Homelessness and Public Health Ganann R 1, Fitzpatrick-Lewis D 1, Ciliska D 1, Kouyoumdjian F 2, Hwang SW 2 1 McMaster University & 2 University of Toronto,

Homelessness and Public Health

Ganann R1, Fitzpatrick-Lewis D1, Ciliska D1, Kouyoumdjian F2, Hwang SW2

1McMaster University & 2University of Toronto, Canada

Interventions to improve the health and health care access of homeless populations

July 2012

Outline Context-setting Building on the existing evidence Rapid literature review approach

Question Methods Results

Synthesis of evidence Effectiveness of interventions for specific sub-

groups of homeless Implications

The face of homelessness

Can be experienced across gender, age, marital status, immigrants or non-immigrants1

Estimates of homelessness are often conservative due to: Challenges with enumeration Hidden homelessness

80% may not be absolutely homeless yet are marginally housed (e.g., unsafe housing, at risk for eviction, “couch surfing”, temporarily housed)2,3

Homeless populations have been identified as priority populations

Homelessness has received increased attention in the last 5 years within public health and policy arenas4,5

Strategies to address poverty reduction and social determinants of health are of interest to policymakers and providers

There are gaps in the literature examining:

Interventions to address homelessness

Interventions that are effective in improving health for homeless populations

Interventions that are effective in improving access to health care for homeless populations

A systematic review was done in 2005 6

Considerable new research in the last 5 years examining homeless populations :

– Interventions to improve health– Interventions to improve health care

access/utilization

Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE. Interventions to improve the health of the homeless: a systematic review. Am J Prev Med. 2005 Nov;29(4):311-9. Review. PMID: 16242595

An updated rapid systematic review 7

Rapid review questions driven by a request from a local health department to synthesize literature on homelessness and:– Health

– Health care access/utilization

– Housing status

Fitzpatrick-Lewis D, Ganann R, Krishnaratne S, Ciliska D, Kouyoumdjian F, Hwang SW. Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review. BMC Public Health. 2011 Aug 10;11:638. Review. PMID: 21831318

Focusing the research question – PICO 7

Population People who were homeless, marginally housed, or at risk of

homelessness

Intervention Any community-based intervention to improve the health or health

care utilization of homeless persons

Comparison Group No intervention or another intervention

Outcomes Health indicators, access to health services, housing status

Rapid review search strategy Update to previous review published in 2005

Focus on research published between 2004-2009

Bibliographic database search PsycINFO, OVID MEDLINE, OVID HealthStar,

CINAHL, Sociological Abstracts

Hand search of grey literature and key journals

Only articles published in English included

Acceptable study designs for review

Randomized Controlled Trials (RCTs)

Quasi-experimental (QE)

Cluster Controlled Trials (CCT)

Analytic cohort

Case control

Observational Cohorts

Rapid review methods

Titles and abstracts:Two reviewers independently screened 10% for

relevanceHigh level of inter-rater reliability allowed for one

reviewer to screen remaining studies

Full text reviews:Two reviewers independently conducted full text

reviews for relevance

Rapid review methods

All included studies underwent methodological quality assessment using tool developed by EPHPP8

Studies were rated as strong, moderate, or weak

Data extraction conducted on all studies rated as strong or moderate quality

Study inclusion/exclusion flowchart

Study inclusion/exclusion flowchart

Reasons for exclusion at full text screening: Studies did not

indicate:▪ Population of

interest▪ Community-based

intervention▪ Outcomes of

interest▪ Comparison group

Study inclusion/exclusion flowchart

Reasons for exclusion at full text screening: Studies did not

indicate:▪ Population of

interest▪ Community-based

intervention▪ Outcomes of

interest▪ Comparison group

Global quality rating includes: Selection bias Study design Confounders Blinding Data collection

Characteristics of included studies:S=Strong, M=Moderate, W=Weak

Results of included studies grouped by homeless population targeted by intervention

Interventions for homeless people with: Mental illness (n=1)9

Substance abuse (n=3)10-15

Concurrent disorders (n=1)16-21

e.g., mental health & substance abuse HIV (n=5)22-28

Note: In several cases the outcomes from a single study were reported across

multiple publications.

