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This research explores the incidence of child maltreatment among homeless families. The maltreatment explored in the study includes physical, emotional and sexual abuse. The data reported a high incidence of child maltreatment in the lives of the homeless. The policy implications for these findings are discussed.

There are two dominant approaches to implementing permanent supportive housing (PSH), namely place-based (PB) and scattered-site (SS). Formal guidance does not distinguish between these two models and only specifies that PSH should be reserved for those who are most vulnerable with complex health needs. To consider both system- and self-selection factors that may affect housing assignment, this study applied the Gelberg-Anderson behavioral model for vulnerable populations to compare predisposing, enabling, and need factors among people experiencing homelessness (PE) by whether they were assigned to PB-PSH (n = 272) or SS-PSH (n = 185) in Los Angeles County during the COVID-19 pandemic. This exploratory, observational study also included those who were approved but did not receive PSH (n = 94). Results show that there are notable differences between (a) those who received PSH versus those who did not, and (b) those in PB-PSH versus SS-PSH. Specifically, PEH who received PSH were more likely to be white, US-born, have any physical health condition, and have lower health activation scores. PEH who received PB- versus SS-PSH were more likely to be older, Black, have any alcohol use disorder, and have higher health activation scores. These findings suggest that homeless service systems may consider PB-PSH more appropriate for PEH with higher needs but also raises important questions about how race may be a factor in the type of PSH that PEH receive and whether PSH is received at all.

More than 500,000 people experience homelessness in the United States, and many turn to transit vehicles, stops, and stations for shelter. We present findings from a survey of 115 U.S. and Canadian transit operators that inquired about homelessness on transit systems. We find that homelessness is broadly present, though more concentrated on central hotspots, and worsened during the pandemic. In response, transit agencies often initiate a combination of punitive and outreach strategies. Based on our findings, we argue for better data collection, establishment of policies and protocols, engagement in outreach strategies, and partnering with service providers.

Homelessness is a public health concern in California and throughout the United States. Intimate partner violence (IPV) is a risk factor for experiencing homelessness. Few studies have examined the interplay between IPV, homelessness, and housing. Qualitative methods can provide a greater understanding of the lived experience of IPV and homelessness to identify potential solutions. We purposefully sampled 104 adults who reported experiencing IPV in the California Statewide Study of People Experiencing Homelessness (CASPEH), a representative, mixed-methods study. We administered semi-structured interviews focusing on IPV and six other topic areas pertaining to homelessness from October 2021 to May 2022. We created and applied a codebook with a multidisciplinary team using a hybrid of deductive and inductive logic. Our analysis included all participants who discussed IPV and homelessness across the seven studies. We conducted a thematic analysis using an interpretivist approach and informed by grounded theory. We found that violence within a partnership was multidimensional (physical, sexual, emotional, and financial) and bidirectional. We identified six themes: (1) IPV precipitated and prolonged homelessness; (2) Need for housing, financial stability, and material resources influenced staying in abusive relationships; (3) Alcohol and illicit substance use exacerbated violence between partners; (4) Participants struggled to find resources in domestic violence (DV) shelters; (5) The healthcare system did not provide substantial support; and (6) discrimination and stigma influenced equitable access to housing and DV resources. Experiencing IPV contributed to homelessness and impeded returns to housing. Limitations in current IPV resources impede care. We propose equitable expansion of survivor-centered services that improve access to long-term subsidized housing, prevent IPV and homelessness with flexible funding options, and facilitate rapid exits from homelessness through trauma-informed, non-congregate shelter that transitions to permanent housing.

