Compliance of homeless mentally ill persons with assertive community treatment.
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Activities of Daily Living↗
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A profile of clients served by a mobile outreach program for homeless mentally ill persons.
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Adult↗
Peer education project with persons who have experienced homelessness.
This paper describes an unconventional health education project implemented by nurse practitioners in a nurse-managed clinic serving persons who are homeless. The nurse practitioners perceived that there were a number of potential barriers to providing health education to the homeless patients. These barriers included the fact that this patient population is part of a marginalized subculture affected by a variety of overwhelming social problems. An additional barrier was that the nurses often differed from their homeless patients in terms of race, gender, socioeconomic status, formal education, culture, and life experience. The nurse practitioners designed the Peer Health Education Project (PHEP) to try to overcome some of these barriers. The purpose of the PHEP was to increase the health education knowledge and empowerment of persons who had experienced homelessness so that they could serve as peer health educators with others who were living on the streets. The project model was based on the philosophy of Paulo Freire (1973). The peer health educators served as both leaders and participants in each education session. The educators set the agenda and the nurses acted as facilitators. The project was successful in preparing peer educators. Other indicators of the success of the project included increased empowerment, self-esteem, dignity, hope self-confidence, and community participation of the peer educators.
Adult↗
Discriminant analyses of willingness to talk with a counselor and most difficult issues in the experience of unsheltered homeless men: self-actualization, loneliness, and depression.
Stepwise discriminant analyses of willingness to talk with a counselor (Wilks Lambda=.75, p<.001) and most difficult issues (Wilks Lambda=.81, p<.001) in 145 unsheltered homeless men's experience were examined using self-actualization constructs, loneliness, depression, and history-of-being-homeless variables. For example, homeless men with higher scores on loneliness, autonomy, courage, Jonah Complex, and self-acceptance were less willing to talk with a counselor. The variable, longer intervals of having a home after a first homeless episode, was associated with personal issues rather than with homeless issues. Selected participants' responses to the items, "what have you learned from your homeless experience that you could not have learned any other way" and "what would you like for me to know about your experience of homelessness," are posted to give perspective on a homeless person's internal frame of reference. This phenomenological approach indicated strengths as well as weaknesses of homeless men. Counseling programs should embrace all homeless persons including mentally well, nondrug-dependent homeless individuals.
Adaptation, Psychological↗
Characteristics of homeless HIV-positive outreach responders in urban US and their success in primary care treatment.
Homeless HIV+ persons with persistent mental illness and substance use disorders need services, but are hard to reach and enrol into treatment. Connecting them to services is a major challenge of the AIDS epidemic. This report describes characteristics of homeless HIV+ substance abusers who responded to outreach and enrolled in integrated treatment services. The target population was urban, homeless, HIV+ individuals with substance dependence and/or mental illness diagnoses. Health and physical functioning were measured using a refinement of the Medical Outcomes Study Health Survey. Questions based on the PRIME-MD measured subjects' mental health status. Outreach occurred at shelters, soup kitchens, and on the streets. The outreach team consisted of a nurse, substance abuse counsellor, and a formerly homeless person. Outreach contacted 3,059 individuals; 1,446 entered the clinic, 110 of 206 eligible candidates enrolled in the study, and 82.7% of study participants completed 12-month follow-up interviews. Enrollees exhibited 5th percentile composite health scores. They reported heavy street drug use and unmet service needs particularly for housing and financial assistance. Outreach successfully recruited targeted individuals into treatment. They stayed in treatment and demonstrated improvements on measures of physical and mental health 12-months later.
Adult↗
Pathways to homelessness among the mentally ill.
