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1.
J Health Care Poor Underserved ; 31(1): 441-454, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32037341

RESUMO

We assessed the ability of high-risk criteria developed by Boston Health Care for the Homeless Program to identify increased mortality during a 10-year cohort study (January 2000-December 2009) of 445 unsheltered adults. To qualify as high-risk for mortality, an individual slept unsheltered for six consecutive months or longer plus had one or more of the following characteristics: tri-morbidity, defined as co-occurring medical, psychiatric, and addiction diagnoses; one or more inpatient or respite admissions; three or more emergency department visits; 60 years old or older; HIV/AIDS; cirrhosis; renal failure; frostbite, hypothermia, or immersion foot. A total of 119 (26.7%) individuals met the high-risk criteria. The remaining 326 individuals in the cohort were considered lowerrisk. During the study, 134 deaths occurred; 52 (38.8%) were among high-risk individuals. Compared with sheltered individuals, the age-standardized mortality ratio for the high-risk group was 4.0 (95% confidence interval 3.0, 5.2) times higher and for the lower-risk group was 2.2 (1.8, 2.8) times higher. The hazard ratio, a measure of survival, for the high-risk group was 1.7 (1.2, 2.4) times that of the lower-risk group. High-risk criteria predicted an increased likelihood of mortality among unsheltered individuals. The lower-risk group also had high mortality rates compared with sheltered individuals.

2.
Artigo em Inglês | MEDLINE | ID: mdl-31795464

RESUMO

The objective of this study was to examine longitudinal associations between perceived quality of living spaces and mental and physical health-related quality of life (HRQoL) among homeless and vulnerably housed individuals living in three Canadian cities. The Health and Housing in Transition (HHiT) study was a prospective cohort study conducted between 2009 and 2013 of N = 1190 individuals who were homeless and vulnerably housed at baseline. Perceived quality of living spaces (based on rated comfort, safety, spaciousness, privacy, friendliness and overall quality) and both mental and physical HRQoL were assessed at baseline and at four annual follow up points. Generalized estimating equation (GEE) analyses were used to examine associations between perceived quality of living spaces and both mental and physical HRQoL over the four-year study period, controlling for time-varying housing status, health and socio-demographic variables. The results showed that higher perceived quality of living spaces was positively associated with mental (b = 0.42; 95% CI 0.38-0.47) and physical (b = 0.11; 95% CI 0.07-0.15) HRQoL over the four-year study period. Findings indicate that policies aimed at increasing HRQoL in this population should prioritize improving their experienced quality of living spaces.

3.
BMJ Open ; 9(10): e030221, 2019 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-31594882

RESUMO

OBJECTIVES: To validate case ascertainment algorithms for identifying individuals experiencing homelessness in health administrative databases between 2007 and 2014; and to estimate homelessness prevalence trends in Ontario, Canada, between 2007 and 2016. DESIGN: A population-based retrospective validation study. SETTING: Ontario, Canada, from 2007 to 2014 (validation) and 2007 to 2016 (estimation). PARTICIPANTS: Our reference standard was the known housing status of a longitudinal cohort of housed (n=137 200) and homeless or vulnerably housed (n=686) individuals. Two reference standard definitions of homelessness were adopted: the housing episode and the annual housing experience (any homelessness within a calendar year). MAIN OUTCOME MEASURES: Sensitivity, specificity, positive and negative predictive values and positive likelihood ratios of 30 case ascertainment algorithms for detecting homelessness using up to eight health service databases. RESULTS: Sensitivity estimates ranged from 10.8% to 28.9% (housing episode definition) and 18.5% to 35.6% (annual housing experience definition). Specificities exceeded 99% and positive likelihood ratios were high using both definitions. The most optimal algorithm estimates that 59 974 (95% CI 55 231 to 65 208) Ontarians (0.53% of the adult population) experienced homelessness in 2016, a 67.3% increase from 2007. CONCLUSIONS: In Ontario, case ascertainment algorithms for identifying homelessness had low sensitivity but very high specificity and positive likelihood ratio. The use of health administrative databases may offer opportunities to track individuals experiencing homelessness over time and inform efforts to improve housing and health status in this vulnerable population.

