Integrated cognitive behavioral treatment for substance use and depressive symptoms: a homeless case series and feasibility study.

BACKGROUND: Homelessness is associated with high prevalence of psychiatric disorders such as substance use disorders, including alcohol use disorder, and depression. METHODS: This case series and feasibility trial evaluated a novel integrated cognitive behavioral treatment (ICBT), which was adapted specifically for homeless individuals and developed to treat substance use and depressive symptoms simultaneously. The ICBT was delivered among four homeless individuals enrolled in the Treatment First program (a social services program where treatment is offered in conjunction with temporary transitional housing), who had access to stable and sober housing milieus. RESULTS: The ICBT was rated high in expectancy of improvement, credibility, and satisfaction, with few treatment-related adverse events, and fairly high treatment retention. At 12 months follow-up, three of four participants were not homeless anymore. Some participants experienced short-term reductions in substance use and/or depressive symptoms. CONCLUSIONS: The study provided preliminary support that the ICBT can be a feasible and potentially effective treatment for homeless individuals with substance use and/or depressive symptoms. However, the delivery format within the Treatment First program was not feasible. The ICBT could be offered within the social services Housing First program instead (where permanent housing is offered before treatment), or to non-homeless individuals. TRIAL REGISTRATION: The study was registered retrospectively at ClinicalTrials.gov (NCT05329181).

Factors Associated with Providers' Work Engagement and Burnout in Homeless Services: A Cross-national Study.

The complexity of homeless service users' characteristics and the contextual challenges faced by services can make the experience of working with people in homelessness stressful and can put providers' well-being at risk. In the current study, we investigated the association between service characteristics (i.e., the availability of training and supervision and the capability-fostering approach) and social service providers' work engagement and burnout. The study involved 497 social service providers working in homeless services in eight different European countries (62% women; mean age = 40.73, SD = 10.45) and was part of the Horizon 2020 European study "Homelessness as Unfairness (HOME_EU)." Using hierarchical linear modeling (HLM), findings showed that the availability of training and supervision were positively associated with providers' work engagement and negatively associated with burnout. However, results varied based on the perceived usefulness of the training and supervision provided within the service and the specific outcome considered. The most consistent finding was the association between the degree to which a service promotes users' capabilities and all the aspects of providers' well-being analyzed. Results are discussed in relation to their implications for how configuration of homeless services can promote social service providers' well-being and high-quality care.

Goals and Principles of Providers Working with People Experiencing Homelessness: A Comparison Between Housing First and Traditional Staircase Services in Eight European Countries.

The implementation and adaptation of the Housing First (HF) model represented profound changes the structure and delivery, goals, and principles of homeless services. These features of homeless services directly influence providers, their work performance and the clients' outcomes. The present research, conducted in eight European countries, investigated how social providers working in HF or TS (Traditional Staircase) describe and conceptualize the goals and the principles of their services. Data were collected through 29 focus group discussions involving 121 providers. The results showed that HF and TS had similar and different goals for their clients in the following areas: support, social integration, satisfaction of needs, housing, and well-being. HF providers emphasized clients' autonomy and ability to determine their personal goals, with housing being considered a start on the path of recovery, while TS were more focused on individual clients' basic needs with respect to food, health and finding temporary accommodations. HF providers privileged the person-centered approach and housing as a right, while TS providers were more focused on helping everyone. Implications of the results are discussed as suggestions both for practice and for research.

Facets of Male Violence Against Women With Substance Abuse Problems: Women With a Residence and Homeless Women.

The aims of this study were to investigate the type and extent to which women with substance abuse problems have been exposed to male violence during their lifetime, and to examine possible differences between women with a residence (WR) and homeless women (HW). The total sample included 79 women (WR, n = 35; HW, n = 44; M age = 47.8 years). Of the total sample, 72 women (91%) had experienced different kinds of male violence, 88% from former partners, and 26% from male friends or acquaintances. Of the 72 women, 71% further reported "Countless occasions of violent events," and 36% had been forced to commit criminal acts. Abused women who had been forced to commit criminal acts were significantly more frequently found to be homeless, have reported parental alcohol and/or drug problems, have witnessed domestic violence in childhood, have been victims of sexual violence, have used illicit drugs as a dominant preparation, and have injected illicit drugs. Almost half of the abused women (46%) met criteria for posttraumatic stress disorder (PTSD), where HW showed an almost 4-time higher risk (RR 3.78) than WR. In conclusion there is a particular vulnerability in women with substance abuse to male violence, which has an important impact on their health status. Thus, from a public health perspective, it is suggested that for those women who have experienced male violence, treatment protocols need to include both assessing and addressing the impact of such experience in relation to substance abuse as well as concomitant health concerns.