BACKGROUND: Persons with mental illness are over-represented among the homeless relative to the general population, and mental illness is most likely one of many vulnerabilities that confer risk for homelessness. METHOD: This paper elucidates the pathways to homelessness for persons with mental illness by comparing and contrasting groups of mentally ill homeless persons, non-mentally ill homeless persons, and housed mentally ill persons drawn from RAND's Course of Homelessness (COH) study and the Epidemiological Catchment Area (ECA) survey. RESULTS: Homeless persons share childhood histories of economic and social disadvantage. The mentally ill homeless appear to have a "double dose" of disadvantage: poverty with the addition of childhood family instability and violence. Among the mentally ill homeless, those who became homeless prior to becoming mentally ill have the highest levels of disadvantage and disruption; while those who become homeless after becoming ill have an especially high prevalence of alcohol dependence. CONCLUSIONS: Mental illness may play a role in initiating homelessness for some, but is unlikely in and of itself to be a sufficient risk factor for homelessness. In addition to outreach and treatment programs for adult mentally ill homeless persons, emphasis should be placed on interventions with children and on addressing more pervasive causes of homelessness.
Adult↗
AIDS among the homeless of Boston: a cohort study.
We wanted to compare demographics, risk behaviors, AIDS-defining diagnoses, and survival between homeless and housed persons with AIDS in Boston from 1983 to 1991. Our retrospective cohort study used chart review to identify homeless AIDS cases and data from the Massachusetts AIDS Surveillance Program for comparison of homeless and nonhomeless cases. Seventy-two homeless and 1,536 nonhomeless Boston residents were reported to have AIDS between Jan. 1, 1983, and July 1, 1991. Homeless persons with AIDS were more likely to be African American or Latino (81 vs. 39%, p < 0.0001) and have i.v. drug use as a risk behavior (75 vs. 19%, p < 0.0001). The AIDS-defining diagnoses among the homeless were more commonly disseminated Mycobacterium tuberculosis (9 vs. 2%, p < 0.0001) and esophageal candidiasis (17 vs. 9%, p < 0.01). These differences were not seen when the populations were stratified by i.v. drug use. No significant difference in survival between the homeless and nonhomeless cohorts was found. Homeless individuals with human immunodeficiency virus are significantly different than housed persons, and at greater risk of invasive opportunistic infections. Appropriate clinical strategies can be developed to provide needed care to homeless persons with HIV.
Acquired Immunodeficiency Syndrome↗
Is antisocial personality a valid diagnosis among the homeless?
OBJECTIVE: It has been argued that among the homeless many of the features of antisocial personality may be artifacts of homelessness and that strict application of the diagnostic criteria may be insensitive to social and cultural factors in this group. The authors studied a large group of homeless men and women to investigate the appropriateness of the diagnosis of antisocial personality disorder among the homeless. METHOD: Six hundred homeless men and 300 homeless women were randomly selected from shelters and street locations in St. Louis and interviewed with the National Institute of Mental Health Diagnostic Interview Schedule. RESULTS: In this sample of homeless men and women, most, but not all, adult symptoms of antisocial personality disorder were significantly associated with number of childhood conduct disorder symptoms. The onset of symptoms of antisocial personality disorder usually preceded the onset of homelessness. The rates of antisocial personality disorder were not significantly affected by discounting the antisocial disorder symptoms thought to be confounded with homelessness. CONCLUSIONS: Overall, the data support the appropriateness of the diagnosis of antisocial personality disorder among homeless populations. It cannot be said from these data that homelessness often leads to antisocial behaviors.
Adolescent↗
Provider assessment of eligibility for hepatitis C treatment in HIV-infected homeless and marginally housed persons.
PURPOSE: To characterize the group of providers delivering medical care to HIV and hepatitis C (HCV) co-infected homeless and marginally housed individuals in San Francisco and to assess factors affecting provider decisions to initiate HCV treatment in this population. SUBJECTS AND METHODS: The Research in Access to Care for the Homeless (REACH) cohort is a representative sample of HIV-infected homeless and marginally housed individuals identified from single room occupancy hotels, homeless shelters and free lunch programs in San Francisco. Primary care providers (PCP) for active, HIV/HCV co-infected REACH cohort participants were administered face-to-face, semi-structured interviews. REACH participants were administered quarterly face-to-face structured interviews. RESULTS: 52/62 (83.9%) providers were interviewed regarding 133/155 (85.8%) active, HIV/HCV co-infected patients. Providers classified 94/133 (70.7%) patients as ineligible for HCV treatment. The mean number of reasons for ineligibility was 3.2. Most frequent reasons for provider determination of ineligibility included likelihood of poor medication adherence, depression, active injection drug use and patient disinterest in treatment. In addition, structural barriers to treatment included poor access to testing, delays in evaluation by a gastroenterologist and exclusion from treatment of patients with comorbidities. CONCLUSIONS: While HCV infection is common, HCV treatment is rare in the HIV/HCV coinfected urban poor. On average, the PCP in this study are experienced and are familiar with this patient population. There are many reasons for providers classifying patients as ineligible for HCV treatment. While these reasons indicate that treatment is difficult given chaotic lifestyle and concurrent medical conditions of this population, they are not insurmountable barriers. New treatments and strategies are necessary to treat this population with high rates of hepatitis C infection.