4.
Lancet Psychiatry ; 6(11): 915-925, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31601530

RESUMO

BACKGROUND: Housing First is increasingly implemented for homeless adults with mental illness in large urban centres, but little is known about its long-term effectiveness. The At Home/Chez Soi randomised controlled trial done in five cities in Canada showed that Housing First improved housing stability and other select health outcomes. We extended the At Home/Chez Soi trial at the Toronto site to evaluate the long-term effects of the Housing First intervention on housing and health outcomes of homeless adults with mental illness over 6 years. METHODS: The At Home/Chez Soi Toronto study was a randomised, controlled trial done in Toronto (ON, Canada). Here, we present the results of an extension study done at the same site. Participants were homeless adults (aged ≥18 years) with a serious mental disorder with or without co-occurring substance use disorder. In phase 1, participants were stratified by level of need for mental health support services (high vs moderate), and randomly assigned (1:1) using adaptive randomisation procedures to Housing First with assertive community treatment (HF-ACT), Housing First with intensive case management (HF-ICM), or to treatment as usual (TAU). Participants with moderate support needs were further stratified by ethnoracial status. Considering the nature of the Housing First intervention, study participants and study personnel were not masked to group assignment. Phase 1 participants could choose to enrol in the extension study (phase 2). The primary outcome was the rate of days stably housed per year analysed in the modified intention-to-treat population, which included all randomly assigned participants who had at least one assessment for the primary outcome. Participants contributed data to the study up to the point of their last interview. Multilevel multiple imputation was used to handle missing data. The trial was registered with ISRCTN, ISRCTN42520374. FINDINGS: Between Oct 1, 2009, and March 31, 2013, 575 individuals participated in phase 1 of the Toronto Site At Home/Chez Soi study (197 [34%] participants with high support needs and 378 [66%] with moderate support needs). Of the 378 participants with moderate support needs, 204 were randomly assigned to receive the HF intervention with ICM or with ethnoracial-specific ICM services (HF-ER-ICM; HF-ICM or HF-ER-ICM groups) and 174 were randomly assigned to TAU. Of the 197 participants with high support needs, 97 were randomly assigned to receive the HF intervention with ACT (HF-ACT treatment group) and 100 were randomly assigned to TAU group. Between Jan 1, 2014, and March 31, 2017, 414 (81%) of 575 phase 1 participants participated in the extended phase 2 study. The median duration of follow-up was 5·4 years (IQR 2·1-5·9). Among phase 2 participants, 141 had high support needs (79 participants in the HF-ACT group; 62 participants in the TAU group), and 273 had moderate support needs (160 participants in the HF-ICM or HF-ER-ICM group; 113 participants in the TAU group). 187 high support needs participants (93 participants in the HF-ACT group, 94 participants in the TAU group), and 361 moderate support needs participants (201 participants in the HF-ICM or HF-ER-ICM group, 160 participants in the TAU group) were included in the modified intention-to-treat analysis for the primary outcome. The number of days spent stably housed was significantly higher among participants in the HF-ACT and HR-ICM or HF-ER-ICM groups than participants in the TAU groups at all timepoints. For participants with moderate support needs, the rate ratio (RR) of days stably housed in the Housing First group, compared with TAU, was 2·40 (95% CI 2·03-2·83) in year 1, which decreased to 1·13 (1·01-1·26) in year 6. The RR of days stably housed for participants with high support needs, compared with TAU, was 3·02 (2·43-3·75) in year 1 and 1·42 (1·19-1·69) in year 6. In year 6, high support needs participants in the Housing First group spent 85·51% of days stably housed compared with 60·33% for the TAU group, and moderate needs participants in the Housing First group spent 88·16% of days stably housed compared with 78·22% for the TAU group. INTERPRETATION: Rent supplements and mental health support services had an enduring positive effect on housing stability for homeless adults with mental illness in a large, resource-rich urban centre, with a larger impact on individuals with high support needs than moderate support needs. FUNDING: Mental Health Commission of Canada, Ontario Ministry of Health and Long-Term Care, and the Canadian Institute of Health Research.


Assuntos
Serviços Comunitários de Saúde Mental/métodos , Pessoas em Situação de Rua/psicologia , Pessoas em Situação de Rua/estatística & dados numéricos , Transtornos Mentais/terapia , Avaliação de Programas e Projetos de Saúde/métodos , Habitação Popular/estatística & dados numéricos , Adulto , Feminino , Seguimentos , Humanos , Masculino , Transtornos Mentais/psicologia , Ontário , Tempo , População Urbana/estatística & dados numéricos
5.
JAMA Intern Med ; 2019 Oct 07.
Artigo em Inglês | MEDLINE | ID: mdl-31589276

