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Introduction: Vulnerably housed individuals access emergency departments (EDs) more frequently than the general population. Despite Canada's universal public health care system, vulnerably housed persons face structural barriers to care and experience discrimination from healthcare providers. This study examines how vulnerably housed persons perceive their experience of care in the ED and Urgent Care Center (UCC) in Kingston, Ontario and aims to develop strategies for improving care for this group. Methods: As part of a larger mixed-methods study, narratives were collected from participants attending the ED/UCC as well as community-based partner organizations, asking them to describe an experience of a recent ED visit (< 24 months). Participants could identify as members of up to three equity-deserving groups (EDGs) (for example homeless, part of an ethnic minority, having a disability, experiencing mental health issues). Coding and thematic analysis were completed for the experiences of participants who identified as being vulnerably housed (n = 171). Results were presented back to individuals with lived experience and service providers working with clients with unstable housing. Results: Participants reported judgement related to a past or presumed history of mental health or substance use and based on physical appearance. They also often felt unheard and that they were treated as less than human by healthcare providers. Lack of effective communication about the ED process, wait times, diagnosis, and treatment led to negative care experiences. Participants reported positive experiences when their autonomy in care-decision making was respected. Furthermore, having a patient-centered approach to care and addressing specific patient needs, identities and priorities led to positive care experiences. Conclusions: The ED care experiences of vulnerably housed persons may be improved through healthcare provider training related to trauma-informed and patient-centered care and communication strategies in the ED. Another potential strategy to improve care is to have advocates accompany vulnerably housed persons to the ED. Finally, improving access to primary care may lead to reduced ED visits and better longitudinal care for vulnerably housed persons. [ABSTRACT FROM AUTHOR]

Over the past two decades, homelessness has become more visible, and with it are increased demands for law enforcement to minimise the visibility of people experiencing homelessness, and manage, or ultimately remove, local encampments. While scholarship exists on police responses to homelessness, the role that other security actors, such as municipal bylaw officers, play in managing and regulating homelessness is largely unknown. In this paper, we explore municipal bylaw officers' perceptions of their roles and responsibilities related to homelessness in Ontario, Canada. Our analysis reveals how bylaw officers have become important players in the security governance of homelessness. We demonstrate how bylaw officers' policies, which focus on the regulation of space, are loosely coupled with, or disconnected from, their frontline activities, which require the regulation of people. This loose coupling situates bylaw officers in a perceived regulatory grey zone, requiring them to use discretionary solutions informed by their subjective experiences to govern people experiencing homelessness. The reliance on subjectivity and discretion expands security networks regulating and governing people experiencing homelessness. [ABSTRACT FROM AUTHOR]

Aims: To measure the change in proportion of opioid‐related overdose deaths attributed to people experiencing homelessness and to compare the opioid‐related fatalities between individuals experiencing homelessness and not experiencing homelessness at time of death. Design, setting and participants: Population‐based, time‐trend analysis using coroner and health administrative databases from Ontario, Canada from 1 July 2017 and 30 June 2021. Measurements: Quarterly proportion of opioid‐related overdose deaths attributed to people experiencing homelessness. We also obtained socio‐demographic and health characteristics of decedents, health‐care encounters preceding death, substances directly contributing to death and circumstances surrounding deaths. Findings A total of 6644 individuals (median age = 40 years, interquartile range = 31–51; 74.1% male) experienced an accidental opioid‐related overdose death, among whom 884 (13.3%) were identified as experiencing homelessness at the time of death. The quarterly proportion of opioid‐related overdose deaths attributed to people experiencing homelessness increased from 7.2% (26/359) in July–September 2017 to 16.8% (97/578) by April–June 2021 (trend test P < 0.01). Compared with housed decedents, those experiencing homelessness were younger (61.3 versus 53.1% aged 25–44), had higher prevalence of mental health or substance use disorders (77.1 versus 67.1%) and more often visited hospitals (32.1 versus 24.5%) and emergency departments (82.6 versus 68.5%) in the year prior to death. Fentanyl and its analogues more often directly contributed to death among people experiencing homelessness (94.0 versus 81.4%), as did stimulants (67.4 versus 51.6%); in contrast, methadone was less often present (7.8 versus 12.4%). Individuals experiencing homelessness were more often in the presence of a bystander during the acute toxicity event that led to death (55.8 versus 49.7%); and where another individual was present, more often had a resuscitation attempted (61.7 versus 55.1%) or naloxone administered (41.2 versus 28.9%). Conclusions: People experiencing homelessness account for an increasing proportion of fatal opioid‐related overdoses in Ontario, Canada, reaching nearly one in six such deaths in 2021. [ABSTRACT FROM AUTHOR]

The 2019 Coronavirus (COVID-19) pandemic severely limited the availability of community resources within the Regional Municipality of Durham, Ontario, Canada. It disrupted the lives of persons experiencing homelessness and other vulnerable populations. To address the gaps in resources, community stakeholders developed two pilot community hubs to respond to the unmet health, housing, and support needs of those impacted. This research utilized a mixed-methods research design to determine the effectiveness of the community hubs in responding to the unmet needs of patrons utilizing the services and the scalability of the community hub model as a viable regional service approach. Surveys were administered in person with seventy-five community hub patrons. Fifteen direct service staff completed self-administered online surveys. Interviews were conducted with five community hub managerial staff and two subject-matter experts who collaborated with one of the community hubs. Results from the study showed that the needs of patrons were deep and entrenched and required a progressive, co-located, integrated health and social service response model. Staff described the services as critical and lifesaving for the patrons. The descriptive statistical analysis revealed that 93% of patrons indicated that services offered by the community hubs met their needs. The main challenge for the community hubs was the lack of core funding. Implications of this study include establishing a regional, evidence-informed, integrated system of care that addresses the healthcare, social service, and housing needs of populations experiencing homelessness. [ABSTRACT FROM AUTHOR]

This article summarizes findings from a scan of COVID-19 policies in Ontario that impact individuals experiencing homelessness. We collected and analyzed policy data between March 2020 and August 2020, from 10 cities, including all municipal-level restrictions and public health measures implemented in response to COVID-19. From our scan, we found that 161 policies had direct or indirect implications for people living in homelessness. These policies were organized into categories that describe 'where' effects were seen - which most often relate to requirements for physical distancing. Some of the most obvious impacts relate to reduced access to needed services and supports in light of non-essential business closures and other service disruptions. Other key impacts relate to the use of public spaces during the pandemic - including access to sanitation facilities, encampment bylaws, changes to public transit services, quarantine and isolation mandates, and the impact of a province-wide stay-at-home order. Overall, in reviewing local responses to the pandemic, it is critical to consider the disproportionate impacts of restrictive public health measures on already marginalized groups and continue to learn about strategies that aim to protect all members of society. [ABSTRACT FROM AUTHOR]

