Prehospital Care for Persons Experiencing Homelessness: A Cross-Sectional Survey of the Challenges, Experiences, and Perspectives of Operational EMS Agency Medical Directors.

OBJECTIVE: Persons experiencing homelessness (PEH) are among the most vulnerable populations and experience significant health disparities. Nationally, PEH utilize Emergency Medical Services (EMS) at disproportionately higher rates than their housed peers. Developing optimal strategies to care for PEH has become critically important. However, limited data exists on best practices, challenges, and experiences of providing care to PEH. The objective of this study was to describe the experiences, challenges and perspectives of operational EMS agency medical directors in Los Angeles (LA) County as they confront the homelessness crisis. METHODS: We performed a cross-sectional survey of 9-1-1 operational EMS agency medical directors in LA County, which has one of the largest populations of PEH nationally. Twenty-nine 9-1-1 operational EMS agencies operate in LA County. The link to an anonymous, web-based survey examining documentation, training, resources, operational impact, and care challenges was emailed to medical directors with three reminders during the study period (4/19/2023-9/15/2023). RESULTS: Three quarters (75.9%; 22/29) of operational EMS agencies responded to the survey, with all questions answered in 69% (20/29) of surveys. Of these, 68.2% (15/22) of agencies document housing status and 75% (15/20) agreed or strongly agreed that homelessness presents operational challenges. No operational EMS agency reported adequate EMS clinician training on homelessness. Operational EMS agencies most commonly utilized domestic violence resources (43%, 9/21), social services (38%, 8/21), and law enforcement (38%, 8/21) services to assist PEH. Referrals were limited by accessibility (86%, 18/21), time (52%, 11/21), lack of awareness (52% 11/21) and lack of mandates (52%, 11/21). All operational EMS agencies agreed or strongly agreed that mental health and substance use disorders are major issues for PEH. The most common daily challenges reported were mental health (55%, 11/20), substance use (55%, 11/20), and patient resistance (35%, 7/20). CONCLUSION: In LA County, EMS agencies experience important operational and clinical challenges in caring for PEH, with limited resources, minimal training, and high rates of substance use disorders and mental health comorbidities. Further prehospital research is essential to standardize documentation of housing status, to identify areas for intervention, increase linkage to services, and define best practices.

Characterizing Multisystem Barriers to Women's Residential SUD Treatment: A Multisite Qualitative Analysis in Los Angeles.

Residential substance use disorder (SUD) treatment programs are challenged by the differing values of the problem-solving court (PSC) and child welfare (CW) systems, along with communication barriers between staff. This study aimed to understand, from the viewpoints of SUD treatment providers, how divergent values and communication barriers adversely affect women's residential SUD treatment. We conducted qualitative semistructured interviews with 18 SUD treatment clinicians and six directors from four women's residential SUD treatment programs. Using a thematic analysis framework, we identified salient themes across specified codes. Analysis revealed six main themes, suggesting differing values and communication barriers across the SUD, PSC, and CW systems adversely affect the provision of SUD treatment. For differing values, three main themes emerged: (a) unaddressed trauma and fear of mental health treatment seeking; (b) perceptions of mothers with a SUD; and (c) the Adoption and Safe Families Act (ASFA) timeline as a barrier to SUD treatment provision. For communication barriers, three themes emerged: (a) inadequate communication and responsiveness with PSC and CW systems adversely affect treatment coordination, induce patient stress, and treatment disengagement; (b) lack of PSC and CW communication regarding child visitation planning adversely affects treatment motivation and retention; and (c) competing ASFA, PSC, and CW priorities and inadequate cross-system communication adversely affect treatment planning. Treatment providers face significant barriers in providing effective treatment to women simultaneously involved in the CW and PSC systems. Aligning values and addressing communication barriers, changes in policy, and enhanced cross-system training are crucial. Additionally, it is essential to reevaluate the ASFA timeline to align with the long-term treatment needs of mothers with a SUD. Further research should explore the viewpoints of patients, CW, and PSC staff to gain deeper insights into these SUD treatment barriers.