RESUMO

Importance: Nonadherence to treatment with medicines is common globally, even for life-saving treatments. Cost is one important barrier to access, and only some jurisdictions provide medicines at no charge to patients. Objective: To determine whether providing essential medicines at no charge to outpatients who reported not being able to afford medicines improves adherence. Design, Setting, and Participants: A multicenter, unblinded, parallel, 2-group, superiority, outcomes assessor-blinded, individually randomized clinical trial conducted at 9 primary care sites in Ontario, Canada, enrolled 786 patients between June 1, 2016, and April 28, 2017, who reported cost-related nonadherence. Follow-up occurred at 12 months. The primary analysis was performed using an intention-to-treat principle. Interventions: Patients were randomly allocated to receive free medicines on a list of essential medicines in addition to otherwise usual care (n = 395) or usual medicine access and usual care (n = 391). Main Outcomes and Measures: The primary outcome was adherence to treatment with all medicines that were appropriately prescribed for 1 year. Secondary outcomes were hemoglobin A1c level, blood pressure, and low-density lipoprotein cholesterol levels 1 year after randomization in participants taking corresponding medicines. Results: Among the 786 participants analyzed (439 women and 347 men; mean [SD] age, 51.7 [14.3] years), 764 completed the trial. Adherence to treatment with all medicines was higher in those randomized to receive free distribution (151 of 395 [38.2%]) compared with usual access (104 of 391 [26.6%]; difference, 11.6%; 95% CI, 4.9%-18.4%). Control of type 1 and 2 diabetes was not significantly improved by free distribution (hemoglobin A1c, -0.38%; 95% CI, -0.76% to 0.00%), systolic blood pressure was reduced (-7.2 mm Hg; 95% CI, -11.7 to -2.8 mm Hg), and low-density lipoprotein cholesterol levels were not affected (-2.3 mg/dL; 95% CI, -14.7 to 10.0 mg/dL). Conclusions and Relevance: The distribution of essential medicines at no charge for 1 year increased adherence to treatment with medicines and improved some, but not other, disease-specific surrogate health outcomes. These findings could help inform changes to medicine access policies such as publicly funding essential medicines. Trial Registration: ClinicalTrials.gov identifier: NCT02744963.

6.
Artigo em Inglês | MEDLINE | ID: mdl-31491874

RESUMO

Hypothermia is a preventable condition that disproportionately affects individuals who experience homelessness, yet limited data exist to inform the response to cold weather. To fill this gap, we examined the association between meteorological conditions and the risk of hypothermia among homeless individuals. Hypothermic events were identified from emergency department charts and coroner's records between 2004 and 2015 in Toronto, Canada. A time-stratified case-crossover design with conditional logistic regression was used to assess the relationship between the meteorological conditions (minimum temperature and precipitation) and the risk of hypothermia. There were 97 hypothermic events identified: 79 injuries and 18 deaths. The odds of experiencing a hypothermic event increased 1.64-fold (95% CI: 1.30-2.07) with every 5 °C decrease in the minimum daily temperature and 1.10-fold (95% CI: 1.03-1.17) with every 1 mm increase in precipitation. The risk of hypothermia among individuals experiencing homelessness increased with declining temperature; however, most cases occurred during periods of low and moderate cold stress. 72% occurred when the minimum daily temperatures were warmer than -15 °C. These findings highlight the importance of providing a seasonal cold weather response to prevent hypothermia, complemented by an alert-based response on extremely cold days.

7.
Am J Health Syst Pharm ; 76(17): 1288-1295, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31418791

RESUMO

PURPOSE: Results of a study to elucidate perceptions, attitudes, and beliefs about prescribed medications held by hospitalized patients who are homeless are reported. METHODS: A qualitative descriptive study involving semistructured interviews was conducted to gather information and characterize hospitalized homeless patients' views and attitudes regarding medication use, with a focus on medication nonadherence. Medication nonadherence has been shown to be a factor contributing to higher rates of emergency department visits, increased hospital lengths of stay, and increased healthcare costs in homeless populations. Interviews were conducted during patients' admissions to the internal medicine service of a tertiary care, inner-city hospital. Interviews were audio-recorded and transcribed. Data were analyzed using conventional qualitative content analysis to generate data-driven codes and themes. RESULTS: Twelve interviews were conducted (median patient age, 48.5 years). Eight patients (66.7%) were living in a shelter, and 11 (91.7%) had a mental illness. Patients were prescribed a median of 4 medications at the time of hospital admission. Four themes were identified: (1) a new appreciation of medications was acquired during hospitalization, (2) medications were perceived as necessary for maintaining health, (3) there was an interest in receiving medication education, and (4) concerns were expressed regarding medication adverse effects. CONCLUSION: In interviews conducted during hospital admission, homeless patients expressed positive perceptions about the necessity of their medications but also concerns about medication adverse effects. Interventions to improve adherence may be successful if directed toward addressing treatment-related concerns.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Pessoas em Situação de Rua/psicologia , Hospitalização , Adesão à Medicação/estatística & dados numéricos , Adulto , Idoso , Feminino , Humanos , Entrevistas como Assunto , Masculino , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Percepção , Medicamentos sob Prescrição/administração & dosagem , Medicamentos sob Prescrição/efeitos adversos
8.
BMC Health Serv Res ; 19(1): 482, 2019 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-31300051

