Satisfaction with health and community services among homeless and formerly homeless individuals in Quebec,Canada

User satisfaction is a crucial quality indicator in health service provision. Few studies have measured user satisfaction among homeless and formerly homeless individuals, despite the high prevalence of mental health disorders (MHD) in this population. The purpose of this study was to assess overall satisfaction among 455 homeless and formerly homeless individuals who were receiving health and community services, and to identify factors associated with user satisfaction. Data collection occurred between January and September 2017. Study participants were 18 years old or over, with experience of homelessness in the current or recent past. They completed a questionnaire eliciting socio‐demographic information, and data on residential history, service use and satisfaction and health profiles. Multivariate linear analysis was performed on overall satisfaction with health and community services in the previous 12 months. Independent variables were organised as predisposing, enabling and needs factors based on the Gelberg–Andersen Behavioral Model. The mean satisfaction score was 4.11 (minimum: 1; maximum: 5). Variables associated with greater user satisfaction included: older age, residence in permanent housing, common MHD (e.g., depression, anxiety), having a family physician, having a case manager, strong social network, good quality of life and, marginally, male sex and having substance use disorders (SUD). By contrast, frequent users of public ambulatory health services were the most dissatisfied. User satisfaction was more strongly associated with enabling factors. Strategies for improving satisfaction include: promoting more tailored primary care programmes (including family physician) adapted to the needs of this population, better integrating primary care with specialised services including SUD integrated treatment and enhancing continuity of care through the reinforcement of case management services. Further efforts aimed at increasing access to permanent housing with supports, and eliciting more active involvement by relatives and friends may also improve user satisfaction with services, and reduce unnecessary service use.     

Psychiatric symptoms, health services, and HIV risk factors among homeless women

The authors determined whether psychiatric symptoms and lack of health and/or social services contacts were associated with HIV risk behaviors among a probability sample of homeless women. Women were interviewed regarding socioeconomic indicators, psychiatric symptoms, health and/or social services contacts, and past-year HIV risk behaviors. Overall, 8 percent of the women injected drugs, 64 percent engaged in unprotected sex, and 22 percent traded sex. Multiple logistic regression results revealed that substance abuse was positively associated with injection drug use and trading sex. Homeless women with case managers were less likely to inject drugs. Although barriers to obtaining drug treatment were associated with trading sex, women attending self-help meetings for substance abuse were also more likely to trade sex. Homeless women who are substance abusers are vulnerable to HIV risk behaviors. Risk reduction interventions for homeless women should be implemented through substance abuse and intensive case management programs.     

Drug problems among homeless individuals in Toronto,Canada: prevalence,drugs of choice,and relation to health status

Background  

Drug use is believed to be an important factor contributing to the poor health and increased mortality risk that has been widely observed among homeless individuals. The objective of this study was to determine the prevalence and characteristics of drug use among a representative sample of homeless individuals and to examine the association between drug problems and physical and mental health status.     

Sexual risk-taking among homeless young people in Pakistan

Homeless young people who engage in sex work are at increased risk of HIV and other sexually transmitted infections like chlamydia, gonorrhoea, syphilis and herpes. Semi-structured interviews were conducted with 29 homeless young people between the ages of 16 and 25 years from Rawalpindi, Pakistan, to explore how sexual practices were mediated through social and contextual conditions. Participants engaged in sex for a range of reported reasons, most commonly to generate income, but also to build intimacy and to establish intimate partnerships which could bring physical protection and social and emotional support. Although participants were aware of the sexual health risks attached to condomless sex, they engaged in it due to the social obligations of intimate partnerships, financial considerations and to better manage potentially violent situations. Instead of condoms, participants used alternate methods like withdrawal, oral sex, post-sex douching and specific sexual positions. These were not always useful, and some methods might have inadvertently increased their risk of HIV. The study findings suggest that an integrated health promotion approach that goes beyond the health sector and a singular emphasis on risk awareness may help reduce young people's risk of homelessness and sexual health risks.     

Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998-2007

While tuberculosis (TB) in Canadian cities is increasingly affecting foreign-born persons, homeless persons remain at high risk. To assess trends in TB, we studied all homeless persons in Toronto who had a diagnosis of active TB during 1998-2007. We compared Canada-born and foreign-born homeless persons and assessed changes over time. We identified 91 homeless persons with active TB; they typically had highly contagious, advanced disease, and 19% died within 12 months of diagnosis. The proportion of homeless persons who were foreign-born increased from 24% in 1998-2002 to 39% in 2003-2007. Among foreign-born homeless persons with TB, 56% of infections were caused by strains not known to circulate among homeless persons in Toronto. Only 2% of infections were resistant to first-line TB medications. The rise in foreign-born homeless persons with TB strains likely acquired overseas suggests that the risk for drug-resistant strains entering the homeless shelter system may be escalating.     

