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When people leave correctional institutions, they face myriad personal, social and structural barriers to reentry, including significant challenges with mental health, substance use, and homelessness. However, there are few reentry programs designed to support people's health, wellbeing, and social integration, and there are even fewer evaluations of such programs. The purpose of this article is to report the qualitative findings from an early process evaluation of the Reintegration Centre-a peer-led service hub designed to support men on the day they are released from custody. We conducted semi-structured qualitative interviews and examined quantitative service intake data with 21 men who accessed the Reintegration Centre immediately upon release. Participants encountered significant reentry challenges and barriers to service access and utilization. The data suggest that the peer-led service hub model enhanced the service encounter experience and efficiently and effectively addressed reentry needs through the provision of basic supports and individualized service referrals. Notably, the Reintegration Centre's proximity to the detention centre facilitated rapid access to essential services upon release, and the peer-support workers affirmed client autonomy and moral worth in the service encounter, fostering mutual respect and trust. Locating reentry programs near bail courts and detention centres may reduce barriers to service access. A peer-led service hub that provides immediate support for basic needs along with individualized service referrals is a promising approach to reentry programs that aim to support post-release health, wellbeing, and social integration. A social system that fosters cross-sectoral collaboration and continuity of care through innovative funding initiatives is vital to the effectiveness and sustainability of such reentry programs.

Introduction Initial reports suggest people experiencing homelessness (PEH) are at high risk for SARS-CoV-2 infection and associated morbidity and mortality. However, there have been few longitudinal evaluations of the spread and impact of COVID-19 among PEH. This study will estimate the prevalence and incidence of COVID-19 infections in a cohort of PEH followed prospectively in Toronto, Canada. It will also examine associations between individual-level and shelter-level characteristics with COVID-19 infection, adverse health outcomes related to infection and vaccination. Finally, the data will be used to develop and parameterise a mathematical model to characterise SARS-CoV-2 transmission dynamics, and the transmission impact of interventions serving PEH.Design, methods and analysis Ku-gaa-gii pimitizi-win will follow a random sample of PEH from across Toronto (Canada) for 12 months. 736 participants were enrolled between June and September 2021, and will be followed up at 3-month intervals. At each interval, specimens (saliva, capillary blood) will be collected to determine active SARS-CoV-2 infection and serologic evidence of past infection and/or vaccination, and a detailed survey will gather self-reported information, including a detailed housing history. To examine the association between individual-level and shelter-level characteristics on COVID-19-related infection, adverse outcomes, and vaccination, shelter and healthcare administrative data will be linked to participant study data. Healthcare administrative data will also be used to examine long-term (up to 5 years) COVID-19-related outcomes among participants.Ethics and dissemination Ethical approval was obtained from the Unity Health Toronto and University of Toronto Health Sciences Research Ethics Boards (# 20-272). Ku-gaa-gii pimitizi-win was designed in collaboration with community and service provider partners and people having lived experience of homelessness. Findings will be reported to groups supporting Ku-gaa-gii pimitizi-win, Indigenous and other community partners and service providers, funding bodies, public health agencies and all levels of government to inform policy and public health programs.

Abstract Background Homelessness constitutes a traumatic period that adversely impacts health and quality of life outcomes. The potential mitigating effects of resilience on quality of life levels in people experiencing homelessness are underresearched. This study assesses the longitudinal associations between resilience and quality of life scores among adults experiencing homelessness and mental illness. Methods This study is a secondary analysis of longitudinal data collected over 6 years from participants (N = 575) of the At Home/Chez Soi study on Housing First, Toronto site. Repeatedly measured resilience scores are the primary exposure and repeatedly measured global quality of life scores and mental health-specific quality of life scores are the primary outcomes. Mixed effect models were used to assess the association between the exposures and the outcomes. Results The majority of the participants were men (69.2%) and were on average 40.4 (± 11.8) years old at baseline. The average resilience score ranged between 5.00 to 5.62 over 8 data collection points across the 6-year follow-up period. After adjusting for gender, age, ethno-racial background, Housing First intervention, physical and mental comorbidities, and lifetime homelessness, higher resilience scores were positively associated with higher Global quality of life (Adjusted-coefficient: 0.23, 95% CI 0.19–0.27) and mental health-related quality of life values (Adjusted-coefficient: 4.15, 95% CI 3.35–4.95). Conclusion In homeless adults with mental illness, higher resilience levels were positively associated with higher global and mental health related quality of life values. Further interventions and services aimed to enhance resilience mechanisms and strategies are warranted to enhance better mental health and quality of life outcomes of this population group. Trial registration At Home/Chez Soi trial was registered with ISRCTN, ISRCTN42520374. Registered 18 September 2009, http://www.isrctn.com/ISRCTN42520374.