RESUMO

BACKGROUND: Health utility assessments are important for economic evaluations but few instruments have been validated in homeless people with mental illness. We examined the convergent validity of the EuroQol-5 Dimension 3-level questionnaire (EQ-5D-3L) as a measure of quality of life in homeless adults with mental illness. METHODS: Data were from Toronto participants in At Home/Chez Soi, a 24-month randomized controlled trial of Housing First (immediate access to scattered site housing and mental health support services) compared to treatment as usual for homeless adults with a mental disorder (n = 575). Participants completed the EQ-5D-3L at 6 month intervals. We tested convergent validity, hypothesizing strong correlation (r > 0.6) with the Lehman Quality of Life Interview 20 (QOLI-20) index and moderate correlations (r > 0.3) with the Colorado Symptom Index (CSI), Recovery Assessment Scale (RAS), and number of comorbidities. We also examined correlations between EQ-5D-3L scores and the QOLI-20 over time using a linear mixed-effects model. RESULTS: The EQ-5D-3L was not strongly correlated with the QOLI-20 (r ranged from 0.31-0.52 at various time points). The EQ-5D-3L was moderately correlated with the CSI, RAS, and number of comorbidities. The Snijders/Bosker r2 for longitudinal validity between the EQ-5D-3L and QOLI-20 within subjects over time was 0.2094 (square-root r = 0.4576). CONCLUSIONS: The EQ-5D-3L did not demonstrate strong convergent validity in homeless people with mental illness but was moderately correlated with several instruments. Further research is warranted to determine the optimal method for measuring health utilities in this population. TRIAL REGISTRATION: International Standard Randomised Control Trial Registry ISRCTN42520374 assigned on August 18, 2009.


Assuntos
Pessoas em Situação de Rua/psicologia , Transtornos Mentais/epidemiologia , Qualidade de Vida , Inquéritos e Questionários , Adulto , Feminino , Pessoas em Situação de Rua/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes
9.
Can J Psychiatry ; 64(10): 718-725, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31248276

RESUMO

OBJECTIVE: We aimed to describe interactions between police and persons who experience homelessness and serious mental illness and explore whether housing status is associated with police interactions. METHOD: We conducted a secondary analysis of 2008 to 2013 data from the Toronto, Canada, site of the At Home/Chez Soi study. Using police administrative data, we calculated the number and types of police interactions, the proportion of charges for acts of living and administration of justice, and the proportion of occurrences due to victimization, involuntary psychiatric assessment, and suicidal behavior. Using generalized estimating equations, we estimated the odds of police interaction by housing status. RESULTS: This study included 547 adults with mental illness who were homeless at baseline. In the year prior to randomization, 55.8% of participants interacted with police, while 51.7% and 43.0% interacted with police in Study Years 1 and 2, respectively. Of 2,228 charges against participants, 12.6% were due to acts of living and 21.2% were for administration of justice. Of 518 occurrences, 41.1% were for victimization, 45.6% were for mental health assessment, and 22.2% were for suicidal behavior. The odds of any police interaction during the past 90 days was 47% higher for those who were homeless compared to those who were stably housed (95% CI 1.26 to 1.73). CONCLUSIONS: For people who experience homelessness and mental illness in Toronto, Canada, interactions with police are common. The provision of stable housing and changes in policy and practice could decrease harms and increase health benefits associated with police interactions for this population.

