H omeless and vulnerably housed populations are heterogeneous 1 and continue to grow in numbers in urban and rural settings as forces of urbanization collide with gentrification and austerity policies. 2 Collectively, they face dangerous living conditions and marginalization within health care systems. 3 However, providers can improve the health of people who are homeless or vulnerably housed, most powerfully by following evidence-based initial steps, and working with communities and adopting anti-oppressive practices. 1,4,5 Broadly speaking, "homelessness" encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it. 6 Under such conditions, individuals and families face intersecting social, mental and physical health risks that significantly increase morbidity and mortality. 7,8 For example, people who are homeless and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population. 7,9 Canadian research reports that people who experience homelessness face life expectancies as low as 42 years for men and 52 years for women. 7 A generation ago, homeless Canadians were largely middleaged, single men in large urban settings. 10 Today, the epidemiology has shifted to include higher proportions of women, youth, Indigenous people (Box 1), immigrants, older adults and people from rural communities. 13,14 For example, family homelessness (and therefore homelessness among dependent children and youth) is a substantial, yet hidden, part of the crisis. 15 In 2014, of the estimated 235 000 homeless people in Canada, 27.3% were women, 18.7% were youth, 6% were recent immigrants or migrants, and a growing number were veterans and seniors. 10
Background Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. Methods and findings We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case
BackgroundPersons experiencing homelessness and vulnerable housing or those with lived experience of homelessness have worse health outcomes than individuals who are stably housed. Structural violence can dramatically affect their acceptance of interventions. We carried out a systematic review to understand the factors that influence the acceptability of social and health interventions among persons with lived experience of homelessness.MethodsWe searched through eight bibliographic databases and selected grey literature sources for articles that were published between 1994 and 2019. We selected primary studies that reported on the experiences of homeless populations interacting with practitioners and service providers working in permanent supportive housing, case management, interventions for substance use, income assistance, and women- and youth-specific interventions. Each study was independently assessed for its methodological quality. We used a framework analysis to identify key findings and used the GRADE-CERQual approach to assess confidence in the key findings.FindingsOur search identified 11,017 citations of which 35 primary studies met our inclusion criteria. Our synthesis highlighted that individuals were marginalized, dehumanized and excluded by their lived homelessness experience. As a result, trust and personal safety were highly valued within human interactions. Lived experience of homelessness influenced attitudes toward health and social service professionals and sometimes led to reluctance to accept interventions. Physical and structural violence intersected with low self-esteem, depression and homeless-related stigma. Positive self-identity facilitated links to long-term and integrated services, peer support, and patient-centred engagement.ConclusionsIndividuals with lived experience of homelessness face considerable marginalization, dehumanization and structural violence. Practitioners and social service providers should consider anti-oppressive approaches and provide, refer to, or advocate for health and structural interventions using the principles of trauma-informed care. Accepting and respecting others as they are, without judgment, may help practitioners navigate barriers to inclusiveness, equitability, and effectiveness for primary care that targets this marginalized population.
The indicators assessed in this study point to a benefit for patients under the care of female physicians. Potential explanations are discussed.
Worldwide, over 1.8 billion people lack adequate housing and almost 25% of the world's urban population reside in informal accommodation (United Nations Human Rights Council, 2019). "People with a lived experience of homelessness" is a term coined to describe individuals who are, have been, or at risk of becoming homeless. This population lacks stable, permanent, appropriate housing, or may be without immediate prospect, means and ability to acquire it. Such physical living situations can include emergency shelters or provisional accommodations (Canadian Observatory on Homelessness, 2017). This population continues to grow, giving rise to a major international clinical and public health priority. Homelessness is strongly associated with high levels of morbidity (Hwang, Wilkins, Tjepkema, O'Campo, & Dunn, 2009) and mortality (Nordentoft & Wandall-Holm, 2003). People with lived experience of homelessness are at an increased risk for acute illnesses, such as traumatic injury
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