Abstract Background Dental problems (DPs) and physical chronic diseases (CDs) are highly prevalent and incident in people with low socioeconomic status such as homeless individuals. Yet, evidence on the association between DPs and physical CDs in this population is limited. In the present study, we assessed the association between DPs and type and number of CDs in individuals experienced chronic homelessness and serious mental health problems. Methods We analyzed cross-sectional baseline data from 575 homeless adults with serious mental health problems participating in the Toronto site of the At Home/Chez Soi randomized controlled trial. Chronic DPs (lasting at least 6 months) were the primary exposure variable. Presence of self-reported CDs, including heart disease, effect of stroke, hypertension, diabetes, asthma, chronic bronchitis/emphysema, stomach or intestinal ulcer, inflammatory bowel disease, migraine, thyroid problems, arthritis, kidney/bladder problems, liver disease (other than hepatitis), and iron-deficiency anemia, were the primary outcomes. The total number of CDs was also analyzed as a secondary outcome. Logistic regression models were used to assess the association between DPs with each of the studied CDs, and negative binomial regression was used to test the association between DPs with the number of CDs. Results In our 575 homeless participants (68.5% males) with mean age 40.3 (11.8) years, a high proportion had DPs (42.5%). The presence of DPs was positively associated with heart disease (adjusted odds ratio (AOR):4.19,1.67–10.52), diabetes (AOR:2.17,1.13–4.17), chronic bronchitis (AOR:2.34,1.28–4.29), stomach or intestinal ulcer (AOR:3.48,1.80–6.73), inflammatory bowel disease (AOR:2.52,1.38–4.60), migraine (AOR:1.80,1.20–2.72), arthritis (AOR:2.71,1.71–4.29), kidney/bladder problems (AOR:2.43,1.30–4.54), and iron-deficiency anemia (AOR:3.28,1.90–5.65). DPs were also associated with a higher number of CDs (IRR: 1.62,1.38–1.90). Conclusion Dental health problems in homeless individuals with serious mental disorders are associated with several CDs. Dental care should be better integrated into existing social and health programs serving this population to improve their overall health status. The AH/CS study is registered with the International Standard Randomized Control Trial Number Register (ISRCTN42520374).

Objective We assessed the critical role of Housing First (HF) programs and frontline workers in responding to challenges faced during the first wave of the COVID-19 pandemic. Method Semi-structured interviews were conducted with nine HF frontline workers from three HF programs between May 2020 and July 2020, in Toronto, Canada. Information was collected on challenges and adjustments needed to provide services to HF clients (people experiencing homelessness and mental disorders). We applied the Analytical Framework method and thematic analysis to our data. Results Inability to provide in-person support and socializing activities, barriers to appropriate mental health assessments, and limited virtual communication due to clients’ lack of access to digital devices were among the most salient challenges that HF frontline workers reported during the COVID-19 pandemic. Implementing virtual support services, provision of urgent in-office or in-field support, distributing food aid, connecting clients with online healthcare services, increasing harm reduction education and referral, and meeting urgent housing needs were some of the strategies implemented by HF frontline workers to support the complex needs of their clients during the pandemic. HF frontline workers experienced workload burden, job insecurity and mental health problems (e.g. distress, worry, anxiety) as a consequence of their services during the first wave of the COVID-19 pandemic. Conclusion Despite the several work-, programming- and structural-related challenges experienced by HF frontline workers when responding to the needs of their clients during the first wave of the COVID-19 pandemic, they played a critical role in meeting the communication, food, housing and health needs of their clients during the pandemic, even when it negatively affected their well-being. A more coordinated, integrated, innovative, sustainable, effective and well-funded support response is required to meet the intersecting and complex social, housing, health and financial needs of underserved and socio-economically excluded groups during and beyond health emergencies.