Are clear boundaries a prerequisite for well-functioning collaboration in home health care? A mixed methods study.

AIM: The aim of this study was to examine whether professional collaboration in home health care is associated with clear boundaries between principals' areas of responsibility and the professions areas of responsibility, respectively. METHODS: Data were derived from a web-based survey that was carried out in one county in the middle of Sweden during spring 2013. Participants were health professionals and managers from the county council and from all the municipalities in the county. Both structured and open-ended questions were utilised. A total of 421 individuals (90% women) answered the structured questions, and 91 individuals (22% of the 421) answered the open-ended questions. Quantitative data were analysed with descriptive statistics methods, tests of independence and of correlation strength. Qualitative data were analysed with content analysis. RESULTS: The results from the structured questions showed that well-functioning collaboration was associated with clear boundaries between principals in the county overall, and for respondents in two of three parts of the county. Association between clear boundaries between professions and well-functioning collaboration was found in the county overall among the municipality population. However, in one part of the county, we did not find any correlations between well-functioning collaboration and clear boundaries between professions or principals, with the exception of home help services. The analysis of the open questions gave similar results as the quantitative analysis, illustrated within three themes: The significance of concepts, trust and interdependence, and collaboration as a means for well-being. CONCLUSION: The results indicate that, recently after an organisational change, clear boundaries between the principals' areas of responsibility and professions' area of responsibility respectively are necessary for effective cooperation between professionals. If the organisation and professionals have previous positive experience of colocated activities, clear boundaries do not share the same importance.

Changes over time in the risk of hospitalization for physical diseases among homeless men and women in Stockholm: A comparison of two cohorts.

AIMS: To follow-up hospitalization for physical diseases among homeless men and women compared with a control group from the general population. The study also investigated the changes in the difference between the homeless men and women and the general population over time by comparing two cohorts of homeless people (2000-2002 and 1996). METHODS: A total of 3887 people (24% women) who were homeless during the period 2000-2002 were compared with 11,661 people from the general population with respect to hospitalization for physical diseases and injuries (2000-2010). Indirect comparisons were used to compare the relative risk (RR) of hospitalization between the cohort of people who were homeless in 2000-2002 with a cohort of those who were homeless in 1996. RESULTS: Homeless people have an RR of being hospitalized for physical diseases twice that of the general population. The largest differences were found in skin diseases, infections, injury/poisoning and diseases of the respiratory system. Indirect comparison between people who were homeless in 2000-2002 and 1996 showed an increasing difference between young (18-35 years) homeless men and men in the control group (RR 1.32). The difference had also increased between homeless men and men in the control group for hospitalization for heart disease (RR 1.35), chronic obstructive pulmonary disease (RR 2.60) and poisoning (RR 1.89). Among women, the difference had decreased between homeless women and women in the control group for skin disease (RR 0.20) and injury/poisoning (RR 0.60). There was no significant difference between the sexes in the two homeless cohorts. CONCLUSIONS: There was no improvement in excess hospitalization among homeless people over time. The difference between young homeless men and young men in the general population increased between 1996 and 2000-2002.

Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis.

BACKGROUND: 100 million people worldwide are homeless; rates of mortality and morbidity are high in this population. The contribution of infectious diseases to these adverse outcomes is uncertain. Accurate estimates of prevalence data are important for public policy and planning and development of clinical services tailored to homeless people. We aimed to establish the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people. METHODS: We searched PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature for studies of the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless populations. We also searched bibliographic indices, scanned reference lists, and corresponded with authors. We explored potential sources of heterogeneity in the estimates by metaregression analysis and calculated prevalence ratios to compare prevalence estimates for homeless people with those for the general population. FINDINGS: We identified 43 eligible surveys with a total population of 63,812 (59 736 homeless individuals when duplication due to overlapping samples was accounted for). Prevalences ranged from 0·2% to 7·7% for tuberculosis, 3·9% to 36·2% for hepatitis C virus infection, and 0·3% to 21·1% for HIV infection. We noted substantial heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus infection, and HIV infection (all Cochran's χ(2) significant at p<0·0001; I(2)=83%, 95% CI 76-89; 95%, 94-96; and 94%, 93-95; respectively). Prevalence ratios ranged from 34 to 452 for tuberculosis, 4 to 70 for hepatitis C virus infection, and 1 to 77 for HIV infection. Tuberculosis prevalence was higher in studies in which diagnosis was by chest radiography than in those which used other diagnostic methods and in countries with a higher general population prevalence than in those with a lower general prevalence. Prevalence of HIV infection was lower in newer studies than in older ones and was higher in the USA than in the rest of the world. INTERPRETATION: Heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus, and HIV suggests the need for local surveys to inform development of health services for homeless people. The role of targeted and population-based measures in the reduction of risks of infectious diseases, premature mortality, and other adverse outcomes needs further examination. Guidelines for screening and treatment of infectious diseases in homeless people might need to be reviewed. FUNDING: The Wellcome Trust.

