Inequitable access to health care increases morbidity and mortality among people experiencing homelessness. Peer advocates ('peers') with lived experience may help others to access health care. To evaluate the impact and cost-consequence of Groundswell's Homeless Health Peer Advocacy programme on healthcare access, the processes through which it operates and the impact for peer advocates themselves. A participatory mixed-method design with three components: qualitative study (A), prospective cohort (B), and cost-consequence analysis (C) using cohort and programmatic data. Ethical approval: Dulwich Research Ethics Committee (Integrated Research Application System 271312). London, United Kingdom (2019-23) coinciding with COVID-19 and disruptions to the National Health Service, Homeless Health Peer Advocacy and housing services. Homeless Health Peer Advocacy clients and non-clients (A-C); Homeless Health Peer Advocacy staff, volunteers and homelessness-sector stakeholders (A). Peer advocates accompany clients to healthcare appointments and provide support to address barriers to access. Primary: probability of 'did not attend' at a scheduled outpatient appointment within 12 months of cohort enrolment. Secondary: number of inpatient admissions and accident and emergency visits. (A) In-depth interviews and focus groups; (B) Structured questionnaires and National Health Service Hospital Episode Statistics; (C) Groundswell programme data and cohort findings. Qualitative (A): Peer advocacy empowered clients by building cultural health capitals (skills and communication that support healthcare interactions) and strengthening social and economic resources. Advocates themselves gained social, cultural, human and physical resources, though benefits were greatest for those with some pre-existing stability. Cohort (B): Compared with non-clients, Homeless Health Peer Advocacy clients showed no difference in did not attend rates (rate ratio 0.97, 95% confidence interval 0.67 to 1.42) or accident and emergency visits (mean difference 0.86, 95% confidence interval -0.06 to 1.79) for the other pre-specified outcomes. Clients had 1.14 more inpatient admissions (95% confidence interval 0.52 to 1.75). Sensitivity analyses with imputed data suggested higher numbers of outpatient attendances, outpatient 'did not attends', accident and emergency visits and admissions among clients. Secondary analyses suggested differences by levels of anxiety and depression. Cost-consequence (C): Median annual cost per client was £353 (£176 per scheduled engagement). Evidence of National Health Service cost saving was inconclusive. The COVID-19 disrupted both Homeless Health Peer Advocacy delivery and National Health Service services. Non-randomised design may have introduced bias. Homeless Health Peer Advocacy enhances clients' cultural health capital and helps peer advocates achieve their goals. We cannot state whether peer advocacy reduces 'did not attends' or demonstrate cost savings, but it was associated with more inpatient admissions and, in sensitivity analyses, more outpatient appointments. Research should explore how peer advocacy addresses stigma in health care and hostel settings and develop outcome measures that capture wider systemic change. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 17/44/40. Groundswell pioneered Homeless Health Peer Advocacy in London, where people with lived experience of homelessness support others to access health care, a model being adapted by others. Peer advocates provide one-to-one support, helping clients attend healthcare appointments and navigate services. Evidence on the impacts, costs and mechanisms of Homeless Health Peer Advocacy remains limited. Our study asked: how, and to what extent, can peer support change hospital use by people experiencing homelessness? We combined qualitative and quantitative methods. First, we conducted in-depth interviews with peer advocates, clients, homeless people not in the programme and staff in the homelessness sector. These interviews explored how peer advocacy may affect health engagement, well-being, housing and employment. Second, we analysed National Health Service hospital data for 158 people who attended appointments with peer advocates and 153 similar people without advocates, comparing healthcare use over 12 months. Finally, we estimated programme costs and potential National Health Service savings. The research took place during COVID-19 lockdowns when peer advocacy services and wider health care were disrupted. Interviews identified three main mechanisms of peer advocacy: (1) building clients’ skills to manage their health care, (2) advocating directly with services and (3) providing material or social support. Benefits were reported for both clients and peer advocates, with some peers achieving personal goals through their role. Quantitative findings were mixed. Homeless Health Peer Advocacy did not clearly reduce missed appointments or emergency service use but was associated with more outpatient attendance, particularly among people with moderate anxiety or depression, and more hospital admissions for treatment. Homeless Health Peer Advocacy cost £176 per healthcare appointment supported. We found no clear evidence that Homeless Health Peer Advocacy saved National Health Service money, given uncertain effects on service use. In conclusion, Homeless Health Peer Advocacy helps people who are homeless through skills-building, advocacy and support. Future research should examine its role in reducing stigma within health care and hostel settings.
