Cycles of instability: Proximal and distal influences on residential instability among people with histories of homelessness in three Canadian cities.

People with histories of homelessness often have difficulties obtaining and maintaining adequate housing. This qualitative study examined the residential transitions of people with histories of residential instability and homelessness to understand factors contributing to the instability they experience. Interviews were conducted with 64 participants about their housing transitions, in the final year of a 4-year, prospective cohort study in three Canadian cities (Ottawa, Toronto, and Vancouver). Findings showed that participants pointed to both distal and proximal factors as affecting residential transitions, including interpersonal conflict, safety concerns, substance use, poverty, pests, and health. Many reported disconnection from their housing and a lack of improvement from one housing situation to the next, demonstrating how even when housed, instability persisted. Our study highlights the complexity associated with participants' often unplanned and abrupt residential transitions. The complex and distal issues that affect housing transitions require structural changes, in addition to individual-based interventions focused on the proximal problems.

The Association of Residential Instability and Hospitalizations among Homeless and Vulnerably Housed Individuals: Results from a Prospective Cohort Study.

The present study examined the association of residential instability with hospitalizations among homeless and vulnerably housed individuals over a 4-year time period. Survey data were linked to administrative records on hospitalizations. Specifically, we used data from the Health and Housing in Transition study, a prospective cohort study that tracked the health and housing status of homeless and vulnerably housed individuals in Canada. Responses from Vancouver-based participants (n = 378) from baseline and 3 follow-ups were linked to their administrative health records on hospitalizations (Discharge Abstract Database - Hospital Separation Files; 2008-2012). A generalized estimating equations model was used to examine associations between the number of residential moves and any hospitalizations during each year (none versus ≥ 1 hospitalizations). Analyses included demographic and health variables. Survey data were collected via structured interviews. Hospitalizations were derived from provincial administrative health records. A higher number of residential moves were associated with hospitalization over the study period (adjusted odds ratio: 1.14; 95% confidence interval: 1.01, 1.28). Transgender, female gender, perceived social support, better self-reported mental health, and having ≥ 3 chronic health conditions also predicted having been hospitalized over the study period, whereas high school/higher education was negatively associated with hospitalizations. Our results indicate that residential instability is associated with increased risk of hospitalization, illustrating the importance of addressing housing as a social determinant of health.

Avoidable Mortality Rates Decrease but Inequity Gaps Widen for Marginalized Neighborhoods: A Population-Based Analysis in Ontario, Canada from 1993 to 2014.

Avoidable mortality (AM) is a health indicator used to examine trends in avoidable deaths amenable to public health and medical interventions. AM is more likely amongst marginalized populations. Our objective was to examine trends in AM rates by level of neighborhood marginalization. Decedents under age 75 years in Ontario from 1993 to 2014 (n = 691,453) were assigned to a quintile-level of each Ontario Marginalization (ON-Marg) Index dimension: material deprivation, residential instability, dependency, and ethnic concentration. We calculated ON-Marg Index dimension and quintile specific age- and sex-standardized AM incidence rates. We then calculated annual AM rate ratios between the most (Q5) and least (Q1) marginalized quintiles for each ON-Marg dimension. To describe the inequity gap in AM over time we calculated the absolute difference in the Q5/Q1 rate ratio between 2014 and 1993 for each dimension. AM rates in Ontario were almost halved (48.6%) from 1993 to 2014 (216 vs. 111 per 100,000 population). This decline was greater for treatable AM (75 vs. 36 per 100,000 population) than preventable AM (128 vs. 88 per 100,000 population). The inequity gap in AM Q5/Q1 rate ratios (RR) between 1993 and 2014 widened for all marginalization dimensions: dependency (RR 2.11-2.58), ethnic concentration (RR 0.59-0.48), material deprivation (RR 1.63-2.23), and residential instability (RR 2.01-2.43). To attain further declines in AM, policymakers and governments must address AM due to preventable deaths in neighborhoods highly marginalized by dependency, material deprivation, and residential instability.

