Places in protecting housing per 100 000 inhabitants from 1990 to 2012, Western Europe

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How has the extent of institutional mental healthcare changed in Western Europe? Analysis of data since 1990.

Chow WS¹, Priebe S¹.

¹Unit for Social and Community Psychiatry (WHO Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK.

BMJ Open. 2016 Apr 29;6(4):e010188. doi: 10.1136/bmjopen-2015-010188.

Case Management Models in Permanent Supported Housing Programs for People with Complex Behavioral Issues who are Homeless

OBJECTIVE:

The purpose of this article is to examine two evidence-based models of case management for people with co-occurring disorders and histories of chronic homelessness, and to better understand their roles in permanent supported housing. Critical Time Intervention and Assertive Community Treatment are examined in terms of key elements, how they assist in ending homelessness, as well as the role they play in an individual's recovery from co-occurring disorders.

METHODS:

Participants in two supported housing programs were interviewed at baseline and 6 months. One program used Critical Time Intervention (n = 144) and the other used Assertive Community Treatment (n = 90). Staff in both programs were interviewed about their experiences and fidelity assessments were conducted for each program.

RESULTS:

Both programs operated at high levels of fidelity. Despite similar criteria for participation, there were significant differences between groups. Critical Time Intervention participants were older, more likely to be male, more likely to be homeless, and reported greater psychiatric symptoms and higher levels of substance use (all p's < .001). Separate outcome analyses suggested that each program was successful in supporting people to transition from homelessness to stable housing; 88.6% of Assertive Community Treatment participants were homeless at baseline, while at 6 months 30% were homeless (p < .001), and 91.3% of those in the Critical Time Intervention were homeless at baseline, while 44.3% were homeless at 6 months (p < .001). Participants in the Critical Time Intervention program also showed significant decreases in alcohol use, drug use and psychiatric symptoms (all p's < .01). The preliminary results suggest that each case management model is helpful in assisting people with complex behavioral health needs and chronic homelessness to move to stable housing.

CONCLUSIONS:

Permanent supported housing seems to be an effective way to end homelessness among people with co-occurring disorders. Further research is needed to determine which case management models work most effectively with supported housing to help policy makers and program directors make informed decisions in developing these programs.

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By:  Clark C1, Guenther CC1, Mitchell JN1.

• 1 University of South Florida , Department of Mental Health Law and Policy. 
• J Dual Diagn. 2016 Apr 12:0

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The Hidden Work of Exiting Homelessness: Challenges of Housing Service Use and Strategies of Service Recipients

This study explored the experiences of parents attempting to re-attain housing after a shelter stay. 

Eighty parents participated in semistructured face-to-face interviews approximately six months after being recruited from shelters in four states across the U.S. Qualitative analyses identified common challenges of service use, strategies of service recipients, and characteristics of positive and negative service experiences.

Challenges of service use included "catch-22s" resulting from incongruity between service policies/procedures and participants' contexts and/or requirements of other services, confusion and uncertainty resulting from absent or insufficient communication about services, and long waitlists. 

Participants demonstrated persistence and determination, networked with service providers, and activated formal resources. Positive service experiences were tailored to families' needs and marked by clear and consistent communication between providers and with service recipients. 

Findings suggest effective health communication tactics should be applied to housing services. Providers should collaborate to ensure service attainment does not impede other pathways to stability.

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By:  Mayberry LS1.

• 1Division of General Internal Medicine & Public Health, Vanderbilt University Medical Center Nashville, TN. 
• J Community Psychol. 2016 Apr 1;44(3):293-310. Epub 2016 Mar 9.

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Associations of Financial Stressors & Physical Intimate Partner Violence Perpetration

Background

Contextual factors, such as exposure to stressors, may be antecedents to IPV perpetration. These contextual factors may be amenable to modification through intervention and prevention. However, few studies have examined specific contextual factors. To begin to address this gap, we examined the associations between financial stressors and three types of physical IPV perpetration.

Methods

This analysis used data from Wave IV of The National Longitudinal Study of Adolescent to Adult Health. We used logistic regression to examine the associations of financial stressors and each type of IPV (minor, severe, causing injury), and multinomial logit regression to examine the associations of financial stressors and patterns of co-occurring types of IPV perpetration (only minor; only severe; minor and severe; minor, severe, and causing injury; compared with no perpetration).

