COVID-19 vaccine hesitancy among persons living in homeless shelters in France

COVID-19 vaccine hesitancy is frequent and can constitute a barrier to the dissemination of vaccines once they are available. Unequal access to vaccines may also contribute to socioeconomic inequalities with regard to COVID-19. We studied vaccine hesitancy among persons living in homeless shelters in France between May and June 2020 (n = 235). Overall, 40.9% of study participants reported vaccine hesitancy, which is comparable to general population trends in France. In multivariate regression models, factors associated with vaccine hesitancy are: being a woman (OR = 2.55; 95% CI 1.40–4.74), living with a partner (OR = 2.48, 95% CI 1.17–5.41), no legal residence in France (OR = 0.51, 95% CI 0.27–0.92), and health literacy (OR = 0.38, 95% CI 0.21, 0.68). Our results suggest that trends in vaccine hesitancy and associated factors are similar among homeless persons as in the general population. Dissemination of information on vaccine risks and benefits needs to be adapted to persons who experience severe disadvantage.     

Australian homeless persons’ experiences of social connectedness,isolation and loneliness

Both loneliness and a lack of social integration are associated with serious physical and psychological health issues. One population highly susceptible to social isolation and loneliness are individuals who are homeless, who also experience high rates of mental disorder and relationship breakdown. Despite this, little research has explored how social networks, isolation and loneliness are experienced for those with a history of homelessness. In‐depth, semi‐structured interviews were used to get a nuanced understanding of how social networks and isolation are experienced and understood by individuals experiencing homelessness. Sixteen participants who were either homeless (n = 11) or previously homeless (n = 5) in Sydney, Australia, completed one‐off interviews that were audio‐recorded and transcribed. Data were analysed using thematic analysis. Participants constructed their social networks as being both constrained and enabled by marginalisation. They experienced rejection from the non‐homeless: the loss of critical network members, including rejection from family and a lack of companionship, and low quality and precarious relationships within the homeless community. These accounts were best conceptualised through loneliness theory. Participant's accounts signal that the homeless will likely continue feeling isolated if mainstream attitudes towards homelessness remain stigmatising and discriminatory.     

Trends in COVID-19 vaccination intent and factors associated with deliberation and reluctance among adult homeless shelter residents and staff, 1 November 2020 to 28 February 2021 – King County,Washington

IntroductionLittle is known about COVID-19 vaccination intent among people experiencing homelessness. This study assesses surveyed COVID-19 vaccination intent among adult homeless shelter residents and staff and identifies factors associated with vaccine deliberation (responded “undecided”) and reluctance (responded “no”), including time trends.MethodsFrom 11/1/2020–2/28/21, we conducted repeated cross-sectional surveys at nine shelters in King County, WA as part of ongoing community-based SARS-CoV-2 surveillance. We used a multinomial model to identify characteristics associated with vaccine deliberation and reluctance.ResultsA total of 969 unique staff (n = 297) and residents (n = 672) participated and provided 3966 survey responses. Among residents, 53.7% (n = 361) were vaccine accepting, 28.1% reluctant, 17.6% deliberative, and 0.6% already vaccinated, whereas among staff 56.2% were vaccine accepting, 14.1% were reluctant, 16.5% were deliberative, and 13.1% already vaccinated at their last survey. We observed higher odds of vaccine deliberation or reluctance among Black/African American individuals, those who did not receive a seasonal influenza vaccine, and those with lower educational attainment. There was no significant trend towards vaccine acceptance.ConclusionsStrong disparities in vaccine intent based on race, education, and prior vaccine history were observed. Increased vaccine intent over the study period was not detected. An intersectional, person-centered approach to addressing health inequities by public health authorities planning vaccination campaigns in shelters is recommended.Clinical Trial Registry Number: NCT04141917.     

Perceptions,Attitudes, and Experience Regarding mHealth Among Homeless Persons in New York City Shelters

Mobile health may be an effective means of providing access and education to the millions of homeless Americans. We conducted semi-structured interviews with 50 homeless people from different shelters in New York City to evaluate their perceptions, attitudes, and experiences regarding mobile health. Participants’ average age was 51.66 (SD = 11.34) years; duration of homelessness was 2.0 (SD = 3.10) years. The majority had a mobile phone with the ability to receive and send text messages. Most participants attempted to maintain the same phone number over time. The homeless were welcoming and supportive of text messaging regarding health care issues, including appointment reminders, health education, or management of diseases considering their barriers and mobility, and believed it would help them access necessary health care. Overwhelmingly they preferred text reminders that were short, positively framed, and directive in nature compared to lengthy or motivational texts. The majority believed that free cell phone plans would improve their engagement with, help them navigate, and ultimately improve their access to care. These positive attitudes and experience could be effectively used to improve health care for the homeless. Policies to improve access to mobile health and adapted text messaging strategies regarding the health care needs of this mobile population should be considered.     