Does Housing Status Matter in Emergency Medical Services Administration of Naloxone? A Prehospital Cross-sectional Study.

Introduction: Persons experiencing homelessness (PEH) use emergency medical services (EMS) at disproportionately high rates relative to housed individuals due to several factors including disparate access to healthcare. Limited access to care is compounded by higher rates of substance use in PEH. Despite growing attention to the opioid epidemic and housing crisis, differences in EMS naloxone administration by housing status has not been systematically examined. Our objective in this study was to describe EMS administration of naloxone by housing status in the City of Los Angeles. Methods: This was a 12-month retrospective, cross-sectional analysis of electronic patient care reports (ePCRs) for all 9-1-1 EMS incidents attended by the Los Angeles Fire Department (LAFD), the sole EMS provider agency for the City of Los Angeles during the study period, January-December 2018. During this time, the City had a population of 3,949,776 with an estimated 31,825 (0.8%) PEH. We included in the study individuals to whom LAFD personnel had administered naloxone. Housing status is a mandatory field on ePCRs. The primary study outcome was the incidence of EMS naloxone administration by housing status. We used descriptive statistics and logistic regression models to examine patterns by key covariates. Results: There were 345,190 EMS incidents during the study period. Naloxone was administered during 2,428 incidents. Of those incidents 608 (25%) involved PEH, and 1,820 (75%) involved housed individuals. Naloxone administration occurred at a rate of 19 per 1,000 PEH, roughly 44 times the rate of housed individuals. A logistic regression model showed that PEH remained 2.38 times more likely to receive naloxone than their housed counterparts, after adjusting for gender, age, and respiratory depression (odds ratio 2.38, 95% confidence interval 2.15-2.64). The most common provider impressions recorded by the EMS responders who administered naloxone were the same for both groups: overdose; altered level of consciousness; and cardiac arrest. Persons experiencing homelessness who received naloxone were more likely to be male (82% vs 67%) and younger (41.4 vs 46.2 years) than housed individuals. Conclusion: In the City of Los Angeles, PEH are more likely to receive EMS-administered naloxone than their housed peers even after adjusting for other factors. Future research is needed to understand outcomes and improve care pathways for patients confronting homelessness and opioid use.

Life Meaning in a Social Context Among Formerly Homeless Residents of Permanent Supportive Housing.

Objective: Experiencing a life of meaning is considered fundamental to "what makes life worth living," yet investigation of life meaning among persons with lived experiences of homelessness is lacking. This study seeks to understand life meaning among formerly homeless residents of permanent supportive housing through an examination of its association with social context. Method: Data were collected through interviews with 383 persons with experience of chronic homelessness who were provided permanent supportive housing (PSH). Recruitment of participants occurred through partnerships with 26 providers of PSH in Los Angeles County, California. Multivariate logistic regression models were employed to understand association of life meaning with hypothesized social contextual variables, controlling for demographic and background characteristics. Results: Community integration and sense of belonging were significantly and positively associated with life meaning, consistent with findings from previous research involving persons not identified as experiencing homelessness. Conclusions: Findings suggest opportunities for service providers to facilitate life meaning among residents of supportive housing. Specific attention to life meaning and its social context is consistent with the World Health Organization's position that well-being is a significant aspect of health.

Views on health activation and support services among formerly homeless adults living in Permanent Supportive Housing in the United States.