Abstract Social isolation and loneliness (SIL) are public health challenges that disproportionally affect individuals who experience structural and socio-economic exclusion. The social and health outcomes of SIL for people with experiences of being unhoused have largely remained unexplored. Yet, there is limited synthesis of literature focused on SIL to appropriately inform policy and targeted social interventions for people with homelessness experience. The aim of this scoping review is to synthesize evidence on SIL among people with lived experience of homelessness and explore how it negatively impacts their wellbeing. We carried out a comprehensive literature search from Medline, Embase, Cochrane Library, PsycINFO, CINAHL, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index for peer-reviewed studies published between January 1st, 2000 to January 3rd, 2023. Studies went through title, abstract and full-text screening conducted independently by at least two reviewers. Included studies were then analyzed and synthesized to identify the conceptualizations of SIL, measurement tools and approaches, prevalence characterization, and relationship with social and health outcomes. The literature search yielded 5,294 papers after removing duplicate records. Following screening, we retained 27 qualitative studies, 23 quantitative studies and two mixed method studies. SIL was not the primary objective of most of the included articles. The prevalence of SIL among people with homelessness experience varied from 25 to 90% across studies. A range of measurement tools were used to measure SIL making it difficult to compare results across studies. Though the studies reported associations between SIL, health, wellbeing, and substance use, we found substantial gaps in the literature. Most of the quantitative studies were cross-sectional, and only one study used health administrative data to ascertain health outcomes. More studies are needed to better understand SIL among this population and to build evidence for actionable strategies and policies to address its social and health impacts.

Background: Housing First (HF)-based interventions have been implemented in North America and beyond to help people exit homelessness. The effect of these interventions on access to primary and specialist care services is not well-defined. This study assesses the long-term effects of an HF intervention for homeless adults with mental illness on primary care physician (PCP) and non-primary care physician (non-PCP) visits. Methods: This is a secondary analysis of the At Home/Chez Soi study, a randomized trial of HF for homeless adults with mental illness in Toronto, Canada. High-need (HN) participants were randomized to HF with assertive community treatment (HF-ACT) or treatment as usual (TAU). Moderate needs (MN) participants were randomized to HF with intensive case management (HF-ICM) or TAU. The primary outcomes were the incidence and the number of visits to a PCP and non-PCP over 7-years post-randomization, compared to the 1-year pre-randomization. Results: Of 575 enrolled participants, 527 (80 HN and 347 MN) participants were included in the analyses. HN participants who received HF-ACT had a significant reduction in the number of visits to a PCP compared to TAU participants (ratio of rate ratios (RRR): 0.66, 95% CI: 0.48-0.93) and a significant reduction in the number of non-PCP visits compared with TAU participants (RRR: 0.64, 95% CI: 0.42-0.97) in the 7-years post-randomization compared to the 1-year pre-randomization. MN participants who received HF-ICM had a significant increase in incident visits to a PCP compared to TAU participants (RRR: 1.66, 95% CI: 1.10-2.50). No effect of HF-ICM was observed on the incidence or number of non-PCP visits. Conclusion: HF has differing effects on visits to PCPs and non-PCPs among homeless people with high and moderate needs for mental health supports. HF does not result in a consistent increase in PCP and non-PCP visits over a 7-year follow-up period. The At Home/Chez Soi study is registered with ISRCTN (ISRCTN, ISRCTN42520374).