Adult↗
Personal and family distress in homeless adolescents.
Previous research has indicated that homeless children exhibit high rates of behavioral and emotional problems and come from families characterised by conflict and rejection. Further, some evidence exists to show that family variables may relate to adolescent distress differently for homeless males and females. In this study, 117 homeless adolescents were compared to a sample of non-homeless youths on the self reported incidence of personal and family problems. The homeless children reported the highest incidence of all behavioral and emotional problems, parental marital discord, overprotection, and the lowest levels of parental care and acceptance. Sex effects were not evident in reported levels of personal or family problems. However, substantially more variance in the adolescents level of behavioral and emotional disturbance was predictable from family measures for females than males. Overall, the results point to the importance of incorporating family distress models in the understanding and remediation of adolescent homelessness.
Adolescent↗
Neuropsychological function in homeless mentally ill individuals.
Because little data are available on the neuropsychological functioning of severely and persistently mentally ill (SPMI) persons who are homeless, our primary goal was to describe accurately and extensively the general neuropsychological functioning of a large group of such homeless individuals. In addition, we have sought to examine the relationship between some neuropsychological functions and demographic, illness, and clinical state measures in this population. A 5-hour neuropsychological test battery was administered to 116 SPMI homeless individuals. Neuropsychological, diagnostic, substance abuse, clinical, and psychopathology data were obtained in a standardized manner. SPMI homeless individuals were significantly impaired on a wide range of neuropsychological functions. Specific test performances were most significantly related to precursor variables (level of education and parental socioeconomic status) and state variables (level of psychosis and anticholinergic medication dose). Gender and substance abuse had significant effects limited to sustained attention. Neuropsychological performance was impaired in this sample of homeless SPMI persons. Further research, using profile analysis to directly compare groups composed of homeless persons without psychiatric illness or demographically matched persons of comparable psychiatric status who are not homeless will help clarify the role of homelessness and psychosis on neuropsychological function.
Adult↗
Effects of homelessness on the quality of life of persons with severe mental illness.
OBJECTIVE: This study assessed the relationship between homelessness and specific quality-of-life problems for persons with severe and persistent mental illness. METHODS: The objective and subjective quality of life of 106 homeless persons with severe mental illness who lived on the streets or in shelters in Baltimore was compared with that of 146 domiciled persons with severe mental illness who lived in the community. RESULTS: Objective and subjective quality of life of the homeless subjects was clearly worse than that of the domiciled group in the areas of living situation, family and social relations, employment, daily activities, and legal and safety problems. Homeless subjects were also less likely to have federal disability entitlements. CONCLUSIONS: Poorer quality of life is associated with homelessness among persons with severe mental illness. Their quality of life may be improved by efforts to increase their access to disability entitlements and treatment services and to help them develop supportive social networks.
Adult↗
A personal perspective: caring for homeless people with AIDS.
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Acquired Immunodeficiency Syndrome↗
Touched by homelessness: an examination of hospitality for the down and out.
OBJECTIVES: This study investigated patterns of "doubled-up" homelessness using an indirect measure based on host households. METHODS: In random household telephone surveys conducted in Alabama between 1990 and 2000 and nationally in 1997, respondents indicated whether any individual had stayed with them during the past year because that person was homeless. RESULTS: The percentage of Alabama households providing shelter during the past year declined from 16.2% in 1990 to 7.1% in 2000. The national rate for providing shelter in 1997 was 18.0%. CONCLUSIONS: Many households provide shelter to people to prevent them from being literally homeless. As the economy has expanded, these rates have declined in Alabama.