Research aimed at identifying and evaluating approaches to homelessness has predominately focused on strategies for supporting tenancy sustainment. Fewer studies focus on strategies for enabling thriving following homelessness, and the perspectives of service providers and organisational leaders (SPOL) on this topic are rare. We conducted this study in the context of a community‐based participatory research project in two cities in Ontario, Canada. This research was aimed at identifying the strengths and challenges of existing supports in enabling thriving following homelessness, followed by co‐designing a novel intervention alongside persons with lived experience of homelessness (PWLEH) and SPOL. The current study presents the findings of interviews conducted in 2020–2021 with SPOL in organisations serving PWLEH. We interviewed 60 individuals including service providers (n = 38; 63.3%) and organisational leaders (n = 22; 36.7%) using semi‐structured qualitative interviews. Interviews were conducted and recorded on Zoom to align with physical distancing protocols associated with the COVID‐19 pandemic. Recordings were transcribed verbatim and analysed abductively informed by the lenses of social justice and health equity. The essence of our findings is represented by a quote from a research participant: 'We stick people in a house and say okay, you're housed. The problem is solved'. This essence was expressed through five themes: (1) stuck in a system that prevents thriving, (2) substance use as an important coping strategy that prevents tenancy sustainment and thriving, (3) the critical importance of targeting community integration following homelessness, (4) incorporating peer expertise as imperative and (5) people need to be afforded options in selecting housing and services following homelessness. Our findings indicate that SPOL envision possibilities of thriving following homelessness yet are embedded within a system that often prevents them from supporting individuals who are leaving homelessness to do so. Research, practice and policy implications are discussed. [ABSTRACT FROM AUTHOR]

This paper provides a theoretical and empirical intervention into housing research by applying the geospatial lens of the rural-urban space (RUS) to the social problem of homelessness, a conceptual linkage absent in the Canadian context. Drawing on original data from 80 surveys, four focus groups, and a community feedback session, we identify and interrogate key local impacts of systemic shifts in the housing market and associated policy responses in Dufferin County, Ontario, a RUS community located 80km northwest of Toronto. We find that for people experiencing homelessness within RUS communities, the intersecting consequences of multiple forms of structural marginalization, such as low wages and social assistance rates and discrimination, can quickly destabilize housing. We emphasize the importance of attending to housing in RUS communities and developing housing policy strategies. [ABSTRACT FROM AUTHOR]

Violence is a critical issue in homeless shelters that affects service users and staff, yet there is limited evidence on how shelter-based violence occurs. The objective of this qualitative study was to investigate the antecedents and consequences of shelter-based violence from the perspectives of service users and staff. Purposive sampling was used to recruit individuals experiencing homelessness and shelter staff in a large metropolitan city in Ontario, Canada. Data from in-depth interviews with 56 individuals experiencing homelessness and 30 shelter staff were analyzed. Findings showed that shelter-based violence toward service users and staff was perceived to manifest in response to three interacting factors: (a) burden of homelessness and shelter living, (b) individual histories and marginalization, and (c) interpersonal conflict. These antecedents had a hierarchical structure in that each subsequent factor exacerbated the risk of previous ones and culminated with the most proximal factor for violence. There were three primary outcomes of shelter-based violence reported by service users and staff: (a) health and environmental harms, (b), procedural enforcement, and (c) avoidant behaviors. Avoidance was often a subsequent impact following health harms, as was procedural enforcement to a lesser extent. Overall, the study findings demonstrate that shelter-based violence is a complex and dynamic problem that is perceived to be the result of interacting structural, environmental, programmatic, interpersonal, and individual factors, with similar consequences for service users and staff. Implications for preventing violence through shelter design and service delivery are discussed. [ABSTRACT FROM AUTHOR]

[Display omitted] To compare processes of diabetes care by homeless status. A population-based propensity matched cohort study was conducted in Ontario, Canada. People with diabetes were identified in administrative healthcare data between April 2006 and March 2019. Those with a documented history of homelessness were matched to non-homeless controls. Data on processes of care measures included glucose monitoring tests, screening for microvascular complications, and physician follow-up. Differences in processes of care were compared by homeless status using proportions, risk ratios, and rate ratios. Of the 1,076,437 people with diabetes, 5219 matched pairs were identified. Homelessness was associated with fewer tests for glycated hemoglobin (RR = 0.63; 95 %CI: 0.60–0.67), LDL cholesterol (RR = 0.80; 95 %CI: 0.78–0.82), serum creatinine (RR = 0.94; 95 %CI: 0.92–0.97), urine protein quantification (RR = 0.62; 95 %CI: 0.59–0.66), and eye examinations (RR = 0.74; 95 %CI: 0.71–0.77). People with a history of homelessness were less likely to use primary care for diabetes management (RR = 0.62; 95 %CI: 0.59–0.66) or specialist care (RR = 0.87; 95 %CI: 0.83–0.91) compared to non-homeless controls. Disparities in diabetes care are evident for people with a history of homelessness and contribute to excess morbidity in this population. These data provide an impetus for investment in tailored interventions to improve healthcare equity and prevent long-term complications. [ABSTRACT FROM AUTHOR]