There is a paucity of outcome data among homeless individuals with inflammatory bowel diseases (IBD). We reported rates of homelessness among inpatients with Crohn's disease (CD) and ulcerative colitis (UC) and examined inpatient outcomes. The Healthcare Utilization Project (HCUP) State Inpatient Databases from New York, Arizona, Massachusetts and Florida for 2013 and 2014 were used to identify adults ≥ 18 years admitted with IBD identified by ICD-9 codes. Homeless patients were propensity score matched using a one-to-ten greedy nearest-neighbor approach to non-homeless patients to balance the distribution of baseline covariates. Differences in mortality, endoscopy utilization, surgical treatment and post-operative complications were reported as odds ratios with 95% confidence intervals (CI). A total of 115,008 IBD hospitalizations were identified of which 61% (n = 70,457) were CD discharges while 39% (n = 44,551) were UC discharges. Homelessness was associated with 0.7% (n = 469) of CD discharges and 0.9% (n = 415) of UC discharges. Mortality and endoscopy utilization rates were comparable between homeless and non-homeless patients with CD and UC. Surgical treatment was also broadly similar except for lower odds of bowel resection among homeless IBD patients with UC compared to domiciled IBD patients with UC (OR: 0.41, 95% CI: 0.20 to 0.84). Post-operative complications were also comparable except for lower rates of venous thromboembolism among homeless patients with CD (OR: 0.61, 95% CI: 0.38 to 0.97) whereas it was higher for homeless patients with UC (OR: 1.58, 95% CI: 1.08 to 2.30). Homeless IBD patients have comparable inpatient outcomes with non-homeless IBD patients.
Despite well-publicized initiatives to reduce veteran homelessness, current nationally representative data on its prevalence, correlates, and mental health burden are limited. To address this gap, data were analyzed from the 2025-2026 National Health and Resilience in Veterans Study (NHRVS), a nationally representative web-based survey of 2,636 U.S. military veterans. Two-proportion z tests compared lifetime homelessness prevalence across three nationally representative NHRVS cohorts conducted in 2015, 2019-2020, and 2025-2026. Multivariable logistic regression and relative importance analyses examine sociodemographic, military, psychiatric, trauma, and functional correlates of lifetime homelessness. Results revealed that the weighted lifetime homelessness prevalence was 11.4% (95% CI: 9.7-13.1%), which was significantly higher than in 2015 (8.5%; p = .003) but comparable to 2019-2020 (10.2%; p = .11). Most veterans with a homelessness history first experienced homelessness after military discharge (69.6%), with a median duration of 36 months. Relative importance analyses identified lifetime major depressive (11.8%), generalized anxiety (11.2%), and posttraumatic stress (10.7%) disorders, adverse childhood experiences (7.8%), and social anxiety disorder (7.7%) as the strongest correlates of lifetime homelessness. After full adjustment, lifetime homelessness history was associated with significantly elevated odds of current alcohol, drug, and nicotine use disorders (AORs: 1.76, 2.24, 2.84, respectively), at-risk/problem gambling (AOR = 2.13), suicidal ideation (AOR = 1.44), and lifetime suicide attempt (AOR = 1.75). Collectively, results of this study suggest that homelessness among U.S. veterans remains a significant public health concern, with psychiatric disorders and childhood adversity as its strongest correlates. Independent associations with current substance use disorders and suicidal thoughts and behaviors underscore the importance of integrated mental health strategies that concurrently address housing instability, addictive behaviors, and suicide risk in this population.
