Differences in Mental Health Between Female Sexual Minority and Heterosexual Youth with a Substance Use Disorder Who Are Experiencing Homelessness.

Purpose: The purpose of this study was to examine differences in mental health outcomes of two groups within youth experiencing homelessness (YEH) and who have a substance use disorder (SUD): sexual minority (SM) and heterosexual females. Methods: This study used baseline data from four randomized clinical trials of substance use interventions for YEH with a SUD to examine differences in depression and suicidality between SM and heterosexual female youth. Participants were between 12 and 24 years of age. Meta-analytic methods were used to aggregate data across studies to estimate differences in mental health. Results: Results indicated that female SM-YEH had higher depression symptoms (Hedge's g [g]=0.20; 95% confidence interval [CI] 0.01-0.39), higher risk of a history of suicide behavior (risk ratio = 1.63; 95% CI: 1.17-2.27), and a greater number of suicide behaviors (g = 0.31; 95% CI: 0.09-0.54) compared to their heterosexual peers. These effect sizes were not moderated by age. Conclusion: Female SM-YEH had elevated levels of depression and suicidality compared to their heterosexual peers. The findings of this study align with research on mental health disparities between SM and heterosexual youth generally, which underscores the unique struggles and risks associated with identifying as a female SM-YEH with a SUD.

"What is our actual impact?": A mixed-method assessment of a Belgian shelter for homeless men.

This paper presents an outcomes assessment carried out in an 84-bed long-term shelter for homeless men in Brussels. In the context of increasing Housing First studies, it investigates an instance of the traditional "treatment first" model and provides a new Belgian case study. Adopting a multidimensional approach, it aims to better understand what impact an average stay in a long-term shelter has on its residents. The assessment investigated several outcomes-income and housing, physical and mental health, life skills, social and assistance network-and relied on a participative mixed-method design. Although the shelter mission is broad and ambitious (i.e. autonomy, global well-being and reintegration into society), the assessment results show that the shelter struggles to have positive effects on the residents beyond the provision of basic care (a roof, food, administrative support) and that the stress felt by the residents even tends to increase during their stay. Several recommendations collectively emerged from the assessment: individualizing shelter support and making it evolve during the stay, reducing the size of the shelter while at the same time fostering community living, developing partnerships. At the public policy level, we would recommend revising the mission of long-term shelters in accordance with their means.

A community-academic partnership to develop an implementation support package for overdose prevention in permanent supportive housing.

INTRODUCTION: The overdose crisis in the U.S. disproportionately impacts people experiencing homelessness. Permanent supportive housing (PSH) - permanent, affordable housing with voluntary support services - is an effective, evidence-based intervention to address homelessness. However, overdose risk remains high even after entering PSH for individual and structural reasons. In this study, we aimed to refine a set of evidence-based overdose prevention practices (EBPs) and an associated implementation support package for PSH settings using focus groups with PSH tenants, frontline staff, and leaders. METHODS: Our community-academic team identified an initial set of overdose EBPs applicable for PSH through research, public health guidance, and a needs assessment. We adapted these practices based on feedback from focus groups with PSH leaders, staff, and tenants. Focus groups followed semi-structured interview guides developed using the EPIS (Exploration, Preparation, Implementation, Sustainment) framework constructs of inner context, outer context, and bridging factors related to overdose prevention and response. RESULTS: We conducted 16 focus groups with 40 unique participants (14 PSH tenants, 15 PSH staff, 11 PSH leaders); focus groups were held in two iterative rounds and individuals could participate in one or both rounds. Participants were diverse in gender, race, and ethnicity. Focus group participants were enthusiastic about the proposed EBPs and implementation strategies, while contributing unique insights and concrete suggestions to improve upon them. The implementation support package contains an iteratively refined PSH Overdose Prevention (POP) Toolkit with 20 EBPs surrounding overdose prevention and response, harm reduction, and support for substance use treatment and additional core implementation strategies including practice facilitation, tenant-staff champion teams, and learning collaboratives. CONCLUSIONS: This manuscript describes how robust community-academic partnerships and input from people with lived experience as tenants and staff in PSH informed adaptation of evidence-based overdose prevention approaches and implementation strategies to improve their fit for PSH settings. This effort can inform similar efforts nationally in other settings serving highly marginalized populations. We are currently conducting a randomized trial of the refined overdose prevention implementation support package in PSH.