Objectives: Conducting longitudinal health research about people experiencing homelessness poses unique challenges. Identification through administrative data permits large, cost-effective studies; however, case validity in Ontario is unknown after a 2018 Canada-wide policy change mandating homelessness coding in hospital databases. We validated case definitions for identifying homelessness using Ontario health administrative databases after introduction of this coding mandate., Study Design and Setting: We assessed 42 case definitions in a representative sample of people experiencing homelessness in Toronto (n = 640) from whom longitudinal housing history (ranging from 2018 to 2022) was obtained, and a randomly selected sample of presumably housed people (n = 128,000) in Toronto. We evaluated sensitivity, specificity, positive and negative predictive values, and positive likelihood ratios to select an optimal definition, and compared the resulting true positives against false positives and false negatives to identify potential causes of misclassification., Results: The optimal case definition included any homelessness indicator during a hospital-based encounter within 180 days of a period of homelessness (sensitivity = 52.9%; specificity = 99.5%). For periods of homelessness with ≥1 hospital-based healthcare encounter, the optimal case definition had greatly improved sensitivity (75.1%) while retaining excellent specificity (98.5%). Review of false positives suggested that homeless status is sometimes erroneously carried forward in healthcare databases after an individual transitioned out of homelessness., Conclusion: Case definitions to identify homelessness using Ontario health administrative data exhibit moderate to good sensitivity and excellent specificity. Sensitivity has more than doubled since the implementation of a national coding mandate. Mandatory collection and reporting of homelessness information within administrative data present invaluable opportunities for advancing research on the health and healthcare needs of people experiencing homelessness., Competing Interests: Declaration of competing interest There are no competing interests for any author., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

The authors comment on substance use by people experiencing homelessness (PEH) in Covid-19 isolation and recovery settings, by examining the experiences in Boston, Massachusetts and Toronto, Ontario. Topics discussed include how institutional, regional, and federal drug policies and substance use services facilitated or impeded care for PEH who used substances during the pandemic, and information on establishment of isolation and recovery sites.

Service restrictions refer to temporary or permanent bans of individuals from a program or an organization's services, and are widely used in emergency shelter systems. Limited research exists on how service restrictions unfold and their impacts on people experiencing homelessness. This qualitative study used in-depth interviews with timeline mapping to examine the antecedents and consequences of service restrictions from emergency shelters among people experiencing homelessness in two cities in Ontario, Canada. A total of 49 people experiencing homelessness who had been restricted from an emergency shelter program in the past year were recruited and included in the study analysis. A pragmatic and integrative approach was used for data analysis that involved the development of meta-matrices to identify prominent and divergent perspectives and experiences with regard to service restriction antecedents and consequences. Study findings underscored that service restrictions were often the result of violence and aggression, primarily between service users. There were regional differences in other service restriction reasons, including substance use and possession. Service restrictions affected the shelter status of almost all participants, with many subsequently experiencing unsheltered homelessness, and cycling through institutional health, social, and criminal justice services (i.e., institutional circuitry). Other health and social consequences included substance use relapses and hospitalizations; cold-related injuries due to post-restriction unsheltered homelessness; suicidality; food insecurity; diminished contact with support network and connections; and intense feelings of anger, fear, and hopelessness. Overall, the study findings advance our understanding of the role of homeless services in pathways into unsheltered homelessness and institutional circuitry, which raise critical questions about how to mitigate the harms associated with service restrictions, while concurrently facilitating safety and upholding the rights of people experiencing homelessness and emergency shelter staff. • Service restrictions are widely used in emergency shelter systems. • Service restrictions are often the result of violence and aggression. • Unsheltered homelessness is a common outcome of service restrictions. • Service restrictions exacerbate the burden on health, social, and justice services. • Service restrictions can also yield serious health consequences. [ABSTRACT FROM AUTHOR]

Background: Healthcare costs are disproportionately incurred by a relatively small group of people often described as high-cost users. Understanding the factors associated with high-cost use of health services among people experiencing homelessness could help guide service planning.Methods: Survey data from a general cohort of adults with a history of homelessness and a cohort of homeless adults with mental illness were linked with administrative healthcare records in Ontario, Canada. Total costs were calculated using a validated costing algorithm and categorized based on population cut points for the top 5%, top 6-10%, top 11-50% and bottom 50% of users in Ontario. Multinomial logistic regression was used to identify the predisposing, enabling, and need factors associated with higher healthcare costs (with bottom 50% as the reference).Results: Sixteen percent of the general homeless cohort and 30% percent of the cohort with a mental illness were in the top 5% of healthcare users in Ontario. Most healthcare costs for the top 5% of users were attributed to emergency department and inpatient service costs, while the costs from other strata were mostly for physician services, hospital outpatient clinics, and medications. The odds of being within the top 5% of users were higher for people who reported female gender, a regular medical doctor, past year acute service use, poor perceived general health and two or more diagnosed chronic conditions, and were lower for Black participants and other racialized groups. Older age was not consistently associated with higher cost use; the odds of being in the top 5% were highest for 35-to-49-year year age group in the cohort with a mental illness and similar for the 35-49 and ≥ 50-year age groups in the general homeless cohort.Conclusions: This study combines survey and administrative data from two cohorts of homeless adults to describe the distribution of healthcare costs and identify factors associated with higher cost use. These findings can inform the development of targeted interventions to improve healthcare delivery and support for people experiencing homelessness. [ABSTRACT FROM AUTHOR]

Background: Adults with intellectual and developmental disabilities (IDD) have high rates of homelessness. This observational study evaluates Bridges to Housing, a cross‐sector intervention offering immediate access to housing and supports to this population in Toronto, Canada. Methods: Twenty‐six participants, enrolled between April 2016 and December 2017, were assessed at baseline, six and 12 months post‐enrolment. Descriptive statistics and generalized linear modelling evaluated quality of life (QOL) and service needs outcomes. Twenty‐one service users and providers participated in semi‐structured interviews between August 2017 and June 2018 to elicit their experiences of the intervention, which were analysed thematically. Results: Twelve months post‐enrolment, 24 participants were successfully housed and reported increased QOL scores (F(2,43) = 13.73, p = <.001) and decreased perceived unmet service needs (Wald χ2(2) = 12.93, p =.002). Individual‐, intervention‐ and system‐level characteristics facilitated housing stability in this population. Conclusions: Cross‐sector approaches can improve outcomes for homeless adults with IDD and may have an important role in supporting this marginalized population. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Occupational Therapy is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Aims: A significant proportion of adults who are admitted to psychiatric hospitals are homeless, yet little is known about their outcomes after a psychiatric hospitalisation discharge. The aim of this study was to assess the impact of being homeless at the time of psychiatric hospitalisation discharge on psychiatric hospital readmission, mental health-related emergency department (ED) visits and physician-based outpatient care. Methods: This was a population-based cohort study using health administrative databases. All patients discharged from a psychiatric hospitalisation in Ontario, Canada, between 1 April 2011 and 31 March 2014 (N = 91 028) were included and categorised as homeless or non-homeless at the time of discharge. Psychiatric hospitalisation readmission rates, mental health-related ED visits and physician-based outpatient care were measured within 30 days following hospital discharge. Results: There were 2052 (2.3%) adults identified as homeless at discharge. Homeless individuals at discharge were significantly more likely to have a readmission within 30 days following discharge (17.1 v. 9.8%; aHR = 1.43 (95% CI 1.26–1.63)) and to have an ED visit (27.2 v. 11.6%; aHR = 1.87 (95% CI 1.68–2.0)). Homeless individuals were also over 50% less likely to have a psychiatrist visit (aHR = 0.46 (95% CI 0.40–0.53)). Conclusion: Homeless adults are at higher risk of readmission and ED visits following discharge. They are also much less likely to receive post-discharge physician care. Efforts to improve access to services for this vulnerable population are required to reduce acute care service use and improve care continuity. [ABSTRACT FROM AUTHOR]

