Improving Traumatic Stress with Justice-Impacted Women and Women Experiencing Homelessness: A Pilot Study of Narrative Exposure Therapy.

OBJECTIVE: We sought to investigate the feasibility, acceptability, and impact of a brief, manualized trauma-focused intervention aimed at improving PTSD symptoms in persons with complex PTSD, Narrative Exposure Therapy (NET). DESIGN: Using a mixed methods approach, we tested the feasibility, acceptability, and impact of NET in a sample of trauma-affected women in traumatogenic circumstances: justice-impacted women in prison and women experiencing homelessness in a shelter. We quantitatively assessed data using a single sample, pre-/post-intervention design. We qualitatively assessed self-described symptom change and opportunities for intervention adaptation using a content analysis approach. METHODS: Sixteen trauma-affected participants completed the intervention protocol. NET interventionists included one nurse practitioner, one registered nurse, and one nursing student. All NET participants attended pre-/post-intervention visits and active NET sessions. In-depth interviews were conducted at pre- and post-intervention, alongside a diagnostic battery. RESULTS: NET was both highly feasible and acceptable among participants. Participants significantly improved on the intervention-specific outcome of PTSD symptoms, as well as somatic symptom burden, with large effect sizes. Participants also improved on subjective self-described symptom change. Participants offered recommendations regarding opportunities to enhance population-specific intervention acceptability. CONCLUSIONS: Results from this pilot study are consistent with previous evidence demonstrating that NET facilitates improvements in women with traumatic stress. Findings of high feasibility, acceptability, and impact supports the use of NET in JW and WEH. Integrating participant recommendations to optimize acceptability may further support scalability and reach of NET. Replication with a larger sample and within a randomized controlled design is required to definitively determine effectiveness.

Mortality by Age, Gender, and Race and Ethnicity in People Experiencing Homelessness in Boston, Massachusetts.

Importance: People experiencing homelessness (PEH) face disproportionately high mortality rates compared with the general population, but few studies have examined mortality in this population by age, gender, and race and ethnicity. Objective: To evaluate all-cause and cause-specific mortality in a large cohort of PEH by age, gender, and race and ethnicity. Design, Setting, and Participants: An observational cohort study was conducted from January 1, 2003, to December 31, 2018. All analyses were performed between March 16, 2021, and May 12, 2022. A cohort of adults (age ≥18 years) seen at the Boston Health Care for the Homeless Program (BHCHP), a large federally funded Health Care for the Homeless organization in Boston, Massachusetts, from January 1, 2003, to December 31, 2017, was linked to Massachusetts death occurrence files spanning January 1, 2003, to December 31, 2018. Main Outcomes and Measures: Age-, gender-, and race and ethnicity-stratified all-cause and cause-specific mortality rates were examined and compared with rates in the urban Northeast US population using mortality rate ratios (RRs). Results: Among the 60 092 adults included in the cohort with a median follow-up of 8.6 (IQR, 5.1-12.5) years, 7130 deaths occurred. The mean (SD) age at death was 53.7 (13.1) years; 77.5% of decedents were men, 21.0% Black, 10.0% Hispanic/Latinx, and 61.5% White. The all-cause mortality rate was 1639.7 deaths per 100 000 person-years among men and 830 deaths per 100 000 person-years among women. The all-cause mortality rate was highest among White men aged 65 to 79 years (4245.4 deaths per 100 000 person-years). Drug overdose was a leading cause of death across age, gender, and race and ethnicity groups, while suicide uniquely affected young PEH and HIV infection and homicide uniquely affected Black and Hispanic/Latinx PEH. Conclusions and Relevance: In this large cohort study of PEH, all-cause and cause-specific mortality varied by age, gender, and race and ethnicity. Tailored interventions focusing on those at elevated risk for certain causes of death are essential for reducing mortality disparities across homeless-experienced groups.

Biopsychosocial Model of Traumatic Stress Symptoms in Women Experiencing Homelessness: A Qualitative Descriptive Study.

Trauma is nearly ubiquitous among women experiencing homelessness (WEH). WEH develop post-traumatic stress disorder (PTSD) at rates far exceeding the general population. The consequences of untreated PTSD can cascade, exacerbating existing physical, mental, and social health inequities, placing this population at risk for disproportionate biopsychosocial health adversity. Despite the outsized impact of PTSD, WEH are less likely to access or receive appropriate trauma-focused services. Understanding the unique and intersecting factors that contribute to the disproportionate PTSD toll on WEH may elucidate risk and protective factors, as well as possible intervention pathways to address the disparate trauma burden. This study employed a qualitative descriptive approach to develop understanding of the determinants of trauma risk, exposure, and outcomes among WEH. Semi-structured interviews were completed with 10 WEH, six shelter staff, four mental health professionals. Six deductively biopsychosocial model-derived themes were identified, alongside supporting categories. Themes/categories highlighted the role of biological, psychological, and socio-environmental determinants in shaping risk for and actualization of traumatic events and adverse outcomes. Trauma played an outsized role in shaping the health of WEH participants in this study, and the need for and interest in tailored trauma screening, treatment, psychoeducation options was highlighted. Recursive relationships between biopsychosocial determinants and trauma impact were identified. Participants emphasized population tailored trauma-focused interventions, specifically brief co-designed and community partner implemented interventions that address substance use behaviors, while leveraging the strengths of WEH. Addressing the marked trauma burden in WEH shows promise in promoting measurable biopsychosocial health improvements in this resilient yet overlooked population.

