Epidemiological features of depression and anxiety among homeless adults with healthcare access problems in London, UK: descriptive cross-sectional analysis.

BACKGROUND: In England in 2021, an estimated 274 000 people were homeless on a given night. It has long been recognised that physical and mental health of people who are homeless is poorer than for people who are housed. There are few peer-reviewed studies to inform health and social care for depression or anxiety among homeless adults in this setting. AIMS: To measure the symptoms of depression and anxiety among adults who are homeless and who have difficulty accessing healthcare, and to describe distribution of symptoms across sociodemographic, social vulnerability and health-related characteristics. METHOD: We completed structured questionnaires with 311 adults who were homeless and who had difficulty accessing healthcare in London, UK, between August and December 2021. We measured anxiety and depression symptoms using the 4-item Patient Health Questionnaire (PHQ-4) score. We compared median PHQ-4 scores across strata of the sociodemographic, social vulnerability and health-related characteristics, and tested for associations using the Kruskal-Wallis test. RESULTS: The median PHQ-4 score was 8 out of 12, and 40.2% had scores suggesting high clinical need. Although PHQ-4 scores were consistently high across a range of socioeconomic, social vulnerability and health-related characteristics, they were positively associated with: young age; food insecurity; recent and historic abuse; joint, bone or muscle problems; and frequency of marijuana use. The most common (60%) barrier to accessing healthcare related to transportation. CONCLUSIONS: Adults who are homeless and have difficulty accessing healthcare have high levels of depression and anxiety symptoms. Our findings support consideration of population-level, multisectoral intervention.

The role of social support in the experience of life with ischemic heart disease for socially disadvantaged patients: A qualitative study.

OBJECTIVES: Ischemic heart disease (IHD) displays wide social inequalities that are often explained with reference to lifestyle factors. However, research indicates that social support may also play an important role in social inequality in IHD. This study aims to explore the role of social support in the experience of life with IHD for socially disadvantaged patients. METHODS: The study was conducted as a critical hermeneutic qualitative study in Denmark between October 2018 and August 2019. Data consist of in-depth qualitative interviews with 30 socially disadvantaged patients with IHD. RESULTS: The findings showed a notable difference between the participants who were engaged in close and supportive social relationships and those who were not. Life with IHD for those who lacked supportive relationships tended to be marked by feelings of chaos, powerlessness and meaninglessness. Contrarily, those who were engaged in supportive relationships received help to navigate their life with illness, reconcile with what had happened to them, feel empowered, and gain a sense of meaning in their life.Discussion: Social support from close social relationships appears to be crucial for socially disadvantaged ischemic heart patients, and should be encouraged and facilitated in healthcare and interventions targeting this patient group.

Artificial intelligence and medical education: A global mixed-methods study of medical students' perspectives.

Objective: Medical students, as clinicians and healthcare leaders of the future, are key stakeholders in the clinical roll-out of artificial intelligence-driven technologies. The authors aim to provide the first report on the state of artificial intelligence in medical education globally by exploring the perspectives of medical students. Methods: The authors carried out a mixed-methods study of focus groups and surveys with 128 medical students from 48 countries. The study explored knowledge around artificial intelligence as well as what students wished to learn about artificial intelligence and how they wished to learn this. A combined qualitative and quantitative analysis was used. Results: Support for incorporating teaching on artificial intelligence into core curricula was ubiquitous across the globe, but few students had received teaching on artificial intelligence. Students showed knowledge on the applications of artificial intelligence in clinical medicine as well as on artificial intelligence ethics. They were interested in learning about clinical applications, algorithm development, coding and algorithm appraisal. Hackathon-style projects and multidisciplinary education involving computer science students were suggested for incorporation into the curriculum. Conclusions: Medical students from all countries should be provided teaching on artificial intelligence as part of their curriculum to develop skills and knowledge around artificial intelligence to ensure a patient-centred digital future in medicine. This teaching should focus on the applications of artificial intelligence in clinical medicine. Students should also be given the opportunity to be involved in algorithm development. Students in low- and middle-income countries require the foundational technology as well as robust teaching on artificial intelligence to ensure that they can drive innovation in their healthcare settings.

'Progression capitals': How homeless health peer advocacy impacts peer advocates.

This article presents analysis from a qualitative evaluation of a homeless health peer advocacy (HHPA) service in London, United Kingdom. Whilst evidence is growing for the impact of peer programming on clients, understanding of the impact on peers themselves is limited in the context of homelessness. Research here is vital for supporting sustainable and effective programmes. Analysis of interview data with 14 current and former peer advocates, 2 members of staff and 3 external stakeholders suggests peer advocacy and its organizational setting can generate social, human, cultural and physical resources to help peer advocates fulfil their own life goals. We explore these with reference to 'recovery capital', reframed as 'progression capitals' to reflect its relevance for pursuits unrelated to clinical understandings of recovery. Progression capitals can be defined as resources to pursue individually determined goals relating to self-fulfilment. We find engagement with, and benefits from, a peer advocacy service is most feasible among individuals already possessing some 'progression capital'. We discuss the value of progression capitals for peers alongside the implications of the role being unsalaried within a neoliberal political economy, and comment on the value that the progression capitals framework offers for the development and assessment of peer interventions more broadly.