This column describes the development of a partnership between health care, housing, and intellectual disability services to support efforts by homeless adults with intellectual disabilities to exit homelessness. Applying a Housing First approach and philosophy, the partners launched a pilot intervention, which at its first phase engaged 26 homeless adults with intellectual disabilities in Toronto. This cross-sector service model was acceptable to service users, who reported positive experiences and good program engagement. Key enablers of success included the program's capacity to address complexity, stakeholders' approach to choice and compromise, and fulsome collaboration and communication at every level. [ABSTRACT FROM AUTHOR]

Background.: Boredom has been reported as a frequent problem experienced by homeless persons, with implications for mental and social well-being. Purpose.: This study aimed to explore the nature and impact of boredom in the lives of homeless and formerly homeless persons. Method.: A mixed-methods design was used to engage 13 participants in a structured 92-item quantitative interview using six standardized measures, followed by a semistructured qualitative interview. Correlational analyses were performed with the data compiled from the quantitative interviews, and grounded theory strategies were used to analyze our qualitative data. The two analyses were integrated at the stage of interpretation. Findings.: Boredom was described as a profound and pervasive experience for homeless persons, imposing deleterious impacts on mental well-being and driving substance use. A strong positive correlation between meaningful activity and mental well-being (r s =.767, p <. 01) and a strong negative correlation between boredom and belonging in one's community (r s = –.771, p <.01) were identified. Implications.: Boredom is a critical topic of study for occupational therapy in the area of homelessness. Future research is needed to design and test interventions to optimize the mental well-being, participation, and social connectedness of this population. [ABSTRACT FROM AUTHOR]

Perceived stress has been associated with adverse health outcomes. Although people experiencing homelessness often report multiple acute and chronic stressors, research on resilience and perceived stress on the general homeless population is limited. This longitudinal study examined homeless adults with mental illness who were part of a 24‐month trial of Housing First to explore: (a) changes in levels of resilience and perceived stress during the trial, and (b) the association between levels of resilience and perceived stress with measures of social support, social functioning and percentage of days stably housed over the study period. This longitudinal study (2009–2013) that used trial data included 575 participants in Toronto, Ontario. Of these individuals, 507 were included in this study. Connor‐Davidson Resilience Scale and Perceived Stress Scales (PSS) measured the two outcomes, resilience and perceived stress. Time (baseline, 12 and 24 months), housing stability and three measures of social support and social functioning were the main predictors. A longitudinal analysis was done with repeated measures analysis of resilience and perceived stress using linear mixed models with random intercepts. Mean resilience scores increased (baseline: 5.1 [95% CI: 4.9, 5.2], 12 months: 5.5 [95% CI: 5.3, 5.7], 24 months: 5.6 [95% CI: 5.4, 5.8]), and PSS scores decreased (baseline: 22.3 [95% CI: 21.5, 23.0], 24 months: 18.6 [95% CI: 17.9, 19.4]). In the multivariable analyses, increased resilience was associated with higher scores on the three social support and social functioning measures, (estimates = 0.12, 0.04, 0.02) but not percentage days stably housed. Lower PSS scores were associated with higher scores on all three social support and social functioning measures (−0.20, −0.33, −0.21) and higher percentages of days stably housed (−0.015). Strong social support and social functioning may minimise the harmful effects of stressful life events on homeless individuals by increasing resilience and reducing stress. Interventions to help homeless people build appropriate support networks should be delivered in parallel to efforts that increase housing stability. [ABSTRACT FROM AUTHOR]

Objective: Homelessness has been identified as an important risk factor for suicide death, but there is limited research characterising homeless people who die by suicide. The goal of this study is to identify personal, clinical, and suicide method-related factors that distinguish homeless and precariously housed people who die from suicide from those who are not homeless at the time of suicide.Methods: Coroner records were reviewed for all suicide deaths in Toronto from 1998 to 2012. Data abstracted included housing status as well as other demographics, clinical variables such as the presence of mental illness, and suicide method.Results: Of 3319 suicide deaths, 60 (1.8%) were homeless and 230 (6.9%) were precariously housed. Homeless and precariously housed people were each younger than nonhomeless people ( P < 0.0001). Compared with nonhomeless, homeless people were more likely to be male and less likely to be married, to have interpersonal conflict, or to leave a suicide note. Homeless people and precariously housed were more likely to have died by fall/jump than nonhomeless people (62%, 57%, and 29%, respectively).Conclusions: Homeless and precariously housed people are overrepresented among suicide deaths in a large urban center and differ demographically, clinically, and in their suicide method from nonhomeless people who die by suicide. Targeted suicide prevention strategies should aim to address factors specific to homeless people. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to identify challenges and facilitators of sustaining a Housing First intervention at the conclusion of a research demonstration project in Toronto.Methods: This qualitative study included key informant interviews with organizational leaders (N=13) and focus groups with service team members (N=14) and program participants (N=9) of the At Home/Chez Soi Research Demonstration Project. Thematic analysis was used to identify key themes related to sustainability of Housing First beyond the demonstration phase.Results: Factors that helped secure long-term funding support for Housing First included the positive findings of a rigorous evaluation, early stakeholder engagement, and strong local leadership. Reduced funding, poor intersectoral integration, and lack of central oversight threatened fidelity to the evidence-based model and challenged sustainability.Conclusions: Evidence-based complex interventions such as Housing First require robust intersectoral collaboration and flexible systems for funding and monitoring to ensure continuing model fidelity and responsiveness to changing contexts. [ABSTRACT FROM AUTHOR]

