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PubMed1989

[Mentally ill homeless persons].

Homelessness is a social problem but it is frequently associated with other problems connected with health. Abuse of illegal and legal intoxicants and severe mental illness among homeless persons make it increasingly difficult to provide support and help for homeless persons solely by means of social measures. Mentally ill homeless individuals are frequently well known both by the social authorities and by the staff of psychiatric hospitals. They have frequently been offered the traditional forms of help and therapeutic measures traditionally employed without this resulting in "cure and stability" and they are frequently left to their own devices. Many of the mentally ill homeless persons have some form of addiction which renders their existence more difficult. Hostels and homes for care do not traditionally offer homes for this type of clientele but this may prove necessary. It will be necessary to provide new measures, e.g. domiciliary forms for this group but without a multidisciplinary therapeutic team and without cooperation between the social services and the health services this can scarcely prove successful.

Adolescent↗
PubMed1991

Nutrition and the homeless person.

Homeless persons include men, women, and children who are among the poorest of America's poor. A review is provided of the eating patterns of the homeless, their special nutritional problems, and controversial nutritional issues involving them. Also discussed are ways in which community health nurses (CHNs) can (a) help upgrade the nutritional standards of community-based shelters and other facilities which feed the homeless, and (b) provide suggestions to such food providers to improve the social climate during mealtimes.

Adult↗
PubMed2005

Treatment preferences for resuscitation and critical care among homeless persons.

CONTEXT: Homeless people are at increased risk of critical illness and are less likely to have surrogate decision makers when critically ill. Consequently, clinicians must make decisions independently or with input from others such as ethics committees or guardians. No prior studies have examined treatment preferences of homeless to guide such decision makers. DESIGN: Interviewer-administered, cross-sectional survey of homeless persons. SETTING: Homeless shelters in Seattle, WA. PARTICIPANTS: Two hundred twenty-nine homeless individuals with two comparison groups: 236 physicians practicing in settings where they are likely to provide care for homeless persons and 111 patients with oxygen-dependent COPD. MEASUREMENTS: Participants were asked whether they would want intubation with mechanical ventilation or cardiopulmonary resuscitation in their current health, if they were in a permanent coma, if they had severe dementia, or if they were confined to bed and dependent on others for all care. RESULTS: Homeless men were more likely to want resuscitation than homeless women (p < 0.002) in coma and dementia scenarios. Homeless men and women were both more likely to want resuscitation in these scenarios than physicians (p < 0.001). Nonwhite homeless were more likely to want resuscitation than white homeless people (p < 0.033), and both were more likely to want resuscitation than physicians (p < 0.001). Homeless are also more likely to want resuscitation than patients with COPD. The majority (80%) of homeless who reported not having family or not wanting family to make medical decisions prefer a physician make decisions rather than a court-appointed guardian. CONCLUSIONS: Homeless persons are more likely to prefer resuscitation than physicians and patients with severe COPD. Since physicians may be in the position of making medical decisions for homeless patients and since physicians are influenced by their own preferences when making decisions for others, physicians should be aware that, on average, homeless persons prefer more aggressive care than physicians. Hospitals serving homeless individuals should consider developing policies to address this issue.

Adult↗
PubMed2001

Factors associated with the health care utilization of homeless persons.

CONTEXT: Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective. OBJECTIVE: To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons. DESIGN AND SETTING: Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients. SUBJECTS: A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996. MAIN OUTCOME MEASURES: Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year. RESULTS: Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75). CONCLUSIONS: In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.

Adult↗
PubMed1997

[Health status and medical care accessibility of single, homeless persons].