Lifetime and five-year prevalence of homelessness in the United States.

OBJECTIVE. Intense debate exists concerning the number of homeless people in the United States. Previous studies, counting currently homeless people, have provided point-prevalence estimates of homelessness but have been criticized on methodological grounds. This study reports lifetime and 5-year prevalence estimates of homelessness using a different methodological approach. METHODS. Random-digit dialing was used to interview 1507 adults living in households with telephones in the 48 contiguous states in the fall of 1990. Respondents were asked whether they had ever been homeless and if so, where they had slept while homeless. RESULTS. Lifetime and 5-year prevalence of all types of homelessness combined were 14.0% (26 million people) and 4.6% (8.5 million people), respectively. Lifetime "literal homelessness" (sleeping in shelters, abandoned buildings, bus and train stations, etc.) was 7.4% (13.5 million people). Five-year (1985 through 1990) prevalence of self-reported homelessness among those who had ever been literally homeless was 3.1% (5.7 million people). CONCLUSIONS. The magnitude of the problem of homelessness is much greater than most previous attempts to enumerate homeless people have led us to believe. This finding requires reconsideration of inferences about the causes of homelessness that were derived from point-prevalence studies of currently homeless people.     

A Qualitative Study of Homeless Fathers: Exploring Parenting and Gender Role Transitions*

Abstract: The present qualitative research focuses on homeless fathers living with their children in family shelters. Data were collected through semistructured, face‐to‐face interviews with homeless fathers (n= 9) and shelter directors (n= 3). Findings suggest that how fathers made meaning of their experiences in a homeless shelter was related to contextual factors and constructions of masculinity. Contextual constraints deriving from unemployment, behavioral and psychological restrictions of shelters, and new parenting roles led men to reassess their parental and masculine role identities. Results further suggest that homeless shelters may provide a unique point for intervention services to assist poor fathers.     

Conceptualizing Prevention as the First Line of Offense Against Homelessness: Implications for the Federal Continuum of Care Model

The federal continuum of care model does not adequately address prevention as the first line of offense against homelessness. As a result, people with acute housing needs are quickly channeled into emergency shelters, exposing them to the destructive cycle of homelessness. Emergency shelters provide an island of refuge, but remove many people from the social mainstream, weaken their capacity for self-help, and increase risk of long-term dependency. Our position emerges from interviews with people residing in the largest homeless shelter in Central Florida, feedback from a regional advisory committee of civic leaders and service providers, and consistencies with findings reported in the literature. The Community Prevention Model that we offer for discussion reinforces competencies and strengths, promotes independent living and social mainstreaming, and utilizes emergency shelters as a last resort.     

Nowhere to go: exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto,Canada

ObjectivesA main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts.MethodsGuided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare.ResultsHistorical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging.ConclusionOur results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.     

Homelessness Experiences,Sexual Orientation,and Sexual Risk Taking Among High School Students in Los Angeles

PurposePrior studies reported homeless adolescents engage in more sexual risk than their housed peers. However, these comparisons are typically made post hoc by comparing homeless adolescent community-based samples with high school probability samples. This study uses a random sample of high school students to examine homelessness experiences and sexual risk behaviors.MethodsA supplemental survey to the Youth Risk Behavior Survey containing questions regarding homelessness and sexual health was administered to Los Angeles high school students (N = 1,839). Multivariate logistic regressions assessed the associations between demographics, past year homelessness experiences (i.e., place of nighttime residence), and being sexually active and condom use at last intercourse.ResultsHomelessness experiences consisted of staying in a shelter (10.4%), a public place (10.1%), and with a stranger (5.6%). Lesbian, gay, bisexual, transgender, questioning (LGBTQ), younger, and male adolescents were more likely to experience homelessness. LGBTQ adolescents were also more likely to report staying with a stranger and less likely to report staying in a shelter. Compared to adolescents who stayed in shelters, adolescents who stayed with strangers and in public places were more likely to engage in unprotected sex at last intercourse.ConclusionsAdolescents who report sexual activity and sexual risk taking are more likely to report homelessness experiences. With regard to sexual health, staying with strangers could be a particularly risky form of homelessness; LGBTQ and black adolescents are more likely to experience this form of homelessness. Efforts to reduce homelessness and sexual risk-taking need to recognize the specific vulnerabilities faced by these populations.     