Service Engagement Among People Experiencing Homelessness and Mental Disorders: A Call for Person-centred Innovations.

In recent years, there has been increased support for the use of coercive policies to address the seemingly intractable problem of homelessness among people with mental disorders in North America. Although these policy approaches respond to a critical issue, rising rates of unsheltered homelessness, low service engagement and concerns about disruptive behaviors in public settings, they are unlikely on their own to be successful. To avoid coercive practices, there is an urgent need to consider alternative, person-centred approaches to promote service engagement among people experiencing homelessness and mental disorders, with input from those with lived experience and frontline homeless service providers. Three person-centred approaches are proposed for consideration: (1) cross-sectoral service delivery models, (2) peer-led services, and (3) financial incentives. These approaches merit further study to support voluntary treatment engagement and exits from homelessness among people with mental and substance use disorders and safeguard the human rights of this population.

The Underuse of Clozapine and Long-Acting Injectable Antipsychotics.

Schizophrenia is among the most devastating and costly human diseases. The public face of the failure to appropriately treat schizophrenia includes approximately 100,000 homeless individuals with schizophrenia and related psychoses and 200,000 incarcerated individuals with similar diagnoses. Clozapine and long-acting injectable antipsychotics are among the most effective treatments, but both are markedly underused. The following organizations should take responsibility for fixing this problem: National Institute of Mental Health, Patient-Centered Outcomes Research Institute, Substance Abuse and Mental Health Services Administration, Centers for Medicare and Medicaid Services, U.S. Food and Drug Administration, American Psychiatric Association, and patient and family advocacy groups.

A mixed-methods study of VA video connect utilization among veterans with diabetes experiencing housing instability during the pandemic.

Introduction: Prior to the coronavirus disease-2019 (COVID-19) pandemic the U.S. Department of Veterans Affairs (VA) had the largest telehealth program in the United States. The pandemic motivated providers within the VA to expand telehealth in effort to reduce disrupted care while mitigating risks. The pandemic provides a rare opportunity to examine how to better engage veterans experiencing housing instability (HI) in telehealth diabetes care. Methods: Mixed methods design to examine VA video connect (VVC) diabetes care utilization among veterans experiencing HI from March 1, 2019, to March 1, 2022, combining multivariable regression analyses of VA administrative data with semi-structured interviews. Study aims included: (a) examine changes in diabetes care delivery mode over the peri-pandemic timeframe; (b) identify sociodemographic and clinical characteristics associated with VVC care among veterans with HI; and (c) understand the facilitators and barriers of VVC utilization. Results: Totally, 5904 veterans were eligible for study analysis. Veterans who are female (OR: 1.63; 95% CI: 1.3, 2.0; p < 0.0001), self-identify as Hispanic (OR: 1.44; 95% CI: 1.1, 1.9; p = 0.02), are married (OR: 1.39; 95% CI: 1.2, 1.6; p < 0.0001), and are in VA priority group 1 (OR: 1.21; 95% CI 1.1, 1.4; p = 0.004) were more likely to use VVC the pandemic. Veterans of older age (OR: 0.97; 95% CI: 0.97, 0.98; p < .0001) and rural dwelling (OR: 0.85; 95% CI: 0.7, 1.2; p = 0.04), were less likely to use VVC. Thirteen VA providers and 15 veterans were interviewed. Veterans reported that decisions about using VVC were driven by limitations in in-person care availability, safety, and convenience. Discussion: Telehealth played an important role in providing veterans with HI access to diabetes care during the pandemic. Future interventions should seek to increase education and technology in effort to increase VVC uptake into routine diabetes care to ensure veterans' optimal and equitable access.

Design of a Location-Based Case-Control Study of Built Environment Risk Factors for Pedestrian Fatalities in the U.S.