Peer advocacy and access to healthcare for people who are homeless in London, UK: a mixed method impact, economic and process evaluation protocol.

INTRODUCTION: People who are homeless experience higher morbidity and mortality than the general population. These outcomes are exacerbated by inequitable access to healthcare. Emerging evidence suggests a role for peer advocates-that is, trained volunteers with lived experience-to support people who are homeless to access healthcare. METHODS AND ANALYSIS: We plan to conduct a mixed methods evaluation to assess the effects (qualitative, cohort and economic studies); processes and contexts (qualitative study); fidelity; and acceptability and reach (process study) of Peer Advocacy on people who are homeless and on peers themselves in London, UK. People with lived experience of homelessness are partners in the design, execution, analysis and dissemination of the evaluation. ETHICS AND DISSEMINATION: Ethics approval for all study designs has been granted by the National Health Service London-Dulwich Research Ethics Committee (UK) and the London School of Hygiene and Tropical Medicine's Ethics Committee (UK). We plan to disseminate study progress and outputs via a website, conference presentations, community meetings and peer-reviewed journal articles.

The role of drug treatment and recovery services: an opportunity to address injection initiation assistance in Tijuana, Mexico.

BACKGROUND: In the U.S. and Canada, people who inject drugs' (PWID) enrollment in medication-assisted treatment (MAT) has been associated with a reduced likelihood that they will assist others in injection initiation events. We aimed to qualitatively explore PWID's experiences with MAT and other drug treatment and related recovery services in Tijuana Mexico, a resource-limited setting disproportionately impacted by injection drug use. METHODS: PReventing Injecting by Modifying Existing Responses (PRIMER) seeks to assess socio-structural factors associated with PWID provision of injection initiation assistance. This analysis drew on qualitative data from Proyecto El Cuete (ECIV), a Tijuana-based PRIMER-linked cohort study. In-depth qualitative interviews were conducted with a subset of study participants to further explore experiences with MAT and other drug treatment services. Qualitative thematic analyses examined experiences with these services, including MAT enrollment, and related experiences with injection initiation assistance provision. RESULTS: At PRIMER baseline, 607(81.1%) out of 748 participants reported recent daily IDU, 41(5.5%) reported recent injection initiation assistance, 92(12.3%) reported any recent drug treatment or recovery service access, and 21(2.8%) reported recent MAT enrollment (i.e., methadone). Qualitative analysis (n = 21; female = 8) revealed that, overall, abstinence-based recovery services did not meet participants' recovery goals, with substance use-related social connections in these contexts potentially shaping injection initiation assistance. Themes also highlighted individual-level (i.e., ambivalence and MAT-related stigma) and structural-level (i.e., cost and availability) barriers to MAT enrollment. CONCLUSION: Tijuana's abstinence-based drug treatment and recovery services were viewed as unable to meet participants' recovery-related goals, which could be limiting the potential benefits of these services. Drug treatment and recovery services, including MAT, need to be modified to improve accessibility and benefits, like preventing transitions into drug injecting, for PWID.

"Another Person Was Going to Do It": The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.-Mexico Border Region.

Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation.

"They accept me, because I was one of them": formative qualitative research supporting the feasibility of peer-led outreach for people who use drugs in Dakar, Senegal.

BACKGROUND: Peer outreach harm reduction initiatives are being developed with and for people who use drugs in Dakar, Senegal. This is in response to growing injecting drug use across the West Africa region and linked emerging epidemics of HIV and hepatitis C. We undertook formative qualitative research to explore the feasibility and potential of peer outreach in this context and in particular how outreach could be linked to fostering community-level processes of change. METHODS: We undertook a total of 44 semi-structured qualitative interviews. Thirty-four interviews were with people who used drugs (comprised of 25 participants who had injected at least once in their life) and included 11 peer educators who delivered "awareness-raising" harm reduction activities. We also interviewed 10 service providers involved in the planning and monitoring of peer outreach initiatives. We used thematic analysis to identify key characteristics of how peer-led outreach is being delivered, beneficiary need, and the nature of the social networks in which the awareness-raising activities operate. RESULTS: Through interviews with peer educators, people who use drugs, and service providers, four main overlapping themes are identified as follows: peer educators as a bridge to responsibilization through awareness-raising activities, awareness-raising activities as an enactment of recovery, awareness raising through social network diffusion, and the contexts and constraints of peer outreach engagement through awareness-raising activities. CONCLUSIONS: The study results suggest that peer education is on a trajectory to develop into a central role for harm reduction interventions in Dakar, Senegal. This research shows how peer education is bound in processes of responsibilization and self-change, which link to varying possibilities for risk reduction or recovery. For peer education to achieve a range of significant goals, broader structural and system changes should be implemented in the region. We caution that without such changes, awareness-raising activities and the role of peer educators may instead become part of state- and agency-sponsored processes of seeking to responsibilize individuals for health and harm reduction.