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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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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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Mental Health and Medical Health Disparities in 5135 Transgender Veterans Receiving Healthcare in the Veterans Health Administration: A Case-Control Study

PURPOSE:

There are no large controlled studies of health disparities in transgender (TG) or gender dysphoric patients. The Veterans Health Administration (VHA) is the largest healthcare system in the United States and was an early adopter of electronic health records. We sought to determine whether medical and/or mental health disparities exist in VHA for clinically diagnosed TG veterans compared to matched veterans without a clinical diagnosis consistent with TG status.

METHODS:

Using four ICD-9-CM codes consistent with TG identification, a cohort of 5135 TG veterans treated in VHA between 1996 and 2013 was identified. Veterans without one of these diagnoses were matched 1:3 in a case-control design to determine if medical and/or mental health disparities exist in the TG veteran population.

RESULTS:

In 2013, the prevalence of TG veterans with a qualifying clinical diagnosis was 58/100,000 patients. Statistically significant disparities were present in the TG cohort for all 10 mental health conditions examined, including depression, suicidality, serious mental illnesses, and post-traumatic stress disorder. TG Veterans were more likely to have been homeless, to have reported sexual trauma while on active duty, and to have been incarcerated. Significant disparities in the prevalence of medical diagnoses for TG veterans were also detected for 16/17 diagnoses examined, with HIV disease representing the largest disparity between groups.

CONCLUSION:

This is the first study to examine a large cohort of clinically diagnosed TG patients for psychiatric and medical health outcome disparities using longitudinal, retrospective medical chart data with a matched control group. TG veterans were found to have global disparities in psychiatric and medical diagnoses compared to matched non-TG veterans. These findings have significant implications for policy, healthcare screening, and service delivery in VHA and potentially other healthcare systems.

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By:  Brown GR1,2, Jones KT3.

• 1 Psychiatry Service, Mountain Home Veterans Affairs Medical Center , Johnson City, Tennessee.
• 2 Department of Psychiatry and Behavioral Sciences, Quillen College of Medicine, East Tennessee State University , Johnson City, Tennessee.
• 3 Office of Health Equity , Veterans Health Administration, Washington, District of Columbia.
• LGBT Health. 2016 Apr;3(2):122-31. doi: 10.1089/lgbt.2015.0058. Epub 2015 Dec 16. 

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Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: The Veterans Health Administration's "Homeless Patient Aligned Care Team" Program

INTRODUCTION:

Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites.

METHODS:

We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.

RESULTS:

More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.

CONCLUSION:

Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Below:  Homeless-patient aligned care team model for treatment engagement

Full article at:   http://goo.gl/0S9gb5

By:  O'Toole TP1, Johnson EE2, Aiello R2, Kane V3, Pape L2.

• 1National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02909. Email: Thomas.OToole@va.gov.
• 2The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island.
• 3The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island and Lebanon VA Medical Center, Lebanon, Pennsylvania. 
• Prev Chronic Dis. 2016 Mar 31;13:E44. doi: 10.5888/pcd13.150567.

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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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The Impact of Being Homeless on the Unsuccessful Outcome of Treatment of Pulmonary TB in São Paulo State, Brazil

BACKGROUND:

Tuberculosis (TB) is a major public health problem requiring complex treatment, the success of which depends on biological, social, and institutional factors. São Paulo State (SPS), in Brazil, has a high TB burden. Because of high socioeconomic heterogeneity and chaotic urbanisation, homelessness might play an important role in the TB burden in SPS. Our aim was to determine the association between homelessness and outcome of treatment of pulmonary TB (PTB) in SPS.

METHODS:

A historical cohort from the routine SPS TB database for 2009-2013 was analysed. The study population was newly diagnosed adult patients with PTB. Homelessness was ascertained at notification or when treatment started. Our outcome was unsuccessful outcome of treatment. We used logistic regression to adjust for potential confounders and multiple imputation for missing data.