Background: Hospital readmission rates are a widely used quality indicator that may be elevated in disadvantaged populations.Objective: The objective of this study was to compare the hospital readmission rate among individuals experiencing homelessness with that of a low-income matched control group, and to identify risk factors associated with readmission within the group experiencing homelessness.Design: We conducted a 1:1 matched cohort study comparing 30-day hospital readmission rates between homeless patients and low-income controls matched on age, sex and primary reason for admission. Multivariate analyses using generalized estimating equations were used to assess risk factors associated with 30-day readmission in the homeless cohort.Participants: This study examined a cohort of 1,165 homeless adults recruited at homeless shelters and meal programs in Toronto, Ontario, between 6 December 2004 and 20 December 2005.Main Measures: The primary outcome was the occurrence of an unplanned medical or surgical readmission within 30 days of discharge from hospital.Key Results: Between 6 December 2004 and 31 March 2009, homeless participants (N = 203) had 478 hospitalizations and a 30-day readmission rate of 22.2 %, compared to 300 hospitalizations and a readmission rate of 7.0 % among matched controls (OR = 3.79, 95 % CI 1.93-7.39). In the homeless cohort, having a primary care physician (OR = 2.65, 95 % CI 1.05-6.73) and leaving against medical advice (OR = 1.96, 95 % CI 0.99-3.86) were associated with an increased risk of 30-day readmission.Conclusions: Homeless patients had nearly four times the odds of being readmitted within 30-days as compared to low-income controls matched on age, sex and primary reason for admission to hospital. Further research is needed to evaluate interventions to reduce readmissions among this patient population. [ABSTRACT FROM AUTHOR]

Background: Problem gambling and homelessness are recognized as important public health concerns that significantly impact individuals, their friends and families, communities and broader society. We aimed to explore the experiences with health and social services of men who had histories of problem gambling and housing instability in Toronto, Ontario.Methods: We used a community-based participatory approach with a multi-service agency serving low-income individuals. We conducted qualitative interviews with men (n = 30) who had experienced problem gambling and housing instability. Our interviews employed open-ended questions to elicit men's perceptions of services related to housing instability, problem gambling and other comorbid conditions (e.g., mental illness, substance use). We reviewed relevant themes related to experiences with services (e.g., Use of and feedback on: health and social services, housing services, justice/legal aid services, substance use services, gambling services; stigma; goals; triggers; physical health; coping strategies; finances; relationships; barriers to services and recommendations for services).Results: The concept of person-centred engagement was identified as a main overarching theme, and seemed to be lacking in most of the men's experiences of services. Person-centred engagement for these men entailed empowerment and autonomy; empathy, compassion and sincerity; respectful communication; and tailored and holistic life plans. While there was a strong emphasis placed on independence, the men identified the importance of positive therapeutic relationships as being critical aspects of the recovery process. Based on our analyses, several recommendations were identified: 1) Increasing general awareness of services for problem gambling; 2) Delivering integrated services in a one-stop-shop; 3) Addressing mental health with psychotherapy and pharmacotherapy; 4) Providing timely access to prevention and recovery services; and 5) Enhancing life skills with peer support.Conclusions: Our study highlighted that most of the men we interviewed were not having their health and social needs met. Services need to address the intersection of problem gambling, housing instability, and other comorbidities. Ensuring services are grounded in person-centred engagement appears to be critical for optimal service delivery. [ABSTRACT FROM AUTHOR]

The present study examined how a six-week family literacy programme contributed to supporting the efforts 12 mothers living in a residential shelter were making to foster their preschool children's literacy development. We compared pre- and post-programme interviews to explore whether the mothers applied the literacy strategies discussed in the programme during their daily interactions with their children. Guided by our theoretical perspective, funds of knowledge, data, were analysed through the lens of a Family Strengths Model and thus focused on how learning opportunities were embedded within the families' daily experiences. Findings are presented under two main themes: (1) the mothers' use of the environment as a tool for literacy teaching and (2) use of programme materials and activity ideas in the home environment. Overall, findings indicate that the mothers applied strategies they learned in the programme to their daily interactions with their children, which indicate that the families participating in this study increased their involvement in their children's literacy learning. Our experiences with this transient population illustrate the importance of educators partnering with families, respecting what they are doing to support their children's literacy learning, and building on these efforts by providing them with resources and ideas that support literacy learning. Consideration should be given to the types of resources provided to families living in non-permanent housing in order to maintain their access to literacy activities. [ABSTRACT FROM AUTHOR]

Objective: To assess the accuracy of self-reported ambulatory care visits, emergency department (ED) encounters, and overnight hospitalizations in a population-based sample of homeless adults.Data Source: Self-report survey data and administrative health care utilization databases.Study Design: Self-reported health care use in the past 12 months was compared to administrative encounter records among 1,163 homeless adults recruited in 2004-2005 from shelters and meal programs in Toronto, Ontario.Data Extraction Methods: Self-reported health care use was assessed using a structured face-to-face survey. Each participant was linked to administrative databases using a unique personal health number or their first name, last name, sex, and date of birth.Principal Findings: The sensitivity of self-report for ambulatory care visits, ED encounters, and overnight hospitalizations was 89, 80, and 73 percent, respectively; specificity was 37, 83, and 91 percent. The mean difference between self-reported and documented number of encounters in the past 12 months was +1.6 for ambulatory care visits (95 percent CI = 0.4, 2.8), -0.6 for ED encounters (95 percent CI = -0.8, -0.4), and 0.0 for hospitalizations (95 percent CI = 0.0, 0.1).Conclusions: Adults experiencing homelessness are quite accurate reporters of their use of health care, especially for ED encounters and hospitalizations. [ABSTRACT FROM AUTHOR]

The article reports on the issues of coercive control (CC), posttraumatic stress disorder, and the effects of childhood maltreatment and physical partner abuse among homeless women, and mentions intimate relationships with psychological abuse; and relation between CC and mental health of victims.

