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Urban outbreaks of Q fever have occurred after exposure to slaughterhouses or parturient cats. We detected an outbreak of Q fever in a homeless shelter in Marseilles. Investigations showed that the main factors exposing persons to Coxiella burnetii were an abandoned slaughterhouse, used for an annual Muslim sheep feast, and wind.
OBJECTIVES: To measure knowledge and perceived susceptibility to tuberculosis among homeless adults in San Francisco and attitudes toward control measures used to improve adherence to treatment for tuberculosis. DESIGN: A cross-sectional survey via interview of homeless shelter residents was done at five shelters. RESULTS: Of 292 persons interviewed, 21.6% reported a positive skin test, and 57.1% of the positives had received preventive therapy. Over 60% had misconceptions about transmission, in particular confusion with transmission of the human immunodeficiency virus (HIV). Knowledge of skin testing procedures and symptoms was generally good, and most reported health care providers as the main source of information. Over half reported concern about catching tuberculosis and over 80% favored controls to ensure adherence, in particular directly observed therapy. Higher TB knowledge score (P = 0.0155) and male sex (P = 0.0357) were associated with a favorable attitude toward directly observed therapy. CONCLUSIONS: Health care providers should expand educational messages beyond skin testing. Greater knowledge about tuberculosis may increase acceptance of control measures. Targeted education plus social norms favoring completion of therapy may improve screening and treatment outcomes in this population.
SETTING: From July 1997 through May 1998, ten tuberculosis (TB) cases were reported among men in a Syracuse New York homeless shelter for men. OBJECTIVE AND DESIGN: Investigation to determine extent of, and prevent further, transmission of Mycobacterium tuberculosis. RESULTS: Epidemiologic and laboratory evidence suggests that eight of the ten cases were related. Seven cases had isolates with matching six-band IS6110 DNA fingerprints; the isolate from another case had a closely related fingerprint pattern and this case was considered to be caused by a variant of the same strain. Isolates from eight cases had identical spoligotypes. The source case had extensive cavitary disease and stayed at the shelter nightly, while symptomatic, for almost 8 months before diagnosis. A contact investigation was conducted among 257 shelter users and staff, 70% of whom had a positive tuberculin skin test, including 21 with documented skin test conversions. CONCLUSIONS: An outbreak of related TB cases in a high-risk setting was confirmed through the use of IS6110 DNA fingerprinting in conjunction with spoligotyping and epidemiologic evidence. Because of the high rate of infection in the homeless population, routine screening for TB and preventive therapy for eligible persons should be considered in shelters.
The analysis using the systems approach, analogue simulation, practical conclusions of the probability theory, mathematical statistical methods, programme-oriented work organization revealed and eliminated a number of neglects that had put bounds to scabies morbidity reduction among Moscovites. In 1998, the number of the foci that dermatovenereological facilities were unaware of substantially showed a 6.9-fold decrease. Therefore, the incidence of scabies reduced by 14.6% in the city in 1998. The paper presents the guidelines developed by the authors, which will ensure that the incidence rates of scabies be 25.07 per 100,000 Moscovites by 2005. It analyzes the scabies epidemiological situation among the homeless and possible measures to promote health in this group of persons.
OBJECTIVE: To report on the backgrounds and physical and emotional well-being of street children using two street shelters in Kyiv, Ukraine. This study is important because personal accounts of street children may highlight individual or family factors that are associated with vulnerability for and risk of poor mental health, and these could have serious repercussions for the future. This study also poses a challenge to research because street children are a highly elusive population that services find hard to reach. METHODS: Ninety-seven children were recruited and interviewed using a semistructured, psychosocial interview schedule; psychopathology was measured using the Strengths and Difficulties Questionnaire (SDQ) and the Mood and Feelings Questionnaire (MFQ). RESULTS: Seventy percent of street children scored for behavioral and emotional difficulties on the SDQ, and 74% scored for depression on the MFQ. Current health problems were reported by 78%, with 43% described as persistent or severe. Two thirds of the children in this sample were not homeless but had chosen life on the streets in preference to permanent residence with their families. Their "survival" history on the streets contributed to the development of three different profiles of vulnerability. CONCLUSIONS: High rates of physical and emotional problems in a population of street children, many of whom were still connected to their families, emphasize the importance of developing different approaches for children with different vulnerabilities. This study also demonstrates the feasibility of embedding on-going field research into the service dimension of "front-line" social care agencies.