Individuals who have experienced chronic homelessness often have unmet physical and mental health needs and experiences of trauma and stigma. This study aimed to measure, for the first time, health activation (self-advocacy and empowerment) levels among formerly homeless adults living in Permanent Supportive Housing or PSH (referred to hereafter as residents). In addition, residents' experiences accessing health services, and their sense of health activation and efforts to manage their health within PSH settings, were explored. A mixed-methods study was conducted in Southern California (October 2018-June 2019) using a validated survey and interviews with a randomly selected group of residents (n = 61) from three PSH agencies. Activation levels were measured using the Patient Activation Measure. Descriptive and univariate survey analyses were conducted. Interview data was analysed using NVivo. Two coders coded all transcripts, and team meetings were held to reach consensus. Results showed most residents were female (64%), racial and ethnic minorities (66%), on average 54-year-olds, with 37 months of PSH residency, and 43% were taking some action to manage their health (intermediate activation level). Challenges accessing care were due to breakdowns in care, unpleasant experiences with providers, low health literacy and feeling overwhelmed by co-occurring chronic conditions. Health activation related to knowing when to take care of their health on their own and when to seek care. Unique challenges emerged related to PSH, such as lack of resident control within the housing setting and limited personnel responding to health emergencies. These challenges were magnified because residents live alone, per PSH requirements.

Distance Between Home and the Admitting Hospital and Its Effect on Survival of Low Socioeconomic Status Population With Staphylococcus aureus Bacteremia.

OBJECTIVE: Bacteremia is the presence of bacteria in the bloodstream. The objective of this study was to determine the relationship between low socioeconomic status (SES) and the epidemiology, process of care, and outcomes of patients with Staphylococcus aureus bacteremia (SAB). METHODS: We conducted a multicenter, retrospective, cohort study that evaluated adult patients with SAB in 3 Los Angeles County hospitals from July 15, 2012, through May 31, 2018. We determined SES (low SES, intermediate SES, and high SES) for each patient and compared sociodemographic and epidemiologic characteristics, management of care received by patients with SAB (ie, process of care), and outcomes. We used a Cox proportional hazards model to determine predictors of 30-day mortality for each SES group. RESULTS: Of 915 patients included in the sample, 369 (40%) were in the low-SES group, 294 (32%) in the intermediate-SES group, and 252 (28%) in the high-SES group. Most significant predictors of 30-day mortality in the Cox proportional hazards model were admission to an intensive care unit (hazard ratio [HR] = 9.04; 95% CI, 4.26-19.14), Pitt bacteremia score ≥4 indicating critical illness (HR = 4.30; 95% CI, 2.49-7.44), having ≥3 comorbidities (HR = 2.05; 95% CI, 1.09-3.85), and advanced age (HR = 1.03; 95% CI, 1.01-1.05). Distance between home and admitting hospital affected mortality only in the low-SES group (HR = 1.02; 95% CI, 1.00-1.02). CONCLUSIONS: SES did not independently affect the outcome of SAB; however, the farther the patient's residence from the hospital, the greater the negative effect on survival in a low-SES population. Our findings underscore the need to develop multipronged, targeted public health efforts for populations that have transportation barriers to health care.

Service utilisation changes in the transition to permanent supportive housing: The role of the housing environment and case management.

This study examines whether routine, low-cost service use changes in the transition from homelessness to permanent supportive housing (PSH) and explores whether housing model, neighbourhood and level of case management engagement affect utilisation of routine services. Data come from a prospective longitudinal study of adults experiencing homelessness who entered PSH in Los Angeles between 2014 and 2016 and participated in four interviews: pre-housing (i.e., while experiencing homelessness), and 3, 6 and 12 months after move-in. Mixed effects logistic regression assessed the effects of demographics, case management, housing model and neighbourhood location on service utilisation at each time point across five domains: basic needs, financial, educational, mental health and physical health. Longitudinal unmet need for services and onsite service use contextualised findings. Service utilisation significantly decreased at each time point in the domains of basic needs, financial and mental health. Neighbourhood was significantly associated with basic needs and mental health service use, while housing model was associated with financial service utilisation. Case management was associated with all service use outcomes with all relationships demonstrating more case management visits was associated with greater odds of routine service utilisation. Unmet service needs were consistent over time. Onsite service utilisation was low across all residents. Results indicate that routine service use declines with length of tenancy while unmet need for services remain prevalent. Case management appears to be critical in facilitating routine service use, while the housing environment should be considered to ensure residents have accessible and proximal routine care.