Interventions for homeless people with mental illness:

Forchuk et al. 2008: Pilot study, RCT

Purpose was to examine the effectiveness of an intervention in preventing homelessness upon discharge from psychiatric admission

Intervention: Provision of housing + rent assistance vs. usual

care

Outcomes at 3 and 6 months follow up: Intervention group: all remained housed Control group: all but one remained homeless

Interventions for homeless people with substance abuse issues:

Larimer et al. 2009, QE; Milby et al. 2004, RCT; Milby et al., 2005 RCT

Housing + case management (vs. usual) Small decreases in alcohol consumption at 12 months,

health services utilization over time10

Behavioural day treatment (DT) + abstinence contingent housing (ACH) & work therapy (vs. DT alone): Sustained abstinence, lower relapse rates; days housed

improved across both groups12

DT + no housing (NH), DT + ACH, DT + non-ACH: ACH more effective than NH and NACH in terms of

weeks abstinent; all were effective in increasing days housed14

Interventions for homeless people with concurrent disorders:

Tsemberis et al., 2003, RCT

Non-abstinence contingent housing and supportive services was more effective than usual care (outreach and drop-in services + congregate living arrangements) in terms of: Days spent homeless Need for substance abuse treatment Higher mental health services utilization

No difference in psychiatric outcomes

Interventions for homeless people with HIV: Kushel et al. 2006, Rotheram-Borus et al. 2009, Scwarcz et al. 2009, Slesnick et al.

2007, Wolitski et al. 2009

Case management (vs. usual care): Increased adherence to antiretroviral therapy22

Educational modules (vs. usual care): Decreased # of days of alcohol/marijuana use, # of risky

sexual acts, # days of hard drug use23,25

Rental assistance + case management (vs. usual care): Improved self-reported physical/mental health, housing

tenure27

Housing significantly impacts 5-year HIV/AIDS survival rates compared to homeless24

IMPLICATIONSFor policy & practice

Key points from the 2005 and 2011 systematic reviews

Effects of provision of housing for homeless populations living with mental illness and/or substance

abuse Increased:

Housing tenure

Decreased: Substance abuse Relapses from periods of abstinence Health services utilization

Greater impact on sustained abstinence when housing intervention is contingent on abstinence Consistent with previous systematic review

findings6

Specific approaches for homeless populations living with HIV:

Consistent case management can improve: Mental health, use of health services, overall

health, antiretroviral therapy adherence

Housing services targeting those with HIV can improve: Housing status

Case management can decrease: Substance abuse and risk behaviours

Structured education approaches can reduce: Sexual risk behaviour in youth

Future research should examine the effectiveness of interventions targeting:

Population sub-groups: women, families, children, youth

Homeless individuals living with chronic diseases:

HIV/AIDS, tuberculosis, schizophrenia, diabetes, hepatitis C

References1. Frankish CJ, Hwang SW, Quantz D: Homelessness and health in Canada:

research lessons and priorities. Can J Public Health 2005, 96(Suppl 2): S23-29

2. Trypuc B, Robinson J: Homeless in Canada: A funder’s primer in understanding the tragedy on Canada’s streets. King City, ON; 2009, 1-66.

3. Frankish CJ, Hwang SW, Quantz D: The relationship between homelessness and health: An overview of research in Canada. Finding home: Policy options for addressing homelessness in Canada. edn.; 2009, 1-21.

4. Butler-Jones D: The Chief Public Health Officer’s report on the state of public health in Canada. Ottawa: Public Health Agency of Canada; 2008.

5. Ontario Ministry of Health and Long Term Care: Ontario Public Health Standards. Toronto, ON: The Queen’s Printer for Ontario; 2008.

6. Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE: Interventions to improve the health of the homeless: a systematic review. Am J Prev Med 2005, 29(4):311-319.

7. Fitzpatrick-Lewis D, Ganann R, Ciliska D, Krishnaratne S, Kouyoumdjian FG, Hwang SW: Effectiveness of interventions to improve the health and housing status of homeless people: a rapid systematic review, BMC Public Health, 2011, 11: 638.

8. Thomas BH, Ciliska D, Dobbins M, Micucci S: A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs 2004, 1(3):176-184.

References9. Forchuk C, MacClure SK, Van Beers M, Smith C, Csiernik R, Hoch J, Jensen E:

Developing and testing an intervention to prevent homelessness among individuals discharged from psychiatric wards to shelters and ‘No Fixed Address’. J Psychiatr Ment Health Nurs 2008, 15(7):569-575.

10.Larimer ME, Malone DK, Garner MD, Atkins DC, Burlingham B, Lonczak HS, Tanzer K, Ginzler J, Clifasefi SL, Hobson WG, et al: Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA 2009,301(13):1349-1357.