To evaluate trends, demographics, and visit characteristics in pediatric emergency department (ED) visits for homelessness in relation to state and federal policies before and during the COVID-19 pandemic. We conducted a retrospective cohort study of pediatric ED visits for homelessness from 2019-2021 at an urban tertiary care children's hospital. Visit rates were analyzed in relation to the 2019 repeal of a restrictive shelter eligibility state policy and the implementation and expiration of state and federal COVID-19 eviction moratoria. Demographic and clinical characteristics were compared before and during the pandemic. Among 1,045 visits, the rate of pediatric ED visits for homelessness per 1,000 total visits declined modestly after the 2019 policy repeal, then spiked in January 2021 following the end of COVID-19 eviction moratoria. During the pandemic, children presenting for homelessness were more likely to be Hispanic (72.5% vs 53.4%, P<0.001), have Spanish-speaking caregivers (59.1% vs 40.1%, P<0.001), and have chronic medical conditions (25.2% vs 14.6%, P<0.001), compared with before the pandemic. Families were less likely to have eviction as the reason for their homelessness (6.2% vs 11.4%, P=0.010) during the pandemic, and were more likely to cite loss of job or income (11.2% vs 4.9%, P=0.001). Pediatric ED visits for homelessness persisted throughout the pandemic, with notable demographic shifts and changing causes of homelessness. These findings demonstrate the inequitable impact of the pandemic on different groups of children, underscore the limitations of temporary housing protections, and highlight the need for durable, equity-driven housing policies.
People experiencing both homelessness and severe mental illness have complex needs requiring coordinated multi-sectoral and multilevel interventions. Several systematic reviews of interventions exist internationally; however, evidence on the mechanism of change and contextual factors is limited. The proposed realist review aims to synthesize evidence to understand what interventions work, how, why, for whom, and under what circumstances in low and middle-income country settings. This work is nested within the National Institute for Health and Care Research (NIHR) Global Health Research Group on Homelessness and Mental Health in Africa (HOPE) project in Ethiopia, Ghana, and Kenya. In HOPE, we use participatory methods to develop and evaluate community-based interventions to address the unmet needs of people who are homeless and have severe mental illness living in the three countries. This protocol details the methodology for a realist review to inform the development, testing, and refinement of a programme theory for intervention. The review will follow five iterative steps. Step 1: Clarify the review scope and develop initial programme theories (IPTs). Step 2: Search for evidence across electronic databases and hand search for published studies to test and refine the IPTs. Step 3: Select and appraise studies. Step 4: Extract data, Step 5: Analyse and synthesize extracted data. The IPTs will be supplemented with formal theories to enhance their explanatory power. Key stakeholders will give critical inputs throughout the review process. The findings of the realist review will inform the development of contextually relevant programme theories to address the unmet needs of people who are homeless and have severe mental illness in LMICs, which will then be tested and refined within a realist evaluation. PROSPERO registration: CRD420251067136. People experiencing both homelessness and severe mental illness (a group of illnesses such as schizophrenia that greatly interfere with life activities) have many unmet needs. Fulfilling these needs requires coordinated involvement of many organizations and individuals. There is a lack of evidence, particularly in developing countries, regarding the interventions available to address these complex needs. This protocol details how we will synthesize evidence and develop a programme theory to explore what interventions might work to address the unmet needs of people who are homeless and have severe mental illness, for whom, and under what circumstances and why interventions these interventions work, We will work with key stakeholders including people who are homeless and have severe mental illness throughout the study process. The findings will inform the development of contextually relevant programme theories to address the unmet needs of this population in developing countries.
