Differential Risk for Homelessness among US Male and Female Veterans with a Positive Screen for Military Sexual Trauma

IMPORTANCE:

Military sexual trauma (MST) is associated with adverse physical and mental health outcomes following military separation. Recent research suggests that MST may be a determinant in several factors associated with post deployment homelessness.

OBJECTIVE:

To evaluate MST as an independent risk factor for homelessness and to determine whether risk varies by sex.

DESIGN, SETTING, AND PARTICIPANTS:

A retrospective cohort study of US veterans who used Veterans Health Administration (VHA) services between fiscal years 2004 and 2013 was conducted using administrative data from the Department of Defense and VHA. Included in the study were 601 892 US veterans deployed in Iraq or Afghanistan who separated from the military between fiscal years 2001 and 2011 and subsequently used VHA services.

EXPOSURE:

Positive response to screen for MST administered in VHA facilities.

MAIN OUTCOMES AND MEASURES:

Administrative evidence of homelessness within 30 days, 1 year, and 5 years following the first VHA encounter after last deployment.

RESULTS:

The mean (SD) age of the 601 892 participants was 38.9 (9.4) years, 527 874 (87.7%) were male, 310 854 (51.6%) were white, and 382 361 (63.5%) were enlisted in the Army. Among veterans with a positive screen for MST, rates of homelessness were 1.6% within 30 days, 4.4% within 1 year, and 9.6% within 5 years, more than double the rates of veterans with a negative MST screen (0.7%, 1.8%, and 4.3%, respectively). A positive screen for MST was significantly and independently associated with postdeployment homelessness. In regression models adjusted for demographic and military service characteristics, odds of experiencing homelessness were higher among those who screened positive for MST compared with those who screened negative (30-day: adjusted odds ratio [AOR], 1.89; 95% CI, 1.58-2.24; 1-year: AOR, 2.27; 95% CI, 2.04-2.53; and 5-year: AOR, 2.63; 95% CI, 2.36-2.93). Military sexual trauma screen status remained independently associated with homelessness after adjusting for co-occurring mental health and substance abuse diagnoses in follow-up regression models (30-day: AOR, 1.62; 95% CI, 1.36-1.93; 1-year: AOR, 1.49; 95% CI, 1.33-1.66; and 5-year: AOR, 1.39; 95% CI, 1.24-1.55). In the fully adjusted models, the interaction between MST status and sex was significant in the 30-day and 1-year cohorts (30-day: AOR, 1.54; 95% CI, 1.18-2.02; and 1-year: AOR, 1.46; 95% CI, 1.23-1.74), denoting higher risk for homelessness among males with a positive screen for MST.

CONCLUSIONS AND RELEVANCE:

A positive screen for MST was independently associated with postdeployment homelessness, with male veterans at greater risk than female veterans. These results underscore the importance of the MST screen as a clinically important marker of reintegration outcomes among veterans. These findings demonstrate significant long-term negative effects and inform our understanding of the public health implications of sexual abuse and harassment.

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By:  Brignone E1, Gundlapalli AV2, Blais RK1, Carter ME2, Suo Y2, Samore MH2, Kimerling R3, Fargo JD1.

• 1Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah 2Department of Psychology, Utah State University, Logan.
• 2Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah3Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City4Department of Biomedical Informatics, Univer.
• 3National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California6Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California.
• JAMA Psychiatry. 2016 Apr 20. doi: 10.1001/jamapsychiatry.2016.0101. 

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Cervical Cancer Screening among Homeless Women in the Greater Paris Area (France): Results of the ENFAMS Survey

Little is known about the prevalence of cervical cancer screening (CCS) and its correlates among homeless women in France. The objectives of this study were to determine the prevalence of women who had never been screened for cervical cancer and to identify the associated factors. 

This cross-sectional study was based on data collected in the ENFAMS survey, which was conducted in 2013 among 764 sheltered homeless mothers in the Greater Paris Area. Robust Poisson regression models were used to estimate the association between no lifetime CCS and certain sociodemographic and health-related factors (selected from the behavioral model of vulnerable populations). 

Analyses were carried out separately for women with and without a regular gynaecological follow-up (RGF). The proportion of never-screeners was 33% among the women with an RGF versus 64% among those without an RGF (P<0.001). Among the latter, never having been screened for CCS was associated mainly with socioeconomic conditions, the length of time lived in France, a history of delivery in France and the duration of homelessness. 

In those with an RGF, the factors were mainly poor health service utilization and language difficulties. This first quantitative study of CCS among homeless women in the Greater Paris Area points to the need for it to be proposed and performed more systematically in primary care. 