The location-based case-control design is a useful approach for studies where the exposures of interest are aspects of the environment around the location of a health event such as a pedestrian fatality. In this design locations are the unit of analysis and an enumerated cohort of locations are followed through time for the health events of interest and a case-control study of locations is nested within the cohort. Locations where events occurred (case-locations) are compared to matched locations where these events did not occur (control-locations). We describe the application of this design to the issue of pedestrian fatalities using a cohort of 9,612,698 intersections, 17,737,728 road segments, and 222,318 entrance/exit ramp segments that existed in 2017 across all 384 U.S. Metropolitan Statistical Areas. This cohort of locations was followed up from Jan 1, 2017 to Dec 31, 2018 for pedestrian fatalities using the National Highway Traffic Safety Administration Fatality Analysis Reporting System. In total, 10,587 fatalities were identified as having occurred on cohort locations and 21,174 matched control locations were selected using incidence density sampling. Geographic information systems, spatially linked administrative data sets and virtual neighborhood audits via Google Street View are underway to characterize study locations.

Examining Homeless-Experienced Adults' Smoking Cessation Treatment Use Pre- and Post-Entry into Permanent Supportive Housing.

Background: Homeless-experienced adults smoke at rates 5 times that of the general adult population, and often have limited access to cessation treatments while homeless. Permanent Supportive Housing (PSH) can be a catalyst for cessation treatment utilization, yet little is known about use of these treatments following PSH entry, or how to tailor and implement cessation care that meets homeless-experienced adults' vulnerabilities. Methods: Using Department of Veterans Affairs (VA) administrative data, we assessed smoking status (ie, current, former, non/never) among a cohort of homeless-experienced Veterans (HEVs) housed in Los Angeles-based PSH. We compared cessation treatment use rates (ie, nicotine replacement therapies, cessation medications, psychosocial counseling) pre- and post-housing using Chi-square tests. Predisposing (ie, demographics), enabling (eg, primary care, benefits), and need characteristics (ie, health, mental health, substance use diagnoses) were examined as correlates of cessation treatment utilization pre- and post-housing in univariable and multivariable logistic regression models. Results: Across HEVs (N = 2933), 48.6% were identified as currently-smoking, 17.7% as formerly-smoking, and 14.0% as non/never smoking. Among currently- and formerly-smoking HEVs (n = 1944), rates of cessation treatment use post-housing were significantly lower, compared to pre-housing, across all treatment types. Health, mental health, and substance use was more prevalent among currently- and formerly-smoking HEVs compared to non/never-smoking HEVs, and most diagnoses were positively associated with utilization univariably. However, in multivariable models, cessation clinic referrals and primary care engagement were the only significant (P < .001) predictors of pre-housing and post-housing cessation treatment utilization. Conclusion: Among HEVs, we found high smoking rates and low cessation treatment utilization pre- and post-PSH entry. Efforts to educate providers about this population's desire to quit smoking, support primary care engagement, and increase cessation clinic referrals may bolster their utilization. For homeless-experienced adults, optimizing cessation treatment accessibility by embedding cessation services within PSH and homeless service settings may reduce utilization impediments.

Comparison of Causes of Mortality Between Hospitalized Unsheltered Homeless Patients and Non-Homeless Sex and Age-Matched Controls: A Retrospective Case-Control Study.

Objectives: Roofless individuals represent the most severe category of homelessness. Their clinical characteristics and mortality patterns in Central and Eastern Europe are little known. Methods: A single-center retrospective case-control study at the internal medicine department in Bratislava, Slovakia was conducted. 5694 mortality records from 2010 to 2023 were screened, and 141 (118 men, 23 women) roofless individuals were identified. Patients were sex- and age-matched, with 141 patients from the cohort of non-homeless deceased patients. Results: Compared to controls, roofless people had a higher incidence of immobility (p = 0.02) and hypothermia (p < 0.0001) at admission. 83% of the roofless people were men, and 59% of the roofless people died before reaching old age (60+). Homeless men died more often from infectious disease (p = 0.02), pneumonia being the most common one (60%). Men from the control group died more often from liver diseases (p = 0.03). There were no significant differences in the causes of mortality between women. Conclusion: These findings could help to reduce the invisibility of the issue of massive premature mortality amongst homeless populations and roofless individuals, in particular.

"I drink less and that's no small matter": a qualitative descriptive study of a managed alcohol program evaluation in Barcelona.