Heart failure (HF) is a major global public health challenge and a leading cause of morbidity and mortality, particularly among older adults. The rising prevalence of HF is driven by aging populations and the increasing burden of chronic conditions such as hypertension, diabetes, and obesity. In Canada alone, over 750,000 individuals live with HF, with over 100,000 new cases diagnosed annually. Despite advancements in pharmacological and device-based treatments, HF remains a primary cause of hospital admissions, with readmission rates exceeding 20% within 30 days. The associated healthcare costs are projected to reach $2.8 billion annually by 2030. Older adults experiencing homelessness represent a particularly vulnerable population at risk for HF. Homelessness is associated with increased exposure to cardiovascular risk factors, including inadequate access to preventive healthcare, high rates of comorbid conditions, and environmental stressors. Evidence suggests that individuals experiencing homelessness have a significantly higher incidence and earlier onset of HF compared to the general population, yet this intersection remains underexplored in the literature. This paper outlines the protocol for a systematic review and meta-analysis that aims to address this gap by synthesizing the prevalence, incidence, and mortality of HF among older adults who have experienced homelessness. This systematic review will follow the PRISMA and MOOSE guidelines and has been registered on the Open Science Framework. We will include studies examining the prevalence, incidence, or mortality of HF among older adults (aged 50 and above) with a history of homelessness. The decision to lower the age threshold to 50 reflects the accelerated aging process observed in this population, who often experience age-related conditions at a younger chronological age. Eligible study designs include cross-sectional, cohort, and case-control studies. Quantitative data from peer-reviewed publications and grey literature will be included, with no language or date restrictions. A comprehensive search strategy will be applied across major electronic databases, including Medline, Embase, Cochrane Library, and ISI Web of Science. We will also perform grey literature searches through Google Scholar and governmental websites. Backward citation tracking will be conducted to identify additional relevant studies. Study selection will involve independent screening by three reviewers, with disagreements resolved by consensus. Data extraction will include study characteristics, participant demographics, and HF-related outcomes. Risk of bias will be assessed using the Joanna Briggs Institute Checklist for Prevalence Studies and the ROBINS-E tool for non-randomized studies. The review will estimate pooled prevalence, incidence, and mortality rates of HF in older adults experiencing homelessness. Where possible, we will conduct subgroup analyses based on age, sex, and comorbidities. Meta-regression and sensitivity analyses will be performed to assess the robustness of the findings. This systematic review and meta-analysis will provide the first comprehensive synthesis of HF epidemiology in older adults experiencing homelessness. By identifying disparities in cardiovascular health outcomes, this study aims to inform public health policies, healthcare delivery, and future research to improve cardiovascular care for this marginalized population.
It is challenging and time-intensive to assess fidelity to complex evidence-based interventions in the homeless service sector. We describe a multi-component procedure to assess fidelity to Critical Time Intervention (CTI)-an evidence-based, time-limited case management practice for homeless-experienced persons undergoing housing transitions-developed for a large-scale pragmatic trial conducted with homeless-experienced Veterans. Using literature review, expert consultation, and pilot testing, we developed a pragmatic, scalable CTI fidelity assessment procedure. We integrated data from: a CTI implementation self-assessment designed to enhance provider practice; 90-minute videoconferences with case managers to collaboratively review charts from ≥2 randomly selected "exemplar cases" assessed for CTI's core components; and field notes from case manager narratives during these videoconferences. At 12- and 18-month timepoints after CTI implementation began with 17 case managers across 15 homeless service agencies, we employed this procedure to assess fidelity to CTI. We used field notes to contextualize differences between self-assessment and expert-rated findings. All case managers self-assessed their CTI practice as well- or ideally-implemented. Expert-rated assessments suggested that all case managers had limited fidelity to at least one of CTI's core components; 4 agencies had inadequate fidelity to the overall practice. Field notes provided explanations for disparate results between the self- and expert-rated assessments, including skill deficits, staff turnover (resulting in limited understanding of CTI's core components), and agency mandates (e.g. for case management visit frequency that were misaligned with CTI). The effectiveness of CTI is contingent on adherence to its core components. Streamlined approaches to fidelity assessment across EBPs in the homeless service sector is important for pragmatic, large-scale implementation efforts. The integration of self-assessment and expert-rated assessments can be applied to other multifaceted EBPs in the homeless service sector. Supplementing fidelity assessments with field notes may be useful to contextualize disparate findings between self- and expert-rated assessments, and to shape feedback to providers that enhances practice fidelity and improves housing outcomes. This project was registered with ClinicalTrials.gov as "Implementing and sustaining Critical Time Intervention in case management programs for homeless-experienced Veterans." Trial registration NCT05312229, registered 4/4/2022.
Evaluate the association between reported homelessness and inpatient resource use among Medicare beneficiaries, and investigate variation therein. Cross-sectional study of 6.3 million 2022 Medicare inpatient claims from 3,200 U.S. hospitals, examining the association between homelessness and three outcomes: cost, length of stay (LOS), and non-intensive care days using multilevel models. Robustness checks were conducted on five cross-sectional clinical subgroups. Among Medicare inpatient discharges, 0.63% reported homelessness, with teaching hospitals reporting 0.67%, in contrast to 0.55% in non-teaching hospitals. Overall, homelessness is associated with $829 (p<.001) higher costs and 2.45 (p<.001) longer LOS, primarily days outside of intensive care. For some patient subpopulations, the homelessness-cost association was greater than the national $829 magnitude. Reported homeless rates vary by hospital type and involve different hospital resources depending on hospital and patient type, including higher costs and longer inpatient hospital stays.
