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PubMed1997

Do the homeless get a fair deal from general practitioners?

Many studies have indicated the health status of homeless people to be typically poorer than that of the general population, with various studies indicating a high prevalence of psychiatric illness, drug or alcohol misuse and associated socio-medical problems. The Bristol Primary Healthcare Project is an agency which was established to provide a local health care service tailored to the needs of people who are homeless. The present study was carried out as part of an evaluation of the service offered locally to homeless people by General Practitioners (GPs). A postal questionnaire survey of 155 general practices within the Avon FHSA area was carried out. Both fundholding and non-fundholding practices were included, within an area including inner city, urban and rural/semi-rural locations. One hundred and seventeen completed questionnaires were returned, providing a response rate of 75%. Twenty-seven percent of practices would fully register a homeless person who seeks to register at the practice, 24% would treat as immediate and necessary and 33% would treat as a temporary resident. Four percent of fundholding practices surveyed would fully register homeless persons and 55% of inner city practices would do so. Seventy-nine percent of doctors indicated that homeless patients were more difficult to treat than other patients. The most frequent problems associated with registering homeless persons were perceived to be the associated social problems (90% of respondents agreed), the lack of medical records (88% agreed), the complex health problems (79% agreed) and the associated alcohol or substance misuse (78% agreed). The study has highlighted a need for government to consider providing incentives to GPs to register homeless people without resulting in adverse effects on their contract targets. The reluctance of some practices to register these patients varied by area and type of practice with doctors at fundholding practices being the most reluctant. There is an identified need for further health education and promotion work and initiatives exemplified by the Bristol Primary Healthcare Project for people who are homeless.

Attitude of Health Personnel↗

PubMed1994

Distress, suicidal thoughts, and social support among homeless adults.

Influences on psychological distress and suicidal thoughts are evaluated with a sample of 218 sheltered homeless adults. Levels of distress and suicidal thoughts are much higher than in the general population, and are comparable to those found by Rossi (1989). Perceived social support lessens distress and suicidal thoughts directly and also buffers homeless persons from the distress associated with traumatic experiences. There is little indication of a mediating (intervening) role of social support. Distress and suicidal thoughts are also associated with increased health problems; homeless history and sociodemographic characteristics are less important as predictors. Distress itself increases suicidal thoughts--directly, and also in interaction with low levels of social support. We conclude that distress among homeless persons is explained by the same types of influences as those that account for distress among the general population--the gravity of homeless persons' economic situation does not preclude sensitivity to the benefits of social support.

Adult↗

PubMed2001

Access to inpatient or residential substance abuse treatment among homeless adults with alcohol or other drug use disorders.

OBJECTIVES: We conducted a theoretically guided study of access to inpatient or residential treatment among a probability sample of homeless adults with alcohol or drug use disorders in Houston, Texas. METHODS: This study used a cross-sectional, retrospective design with data collected from a multistage random sample of 797 homeless adults age 18 or older who were living in Houston shelters and streets in 1996. Structured, face-to-face interviews produced screening diagnoses for alcohol and drug use disorders, treatment use data, and candidate predictors of treatment use. Logistic and linear regression analyses were performed on the subset of 326 homeless persons with either alcohol or drug use disorder. RESULTS: 27.5% of persons with substance use disorder had accessed inpatient or residential treatment during the past year. Controlling for additional need factors such as comorbidity, persons having public health insurance and a history of treatment for substance problems had greater odds of receiving at least one night of treatment. Contrary to expectation, contact with other service sectors was not predictive of treatment access. Schizophrenia and having a partner appeared to hinder access. Greater need for treatment was associated with fewer nights of treatment, suggesting retention difficulties. CONCLUSIONS: This study adds to previous findings on access to health care among homeless persons and highlights a pattern of disparities in substance abuse treatment access. Health insurance is important, but enhancing access to care involves more than economic considerations if homeless persons are to receive the treatment they need. Referral relationships across different service sectors may require strengthening.

Adult↗

PubMed1999

[Organization of antituberculous work with homeless in Saint Petersburg].

The paper deals with organizational measures for detection and treatment of homeless persons with tuberculosis in Saint Petersburg. A total of 1653 homeless tuberculosis patients were followed up in 1991-1997. There was high incidence of tuberculosis in homeless persons (30 detected per 1000 examinees. All agencies, facilities, and services should participate in detecting and treating tuberculosis among homeless subjects. Large-scale solution of this problems requires a package of measures by providing additional funds stipulated by a regional goal-oriented tuberculosis control programme.