Purpose: We examined the housing trajectories of homeless people with mental illness over a follow-up period of 6 years and the association of these trajectories with food security. We then examined the modifying role of psychopathology and alcohol and substance use disorders in this association.Materials and Methods: We followed 487 homeless adults with mental illness at the Toronto site of the At Home/Chez-Soi project—a randomized trial of Housing First. Food security data were collected seven times during the follow-up period. Psychopathology (Colorado Symptom Index score) and alcohol and substance use disorders were assessed at baseline. Housing trajectories were identified using group-based trajectory modeling. Logistic regression was used to estimate the association between housing trajectory groups and food security.Results: Three housing trajectory groups were identified: rapid move to consistent stable housing (34.7%), slow and inconsistent housing (52.1%), and never moved to stable housing (13.2%). Individuals included in the rapid move to consistent housing trajectory group had higher odds of remaining food secure compared with those in the never moved to stable housing trajectory group over the follow-up period [AOR 2.9, 95% CI: 1.3–6.6, P-value: 0.009]. However, when interactions were considered, this association was significant among those with moderate psychopathology but not severe psychopathology. Individuals with substance use disorder and in the never moved to stable housing group had the lowest food security status.Discussion: Severe psychopathology and substance use disorders modified the association between housing trajectories and food security.International Standard Randomized Control Trial Number Register (ISRCTN42520374).

Objectives People experiencing homelessness have a high prevalence and incidence of traumatic brain injury (TBI) due to violence. Little is known about the effectiveness of interventions to reduce TBI in this population. This study assessed the effect of Housing First (HF) on violence-related TBI in adults with experiences of homelessness and mental illness.Design Pragmatic randomised trial.Participants 381 participants in the Toronto site of the At Home/Chez randomised trial.Intervention HF participants were provided with scattered-site housing using rent supplements and supports from assertive community treatment or intensive case management teams (n=218, 57.2%). Control participants had access to treatment as usual (TAU) in the community (n=163, 42.8%).Main outcome measures Primary outcomes were an incident physical violence-related TBI event and the number of physical violence-related TBI events during the follow-up period (January 2014 to March 2017). Interval-censored survival time regression and zero-inflated negative binomial regression were used to assess the effect of HF on primary outcomes.Results Among study participants, 9.2% (n=35) had an incident physical violence-related TBI event, and the mean physical violence-related TBI events was 0.16 (SD ±0.6). Compared with TAU participants, HF participants did not have a significantly lower risk of an incident violence-related TBI event (adjusted HR : 0.58 (95% CI, 0.29 to 1.14)), but they had a significantly lower number of physical violence-related TBI events (unadjusted incidence rate ratio (IRR): 0.22 (95% CI, 0.06 to 0.78); adjusted IRR: 0.15 (95% CI, 0.05 to 0.48)).Conclusion HF may be a useful intervention to reduce the burden of TBI due to physical violence among homeless individuals with mental illness.Trial registration number ISRCTN42520374.

Early paternal involvement in infant care is beneficial to child and maternal health, and possibly for paternal mental health. The purpose of the present study was to examine the relationship between fathers’ involvement in early infant parenting and their depressive symptoms during the infant’s first year in a sample of 881 low-income Black, Hispanic, and White fathers recruited from five sites in the United States (urban, mixed urban/suburban, rural). Home interviews at 1 month after birth assessed three concepts based on prior research and community input: (1) time spent with the infant, (2) parenting self-efficacy, (3) material support for the baby. Paternal depressive symptoms at 1, 6, and 12 months after the birth of a child were assessed with the Edinburgh Postpartum Depression Scale. Generalized estimating equations tested whether the three indicators of father involvement at 1 month after birth predicted lower subsequent paternal depressive symptoms controlling for social and demographic variables. For fathers, greater time spent with the infant, parenting self-efficacy, and material support were all significantly associated with lower paternal depressive symptoms during the first year. When risk of depression (scores > 9) was examined, only parenting self-efficacy among fathers was associated with higher likelihood of clinical depression. Findings have implications for future research on mechanisms linking paternal involvement and paternal mental health, and for possible paid paternal leave policies in the future.