10.
BMC Public Health ; 19(1): 445, 2019 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-31035978

RESUMO

BACKGROUND: Problem gambling (PG) is a serious public health concern that disproportionately affects people experiencing poverty, homelessness, and multimorbidity including mental health and substance use concerns. Little research has focused on self-help and self-management in gambling recovery, despite evidence that a substantial number of people do not seek formal treatment. This study explored the literature on PG self-management strategies. Self-management was defined as the capacity to manage symptoms, the intervention, health consequences and altered lifestyle that accompanies a chronic health concern. METHODS: We searched 10 databases to identity interdisciplinary articles from the social sciences, allied health professions, nursing and psychology, between 2000 and June 28, 2017. We reviewed records for eligibility and extracted data from relevant articles. Studies were included in the review if they examined PG self-management strategies used by adults (18+) in at least a subset of the sample, and in which PG was confirmed using a validated diagnostic or screening tool. RESULTS: We conducted a scoping review of studies from 2000 to 2017, identifying 31 articles that met the criteria for full text review from a search strategy that yielded 2662 potential articles. The majority of studies examined self-exclusion (39%), followed by use of workbooks (35%), and money or time limiting strategies (17%). The remaining 8% focused on cognitive, behavioural and coping strategies, stress management, and mindfulness. CONCLUSIONS: Given that a minority of people with gambling concerns seek treatment, that stigma is an enormous barrier to care, and that PG services are scarce and most do not address multimorbidity, it is important to examine the personal self-management of gambling as an alternative to formalized treatment.


Assuntos
Jogo de Azar/terapia , Autogestão/métodos , Adaptação Psicológica , Jogo de Azar/psicologia , Comportamentos Relacionados com a Saúde , Pessoas em Situação de Rua/estatística & dados numéricos , Humanos , Atenção Plena/métodos , Autogestão/psicologia
11.
Syst Rev ; 8(1): 100, 2019 04 22.
Artigo em Inglês | MEDLINE | ID: mdl-31010419

RESUMO

BACKGROUND: Diabetes is a chronic medical condition that requires patients to be actively engaged in intensive self-management to achieve optimal clinical outcomes. Unfortunately, individuals who are experiencing homelessness often struggle to manage diabetes and consequently suffer numerous and severe complications-both acute and chronic. There are many barriers to optimal diabetes self-management among this population, and this may be exacerbated by the lack of tailoring and customization of care to this unique population. Given this disconnect, it is likely that many organizations have attempted to provide specialized innovations for this population-which may or may not be reported in the formal literature. Our objective is to perform a scoping review to summarize and synthesize the experiences of those who have attempted to provide tailored interventions. METHODS: We propose a mixed methods scoping review that will include both a formal search of the published literature (MEDLINE, CINAHL, EMBASE, Web of Science, Scopus) and a thorough search of the grey literature. Eligible articles and documents are those that report on an intervention or guideline for the management of diabetes among those experiencing homelessness. All titles and abstracts will undergo duplicate review, as will the full article/document. We will include any report that either includes a description of an intervention or provides recommendations for the treatment of individuals who are homeless with diabetes. We will extract both qualitative and quantitative data for analysis and interpretation. Meta-analysis will not be performed. DISCUSSION: Those experiencing homelessness who also have diabetes often struggle to manage their chronic condition. When care is tailored to suit their needs, it is feasible that outcomes may be improved. By collating and synthesizing information from diverse organizations and jurisdictions, we hope to facilitate the sharing of knowledge with others who wish to provide this type of care.

12.
Suicide Life Threat Behav ; 49(6): 1630-1636, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-30907470

RESUMO

OBJECTIVE: Suicide is a leading cause of death, yet the accurate prediction of suicidal behavior is an elusive target for clinicians and researchers. The current paper examines the predictive validity of the Mini Neuropsychiatric Interview (MINI) Suicidality subscale for suicide attempts (SAs) for a homeless population with mental illness. METHODS: Two thousand two hundred and fifty-five homeless individuals with mental illness across five Canadian cities enrolled in the At Home/Chez Soi Housing First trial interviewed at baseline using the MINI Suicidality subscale with 2-year follow-up of self-reported SAs. RESULTS: Two thousand two hundred and twenty-one participants were included in the analysis. High rates of mood and substance use disorders were present (56.5% and 67.4%, respectively). The mean MINI Suicidality subscale score was 7.71. Among 1,700 participants with follow-up data, 11.4% reported a SA over the 2-year study period. MINI Suicidality subscale scores were predictive of SAs (AUC ≥ 0.70) among those with and without a history of SAs, even among those with missing answers. A positive predictive value of 0.20 and a negative predictive value of 0.95 were demonstrated, with a relatively low number needed to assess of 4.5-5. CONCLUSION: The MINI Suicidal subscale shows promise as an easy to use and accurate suicide risk prediction tool among homeless individuals with mental illness.