Social Network Change after Moving into Permanent Supportive Housing: Who Stays and Who Goes?

Social relationships are important among persons experiencing homelessness, but there is little research on changes in social networks among persons moving into permanent supportive housing (PSH). Using data collected as part of a longitudinal study of 405 adults (aged 39+) moving into PSH, this study describes network upheaval during this critical time of transition. Interviews conducted prior to and after three months of living in PSH assessed individual-level characteristics (demographics, homelessness history, health and mental health) and included a social network component that assessed network size and composition (demographics, relationship type, social support); interviewers utilized network member characteristics to assess whether network members were new or sustained between baseline and 3 months post-housing. Multilevel logistic regression models assessed what characteristics of network members were associated with being newly-gained or persisting in networks 3 months after moving into PSH. We found that only one-third of social networks were retained during the transition to PSH, and that veterans, African Americans and other persons of racial/ethnic minorities, and those living in scattered-site housing were more likely to experience network disruption. Relatives, romantic partners, and service providers were most likely to be retained after move-in. Some network change was moderated by tie strength, including the retention of street-met persons. Implications are discussed.

Construct, concurrent, and real-world predictive validity of the Difficulties in Emotion Regulation (DERS-18) among young adults with history of homelessness.

Skills in emotional regulation are vitally important for enabling homeless young adults to navigate the complex and chaotic settings associated with homelessness. The current study seeks to test the construct, concurrent, and predictive validity of the Difficulties in Emotional Regulation Scale (DERS-18) in a sample of formerly and currently homeless young adults. Data come from a study of HIV risk among young adults who have experienced homelessness, including both those currently experiencing homelessness (n = 99) and in permanent housing (n = 120), collected between 2017 and 2019 in Los Angeles, CA. Structural Equation Modeling was used to complete Confirmatory Factor Analysis and Path Models focused on the relationship between mental health symptomatology and emotional regulation. Linear regression models tested the link between affective intensity and instability and the DERS-18. Model fit indices pointed to the five-factor solution of the DERS-18, excluding the Awareness subscale. Clinical scores of anxiety, depression, and PTSD were found to have a significant, positive correlation with DERS. Both intensity and instability of negative affect were associated with greater difficulty in emotional regulation, while the increased intensity of positive affect was associated with increased skills in emotional regulation. This study addressed several gaps in both homelessness and emotional regulation literature. The DERS-18 was found to have construct, concurrent, and predictive validity in our sample. Future work should consider the use of the DERS-18 to assess skills in emotional regulation, understand outcomes, and better tailor interventions for young adults who have experienced homelessness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

DOES THE TIMING OF INCARCERATION IMPACT THE TIMING AND DURATION OF HOMELESSNESS? EVIDENCE FROM "THE TRANSITIONS TO HOUSING" STUDY.

Compared to their non-homeless peers, chronically homeless adults are much more likely to have a history of incarceration. In turn, homelessness is associated with increased morbidity, lack of access to adequate healthcare services, and decreased life expectancy. This study investigates whether age at first incarceration is associated with age at first homeless experience and with lifetime duration of literal homelessness. Study participants are homeless adults entering permanent supportive housing (PSH) in Los Angeles County, California, that have experienced incarceration prior to their first experience of homelessness (n=230). Multivariate linear regressions were conducted to determine association between age at first incarceration with: 1) age at first literal homelessness and 2) lifetime duration of literal homelessness. Results indicate that incarceration as a juvenile and young adult is significantly associated with earlier literal homelessness experiences and may be associated with longer durations of literal homelessness, for adults entering PSH. Moreover, women incarcerated as juveniles and entering PSH first experienced literal homelessness earlier than comparable men. Our findings suggest the need for long-term supportive services for persons incarcerated before 25 years old, especially for women. Moreover, these findings refine the working knowledge that prior incarceration increases risk for prolonged homelessness and can help agencies complete more accurate risk assessments.

Changes in Physical Assault Among Adults Moving Into Permanent Supportive Housing.