Health-related quality of life (EQ-5D) among homeless persons compared to a general population sample in Stockholm County, 2006.

AIMS: To describe and compare health-related quality of life (HRQoL) among homeless persons with a general population sample in Stockholm County, 2006, and to analyse the importance of certain social determinants of health among the homeless. METHODS: Face-to-face interviews with 155 homeless persons and a postal survey to a general population sample, mainly based on the same questionnaire, including questions on social determinants of health and HRQoL measured with the EQ-5D. RESULTS: Chronic illness was three times more common among the homeless. HRQoL was worse among homeless persons than in the general population sample: the homeless reported more problems, especially more severe problems, in all the EQ-5D dimensions and had considerably lower EQ-5D(index) and EQ(VAS) score than the general population. Most problems were reported in the dimension anxiety/depression. Among the homeless, longer duration and more severe degree of homelessness lowered HRQoL, but few determinants were statistically significantly related to HRQoL. Having mental disease significantly lowered HRQoL. CONCLUSIONS: This study was an attempt to include hard-to-reach groups in an assessment of population health. Homeless persons had considerably worse HRQoL than the general population and reported most problems in the dimension anxiety/depression. Some diseases may contribute to causing homelessness; others may be seen as consequences. Homeless persons are a vulnerable group in society. Further interview studies are needed based on larger sample of homeless persons to explore health determinants such as sex, age, socioeconomic factors, duration and degree of homelessness, and health-related behaviours among the homeless persons.

Family psychosocial characteristics influencing criminal behaviour and mortality--possible mediating factors: a longitudinal study of male and female subjects in the Stockholm Birth Cohort.

BACKGROUND: Family psychosocial characteristics in childhood have been associated with children's development into criminal behaviour and mortality. This study explored these possible relationships and examined alcohol and/or drug use and mental problems as possible mediating factors, highlighting gender-specific patterns. METHODS: Data from Swedish subjects born in 1953 (n = 14,294) from the Stockholm Birth Cohort study were examined. Several indicators of adverse family factors and individual problems were included in the present study. The information was derived from various data sources, covering different periods. Gender-specific associations with incidence of criminality (1966-1980) and mortality (1981-2009) were analysed using logistic regression. Furthermore, the population attributable fraction (PAF) was calculated for all variables in the fully adjusted models which were positively related to the outcome. RESULTS: Overall incidence of criminality and mortality was (m/f 32.3/6.6) and (m/f 6.1/3.5), respectively. The results showed that all aspects of family psychosocial and individual problems studied were associated with criminality for both genders. Among males, individual problems seemed to partly mediate these relations, but the associations remained statistically significant. Interestingly, the PAF analysis revealed a reduction in criminality of 17.5% when individual problems with alcohol and/or drug use were considered. Among females, a significant impact of alcohol and/or drug use on the association between family psychosocial characteristics and subsequent criminality was obtained. Inclusion of father's occupational class only somewhat reduced the estimates for the genders. Concerning male mortality, father's alcohol abuse was significantly related to an increased risk. When individual criminality was accounted for, the association was substantially reduced but remained statistically significant. Among females, when adjusting for family psychosocial factors, only the association between parents' mental problems and females' mortality was significant. None of the individual problem variables managed to explain this association. CONCLUSIONS: Family psychosocial characteristics were associated with both subsequent criminal behaviour and mortality. These connections were partly explained by individual risk factors, especially by alcohol and/or drug use. The practical implications of the findings point to the importance of addressing the individual's alcohol and/or drug use in reducing criminal behaviour, which would also lower the mortality rates.

Mortality and causes of death among homeless women and men in Stockholm.