Exposure to deprived socioeconomic conditions during the peri-conception and early childhood periods can have a negative long-term impact on individuals’ health and that of their progeny. We aimed to examine whether relatives’ birth period affected index-child (grand-child) birthweight status in the Lifeways Cross-Generation Cohort in the Republic of Ireland. Participants were 943 mothers and offspring, 890 fathers, 938 maternal grandmothers (MGM), 700 maternal grandfathers (MGF) 537 paternal grandmothers (PGM) and 553 paternal grandfathers (PGF). Index-child’s birthweight was sex-for-gestational age standardised (UK1990 population), and then classified into low birthweight (≤10th percentile) and high-birthweight (≥90th percentile) and compared against normal-birthweight (>10th to

BackgroundFew studies have examined how food insecurity changes over time when living with severe mental disorders or substance use disorders. This study identifies food insecurity trajectories of homeless adults participating in a trial of a housing intervention and examines whether receiving the intervention and having specific mental and substance disorders predict food insecurity trajectories.Materials and methodsWe studied 520 participants in the Toronto site of the At Home/Chez-Soi project. Food insecurity data were collected at seven times during a follow-up period of up to 5.5 years. Mental and substance use disorders were assessed at baseline. Food insecurity trajectories were identified using group based-trajectory modeling. Multinomial logistic regression was used to examine the effects of the intervention and mental and substance use disorders on food insecurity trajectories.ResultsFour food insecurity trajectories were identified: persistently high food insecurity, increasing food insecurity, decreasing food insecurity, and consistently low food insecurity. Receiving the intervention was not a predictor of membership in any specific food insecurity trajectory group. Individuals with major depressive episode, mood disorder with psychotic features, substance disorder, and co-occurring disorder (defined as having at least one alcohol or other substance use disorder and at least one non-substance related mental disorder] were more likely to remain in the persistently high food insecurity group than the consistently low food insecurity group.ConclusionA persistently high level of food insecurity is common among individuals with mental illness who have experienced homelessness, and the presence of certain mental health disorders increases this risk. Mental health services combined with access to resources for basic needs, and re-adaptation training are required to enhance the health and well-being of this population.

Stigma and discrimination toward individuals experiencing homelessness and mental disorders remain pervasive across societies. However, there are few longitudinal studies of stigma and discrimination among homeless adults with mental illness. This study aimed to identify the two-year group trajectories of stigma and discrimination and examine the predictive role of mental health characteristics among 414 homeless adults with mental illness participating in the extended follow-up phase of the Toronto At Home/Chez Soi (AH/CS) randomized trial site. Mental health-related perceived stigma and discrimination were measured at baseline, one, and two years using validated scales. Group-based-trajectory modelling was used to identify stigma and discrimination group trajectory memberships and the effect of the Housing First treatment (rent supplements and mental health support services) vs treatment as usual on these trajectories. The associations between mental health-related characteristics and trajectory group memberships were also assessed using multinomial logistic regression. Over two-years, three group trajectories of stigma and discrimination were identified. For discrimination, participants followed a low, moderate, or increasingly high discrimination group trajectory, while for stigma, participants followed a low, moderate or high stigma group trajectory. The Housing First treatment had no significant effect on discrimination or stigma trajectories groups. For the discrimination trajectories, major depressive episode, mood disorder with psychotic features, alcohol abuse, suicidality, severity of mental health symptoms, and substance use severity in the previous year were predictors of moderate and increasingly high discrimination trajectories. History of discrimination within healthcare setting was also positively associated with following a moderate or high discrimination trajectory. For the stigma trajectories, substance dependence, high mental health symptoms severity, substance use severity, and discrimination experiences within healthcare settings were the main predictors for the moderate trajectory group; while substance dependence, suicidality, mental health symptom severity, substance use severity and discrimination experiences within health care setting were also positive predictors for the high stigma trajectory group. Ethno-racial status modified the association between having a major depression episode, alcohol dependence, and the likelihood of being a member of the high stigma trajectory group. This study showed that adults experiencing mental illness and homelessness followed distinct stigma and discrimination group trajectories based on their mental health-problems. There is an urgent need to increase focus on strategies and policies to reduce stigma and discrimination in this population.