13.
PLoS One ; 14(2): e0211704, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30730929

RESUMO

We sought to characterize the association between a forensic event (arrest or incarceration) with housing vulnerability and mental and physical health status over a four-year follow-up among a cohort of homeless and vulnerably housed individuals in Vancouver, Toronto and Ottawa. Data were obtained from the Health and Housing in Transition Study, a prospective cohort study of homeless and vulnerably housed individuals between 2009 and 2012. Participants were interviewed in-person at baseline (N = 1190) and at four annual follow-up time points. We used generalized estimating equations to characterize the independent associations between a forensic event and the number of residential moves and SF-12 physical and mental health component scores over the four-year follow-up period. We analyzed data from 1173 homeless and vulnerably housed participants. Forensic events were reported by 446 participants at baseline. In multivariate analyses, a history of forensic event in the preceding twelve months was independently associated with an increased number of residential moves over the four-year follow-up period (ARR 1.24; 95% CI 1.19-1.3). It was not, however, independently associated with a change in physical or mental health status (respective ß-estimates; 95% CI: -0.34; -1.02, 0.34, and -0.69; -1.5, 0.2). Female gender and a history of problematic substance use were significantly associated with all three primary outcomes. This suggests arrest or incarceration is associated with increased housing vulnerability. The results underline the importance of supporting individuals experiencing arrest or incarceration with post-release planning in order to obtain stable housing after discharge.


Assuntos
Pessoas em Situação de Rua/estatística & dados numéricos , Habitação/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Adulto , Estudos de Coortes , Nível de Saúde , Humanos , Masculino , Saúde Mental/estatística & dados numéricos
14.
Health Soc Care Community ; 27(4): 1053-1062, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30734374

RESUMO

Perceived stress has been associated with adverse health outcomes. Although people experiencing homelessness often report multiple acute and chronic stressors, research on resilience and perceived stress on the general homeless population is limited. This longitudinal study examined homeless adults with mental illness who were part of a 24-month trial of Housing First to explore: (a) changes in levels of resilience and perceived stress during the trial, and (b) the association between levels of resilience and perceived stress with measures of social support, social functioning and percentage of days stably housed over the study period. This longitudinal study (2009-2013) that used trial data included 575 participants in Toronto, Ontario. Of these individuals, 507 were included in this study. Connor-Davidson Resilience Scale and Perceived Stress Scales (PSS) measured the two outcomes, resilience and perceived stress. Time (baseline, 12 and 24 months), housing stability and three measures of social support and social functioning were the main predictors. A longitudinal analysis was done with repeated measures analysis of resilience and perceived stress using linear mixed models with random intercepts. Mean resilience scores increased (baseline: 5.1 [95% CI: 4.9, 5.2], 12 months: 5.5 [95% CI: 5.3, 5.7], 24 months: 5.6 [95% CI: 5.4, 5.8]), and PSS scores decreased (baseline: 22.3 [95% CI: 21.5, 23.0], 24 months: 18.6 [95% CI: 17.9, 19.4]). In the multivariable analyses, increased resilience was associated with higher scores on the three social support and social functioning measures, (estimates = 0.12, 0.04, 0.02) but not percentage days stably housed. Lower PSS scores were associated with higher scores on all three social support and social functioning measures (-0.20, -0.33, -0.21) and higher percentages of days stably housed (-0.015). Strong social support and social functioning may minimise the harmful effects of stressful life events on homeless individuals by increasing resilience and reducing stress. Interventions to help homeless people build appropriate support networks should be delivered in parallel to efforts that increase housing stability.