Background: The concurrence of homelessness and alcohol use disorder (AUD) has negative consequences in affected individuals. Managed alcohol programs (MAPs), a harm reduction strategy based on providing regular doses of alcohol to individuals with AUD, have emerged as a potential solution to reduce alcohol-related harms.Objectives: This study examined the impact of a MAP implemented in Barcelona on patterns of alcohol and other psychoactive substance use, health, and quality of life among people who use drugs and were experiencing homelessness. The research also incorporated a gender perspective and focused on individuals who had accessed a residential center.Methods: A descriptive qualitative design was used, employing semi-structured interviews with eight participants who were enrolled in the MAP (three women, five men) and four program professionals. Thematic analysis was used to analyze the resulting data.Results: The domains guiding the study appeared as outcome themes: patterns of use of alcohol and other substances, health, quality of life and impact on female-identified participants. Participants reported improved health due to reduced consumption of alcohol and other substances, better anxiety management, and reconnection to health services. The participants reported enhanced quality of life, including feeling safer, and better use of time, which had been spent on meeting their basic needs. Women reported that a key benefit of the program was living in a sexism-free environment.Conclusion: These results appear to demonstrate that harm reduction strategies prioritizing basic needs and adopting a gender-sensitive perspective can positively impact the health and quality of life of people experiencing homelessness with AUD.

Pathways to social integration among homeless-experienced adults with serious mental illness: a qualitative perspective.

BACKGROUND: Social integration (i.e., reciprocal interactions with peers and community members) is a notable challenge for many homeless-experienced adults with serious mental illness (SMI). In this study, we examine a range of housing services offered to homeless-experienced adults with SMI and identify the impacts of supportive services on participants' social integration outcomes, with the goal of improving services in transitional and permanent housing settings for homeless-experienced adults with SMI. METHODS: Through semi-structured interviews with homeless-experienced adults with SMI (n = 30), we examine the impacts of housing and service settings on participants' social integration. Participants received services in a variety of housing settings, including transitional housing with congregate/shared living (n = 10), transitional housing with individual quarters (n = 10), and permanent supportive housing (n = 10). RESULTS: Participants expressed caution in developing social relationships, as these could pose barriers to recovery goals (e.g., substance use recovery). For many, social integration was secondary to mental and physical health and/or housing stability goals. Individual quarters gave individuals a place of respite and a sense of control regarding when and with whom they socialized. Meeting recovery goals was strongly related to connecting to and receiving a range of supportive services; interviews suggest that proximity to services was critical for engagement in these resources. CONCLUSIONS: Programs serving homeless experienced adults with SMI should seek to understand how individuals conceptualize social integration, and how social relationships can either support or hinder participants' recovery journey.

Health-related issues of people experiencing homelessness in Thailand: a scoping review.

Introduction: Homelessness is a significant global challenge affecting people worldwide. In Thailand, the health-related issues of people experiencing homelessness have not been a major research focus. This scoping review aims to explore the scope of research on health-related issues among people experiencing homelessness in Thailand. Methods: Eight databases (ACI, AMED, Embase, PsycINFO, PubMed, Scopus, TCI, and Web of Science) were searched from inception of each database to August 2022. The search terms consisted of terms related to people experiencing homelessness in Thailand. Research articles published in Thai or English were included. Results: Of 186 articles, 167 were excluded during duplicate removal (n = 45), title and abstract screening (n = 106), seeking for full-text articles (n = 2), and full-text screening (n = 14). Nineteen articles were included for extraction and synthesis. Three topics (health status, causes of homelessness and effects of homelessness on health, healthcare and social services) were summarised. The included studies described mental health (e.g., depression, suicide, alcohol and drug dependence), physical health (e.g., poor self-hygiene, injuries, accidents), and health behaviours (e.g., alcohol drinking, substance use, unsafe sex). Social behaviours and health problems linked to homelessness, and several factors related to health and living conditions (e.g., stigma, discrimination) were reported. People experiencing homelessness had some barriers to access to healthcare and social services (e.g., health insurance, social welfare, financial difficulties). Conclusions: The majority of studies on health-related issues in people experiencing homelessness in Thailand are descriptive studies. Future studies should focus on the interactions and mechanisms between homelessness and health.

Child Mental Health, Homelessness, and the Shelter System: Evidence from Medicaid in New York City.

