percentage of time in stable residences compared to TAU participants (75.1% 95% CI 70.5 to 79.7 vs. 39.3% 95% CI 34.3 to 44.2, respectively). Similarly, community functioning (MCAS) improved significantly from baseline in HF compared to TAU participants (change in mean difference = +1.67 95% CI 0.04 to 3.30). There was a significant reduction in the number of days spent experiencing alcohol problems among the HF compared to TAU participants at 24 months (ratio of rate ratios = 0.47 95% CI 0.22 to 0.99) relative to baseline, a reduction of 53%. Although the number of emergency department visits and days in hospital over 24 months did not differ significantly between HF and TAU participants, fewer HF participants compared to TAU participants had 1 or more hospitalizations during this period (70.4% vs. 81.1%, respectively; P=0.044). Compared to non-racialized HF participants, racialized HF participants saw an increase in the amount of money spent on alcohol (change in mean difference = $112.90 95% CI 5.84 to 219.96) and a reduction in physical community integration (ratio of rate ratios = 0.67 95% CI 0.47 to 0.96) from baseline to 24 months. Secondary analyses found a significant reduction in the number of days experiencing problems due to alcohol use among foreign-born (vs. Canadian-born) HF participants at 24 months (ratio of rate ratios = 0.19 95% 0.04 to 0.88), relative to baseline. Compared to usual care, HF with ICM can improve housing stability and community functioning and reduce the days of alcohol related problems in an ethnically diverse sample of homeless adults with mental illness within 2-years.
Trial Registration
Controlled-Trials.com ISRCTN42520374.
doi:10.1371/journal.pone.0130281
PMCID: PMC4503775  PMID: 26176621
7.  Factors Associated with Poor Mental Health Status among Homeless Women with and without Dependent Children 
Community mental health journal  2013;50(5):553-559.
The purpose of this study was to estimate the prevalence of mental health problems among a representative sample of homeless women with and without dependent children and determine if the effects of risk factors for mental health are modified by the presence of dependent children. Homeless women (n=522) were recruited in 2004–2005 from shelters and meal programs in Toronto, Canada. Linear and logistic regression was performed to identify factors associated with mental health status. Poor mental health was associated with low perceived access to social support, physical/sexual assault in the past 12 months, presence of a chronic health condition, and presence of a drug use problem in the past month. Efforts to improve mental health in this population will need to address the associated problems of victimization, substance abuse, and lack of social supports.
doi:10.1007/s10597-013-9605-7
PMCID: PMC3883929  PMID: 23423484
Mental health; Women; Homeless persons; SF-12; Addiction Severity Index
8.  Research on the health of people who experience detention or incarceration in Canada: a scoping review 
BMC Public Health  2015;15:419.
Background
We conducted a scoping review to define the extent and type of quantitative health status research conducted from 1993 to 2014 with people who have experienced detention or incarceration in correctional facilities in Canada.
Methods
We searched 15 databases, reviewed reference lists and relevant websites, and consulted with key stakeholders to identify eligible studies. We reviewed records for eligibility and extracted relevant data from eligible articles.
Results
We identified 194 studies that were eligible for inclusion. Most studies were conducted with males and with persons in federal facilities, and focused on mental health, substance use, and social determinant of health outcomes.