The travel experiences of unhoused women in Los Angeles present a critical yet underexplored aspect of urban mobility and homelessness. This report aims to fill the gap in literature addressing the unique travel patterns and challenges this group faces, emphasizing the need for solutions tailored to their mobility needs. Interviews with unhoused women in Los Angeles were conducted to gauge their travel patterns and primary safety concerns. Interviews took place in Van Nuys and Little Tokyo to reflect the differences in travel experiences between the suburbs and the inner city. Homelessness resources are more concentrated in Central City Los Angeles, where Little Tokyo is located, providing a model for what could be possible in terms of mobility, safety, and access to public transportation. Conversely, in Van Nuys, resources are sparse and spread out, compelling unhoused women to travel greater distances and optimize their travel time by multitasking.Key takeaways include reliance on community networks, increasing preference for biking as an affordable and eco-friendly travel mode, and the use of bikes and fare-free transit for feelings of autonomy and independence. Additionally, despite concerns about safety when alone, unhoused women are still wary of law enforcement, and anti-homeless measures like 41.18 lead to continuous displacements, disrupting daily routines.Findings suggest addressing the fundamental issue of housing, implementing robust data collection, partnering with homelessness advocacy groups, securing funding for essential amenities, and making infrastructural improvements to support the autonomy, mobility, and safety of unhoused women. All in all, a comprehensive approach is necessary to provide effective relief.

California faces a severe housing crisis, characterized by soaring rents, limited affordability, and increasing homelessness. Latinos, in particular, suffer disproportionately from housing insecurity, which is defined as a spectrum of housing precarity – ranging from homelessness to substandard living conditions. This report employs a mixed-methods approach to analyze housing insecurity in California. Its quantitative analysis introduces novel housing insecurity estimates, using data from the California Department of Education and the American Community Survey. Qualitative data from literature reviews and semi-structured interviews provide deeper insights into the factors driving housing insecurity and potential policy solutions.The findings reveal a high prevalence of housing insecurity, especially among Latinos. In 2022, approximately 1.3 million Californians were housing insecure, significantly higher than the 820,961 in doubled-up housing in 2021 and nearly eight times the 171,521 counted as homeless in 2022. Latinos, comprising 39.5% of the state's population, represent 68% of the housing insecure. The majority of housing insecure individuals reside in Southern California, with over 55% concentrated in Los Angeles, Orange, San Bernardino, San Diego, and San Bernardino counties, and Latinos account for 71.8% of this housing insecure population.Ultimately, this analysis underscores the imperative of broadening the conceptualization of homelessness support to encompass a spectrum of services for those experiencing housing insecurity. By adopting the inclusive framework of housing insecurity, policymakers and stakeholders can develop tailored interventions to address some identified causes of housing insecurity, including housing affordability, access to transportation, culturally competent services, and immigration support.

OBJECTIVES: To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery. DESIGN: Retrospective cohort study. SETTING: Mariner claims database. PATIENTS/PARTICIPANTS: Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study. INTERVENTION: Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing. MAIN OUTCOME MEASURES: One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation. RESULTS: Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08-2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08-1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00-1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59-0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63-1.18, P = 0.41). CONCLUSIONS: Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population. LEVEL OF EVIDENCE: Prognostic Level III.

BackgroundLong-acting (LA) antiretrovirals may provide meaningful benefit to people who use drugs and people experiencing homelessness (PEH) who face disproportionate structural and psychosocial barriers in adhering to daily oral HIV antiretroviral therapy or pre-exposure prophylaxis (PrEP), but their use in these populations has not been studied.SettingThe Maria X. Martinez Health Resource Center is a low-barrier (eg, no appointment) community-based clinic serving San Francisco PEH.MethodsA multidisciplinary care model with robust monitoring and outreach support was developed to provide LA antiretroviral therapy (ART) and LA-PrEP to eligible patients experiencing difficulties adhering to oral antiretrovirals. Feasibility was assessed by evaluating the rates of HIV viremia and on-time injections among patients receiving LA antiretrovirals over the first 24 months of program implementation.ResultsBetween November 2021 and November 2023, 33 patients initiated LA-ART or LA-PrEP (median age, 37 years; 27% transgender/nonbinary; 73% non-White; 27% street homeless; 52% sheltered homeless; 30% with opioid use disorder; 82% with methamphetamine use disorder). Among 18 patients with HIV, 14 initiated LA-ART injections with detectable viremia (median CD4 count, 340 cells/mm 3 ; mean log 10 viral load, 3.53; SD, 1.62), 8 had never previously been virally suppressed, and all but 1 achieved or maintained virologic suppression (mean, 9.67 months; SD, 8.30). Among 15 LA-PrEP patients, all remained HIV negative (mean, 4.73 months; SD, 2.89). Of 224 total injections administered, 8% were delayed >7 days.DiscussionThe implementation of LA antiretrovirals is feasible in low-barrier, highly supportive clinical settings serving vulnerable PEH. Expansion of such programs will be critical in ending the HIV epidemic.