Communicable Disease Control↗

PubMed2000

Faculty practice at a homeless shelter for women and children.

Homelessness in America has significantly increased in recent years. Exact numbers of homeless persons in the United States are difficult to assess, though estimates of homeless persons range from 250,000 to 3 million. The homeless population has shifted to include women and children, including two parent families. Providing health care for the homeless is one of the most important and challenging health issues today. There are many barriers to providing adequate health care. The purpose of this article is to describe the complexity of the role and the experiences of a pediatric nurse practitioner at a clinic in a homeless shelter that houses approximately 30 women and children.

Adolescent↗

PubMed2001

Validation of the brief instrumental functioning scale in a homeless population.

This report describes the psychometric properties of the six-item Brief Instrumental Functioning Scale (BIFS), a self-report questionnaire for measuring instrumental functioning in community populations, and the results of a study to validate the scale among homeless persons. The participants in the study were 1,509 homeless persons, of whom 1,077, or 71 percent, were seriously mentally ill, substance dependent, or both. Confirmatory factor analysis provided evidence for the unidimensionality of the items in the scale. The BIFS had high internal consistency, respectable stability, and reasonable convergent validity. The BIFS is useful for community populations when self-report data on functioning are required. Additional research is needed to develop and validate comparable scales for assessing other domains of functioning.

Adolescent↗

PubMed1998

Differential patterns of mental disorders among the homeless in Madrid (Spain) and Los Angeles (USA).

In this paper we compare rates of mental disorders (major depression, dysthymia, cognitive impairment, and schizophrenia) among homeless people in Madrid and Los Angeles (LA) and examine the ordering of the onset of both conditions (i.e., homelessness and mental disorders). In the Madrid study, 262 homeless persons were interviewed using the CIDI. In the LA study, 1563 homeless persons were interviewed with the DIS. To make an item-by-item comparison, we companied the databases from both studies to submit a single database to statistical analyses. Results showed no significant differences in DSM-III-R life-time prevalence rates of mental disorders between both samples. However, the Madrid sample showed higher 12-month prevalence rates of dysthymia and cognitive impairment as compared to the LA sample. Most subjects across both cities first experienced symptoms of their mental disorders before first becoming homeless. The only significant difference was that all of the depressed adults in Madrid experienced depression prior to first becoming homeless, whereas this was the case for only 59.1% of LA depressed homeless people. We discuss the reasons for these cultural differences and their implications for cross-national public health research and intervention.

Adolescent↗

PubMed1991

Ethnographic methods in the development of census procedures for enumerating the homeless.

The use of ethnographic methods to estimate the number of homeless persons in the United States is explored. The authors describe how "ethnographic methods were integrated with survey procedures in a 1989 Census Bureau pilot test of an experimental daytime count of homeless persons in Baltimore, MD. We demonstrated that ethnographic techniques do not have to be merely supplemental to survey research, but can play an integral part in shaping the entire procedure. Ethnographic data proved valuable for choosing sites, designing questionnaires and developing new interview approaches, and have since proven equally useful in interpreting the test results."

Americas↗

PubMed1991

Characteristics and risk behaviors of homeless black men seeking services from the Community Homeless Assistance Plan--Dade County, Florida, August 1991.

The number of homeless persons in the United States has been estimated to range from 600,000 to 3 million (Dr. Barbara Cohen, The Urban Institute, personal communication, 1991), with higher concentrations of these persons in several large urban centers. Because of the circumstances of homelessness, neither the health status nor the public health needs of these persons are well defined. In Dade County (which includes incorporated Miami), Florida (1990 population: 1.9 million), the average daily number of persons who are homeless is estimated to be 6000; during a 1-year period, approximately 10,000 persons are homeless at some time (Dr. Andrew Cherry, Barry University, Miami, personal communication, 1991). This report presents findings from a survey conducted in August 1991 to assess the health risks of homeless persons in Dade County seeking services from the Community Homeless Assistance Plan (CHAP), a pilot case-management project that places homeless persons into housing, jobs, and appropriate social services.

Adolescent↗

PubMed1990

Depression among the homeless.