Conclusions
Health status data are limited for several outcomes, such as chronic disease, injury and sexual and reproductive health, and for persons in provincial facilities and post-release. Efforts should be made to improve data collection and knowledge dissemination, so that relevant data can be used more effectively to improve health and health care in this population.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-015-1758-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12889-015-1758-6
PMCID: PMC4443600  PMID: 25943182
Prisoners; Health status; Canada; Review
9.  Development and Initial Validation of the Observer-Rated Housing Quality Scale (OHQS) in a Multisite Trial of Housing First 
Quality of housing has been shown to be related to health outcomes, including mental health and well-being, yet “objective” or observer-rated housing quality is rarely measured in housing intervention research. This may be due to a lack of standardized, reliable, and valid housing quality instruments. The objective of this research was to develop and validate the Observer-Rated Housing Quality Scale (OHQS) for use in a multisite trial of a “housing first” intervention for homeless individuals with mental illness. A list of 79 housing unit, building, and neighborhood characteristics was generated from a review of the relevant literature and three focus groups with consumers and housing service providers. The characteristics were then ranked by 47 researchers, consumers, and service providers on perceived importance, generalizability, universality of value, and evidence base. Items were then drafted, scaled (five points, half values allowed), and pretested in seven housing units and with seven raters using cognitive interviewing techniques. The draft scale was piloted in 55 housing units in Toronto and Winnipeg, Canada. Items were rated independently in each unit by two trained research assistants and a housing expert. Data were analyzed using classical psychometric approaches and intraclass correlation coefficients (ICC) for inter-rater reliability. The draft scale consisted of 34 items assessing three domains: the unit, the building, and the neighborhood. Five of 18 unit items and 3 of 7 building items displayed ceiling or floor effects and were adjusted accordingly. Internal consistency was very good (Cronbach’s alpha = 0.90 for the unit items, 0.80 for the building items, and 0.92 total (unit and building)). Percent agreement ranged from 89 to 100 % within one response scale value and 67 to 91 % within one half scale value. Inter-rater reliability was also good (ICCs were 0.87 for the unit, 0.85 for the building, and 0.93 for the total scale). Three neighborhood items (e.g., distance to transit) were found to be most efficiently rated using publicly available information. The physical quality of housing can be reliably rated by trained but nonexpert raters using the OHQS. The tool has potential for improved measurement in housing-related health research, including addressing the limitations of self-report, and may also enable documenting the quality of housing that is provided by publicly funded housing programs.
doi:10.1007/s11524-013-9851-6
PMCID: PMC3978156  PMID: 24477427
Housing quality; Standardized measures; Housing-related health research; Public housing; Homelessness; Mental health
10.  The health of homeless immigrants 
Background
This study examined the association between immigrant status and current health in a representative sample of 1,189 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 programs (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) compared to 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 standard deviation 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 compared to other homeless people.
doi:10.1136/jech.2009.088468
PMCID: PMC2773541  PMID: 19654122
homelessness; migration and health
11.  Cardiovascular risk factors and 30-year cardiovascular risk in homeless adults with mental illness 
BMC Public Health  2015;15:165.
Background
Cardiovascular disease (CVD) is a leading cause of death among homeless people. This study examines CVD risk factors and 30-year CVD risk in a population of homeless individuals with mental illness.
Methods
CVD risks factors were assessed in 352 homeless individuals with mental illness in Toronto, Canada, at the time of their enrollment in the At Home/Chez Soi Project, a randomized trial of a Housing First intervention. The 30-year risk for CVD (coronary death, myocardial infarction, and fatal or nonfatal stroke) was calculated using published formulas and examined for association with need for mental health services, diagnosis of psychotic disorder, sex, ethnicity, access to a family physician and diagnosis of substance dependence.
Results
The 30-year CVD risk for study participants was 24.5 ± 18.4%, more than double the reference normal of 10.1 ± 7.21% (difference = −13.0% 95% CI −16.5% to −9.48%). Univariate analyses revealed 30-year CVD risk was greater among males (OR 3.99, 95% CI 2.47 to 6.56) and those who were diagnosed with substance dependence at baseline (OR 1.94 95% CI 1.23 to 3.06) and reduced among those who were non-white (OR 0.62 95% CI 0.39 to 0.97). In adjusted analyses, only male sex (OR 4.71 95% CI 2.76 to 8.05) and diagnosis of substance dependence (OR 1.78 95% CI 1.05 to 3.00) remained associated with increased CVD risk.
Conclusions
Homeless people with mental illness have highly elevated 30-year CVD risk, particularly among males and those diagnosed with substance dependence. This study adds to the literature by reporting on CVD risk in a particularly vulnerable population of homeless individuals experiencing mental illness, and by using a 30-year CVD risk calculator which provides a longer time-frame during which the effect of modifiable CVD risk factors could be mitigated.
Trial registration
Current Controlled Trials ISRCTN42520374
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-015-1472-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s12889-015-1472-4
PMCID: PMC4339633  PMID: 25886157
Cardiovascular diseases; Cardiovascular risk factors; Homeless persons; Mental illness
12.  Severe anemia from bedbugs 
doi:10.1503/cmaj.090482
PMCID: PMC2734207  PMID: 19720710
13.  Science and ideology 
Open Medicine  2007;1(2):e99-e101.