Residential instability during adolescence predicts earlier age at onset of psychosis: The moderating role of extraversion.

INTRODUCTION: Residential instability (RI) during adolescence is associated with poor health outcomes. Also, extraversion has been shown to be a moderator of these associations. However, the associations between RI, extraversion, and age at onset of psychosis (AOP) remain unknown. METHODS: Data were collected from patients with first-episode psychosis (FEP). Linear regression models assessed the association between RI during adolescence and AOP. Extraversion was tested as a moderator using the interaction term RI-by-extraversion. RESULTS: Among 89 participants with FEP, both RI (adjusted ß = -.278, p = .006) and the interaction term RI-by-extraversion (adjusted ß = .290, p < .001) were associated with earlier AOP. Stratified analyses showed that RI was only significantly associated with earlier AOP among those with low extraversion (adjusted ß = -.598, p < .001). CONCLUSIONS: RI predicted earlier AOP and this association was moderated by extraversion. These findings suggest that extraversion may buffer the negative relationship between RI and AOP. Future research should replicate these findings.

Residential instability during adolescence and health and wellbeing in adulthood: A longitudinal outcome-wide study.

Although prior research suggests that residential instability during adolescence can have long-term impacts on health and wellbeing, few studies have identified a robust comparison group and considered a broad set of outcomes. To address these knowledge gaps, we examined the associations between residential instability during adolescence and a wide range of adult health and wellbeing outcomes using an outcome-wide design in the National Longitudinal Study of Adolescent to Adult Health. We defined residential instability as two or more moves between Waves I and II (ages 13-18 years). We assessed outcomes at ages 33-43 years (Wave V) in nine domains: biomarkers, physical health, health behaviors, psychological distress, psychological wellbeing, social behaviors, social wellbeing, trauma/victimization, and socioeconomic attainment. Results of doubly-robust targeted maximum likelihood estimation, adjusting for pre-exposure values of the outcome variables and cofounders (Wave I), showed little evidence of an association for certain outcomes, all of which disappeared after accounting for multiple comparisons. Our results suggest that residential instability in adolescence does not lead to worse health and wellbeing in adulthood, but rather, outcome differences between groups are due to pre-existing differences prior to residential instability in adolescence.

Using natural language processing to identify the status of homelessness and housing instability among serious illness patients from clinical notes in an integrated healthcare system.

Background: Efficiently identifying the social risks of patients with serious illnesses (SIs) is the critical first step in providing patient-centered and value-driven care for this medically vulnerable population. Objective: To apply and further hone an existing natural language process (NLP) algorithm that identifies patients who are homeless/at risk of homeless to a SI population. Methods: Patients diagnosed with SI between 2019 and 2020 were identified using an adapted list of diagnosis codes from the Center for Advance Palliative Care from the Kaiser Permanente Southern California electronic health record. Clinical notes associated with medical encounters within 6 months before and after the diagnosis date were processed by a previously developed NLP algorithm to identify patients who were homeless/at risk of homelessness. To improve the generalizability to the SI population, the algorithm was refined by multiple iterations of chart review and adjudication. The updated algorithm was then applied to the SI population. Results: Among 206 993 patients with a SI diagnosis, 1737 (0.84%) were identified as homeless/at risk of homelessness. These patients were more likely to be male (51.1%), age among 45-64 years (44.7%), and have one or more emergency visit (65.8%) within a year of their diagnosis date. Validation of the updated algorithm yielded a sensitivity of 100.0% and a positive predictive value of 93.8%. Conclusions: The improved NLP algorithm effectively identified patients with SI who were homeless/at risk of homelessness and can be used to target interventions for this vulnerable group.

Application of natural language processing to identify social needs from patient medical notes: development and assessment of a scalable, performant, and rule-based model in an integrated healthcare delivery system.