The homeless population in Germany is continually increasing. Featuring prominently among those on the increase are women, young persons and homeless people from East Germany. Studies of the health of homeless individuals in recent years show that indices of illness are far higher for many disorders than for comparable groups who are housed. One result from a recent study by the University of Mainz (1994) was that more than 90% of homeless people urgently need medical treatment. According this research, the main health problems of the homeless are: cardiac disease (hypertension, CAD) (52.5%), skin disease (scabies, lice, leg ulcers, abscesses, pyodermias) and acute infections (50%), lower respiratory tract (COAD) (47.5%) and trauma victims (50%), followed by liver (30%), kidney (25%) and gastrointestinal diseases (GU) (20%). The problems of alcoholism and mental disorders of various sorts are added to this picture. Violence to homeless people is increasing. A lot of homeless people are multi-morbid. The relationship between the time of homelessness and the state of illness was not linear. It was found that in the beginning of homelessness most of the homeless people were in a poor physical condition. The poor physical condition of homeless people does not stem from only one cause, but results from a combination of different factors: individual social conditions (social class; social relations; sedentary lifestyle), personal or family life crisis (life events and coping behaviour), the individual risk behaviour (for instance the bizarre sleeping accommodations, alcohol and cigarette consumption unemployment in a depressed economy, structure of the society (cutbacks in government welfare and social service programmes). As a result of bad experiences with existing medical institutions, homeless persons do not consult the doctor or too late. Many are afraid of large institutions; most are not members of a health insurance scheme (uninsured); and many are perceived in some sense to be "undesirable" as patients. Medical care offers for homeless people must be re-examined and changed appropriately in accordance with the requirements of the patients and the acceptability of the measures. Health care for the homeless is sorely needed. It is an urgent necessity to create special low-level acceptance medical care institutions. This health care service should be made available to homeless persons at the places where they gather (to set up a mobile medical service, medical streetwork, medical care ambulances). The interdisciplinary theme approach, which integrates the skills of physicians, nurses and social workers, is an invaluable strategy for establishing though and continuous care. Without good health, homeless people cannot resolve their other basic problems; and people simply cannot be healthy if they do not have a stable place to live.

Adult↗
PubMed2000

Quality of life of homeless persons with mental illness: results from the course-of-homelessness study.

OBJECTIVE: The quality of life of homeless persons with mental illness was compared with that of homeless persons without mental illness. METHODS: Subjective and objective quality-of-life ratings were obtained in face-to-face interviews with 1,533 homeless adults in Los Angeles, who were identified using probability sampling of people on the streets and at shelters and meal facilities; 520 subjects were tracked for 15 months. Ratings of homeless persons with and without mental illness were compared using chi square tests and regression analyses. RESULTS: Mentally ill homeless persons were significantly more likely than those without mental illness to receive Supplemental Security Income, Social Security Disability Insurance, Veterans Affairs disability benefits, or Medicaid. However, those with mental illness still fared significantly worse in terms of physical health, level of subsistence needs met, victimization, and subjective quality of life. Differences between groups in the subjective quality-of-life ratings were accounted for by modifiable factors such as income and symptoms rather than by nonmodifiable demographic characteristics. CONCLUSIONS: Interventions most likely to improve the quality of life of homeless persons with mental illness include those that stress maintenance of stable housing and provision of food and clothing and that address physical health problems and train individuals to minimize their risk of victimization. Interventions that decrease depressive symptoms might also improve subjective quality of life.

Adult↗
PubMed1991

Deaths among homeless persons--San Francisco, 1985-1990.

In San Francisco (1990 population: 723,959), an estimated 6000-18,000 persons are homeless. To characterize the causes of death among homeless persons in San Francisco during 1985-1990, the Health Care for the Homeless Program, San Francisco Department of Public Health, reviewed records of homeless decedents from the city medical examiner's (ME's) office. This report summarizes the results of that study.

Adult↗
PubMed2006

Substance abuse treatment and psychiatric comorbidity: do benefits spill over? Analysis of data from a prospective trial among cocaine-dependent homeless persons.

BACKGROUND: Comorbid psychiatric illness can undermine outcomes among homeless persons undergoing addiction treatment, and psychiatric specialty care is not always readily available. The prognosis for nonsubstance abuse psychiatric diagnoses among homeless persons receiving behaviorally-based addiction treatment, however, is little studied. RESULTS: Data from an addiction treatment trial for 95 cocaine-dependent homeless persons (1996-1998) were used to profile psychiatric diagnoses at baseline and 6 months, including mood-related disorders (e.g. depression) and anxiety-related disorders (e.g. post-traumatic stress disorder). Treatment interventions, including systematic reinforcement for goal attainment, were behavioral in orientation. There was a 32% reduction in the prevalence of comorbid non-addiction psychiatric disorder from baseline to 6 months, with similar reductions in the prevalence of mood (-32%) and anxiety-related disorders (-20%) (p = 0.12). CONCLUSION: Among cocaine-dependent homeless persons with psychiatric comorbidity undergoing behavioral addiction treatment, a reduction in comorbid psychiatric disorder prevalence was observed over 6 months. Not all participants improved, suggesting that even evidence-based addiction treatment will prove insufficient for a meaningful proportion of the dually diagnosed homeless population.