People experiencing homelessness have disproportionately high rates of early-onset geriatric conditions and decades-early mortality. These phenomena are well documented but not well understood, particularly for younger adults experiencing homelessness (e.g., those aged 18-39 years). This cross-sectional study compares functional limitation prevalences in a sample of adults experiencing homelessness with those in the general adult population in Los Angeles County. The Periodic Assessment of Trajectories of Housing, Homelessness, and Health Study indentified adults experiencing homelessness in Los Angeles County (analytic sample n=633); 2019-2023 American Community Survey data defined the adult Los Angeles County population (weighted n=7,790,124). Overall, age-specific, and age- and sex-standardized functional limitation item prevalences were calculated and compared between the two samples. Study participants aged 25-59 years, men, and non-Hispanic Black individualswere overrepresented compared to Los Angeles County adults. Overall and age-specific functional limitations were higher and did not uniformly increase among study participants versus Los Angeles County adults (55% vs 13% reporting any functional limitation, respectively). The age- and sex-standardized prevalence of any functional limitation was 59%-6.2 times higher among study participants versus Los Angeles County adults. This work adds to the literature documenting a substantial functional limitation burden among unhoused populations. Functional limitation prevalences were elevated but showed no consistent trend by age in the Periodic Assessment of Trajectories of Housing, Homelessness, and Health Study; age and sex distribution differences did not explain differences between the two samples.
The article examines the similarities and differences related to health among women experiencing homelessness (N=292) across four countries with different cultures and income levels: Spain (n=136), Argentina (n=72), Puerto Rico (n=54), and Nicaragua (n=30). Data were collected through a structured interview, in order to ensure the homogeneity of the data and to reduce potential reading or comprehension difficulties. Results show that women experiencing homelessness interviewed in all four countries perceived their own health status as poor, with high rates of women reporting medically diagnosed severe or chronic illnesses and/or disabilities. Women who had been diagnosed with a severe or chronic illness were older on average, had experienced homelessness for longer, and consumed sedatives or tranquilizers, had used drugs, and had attempted suicide to a greater extent than those without such diagnoses. Univariate analyses were complemented by multivariate ones to identify women who were at higher health risk. Results from logistic regression suggest that increasing age, excessive drug use, and having attempted suicide are significant predictors of suffering a diagnosed severe or chronic illness among women experiencing homelessness. These findings may help guide future prevention strategies and detect indicators of especially negative outcomes, while recognizing the importance of the context, as women experiencing homelessness in countries with lower income levels face situations of increased vulnerability in relation to health issues.
This article aims to examine the contribution of the Alternative Model for Personality Disorders (AMPD) in relation to social exclusion and substance use. Indeed, numerous studies converge in highlighting a higher prevalence of personality disorders and substance use among homeless individuals. Since its publication in 2013 the DSM-5 has proposed an Alternative Model for Personality Disorders, allowing for an assessment of personality based on two criteria: the level of personality functioning (Criterion A) and pathological personality traits (Criterion B). The tools developed for this model - the Level of Personality Functioning Scale Brief Form and the Personality Inventory for DSM-5-Brief Form - have been validated in French, enabling their use in clinical research on French-speaking populations. The LPFS-BF and the PID-5-BF were administered to 30 voluntary residents of social reintegration centers. Additionally, a control group of 30 individuals from the general population was selected to ensure gender and age homogeneity between the groups. Fisher's exact test, binomial logistic regression analysis, and linear regression analysis were conducted to explore the relationships between personality factors, substance use, and precariousness. The analysis of mean scores did not reveal significant personality differences between residents in social reintegration centers and the general population; only substance use was found to be significantly higher among homeless individuals (P>001). Fisher's exact test confirmed the relationship between social exclusion, substance use, and the risk of personality disorders (P>001). A high-risk score for personality disorders was associated with a more than ninefold increase in the likelihood of high-risk substance use (relative risk=9.63, 95% CI: 1.5-63.5) among homeless individuals. Binomial logistic regression analysis identified self-direction as a protective factor against precariousness, whereas disinhibition was identified as a risk factor. Specifically, the combination of low self-direction and high disinhibition appeared to increase the risk of homelessness. Finally, self-direction (P=0.012), negative affectivity (P=0.047), and detachment (P=0.034) were found to play a significant role in the risk of developing a substance use disorder (n=60). Self-direction emerged as a key factor in the relationship between substance use and precariousness. These results highlight the relevance of the Alternative Model for Personality Disorders (AMPD) in understanding the interactions among psychosocial difficulties, substance use, and personality. In particular, they emphasize that among homeless individuals an increased risk of personality disorders is closely associated with risky substance use. Furthermore, self-direction emerges as a key factor in mitigating vulnerability to precariousness, whereas disinhibition constitutes a risk factor. These findings offer promising avenues for the development of targeted interventions aimed at enhancing personal resources and reducing risky behaviors among this highly vulnerable population. The issue of the homeostatic function of personality also arises and warrants investigation in future research.
