Abstract

Surveillance of Mortality associated with Homelessness: Excess mortality estimates over time, geography, sex and racial disparities

Ben King, PhD MPH¹, Chandler Childress², Emily Curran², Livia Frost³, David Buck, MD MPH⁴ (1)University of Houston, College of Medicine, (2)University of Texas Houston, School of Public Health, (3)Baylor College of Medicine, (4)University of Houston, Community Health

APHA 2022 Annual Meeting and Expo

Background: People experiencing homelessness are an often-neglected population in public health and vital record systems. Understanding what causes of death are most associated with exposure to homelessness can allow for development of better prevention strategies for this population. A pilot, community report has been developed to summarize these significant causes of death.

Methods: Records were collected from the Harris County Institute of Forensic Sciences, from January 2009 to January 2021. Cases associated with homelessness were stratified by year, manner, and geography. Differences in manner of death (Accident, Homicide, Suicide, Natural, and Other) were tested for significant trends over time and between demographic groups. ArcGIS was used to map location data of deaths.

Results: Overall, the number of mortalities has significantly risen over the 13 years studied, from 2009’s total of 68 up to 138 in 2020. The mapped distribution of deaths associated with homelessness was widespread, seemingly independent of neighborhood-level socioeconomic indicators. The age of deaths associated with homelessness increased slightly over the observed period (rho=0.10; p=0.001). In 2021, excess risk of death by accident was 3.5 times greater for individuals experiencing homelessness (OR=3.52, 95%CI: 2.40-5.16), while odds of both homicide and suicide deaths were lower than remaining cohort (OR=0.18, 95%CI: 0.06-0.58; OR=0.15, 95%CI: 0.04-0.63 respectively). The males were more likely to die by accident and natural causes when compared to female (p=0.003; 0.001). Suicides, homicides, and accidents are significantly associated with younger ages (all p<0.005), while natural causes are more associated with older ages (p<0.001). Suicide was also associated with White race (p<0.001), relative to all other race groups.

Discussion: In tracking the homeless causes of death through this mortality report, health professionals and researchers can better provide interventions to reduce excess mortality. However, the lower odds of death from homicide and suicide are likely a result of competing risks and surveillance bias due to the jurisdictional rules of medical examiner investigations. More study, incorporating vital record systems and shelter reporting systems will improve the validity of estimates going forward.

Abstract

Strategies to Assess Familial Housing Instability Within Primary Care

Grace Anne Ludvik, BS--Public Health (Anticipated December 2022)¹, Meghan Mason, PhD, MPH¹, Jacki Hart, MD², Avik Chatterjee, MD, MPH³, Ken Huynh, BS--Human Biology⁴, Sims Ma, BS--Global Disease Biology⁵, Christine Ma, MD⁶, Marvin So, BA, MPH⁷ (1)St. Catherine University, (2)Bassuk Center, (3)Boston University School of Medicine and Boston Medical Center, (4)California State University, (5)University of California, Davis, (6)University of California, San Francisco, (7)University of Minnesota

APHA 2022 Annual Meeting and Expo

Background: Families experiencing housing instability are traditionally difficult to identify and consequently more vulnerable to immediate and long-term adverse health outcomes. While a variety of tools exist to assess housing status in clinical settings for individual adults, research around effective and appropriate tools for use with families is lacking. Standardized housing screening tools would allow health care providers to identify families in need of secure housing, provide equitable population access to housing resources, and be attentive to related adverse health outcomes. This systematic review sought to characterize existing tools evaluating housing instability as the first step in establishing and validating a universal tool for assessing familial housing statuses during primary care visits. This resource would serve as an upstream strategy to better address social determinants of health within the clinical setting.
Methods: We conducted a systematic review across five databases utilizing terms representative of the housing instability continuum. Two independent reviewers examined each study abstract for the following inclusion criteria: discusses housing instability; indicates screening for housing status; U.S. population; written in English; and published 2008-2020. Abstracts that passed initial screening were further reviewed for eligibility based on contents around housing definitions and questions used to evaluate housing status. We resolved differing opinions on inclusion/exclusion through discussion.
Results: Of the 8,713 articles retrieved in the initial search, 332 were eligible for data extraction. The most common definitions of housing instability within literature include “homeless (living in a place not designated for human habitation); “residential mobility (frequently changing residence), and “unstably housed (being high-risk for loss of current housing). Assessments ranged from simple questionnaires to validated tools like the Veterans Affairs’ Homelessness Prevention Screening Toolkit; however, such screening tools were limited by their lack of research around successful use among children and families.
Conclusion: This systematic review further vindicates the need for a validated, standardized screening tool specifically targeting the identification of the full spectrum of familial housing instability within primary care. Methods in screening could be applied as a broader assessment of the social determinants of health or as a separate screening entity. It has been demonstrated that unstable housing negatively impacts health, particularly among children and families–given this, an uncomplicated, time-efficient, population-specific screening tool is vital. This resource will aim to increase equitable population access to housing support interventions by serving as secondary prevention against adverse health outcomes associated with unstable housing.