Nutrition and health services needs among the homeless

This review discusses nutrition and related health problems among homeless Americans, summarizes recent information, and identifies needs for services and future research. The nature of homelessness today provides a context for the discussion. Many homeless persons eat fewer meals per day, lack food more often, and are more likely to have inadequate diets and poorer nutritional status than housed U.S. populations. Yet many homeless people eligible for food stamps do not receive them. While public and private agencies provide nutritious food and meals for homeless persons, availability of the services to homeless persons is limited. Many homeless people lack appropriate health care, and certain nutrition-related health problems are prevalent among them. Compared with housed populations, alcoholism, anemia, and growth problems are more common among homeless persons, and pregnancy rates are higher. The risks vary among homeless persons for malnutrition, nutrition-related health problems, drug and alcohol abuse, and mental illness. For example, among homeless persons, fewer heads of families than single adults are substance abusers, and mental illness varies in prevalence among single men, single women, and parents in homeless families. Homeless persons need improved access to food, nutrition, and health services. More nutrition education needs to be available to them and to service providers. Use of representative samples and validation of self-reported nutrition and health data will help future investigators to clarify the relationships between the characteristics of the homeless and their nutritional status.     

Predicting health services utilization among homeless adults: a prospective analysis

This study expands on the Andersen-Newman health services utilization (HSU) model. In a community-based homeless sample (n = 363) baseline predisposing, enabling, and needs-based variables predicted hospitalization and ambulatory outpatient service utilization within 1 year after baseline. Standard predisposing and enabling variables were supplemented with latent constructs representing substance use, mental illness, poor housing status, social support, community support, and barriers to health care. Need is represented by baseline health status. Poor physical health, more barriers, drug use, African American ethnicity, less community support, and less education predicted hospitalization, the least desirable form of HSU. Poor health, female gender, a regular source of care, community support, drug use, and fewer alcohol problems predicted an office visit. Because outpatient visits for acute conditions provide an opportunity for generally neglected preventive services and health screenings, this study suggests convenient multiservice health-related programs for the homeless that include drug and alcohol treatment.     

Sexual and behavioral health disparities among African American sexual minority men and women

ABSTRACT

Introduction: Sexual and behavioral health disparities have been consistently demonstrated between African American and White adults and between sexual minority and heterosexual communities in the United States; however, few studies using nationally representative samples have examined disparities between sexual minority and heterosexual adults within African American populations. The purpose of this study was to examine the prevalence of sexual and behavioral health outcomes between sexual minority and heterosexual African American adults and to examine whether there were different patterns of disparities for African American sexual minority men and women, respectively.

Methods: We analyzed data from 4502 African American adults who participated in the 2001–2015 waves of the National Health and Nutrition Examination Survey. Using multivariable analyses, we examined differences in HIV, sexually transmitted infections, mental health, and substance use among African American sexual minority and heterosexual men and women.

Results: After adjusting for sociodemographic variables, African American sexual minority men had significantly higher odds of HIV, sexually transmitted infections, and poor mental health compared to their heterosexual male counterparts, whereas African American sexual minority women had significantly higher odds of Hepatitis C, poor mental health, and substance use compared to their heterosexual female counterparts.

Conclusions: These findings demonstrate notable sexual orientation disparities among African American adults. Disparities persisted beyond the role of sociodemographic factors, suggesting that further research utilizing an intersectional approach is warranted to understand the social determinants of adverse health outcomes among African American sexual minority men and women.     

Constructions and experiences of sexual health among young,heterosexual, unmarried Muslim women immigrants in Australia

Minority ethnic immigrant women are frequently vulnerable to poor sexual health outcomes, due to poor use of sexual health services, lack of knowledge and social stigma associated with the discussion of sexuality. This paper explores the sexual health accounts provided by a group of young, unmarried heterosexual Muslim women immigrants residing and studying in Sydney, an under-researched group in the Australian context. Ten semi-structured interviews were conducted, focusing on sex before marriage, spouse selection and contraceptive use. Feminist discourse analysis identified ‘purity versus corruption’ as the primary construction of women's sexuality, where women positioned their sexual behaviour as that of purity and uninvolvement or corruption through unwedded participation. The subthemes ‘maintaining ignorance and naivety’, ‘remaining virginal’, ‘sex segregation’ and ‘the fallen woman’ capture women's personal sexuality-related experiences and values within the context of their religious and cultural communities. Additional research with this community is needed to examine the effects of negative social constructions of sex on young sexually active Muslim women, as well as further research on young women's sexual health within immigrant communities.     

Provision of contraceptive services to homeless women: results of a survey of health care for the homeless providers

Homeless women have both a higher rate of pregnancy and a higher proportion of unintended pregnancies than other American women. The authors sought to learn about contraception services offered by providers of health care to homeless women and barriers to provision of long-acting, reversible contraception in these settings. A survey of the 31 member organizations in the national Health Care for the Homeless Practice-Based Research Network was conducted, inquiring about services provided and barriers to service provision. Among the 20 responding organizations (65% response rate), 17 directly provided contraceptive services; two referred patients elsewhere, and one provided no contraceptive services. All 17 that provided such services provided condoms; 15 provided oral contraceptives; 14 provided injectable contraception; 6 provided intrauterine devices, and 2 provided contraceptive implants. Barriers to providing the last two methods included lack of provider training, lack of resources for placement, costs, and concerns about complications. The present survey results suggested very limited access for homeless women across the country to the two most effective means of long-acting, reversible contraception. Modest investments of resources could reduce a number of barriers to providing these services.     