Objectives: To develop and test a scalable, performant, and rule-based model for identifying 3 major domains of social needs (residential instability, food insecurity, and transportation issues) from the unstructured data in electronic health records (EHRs). Materials and Methods: We included patients aged 18 years or older who received care at the Johns Hopkins Health System (JHHS) between July 2016 and June 2021 and had at least 1 unstructured (free-text) note in their EHR during the study period. We used a combination of manual lexicon curation and semiautomated lexicon creation for feature development. We developed an initial rules-based pipeline (Match Pipeline) using 2 keyword sets for each social needs domain. We performed rule-based keyword matching for distinct lexicons and tested the algorithm using an annotated dataset comprising 192 patients. Starting with a set of expert-identified keywords, we tested the adjustments by evaluating false positives and negatives identified in the labeled dataset. We assessed the performance of the algorithm using measures of precision, recall, and F1 score. Results: The algorithm for identifying residential instability had the best overall performance, with a weighted average for precision, recall, and F1 score of 0.92, 0.84, and 0.92 for identifying patients with homelessness and 0.84, 0.82, and 0.79 for identifying patients with housing insecurity. Metrics for the food insecurity algorithm were high but the transportation issues algorithm was the lowest overall performing metric. Discussion: The NLP algorithm in identifying social needs at JHHS performed relatively well and would provide the opportunity for implementation in a healthcare system. Conclusion: The NLP approach developed in this project could be adapted and potentially operationalized in the routine data processes of a healthcare system.

The associations between area-level residential instability and gray matter volumes from the North American Prodrome Longitudinal Study (NAPLS) consortium.

INTRODUCTION: Area-level residential instability (ARI), an index of social fragmentation, has been shown to explain the association between urbanicity and psychosis. Urban upbringing has been shown to be associated with reduced gray matter volumes (GMV)s of brain regions corresponding to the right caudal middle frontal gyrus (CMFG) and rostral anterior cingulate cortex (rACC). We hypothesize that greater ARI will be associated with reduced right CMFG and rACC GMVs. METHODS: Data were collected at baseline as part of the North American Prodrome Longitudinal Study Phase 2. Counties where participants resided during childhood were geographically coded using the US Census to area-level factors. ARI was defined as the percentage of residents living in a different house 5 years ago. Generalized linear mixed models tested associations between ARI and GMVs. RESULTS: This study included 29 healthy controls (HC)s and 64 clinical high risk for psychosis (CHR-P) individuals who were aged 12 to 24 years, had remained in their baseline residential area, and had magnetic resonance imaging scans. ARI was associated with reduced right CMFG (adjusted ß = -0.258; 95% CI = -0.502 to -0.015) and right rACC volumes (adjusted ß = -0.318; 95% CI = -0.612 to -0.023). The interaction term (ARI-by-diagnostic group) in the prediction of both brain regions was not significant, indicating that the relationships between ARI and regional brain volumes held for both CHR-P and HCs. CONCLUSIONS: ARI may adversely impact similar brain regions as urban upbringing. Further investigation into the potential mechanisms of the relationship between ARI and neurobiology, including social stress, is needed.

Association between residential instability at individual and area levels and future psychosis in adolescents at clinical high risk from the North American Prodrome Longitudinal Study (NAPLS) consortium.

OBJECTIVE: Accumulating evidence supports an association between residential instability and increased risk for psychosis, but the association between residential instability and conversion to psychosis among adolescents at clinical high risk (CHR) is unclear. In this study, we determined whether individual-level and area-level residential instability and their interaction are associated with conversion to psychosis within two years. METHODS: Data were collected as part of the North American Prodrome Longitudinal Study Phase 2. Individual-level residential instability, defined as having ever moved during lifetime, was derived from the Life Events Scale. Area-level residential instability, defined as the percentage of people who were not living in the same house five years ago, was derived from the U.S. Decennial Censuses. RESULTS: This study included 285 adolescents at CHR (including 36 subjects who later converted to full psychosis). We found that individual-level residential instability was associated with conversion (adjusted OR = 2.769; 95% CI = 1.037-7.393). The interaction between individual-level and area-level residential instability was significant (p = 0.030). In a subgroup of CHR participants who have never moved (n = 91), area-level residential instability during childhood was associated with conversion (adjusted OR = 1.231; 95% CI = 1.029-1.473). Conversely, in a subgroup of CHR participants who resided in residentially stable areas during childhood (n = 142), the association between individual-level residential instability and conversion remained significant (adjusted OR = 15.171; 95% CI = 1.753-131.305). CONCLUSIONS: These findings suggest that individual-level and area-level residential instability may be associated with conversion to psychosis.