BACKGROUND: Approximately 70-80% of people experiencing homelessness in the United States use tobacco. Smoking cessation programs specifically for this population have been found to be less effective for African American participants. The purpose of this study was to explore discrimination experiences and their impact on smoking habits and readiness to quit cigarette smoking while experiencing homelessness. METHODS: In the qualitative phase of this mixed methods study, five focus groups were conducted for African Americans residing in a homeless shelter in Skid Row, Los Angeles, CA. Using a semi-structured interview guide, we asked participants about discrimination experiences, how smoking habits were impacted by these experiences, and tools needed to successfully abstain from cigarette smoking. Qualitative descriptive content analysis was used to explore discrimination experiences and its association with readiness to quit cigarette smoking. RESULTS: Of the 17 participants, 14 (82.4%) were male, and the average age was 46.8 years. Using a qualitative In Vivo coding method, three themes were revealed: Experiencing Discrimination while Black, The Psychosocial Fabric-Why Quitting Cigarette Smoking is a Challenge, and The Lesser of Two Evils-Choosing to Smoke over More Harmful Options. Participants discussed working in the blue-collar workforce while Black, identifying as a double minority, smoking to cope with stress, early exposure to cigarettes, smoking being a central part of ones belonging to a group, and the legality of cigarette smoking. DISCUSSION: Our findings show that African Americans experiencing homelessness (1) may experience discrimination in multiple settings, regardless of housing status, (2) could have grown up around cigarette smoking and remain surrounded by it while experiencing homelessness, and (3) may experience a calming effect with smoking, which slows some from reacting negatively to adverse situations. CONCLUSION: Barriers to successfully abstaining from smoking are multifactorial among African Americans experiencing homelessness and should be addressed individually. Future research should explore the cultural tailoring of interventions that support cessation efforts unique to minoritized populations to improve smoking cessation programs offered to this population.

Rates of homelessness among adults aged 50 and over are rising. Common strategies for exiting homelessness rely on social and family support. However, intergenerational trauma may disrupt these social support networks and contribute to homelessness. Understanding the impact of intergenerational trauma on living with family or friends may give insight into addressing homelessness among older adults. We purposefully sampled 46 adults who reported living with family or friends from the HOPE HOME study cohort (350 community-recruited adults, ≥ 50 years and experiencing homelessness in Oakland, California) and 19 family/friends who had hosted the participants in their living spaces. We conducted independent, semi-structured interviews and used grounded theory methodologies to analyze data. We identified four major themes from the interviews: (1) Intergenerational trauma was common and made it difficult to stay with family or friends; (2) Participants and hosts sought to protect future generations from intergenerational trauma; (3) Relationships endured despite intergenerational trauma; and (4) social structures exacerbated the impact of intergenerational trauma and played a significant role in perpetuating homelessness. Trauma-informed policies that confront the structures that propagate or exacerbate intergenerational trauma may mitigate their impact and facilitate housing for older adults.

Over the past few decades, scholars and educators have challenged the traditional focus of architectural history on styles and formal features, placing more emphasis on user experience. This experience, however, is not common to all. Each sector of society understands, inhabits, and utilizes architecture differently, leading to divergent ways of performing one’s identity within the city. For example, unhoused people are often excluded from full participation in public life. This commentary shares an experiment that complements an architectural history course with a set of assignments where students engage with sociopolitical aspects of the built environment through mapping and analyzing anti-homeless, hostile design in Eugene, Oregon.