RESULTS:

We analysed 61,817 patients; 1726 (2.8 %, 95%CI 2.7-2.9 %) were homeless. Homeless patients were concentrated in bigger cities, were more frequently middle-aged males, had black/brown skin colour, and had received less education (P < 0.001, for all). Alcohol and drug use was three times more frequent in homeless patients (43.2 % vs 14.4 %, 30.2 % vs. 9.4 %, P < 0.001, respectively). HIV testing was less common among the homeless, of whom 17.3 % were HIV positive compared with 8.5 % among the not homeless population (P < 0.001). Microbiologic confirmation was more frequent among the homeless (91.6 % vs. 84.8 %, P < 0.001). Unsuccessful outcome of treatment was 57.3 % among thehomeless and 17.5 % among the not homeless (OR = 6.32, 95%CI 5.73-6.97, P < 0.001), mainly due to loss to follow-up (39 %) and death (10.5 %). After full-adjustment for potential confounders, homelessness remained strongly associated with lower treatment success (aOR = 4.96, 95 % CI 4.27-5.76, P < 0.001). HIV status interacted with homelessness: among HIV-infected patients, the aOR was 2.45 (95%CI 1.90-3.16, Pinteraction < 0.001). The population attributable fraction for the joint effect of homelessness, alcohol and drug use was almost 20 %.

CONCLUSIONS:

Confirming our hypothesis, homelessness led to a marked reduction in the successful treatment of newly diagnosed pulmonary tuberculosis. Homelessness and associated conditions were important contributors to lack of treatment success in pulmonary tuberculosis in São Paulo. A multifaceted intervention must be implemented to target this vulnerable population.

Below:  Intersection between homelessness, alcohol use and drug use

Full article at:  http://goo.gl/Fevw64

By:  Ranzani OT1,2, Carvalho CR3, Waldman EA4, Rodrigues LC5.

• 1Pulmonary Division, Heart Institute (InCor), Medical School, University of São Paulo, Av. Dr. Arnaldo, 455, 2° andar, sala 2144, Post-code 01246903, São Paulo, Brazil. otavioranzani@yahoo.com.br.
• 2London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, Room G9a, Post-code WC1E 7HT, London, UK. otavioranzani@yahoo.com.br.
• 3Pulmonary Division, Heart Institute (InCor), Medical School, University of São Paulo, Av. Dr. Arnaldo, 455, 2° andar, sala 2144, Post-code 01246903, São Paulo, Brazil.
• 4Department of Epidemiology, Faculty of Public Health, University of Sao Paulo, Av. Dr. Arnaldo, 715, Post-code 01246904, São Paulo, Brazil.
• 5London School of Hygiene & Tropical Medicine (LSHTM), Keppel Street, Room G9a, Post-code WC1E 7HT, London, UK. 
• BMC Med. 2016 Mar 23;14(1):41. doi: 10.1186/s12916-016-0584-8.

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Active Case Finding among Homeless People as a Means of Reducing the Incidence of Pulmonary Tuberculosis in General Population

The incidence of tuberculosis (TB) declined more than two-fold, compared with the national average, in the northeastern region of Poland in the period of 2003-2012. During that time, four programs of active case finding of TB were conducted as part of which a total of 944 homeless individuals were examined and 21 cases of active TB were detected. 

The objective of the present study was to find out whether the observed beneficial epidemiological trend could be a result of those programs. We addressed the issue of how the active case finding programs in the homeless community affected the TB incidence in the general population using a modified crisscross SIS-type (Susceptible - Infected - Susceptible) model which describes the dynamics of TB spread between the homeless and non-homeless populations. The values calculated from our model proved highly congruent with the actual epidemiological data. 

Our analysis showed a significant decline in TB incidence within 1 year of completion of each active case finding program. The model shows that each identified and cured case in the homeless community reduced the number of new cases in the general population by 3-4 within 1 year and by up to 20 within 5 years.

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By:  Romaszko J1, Siemaszko A2, Bodzioch M2, Buciński A3, Doboszyńska A4.

• 1Family Medicine Unit, University of Warmia and Mazury in Olsztyn, 30 Warszawska St, 10-082, Olsztyn, Poland. jerzy.romaszko@uwm.edu.pl.
• 2Faculty of Mathematics and Computer Science, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland.
• 3Department of Biopharmacy, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland.
• 4Pulmonary Department, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland. 
• Adv Exp Med Biol. 2016 Mar 19. 

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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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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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