Mortality Trends Among Adults Experiencing Homelessness in Boston, Massachusetts From 2003 to 2018.

This cohort study involves assessing causes of death among people experiencing homelessness in Boston from 2003 to 2018.

Regional Differences in Added Sweetener Knowledge, Consumption and Body Mass Index in People with HIV in the United States.

This analysis of U.S.-based survey data reports regional differences (Northeast, Midwest, South, and West) in sweetener knowledge, consumption, and body mass index (BMI) among 877 people with HIV (PLWH; median age 54 years). BMI was lowest in the West and highest in the Midwest. Respondents in the West reported greater sweetener knowledge than in the Northeast, Midwest, and South. Respondents from the West reported lower sweetener consumption than the Midwest and South. Regional differences in BMI, sweetener knowledge, and consumption were demonstrated. Findings support consideration of regional differences when providing nutrition education.

RESUMEN: Ese analisis de los datos de la encuesta con sede en los Estados Unidos informa las diferencias regionales (noreset, medio oeste, sur, y oeste) en el conocimiento de los edulcorantes, el consumo, y el índice de masa coporal (IMC) entre 877 personas con VIH (PVVS; mediana de edad de 54 anos). El IMC fue más bajo en el oeste y más alto en el medio oeste. Los encuestados en el oeste informaron un mayor conocimiento de edulcorantes que el noreste, el medio oeste, y el sur. Los encuestados del oeste informaron un menor consumo de edulcorantes que el medio oeste y el sur. Se demostraron diferencias regionales en el IMC, el conocimiento de edulcorantes, y el consumo. Los hallazgos apoyan la consideración de las diferencias regionales al proporcionar educación nutritional.

Exploring Opportunities to Optimize Stress and Trauma-Focused Primary Care with Low-Income Midlife and Older Women.

Trauma and trauma-related symptoms often remain hidden in the lives of low-income midlife and older women. In primary care encounters, midlife and older women are infrequently asked about trauma histories, and symptoms of trauma are commonly misinterpreted. As stress and trauma raise risk morbidity and mortality, under-recognition of trauma is a health equity issue. This secondary qualitative analysis explores stress and trauma as factors that affect primary/preventive care engagement in low-income midlife and older women. Semi-structured interviews were completed with 22 low-income midlife and older women from December 2020-January 2021. A deductive-inductive content analysis approach was guided by the Behavioral Model for Vulnerable Populations. Three categories were identified: (1) stress and competing demands; (2) history and impact of trauma; (3) integrated trauma-related behavioral health focus. Co-designing and culturally adapting stress and trauma screening and interventions may optimize stress and trauma-focused primary care while promoting health equity with socially marginalized women.

Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018.

Importance: Despite high rates of drug overdose death among people experiencing homelessness, patterns in drug overdose mortality, including the types of drugs implicated in overdose deaths, remain understudied in this population. Objective: To describe the patterns in drug overdose mortality among a large cohort of people experiencing homelessness in Boston vs the general adult population of Massachusetts and to evaluate the types of drugs implicated in overdose deaths over a continuous 16-year period of observation. Design, Setting, and Participants: This cohort study analyzed adults aged 18 years or older who received care at Boston Health Care for the Homeless Program (BHCHP) between January 1, 2003, and December 31, 2017. Individuals were followed up from the date of their initial BHCHP encounter during the study period until the date of death or December 31, 2018. Data were analyzed from December 1, 2020, to June 6, 2021. Main Outcomes and Measures: Drug overdose deaths and the types of drugs involved in each overdose death were ascertained by linking the BHCHP cohort to the Massachusetts Department of Public Health death records. Results: In this cohort of 60 092 adults experiencing homelessness (mean [SD] age at entry, 40.4 [13.1] years; 38 084 men [63.4%]), 7130 individuals died by the end of the study period. A total of 1727 individuals (24.2%) died of a drug overdose. Of the drug overdose decedents, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%) individuals, and the mean (SD) age at death was 43.7 (10.8) years. The age- and sex-standardized drug overdose mortality rate in the BHCHP cohort was 278.9 (95% CI, 266.1-292.3) deaths per 100 000 person-years, which was 12 times higher than the Massachusetts adult population. Opioids were involved in 91.0% of all drug overdose deaths. Between 2013 and 2018, the synthetic opioid mortality rate increased from 21.6 to 327.0 deaths per 100 000 person-years. Between 2004 and 2018, the opioid-only overdose mortality rate decreased from 117.2 to 102.4 deaths per 100 000 person-years, whereas the opioid-involved polysubstance mortality rate increased from 44.0 to 237.8 deaths per 100 000 person-years. Among opioid-involved polysubstance overdose deaths, cocaine-plus-opioid was the most common substance combination implicated throughout the study period, with Black individuals having the highest proportion of cocaine-plus-opioid involvement in death (0.72 vs 0.62 in Latinx and 0.53 in White individuals; P < .001). Conclusions and Relevance: In this cohort study of people experiencing homelessness, drug overdose accounted for 1 in 4 deaths, with synthetic opioid and polysubstance involvement becoming predominant contributors to mortality in recent years. These findings emphasize the importance of increasing access to evidence-based opioid overdose prevention strategies and opioid use disorder treatment among people experiencing homelessness, while highlighting the need to address both intentional and unintentional polysubstance use in this population.