BackgroundWater, sanitation, and hygiene (WASH) access is critical to public health and human dignity. People who inject drugs (PWID) experience stigma and structural violence that may limit WASH access. Few studies have assessed WASH access, insecurity, and inequities among PWID. We describe WASH access, social and geographic inequalities, and factors associated with WASH insecurity among PWID in the Tijuana-San Diego metropolitan area.MethodsIn this cross-sectional binational study, we interviewed PWID (age 18+) in 2020-2021 about WASH access and insecurity. City of residence (Tijuana/San Diego) and housing status were considered as independent variables to describe key WASH access outcomes and to assess as factors associated with WASH insecurity outcomes. Measures of association between outcomes and independent variables were assessed using log modified-Poisson regression models adjusting for covariates.ResultsOf 586 PWID (202 Tijuana; 384 San Diego), 89% reported basic access to drinking water, 38% had basic hand hygiene, 28% basic sanitation, and 46% access to bathing, and 38% reported recent open defecation. Participants residing in Tijuana reported significantly higher insecurity in accessing basic drinking water (aRR: 1.68, 95%CI: 1.02-2.76), basic hygiene (aRR: 1.45, 95%CI: 1.28-1.64), and bathing (aRR: 1.21, 95%CI: 1.06-1.39) than those living in San Diego. Participants experiencing unsheltered homelessness experienced significantly higher insecurity in accessing basic drinking water (aRR: 2.03, 95%CI: 1.07-3.86), basic sanitation (aRR: 1.68, 95%CI: 1.48, 1.92), bathing (aRR: 1.84, 95%CI: 1.52-2.22), and improved water sources for cleaning wounds (aRR: 3.12, 95%CI: 1.55-6.29) and for preparing drugs (aRR: 2.58, 95%CI: 1.36-4.89) than participants living in permanent housing.ConclusionWASH access among PWID in the Tijuana-San Diego metropolitan area was low by international standards and lower than the national averages in both countries. Homelessness was significantly associated with WASH insecurity in this population. Concentrated efforts are needed to guarantee continuously available WASH services for PWID-especially those who are unsheltered.

BackgroundLoneliness is more common in older adults and those who face structural vulnerabilities, including homelessness. The homeless population is aging in the United States; now, 48% of single homeless adults are 50 and older. We know little about loneliness among older adults who have experienced homelessness. We aimed to describe the loneliness experience among homeless-experienced older adults with cognitive and functional impairments and the individual, social, and structural conditions that shaped these loneliness experiences.MethodsWe purposively sampled 22 older adults from the HOPE HOME study, a longitudinal cohort study among adults aged 50 years or older experiencing homelessness in Oakland, California. We conducted in-depth interviews about participants perceived social support and social isolation. We conducted qualitative content analysis.ResultsTwenty participants discussed loneliness experience, who had a median age of 57 and were mostly Black (80%) and men (65%). We developed a typology of participants' loneliness experience and explored the individual, social, and structural conditions under which each loneliness experience occurred. We categorized the loneliness experience into four groups: (1) "lonely- distressed", characterized by physical impairment and severe isolation; (2) "lonely- rather be isolated", reflecting deliberate social isolation as a result of trauma, marginalization and aging-related resignation; (3) "lonely- transient", as a result of aging, acceptance and grieving; and (4) "not lonely"- characterized by stability and connection despite having experienced homelessness.ConclusionsLoneliness is a complex and heterogenous social phenomenon, with homeless-experienced older adults with cognitive or functional impairments exhibiting diverse loneliness experiences based on their individual life circumstances and needs. While the most distressing loneliness experience occurred among those with physical impairment and mobility challenges, social and structural factors such as interpersonal and structural violence during homelessness shaped these experiences.