PMCID: PMC2802009  PMID: 20101301
14.  Discharge day 
doi:10.1503/cmaj.051541
PMCID: PMC1421478
15.  Homelessness and harm reduction 
doi:10.1503/cmaj.051505
PMCID: PMC1319346  PMID: 16389237
16.  Bed Bug Infestations in an Urban Environment 
Emerging Infectious Diseases  2005;11(4):533-538.
Bed bug infestations adversely affect health and quality of life, particularly among persons living in homeless shelters.
Until recently, bed bugs have been considered uncommon in the industrialized world. This study determined the extent of reemerging bed bug infestations in homeless shelters and other locations in Toronto, Canada. Toronto Public Health documented complaints of bed bug infestations from 46 locations in 2003, most commonly apartments (63%), shelters (15%), and rooming houses (11%). Pest control operators in Toronto (N = 34) reported treating bed bug infestations at 847 locations in 2003, most commonly single-family dwellings (70%), apartments (18%), and shelters (8%). Bed bug infestations were reported at 20 (31%) of 65 homeless shelters. At 1 affected shelter, 4% of residents reported having bed bug bites. Bed bug infestations can have an adverse effect on health and quality of life in the general population, particularly among homeless persons living in shelters.
doi:10.3201/eid1104.041126
PMCID: PMC3320350  PMID: 15829190
Bed bugs; Parasites; Homeless persons; Urban health; Epidemiology; research
19.  Impact of supervised drug consumption services on access to and engagement with care at a palliative and supportive care facility for people living with HIV/AIDS: a qualitative study 
Introduction
Improvements in the availability and effectiveness of highly active antiretroviral therapy (HAART) have prolonged the lives of people living with HIV/AIDS. However, mortality rates have remained high among populations that encounter barriers to accessing and adhering to HAART, notably people who use drugs. This population consequently has a high burden of illness and complex palliative and supportive care needs, but is often unable to access these services due to anti-drug policies and discrimination. In Vancouver, Canada, the Dr. Peter Centre (DPC), which operates a 24-bed residential HIV/AIDS care facility, has sought to improve access to palliative and supportive care services by adopting a comprehensive harm reduction strategy, including supervised injection services. We undertook this study to explore how the integration of comprehensive harm reduction services into this setting shapes access to and engagement with care.
Methods
Qualitative interviews were conducted with 13 DPC residents between November 2010 and August 2011. Interviews made use of a semistructured interview guide which facilitated discussion regarding how the DPC Residence's model of care (a) shaped healthcare access, (b) influenced healthcare interactions and (c) impacted drug use practices and overall health. Interview transcripts were analysed thematically.
Results
Participant accounts highlight how the harm reduction policy altered the structural-environmental context of healthcare services and thus mediated access to palliative and supportive care services. Furthermore, this approach fostered an atmosphere in which drug use could be discussed without the risk of punitive action, and thus increased openness between residents and staff. Finally, participants reported that the environmental supports provided by the DPC Residence decreased drug-related risks and improved health outcomes, including HAART adherence and survival.
Conclusions
This study highlights how adopting comprehensive harm reduction services can serve to improve access and equity in palliative and supportive care for drug-using populations.
doi:10.7448/IAS.17.1.18855
PMCID: PMC3955762  PMID: 24629844
HIV/AIDS; palliative care; supervised drug consumption services; harm reduction; highly active antiretroviral therapy; qualitative research
20.  Mortality Among Homeless Adults in Boston: Shifts in Causes of Death Over a 15-year Period 
JAMA internal medicine  2013;173(3):189-195.
Background
Homeless persons experience excess mortality, but U.S.-based studies on this topic are outdated or lack information about causes of death. No studies have examined shifts in causes of death for this population over time.
Methods
We assessed all-cause and cause-specific mortality rates in a cohort of 28,033 adults aged 18 years or older who were seen at Boston Health Care for the Homeless Program between January 1, 2003, and December 31, 2008. Deaths were identified through probabilistic linkage to the Massachusetts death occurrence files. We compared mortality rates in this cohort to rates in the 2003–08 Massachusetts population and a 1988–93 cohort of homeless adults in Boston using standardized rate ratios with 95% confidence intervals.