11.Milby JB, Schumacher JE, McNamara C, Wallace D, Usdan S, McGill T, Michael M: Initiating abstinence in cocaine abusing dually diagnosed homeless persons. Drug Alcohol Depend 2000, 60(1):55-67.

12.Milby JB, Schumacher JE, Vuchinich RE, Wallace D, Plant MA, Freedman MJ, McNamara C, Ward CL: Transitions during effective treatment for cocaineabusing homeless persons: establishing abstinence, lapse, and relapse, and reestablishing abstinence. Psychol Addict Behav 2004, 18(3):250-256.

13.Milby JB, Schumacher JE, Wallace D, Frison S, McNamara C, Usdan S, Michael M: Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up. J Consult Clin Psychol 2003, 71(3):619-621.

References14.Milby JB, Schumacher JE, Wallace D, Freedman MJ, Vuchinich RE: To house or not

to house: the effects of providing housing to homeless substance abusers in treatment. Am J Public Health 2005, 95(7):1259-1265.

15.Kertesz SG, Mullins AN, Schumacher JE, Wallace D, Kirk K, Milby JB: Longterm housing and work outcomes among treated cocaine-dependent homeless persons. J Behav Health Serv Res 2007, 34(1):17-33.

16.Gulcur L, Stefancic A, Shinn M, Tsemberis S, Fischer SN: Housing,hospitalization, and cost outcomes for homeless individuals with psychiatric disabilities participating in continuum of care and housing first programmes. Journal of Community & Applied Social Psychology 2003, 13:171-186.

17.Padgett DK, Gulcur L, Tsemberis S: Housing first services for people who are homeless with co-occurring serious mental illness and substance abuse. Research on Social Work Practice 2006, 16:74-83.

18. Tsemberis S, Gulcur L, Nakae M: Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health 2004, 94(4):651-656.

19.Greenwood RM, Schaefer-McDaniel NJ, Winkel G, Tsemberis SJ: Decreasing psychiatric symptoms by increasing choice in services for adults with histories of homelessness. Am J Community Psychol 2005, 36(3-4):223-238.

References20.Gulcur L, Tsemberis S, Stefancic A, Greenwood RM: Community integration of

adults with psychiatric disabilities and histories of homelessness. Community Ment Health J 2007, 43(3):211-228.

21.Stefancic A, Schaefer-McDaniel NJ, Davis AC, Tsemberis S: Maximizing follow-up of adults with histories of homelessness and psychiatric disabilities. Evaluation and Program Planning 2004, 27:433-442

22.Kushel MB, Colfax G, Ragland K, Heineman A, Palacio H, Bangsberg DR: Case management is associated with improved antiretroviral adherence and CD4+ cell counts in homeless and marginally housed individuals with HIV infection. Clin Infect Dis 2006, 43(2):234-242.

23.Rotheram-Borus MJ, Desmond K, Comulada WS, Arnold EM, Johnson M: Reducing risky sexual behavior and substance use among currently and formerly homeless adults living with HIV. Am J Public Health 2009,99(6):1100-1107.

24.Schwarz K, Garrett B, Lee J, Thompson D, Thiel T, Alter MJ, Strathdee S: Positive impact of a shelter-based hepatitis B vaccine program in homeless Baltimore children and adolescents. J Urban Health 2008, 85(2):228-238.

25.Slesnick N, Prestopnik JL, Meyers RJ, Glassman M: Treatment outcome for street-living, homeless youth. Addict Behav 2007, 32(6):1237-1251.

References26.Slesnick N, Kang MJ: The impact of an integrated treatment on HIV risk

behavior among homeless youth: a randomized controlled trial. J Behav Med 2008, 31(1):45-59.

27.Wolitski RJ, Kidder DP, Pals SL, Royal S, Aidala A, Stall R, Holtgrave DR, Harre D, Courtenay-Quirk C: Randomized trial of the effects of housing assistance on the health and risk behaviors of homeless and unstably housed people living with HIV. AIDS Behav 2010, 14(3):493-503.

28.Kidder DP, Wolitski RJ, Royal S, Aidala A, Courtenay-Quirk C, Holtgrave DR, Harre D, Sumartojo E, Stall R: Access to housing as a structural intervention for homeless and unstably housed people living with HIV: rationale, methods, and implementation of the housing and health study. AIDS Behav 2007, 11(6 Suppl):149-161.