BackgroundWater, sanitation, and hygiene (WaSH) insecurity increases the risk of water-related diseases. However, limited research has been conducted on psychosocial distress as it relates to WaSH insecurity, especially among people who inject drugs (PWID). We examined the relationship between WaSH insecurity and related anxiety among PWID living in different housing conditions along the US-Mexico border region.MethodsFrom 2020-2021, a cross-sectional study was conducted among 585 people who injected drugs within the last month in Tijuana (N = 202), San Diego (N = 182), and in both Tijuana and San Diego (N = 201). Participants underwent interviewer-administered surveys related to WaSH access, substance use, and generalized anxiety disorder (GAD-7). Quasi-Poisson regressions were used to assess associations between WaSH insecurity and anxiety in the prior 6-months.ResultsParticipants were 75% male, 42% were unhoused and 91% experienced WaSH insecurity in the prior 6-months. After adjusting for housing status, gender, and age, lack of access to basic drinking water (Adj RR: 1.28; 95% CI: 1.02-1.58), sanitation (Adj RR:1.28; 95% CI: 1.07-1.55), and a daily bath/shower (Adj RR: 1.38; 95% CI: 1.15-1.66) were associated with mild-severe anxiety. The number of WaSH insecurities was independently associated with a 20% increased risk of experiencing anxiety per every additional insecurity experienced (Adj RR: 1.20; CI: 1.12-1.27). We also found a significant interaction between gender and housing status (p = 0.003), indicating that among people experiencing sheltered/unsheltered homelessness, women had a higher risk of mild-severe anxiety compared to men (Adj RR: 1.55; 95% CI: 1.27-1.89). At the same time, among women, those who are unhoused have 37% increased risk of anxiety than those who live in stable housing conditions (Adj RR: 1.37; 95% CI: 1.01-1.89).ConclusionThe lack of specific WaSH services, particularly lack of drinking water, toilets, and daily showers were associated with higher levels of anxiety among PWID in the Tijuana-San Diego border region. Women experiencing homelessness were especially vulnerable. WaSH interventions that provide safe, 24-h access may help to reduce anxiety and health risks associated with WaSH insecurity.

Objectives: Indigenous people experience poorer mental health compared to the general population. Socioeconomic gaps partly explain these disparities. However, there is variability between populations and French overseas territories are understudied. This study examines the prevalence of mental health problems among Indigenous people in New Caledonia and French Polynesia, describing and comparing it with that of their counterparts while considering associated factors. Methods: We used the data from the cross-sectional Mental Health in the General Population survey in the only 3 sites for which information on indigenous status was available: Noumea (2006) and the 'Bush' (2008) in New Caledonia, and French Polynesia (2015–2017). Current mental health issues were screened using the Mini-International Neuropsychiatric Interview. In multivariable analyses, we considered the following factors: gender, age, education level, marital status, occupational activity and monthly income. Results: Overall, 2294 participants were analysed. Among the 1379 indigenous participants, 52.3% had at least one mental health issue. The prevalence of depressive disorder (18.0% vs 11.7%), alcohol use disorder (16.7% vs 11.7%) and suicide risk (22.3% vs 16.7%) were higher among indigenous participants compared to non-indigenous participants. After adjustment, the association between indigenous status and these mental health issues did not persist, except for alcohol use disorder. Conclusion: We found higher prevalence of depressive disorder, alcohol use disorder and suicide risk among indigenous people of French Polynesia and New Caledonia compared to their counterparts. These differences seemed largely explained by socioeconomic disparities. Future studies could explore the use of and access to healthcare by indigenous populations. [ABSTRACT FROM AUTHOR]

This article traces the origins and goals of the abolition movement in the United States that began during the era of chattel slavery to demonstrate that the true aspirations of this movement—a racially just society free of racism and oppression—remain aspirations that are not yet realized. Realizing these aspirations is the real work of abolition and this is the work that social work must embrace today. Yet for social work to truly work toward an anti-racist future, we must also be anti-capitalist. This requires that we work toward both the abolition of harmful, racist systems and abolition of the racial capitalism that maintains these systems. The article concludes with recommendations for scholars and leaders in human service organizations to engage in and advance this work. [ABSTRACT FROM AUTHOR]

Tenancy support services (TSS) allow homeless or institutionalized people with disabilities to obtain and maintain housing in community settings. In the United States, Medicaid is expanding to include coverage for these services. We conducted a comparison case study of two high performing North Carolina (NC) TSS provider agencies, augmented with the voices of key stakeholders in NC and experienced leaders in Louisiana, to explore promising practices for providing effective TSS. Through employing a Housing First philosophy, client centered service delivery, teams with specialized positions, a supportive environment for staff, and staff training TSS outcomes of increased housing, housing retention, improved health, social connection, and enhanced quality of life for residents were achieved. Study findings are intended to inform TSS agencies, state officials, and other stakeholders interested in effective TSS provision. [ABSTRACT FROM AUTHOR]