We identified children who resided in the New York City shelter system during 2015-2020 by matching address histories in Medicaid insurance claims to publicly available homeless shelter addresses, permitting examination of health care use before, during, and after shelter stays. We found that 4.5% of NYC children aged 4-17 with consistent Medicaid coverage entered shelter over a three-to-five-year period. After shelter entry, children had increased probabilities of receiving mental health services, including therapy and diagnoses of neurodevelopmental disorders, but little change in physical health service use. Children placed in shelters co-located with mental health services were similar to children entering other shelters prior to entry but had particularly large and sustained increases in use of mental health services afterwards. Children without prior mental health claims placed in shelters co-located with mental health services were 38-48% more likely to receive mental health therapy and 14-16% more likely to receive neurodevelopmental diagnoses than similar children placed elsewhere. These children were also more likely to receive Supplemental Security Income and stayed in shelter longer. This example illustrates the potential of linking administrative data sets in order to study vulnerable populations.

Resiliency in Persons Experiencing Homelessness: A Concept Analysis Using the Evolutionary Framework.

INTRODUCTION: Homelessness is a critical societal issue, with those affected facing disproportionate chronic and acute health conditions. At the core of understanding their experiences is the concept of resiliency. Understanding resiliency in homelessness is crucial because it highlights the dynamic interplay between inherent qualities and external challenges, underscoring the need to reassess societal value judgements and inform nursing practices in research, education and advocacy. AIM: This paper aims to conduct a comprehensive concept analysis to propose a revised definition of resiliency in the context of homelessness. METHODS: Rogers's evolutionary method was the analytical tool of choice, perfect for examining the fluid and evolving nature of resiliency within the context of homelessness. The method entails analysing the concept's transformation over time and across disciplines, accepting variability in definitions based on the chronological and contextual constructs. DISCUSSION: The findings revealed that resiliency in homelessness is an inherent quality and a developed response shaped by the interplay of innate capacities and environmental challenges. It uncovered a need to reassess societal value judgements. Resiliency among people without housing suggests strengths that go unrecognised by conventional measures. CONCLUSION: The analysis concludes that resiliency is not a static trait but a dynamic process encompassing individual, social and environmental dimensions. In each case, nursing is poised to make a significant difference in nursing research, practice, education and advocacy, potentially inspiring new approaches and interventions. No public or private was used in the development of this article.

A stakeholder co-design approach to designing a dental service for adults experiencing homelessness.

Introduction: The homeless population faces a "cliff edge of inequality" when trying to access essential dental services. There are several additional barriers to accessing dental care in comparison to the general population and the heterogeneous nature of patients presents a significant challenge when designing dental services to meet their needs. Following the Smile4Life report in 2009, there is limited up-to-date and population-specific evidence available for the optimal model of service delivery. Aim: This study aimed to co-design principles for a prospective dental service for adults experiencing homelessness. Methods: A qualitative methodology was used to incorporate experts-by-experience into elements of co-designing a dental service for adults experiencing homelessness. The study combined elements of an experienced-based co-design framework for healthcare innovation with community-based participatory research. Focus groups with people experiencing homelessness and healthcare practitioners were conducted to identify principles for any prospective dental service, as well as several barriers and enablers to establishing a homeless dental service. The findings were transcribed and analysed using thematic analysis on Nvivo software. Results: From the qualitative analysis five key themes emerged: (1) Impact and expectations of oral health while experiencing homelessness, (2) Barriers to accessing dental care; (3) Practitioner's views about homelessness and access to care; (4) Barriers to designing a homeless service and (5) Enablers for co-designing a new model of dental care delivery for the homeless population.Five key principles for a new model of homeless dental service were identified: (i) Services designed to address the needs of patients; (ii) Services delivered in a safe and welcoming environment (iii) Training and consistency of staff; (iv) Focus on dental education (v) Developing peer mentoring and peer support. Conclusion: While the barriers to accessing dental care while homeless are well established and understood by healthcare practitioners, more work is required to gain consensus on the most effective way to deliver an innovative a sustainable dental service for patients experiencing homelessness. Previous negative experiences, lack of readily available information on services and barriers to access in the current system could be addressed by developing peer mentors within the homeless community, empowering individuals to share their knowledge and skills to support others in improving their oral health.

