DDRESSING THE HEALTH NEEDSof the homeless population is a challenge to physicians, health institutions, and federal, state, and local governments. Homelessness is pervasive in the United States, and an estimated 3.5 million individuals are likely to experience homelessness in a given year. 1 To address this problem, 860 cities and counties have enacted 10-year plans to end homelessness, and 49 states have created Interagency Councils on Homelessness. 2 Rates of chronic medical illness are high among homeless adults. With the exception of obesity, stroke, and cancer, homeless adults are far more likely to have a chronic medical illness such as human immunodeficiency virus (HIV), hypertension, and diabetes mellitus and more likely to experience a complication from the illness because they lack adequate housing and regular, uninterrupted treatment. [3][4][5][6] Homeless adults are frequent users of costly emergency department and hospital services, largely paid for by public dollars. [7][8][9][10][11][12][13][14] The combination of chronic medical illnesses and poor access to primary health care has substantial health and economic consequences.Prior intervention research has focused on subgroups of the homeless For editorial comment see p 1822. Context Homeless adults, especially those with chronic medical illnesses, are frequent users of costly medical services, especially emergency department and hospital services. Objective To assess the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical illnesses. Design, Setting, and Participants Randomized controlled trial conducted at a public teaching hospital and a private, nonprofit hospital in Chicago, Illinois. Participants were 407 social worker-referred homeless adults with chronic medical illnesses (89% of referrals) from September 2003 until May 2006, with follow-up through December 2007. Analysis was by intention-to-treat.Intervention Housing offered as transitional housing after hospitalization discharge, followed by placement in long-term housing; case management offered onsite at primary study sites, transitional housing, and stable housing sites. Usual care participants received standard discharge planning from hospital social workers.Main Outcome Measures Hospitalizations, hospital days, and emergency department visits measured using electronic surveillance, medical records, and interviews. Models were adjusted for baseline differences in demographics, insurance status, prior hospitalization or emergency department visit, human immunodeficiency virus infection, current use of alcohol or other drugs, mental health symptoms, and other factors. ResultsThe analytic sample (n=405 [n=201 for the intervention group, n=204 for the usual care group]) was 78% men and 78% African American, with a median duration of homelessness of 30 months. After 18 months, 73% of participants had at least 1 hospitalization or emergency department visit. Compared with the usual care group, the inter...

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Objectives. We assessed the health impact of a housing and case management program, the Chicago Housing for Health Partnership, for homeless people with HIV. Methods. HIV-positive homeless inpatients at a public hospital (n = 105) were randomized to usual care or permanent housing with intensive case management. The primary outcome was survival with intact immunity, defined as CD4 count ≥ 200 and viral load < 100 000. Secondary outcomes were viral loads, undetectable viral loads, and CD4 counts. Results. Outcomes were available for 94 of 105 enrollees (90%). Of 54 intervention participants, 35 (65%) reached permanent housing in program housing agencies. After 1 year, 55% of the intervention and 34% of the usual care groups were alive and had intact immunity (P = .04). Seventeen intervention (36%) and 9 usual care (19%) participants had undetectable viral loads (P = .051). Median viral loads were 0.89 log lower in the intervention group (P = .03). There were no statistical differences in CD4 counts. Conclusions. Homelessness is a strong predictor of poor health outcomes and complicates the medical management of HIV. This housing intervention improved the health of HIV-positive homeless people.

Objective To determine the prevalence of physical violence during pregnancy and the factors associated with it.Design A population-based, multicentre, cross sectional household survey.Setting Rural, slum and urban non-slum areas of Bhopal, Chennai, Delhi, Lucknow, Nagpur, Trivandrum and Vellore, in India. Participants A total of 9938 women who were 15 to 49 years of age and living with a child younger than 18 years old. Methods Probability proportionate to size sampling of households was performed in three strata. Trained field workers administered a structured questionnaire. Women who reported domestic violence were asked about violence during pregnancy. Outcome variables included six violent behaviours: slap, hit, kick, beat, use of weapon and harm in any other way. Moderate to severe violence was defined as experience of any one or more of the following behaviours: hit, beat or kick. Odds ratios were calculated for risk and protective factors of violence during pregnancy using logistic regression. Main outcome measures Physical spousal violence.Results The lifetime experience, during pregnancy, of being slapped was 16%, hit 10%, beat 10%, kicked 9%, use of weapon 5% and harmed in any other way 6%. Eighteen percent of women experienced at least one of these behaviours and 3% experienced all six. The overall prevalence of moderate to severe violence during pregnancy was 13%. Logistic regression showed that the factors determining whether a woman experienced moderate to severe violence during pregnancy were: husband accusing wife of an affair (OR 7.1; 95% CI 5.1 to 9.8), dowry harassment (OR 4.1; 95% CI 2.8 to 6.1), husband having an affair (OR 3.7; 95% CI 2.8 to 4.8), husband being regularly drunk (OR 3.2; 95% CI 2.6 to 4.1), low education of husband (OR 2.8; 95% CI 1.4 to 5.6), substance abuse by husband (OR 2.6; 95% CI 1.3 to 5.5), no social support (OR 1.8; 95% CI 1.1 to 3.0), three or more children (OR 1.6; 95% CI 1.2 to 2.1) and household crowding (OR 1.1; 95% CI 1.0 to 1.2). Conclusion In this study, 12.9% of women experienced moderate to severe physical violence during pregnancy. Suspicion of infidelity, dowry harassment, husband being regularly drunk and low education of husband were the main risk factors for violence during pregnancy.

Context-Although partner violence screening has been endorsed by many health organizations, there is insufficient evidence that it has beneficial health outcomes.