Results

Fewer men perpetrated threats/minor physical IPV (6.7 %) or severe physical IPV (3.4 %) compared with women (11.4 % and 8.8 %, respectively). However, among physical IPV perpetrators, a higher percentage of men (32.0 %) than women (21.0 %) reported their partner was injured as a result of the IPV. In logistic regression models of each type of IPV perpetration, both the number of stressors experienced and several types of financial stressors were associated with perpetrating each type of IPV. Utilities nonpayment, housing nonpayment, food insecurity, and no phone service were associated with increased odds of perpetrating each form of IPV in adjusted analysis. Eviction was associated with perpetrating severe physical IPV but not threats/minor IPV or IPV causing injury. In multinomial logit regression comparing patterns of IPV perpetration to perpetrating no physical IPV, the relationships of financial stressors were less consistent. Food insecurity was associated with perpetrating only minor physical IPV. Comparatively, overall number of financial stressors and four types of financial stressors (utilities nonpayment, housing nonpayment, food insecurity, and disconnected phone service) were associated with perpetrating all three forms of physical IPV.

Conclusions

Combined with prior research, our results suggested interventions to improve financial well-being may be a novel way to reduce physical IPV perpetration.

Estimated proportion and 95 % confidence estimates of exposure to financial stressors and perpetration of three forms of physical IPV

	Men	Women	Difference
	Percent (95 % CI)		P-valuea
Financial stressors
Number of financial stressors			<.0001
None	77.2 (75.4–79.1)	72.3 (70.2–74.5)
1–2	16.3 (14.2–18.4)	18.8 (16.8–20.8)
3–4	5.2 (4.1–6.2)	7.3 (6.0–8.6)
5–6	1.4 (0.9–1.8)	1.5 (1.0–2.0)
Utilities nonpayment
Yes	12.7 (11.5–14.0)	17.6 (15.7–19.4)	<.0001
No	87.3 (86.0–88.5)	82.4 (80.6–84.3)
Housing nonpayment
Yes	9.4 (8.4–10.4)	10.2 (9.0–11.3)	.26
No	90.6 (89.6–91.6)	89.8 (88.7–91.0)
Food insecurity
Yes	9.9 (8.7–11.1)	14.0 (12.6–15.3)	<.0001
No	90.1 (88.9–91.3)	86.0 (84.7–87.4)
No phone service
Yes	7.8 (6.8–8.8)	10.4 (9.3–11.5)	<.0001
No	92.2 (91.2–93.2)	89.6 (88.5–90.7)
Utilities turned off
Yes	5.4 (4.6–6.3)	5.4 (4.6–6.1)	.82
No	94.6 (93.7–95.4)	94.7 (93.9–95.4)
Evicted
Yes	1.0 (0.7–1.4)	1.0 (0.7–1.4)	.93
No	99.0 (95.6–99.3)	98.9 (98.6–99.3)
Intimate partner violence perpetration
Threats/Minor physical
Yes	6.7 (5.7–7.5)	11.4 (10.1–12.7)	<.0001
No	93.4 (92.5–94.3)	88.6 (87.3–89.9)
Severe physical
Yes	3.4 (2.9–4.0)	8.8 (7.8–9.9)	<.0001
No	96.6 (96.0–97.2)	91.2 (90.1–92.2)
If Yes to physical, caused injury
Yes	32.0 (25.6–38.5)	21.0 (17.7–24.4)	.003
No	68.0 (61.5–74.4)	79.0 (75.6–82.3)

aChi-square test

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

By:  Laura M. Schwab-Reese, Corinne Peek-Asa, and Edith Parker

Department of Community & Behavioral Health, University of Iowa College of Public Health, Iowa City, IA 52240 USA

Department of Occupational & Environmental Health, University of Iowa College of Public Health, Iowa City, IA 52240 USA

Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, University of Colorado, Anschutz Medical Campus, 13123 E 16th Ave, B390, Aurora, CO 80045 USA

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Homeless Shelters’ Policies on Sex Offenders: Is This Another Collateral Consequence?

The primary focus of sex offender research has been on the efficacy and collateral consequences of sex offender registration and notification (SORN) and residence restrictions. Past scholarship has found these laws to cause numerous re-entry barriers for sex offenders. Such barriers have affected sex offenders’ ability to find and maintain housing, employment, and social support. Moreover, registered sex offenders (RSOs) have become homeless due to such laws. 

Although previous scholarship has highlighted the collateral consequences of SORN, there is a lack of scholarship addressing homeless sex offenders. Specifically, the current study assesses policies regarding RSO access to homeless shelters in a four-state region, focusing on the effect of structural, procedural, and geographic factors, as well as a shelter’s proximity to children. 

Drawing on the loose coupling organizational framework, the findings suggest that a small maximum occupancy, unwritten policies for RSOs, being in Kentucky or Tennessee, being located near a school, and being near a higher proportion of homes with children all decrease the odds that a homeless shelter allows RSOs. Furthermore, although unwilling to make exceptions to the policies regarding RSOs, shelters were generally willing to make exceptions to other policies governing shelter accessibility.