Very little is known about one of the most common mental health problems facing the homeless: high levels of depressive symptomatology. This paper explains variation in the prevalence of depressive symptoms (CES-D) for a random sample of 150 shelter- and street-based homeless persons in the Birmingham metropolitan area. Fifty-nine percent of the sample show the signs of "probable clinical caseness"; yet there is significant variation in the level of symptomatology. A modified version of the social resources model explains 31 percent of the variation in CES-D scores. Although psychological resources play an important role in the distress outcome, as predicted, social supports are found to have limited impact on depression. Life circumstances have significant direct effects on depression. Persons with previous histories of mental illness and with extensive life event histories are more susceptible to distress. Younger persons, the chronically homeless, the street-based homeless, the sick, and the less educated are also more likely to experience depression. This study suggests the importance of understanding homelessness both as a psychological condition and as a complex set of life circumstances and physical deprivations.

Adult↗

PubMed1988

Criminal activity among the homeless: a study of arrests in Baltimore.

To illuminate the role of criminal activity among the homeless, particularly the homeless mentally ill, the author compared 634 arrests of homeless persons with 50,524 arrests in the general population that were made in Baltimore in 1983. Significant differences were found in the demographic characteristics of the two groups of arrested persons and in the types of offenses prompting the arrests. Among the homeless, those arrested were more likely to be male, white, and over age 45 and to have committed trivial, victimless crimes. Evidence suggests that ostensibly serious offenses such as assault, larceny, and burglary charged to homeless persons tended to involve petty thievery, entry into vacant buildings, and other acts aimed at maintaining subsistence in the absence of housing.

Adolescent↗

PubMed1990

Homeless men and women: commonalities and a service gender gap.

Gender differences among homeless persons on a host of variables were examined. A stratified random sample of 248 homeless persons staying in shelters in St. Louis provided data for the study. More similarities than differences between men and women were found. However, men tended to be homeless for longer periods and were more likely than women to sleep on the streets. Men were also more likely than women to have a drinking problem and to have been convicted of a crime. Men were less likely than women to ever have been married and to be caring for dependent children. The most striking gender differences occurred on service utilization variables; women were much more likely than men to have received social services. Comparison of our data with previous studies and potential explanations for the gender gap in service utilization are offered.

Adult↗

PubMed2000

Mortality among men using homeless shelters in Toronto, Ontario.

CONTEXT: Homeless persons in US cities have high mortality rates. However, few comparison data exist for death rates among homeless persons in other developed countries. OBJECTIVES: To compare mortality rates among men using homeless shelters and the general population in Toronto, Ontario, and to determine whether mortality rates differ significantly among men using homeless shelters in Canadian and US cities. DESIGN: Cohort study conducted from 1995 through 1997, with a mean follow-up of 2.6 years. PARTICIPANTS: Men aged 18 years or older who used homeless shelters in Toronto in 1995 (n=8933). MAIN OUTCOME MEASURE: Mortality rate ratios comparing age-specific mortality rates among men using homeless shelters in Toronto with those of men in the general population of Toronto and of men using homeless shelters in New York, NY; Boston, Mass; and Philadelphia, Pa. RESULTS: Men using homeless shelters in Toronto were more likely to die than men in the city's general population. Mortality rate ratios were 8.3 (95% confidence interval [CI], 4.4-15.6) for men aged 18 to 24 years, 3.7 (95% CI, 3.0-4.6) for men aged 25 to 44 years, and 2.3 (95% CI, 1.8-3.0) for men aged 45 to 64 years. In most cases, however, the risk of death was significantly lower for men using homeless shelters in Toronto than for those in US cities. For men aged 25 to 44 years using homeless shelters, mortality rate ratios were 0.52 (95% CI, 0.41-0.65) for Toronto compared with Boston and 0.61 (95% CI, 0.44-0.85) for Toronto compared with New York City. For men aged 35 to 54 years using homeless shelters, the mortality rate ratio was 0.42 (95% CI, 0.27-0.66) for Toronto compared with Philadelphia. CONCLUSIONS: Mortality rates among men who use homeless shelters in Toronto, while higher than in the general population of Toronto, are much lower than mortality rates observed among men using homeless shelters in 3 major US cities. Further study is needed to identify the reasons for this disparity.

Adult↗

PubMed1991

Universal self-care requisites as identified by homeless elderly men.

1. Given the current economic climate, the number of homeless persons, and the nature of their needs, nurses must be prepared to facilitate movement of all homeless persons toward self-care. 2. Nurses can contribute to the self-care of homeless elderly men by recognizing and eliciting requisites, associated actions, and nursing interventions that reinforce meeting of needs. 3. Study results support Orem's proposition that universal self-care requisites are common to all individuals regardless of age, sex, developmental level, health state, or internal or external conditions. 4. A number of participant's statements used to formulate themes suggested a relationship to more than one category of universal self-care requisites, which suggests that the categories are not mutually exclusive.