Increased proportions of invasive pneumococcal disease cases amongs adults experiencing homelessness sets stage for new serotype 4 capsular-switch recombinant.

BACKGROUND: The Centers for Disease Control and Prevention's Active Bacterial Core surveillance (ABCs) identified increased serotype 4 invasive pneumococcal disease (IPD), particularly among adults experiencing homelessness (AEH). METHODS: We quantified IPD cases during 2016-2022. Employing genomic-based characterization of IPD isolates, we identified serotype-switch variants. Recombinational analyses were used to identify the genetic donor and recipient strains that generated a serotype 4 progeny strain. We performed phylogenetic analyses of the serotype 4 progeny and serotype 12F genetic recipient to determine genetic distances. RESULTS: We identified 30 inter-related (0-21 nucleotide differences) IPD isolates recovered during 2022-2023, corresponding to a serotype 4 capsular-switch variant. This strain arose through a multi-fragment recombination event between serotype 4/ST10172 and serotype 12F/ST220 parental strains. Twenty-five of the 30 cases occurred within Oregon. Of 29 cases with known residence status, 16 occurred in AEH. Variant emergence coincided with a 2.6-fold increase (57 to 148) of cases caused by the serotype 4/ST10172 donor lineage in 2022 compared to 2019 and its first appearance in Oregon. Most serotypes showed sequential increases of AEH IPD/all IPD ratios during 2016-2022 (for all serotypes combined, 247/2198, 11.2% during 2022 compared to 405/5317, 7.6% for 2018-2019, p<0.001). Serotypes 4 and 12F each caused more IPD than any other serotypes in AEH during 2020-2022 (207 combined reported cases primarily in 4 western states accounting for 38% of IPD in AEH). CONCLUSION: Expansion and increased transmission of serotypes 4 and 12F among adults potentially led to recent genesis of an impactful hybrid "serotype-switch" variant.

Prevalence, risks and outcomes of frailty in People Experiencing Homelessness: a protocol for secondary analysis of Health Needs Audit data.

Frailty describes a health state related to ageing where people become less resilient to health challenges and more likely to have adverse outcomes if they become unwell. People experiencing homelessness (PEH) are known to have poor health, with research suggesting that many become frail at a younger age than the general population. Previous research using small-scale primary data collection suggests that the prevalence of frailty in homeless populations varies widely (16-55%), with variations in sample sizes and settings partially accounting for differences in current estimates. The prevalence, risks, and outcomes of frailty in PEH are poorly understood. We propose to carry out a secondary analysis of existing health survey data collected from 2,792 PEH. This will involve creating a Frailty Index (FI) to identify frail people within the dataset. Regression analyses will be used to identify associations between potential risk factors and outcomes of frailty in this population. This protocol will: 1) Outline the creation of a FI to assess the frailty prevalence within a dataset of health information collected from a cohort of PEH and 2) Describe proposed methods of regression analysis for identification of associations between frailty and risks factors/outcomes of frailty in the cohort of PEH within the dataset. The processes described in this paper can inform future development of FIs in other datasets. It is expected that the FI created will be an appropriate and robust method for identifying frailty in a cohort of PEH and results of the secondary data analysis will provide a more robust estimate of the associations between frailty and risk factors/outcomes.

Burn Care in the Street: A Survey of the Current Landscape of Burn Care Provided by Street Medicine Teams.

People experiencing homelessness are at increased risk for serious burn injuries and face additional barriers to care such as inability to perform wound care and difficulty with follow-up. Although not burn-specific, street medicine programs provide direct medical care to people experiencing unsheltered homelessness in their own environment and may be well positioned to bridge this gap in burn care for this population. We conducted a cross-sectional survey to characterize the burn care experience of street medicine teams with providing burn care for people experiencing homelessness. The 60 respondents included 18 (30%) physicians, 15 (25%) nurse practitioners or physician assistants, 15 (25%) registered nurses, and 6 (10%) medical students, and 6 (10%) other team members. The most common reported barriers to care were prior negative experiences with emergency departments, and transportation to burn centers. There was regional variability in frequency of providing burn care, which was reflected in respondent comfort with assessing and treating burns. Burns were most often dressed with daily dressings such as a non-adherent dressing over silver sulfadiazine or bacitracin. Silver-based contact dressings were rarely used. Street medicine teams in the United States are treating burn injuries among people experiencing homelessness, though management practices and experience treating burns was variable. As street medicine programs continue to grow, burn-related education, training, and connections to local burn centers for team members is important. Through strengthened partnerships between burn centers and street medicine teams, these programs may be well positioned to bridge the gap in burn care for people experiencing homelessness.