Adult↗
PubMed1993

Enumerating deaths among homeless persons: comparison of medical examiner data and shelter-based reports--Fulton County, Georgia, 1991.

Characteristics of causes of death and mortality patterns in homeless populations have been constrained by limitations in both the accuracy of estimates of the size of the homeless population and enumeration of the number of deaths of homeless persons (1,2). For example, studies of mortality among homeless persons in Fulton County (Atlanta), Georgia, based on medical examiner records estimated approximately 40 deaths of homeless persons annually (1,3); in contrast, a media report based on information supplied by shelters for homeless persons reported 191 deaths of homeless persons in Atlanta during 1991 (4,5). As a basis for improving characterization of mortality patterns in the homeless population of Fulton County, Emory University and CDC assessed the differences in the estimates of deaths among homeless persons that were obtained from medical examiner records and those based on death reports from shelters that are in or adjacent to Fulton County (1990 population: 648,951) during 1991. This report summarizes the findings of that study.

Coroners and Medical Examiners↗
PubMed2002

Schizophrenia in homeless persons: a systematic review of the literature.

OBJECTIVE: This article systematically reviews studies of prevalence of schizophrenia in homeless persons. METHOD: Medline and PsychInfo were searched using the key words: homeless person, mental illness, psychosis, and schizophrenia. The bibliographies of identified articles were also reviewed. RESULTS: Study designs varied considerably. The rate of schizophrenia in homeless persons reported in the 33 published reports, representing eight different countries, ranged from 2 to 45%. In the 10 methodologically superior studies, the prevalence range was 4-16% and the weighted average prevalence was 11%. In addition, rates were higher in younger persons, women and the chronically homeless. Slightly less than half of the homeless persons with schizophrenia were not currently receiving treatment. CONCLUSION: Schizophrenia is much more prevalent among homeless persons than in the population at large. Future research should focus on better ways of meeting the mental health care needs of homeless people with schizophrenia.

Antipsychotic Agents↗
PubMed1995

Staying connected: the core of facilitating health care for homeless persons.

A grounded theory study explored the ways nurses and others in nurse-managed shelter clinics facilitate health care for homeless persons. Analysis of in-depth interview and participant observation data yielded a core category, "staying connected," that represents the essence of what the staff do to facilitate care for homeless persons. The three most important aspects of "staying connected" are the links that nurses establish with the homeless patient, the connections nurses establish in the form of networks with other providers, and facilitation of the homeless person's connections with the health care system. The nurses' descriptions of "staying connected" demonstrate the barriers to facilitating health care and the breakdowns that occur while trying to facilitate care for homeless persons. The barriers include lack of health insurance, insensitivity of health care providers towards homeless persons, stigmatization, cultural barriers, and communication breakdowns. Homeless persons are socially, economically, and politically vulnerable in the American health care system. Nurses have a powerful influence, both macro- and micro-socially, in facilitation of care for this population.

Adult↗
PubMed1995

The test-retest reliability of standardized instruments among homeless persons with substance use disorders.

OBJECTIVE: Standardized instruments are widely used to assess homeless persons, but basic data on their reliability and validity in these populations have not been available. The purpose of this study was to examine the reliability of standardized instruments used in a cooperative agreement on homeless persons with substance use disorder. METHOD: This study examined the 1-week test-retest reliability of the Alcohol Dependence Scale, the Addiction Severity Index and the Personal History Form, using 189 randomly selected subjects participating in a multisite study of services for homeless persons with alcohol and other drug abuse problems. In addition to scales and items, factors hypothesized to influence reliability related so subject, interviewer and setting were examined. RESULTS: Results showed substantial reliability for scale scores (> .60) but mixed reliability for individual items. Reliability was greater when items were factual and based on a recent time interval, and when subjects were interviewed in a protected setting. Higher reliability was also related to younger age, female gender, a first episode of homelessness and lower severity of psychiatric problems. CONCLUSIONS: Reliability should be examined in individual studies of homeless persons, and efforts should be made to minimize controllable sources of unreliability.