Aged↗

PubMed2002

Role of social disadvantage in crime, joblessness, and homelessness among persons with serious mental illness.

Research on mental illness in relation to social problems such as crime, unemployment, and homelessness often ignores the broader social context in which mental illness is embedded. Policy, research, and practice will be improved if greater attention is given to social context. The authors critically analyze the approach used in much of the psychiatric services literature to infer links between mental illness and social problems. They compare these studies with studies that have been more validly conceptualized to account for social context. With this broader perspective, the impact of mental illness on crime, unemployment, and homelessness appears to be much smaller than that implied by much of the psychiatric services literature. Poverty moderates the relationship between serious mental illness and social problems. Factors related to poverty include lack of education, problems with employment, substance abuse, and a low likelihood of prosocial attachments. This relationship is often complicated and is not amenable to simple explanations. Research and policy that take this complexity into account may lead to greater effectiveness in interventions for persons with serious mental illness.

Adaptation, Psychological↗

PubMed2002

[Residential care and regional psychiatric care:].

OBJECTIVES: In Linz, capital of the province of Upper Austria, there is a considerable shortage of supported housing. Yet the rate of places available reaches 0.9/1000 inhabitants, thus already exceeding the recommended number. METHODS: A comprehensive investigation was started concerning all persons living in supported housing facilities. Services for psychiatric patients (n = 190) were included as well as services for homeless persons (n = 159). RESULTS: Only 41 % of the psychiatric patients and 31 % of the homeless people actually belonged into the region. Also among those who have been living less than one year in the facility, 45 % of the psychiatric and 67 % of the homeless persons come from outside, thus indicating, that the migration of patients is still going on. Among the homeless 69 % were mentally ill. While in the psychiatric services schizophrenic and affective psychoses were predominant, addictive disorders prevailed in the services for the homeless. CONCLUSIONS: It is the aim of mental health services in Upper Austria to care for the patients within their home regions. All regions are providing a fair amount of places for supported housing. Despite this a considerable number of patients keeps coming to the provincial capital. The causes and consequences of this process are discussed.

Adult↗

PubMed1992

A portrait of homelessness.

The homeless elderly are vulnerable, silent, and fearful. Their trajectory into homelessness more often than not precludes recovery and takes them on a course toward early death or nursing home placement. Psychiatric nurses who work in community or acute care settings are in key positions to recognize elderly victims of homelessness, assess their needs, match them to services, start them on the road to recovery, and become their advocates. The definition of a homeless person as agreed on in the Report of the Federal Task Force on Homelessness and Severe Mental Illness (1992) is the one used in the Stewart B. McKinney Homeless Assistance Act (Public Law 100-77). A homeless person is someone "who lacks a fixed, regular, and adequate nighttime residence" and whose main nighttime residence is a "supervised public or private shelter designed to provide temporary living accommodations; an institution that provides a temporary residence for individuals intended to be institutionalized; or a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings." This definition, then, excludes those individuals living on the "fringes" in substandard or condemned housing, a condition that warrants attention in general and particularly among the elderly.

Aged↗

PubMed2004

Tuberculosis knowledge, perceived risk and risk behaviors among homeless adults: effect of ethnicity and injection drug use.

The objectives of this study were to investigate Tuberculosis (TB) knowledge, perceived risk, and risk behaviors in a sample of homeless persons with latent TB in the Skid Row district of Los Angeles. Particular emphasis was given to comparing these variables among homeless persons of varying ethnic backgrounds and among those who did and did not report a history of injection drug use (IDU). Baseline data were collected from 415 homeless individuals recruited to participate in a Tuberculosis chemoprophylaxis intervention. Areas of interest relative to TB knowledge and perceived risk for infection were behavioral factors surrounding substance use and abuse; personal factors measured in terms of current depression; and sociodemographic and situational factors, such as age, ethnicity, history of incarceration, and duration of homelessness. Findings revealed differences in substance abuse. IDUs were more likely to have histories of daily drug use and alcohol dependency, but were less apt to report recent use of crack cocaine. TB knowledge deficits centered on ignorance with respect to modes of transmission and risk factors for TB infection. IDU was also associated with depression. Latinos and IDUs were most likely to lack TB knowledge. There is a pressing need for accessible, available, culturally acceptable and sustained TB screening and intervention programs designed to address multiple risk factors and knowledge deficits with respect to TB infection in homeless populations.

Adult↗