Neighbourhood-level marginalization and avoidable mortality in Ontario, Canada: a population-based study.

OBJECTIVE: To examine the impact of neighbourhood marginalization on avoidable mortality (AM) from preventable and treatable causes of death. METHODS: All premature deaths between 1993 and 2014 (N = 691,453) in Ontario, Canada, were assigned to quintiles of neighbourhood marginalization using the four dimensions of the Ontario Marginalization Index: dependency, ethnic concentration, material deprivation, and residential instability. We conducted two multivariate logistic regressions to examine the association between neighbourhood marginalization, first with AM compared with non-AM as the outcome, and second with AM from preventable causes compared with treatable causes as the outcome. All models were adjusted for decedent age, sex, urban/rural location, and level of comorbidity. RESULTS: A total of 463,015 deaths were classified as AM and 228,438 deaths were classified as non-AM. Persons living in the most materially deprived (OR, 1.24; 95% CI, 1.22 to 1.27) and residentially unstable neighbourhoods (OR, 1.13; 95% CI, 1.11 to 1.15) had greater odds of AM, particularly from preventable causes. Those living in the most dependent (OR, 0.91; 95% CI, 0.89 to 0.93) and ethnically concentrated neighbourhoods (OR, 0.93; 95% CI, 0.91 to 0.93) had lower odds of AM, although when AM occurred, it was more likely to arise from treatable causes. CONCLUSION: Different marginalization dimensions have unique associations with AM. By identifying how different aspects of neighbourhood marginalization influence AM, these results may have important implications for future public health efforts to reduce inequities in avoidable deaths.

Effects of Residential Instability of Renters on Their Perceived Health Status: Findings from the Korean Welfare Panel Study.

Identifying the impact of housing instability on the health status of renters with relatively high economic difficulties is important for the improvement of renters' quality of life and their social security. Accordingly, this study adopted a panel data regression approach to examine the associations between residential instability and perceived health status-including physical and mental health-using 14 waves (2006-2019) of longitudinal data collected by the Korean Welfare Panel Study. The results showed that residential instability significantly affected perceived health status, and renters who experienced residential instability perceived worse health status and had more severe depression than those who did not experience residential instability. Moreover, failure to meet the minimum housing standard worsened depression in renters. Despite assistance benefits from the government, permanent rental housing and the national basic living security were also factors that worsened depression. Dissatisfaction with one's residential environment and social relationships were also associated with increased depression. We recommend that the overall quality of housing welfare services, including a focus on the mental health of low-income renters, be improved by expanding the range of services, increasing the number of professional housing welfare workers, and supplying community facilities for increasing residential and social relationship satisfactions.

Residential instability, neighborhood deprivation, and pediatric asthma outcomes.