Invited commentary: co-occurring health conditions among women living with profound life challenges

People challenged by homelessness are living with several losses including the loss of a home, employment, economic security, health or well-being, and personal security. Assistance programs for people who are homeless consist of housing, emergency shelter, food services, employment assistance, peer support, medical care, and mental health services. An article by Riley et al. (Am J Epidemiol. 2011;175(5):515-522) appearing in this issue of the Journal examines the relation between basic subsistence needs and health outcomes in a cohort of 129 human immunodeficiency virus-infected women who were recruited from a probability sample of low-income hotels, homeless shelters, and free food programs in San Francisco, California. The results of their study underscore the importance of addressing subsistence needs and providing access to medical and psychological treatment for homeless and unstably housed women. In addition to subsistence needs, more attention should be given to comorbid psychiatric and medical conditions that occur among homeless women, including trauma-related disorders.     

The HIV Risk Reduction Needs of Homeless Women in Los Angeles

BackgroundSubstance use, housing instability, and transactional sex all contribute to HIV risk engagement among homeless women. Because of the increased risk of HIV among homeless women, this study sought to understand the context of sexual behaviors and condom use among homeless women and elucidate modifiable factors that can be targeted by interventions.MethodsHomeless women (n = 45) participated in focus groups (n = 6) at shelters throughout Los Angeles County. Thematic analyses revealed that similar to other high-risk women, homeless women engage in sex with multiple types of partners (steady, casual, and transactional).FindingsOur findings indicate that, similar to use among other high-risk women, condom use by homeless women varied by type of partner. Substance use also contributed to condom non-use. In a departure from previous research, homeless women reported overarching feelings of hopelessness. Participants spoke of hopelessness contributing to risk engagement, specifically the number of ongoing stressors experienced because of homelessness contributing to despair. Without acknowledgement of this unique quality of homelessness, women felt their risk reduction needs would never truly be understood.ConclusionsInterventions involving homeless women should include self-esteem building, acknowledgment and use of inherent resilience qualities gained during homelessness, respect for current knowledge and skills, and an exploration of when women choose to trust their partners and how they make safer sex choices.     

Measuring pain in the context of homelessness

Purpose  The primary objective of this study was to inform the development of measures of pain impact appropriate for all respondents, including homeless individuals, so that they can be used in clinical research and practice. The secondary objective was to increase understanding about the unique experience of homeless people with pain. Methods  Seventeen homeless individuals with chronic health conditions (often associated with pain) participated in cognitive interviews to test the functioning of 56 pain measurement items and provided information about their experience living with and accessing treatment for pain. Results  The most common problems identified with items were that they lacked clarity or were irrelevant in the context of homelessness. Items that were unclear, irrelevant and/or had other identified problems made it difficult for participants to respond. Participants also described multiple ways in which their pain was exacerbated by conditions of homelessness and identified barriers to accessing appropriate treatment. Conclusions  Results suggested that the majority of items were problematic for the homeless and require substantial modifications to make the pain impact bank relevant to this population. Additional recommendations include involving homeless in future item bank development, conducting research on the topic of pain and homelessness, and using cognitive interviewing in other types of health disparities research.     

The montefiore community children's project: A controlled study of cognitive and emotional problems of homeless mothers and children

Objectives This study compares the prevalence of emotional, academic, and cognitive impairment in children and mothers living in the community with those living in shelters for the homeless. Method In New York City, 82 homeless mothers and their 102 children, aged 6 to 11, recruited from family shelters were compared to 115 nonhomeless mothers with 176 children recruited from classmates of the homeless children. Assessments included standardized tests and interviews. Results Mothers in shelters for the homeless showed higher rates of depression and anxiety than did nonhomeless mothers. Boys in homeless shelters showed higher rates of serious emotional and behavioral problems. Both boys and girls in homeless shelters showed more academic problems than did nonhomeless children. Conclusion Study findings suggest a need among homeless children for special attention to academic problems that are not attributable to intellectual deficits in either children or their mothers. Although high rates of emotional and behavioral problems characterized poor children living in both settings, boys in shelters for the homeless may be particularly in need of professional attention.     