The homeless population in Bogotá exhibits complex social and health vulnerabilities, with a high prevalence of chronic and communicable diseases such as hypertension, diabetes, tuberculosis, HIV/AIDS, and cancer. These conditions hinder epidemiological surveillance and timely public health decision-making, particularly in contexts of social exclusion. To develop and evaluate an artificial intelligence-based predictive model aimed at identifying disease occurrence risk profiles among the homeless population in Bogotá, in order to support public health decision-making. Data from the 2024 Bogotá Homeless Census were analyzed, comprising 10 478 records and 46 demographic, clinical, and socioeconomic variables. Data processing and model development followed the CRISP-DM methodology. The extreme gradient boosting (XGBoost) algorithm was implemented to predict disease occurrence. Model performance was evaluated in terms of accuracy, sensitivity, and the F1-score, while interpretability was assessed through SHAP (SHapley Additive exPlanations) values. Additionally, metrics related to social trust, system response time, and potential health impacts were examined. The model achieved an accuracy of 0.91, a sensitivity of 0.57, and an F1-score of 0.70, striking an adequate balance between identifying high-risk individuals and reducing false positives. SHAP analysis identified hypertension, diabetes, and HIV/AIDS as the main predictors of classification. However, complementary metrics revealed limitations in social trust (TAS = 0.49), system response time (SRT = 24.86 hours), and potential health impact (PHIS = 0.24). These findings suggest that explainable artificial intelligence (XAI) models may support public health surveillance and intervention prioritization in homeless populations by identifying epidemiological risk profiles. However, the models' applicability remains context-specific and requires external validation before implementation across other vulnerable populations or healthcare settings.
Homelessness is an important public health issue, and the number of individuals experiencing unsheltered homelessness has increased since 2020. On June 28, 2024, the US Supreme Court issued a 6-to-3 decision in City of Grants Pass v Johnson, which broadened the authority of local governments to prohibit public camping. The National Call Center for Homeless Veterans (NCCHV) offers a 24/7 virtual option for veterans to access services to address housing instability. The objective of this study was to assess whether expanded local enforcement authority affected inflow and characteristics of individuals contacting NCCHV after the Grants Pass decision. We used data from 418 814 contacts to NCCHV from January 1, 2023, through December 31, 2024. We conducted 3 types of analyses: (1) bivariate analysis comparing changes in contact characteristics using Wald χ2 tests, (2) direct comparisons of average weekly call volume using paired t tests, and (3) an interrupted time-series analysis using an autoregressive linear regression model. While we did not observe seasonal variations in call volume, we found a significant increase in average weekly NCCHV call volume between the pre- and post-Grants Pass periods, from 3926.6 to 4394.8 calls (mean [95% CI] change in average weekly call volume: 468.2 [216.8-719.6; P = .005). This study provides an indication of the association between the Grants Pass decision and an increase in help-seeking behavior (potentially representing increased needs) among veterans experiencing housing instability. Future work should assess on-the-ground changes in the needs of individuals experiencing housing instability and responses offered by providers of homeless services.