Abstract

A qualitative exploration of the lived experiences of homelessness during pregnancy in Washington DC

Noelene Jeffers, PhD, MSN, CNM¹, Christina Marea, PhD, MA, MSN, CNM², Andrew Lozano³, Makeda Vanderpuije, MPH, CPH³, Kelly McShane, MBA⁴ (1)Johns Hopkins Bloomberg School of Public Health, (2)Georgetown School of Nursing and Health Studies, (3)DC Health Office of Health Equity, (4)Community of Hope

APHA 2022 Annual Meeting and Expo

Background: Housing insecurity is a social determinant of perinatal health. People experiencing homelessness in pregnancy and their infants experience increased adverse outcomes during pregnancy, the first year after birth, and early childhood. Washington, DC has poor perinatal outcomes, significant challenges with homelessness, and persistent racial disparities in perinatal health and homelessness. This study is a collaboration between the DC Health Office of Health Equity, Community of Hope - a federally qualified health center providing housing services, and clinical researchers.

Objectives: Grounded in a reproductive justice framework, we sought to explore the lived experiences of people who have experienced homelessness during pregnancy in DC.

Methods: We conducted in-depth individual interviews (N=20) with DC residents who experienced homelessness during pregnancy. The semi-structured interview guide explored lived experiences of homelessness in pregnancy, strategies they used to meet their needs, perceptions of services used, and recommendations for how District government and healthcare systems can better support the perinatal health and wellbeing of people experiencing homelessness during pregnancy. We analyzed the data using thematic analysis and an action-oriented research approach.

Results: People who experience homelessness during pregnancy often describe histories of childhood and adolescent housing instability, strained parental and family relationships, and mental health challenges. Participants reported challenges accessing housing and social services during pregnancy due to competing demands and complex program requirements that serve as barriers to access. Participants describe challenges in caring for themselves and their pregnancies while homeless, sometimes attributing pregnancy complications to their housing status. Participants shared recommendations for how DC housing services can provide better support.

Conclusions: Safe and stable housing access is a critical need for pregnant people in order to ensure that they are able to have a child and raise their families in a safe and sustainable environment. Homelessness contributes to adverse perinatal health outcomes and is part of mutually reinforcing systems driven by structural racism. Housing support must be meaningfully accessible and address the complex social histories that clients bring with them.

Public Health Implications: Addressing the negative perinatal health effects of homelessness during pregnancy requires a life course approach, and multi-sectoral collaboration between community-based organizations, health systems, and government safety net services. Achieving health equity for birthing people in Washington DC requires concerted political will to support families with long-term commitment to providing a safe and sustainable environment for growing a family.

Abstract

Triple stigma: Experiences of racism and addiction-and homelessness-related stigmas among overdose survivors in Boston

Jaylen Clarke, MSc¹, Jeff Desmarais, MA², Andres Hoyos-Cespedes, MPH CPH ², Alykhan Nurani , MS³, Shannon E. O'Malley, MS¹, Angela R. Bazzi, PhD MPH⁴, Dan Dooley¹, Simeon Kimmel, MD MA³, Sunday Taylor, PhD¹, Ranjani Paradise, PhD² (1)Boston Public Health Commission, (2)Institute for Community Health, (3)Boston Medical Center, (4)Boston University School of Public Health and University of California San Diego

APHA 2022 Annual Meeting and Expo

Background

Opioid overdoses and homelessness are intertwined critical public health issues. Experiencing homelessness is associated with higher risk of fatal and nonfatal overdose, and in Massachusetts, the drug overdose mortality rate among homeless people ages 25-44 was 16 to 24 times higher than that of the general population (Baggett et al., 2014). Furthermore, there are racial inequities in opioid overdose mortality and post overdose treatment receipt in Massachusetts (Massachusetts Department of Public health, 2021; Dooley et al., Boston Public Health Commission, 2019).

As Experiences of stigma can reduce treatment readiness (Muncan et al., 2020), we sought to explore how racism, anti-addiction related stigma, and anti-homelessness related stigma has been experienced among overdose survivors in Boston who identify as Black and were experiencing homelessness.

Methods

The Boston Overdose Linkage to Treatment Study was a qualitative examination of racial equity in post-overdose access to and experiences of addiction treatment involving semi-structured interviews with overdose survivors in Boston, MA. This analysis focused on a subsample of participants who identified as Black and were experiencing homelessness. The participants were interviewed between 3 weeks and 3 months after their most recent opioid overdose. We coded transcripts and used the Framework Analysis approach to identify stigma-related themes.

Results

Black participants frequently reported feeling mistreated by treatment and service providers, with many specifically referencing hospital staff. Specifically, Black respondents reported that they experienced racism, anti-addiction related stigma, and/or anti-homelessness related stigma. One person said, “It is a lot of lack of respect. Especially if they know you're an addict they definitely don't give you the full respect that you deserve . Another said, “I feel like they give more treatment to the White people than they do Hispanics and Blacks. There was variation in which types of stigmas participants felt were most relevant to their experiences, and some Black participants were unsure if race played a role in their mistreatment. Black participants experiencing homelessness frequently cited the marginalization and stigmatization of homelessness at impacting how they thought about and engaged with different treatment options and services.

Implications

Black people who use opioids and experience homelessness frequently reported “triple stigma across their intersectional identities. Understanding experiences of stigma among this vulnerable population can help healthcare workers and other service providers improve care delivery ensuring that dignity and respect are provided to people who have been marginalized.