Results
1,302 deaths occurred during 90,450 person-years of observation. Drug overdose (n=219), cancer (n=206), and heart disease (n=203) were the major causes of death. Drug overdose accounted for one-third of deaths among adults <45 years old. Opioids were implicated in 81% of overdose deaths. Mortality rates were higher among whites than non-whites. Compared to Massachusetts adults, mortality disparities were most pronounced among younger individuals, with rates about 9-fold higher in 25–44 year olds and 4.5-fold higher in 45–64 year olds. In comparison to 1988–93, reductions in HIV deaths were offset by 3- and 2-fold increases in deaths due to drug overdose and psychoactive substance use disorders, resulting in no significant difference in overall mortality.
Conclusions
The all-cause mortality rate among homeless adults in Boston remains high and unchanged since 1988–93 despite a major interim expansion in clinical services. Drug overdose has replaced HIV as the emerging epidemic. Interventions to reduce mortality in this population should include behavioral health integration into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness.
doi:10.1001/jamainternmed.2013.1604
PMCID: PMC3713619  PMID: 23318302
21.  Is “Appearing Chronically Ill” a Sign of Poor Health? A Study of Diagnostic Accuracy 
PLoS ONE  2013;8(11):e79934.
Objective
To determine the sensitivity and specificity of a physician’s assessment that a patient “appears chronically ill” for the detection of poor health status.
Methods
The health status of 126 adult outpatients was determined using the 12-Item Short Form Health Survey (SF-12). Physician participants (n = 111 residents and faculty) viewed photographs of each patient participant and assessed whether or not the patient appeared chronically ill. For the entire group of physicians, the median sensitivity and specificity of “appearing chronically ill” for the detection of poor health status (defined as SF-12 physical health score below age group norms by at least 1 SD) were calculated. The study took place from February 2009 to January 2011.
Results
Forty-two participants (33%) had an SF-12 physical health score ≥1 SD below age group norms, and 22 (18%) had a score ≥2 SD below age group norms. When poor health status was defined as an SF-12 physical score ≥1 SD below age group norms, the median sensitivity was 38.1% (IQR 28.6–47.6%), specificity 78.6% (IQR 69.0–84.0%), positive likelihood ratio 1.64 (IQR 1.42–2.15), and negative likelihood ratio 0.82 (IQR 0.74–0.87). For an SF-12 physical score ≥2 SD below age group norms, the median sensitivity was 45.5% (IQR 36.4–54.5%), specificity 76.9% (IQR 66.3–83.7%), positive likelihood ratio 1.77 (IQR 1.49–2.25), and negative likelihood ratio 0.75 (IQR 0.66–0.86).
Conclusions
Our study suggests that a physician’s assessment that a patient “appears chronically ill” has poor sensitivity and modest specificity for the detection of poor health status in adult outpatients. The associated likelihood ratios indicate that this assessment may have limited diagnostic value.
doi:10.1371/journal.pone.0079934
PMCID: PMC3842283  PMID: 24312192
22.  Substance Use and Access to Health Care and Addiction Treatment among Homeless and Vulnerably Housed Persons in Three Canadian Cities 
PLoS ONE  2013;8(10):e75133.
Introduction
We examined the prevalence of substance use disorders among homeless and vulnerably housed persons in three Canadian cities and its association with unmet health care needs and access to addiction treatment using baseline data from the Health and Housing in Transition Study.
Methods
In 2009, 1191 homeless and vulnerably housed persons were recruited in Vancouver, Toronto, and Ottawa, Canada. Interviewer administered questionnaires collected data on socio-demographics, housing history, chronic health conditions, mental health diagnoses, problematic drug use (DAST-10≥6), problematic alcohol use (AUDIT≥20), unmet physical and mental health care needs, addiction treatment in the past 12 months. Three multiple logistic regression models were fit to examine the independent association of substance use with unmet physical health care need, unmet mental health care need, and addiction treatment.
Results
Substance use was highly prevalent, with over half (53%) screening positive for the DAST-10 and 38% screening positive for the AUDIT. Problematic drug use was 29%, problematic alcohol use was lower at 16% and 7% had both problematic drug and alcohol use. In multiple regression models for unmet need, we found that problematic drug use was independently associated with unmet physical (adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI] 1.43–2.64) and unmet mental (AOR 3.06; 95% CI 2.17–4.30) health care needs. Problematic alcohol use was not associated with unmet health care needs. Among those with problematic substance use, problematic drug use was associated with a greater likelihood of accessing addiction treatment compared to those with problematic alcohol use alone (AOR 2.32; 95% CI 1.18–4.54).