Access to primary care services is essential for promoting mental health, yet immigrants experiencing homelessness face significant barriers to care. This study explores factors that influence access to primary care services in the UK. A qualitative design was employed, involving in-depth semi-structured interviews with 30 immigrants experiencing homelessness and 30 stakeholders across healthcare, voluntary, and local authority sectors. Data were analysed using thematic analysis, guided by the Levesque framework of healthcare access and an intersectionality lens. Findings reveal that access is influenced by intersecting structural barriers, including fear of detention and deportation, cultural stigma surrounding mental health, digital exclusion, and financial hardship. These barriers delay help-seeking and shift care-seeking toward emergency services. Increasing reliance on digital systems in primary care further excludes individuals with limited access to devices, connectivity, or digital skills. These findings indicate that barriers to accessing primary care services may hinder the early identification and preventive management of mental health needs among homeless immigrants. Improving access requires structural reforms that address legal, financial, and digital barriers, alongside more culturally responsive and trust-based care. Without such changes, digital health innovations risk reinforcing existing inequalities and limiting the role of primary care in early mental health intervention and prevention.
In Burke County, North Carolina, a Hepatitis A outbreak among unsheltered residents exposed gaps in access to clinic-based care and prompted early, ad hoc "backpack medicine" outreach efforts to deliver care directly in nontraditional settings. While this approach addressed immediate needs, it highlighted the inadequacy of isolated interventions, prompting local partners to pursue more structured, coordinated, and community-driven approaches to homeless health system design. This project report describes how Burke County Public Health, in partnership with the University of North Carolina at Chapel Hill, applied systems thinking, community coalition building, and human-centered design to transition from reactive outreach to a structured, sustainable mobile health delivery model for people experiencing homelessness. Guided by Community Coalition Action Theory (CCAT), partners used human-centered design methods to engage over 40 community stakeholders and 10 individuals with lived experience of homelessness or housing instability. Through empathy mapping, iterative prototyping, and thematic analysis, the team identified priority service gaps, defined operational requirements, and developed prototype service models, while building cross-agency readiness for implementation.
This narrative describes the journey of a disabled veteran who experienced homelessness before ultimately becoming a physician. Early life instability, including a federal raid on the family home and subsequent homelessness, led to military service as a means of escape and structure. After 10 years of active duty in the Air Force, musculoskeletal injuries and force reduction resulted in an unexpected separation, loss of stability, and a return to homelessness. Despite these challenges, the author pursued higher education using the GI Bill and ultimately entered medical training. During residency, a clinical encounter with an active duty service member facing a potentially career-altering injury highlighted the continuity between patient and physician experiences. This perspective underscores the unique value that physicians with lived military experience bring to veteran care. This story reflects resilience, identity reconstruction, and the importance of shared experience in the care of military populations.
Background: Community-based mental health and social interventions focusing on housing stability, integrated care and psychosocial support are being increasingly recognised as essential for improving the mental health and wellbeing of people experiencing homelessness. However, evidence regarding the effectiveness of these interventions remains fragmented across different models of care and study designs. This review synthesises how these interventions address mental health and social determinants of health. Methods: Following PRISMA 2020 guidelines, a systematic search of six electronic databases (2019-2025) was conducted (PROSPERO: CRD420250653260). The review included 29 quantitative, qualitative, and mixed-methods studies examining community-based interventions for people experiencing homelessness and mental health conditions according to predefined eligibility criteria. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Results: Community-based interventions, particularly Housing First models, were frequently associated with improved housing stability, mental health outcomes, and programme retention. Integrated multidisciplinary services and outreach promote psychosocial wellbeing, continuity of care and reducing emergency service use. Peer-led programmes support social integration, although evidence regarding technology-based interventions was inconsistent, with some studies reporting improved engagement and access to support, while others found limited effects on mental health outcomes. Conclusions: Addressing social determinants of health through structured community-based interventions is essential to tackle mental health inequalities. The findings support the implementation of integrated community-based services combining housing, mental health, and social support. These results may inform policymakers, healthcare providers, and community organisations seeking to reduce mental health inequalities among people experiencing homelessness.