This article highlights the use of direct scribing to gather special education narratives of homeless youth. Direct scribing is a method of qualitative research developed in child welfare practice and adapted for research with foster youth. Its strengths include offering voice, power, and ownership of narratives to participants using minimal technology and the framework of narrativity. The article improves on the rigor of this method, highlighting considerations about “working up” or attention to interactional processes leading up to direct scribing, and the need to offer narrative power to participants. It offers a different take on interview practices including eye contact, listening, and the use of a computer screen as an interface. Through an extensive illumination of the narrativity of one participant, the preparation, process, and outcome of direct scribing are highlighted. The fit between social work values and this method is in keeping with advancing an anti-oppressive focus in research and practice. [ABSTRACT FROM AUTHOR]

Based on ethnographic fieldwork in London, Ontario, Canada, with homeless and street-involved youth in a youth drop-in shelter that I call 'At Home', this paper is an ethnographically grounded narrative analysis of interview content and participant observation with a centre focus on my key informant, a youth from Eastern Europe whom I call 'Marius'. Like many other street youth, Marius lives a life marked by precarity. His daily life is marked by traumatic memories of abandonment and abuse, which has lead to an inability to work; and structural violence facilitated by Ontario's workfare program called Ontario Works, especially its mandate that all 'participants' (i.e. those in receipt of social assistance, such as Marius) seek employment or face termination of their social assistance check. For Marius, the recounting of traumatic memories at At Home opened up a shared rhetorical space from which he could narratively align himself vis-à-vis other street youth as a victim of precarity and trauma and therefore absolve himself of the onus to find employment. Regardless of his narrative positioning, he is constantly terminated from Ontario Works for not submitting proof of citizenship and proof of job-seeking activities. In conclusion, the only way for Marius to find any form of solace from his past and the constraints of OW is through isolation: a cultural stance that serves as a coping mechanism, and allows Marius to muddle through each day, all the while holding precarity and its pursuant anxiety and depression at bay. [ABSTRACT FROM AUTHOR]

Within the areas of literature on both population aging and health and homelessness, little attention has been given to the opportunities and barriers to healthy aging among older persons with a history of homelessness. Set in the context of inner-city Toronto, Canada, this article reports on the findings from qualitative interviews with 29 formerly homeless older persons. The findings illustrate participants' experiences of positive health change since moving into a stable housing environment and the aspects of housing they perceive to have improved their health and wellbeing. The qualitative findings also draw attention to the ongoing barriers to healthy aging that can be experienced among older persons with a history of homelessness. Overall, this study draws on the lived experiences of formerly homeless older persons to offer a better understanding of the long-term effects of homelessness on health, wellbeing, and aging. [ABSTRACT FROM AUTHOR]

This qualitative study explores narrative interviews of street-involved individuals with mental health issues and reflects on how they speak to experiences of both helpful and unhelpful social and mental health service provisions, and the disconnections between what they articulate as needing, and what services and supports they are able to receive. The article draws on and contributes to the field of peer research as the authors use lived experience of homelessness and/or mental health issues to inform both the approach to and analysis of the narratives. This study confirms that participants find the emerging, recovery-oriented structures of service provision more helpful than the dominant, biomedical structures, but that there is a continued disconnect in accessing emerging structure service deliveries. [ABSTRACT FROM PUBLISHER]

We describe the development and implementation of a novel curriculum on marginalization and health at an inner-city academic hospital in Toronto, Canada. The challenges of evaluating complex educational initiatives, particularly those centered on patient advocacy, are identified and potential solutions are discussed. [ABSTRACT FROM AUTHOR]

Recognizing the importance of health-promoting relationships in engaging people who are experiencing homelessness in care, most research on health clinics for homeless persons has involved some recognition of client-provider relationships. However, what has been lacking is the inclusion of a critical analysis of the policy context in which relationships are enacted. In this paper, we question how client-provider relationships are enacted within the culture of community care with people who are experiencing homelessness and how clinic-level and broader social and health policies shape relationships in this context. We explore these questions within a critical theoretical perspective utilizing a critical ethnographic methodology. Data were collected using multiple methods of document review, participant observation, in-depth interviews and focus groups. The participants include both clients at a community health clinic, and all clinic service providers. We explore how clients and providers characterized each other as 'good' or 'bad'. For providers, this served as a means by which they policed behaviours and enforced social norms. The means by which both providers' and clients' negotiated relationships are explored, but this is couched within both local and system-level policies. This study highlights the importance of healthcare providers and clients being involved in broader policy and systemic change. [ABSTRACT FROM AUTHOR]

Objectives. We identified factors associated with inpatient hospitalizations among a population-based cohort of homeless adults in Toronto, Ontario. Methods. We recruited participants from shelters and meal programs. We then linked them to administrative databases to capture hospital admissions during the study (2005-2009). We used logistic regression to identify predictors of medical or surgical and psychiatric hospitalizations. Results. Among 1165 homeless adults, 20% had a medical or surgical hospitalization, and 12% had a psychiatric hospitalization during the study. These individuals had a total of 921 hospitalizations, of which 548 were medical or surgical and 373 were psychiatric. Independent predictors of medical or surgical hospitalization included birth in Canada, having a primary care provider, higher perceived external health locus of control, and lower health status. Independent predictors of psychiatric hospitalization included being a current smoker, having a recent mental health problem, and having a lower perceived internal health locus of control. Being accompanied by a partner or dependent children was protective for hospitalization. Conclusions. Health care need was a strong predictor of medical or surgical and psychiatric hospitalizations. Some hospitalizations among homeless adults were potentially avoidable, whereas others represented an unavoidable use of health services. [ABSTRACT FROM AUTHOR]

Objectives. We identified predictors of emergency department (ED) use among a population-based prospective cohort of homeless adults in Toronto, Ontario. Methods. We assessed ED visit rates using administrative data from the Institute for Clinical Evaluative Sciences (2005-2009). We then used logistic regression to identify predictors of ED use. Frequent users were defined as participants with rates in the top decile (≥ 4.7 visits per person-year). Results. Among 1165 homeless adults, 892 (77%) had at least 1 ED visit during the study. The average rate of ED visits was 2.0 visits per person-year, whereas frequent users averaged 12.1 visits per person-year. Frequent users accounted for 10% of the sample but contributed more than 60% of visits. Predictors of frequent use in adjusted analyses included birth in Canada, higher monthly income, lower health status, perceived unmet mental health needs, and perceived external health locus of control from powerful others; being accompanied by a partner or dependent children had a protective effect on frequent use. Conclusions. Among homeless adults with universal health insurance, a small subgroup accounted for the majority of visits to emergency services. Frequent use was driven by multiple predisposing, enabling, and need factors. [ABSTRACT FROM AUTHOR]

Objectives. We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. Methods.We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). Results. Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. Conclusions. In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services. [ABSTRACT FROM AUTHOR]

The article offers information on a study which seeks to understand the nature of occupational engagement for homeless people living with mental illnesses. It discusses the use of a constant comparative method of analysis in a secondary analysis of 60 interviews with homeless adults living with mental illness. Several themes describing the nature of occupational engagement for homeless people are mentioned.