AIM: To study the mortality and causes of death among homeless men and women in relation to the risk indicators, previous treatment for alcohol and drug abuse, previous treatment for mental disorders and non-Swedish citizenship. METHODS: The mortality was studied in a cohort comprising 1,757 men and 526 women compared with the general population and persons with inpatient treatment for alcohol- and drug-related disorders. The follow-up period was from 1995 to 1997 until the end of 2005. The causes of death were analyzed. RESULTS: 421 deaths occurred during the follow-up period. The relative risk of death was 3.1, with no difference in mortality between homeless men and homeless women. Previous treatment for alcohol and drug abuse disorders was related to excess mortality and previous treatment for mental disease to lower mortality. Homeless people with inpatient treatment for alcohol or drug use disorders had no higher mortality than the general population in Stockholm with a similar history. There was a dominance of alcohol- and drug-related causes of death. DISCUSSION: Compared with previous studies of homeless people in Stockholm the excess mortality among men found in this study is of the same magnitude. Mortality among women is lower. The mortality rate in homeless people with previous treatment for an alcohol and illicit drug use disorder did not differ from those treated for these disorders in the general population. CONCLUSIONS: The most important finding is that excess mortality among homeless men and women in Stockholm is entirely related to alcohol and drug abuse.

Gender, hospitalization and mental disorders among homeless people compared with the general population in Stockholm.

BACKGROUND: The aim was to study the prevalence of mental disorders among homeless men and women admitted for inpatient treatment in hospitals. METHODS: Hospital care utilization of homeless people, 1364 men and 340 women, was compared with a control group consisting of 3750 men and 1250 women from the general population, 1996-2002. RESULTS: Homeless women ran a higher risk for mental disorders than women in the population [risk ratio (RR) 20.88]; their risk was also higher than the risk for homeless men (RR 1.20). Younger homeless women had the highest risk (RR 2.17). Alcohol use disorders were equally common among homeless men and women, but women had more drug use disorders (RR 1.32). Women had higher risk of schizophrenia (RR 2.79), and personality disorders (RR 2.73). When adjustment was made for substance use disorders, no increased risk for mental disorder was found in the homeless group. CONCLUSION: The elevated risk for mental disorders among the homeless was mainly related to substance use problems. Younger homeless women had the highest risk of mental disorder.

Physical diseases among homeless people: gender differences and comparisons with the general population.

AIM: To study morbidity amongst homeless men and women by comparing prevalence of hospital care for somatic diseases and injuries with a control group of men and women from the general population. METHODS: A cohort of 1,364 men and 340 women were documented as homeless in 1996. Comparisons are made concerning hospital care for somatic diseases and injuries (1996-2002) among 3,750 men and 1,250 women from the general population. RESULTS: The relative risk (RR) for homeless men and women of being hospitalised was double that of the men and women in the controls (1.93 and 1.96 respectively). Homeless women had a slightly, not significant, increased risk compared to homeless men (RR 1.10). Younger homeless women had a significant higher risk. Among diagnostic categories, the highest prevalence was found among homeless men in the diagnosis group injury/poisoning (22%). The highest risk was found for skin diseases (RR 36.96) and concerned homeless women. There were a number of gender specific diagnoses, where risks were considerably elevated, such as diseases of the genital organs, viral hepatitis, and poisoning for homeless women, and cerebrovascular diseases, diseases of the liver, and concussion for homeless men. CONCLUSIONS: Homeless people had twice the risk of being hospitalised for physical diseases compared to the general population. Younger women were particularly at risk compared to homeless men and to women in the controls. There were a number of gender specific diagnoses that are important to take into account when planning services for homeless people.

Oral health of homeless adults in Stockholm, Sweden.

The aim of the present study was to record and describe the oral condition of homeless adults in Stockholm, Sweden. There have been no clinical studies of the oral health of the homeless in Sweden since the 1970s. The study population comprised 147 homeless individuals (110 M, 37 F) in the age range 22-77 years. All underwent oral examination, including registration of periodontal status and caries data. The results show that homeless adults in Stockholm have fewer remaining teeth than the general population. Because conservative periodontal treatment is expensive and time-consuming, teeth with doubtful prognoses are usually extracted and only those with optimal periodontal health are retained. Another consequence of inadequate periodontal treatment, including insufficient oral hygiene instruction, is the high percentage of tooth surfaces with plaque accumulation. Heavy plaque accumulation will also have an effect on caries progression, expressed in this study as high DMFT values. Loss of teeth is likely to create dental and chewing problems, possibly resulting in increased dental and medical treatment needs.