Objectives: This study aimed to identify the oral health conditions of homeless individuals in Rome, the most frequently required dental treatments, and to describe a standardized, replicable clinical protocol tailored to the specific needs and access barriers of this vulnerable population. Methods: Five hundred homeless individuals received comprehensive dental examinations at the Primary Care Services of the Dicastery for the Charity Services (Vatican City) between September 2023 and January 2026. Clinical assessments included oral hygiene status, periodontal health, caries prevalence, and degree of edentulism. Treatment interventions were programmed by scheduling subsequent appointments. For patients requiring prosthetic rehabilitation, treatment was sequenced into distinct steps: preparatory treatments (hygiene, extractions, conservative procedures), impression taking, prosthesis try-in, and delivery. Results: Oral health assessment revealed poor or absent hygiene (85.4%), high DMFT scores (63.0%), and root residues (22.4%). Periodontal disease affected 94.0% of participants (gingivitis 73.0%, periodontitis 21.0%). Tooth loss patterns included partial edentulism (12.0%) and complete edentulism (24.0%). A total of 440 appointments were scheduled, with an attendance rate of 78.4%. Prosthetic rehabilitation was completed in 150 patients: 50 received partial dentures (33.3%) and 100 complete dentures (66.7%). Conclusions: The examined homeless individuals experienced severe oral health deterioration characterized by extensive tooth loss and advanced periodontal disease. A substantial prosthetic rehabilitation was needed in this sample. The proposed sequential treatment protocol demonstrated high feasibility and patient adherence in this vulnerable population. Comprehensive dental services that address both immediate emergency needs and long-term rehabilitative care are crucial for improving oral health-related quality of life and facilitating social reintegration. Patient-reported outcomes indicated meaningful improvements in digestive function, aesthetic satisfaction, and employment opportunities following prosthetic rehabilitation.
This study assessed social vulnerabilities, serious psychological distress (SPD), and socioeconomic impacts of the COVID-19 lockdown on slum dwellers and homeless individuals in Ho Chi Minh City (HCMC), Vietnam. It also examined the coverage and sources of cash and food support provided, community actors who assisted with such support, and the continuation of medication for chronic diseases. A cross-sectional survey of 415 participants (383 slum dwellers and 32 homeless individuals) was conducted using a structured questionnaire. Many participants faced social vulnerabilities, and 19.8% exhibited SPD. Job insecurity affected 58.8% of participants, and 60.7% reported income reductions due to the lockdown. During this period, 78.8% received cash support and 84.8% received food support; however, the coverage was significantly lower among homeless individuals, particularly for government-provided assistance. Community actors, most notably neighborhood heads, played key roles in assisting with the provision of cash and food support. The vast majority of patients with chronic illnesses were able to continue their medications during the lockdown, primarily through household drug storage and visits to health facilities. Receiving sufficient food support was significantly associated with reduced odds of SPD. These findings highlight the profound socioeconomic effects of the COVID-19 lockdown on populations with unstable housing in HCMC. The cash and food support, predominantly sourced from the government and donors, achieved high coverage through effective delivery by various community actors. Prescription regulations should be adjusted during lockdowns to allow patients with chronic conditions to stockpile sufficient medication. Mental health support is crucial for populations with unstable housing during pandemics.
Drug overdose is the leading cause of unintentional death in the United States. Studies suggest people experiencing homelessness (PEH) are at higher risk of overdose. Naloxone, trademarked Narcan®, is a medication that can reverse the effects of an opioid overdose. Despite steps taken to increase the availability of naloxone, opioid overdose deaths continue to occur at alarming rates. Few studies have explored naloxone use among PEH, and to the knowledge of the authors, none conducted in the United States have focused on the perspective of this population. The purpose of this study is to describe perceptions of naloxone use and access among PEH. This was a qualitative study with semi-structured interviews conducted between January 2024 and March 2024. Subjects included adults who met the definition of homelessness per the McKinney-Vento Act and were recruited at a medical clinic within a low barrier shelter. Interview questions were developed using Health Belief Frameworks, and interviews were audio recorded, transcribed, then coded using principles of Grounded Theory to identify themes. Twelve interviews were conducted. Analysis of the interview transcripts identified themes including distress and misperceptions surrounding substance use, misconceptions about supportive measures following opioid overdose, and wide availability but limited accessibility of naloxone due to physical and social barriers. Participants expressed a desire for training on naloxone and other opioid overdose response measures. PEH report varying access to naloxone and are conflicted about using the medication. Results of this study will be used to develop programs addressing barriers and promoting facilitators to naloxone use among populations at higher risk for opioid overdose.