Every contact between this hard-to-reach population and health services should be an opportunity to check their screening status and to ensure that those in need actually undergo a Pap test.

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By:  Vuillermoz C1, Vandentorren S, Roze M, Rondet C, Chauvin P.

• 1 Department of Social Epidemiology, INSERM, Institut Pierre Louis d'épidémiologie et de Santé Publique (IPLESP UMRS 1136) 
• b Department of the Inter-Regional Epidemiological Autorithy, French Institute for Public Health Surveillance, Saint-Maurice 
• c Department of General Practice, School of Medicine, Sorbonne Universities, UPMC Univ Paris 06, Paris, France.
• Eur J Cancer Prev. 2016 Feb 18. 

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Cervical Cancer Screening among Homeless Women of New York City Shelters

Introduction

Homeless persons have minimal opportunities to complete recommended cancer screening. The rates and predictors of cervical cancer screening are understudied among homeless women in the US.

Methods

We enrolled 297 homeless women 21-65 years old residing in 6 major New York City shelters from 2012 to 2014. We used a validated national survey to determine the proportion and predictors of cervical cancer screening using cytology (Pap test).

Results

Mean age was 44.72 (±11.96) years. Majority was Black, heterosexual, single, with high school or lower education; 50.9 % were smokers and 41.7 % were homeless more than a year. Despite a 76.5 % proportion of self-reported Pap test within the past 3 years, 65 % of women assumed their Pap test results were normal or did not get proper follow up after abnormal results. Forty-five-point-nine percent of women did not know about frequency of Pap test or causes of cervical cancer. Lower proportion of up-to-date Pap test was associated with lack of knowledge of recommended Pap test frequency (p < 0.01) and relationship between HPV and an abnormal Pap test (p < 0.01).

Conclusions

Self-reported Pap testing in homeless women was similar to a national sample. However, the majority of women surveyed were not aware of their results, received limited if any follow up and had significant education gaps about cervical cancer screening. We recommend improved counseling and patient education, patient navigators to close screening loops, and consideration of alternative test-and-treat modalities to improve effective screening.

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By:  Asgary R1,2, Alcabes A3, Feldman R4, Garland V3, Naderi R5, Ogedegbe G6, Sckell B3.

• 1Departments of Population Health and Medicine, New York University School of Medicine, 227 E30th Street, Room 639, New York, NY, 10016, USA. ramin.asgary@caa.columbia.edu.
• 2Community Medicine Program, NYU Lutheran Family Health Centers, 317 Bowery Street, New York, NY, 10003, USA. ramin.asgary@caa.columbia.edu.
• 3Community Medicine Program, NYU Lutheran Family Health Centers, 317 Bowery Street, New York, NY, 10003, USA.
• 4Department of OBGYN, The Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
• 5New York University School of Medicine, 227 E30th Street, New York, NY, 10016, USA.
• 6Departments of Population Health and Medicine, New York University School of Medicine, 227 E30th Street, Room 639, New York, NY, 10016, USA.
• Matern Child Health J. 2015 Dec 9.  

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Trajectories of Women's Homelessness in Canada's Three Northern Territories

BACKGROUND:

Repairing the Holes in the Net was a 2-year, multilevel action research project designed to inform the development of culturally appropriate and gender-specific services for northern women who are homeless or marginally housed and who face mental health and substance use concerns. The study was designed to learn about the barriers and supports experienced by homeless women in the North when accessing mental health care, shelter, housing and other services; and to inform the work of northern service providers and policy advocates in a position to implement adjustments in their praxis.

METHODS:

This article describes the trajectories of women's service access and their ideas for service improvement from 61 qualitative, semi-structured interviews conducted with homeless women in Whitehorse, Yukon (YT), Yellowknife, Northwest Territories (NT), and Iqualit, Nunavut (NU).

RESULTS:

Unresolved trauma, poverty and social exclusion, inability to find and maintain housing and ineffective services emerged as interconnected and multifaceted challenges related to women's service engagement. In the face of these challenges, women displayed significant resilience and resistance, and offered important ideas for service improvement.

CONCLUSIONS:

The 4 interconnected systemic challenges identified in the research, coupled with specific ideas for change cited by the resilient homeless women interviewed, offer points of entry to improve service policy and delivery. Implementing trauma-informed approaches emerged as a key example of how access to, and quality of, services could be improved for homeless women in the North.