Cognitive Impairments and the Prevention of Homelessness: Research and Practice Review

Cognitive impairments can increase significantly a person’s level of risk for becoming or remaining homeless. Five topics are explored that address these impairments in preventing homelessness: (1) the nature and estimated prevalence of cognitive impairments among people who are homeless, especially those with vulnerabilities like mental illness or substance abuse; (2) the multiple origins of these impairments; (3) how these impairments impact services for people at risk for homelessness; (4) good practice approaches to handling cognitive impairments in homeless shelters, supported housing programs, and other service systems for people at risk for homelessness; and, (5) important research and practice issues requiring further action.     

Adverse Outcomes Among Homeless Adolescents and Young Adults Who Report a History of Traumatic Brain Injury

Objectives. We examined the prevalence of self-reported traumatic brain injury (TBI) among homeless young people and explored whether sociodemographic characteristics, mental health diagnoses, substance use, exposure to violence, or difficulties with activities of daily living (ADLs) were associated with TBI.Methods. We analyzed data from the Wilder Homelessness Study, in which participants were recruited in 2006 and 2009 from streets, shelters, and locations in Minnesota that provide services to homeless individuals. Participants completed 30-minute interviews to collect information about history of TBI, homelessness, health status, exposure to violence (e.g., childhood abuse, assault), and other aspects of functioning.Results. Of the 2732 participating adolescents and young adults, 43% reported a history of TBI. Participants with TBI became homeless at a younger age and were more likely to report mental health diagnoses, substance use, suicidality, victimization, and difficulties with ADLs. The majority of participants (51%) reported sustaining their first injury prior to becoming homeless or at the same age of their first homeless episode (10%).Conclusions. TBI occurs frequently among homeless young people and is a marker of adverse outcomes such as mental health difficulties, suicidal behavior, substance use, and victimization.Homelessness is a serious public health problem that emerges at the intersection of complex socioecological factors. According to US Department of Housing and Urban Development estimates, at least 200 000 children, adolescents, and young adults were homeless on the night of a survey conducted in January 2013, representing one third of all homeless people in the United States.1 Homeless youths may be counted along with families but are often unaccompanied and moving between shelters or living on the streets.The unpredictable and often dangerous circumstances that accompany homelessness leave homeless individuals vulnerable to injury, illness, and victimization. Homeless individuals experience poorer health than people with stable housing and have a shorter life expectancy,2–4 and homeless young people experience high rates of internalizing (e.g., depression), externalizing (e.g., conduct disorder), and substance use disorders.5 A number of studies have documented cognitive difficulties, health problems, and violence exposure among homeless youths6–10; however, traumatic brain injury (TBI) has garnered minimal empirical attention.TBI is a leading cause of death and disability in the United States.11 However, a 2012 systematic review showed that only 8 studies have investigated TBI among homeless populations.12 The lifetime prevalence of TBI in these samples ranged from 8% to 53%, with all but 1 investigation reporting a rate above 20%. Five of the 8 studies were conducted in North America, with each recruiting from a single urban area and only one sampling multiple shelters. Most were limited by modest sample sizes, with only 2 exceeding 100 participants.13,14 Moreover, although 2 studies included adolescents, the samples were small and the prevalence of TBI among youths was not separated from that of adults.13,14 Hwang et al.14 and Oddy et al.15 reported that injuries tend to occur in late adolescence, with 70% or more occurring prior to the onset of homelessness. Hwang et al.14 also found that TBI was associated with mental health, substance use, and other difficulties.To date, no studies to our knowledge have reported TBI prevalence specifically among homeless adolescents and young adults. We sought to determine the prevalence of self-reported TBI among homeless adolescents and young adults in a population-based study and to investigate whether sociodemographic characteristics, mental health history, exposure to violence, and ability to perform routine activities of daily living (ADLs) differ between young people who report a history of TBI and those who do not. We hypothesized that homeless young people with a history of TBI would report greater difficulties in the domains assessed and that most respondents’ first TBI would precede their first episode of homelessness.     