Following the deinstitutionalization of persons with serious mental illness from state hospitals, many persons with serious mental illness did not receive the care that they needed and encountered unexpected negative experiences. Among the negative experiences were frequent rehospitalizations, involvement in the criminal justice system, and homelessness. Seeing these negative outcomes, mental health professionals in the 1980s debated the quality of life of persons with severe and persistent mental illness and concluded that the main goal of treatment was to improve the quality of life of those afflicted. Thus, the quality of life became a critical variable in determining the effectiveness of mental health treatment. This paper reviews studies that used quality of life as an outcome measure in treatment services for persons with serious and persistent mental illness and the policy implications of these studies.
BACKGROUND: The homeless are at very high risk of suffering tuberculosis (TB). The aims of this study were to determine the prevalence and risk factors for tuberculosis infection and disease among the homeless in Barcelona and to evaluate the roles of case finding and contact investigation. METHODS: Observational prevalence study carried out between 1997 and 1998. PARTICIPANTS: 447 homeless patients (394 men and 53 women) were evaluated before admission to shelters and free-meal services. At the same time, 48 co-residents with smear-positive TB patients in 2 long-term shelters were evaluated too. A chest X-ray and Tuberculin Skin Test were performed on all subjects. Sputum smears were processed by the Ziehl-Neelsen and Löwenstein-Jensen procedures in patients with radiographic findings consistent with pulmonary TB. RESULTS: Of the 447 homeless examined, 335 (75%) were infected with Mycobacterium tuberculosis. Active pulmonary TB was diagnosed in five persons (1.11%), and 62 (13.8%) had radiographic evidence of inactive pulmonary TB. Tuberculosis infection was associated with age and smoking, but not with sex or alcohol abuse. No significant differences in infection rates were found between the main group and 48 homeless co-residents of smear-positive subjects. Only 16.9% of the homeless with active TB in Barcelona in the same period were diagnosed through active case-finding, the remainder being mainly detected in hospitals (69.8%) and other several centres (13.3%). CONCLUSIONS: Homeless individuals have a very high risk of TB infection and disease and contact investigation requires specific methods for them. Programmes of screening and supervised treatment should be ensured in this group.
OBJECTIVE: The study assessed the prevalence of severe aggressive behavior and conduct disorder in a population of runaway and homeless adolescents and examined relationships between aggression, conduct disorder, other problem behaviors, and background characteristics. METHODS: A total of 219 runaway and homeless youths recruited through a urban drop-in center were surveyed using the Adolescent Health Survey, a questionnaire about background and mental health experiences, and the revised version of the Diagnostic Interview Schedule for Children. RESULTS: More than half of study participants met criteria for conduct disorder, and 62 percent reported a history of severe aggressive behavior. Although these constructs were related to each other, a third of the subjects met criteria for only one. Childhood sexual abuse was associated with conduct disorder, while living in a home where drugs were used was associated with aggression. Severe aggressive behavior was associated with other problem behaviors, including attempted suicide, behavior that precipitated residential psychiatric treatment, pregnancy, arrests, and convictions. CONCLUSIONS: The assessment and systematic treatment of conduct disorder and aggression among runaway and homeless youths is urgently needed to reduce the effects of the disorder and associated problem behaviors.
BACKGROUND: The spread of human immunodeficiency virus infection to impaired groups has intensified the challenge for its prevention; control of the epidemic now requires behavioral change among persons with limited ability to sustain attention and learn. In this randomized clinical trial, we tested an intervention to reduce sexual risk behaviors among homeless men with severe mental illness. METHODS: Men were recruited from a psychiatric program in a homeless shelter. Of 116 eligible men, 97 (83.6%) participated. Most were African American and had a chronic psychotic disorder and a comorbid substance use disorder. Participants were assigned to a 15-session experimental group intervention or to a 2-session control intervention and observed for 18 months. The 59 participants sexually active before the trial were the main target of the intervention. Sexual risk behavior was the primary outcome. RESULTS: Among the 59 sexually active men, follow-up data were obtained on 59 (100%) for the initial 6-month follow-up and on 56 (95%) for the remainder of the 18-month follow-up. The mean score on a sexual risk index for the experimental group was 3 times lower than for the control group (1.0 vs 3.1; P=.01) during the initial 6-month follow-up and 2 times lower during the remainder of the 18-month follow-up. CONCLUSIONS: This intervention successfully reduced sexual risk behaviors of homeless men with mental illness. The effect diminished over 18 months but did not disappear. Similar approaches may be effective in other impaired high-risk groups.