Many women experiencing homelessness and intimate partner violence (IPV) often do not use formal support services due to barriers such as finances, inaccessibility, controlling partners, and stigma. The current literature lacks studies that examine the formal service experiences of women who have undergone both homelessness and IPV. Therefore, the current study used a qualitative-dominant design and explored the formal service needs of these women, barriers and facilitating factors associated with accessing services, and how the women's identities affected their experiences with formal services. Interviews with 10 women were conducted, and a reflexive thematic analysis was conducted using a critical feminist and intersectionality lens. The most common factors that led to homelessness were conflict and precarious circumstances leading to housing instability. Common barriers were systemic, psychological, dismissal, minimization, and financial barriers. The most common needs were health, finances, and basic necessities. The most common facilitating factors were support networks and resilience, growth, and proactivity. The social positionings most commonly affecting their experiences were class and race/ethnicity. These findings highlighted the voices of marginalized women and can be used to implement positive change in formal services that cater to this subgroup of women. [ABSTRACT FROM AUTHOR]

The status of single women in the eighteenth century was precarious; homelessness and economic dependence plagued the lives of those who chose not to marry. This was the case, at least, for Mary and Charlotte Winn, the unmarried sisters of the 5th Baronet of Nostell Priory. Like many single women, the Winn sisters' archive is sparse. But such a sparseness can be utilised and, in this instance, provides the opportunity for creative methods of recovering women's voices. By exploring the materiality of Mary's and Charlotte's letters, this article demonstrates how these sisters negotiated their distance from the family home through the space they occupied on the page. Paradoxically, moreover, it is this distance that has ensured the survival of their papers. As such, the article concludes by considering the epistolary afterlives of the Winn sisters' letters and addresses how their manuscript legacy has posthumously afforded them a place in the family's history. In effect, paper ties to landed estates, though fragile, remain exactly that – ties. [ABSTRACT FROM AUTHOR]

Aims: Research has associated lack of parental care, physical abuse, and parental substance abuse to homelessness, with the presence of two or more such factors dramatically increasing one's chances of becoming homeless as an adult. Less clear is which (cumulation of) factors may mediate the difference between transitional and recurrent homelessness. Methods: Quantitative analysis of four risk factors—addiction, weak social network, criminal activity, psychopathology—among 69 transitionally and recurrently homeless (RH) adults, followed by in‐depth qualitative analysis of adverse childhood experiences (ACEs) among 30 selected participants. Results: RH participants had higher cumulative risk and a higher prevalence and broader range of ACEs than transitionally homeless participants, with the prevalence of childhood physical abuse marking the greatest difference between the two groups. Recurrent homelessness was also correlated with addiction to hard drugs, criminal activity, and weak social networks. Conclusion: Longitudinal and intervention studies in larger groups are needed to assess causality. [ABSTRACT FROM AUTHOR]

Child labour is a complex social problem worldwide, affecting the physical, moral and educational development of children. A cross sectional quantitative survey research design was used to assess child labour in quarrying activities of the Ga West Municipality, Ghana. The municipality was selected due to evidence in literature of children engaging in quarrying activities. The study examined child labour occurrence and intensity, the working condition of child labourers in the stone quarries; factors influencing child labour in quarrying activities; and the impact of quarrying activities on children. Data which were analysed using probit model and descriptive statistics indicated a negative effect of stone quarry activity on the development, growth and education of the child. Significant influencers were poverty, attitude and poor perception of parents, broken homes, traditional belief systems and migration. The study recommends offering educational support, grants and essential resources to vulnerable households in order to ensure that children remain in school. [ABSTRACT FROM AUTHOR]