People experiencing homelessness experience high rates of physical assault. While this high risk for victimization is well established, there is no research that examines whether victimization rates change over time as persons transition into permanent supportive housing (PSH). Data are from a longitudinal study of adults moving into PSH in the Los Angeles, CA area. Interviews were conducted prior to or within 5 days of moving in, with follow-up interviews at 3, 6, and 12 months after move-in (n = 370 participants completing all four interviews). Each interview assessed characteristics of past 3-month physical assault. Analyses examined change in rates of assault over time and differences by demographic subgroups. We also present findings on the most common locations and perpetrators of assault. Overall, rates of physical assault decreased after participants entered PSH. Statistically significant differences by subgroups varied by time point. Differences identified include higher rates of physical assault among Latino/a respondents, lower rates among African Americans, and higher rates of physical assault among lesbian, gay, bisexual, and transgender (LGBT) respondents. The most frequent location of assault was outside at baseline, 3- and 6-month time points. Strangers were the most common perpetrator at all time points. Rates of perpetration by neighbors nearly doubled from baseline to the 12-month time point, and inside locations for assault were most common at this time point as well. While PSH is an effective intervention in reducing chronic homelessness, it is important to consider other risks to overall health and well-being, such as physical victimization.

Child Abuse Victimization, Depression, and Substance Use Among Homeless Women: Application of General Strain Theory.

The main purpose of this study was to investigate the association between child abuse and substance use among homeless women based on a framework of General Strain Theory, which emphasizes the strong relationship between deviant behaviors and personally experienced strain. In this study, as the strain associated with substance use, child abuse experience in the past was assessed. This research tested three hypotheses about (a) the association between physical and sexual abuse during childhood and substance use (heavy drinking, marijuana use, and crack cocaine use), (b) the mediating effect of depressive symptoms, and (c) the moderating effect of positive social supports on the relationship between abuse during childhood and substance use with a survey and interview data of a randomly selected sample of 445 homeless women in a temporary shelter setting in Los Angeles County between June 2007 and March 2008. Although the results indicated that abuse during childhood was not significantly associated with any form of substance use, the results of multivariate analyses indicated that depressive symptoms fully mediated the four relationships (p < .01; physical abuse and heavy drinking, physical abuse and crack cocaine use, sexual abuse and heavy drinking, and sexual abuse and crack cocaine use). The results of this study also indicated that positive social supports significantly moderate the effect of physical (p < .01) and sexual (p < .05) abuse experience on heavy drinking, which implies that positive social supports would be significant to reduce substance use among homeless women who had a history of physical and sexual abuse during childhood.

Exploring the Association of Community Integration in Mental Health among Formerly Homeless Individuals Living in Permanent Supportive Housing.

Supportive housing has been widely used among persons experiencing chronic homelessness and/or mental health conditions. While it has been demonstrated to be effective in addressing homelessness among populations with complex needs, community integration remains a challenge. Community integration is the extent to which individuals live, participate, and socialize in their community and consists of three aspects: physical, social, and psychological. The study utilized data from the Transitions to Housing project that followed formerly homeless individuals (N = 383) throughout their first year of residence in permanent supportive housing (PSH). The study set out to examine which aspects of community integration are associated with mental health symptoms in this population. Five nested multivariate linear regression models were conducted and then compared. The model that accounted for demographics, substance use, neighborhood quality, and all three aspects of community integration simultaneously was the best fit and explained the most variance in mental health symptoms (24%). The complete model suggested higher levels of psychological integration were significantly associated with decreased mental health symptoms in this sample. This finding suggests fostering a sense of belonging among PSH residents could improve mental health outcomes. Implications for practice and future research are discussed.

Risk behaviour and access to HIV/AIDS prevention services among formerly homeless young adults living in housing programmes.