15.
Am J Prev Med ; 56(4): 487-493, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30799160

RESUMO

INTRODUCTION: Primary care represents an opportunity to improve health for people who experience imprisonment, and screening for colorectal and breast cancer indicate primary care quality. The study objectives were to examine the proportion of people released from provincial correctional facilities who were overdue for colorectal or breast cancer screening on admission to the correctional facility and who were still overdue after 3 years, and to compare findings with data for the general population. METHODS: Administrative data were used to identify people eligible for colorectal and breast cancer screening who were released from provincial correctional facilities in 2010 (N=3,803 and N=249, respectively) and in the general population (N=2,757,584 and N=1,099,942, respectively) in Ontario, Canada. Chi-square tests and log binomial regression models were used to compare the proportion of individuals overdue for screening on admission or on July 1, 2010 for the general population, and still overdue after 3 years. Analyses were conducted in 2017 and 2018. RESULTS: Compared with the general population, people in the corrections group were 1.53 times (95% CI=1.50, 1.55) more likely to be overdue for colorectal cancer screening: 77.1% (95% CI=74.3, 79.9) vs 50.5% (95% CI=50.5, 50.6), and 2.25 times (95% CI=2.06, 2.46) more likely to be overdue for breast cancer screening: 65.9% (95% CI=56.2, 76.8) vs 29.3% (95% CI=29.2, 29.4, both p<0.001). They were also more likely to still be overdue 3 years later: 62.6% (95% CI=60.1, 65.2) vs 33.6% (95% CI=33.5, 33.6) for colorectal cancer and 52.2% (95% CI=43.6, 62.0) vs 20.2% (95% CI=20.1, 20.3) for breast cancer (both p<0.001). CONCLUSIONS: People who experience imprisonment are less likely than the general population to access colorectal and breast cancer screening. This suggests the need to strengthen primary care for this population. Specifically, efforts should be made to improve access to colorectal and breast cancer screening, through health promotion, program delivery, and linkage to community services while in correctional facilities.

16.
Qual Health Res ; 29(13): 1850-1861, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-30253692

RESUMO

Resilience is a factor related to positive health outcomes. Exploring this concept among adults experiencing homelessness can inform interventions while subsequently considering individuals' strengths. A phenomenographic approach was applied to examine this concept among a sample of 22 individuals involved in qualitative interviews. The phenomenographic inquiry identified eight conceptions and found resilience is captured in both positive and negative ways. Conceptions are summarized by two categories, situated in an outcome space which describes the overall resilience experience and the different ways these conceptions are understood and experienced. Categories summarize conceptions as Staying Strong and Sustaining Positive Beliefs, which highlight the construct as being captured by a persistent positive aspect; however, the findings also uniquely describe the influence of negative conceptions toward the overall phenomenon. The findings suggest resilience is recognizable during adversity, and it is a phenomenon that has the potential to be strengthened.

17.
Ann Fam Med ; 16(6): 549-551, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30420371

RESUMO

We aimed to determine if a history of recent imprisonment affects access to primary care. Using patient roles, we telephoned to request an initial appointment with all family physicians (n = 339) who were accepting new patients in British Columbia, Canada. We sequentially assigned patient scenarios: male or female recently released from prison; male or female control. Controls were 1.98 (95% CI, 1.59-2.46) times as likely to be offered an appointment compared with persons recently released from prison, with an absolute risk difference of 41.8% (95% CI, 31.0-52.5). Our study suggests discrimination is a barrier to primary care for people released from prison, even with universal health insurance. We need to improve access to primary care during the high-risk period following prison release.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Prisioneiros/estatística & dados numéricos , Discriminação Social/estatística & dados numéricos , Adulto , Colúmbia Britânica , Feminino , Humanos , Masculino
18.
BMC Health Serv Res ; 18(1): 845, 2018 Nov 09.
Artigo em Inglês | MEDLINE | ID: mdl-30413165

RESUMO

BACKGROUND: Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population. METHODS: We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method. RESULTS: Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care. CONCLUSIONS: Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.


Assuntos
Doença Crônica/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Prisioneiros/estatística & dados numéricos , Prisões/estatística & dados numéricos , Adulto , Assistência Ambulatorial/estatística & dados numéricos , Serviços de Saúde Comunitária/estatística & dados numéricos , Utilização de Instalações e Serviços , Feminino , Medicina Geral/estatística & dados numéricos , Humanos , Masculino , Ontário , Estudos Retrospectivos
19.
JAMA Intern Med ; 178(9): 1242-1248, 2018 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-30073282