Adult↗
Meeting the health needs of homeless or low-income persons: role of the nurse practitioner.
Providing health care for homeless or low-income families presents many challenges and rewards. Nurse practitioners are in a unique position to make a positive impact on the health needs of this population. However, they need to think about the ramifications of their approach, assessment techniques, and intervention strategies to optimize the health care offered. We share our experience in working with this population and lessons we have learned from review of the literature.
Adult↗
[Spread of a drug-resistant strain of mycobacterium tuberculosis among homeless people in a German city].
BACKGROUND: Cases of active pulmonary tuberculosis are much more common among homeless people because of their personal risk factors than in the average population; it is assumed that there are about 500 000 homeless people in the Federal Republic of Germany. Several sputum samples were sent from the tuberculosis advice center of the public health office in Hannover to the governmental institute of public health services of Lower Saxony in fall 1996 in order to carry out laboratory tests for mycobacteria. The isolates found revealed an unusual pattern of drug resistance to streptomycin and rifampin. METHODS: The sputum samples were tested according to the usual standard test procedures as described in DIN 58 943-3 (DIN standard of the German Institute for Standardization) and in MiQ 5/1998 (Quality standards in microbiology-infectiologic diagnostics issued by the German Society for Hygiene and Microbiology [DGHM]. DNA-fingerprinting was carried out by the IS 6110-RFLP-technique. PATIENTS: In Hannover a total of 12 patients with an active pulmonary tuberculosis, whose M. tuberculosis-strains showed resistance to streptomycin and rifampin, were investigated. 9 of the 12 patients were homeless and lodged in a homeless shelter of the city; in one case a healthcare worker acquired a tuberculosis infection while caring for these patients. RESULTS: The identity of the 12 isolated mycobacteria strains could be proved by IS 6110-fingerprinting. The result clearly indicates the existence of a tuberculosis cluster among the homeless people in a German city. The treatment of the homeless persons proved to be difficult because of the lack of compliance; in 4 cases compulsory isolation with therapy in a closed clinic was unavoidable and beforehand 2 of the patients even had to be tracked down by the police. CONCLUSIONS: The German law on the prevention of infectious diseases offers some new possibilities to the public health offices concerning the control and prevention of tuberculosis among homeless persons. For example the public health offices are now allowed to run a "preventive visiting services" prevention and to practice ambulant therapies; the payment of the costs for poor patients is prescribed, too. These possibilities should be used in an extended way, as the efforts to control the spread to tuberculosis among homeless people need to be intensified.
Adult↗
[The homelessness of the young person].
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Psychology, Adolescent↗
Tuberculosis infection and homelessness in Melbourne, Australia, 1995-1996.
OBJECTIVE: To describe tuberculosis infection among persons experiencing homelessness in inner Melbourne, Australia. DESIGN: Homeless people were surveyed during late 1995 and early 1996. In stage one of the study 284 homeless people from crisis and long-term accommodation sites were recruited by means of stratified, systematic, random sampling. In stage two a convenience sample of 100 homeless people from squats and the streets were recruited. Participants completed a questionnaire and Mantoux testing was performed. RESULTS: A past history of tuberculosis was reported by 3%. Thirty-seven per cent had a Mantoux > or =10 mm; 21% > or =15 mm; and 11% > or =20 mm. A Mantoux > or =15 mm was independently associated with being aged > or =40 years, coming from the accommodated sample, overseas birth, and a past history of tuberculosis. Using logistic regression modelling, a Mantoux > or =15 mm was predicted by being aged > or =40 years, overseas birth, and past history of tuberculosis. CONCLUSION: Mantoux test results suggest that this group of homeless people had a high prevalence of infection with the tubercle bacillus. Many aspects of the physical and social circumstances of homeless people predispose to reactivation and have the potential to enhance rapid spread should latent infection become active disease.
Adolescent↗