OBJECTIVE: This study assessed relationships between homelessness, mental disorder, and incarceration. METHODS: Using archival databases that included all 12,934 individuals who entered the San Francisco County Jail system during the first six months of 2000, the authors assessed clinical and behavioral characteristics associated with homelessness and incarceration. RESULTS: In 16 percent of the episodes of incarceration, the inmates were homeless, and in 18 percent of the episodes, the inmates had a diagnosis of a mental disorder; 30 percent of the inmates who were homeless had a diagnosis of a mental disorder during one or more episodes. Seventy-eight percent of the homeless inmates with a severe mental disorder had co-occurring substance-related disorders. Inmates with dual diagnoses were more likely to be homeless and to be charged with violent crimes than other inmates. Multiple regression analyses showed that inmates who were homeless and had co-occurring severe mental disorders and substance-related disorders were held in jail longer than other inmates who had been charged with similar crimes. CONCLUSIONS: People who were homeless and who were identified as having mental disorders, although representing only a small proportion of the total population, accounted for a substantial proportion of persons who were incarcerated in the criminal justice system in this study's urban setting. The increased duration of incarceration associated with homelessness and co-occurring severe mental disorders and substance-related disorders suggests that jails are de facto assuming responsibility for a population whose needs span multiple service delivery systems.
OBJECTIVE: This analysis examined the impact of permanent supportive housing on the use of acute care public health services by homeless people with mental illness, substance use disorder, and other disabilities. METHODS: The sample consisted of 236 single adults who entered supportive housing at two San Francisco sites, Canon Kip Community House and the Lyric Hotel, between October 10, 1994, and June 30, 1998. Eighty percent had a diagnosis of dual psychiatric and substance use disorders. Administrative data from the city's public health system were used to construct a retrospective, longitudinal history of service use. Analyses compared service use during the two years before entry into supportive housing with service use during the two years after entry. RESULTS: Eighty-one percent of residents remained in permanent supportive housing for at least one year. Housing placement significantly reduced the percentage of residents with an emergency department visit (53 to 37 percent), the average number of visits per person (1.94 to .86), and the total number of emergency department visits (56 percent decrease, from 457 to 202) for the sample as a whole. For hospitalizations, permanent supportive housing placement significantly reduced the likelihood of being hospitalized (19 to 11 percent) and the mean number of admissions per person (.34 to .19 admissions per resident). CONCLUSIONS: Providing permanent supportive housing to homeless people with psychiatric and substance use disorders reduced their use of costly hospital emergency department and inpatient services, which are publicly provided.
This study examined factors affecting medical service use among HIV-infected persons with a substance abuse disorder. The sample comprised 190 participants enrolled in a randomized trial of a case management intervention. Participants were interviewed about their backgrounds, housing status, income, alcohol and drug use problems, health status and depressive symptoms at study entry. Electronic medical records were used to assess medical service use. Poisson regression models were tested to determine the effects of need, enabling and predisposing factors on the dependent variables of emergency department visits, inpatient admissions and ambulatory care visits. During a two-year period, 71% were treated in the emergency department, 64% had been hospitalized and the sample averaged 12.9 ambulatory care visits. Homelessness was associated with higher utilization of emergency department and inpatient services; drug use severity was associated with higher inpatient and ambulatory care service use; and alcohol use severity was associated with greater use of emergency medical services. Homelessness and substance abuse exacerbate the health care needs of HIV-infected persons and result in increased use of emergency department and inpatient services. Interventions are needed that target HIV-infected persons with substance abuse disorders, particularly those that increase entry and retention in outpatient health care and thus decrease reliance on acute hospital-based services.
This study examined the reliability and construct validity of a modified version of the Colorado Symptom Index (MCSI), a brief, self-report measure of psychological symptomatology, in a study of interventions to prevent homelessness. Eight projects in a national, cooperative study collected new data at baseline, 6, and 12 months using a set of common measures as well as site-specific instruments. The pooled sample consisted of 1,381 persons in treatment for mental illness or substance abuse (or both), of which 84% had a history of homelessness. The analyses employed classical and Rasch methods to examine the MCSI's content validity, internal consistency and item quality, test/retest reliability, dimensionality, appropriateness for the sample, construct validity, and responsiveness to change. This 14-item scale was found to be a reliable and valid measure of psychological symptoms in this sample. Its content was consistent with other symptom measures, its high internal consistency and test-retest coefficients supported its reliability, its relationships to other measures indicated that it had good construct validity, and it was responsive to change. We conclude that the MC
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