End-stage renal disease and dialysis are complicated illnesses to manage in homeless persons, who often suffer medical comorbidities, psychiatric disease, cognitive impairment and addictions; descriptions of this population and management strategies are lacking. A retrospective review of dialysis patients who were homeless or unstably housed was undertaken at an urban academic Canadian center from 2001 to 2011. Electronic hospital records were analyzed for demographic, housing, medical, and psychiatric history, dialysis history, adherence to treatment, and outcomes. Two detailed cases of homeless patients with chronic kidney disease are presented. Eleven homeless dialysis patients with a mean age of 52.7±12.3 years, mostly men and mostly from minority groups were dialyzed for 41.1±29.2 months. Most resided permanently in shelters, eventually obtained fistula access, and were adherent to dialysis schedules. Patients were often nonadherent to pre-dialysis management, resulting in emergency starts. Many barriers to care for homeless persons with end-stage kidney disease and on dialysis are identified, and management strategies are highlighted. Adherence is optimized with shelter-based health care and intensive team-oriented case management. [ABSTRACT FROM AUTHOR]

Homelessness is an experience of being displaced. Once removed from their personal places, homeless people are barred access to healthy places in which to be. Health clinics for people who are experiencing homelessness offer an opportunity to create health-promoting places. In this study, we explore how place is experienced within a community health clinic for people who are experiencing homelessness. A critical ethnographic methodology was used. Results illustrate how clients and providers contested the space of the clinic. Discourses of safety, health promotion, and privacy were enacted, altered, and resisted in a constant practice of culture-making. Physical components of the space became conceptual components of how place and power in place were understood by clients and providers. Results point to the importance of conceptualizing service users as the key stakeholders in their care, considering how places may be more or less health promoting, and rethinking how safety is conceptualized. [ABSTRACT FROM AUTHOR]

Recent statistics indicate limited condom use, high STI (sexually transmitted infection) rates, and a general lack of knowledge about reproductive and sexual health among homeless youth. This research focuses on the experiences of homeless female and transgendered youth, providing an insider’s perspective on shaping sexual health interventions. This qualitative research is based on life history interviews and participant observation with eight homeless young women who reflect the diversity of the homeless population in Toronto, Ontario, Canada. Their particularized sexual experiences and health-seeking behaviors illustrate the range of issues faced by this community, speaking to the efficacy of current health promotion strategies. Too often faced with judgmental health and social service providers who they perceive to undermine their agency and empowerment, these women highlight the challenges they face when seeking sexual and reproductive health services and information. In addition to speaking to the struggles and frustrations they face in regard to their sexual health and the services with which they choose to interact, the women provide suggestions for improved care. From these, the authors include key recommendations for the provision of culturally competent, sex-positive, and nonjudgmental health services with the hope that health practitioners and promoters can learn from these experiences, both positive and negative, when caring for and supporting young women living in exceptional circumstances. [ABSTRACT FROM PUBLISHER]

This paper uses a ‘grounded’ governmentality framework to examine the political and personal significance of a novel therapeutic intervention targeting chronically homeless individuals with severe alcohol problems. The paper is based on a qualitative case study of ‘Mountainview,’ a residential facility combining medical care and social services with an ‘alcohol management’ program. Drawing on the experiences of program staff and residents, as well as local policy discourses on homelessness, I explore the significance of this intervention in relation to geographies of inclusion and exclusion in the city. The paper traces how Mountainview encompasses novel forms of visualization, valuation, enclosure, and self-examination that together afford ‘street drinkers’ a new, albeit ambivalent, place in the city. [ABSTRACT FROM PUBLISHER]

In an essay in Critical Social Work, Robert Fairbanks suggests that space perspectives need to be accounted for in social work practice if the profession is to procure a more nuanced understanding of the production of social relationships. Yet, Fairbanks s analysis fails to account for the problematic of a spatialised politics of belonging for racialised subjects, and for the connections between racialising practices and (neo)liberal governance on localized social-spatial relations. This paper addresses these shortcoming by accomplishing three objectives: (1) To introduce a renewed vector of space thesis by borrowing from post-colonial writings; (2) To enliven that frame by critically reading visual images produced within the context of social service agencies in Toronto. I examine how these images attempt to reorient codes of difference and belonging in relationship to the representational and material contexts in which they were produced; and (3) To provoke a Social Work response to its own animation of these theoretical precepts. I argue that client produced representations reposition a practice sight-line away from a positioning of client subjectivity as redeemable only in it s neo-liberal guise or as surplus in its democratic value, towards one that allows for an inter-subjective unfolding of identity, place and belonging. [ABSTRACT FROM PUBLISHER]

Objective: The objective of the study was to examine the relationship between foreign birth and symptoms of schizophrenia and psychosis in a clinical sample of homeless persons.Methods: All the charts documented between 2002 and 2007 by a psychiatric outreach team in Ottawa, Canada, were retrospectively reviewed regarding country of birth and psychiatric symptoms identified in a clinical assessment. Data were analyzed by univariate and multivariate logistic regressions.Results: The sample included 552 men and 333 women with data on psychiatric symptoms and country of birth. A total of 106 individuals (12%) were born outside of Canada. This proportion was lower than that observed in the general population of Ottawa or in Canada. Foreign-born individuals were older and had a higher level of education than Canadian-born individuals. Sixteen percent of the sample presented symptoms of schizophrenia, and 15% presented symptoms of psychosis other than schizophrenia. In univariate analyses persons presenting symptoms of schizophrenia or psychosis were more likely to be foreign-born than native-born (odds ratio [OR]=2.92, 95% confidence interval [CI]=1.74-4.90, and OR=4.79, CI=2.92-7.86, respectively). Multivariate analyses gave very similar results (OR=2.62, CI=1.50-4.58, and OR=4.14, CI=2.44-7.03, respectively). A positive trend or significant association was observed for all regions of origin other than the non-Caribbean Americas.Conclusions: This is the first study to report an association between foreign birth and symptoms of schizophrenia and psychosis among homeless persons. These findings are consistent with the increased risk of schizophrenia and psychosis observed among immigrants to European countries. [ABSTRACT FROM AUTHOR]