Evaluation of a community based dental clinic for youth experiencing homelessness in Brisbane

The relationship between homelessness and ill health is complex, and many risk factors for homelessness such as unemployment, low income, and substance abuse are also risk factors for poor oral health. In order to overcome barriers to access dental care, previous studies have recommended integrating dental care, referral pathways, and information within the overall care provided by support services available to people at risk of homelessness. This study aimed to evaluate a dental service developed and implemented to improve access to oral health care of disadvantaged youth in Brisbane. A mobile dental clinic run by volunteer dental professionals was implemented into a community organisation for disadvantaged youth. Participants were clients of Brisbane Youth Services who were disadvantaged youth, ≤25 years and attended the dental clinic in a 1 year period. A questionnaire collected demographic information, a self‐assessment of oral health and an evaluation of their experiences with the dental clinic. Clinical data including DMFT, appointment attendance and items of service provided were collected. One hundred and twelve clients participated in the four dental clinic weeks and its evaluation. Cost was the greatest reported barrier to accessing dental care among participants. More than half (57%) of participants who pre‐booked an appointment failed to attend. A total of 640 services were delivered, with an estimated value of $48,000. The majority (69%, n = 444) of the services provided were preventative services. Almost all of the clients felt the service they received was suitable for them (97%, n = 98) and would use the service again (98%, n = 99). This dental clinic model is feasible and sustainable due to its integration into an existing homeless youth service, low running costs, acceptability to clients and an interest by dental practitioners to volunteer. It provides a useful model which could be scaled up and implemented in other regions.     

Homelessness: Perspectives,Misconceptions, and Considerations for Occupational Therapy

SUMMARY

Like poverty, the problem of homelessness has been with us to varying degrees since the founding of our nation. Attempts to explain homelessness have an equally long history. Hence, the literature and popular media are home to divergent perspectives, explanations, and characterizations of homelessness. The objectives of this paper are to present a unifying taxonomy of prominent perspectives on homelessness, and to illustrate how various perspectives lead to particular characterizations of persons who become homeless. The taxonomy traces the connection between perspectives and interpretations of the problem and helps to illuminate implicit and often unexamined assumptions about who becomes homeless and why. Critical examination of these perspectives is vital because our individual and collective understanding of homelessness is a powerful determinant of how we approach occupational therapy practice with this population. Implications for community practice and program planning for individuals and families in homeless shelters are also discussed.     

Risk factors for long-term homelessness: findings from a longitudinal study of first-time homeless single adults

OBJECTIVES: We examined risk factors for long-term homelessness among newly homeless men and women who were admitted to New York City shelters in 2001 and 2002. METHODS: Interviews were conducted with 377 study participants upon entry into the shelter and at 6-month intervals for 18 months. Standardized assessments of psychiatric diagnosis, symptoms, and coping skills; social and family history; and service use were analyzed. Kaplan-Meier survival analysis and Cox regression were used to examine the association between baseline assessments and duration of homelessness. RESULTS: Eighty-one percent of participants returned to community housing during the follow-up period; the median duration of homelessness was 190 days. Kaplan-Meier survival analysis showed that a shorter duration of homelessness was associated with younger age, current or recent employment, earned income, good coping skills, adequate family support, absence of a substance abuse treatment history, and absence of an arrest history. Cox regression showed that older age group P<.05) and arrest history (P<.01) were the strongest predictors of a longer duration of homelessness. CONCLUSIONS: Identification of risk factors for long-term homelessness can guide efforts to reduce lengths of stay in homeless shelters and to develop new preventive interventions.     

Homeless Children: Needs and Services

This study explored needs of homeless children and shelter services available to them. The first phase of this mixed-method study consisted of open-ended interviews of key personnel in six diverse homeless shelters in metropolitan Atlanta, Georgia. This qualitative data gave direction to the creation of a questionnaire used in a larger follow-up survey of shelters in the state of Georgia. Roughly two-thirds of the 102 reporting shelters that served children provided food, clothing, and school supplies with 40% offering some form of transportation. More than 75% of the shelters were full and did not have space currently available for children, with an additional 10% having only one or two available beds. Most of the shelters lacked important services in the areas of medical and developmental assessments, access to education, childcare, and parent training. Forty-seven percent lacked onsite worker training in the characteristics and needs of homeless children. In addition, while the McKinney Act legally mandates ways to serve homeless children, findings indicate that over half of key informants in homeless shelters were unfamiliar with the law.