Homelessness and Type 2 Diabetes: A Qualitative Study of Facilitators and Barriers to Self-Management and Medication Adherence.

PURPOSE: In this study, we explore the barriers and facilitators to diabetes medication adherence and self-management for people with type 2 diabetes who have experienced homelessness. METHODS: We conducted five focus groups and two interviews with 26 participants. Our multi-disciplinary analysis team utilized principles of grounded theory and conducted thematic analysis with an inductive, iterative process to identify central themes. RESULTS: The majority of participants identified as Black/African American and over half stayed in shelters or had no steady place to stay at enrollment. Three key themes emerged regarding medication adherence and diabetes self-management for people who have experienced homelessness: personal autonomy and security, predictability and stability, and supportive, knowledgeable relationships (both social and medical). We define personal autonomy and security as individual agency and choice when making decisions related to one's health and well-being as well as protection from risk or harm to one's physical or psychological well-being, belongings, or means of income. Predictability and stability take place through the development of a system of connections and routines built over time where individuals can reliably adopt and maintain diabetes self-management activities. Supportive, knowledgeable relationships include medical and social relationships that offer encouragement, information, and hands-on care promoting diabetes self-management and connection to clinical care and resources. Participants also highlighted a "domino effect" where a cascade of events negatively and consequently impacted their health and well-being. We describe the interactions of these themes, the intersection of structural vulnerability and individual social risks, and resulting impacts on medication adherence and diabetes self-management. CONCLUSIONS: Our findings highlight the structural vulnerabilities impacting people experiencing homelessness and identify inflection points of opportunity at structural and individual levels to strengthen diabetes medication adherence and self-management. This understanding can inform policy change and future tailored diabetes interventions.

Financial incentives to increase engagement across the hepatitis C care cascade among people at risk of or diagnosed with hepatitis C: A systematic review.

BACKGROUND: Reversing declining rates of people initiating and completing hepatitis C (HCV) treatment, observed in many countries, is needed to achieve global HCV elimination goals. Providing financial incentives to increase HCV testing and treatment uptake among people at-risk of or living with HCV infection could be an effective intervention. We conducted a systematic review to assess evidence regarding the effectiveness of financial incentives to improve engagement and progression through the HCV care cascade. METHODS: We searched MEDLINE, PubMed and EMBASE for studies published from January 2013 to January 2023 that evaluated financial incentives offered to people living with and at-risk of HCV to increase HCV antibody and or RNA testing, linkage to care, treatment initiation, treatment adherence, treatment completion, and sustained viral load (SVR) testing. Open-label randomised controlled trials (RCTs), controlled non-randomised studies, cohort or observation studies and mixed-methods studies were included, whereas literature reviews, case series and studies which did not report data were excluded. RESULTS: We identified 1,278 studies, with 21 included after full-text screening (14,913 participants); three randomised controlled trials and 18 non-randomised studies. Studies evaluated incentives aimed at improving test uptake (n = 11), engagement in care (n = 13), treatment initiation (n = 8), adherence (n = 3), completion (n = 3) and attainment of SVR (n = 5). Findings provided inconclusive evidence for the effectiveness of incentives in improving engagement in the HCV cascade of care. Determining incentive effectiveness to improve care cascade engagement was limited by low quality study designs, heterogeneity in type (cash or voucher), value (US$5 to $600) and cascade stage being incentivised. No randomised controlled trials assessed the effectiveness of incentives to promote HCV testing, and none showed an impact on treatment uptake. In non-randomised studies (observational comparative), some evidence suggested that incentives promoted HCV testing, but evidence of their role in promoting linkage to care, HCV treatment adherence and treatment completion were mixed. CONCLUSION: Currently, there lacks high-quality evidence evaluating whether financial incentives improve HCV testing and treatment outcomes. Future research should seek to standardise methodologies, compare incentive types and values to enhance engagement in HCV care, and determine factors that support incentives effectiveness.