Aims. This study explored community health nurses' viewpoints about a Canadian online community of practice to support their practice with homeless or underhoused populations. Background. Community health nurses who specifically work with homeless and marginally housed populations often report feelings of isolation and stress in managing complex problems in resource constraints. To strengthen intra-professional ties and enhance information access, an online community of practice was designed, implemented and evaluated by and for them. Methods. Q-methodology was used. Sixty-six statements about the community of practice were collected from an online survey and focus groups, refined and reduced to 44 statements. In 2009, sixteen participants completed the Q-sort activity, rating each statement relative to the others. Scores for each participant were subjected to by-person factor analysis. Results. Respondents fell into two groups -- tacit knowledge warriors and tacit knowledge communicators. Warriors strongly believed that the community of practice could combat stigma associated with homelessness and promote awareness of homelessness issues, and valued its potential to validate and improve practice. Communicators would have used the community of practice more with increased discussion, facilitation and prompt responses. Generally, nurses viewed the community of practice as a place to share stories, validate practice and adapt best practices to their work context. Conclusions. Online communities of practice can be valuable to nurses in specialized fields with limited peer support and access to information resources. Tacit knowledge development is important to nurses working with homeless populations: this needs to be valued in conjunction with scientifically based knowledge. [ABSTRACT FROM AUTHOR]

While tuberculosis (TB) in Canadian cities is increasingly affecting foreign-born persons, homeless persons remain at high risk. To assess trends in TB, we studied all homeless persons in Toronto who had a diagnosis of active TB during 1998-2007. We compared Canada-born and foreign-born homeless persons and assessed changes over time. We identified 91 homeless persons with active TB; they typically had highly contagious, advanced disease, and 19% died within 12 months of diagnosis. The proportion of homeless persons who were foreign-born increased from 24% in 1998-2002 to 39% in 2003-2007. Among foreign-born homeless persons with TB, 56% of infections were caused by strains not known to circulate among homeless persons in Toronto. Only 2% of infections were resistant to first-line TB medications. The rise in foreign-born homeless persons with TB strains likely acquired overseas suggests that the risk for drug-resistant strains entering the homeless shelter system may be escalating. [ABSTRACT FROM AUTHOR]

The mobility that is associated with homelessness creates various challenges to those endeavouring to contain a tuberculosis outbreak or otherwise manage the disease. It is argued that one important dimension missing from current tuberculosis management initiatives is an understanding of how the larger social context influences the mobility of the homeless and creates conditions that are conducive to the spread of this disease. I address this relationship by situating the experiences of the homeless in Toronto within a broader discussion of agency, structure, and the regulatory politics of mobility and place. [ABSTRACT FROM AUTHOR]

The article discusses the homelessness and housing of immigrants and refugees in Toronto, Canada with a focus on the experiences of Canadian-born homeless women and homeless immigrant families. Topics include life in homeless shelters and separations between parents and children, the difficulties of pregnancy and childbirth for homeless women, and the services of family and transition centers. A comparison of the housing situations of Canadian-born women, immigrant women with permanent residence, and non-status migrant women is presented. Policy recommendations for housing, services, and immigration status of immigrants are also included.

Background: Identification of high-risk populations for serious infection due to S. pneumoniae will permit appropriately targeted prevention programs. Methods: We conducted prospective, population-based surveillance for invasive pneumococcal disease and laboratory confirmed pneumococcal pneumonia in homeless adults in Toronto, a Canadian city with a total population of 2.5 M, from January 1, 2002 to December 31, 2006. Results: We identified 69 cases of invasive pneumococcal disease and 27 cases of laboratory confirmed pneumococcal pneumonia in an estimated population of 5050 homeless adults. The incidence of invasive pneumococcal disease in homeless adults was 273 infections per 100,000 persons per year, compared to 9 per 100,000 persons per year in the general adult population. Homeless persons with invasive pneumococcal disease were younger than other adults (median age 46 years vs 67 years, P<.001), and more likely than other adults to be smokers (95% vs. 31%, P<.001), to abuse alcohol (62% vs 15%, P<.001), and to use intravenous drugs (42% vs 4%, P<.001). Relative to age matched controls, they were more likely to have underlying lung disease (12/69, 17% vs 17/272, 6%, P = .006), but not more likely to be HIV infected (17/69, 25% vs 58/282, 21%, P = .73). The proportion of patients with recurrent disease was five fold higher for homeless than other adults (7/58, 12% vs. 24/ 943, 2.5%, P<.001). In homeless adults, 28 (32%) of pneumococcal isolates were of serotypes included in the 7-valent conjugate vaccine, 42 (48%) of serotypes included in the 13-valent conjugate vaccine, and 72 (83%) of serotypes included in the 23-valent polysaccharide vaccine. Although no outbreaks of disease were identified in shelters, there was evidence of clustering of serotypes suggestive of transmission of pathogenic strains within the homeless population. Conclusions: Homeless persons are at high risk of serious pneumococcal infection. Vaccination, physical structure changes or other program to reduce transmission in shelters, harm reduction programs to reduce rates of smoking, alcohol abuse and infection with bloodborne pathogens, and improved treatment programs for HIV infection may all be effective in reducing the risk. [ABSTRACT FROM AUTHOR]

The experiences of transwomen who are homeless are examined, focusing on the consequences of the profound marginalisation that they experience in their everyday lives and the support that they provide to each other as a form of survival. This study was part of a larger community-based, arts-based research project, Coming Together: Homeless Women, Housing and Social Support, which explored how transwomen and non-trans (biological) women who are homeless build support networks with each other in Toronto, Canada. Grounded theory was used to analyse multiple data sources including semi-structured interviews, narratives from feedback sessions and other public events, and data from arts-based research. The results indicated that transwomen who are homeless experienced emotional and psychological injury in their everyday lives due to oppressive conditions such as transphobia, heteronormativity, poverty and the lack of stable and safe housing. Within social service environments, they were often told implicitly or explicitly that they 'do not belong'. The presence of transwomen within these spaces seemed to challenge the underlying assumption of a 'normative' homeless woman, leading some service providers to create informal and discriminatory rules to control their behaviour. However, far from being passive victims, transwomen with experiences of homelessness supported each other by constructing their own family-like networks, which not only provided instrumental and emotional support (e.g., listening ears), but also a basic sense of protection and safety. Some of the exemplary social service efforts are noted. Rcommendations for policy and practice rooted in empowerment and anti-oppressive principles are discussed. [ABSTRACT FROM AUTHOR]