Adult↗
PubMed1992

Prevention and control of tuberculosis among homeless persons. Recommendations of the Advisory Council for the Elimination of Tuberculosis.

Because tuberculosis (TB) is a major problem among homeless persons, the Advisory Council for the Elimination of Tuberculosis has developed recommendations to assist health-care providers, health departments, shelter operators and workers, social service agencies, and homeless persons prevent and control TB in this population. TB should be suspected in any homeless person with a fever and a productive cough of more than 1-3 weeks' duration, and appropriate diagnostic studies should be undertaken. Confirmed or suspected TB in a homeless person should be immediately reported to the health department so that a treatment plan can be decided upon and potentially exposed persons located and examined. Patients with TB should be counseled and voluntarily tested for human immunodeficiency virus (HIV) infection because TB treatment recommendations are different for HIV-seropositive and HIV-seronegative persons (1). TB therapy should be directly observed whenever possible. This may require the establishment of special shelters or other long-term-care arrangements for homeless persons with TB. For each person with an infectious case, an investigation should be conducted to identify exposed persons, and those found to be infected should be considered for preventive therapy. Shelter staff should receive a tuberculin skin test when they start work and every 6-12 months thereafter. Those with positive skin test results should be considered for preventive therapy according to current guidelines. Shelters for the homeless should be adequately ventilated. The installation of ultraviolet lamps also may be useful to further reduce the risk of TB transmission.

Adult↗
PubMed2005

From contact investigation to tuberculosis screening of drug addicts and homeless persons in Rotterdam.

BACKGROUND: In early 2001 there were indications that tuberculosis (TB) was increasingly becoming a problem among drug addicts and homeless persons in Rotterdam, after a periodical screening was discontinued in 1997. A contact investigation around a homeless drug addicted man in Rotterdam with infectious pulmonary TB is described. Contact investigation: A total of 507 drug addicts, homeless persons, and staff of facilities for these risk groups were examined with tuberculin skin testing (TST) and chest radiography. DNA fingerprinting of mycobacteriological cultures through Restricted Fragment Length Polymorphism methodology and molecular epidemiology investigation through cluster analysis were performed. OUTCOME: TST showed an infection prevalence of 29%, especially among staff of services for drug addicts and homeless persons. Six persons with active intrathoracic TB were identified. Cluster analysis demonstrated no relation with the initial case but showed intense transmission of TB among drug addicts and homeless persons in Rotterdam by multiple sources. As a consequence of the findings, a proposal to the Council of the City of Rotterdam resulted in the re-introduction of a comprehensive TB screening programme among these risk groups with mobile digital X-ray units (MXUs). CONCLUSION: This contact investigation gradually obtained the characteristics of a screening of drug addicts and homeless persons. Novel technologies, such as MXUs, facilitate appropriate and efficient outreach approaches to TB control among difficult-to-reach groups. This method and knowledge of individual fingerprints and clusters of TB patients are indispensable for underpinning proposals for change of local TB control strategies and convincing local authorities of the rationale.

Carrier State↗
PubMed1996

[Detection of tuberculosis in homeless persons and their sociopsychological characteristics].

Homeless patients with tuberculosis form a special group. Being out of therapeutical-and-prophylactic institutions sight and violating elementary sanitary regulations, they are, from an epidemic standpoint, the most dangerous part of a tuberculosis reservoir. Tuberculosis morbidity rates in the homeless are extremely high and tens times as great as those among other populations. The existing system for detecting tuberculosis among the homeless is not very effective. Much better results are achieved by nongovernmental philanthropic institutions where homeless persons apply to for medical and social aids. About half the homeless patients with tuberculosis were referred to Tuberculosis Hospital 11 of the International Organization "Physicians Without Boundaries". The patient's personality is, in general, the most vivid terms, characterized as asthenic; with low intelligence and constitution; asocial, aggressive, and being a carrier of the motive of acquired helplessness. This group of patients needs not only medical efforts, but sociolegal and sociopsychological rehabilitation. The activities of Tuberculosis Hospital 11 wherein a room of social aid and rehabilitation has been functioning since 1995 may be an example of a comprehensive approach to tackling the problem of homeless patients with tuberculosis.