Income and employment among homeless people: the role of mental health, health and substance abuse

BACKGROUND: The homeless population is among the poorest of the poor in the United States. Employment and government programs are potential sources of income, but many homeless people face potential barriers to work: many have serious mental and physical disabilities, and many more have alcohol and drug disorders. As a result, most homeless who work do so either for a few hours per day or only some days, which provides little income. General Assistance, a public program of last resort, also provides a low level of income support. More income might be gained through higher levels of work or participation in income support programs for people with disabilities. AIMS OF THE STUDY: To investigate the characteristics of homeless people that impede them in the labor market and in government program participation, paying particular attention to their mental and physical health, as well as their alcohol and drug problems. DATA: Data are from a survey of the homeless population in Alameda County, California, conducted from 1991 to 1993. Our sample is 471 homeless adults randomly selected from area shelters and meal providers, who were reinterviewed approximately 6 months later, regardless of domiciliary status. Mental health and substance use problems were assessed using the Diagnostic Interview Schedule, a structured, psychiatric interview that uses criteria based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 3rd edn (revised). Employment between the first and second interview is categorized as none, low level (less than 6 hours a day or fewer than half the days between interviews) or higher level (at least 6 hours a day for at least half the days). ANALYTICAL PROCEDURES: The models of employment status and program participation are recursive in that homelessness at the first wave of the survey is treated as given. Thus we explore whether, given their initial homelessness, persons can gain or maintain access to income between the two interviews, conditional on the sample member's homelessness, health and disability at the first interview. Using maximum-likelihood methods, we estimate a generalized ordered logit model of whether the person works not at all, at a low level or at a higher level. Participation in disability programs and GA are estimated as probit models over the subsamples of potentially eligible participants. RESULTS: While a surprisingly large number of homeless people work, few homeless persons are able to generate significant earnings from employment alone. Physical health problems that limit work or daily activities, in particular, are barriers to employment. Drug and alcohol abuse and dependence are positively associated with lower work level but are negatively related to higher work level. Program participation is quite low relative to eligibility. Those with physical health problems are substantially more likely than those with mental health problems to be in the more generous disability programs. Substance use disorders are also a barrier to participation in disability programs. DISCUSSION: Mental health, health and disability play a large role in the employment and program participation of the homeless and persons at risk for homelessness. Physical disabilities are a barrier to employment, and those with substance use disorders are most likely to work at lower levels that provide less income. Rates of participation in government programs are low, and people with major mental disorders have especially low participation rate in disability programs. The low rates of participation, particularly in the disability programs, suggest the need for continued research in improving access to income support programs among eligible homeless populations.     

Sexual health and sexual trauma in women with severe mental illness: An exploratory survey of Western Australian community mental health services

Australian women attending community mental health services were surveyed to determine the relationship between sexual trauma, sexual activity, and sexual health seeking behaviors. Self-reported history of “forced sex” was 58.4% (n = 122 out of 220). Latent class analysis revealed a three-class model: “sexually active and health seeking,” “low sexual activity and health seeking” and “low sexual activity and not health seeking.” An association with general practitioner engagement and sexual health seeking behaviors was found. Rates of self-reported sexual trauma reinforce the need for screening and trauma informed care. Groupings may reflect different aspects of recovery associated with sexual health behaviors.     

Engagement with health and social care services: perceptions of homeless young people with mental health problems

The present qualitative study describes and discusses the perspectives and experiences of young homeless people with mental health problems in relation to their interactions with health and social care services. Working in partnership with Streetlink, a supported accommodation assistance programme in Adelaide, Australia, the authors interviewed 10 homeless young people, aged from 16 to 24 years of age, who had experienced mental health problems. In-depth interviews elicited accounts of the best and worst of the participants' experiences of health and social care services. Access to services was not identified as being a significant problem in comparison with the participants' concerns regarding the quality of the services encountered. The central findings stress the importance of a respectful and supportive climate in relation to the qualities of service provision that the young people identified as valuable for their continuing treatment or consultation.     

Barriers to sexual health services for young people in Nepal

Although sexual and reproductive health education and services are provided to young people, current rates of HIV infection and pregnancy are increasing in Nepal, indicating that young people do not always use sexual health services. Health facilities have apparently failed to provide young people with specialized sexual health education and services. This study explored the barriers to using sexual health services, including condom-use among young people in Nepal. Participants from 10 focus groups and 31 in-depth interviews, carried out by a same-sex researcher, reported many socioeconomic, cultural and physical norms that impose barriers to accessing information on sexual health and relevant services. It is concluded that the establishment of youth-friendly service centres in convenient places might help encourage young people to use sexual health services.     

Health status and access to health services among the urban homeless.

Self-reported health status and access to care were reported for 238 homeless adults in Los Angeles. One-third reported their health as fair or poor; women reported more health problems than men. Half (53 per cent) of the sample reported no regular source of care, and most (81 per cent) were without health insurance. Lack of financial resources and health insurance were reported as important barriers to care.