Young adults who experience homelessness have high rates of sexually transmitted infections (STIs) including HIV. Homelessness services programmes that provide housing to young adults have the capacity to reduce STI risk profiles. This study analysed data from 140 formerly homeless adults who moved into a housing programme in Los Angeles County between the ages of 18 and 25 years to investigate risk behaviour and access to HIV/AIDS prevention services. More than three quarters of participants reported sexual activity (vaginal or anal sex) in the prior 3 months, with 63% reporting any unprotected vaginal or anal sex, 29% reporting unprotected sex with a nonserious partner, 40% reporting multiple partners, and 11% reporting exchange sex. About three quarters reported a past-year HIV test. About half of the sample had never heard of pre-exposure prophylaxis (PrEP), 12% had heard of it but didn't know what it was, 25% reported knowing a little bit, and 15% said they knew a lot about PrEP. Slightly more than 4% of the overall sample reported being HIV positive. These findings suggest that housing programmes may be a prime location to implement HIV prevention services.

Mental health change in the transition to permanent supportive housing: The role of housing and social networks.

AIMS: Permanent Supportive Housing (PSH) may improve homeless adults' mental health via housing stabilization and/or improved relational factors, however, the role of housing and social networks on PSH residents' mental health change is minimally understood. METHODS: Interviews were conducted with a baseline sample of adults experiencing homelessness ( N = 421), across their initial year in PSH (3-months, 6-months, and 12-months). Generalized linear mixed models assessed changes in positive past-month psychiatric disability screenings (Modified-Colorado Symptom Index [MCSI]) and probable posttraumatic stress disorder (PC-PTSD) in controlled models, and between and within-subject effects of time-varying social network correlates on mental health changes. RESULTS: Compared with baseline, positive MCSI screens continuously decreased over time (56%, 54%, and 50%) while PC-PTSD screens declined initially (40%) with marginal decreases at remaining follow-ups (39% and 38%). These differences remained significant in controlled models. Gaining a romantic partner was associated with a longitudinal increase in a positive MCSI screening. Between subjects, emotional health counselors and conflicting network members were associated with an increased likelihood in positive screenings, while doctors and case managers were protective. CONCLUSION: Housing may facilitate positive changes in PSH residents' mental health, yet positive screenings remain high. Social network interventions that increase residents' positive interpersonal exchanges and prosocial relationships are warranted.

Longitudinal effects of permanent supportive housing on insomnia for homeless adults.

OBJECTIVES: To examine the longitudinal change in insomnia as adults transition from homelessness to permanent supportive housing (PSH) and whether additional factors may moderate this relationship. METHODS: Standardized interviews were conducted with 331 homeless participants in Los Angeles prior to moving into PSH. Outcomes were measured 3, 6, and 12 months after move-in. Insomnia was assessed using the Sleep Condition Indicator, which is a 2-item validated short-form inventory that is intended to be used in clinical settings as a brief screening instrument for insomnia. Mixed-effects models were used to examine insomnia across all 4 measurement points and to test for interactions between time and covariates. RESULTS: Participants were on average approximately 55 years old and had spent an average of 5.6 years homeless in their lifetime, with approximately 70% identifying as male. Sixty-two percent of the sample screened positive for insomnia disorder at baseline. There was a significantly reduced likelihood of insomnia at each measurement period compared to baseline, but no differences were found between 3, 6, and 12 months. Mental health symptoms, physical health comorbidities, tobacco consumption, and female gender were associated with an increased likelihood of insomnia. CONCLUSION: Findings indicate a significant decrease in insomnia after moving into PSH, regardless of time spent homeless.

Changes in Self-Rated Physical Health After Moving Into Permanent Supportive Housing.