Adult↗
PubMed2002

Psychotic ideation and receipt of government entitlements among homeless persons in New York City.

OBJECTIVE: This study compared changes in receipt of government entitlements by homeless persons with and without psychotic ideation in New York City between January 1997 and July 1998, a period characterized by changing state government policies and greater bureaucratic monitoring of eligibility. METHODS: In conjunction with an experimental study of the efficacy of social work services provided to homeless persons in Manhattan by a mobile medical van, 25 persons who were assessed as having experienced psychotic ideation in the previous year and 134 nonpsychotic persons were followed up after four months to identify changes in their receipt of Medicaid benefits, Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), food stamps, and home relief (state welfare for single persons). The social work intervention was designed to help eligible clients gain access to entitlements and substance abuse treatment. RESULTS: The proportion of clients with psychotic ideation who received Medicaid, food stamps, or home relief decreased during the study period, while the proportion of nonpsychotic clients who received these entitlements increased. Little change was observed in receipt of SSI or SSDI by either group. CONCLUSIONS: Psychotic ideation among homeless persons may be a significant factor in access to and maintenance of government entitlements. In the context of an increasingly restrictive and bureaucratic welfare system, providing assistance to homeless persons who have severe psychopathology presents new challenges to service providers.

Adult↗
PubMedDate not supplied

Homeless persons' decisions to accept or reject public health disease-detection services.

The purpose of this study was to describe the factors that homeless persons report as influencing their decisions to utilize or reject a public health disease-detection program. Although there is copious literature on homelessness, few studies report the real-life perspectives of homeless persons toward health or health promotion. A convenience sample of 55 sheltered and street-dwelling homeless persons, who either resided in or were visiting seven shelters in a large northeastern U.S. city, were interviewed. The interview questions focused on the bases for decisions to accept or reject tuberculosis screening. The in-depth semistructured audio-taped interviews were transcribed, coded, and categorized using Ethnograph software. Interviews were analyzed using the constant comparative content analysis methods. The findings describe homeless persons' reasons for accepting or rejecting a tuberculosis-detection service, the prominent role of shelter personnel in recruitment for health-related interventions, and the confidentiality needs of women with children. This information can assist community health practitioners in designing and advertising health-promotion and disease-detection programming.

Adult↗
PubMed1998

Overcoming service barriers for homeless persons with serious psychiatric disorders.

OBJECTIVE: To help homeless persons with comorbid psychiatric and substance use disorders gain access to community services, in 1993 the Center for Mental Health Services implemented the five-year Access to Community Care and Effective Services, or ACCESS program, in 15 cities. One aim of the program is to encourage collaboration between agencies serving the multiple needs of this population. This study examined the extent of linkages between agencies in the 15 demonstration cities. METHODS: One respondent from each of the 1,060 community-based programs in tie 15 cities rated the extent to which his or her agency was linked with each of the other agencies in the local community in 1994 and again in 1996. Overall, there were 20,801 potential pairwise linkages. Linkages were classified into four types: a mutual tie, in which both agencies send and receive clients; a unidirectional tie, in which one agency sends and the other receives; an attempted tie, in which one agency sends but the other agency does not confirm receiving; and an unattempted tie. RESULTS: In 1994 and 1996, of the 20,801 pairs of potential service linkages, about a third were in place, while the remaining two-thirds were absent. Overall, linkages showed a slight but significant increase between 1994 and 1996. More than half of the linkages changed in type, indicating fluid service systems. CONCLUSIONS: Linkages between community agencies serving homeless persons with comorbid psychiatric and substance use disorders are not extensive. However, they increased slightly under the first two years of the ACCESS program, and there are good reasons to anticipate greater improvements in the future.

Community Mental Health Services↗