The Association of Distinct Social Determinants of Health with Added Sweetener Knowledge and Consumption in a U.S. Sample of People Living with HIV.

Prior studies in people living with HIV (PLWH) suggest added sweetener intake exceeds recommendations and associates with cardiometabolic abnormalities. Little is known of factors that associate with increased sweetener consumption in PLWH. This cross-sectional study explored knowledge and consumption of added sweeteners and associations of social determinants of health (SDoH) among 900 PLWH residing in the United States. Demographics, SDoH, and added sweetener knowledge and consumption were assessed via an online survey, multivariable analyses were completed. Results demonstrate that sex, race, and low educational level associated with lower sweetener knowledge. Race, age, body mass index, income, limited access to fresh fruits/vegetables, and low sweetener knowledge associated with higher sweetener consumption. Findings highlight the need for consideration of specific demographics and inequitable social circumstances when developing nutrition lifestyle strategies, inclusive of added sweetener education, that are feasible and sustainable across diverse community settings of PLWH.

RESUMEN: Estudios previos en personas que viven con el VIH (PLWH) sugieren que la ingesta adicional de edulcorantes excede las recomendaciones y se asocia con anomalías cardiometabólicas. Poco se sabe de los factores que se asocian con un mayor consumo de edulcorantes en PLWH. Este estudio transversal exploró el conocimiento y el consumo de edulcorantes agregados y las asociaciones de los determinantes sociales de la salud (SDoH) entre 900 PLWH que residen en los Estado Unidos. Lo datos demográficos, SDoH, y en conocimiento y el consumo de edulcorantes añadidos se evaluaron mediante una encuesta en línea y se completaron análisis multivariables. Los resultados demuestran que el sexo, la raza y el bajo nivel educativo se asocian con un menor conocimiento sobre edulcorantes. Raza, edad, índice de masa corporal, ingresos, acceso limitado a frutas/verduras frescas y conocimiento bajo sobre edulcorantes asociado con un mayor consumo edulcorantes. Los hallazgos resaltan la necesidad de considerar la demografía específica y las circunstancias sociales desiguales al desarrollar estrategias de estilo de vida nutricional, incluida la educación adicional sobre edulcorantes, que sean factibles y sostenibles en diversos entornos comunitarios de PLWH.

Barriers, facilitators, and opportunities to optimize care engagement in a diverse sample of older low-income women: A qualitative study.

The growing population of aging women in the United States is disproportionately at-risk for adverse physical, behavioral, mental, and psychosocial health conditions. Engagement with preventive care is critical to address these risk factors. A qualitative descriptive approach was used to explore patterns of healthcare use, facilitators, barriers, and opportunities to optimize primary/preventive care engagement among low-income midlife and older women. Themes were deductively derived from the Behavioral Model for Vulnerable Populations. Categories were inductively determined: barriers to care engagement; facilitators of care engagement; opportunities to optimize primary/preventive care engagement. Themes emerging from this study suggest that experiences related to discrimination, psychological health, trauma, and prioritizing care of others negatively influence care engagement; while respect, continuity, and clinician gender and racial/ethnic concordance enhance care participation. Efforts aiming to engage low-income aging women in care should focus on addressing barriers, building on facilitators, and leveraging contemporary telehealth-outreach solutions.

Physical and Behavioral Health Characteristics of Aging Homeless Women in the United States: An Integrative Review.