RESUMO

Importance: Previous studies have shown high mortality rates among homeless people in general, but little is known about the patterns of mortality among "rough sleepers," the subgroup of unsheltered urban homeless people who avoid emergency shelters and primarily sleep outside. Objectives: To assess the mortality rates and causes of death for a cohort of unsheltered homeless adults from Boston, Massachusetts. Design, Setting, and Participants: A 10-year prospective cohort study (2000-2009) of 445 unsheltered homeless adults in Boston, Massachusetts, who were seen during daytime street and overnight van clinical visits performed by the Boston Health Care for the Homeless Program's Street Team during 2000. Data used to describe the unsheltered homeless cohort and to document causes of death were gathered from clinical encounters, medical records, the National Death Index, and the Massachusetts Department of Public Health death occurrence files. The study data set was linked to the death occurrence files by using a probabilistic record linkage program to confirm the deaths. Data analysis was performed from May 1, 2015, to September 6, 2016. Exposure: Being unsheltered in an urban setting. Main Outcomes and Measures: Age-standardized all-cause and cause-specific mortality rates and age-stratified incident rate ratios that were calculated for the unsheltered adult cohort using 2 comparison groups: the nonhomeless Massachusetts adult population and an adult homeless cohort from Boston who slept primarily in shelters. Results: Of 445 unsheltered adults in the study cohort, the mean (SD) age at enrollment was 44 (11.4) years, 299 participants (67.2%) were non-Hispanic white, and 72.4% were men. Among the 134 individuals who died, the mean (SD) age at death was 53 (11.4) years. The all-cause mortality rate for the unsheltered cohort was almost 10 times higher than that of the Massachusetts population (standardized mortality rate, 9.8; 95% CI, 8.2-11.5) and nearly 3 times higher than that of the adult homeless cohort (standardized mortality rate, 2.7; 95% CI, 2.3-3.2). Non-Hispanic black individuals had more than half the rate of death compared with non-Hispanic white individuals, with a rate ratio of 0.4 (95% CI, 0.2-0.7; P < .001). The most common causes of death were noncommunicable diseases (eg, cancer and heart disease), alcohol use disorder, and chronic liver disease. Conclusions and Relevance: Mortality rates for unsheltered homeless adults in this study were higher than those for the Massachusetts adult population and a sheltered adult homeless cohort with equivalent services. This study suggests that this distinct subpopulation of homeless people merits special attention to meet their unique clinical and psychosocial needs.


Assuntos
Pessoas em Situação de Rua/estatística & dados numéricos , Neoplasias/mortalidade , População Urbana , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Boston/epidemiologia , Causas de Morte/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo , Adulto Jovem
20.
PLoS One ; 13(8): e0201592, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30075019

RESUMO

BACKGROUND: Many people experience imprisonment each year, and this population bears a disproportionate burden of morbidity and mortality. States have an obligation to provide equitable health care in prison and to attend to care on release. Our objective was to describe health care utilization in prison and post-release for persons released from provincial prison in Ontario, Canada in 2010, and to compare health care utilization with the general population. METHODS: We conducted a population-based retrospective cohort study. We included all persons released from provincial prison to the community in 2010, and age- and sex-matched general population controls. We linked identities for persons released from prison to administrative health data. We matched each person by age and sex with four general population controls. We examined ambulatory care and emergency department utilization and medical-surgical and psychiatric hospitalization, both in prison and in the three months after release to the community. We compared rates with those of the general population. RESULTS: The rates of all types of health care utilization were significantly higher in prison and on release for people released from prison (N = 48,861) compared to general population controls (N = 195,444). Comparing those released from prison to general population controls in prison and in the 3 months after release, respectively, utilization rates were 5.3 (95% CI 5.2, 5.4) and 2.4 (95% CI 2.4, 2.5) for ambulatory care, 3.5 (95% CI 3.3, 3.7) and 5.0 (95% CI 4.9, 5.3) for emergency department utilization, 2.3 (95% CI 2.0, 2.7) and 3.2 (95% CI 2.9, 3.5) for medical-surgical hospitalization, and 21.5 (95% CI 16.7, 27.7) and 17.5 (14.4, 21.2) for psychiatric hospitalization. Comparing the time in prison to the week after release, ambulatory care use decreased from 16.0 (95% CI 15.9,16.1) to 10.7 (95% CI 10.5, 10.9) visits/person-year, emergency department use increased from 0.7 (95% CI 0.6, 0.7) to 2.6 (95% CI 2.5, 2.7) visits/person-year, and hospitalization increased from 5.4 (95% CI 4.8, 5.9) to 12.3 (95% CI 10.1, 14.6) admissions/100 person-years for medical-surgical reasons and from 8.6 (95% CI 7.9, 9.3) to 17.3 (95% CI 14.6, 20.0) admissions/100 person-years for psychiatric reasons. CONCLUSIONS: Across care types, health care utilization in prison and on release is elevated for people who experience imprisonment in Ontario, Canada. This may reflect high morbidity and suboptimal access to quality health care. Future research should identify reasons for increased use and interventions to improve care.


Assuntos
Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Prisioneiros , Adulto , Assistência Ambulatorial/estatística & dados numéricos , Estudos de Coortes , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Ontário , Saúde da População , Estudos Retrospectivos
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