PURPOSE: Homelessness is associated with poor health outcomes and heightened risk of premature mortality. Permanent supportive housing (PSH) is a key solution for ending homelessness, but there is insufficient evidence of a relationship between PSH and improvements in physical health. Self-rated health-a consistent predictor of mortality-is a meaningful approach to understanding health improvements in PSH. DESIGN: Longitudinal, observational design with interviews at baseline, 3-months, 6-months, and 12-months (with 91% retention at 12-months). SETTING: Permanent supportive housing in Los Angeles, CA. SUBJECTS: Four hundred twenty-one adults moving into PSH (baseline interview prior to/within 5 days of housing). MEASURES: Three self-rated health assessments: general health status, and limitations to physical and social activity because of health problems. RESULTS: Generalized Estimating Equations (controlling for demographics and important health covariates; n = 420) found self-rated general health status improved between baseline and 3-months (coef: 0.13; 95% confidence interval [CI]: 0.02-0.24) and persisted at 12-months (coef: 0.16; 95% CI: 0.05-0.27). Improvements in limitations to physical or social activity because of health problems started at 6-months posthousing (physical: coef: 0.25; 95% CI: 0.12-0.39; social: coef: 0.18; 95% CI: 0.05-0.32) and persisted through 12-months (physical: coef: 0.14; 95% CI: 0.01-0.27; social: coef: 0.16; 95% CI: 0.02-0.29). CONCLUSIONS: Despite limitations associated with observational study design, these findings provide further evidence that PSH may improve health among those with homelessness histories.

The Role of Mental Health and Substance Use in Homeless Adults' Tobacco Use and Cessation Attempts.

Objective: Although tobacco use is prevalent among adults experiencing homelessness, research deficits exist regarding the mental health, substance use, and demographic correlates of tobacco use behaviors in this population. This study examined whether correlates of tobacco use among housed adults identified by the Center for Disease Control (CDC) were significant correlates of tobacco use and cessation attempts among a sample of homeless adults. Methods: Participants (N = 421) were adults experiencing homelessness entering permanent supportive housing programs in Los Angeles. Multivariate logistic regression determined associations of lifetime mental health diagnoses, recent substance use, demographic characteristics, and lifetime literal homelessness with daily tobacco use and cessation attempts. Results: Lifetime diagnoses of schizophrenia, posttraumatic stress disorder, depression, bipolar disorder, and illicit substance use were associated with increased odds of daily tobacco use. A lifetime diagnosis of depression was associated with an increased likelihood of a past 3-month tobacco cessation attempt, while illicit substance use was associated with a lower likelihood of a cessation attempt. Conclusions: Findings suggest that demographic and clinical characteristics associated with tobacco use differ among this sample of homeless adults and those identified by the CDC among housed adults. Mental health conditions and substance use appear to be the primary correlates of tobacco use among adults experiencing homelessness and may be critical in efforts aimed at improving cessation.

A text messaging-based intervention to increase physical activity among persons living in permanent supportive housing: Feasibility and acceptability findings from a pilot study.

OBJECTIVE: Persons who have experienced homelessness and are living in permanent supportive housing experience high rates of health and mental health problems. Given that physical activity is associated with improved health outcomes and persons with homelessness histories report high rates of cell phone use, phone-based interventions to increase physical activity may be effective for improving health and wellbeing among persons in permanent supportive housing. METHODS: To understand the acceptability and feasibility of a cell phone-based physical activity intervention in this population, this 6-week pilot study enrolled 13 persons living in permanent supportive housing. Participants were eligible if they had completed their final, 12-month follow-up interview in a larger, longitudinal study of persons moving into permanent supportive housing in the Los Angeles area, spoke English, and reported comorbid chronic physical and mental health conditions. For the study duration, participants wore a pedometer, received multiple weekly motivational text messages on set days (at times selected by the participant), and responded via text to weekly depression screeners and requests to report their weekly step totals, as recorded by their pedometers. Follow-up interviews asked open-ended questions about study participation and satisfaction. RESULTS: Participants were 53 years old on average, most were female (54%), and most were African-American (62%). Changes to people's physical activity levels were limited, but participants reported increased quality of life during the intervention period. Interviews revealed that the intervention was well received and enjoyable for participants. CONCLUSIONS: The efficacy of utilizing cell phones to improve health and wellbeing among adults living in permanent supportive housing requires further research, but these pilot findings suggest that such interventions are feasible and acceptable.