Background: The average age of the homeless population is and will continue to rise. Although women comprise a significant and growing percentage of this vulnerable population, their age- and sex-specific health characteristics are poorly understood. Materials and Methods: This integrative review appraises published research addressing the physical and behavioral health characteristics of aging homeless women (≥50 years) in the United States (2000-2019). The authors searched six electronic databases to identify eligible studies. Studies were screened for methodological quality by using the Johns Hopkins Nursing Evidence-Based Practice model. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Results: Ten primary studies met the review eligibility criteria. All were level III (non-experimental); nine appraised as "good" quality (level B), and one as "lower" quality (level C). Aging homeless women demonstrate elevated rates of physical health conditions, related to suboptimal nutrition, lower than expected preventive health screening uptake, and geriatric concerns. Disproportionate rates of mental health conditions are compounded by substance use and interpersonal trauma. Familial and social dynamics and socioeconomic disadvantage contribute to social health concerns. Spiritual health is a critically important yet underexplored protective factor. Conclusions: Studies are limited, though collective findings suggest that aging homeless women endure a disproportionate physical, behavioral, and social health burden compared with aging non-homeless women and aging homeless men. Implications for research on early aging, preventative health strategies, and homelessness among women, and clinical practice in the context of geriatric and women's health are described.

Supporting Primary Care Access and Use among Homeless Persons.

With the implementation of the Affordable Care Act (ACA), many homeless persons who previously lacked health insurance gained medical coverage. This paper describes the experiences of homeless persons in accessing and using primary care services, post-implementation of the ACA. Twenty-six semi-structured interviews were completed with homeless persons and primary care providers/staff. Via thematic analysis, themes were identified, categorized by: factors which influence primary care access and use patterns, and strategies to promote consistent primary care use. Maintaining insurance and leveraging systems-based strategies to support primary care access and use may address health disparities and promote health equity.

Behavioral and psychological health inequities in income disparate perimenopausal women: a brief report.

OBJECTIVE: To assess differences in behavioral and psychological health characteristics in perimenopausal women delineated by income disparity. METHODS: A hypothesis generating secondary data analysis was conducted in 33 women, using public health insurance enrollment as a proxy for income. Sociodemographic characteristics were assessed. Study outcomes included behavioral health characteristics: current cigarette smoking, substance abuse history, current exercise, obesity (BMI ≥30); psychological health characteristics, and sleep: depressed mood (Center for Epidemiologic Studies Depression Scale [CES-D]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and sleep (Insomnia Severity Index [ISI]). Group comparisons were assessed via the Student t test, Wilcoxon Rank-Sum test or Chi-square test, and multivariable models. RESULTS: Forty-two percent (n = 14) were designated as income disparate, and sociodemographic characteristics were similar between groups; nearly half were Black/African American. More income disparate women reported current cigarette smoking [71% (10) vs 21%(4), P = 0.004] and substance abuse history [79%(11) vs 5%(1), P < 0.0001]. Fewer income disparate women reported current exercise [57%(8) vs 89%(17), P = 0.03] and more were obese [BMI ≥30; 50%(7) vs 11%(2), P = 0.01]. Income disparate women experienced significantly higher CES-D scores [13.5 (11.75, 23.75) vs 6 (0, 9), P < 0.0001], GAD-7 scores [5.5 (2, 8.75) vs 2 (0, 4), P = 0.04], and ISI scores [11 (5.55) vs 5 (4.36), P = 0.004]. CONCLUSIONS: Findings from this preliminary analysis evidence inequities in behavioral, psychological, and sleep characteristics in perimenopausal women. Awareness of how the social determinants of health impact outcomes among vulnerable perimenopausal women is critical to developing equitable aging opportunities, including customized preventive health screenings and interventions that engage income disparate perimenopausal women.

Video Summary:http://links.lww.com/MENO/A642.

A review of reviews: Sedentary behaviour and cardiovascular disease specific to older people.

BACKGROUND: The incidence of sedentary behaviour and cardiovascular disease impacts the health of older people, potentially leading to serious and negative health consequences. AIM: The purpose of this umbrella review was to identify the systematic reviews that explore the association between sedentary behaviour and cardiovascular disease specific to older people. METHODS: An umbrella review was undertaken to systematically search five databases. Papers included were published between 2011 and 2015. RESULTS: A search yielded 2,163 results. Six reviews met the inclusion criteria. While all six systematic reviews included older people in the overall sample, only one systematic review focused on an entirely older person population. Three of the six systematic reviews provided a meta-analysis, but none of the reviews reported a separate subgroup analysis for a discrete sample of older people CONCLUSION: This umbrella review demonstrates that while sedentary behaviour is associated with cardiovascular disease, a gap exists in the analysis on the relationship specific to older persons. IMPLICATIONS FOR PRACTICE: Interventions aimed at reducing sedentary behaviour may improve cardiovascular health and well-being among older people.