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By:  Shawn M. Rolfe1⇑, Richard Tewksbury1, Ryan D. Schroeder1

¹University of Louisville, KY, USA

Shawn M. Rolfe, University of Louisville, Brigman Hall, Louisville, KY 40292, USA. Email: shawn.rolfe@louisville.edu

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Foreclosure and Health in Southern Europe: Results from the Platform for People Affected by Mortgages

Housing instability has been shown to be related to poorer health outcomes in various studies, mainly in the USA and UK. Affected individuals are more prone to psychiatric (e.g., major depression, anxiety) and physical disorders (e.g., hypertension). This situation has deteriorated with the onset of the economic crisis. One of the most affected countries is Spain, which has high rates of foreclosure and eviction that continue to rise. In response, a civil movement, The Platform for People Affected by Mortgages (PAH), works to provide solutions to its members affected by foreclosure and advocates for the right to decent housing. 

The aims of this study ware to describe and compare the health status of PAH members from Catalonia to a sample of the general population and to analyze the association between health status and mortgage status, foreclosure stage, and other socioeconomic variables, among members of the PAH. We conducted a cross-sectional study using a self-administered online questionnaire (2014) administered to 905 PAH members in Catalonia (>18 years; 559 women and 346 men). Results were compared with health indicators from The Health Survey of Catalonia 2013 (n = 4830). The dependent variables were poor mental health (GHQ 12 ≥ 3), and poor self-reported health (fair or poor). All analyses were stratified by sex. We computed age-standardized prevalence and prevalence ratios of poor mental and self-reported health in both samples. We also analyzed health outcomes among PAH members according to mortgage status (mortgage holders or guarantors), stage of foreclosure, and other socioeconomic variables by computing prevalence ratios from robust Poisson regression models. 

The prevalence of poor mental health among PAH members was 90.6 % in women and 84.4 % in men, and 15.5 and 10.2 % in the general population, respectively. The prevalence of poor self-reported health was 55.6 % in women and 39.4 % in men from the PAH, and 19.2 and 16.1 % in the general population, respectively. These health inequalities were independent of socioeconomic status. The prevalence of poor mental health was higher among individuals in the non-payment stage of foreclosure than among those who were up to date with their payments. 

In contrast, self-reported poor health was more prominent in later stages of foreclosure, such as in post-eviction without dation in payment stage in men. 

We observed a considerably higher prevalence of poor mental and self-reported health among male and female PAH members than in the general population. Public policies that tackle housing instability and its consequences are urgently needed in Spain.

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By:  Vásquez-Vera H1,2,3, Rodríguez-Sanz M1,2,4,5, Palència L2,4, Borrell C6,7,8,9,10.

• 1Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain.
• 2Agència de Salut Pública de Barcelona, Barcelona, Spain.
• 3Centro de Estudios para la Equidad en Salud, Universidad de La Frontera, Temuco, Chile.
• 4CIBER de Epidemiología y Salud pública (CIBERESP), Madrid, Spain.
• 5Institute of Biomedical Research (IIB-Sant Pau), Barcelona, Spain.
• 6Department of Experimental and Health Sciences, Universitat Pompeu Fabra, Barcelona, Spain. cborrell@aspb.cat.
• 7Agència de Salut Pública de Barcelona, Barcelona, Spain. cborrell@aspb.cat.
• 8CIBER de Epidemiología y Salud pública (CIBERESP), Madrid, Spain. cborrell@aspb.cat.
• 9Institute of Biomedical Research (IIB-Sant Pau), Barcelona, Spain. cborrell@aspb.cat.
• 10Agència de Salut Pública de Barcelona, Avinguda Lesseps 1, ES-08023, Barcelona, Spain. cborrell@aspb.cat. 
• J Urban Health. 2016 Mar 3.

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Emergency Department Visits for Homelessness or Inadequate Housing in New York City Before and After Hurricane Sandy

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. 

In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. 

We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. 

Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. 

Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.

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By:  Doran KM1,2, McCormack RP1, Johns EL3, Carr BG4,5, Smith SW1, Goldfrank LR1, Lee DC6,7.

• 1Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA.
• 2Department of Population Health, New York University School of Medicine, New York, NY, USA.
• 3New York City Center for Innovation through Data Intelligence, New York, NY, USA.
• 4Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
• 5Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC, USA.
• 6Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA. david.lee@nyumc.org.
• 7Department of Population Health, New York University School of Medicine, New York, NY, USA. david.lee@nyumc.org. 
• J Urban Health. 2016 Mar 15.