INTRODUCTION: Limited work has directly compared the role of different neighborhood factors or examined their interactive effects on pediatric asthma outcomes. Our objective was to quantify the main and interactive effects of neighborhood deprivation and residential instability (RI) on pediatric asthma outcomes. METHODS: We conducted a retrospective cross-sectional study of patients with a primary diagnosis of asthma hospitalized at a tertiary care pediatric hospital. Residential addresses at the index hospitalization were linked to the state area deprivation index (ADI). RI was coded as the number of residences in the past 4 years. Logistic and ordinal regression and Cox regression survival analyses were used to estimate the effect on the primary outcomes of chronic asthma severity (intermittent, mild persistent, moderate persistent, severe persistent/other) as defined by the National Heart, Lung, and Blood Institute, severe hospitalization (requiring continuous albuterol or intensive care unit care), and time to emergency department (ED) readmission and rehospitalization within 365 days of the index visit, respectively. RESULTS: In the sample (N = 664), 21% had severe persistent/other asthma, 22% had severe hospitalization, 37% were readmitted to the ED, and 19% were rehospitalized. Increasing RI was independently associated with more severe chronic asthma (odds ratio = 1.18, 95% confidence interval [CI] = 1.05, 1.32, P = .004), greater risk of 365-day ED readmission (hazard ratio [HR] = 1.10, 95% CI = 1.05, 1.15, P < .0001), and greater risk of 365-day rehospitalization (HR = 1.09, 95% CI = 1.03, 1.14, P = .002). There were no significant associations between ADI and these outcomes. Further, we did not find significant evidence of interactive effects. CONCLUSIONS: RI appears to be modestly associated with pediatric asthma outcomes, independent of current neighborhood deprivation.

How Does Household Residential Instability Influence Child Health Outcomes? A Quantile Analysis.

At the core of housing and welfare research is a premise that stable residential environments are important to children's health and development. The relationship between housing stability and health outcomes for children is, however, complex; stable housing situations are sometimes associated with poorer health outcomes, and some children may be more or less resilient to residential instability. The Longitudinal Study of Australian Children (LSAC) dataset enables us to longitudinally follow the housing and health of more than 10,000 children and their families. We employ a quantile analysis technique, a currently underutilized tool for testing associations across the distribution of an outcome, to test whether exposure to housing instability has a differential impact on children's health dependent on their initial health status. Our findings suggest that the health outcomes of residential instability are highly dependent on children's initial health status.

Jailed Parents and Their Young Children: Residential Instability, Homelessness, and Behavior Problems.

This study examined family disruption in the form of jailed parents' housing instability in the year leading up to their most recent incarceration, including periods of homelessness with and without their children, and links between parental housing instability and children's behavior problems. Using the Family Stress Proximal Process Model to understand the links between stressors related to family disruption and child outcomes, the study analyzed data from interviews and surveys with 165 jailed fathers and mothers with young children (age 2-6 years) regarding jailed parents' reports of housing instability during the 12 months prior to their incarceration and child behavior problems. Analyses showed that housing instability, homelessness, and recidivism in jailed parents were relatively common, with a significant proportion of the disruptions occurring with young children, although many disruptions involved parental absence from children. Results indicated that the more months that parents lived with their children prior to incarceration in jail during the past year, the less housing instability the parents experienced. Additionally, multiple regression analyses revealed that more housing instability experienced by parents in the year leading up to their incarceration in jail were associated with elevations in children's internalizing and externalizing behavior problems. These results have implications for future research that explores family disruption as a mechanism in understanding recidivism and homelessness among adults and risk for child behavior problems in families affected by parental incarceration.

Perinatal substance use, residential instability, and negative behavioral outcomes among adolescents: Lessons from the maternal lifestyle study.

PROBLEM: Both housing instability and prenatal substance use are known risk factors for behavioral problems among adolescents. METHODS: The purpose of this study was to investigate the association between residential instability (residential mobility and homelessness) and delinquent behaviors among adolescents enrolled in the maternal lifestyle study (MLS), a 16-year research study that explored short-term and long-term effects of in-utero exposure to cocaine and/or opiates (N = 736). Logistic regression was used to measure the association between housing problems with youth crimes, school delinquency, and substance use at 11, 15, and 16 years of age. FINDINGS: Both high-frequency residential mobility and homelessness were associated with deviant behaviors across the entire sample of children born with in-utero cocaine/opiate exposure and those without. CONCLUSIONS: Psychiatric nursing care of youth should include a comprehensive assessment of residential instability to identify risk and target potential interventions.