Conclusions
Problematic drug use among homeless and vulnerably housed individuals was associated with having unmet health care needs and accessing addiction treatment. Strategies to provide comprehensive health services including addiction treatment should be developed and integrated within community supported models of care.
doi:10.1371/journal.pone.0075133
PMCID: PMC3790780  PMID: 24124470
23.  Attitudes towards homeless people among emergency department teachers and learners: a cross-sectional study of medical students and emergency physicians 
BMC Medical Education  2013;13:112.
Background
Medical students’ attitudes and beliefs about homeless people may be shaped by the attitudes of their teachers and one of the most common sites for learning about homeless patients is the emergency department. The objective of this study was to determine if medical students in the preclinical and clinical years and emergency medicine faculty and residents have different attitudes and beliefs about homeless people.
Methods
The Health Professional Attitudes Toward the Homeless Inventory (HPATHI), was administered to all medical students, and emergency medicine physicians and residents at a large academic health sciences center in Canada. The HPATHI examines attitudes, interest and confidence on a 5-point Likert scale. Differences among groups were examined using the Kruskal Wallis test and Pearson’s chi-square test.
Results
The HPATHI was completed by 371 individuals, for an overall response rate of 55%. Analysis of dichotomized median and percentage results revealed 5/18 statements were significant by both methods. On the attitudes subscales physicians and residents as a group were more negative for 2/9 statements and on the confidence subscale more positive for 1/4 statements. The interest subscale achieved overall statistical significance with decreased positive responses among physicians and residents compared to medical students in 2/5 statements.
Conclusion
This study revealed divergences in attitudes, interests and beliefs among medical students and emergency medicine physicians and residents. We offer strategies for training interventions and systemic support of emergency faculty. Emergency medicine physicians can examine their role in the development of medical students through both formal and informal teaching in the emergency department.
doi:10.1186/1472-6920-13-112
PMCID: PMC3765267  PMID: 23968336
24.  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
25.  Probiotics for the prevention of antibiotic-associated diarrhea and Clostridium difficile infection among hospitalized patients: systematic review and meta-analysis 
Open Medicine  2013;7(2):e56-e67.
Background
Antibiotic-associated diarrhea (AAD) and Clostridium difficile infection (CDI) are associated with high morbidity, mortality, and health care costs. Probiotics may mitigate the existing disease burden. We performed a systematic review and meta-analysis to evaluate the efficacy of co-administration of probiotics with antibiotics in preventing these adverse outcomes in adult inpatients.
Methods
Systematic searches of MEDLINE (1946 to May 2012), Embase (1980 to May 2012), and the Cochrane Central Register of Controlled Trials were undertaken on May 31, 2012, to identify relevant publications. We searched for randomized controlled trials, published in English, of adult inpatients who were receiving antibiotics and who were randomly assigned to co-administration of probiotics or usual care, with or without the use of placebo. Studies were included if they reported on AAD or CDI (or both) as outcomes. Data for predetermined criteria evaluating study characteristics, methods, and risk of bias were extracted. Trials were given a global rating of good, fair, or poor by at least 2 reviewers. Meta-analyses were performed using a random-effects model, and pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated.
Results
Sixteen trials met the criteria for inclusion in this review. Four studies were of good quality, 5 were of fair quality, and 7 were of poor quality. Pooled analyses revealed significant reductions in the risks of AAD (RR 0.61, 95% CI 0.47 to 0.79) and CDI (RR 0.37, 95% CI 0.22 to 0.61) among patients randomly assigned to co-administration of probiotics. The number needed to treat for benefit was 11 (95% CI 8 to 20) for AAD and 14 (95% CI 9 to 50) for CDI. With subgroup analysis, significant reductions in rates of both AAD and CDI were retained in the subgroups of good-quality trials, the trials assessing a primarily Lactobacillus-based probiotic formulation, and the trials for which the follow-up period was less than 4 weeks.
Interpretation
Probiotics used concurrently with antibiotics reduce the risk of AAD and CDI
PMCID: PMC3863752  PMID: 24348885

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