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Housing Outcomes & Predictors of Success: The Role of Hospitalization in Street Outreach

SUMMARY:

What is known on the subject? 

• Outreach services are often successful in engaging and housing street homeless individuals. People experiencing homelessness have greatly increased rates of mental illness and substance abuse. 

What this paper adds to existing knowledge? 

• Given the relative lack of research involving street homeless individuals, this retrospective chart review examined factors associated with successful housing by a multidisciplinary street outreach team, including the use of hospitalization as an intervention within a housing first framework. The majority of clients were successfully housed by the end of outreach team involvement. An admission to hospital was strongly associated with successful housing for those with a psychotic disorder. 

What are the implications for practice? 

• Multidisciplinary outreach teams, specifically those with psychiatric and nursing support, successfully work with and house people experiencing street homelessness and psychosis. Mental health nurses embedded in the community are an essential link between inpatient and outpatient care for highly vulnerable street homeless individuals.

ABSTRACT:

Introduction 
Housing-first strategies have helped establish housing as a human right. However, endemic homelessness persists. Multidisciplinary outreach teams that include nursing, social and psychiatric services allow for integrative strategies to engage and support clients on their housing trajectory. 

The following retrospective review focused on the identification of demographic, clinical, and service characteristics that predicted the obtainment of housing, and explored the role of psychiatric hospitalization as an intervention, not an outcome measure, in contrast to previous studies. These have rarely focused on street homelessness. 

Method
A retrospective chart review of 85 homeless, primarily rough-sleeping, clients was conducted to determine housing outcomes and the factors associated with obtaining housing through care provided by a psychiatric street outreach team in Toronto, Canada. Demographics, homelessness duration, diagnosis, hospitalization and housing status were tracked during team involvement. 

Results 
Overall, 46% (36/79) were housed during the study term. Securing housing at the end of treatment/data collection was significantly enhanced by hospitalization. It was significantly diminished by psychosis and prior homelessness >36 months . Twenty-three of 31 (74%) hospitalized clients with psychosis were subsequently housed, compared to 4 of 30 (13%) not hospitalized. 

Discussion 
Multidisciplinary street outreach teams successfully house long-standing homeless clients (>12 months without a permanent address) with serious mental illness and/or substance abuse. Hospitalization can be utilized as a complimentary intervention, particularly for those with psychosis, in the continuum of housing first initiatives, and can contribute to securing housing for those with persistent psychotic disorders. 

Implications for nursing practice Community mental health nurses are uniquely positioned to translate care between hospital and community settings, ensuring timely assessment, intervention and treatment of clients who are historically difficult to engage.

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By:  Lettner BH1, Doan RJ2, Miettinen AW3.

• 1Department of Nursing, University of Toronto, Toronto.
• 2Department of Psychiatry, University of Toronto, Toronto.
• 3Department of Economics, University of Toronto, Toronto. 
• J Psychiatr Ment Health Nurs. 2016 Mar;23(2):98-107. doi: 10.1111/jpm.12287.

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Eviction & Loss of Income Assistance among Street-Involved Youth in Canada

Loss of housing and income assistance among vulnerable youth has not been well described in the literature, yet it is a crucial issue for public health. 

This study examines the prevalence and correlates of loss of income assistance as well as eviction among street-involved youth. We collected data from a prospective cohort of street-involved youth aged 14-26. 

Among 770 participants, 64.3 per cent reported having housing and 77.1 per cent reported receiving income assistance at some point during the study period. Further, 28.6 and 20.0 per cent of youth reported having been evicted and losing income assistance, respectively. 

In multivariable generalized estimating equations analysis, heavy alcohol use, unprotected sex, being a victim of violence, and homelessness were all independently associated with eviction. 

Separately, homelessness, recent incarceration, and drug dealing were independently associated with loss of income assistance. 

Eviction and loss of income assistance are common experiences among street-involved youth with multiple vulnerabilities. Our findings highlight the importance of improving continued engagement with critical social services.

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By:  Zivanovic R1,2, Omura J2, Wood E2,3, Nguyen P2, Kerr T2,3, DeBeck K2,4.

• 1University of British Columbia's (UBC) MD program, Vancouver, Canada.
• 2Urban Health Research Initiative, BC Centre of Excellence in HIV/AIDS, St. Paul's Hospital, 613-1081 Burrard St., Vancouver, Canada V6Z 1Y6.
• 3Department of Medicine, University of British Columbia, Vancouver, Canada V5Z 1M9.
• 4School of Public Policy, Simon Fraser University, Vancouver, Canada V6B 5K3.
• J Public Health Policy. 2016 Mar 10. doi: 10.1057/jphp.2016.12. 

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