Table II. Summary of services used by northern homeless women interviewed, by territory

	Total	Nunavut	NWT	Yukon
	n=61	n=20	n=20	n=21
Number of services reported
Mean	7.3	5.6	6.6	9.6
Range	(3–15)	(3–11)	(3–15)	(4–12)
Type of service (n, %)
Counselling for mental health or addictions concerns	46 (75%)	15 (75%)	13 (65%)	18 (86%)
Family violence shelter	44 (72%)	18 (90%)	8 (40%)	18 (86%)
Income Support	40 (66%)	7 (35%)	16 (80%)	17 (81%)
Housing Authority or other property management	39 (64%)	12 (60%)	12 (60%)	15 (71%)
Social service (e.g. Family and Child Services)	38 (62%)	14 (70%)	13 (65%)	11 (52%)
Homelessness shelter	33 (54%)	9 (45%)	12 (60%)	12 (57%)
Police/justice	29 (48%)	10 (50%)	8 (40%)	11 (52%)
Other community-based resource	28 (46%)	1 (5%)	9 (45%)	18 (86%)
Food-based service	20 (33%)	2 (10%)	3 (15%)	15 (71%)
Educational programming	17 (28%)	1 (5%)	10 (50%)	6 (29%)
Hospital	16 (26%)	4 (20%)	4 (20%)	8 (38%)
Indigenous cultural or wellness service	15 (25%)	3 (15%)	1 (5%)	11 (52%)
Primary health care/nurses station	14 (23%)	3 (15%)	7 (35%)	4 (19%)
In-patient addiction or mental health treatment (in Territory)	11 (18%)	N/A	6 (30%)	5 (24%)
Alcoholics Anonymous	11 (18%)	2 (10%)	4 (20%)	5 (24%)
In-patient addiction or mental health treatment (out of Territory)	10 (16%)	5 (25%)	1 (5%)	4 (19%)
Service for disability support	9 (15%)	1 (5%)	0 (0%)	8 (38%)
Harm reduction service	8 (13%)	N/A	N/A	8 (38%)
Alcohol or drug detox	7 (11%)	N/A	1 (5%)	6 (29%)
Church	5 (8%)	0 (0%)	3 (15%)	2 (10%)
Legal Aid	5 (8%)	3 (15%)	1 (5%)	1 (5%)
Crisis line	2 (3%)	2 (10%)	0 (0%)	0 (0%)

Below:  Four overarching themes emerged from women's descriptions of the trajectory of their homelessness and their experience of accessing services: (a) unresolved trauma, (b) poverty and social exclusion, (c) inability to find and maintain housing and (d) ineffective services. Participants described how a number of vicious cycles made it difficult to find housing, food security and to heal emotionally

 

Full article at:    http://goo.gl/G9wkPv

By:   Schmidt R¹, Hrenchuk C², Bopp J³, Poole N⁴.

¹BC Centre of Excellence for Women's Health, Vancouver, BC, Canada; Rose.schmidt@cw.bc.ca.

²Yukon Status of Women Council, Whitehorse, YT, Canada.

³Four Worlds Centre for Development Learning, Cochrane, AB, Canada.

⁴BC Centre of Excellence for Women's Health, Vancouver, BC, Canada.

  

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Facets of Male Violence Against Women with Substance Abuse Problems: Women with a Residence and Homeless Women

The aims of this study were to investigate the type and extent to which women with substance abuse problems have been exposed to male violence during their lifetime, and to examine possible differences between women with a residence (WR) and homeless women (HW). 

The total sample included 79 women (WR, n = 35; HW, n = 44; M age = 47.8 years). Of the total sample, 72 women (91%) had experienced different kinds of male violence, 88% from former partners, and 26% from male friends or acquaintances. 

Of the 72 women, 71% further reported "Countless occasions of violent events," and 36% had been forced to commit criminal acts. Abused women who had been forced to commit criminal acts were significantly more frequently found to be homeless, have reported parental alcohol and/or drug problems, have witnessed domestic violence in childhood, have been victims of sexual violence, have used illicit drugs as a dominant preparation, and have injected illicit drugs. Almost half of the abused women (46%) met criteria for posttraumatic stress disorder (PTSD), where HW showed an almost 4-time higher risk (RR 3.78) than WR. 

In conclusion there is a particular vulnerability in women with substance abuse to male violence, which has an important impact on their health status. Thus, from a public health perspective, it is suggested that for those women who have experienced male violence, treatment protocols need to include both assessing and addressing the impact of such experience in relation to substance abuse as well as concomitant health concerns.

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By:  Beijer U1, Scheffel Birath C2, DeMartinis V3, Af Klinteberg B4.

• 1Karolinska Institutet, Stockholm, Sweden ulla.beijer@ki.se.
• 2Stockholm Centre for Dependency Disorders, Sweden.
• 3Uppsala University, Sweden Innlandet Hospital Trust, Norway.
• 4Karolinska Institutet, Stockholm, Sweden Stockholm University, Sweden. 

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