Persons experiencing homelessness (PEH) are vulnerable emergency department (ED) patients due to high rates of multi-comorbidity and mortality, as well as a lack of follow up care. Communication of test results pending at discharge (TPAD) is an important area of post-ED follow up care. We examined phone access, successful contact, and change in treatment among PEH and non-PEH with TPAD from the ED. We performed a retrospective cohort study and included all abnormal TPAD and patient telephone notes regarding TPAD over 7 months extracted from the electronic health record of a single, high-volume, urban, safety-net hospital in Denver, Colorado. Two investigators reviewed all data to determine phone access, successful contact, and recommended treatment change. Descriptive statistics were calculated for all variables and compared between PEH and non-PEH. We assessed associations between homelessness and successful contact and phone access while adjusting for age and sex using multivariable logistic regression. A total of 940 patient encounters with TPAD were included. 142 telephone notes regarding abnormal TPAD were included, of which 33 (23 %) were to PEH. Compared to PEH, housed patients were significantly more likely to have access to a phone (+31 %, 95 % CI: 14–48 %), have an active phone (+46 %, 95 % CI: 29–64 %), and be successfully contacted (+42 %, 95 % CI: 24–60 %), but were less likely to have a recommended change in treatment (−14 %, 95 % CI: −24 to −5 %). Homelessness was significantly associated with decreased successful contact (odds ratio [OR] 0.16, 95 % CI: 0.07–0.38) and decreased phone access (OR 0.11, 95 % CI: 0.04–0.33) after adjusting for age and sex. In the subgroup of patients with phone access (n = 124), homelessness was significantly associated with decreased successful contact (OR 0.26, 95 % CI: 0.10–0.70) after adjusting for age and sex. PEH are less likely to have phone access and be successfully contacted regarding TPAD, resulting in untreated or improperly treated infectious disease. Thus, EDs and hospital systems should explore innovative communication solutions, such as shared responsibility models and partnerships with shelters and healthcare for the homeless clinics to improve successful contact with PEH regarding TPAD. • Communication of test results pending at discharge is an important area of post-emergency department follow up care. • Persons experiencing homelessness are less likely to be successfully contacted regarding tests pending at discharge. • EDs should explore innovative solutions to improve successful contact regarding tests pending at discharge. [ABSTRACT FROM AUTHOR]

Pet ownership is an important leisure activity for unhoused people, yet housed people at leisure often disapprove. Reviewing literature from leisure studies and beyond, I consider the tension surrounding this practice through the lenses of critical leisure, multi-species perspectives, and the capabilities approach. I examine (1) how people at leisure react to unhoused pet owners, (2) how pet ownership impacts wellbeing and leisure activities while unhoused, (3) whether the human leisure benefits produced also serve the animals involved, and (4) what actions and attitudes are necessary to alleviate the conflicting leisure interests produced by unhoused pet ownership. Housed people at leisure assume the unhoused cannot care for a pet when they "cannot even take care of themselves." However, these pets generally receive good care, and unhoused pet owners also perceive practical and emotional benefits, though empirical evidence for these benefits is still lacking. While the everyday challenges faced by unhoused pet owners are apparent, more research is needed to assess the physical, psychological, and social benefits they experience by participating in leisure through pet ownership. To address this leisure conflict, animal-accommodating shelter services must be provided, and the public must better understand the relationship between unhoused people and their pets. [ABSTRACT FROM AUTHOR]

In response to Diaspora criticism's recommendations for listening to underground voices, often eclipsed by the leading diaspora figures, the present paper brings attention to the blossoming literary work of the contemporary Moroccan-American writer Laila Lalami. Her fiction, four full-length novels and short prose so far, is argued to intertwine creatively with the major scholarly turns that have marked diasporic literary criticism since its inception in the early 1990s. It registers certain mobility and shifts of concerns from the tropes of homesickness, through homelessness to the rhetoric of transnationalism to grapple with white hegemonic spatiality and politics. However, the focus here is laid on her latest novel The Other Americans (2019) which features minorities from different ethnic backgrounds, yet converging in the enmeshment of their personal lives with the political forces, which intensifies the unsettled issues of identity in the US. Though no material principles of assimilation are proposed, Lalami's implied protagonist's eventual urges for complete integration into mainstream society draw on the power of love and forgetting rather than violence and revenge. In so doing, Lalami's materialist perspective is believed to debunk the Trumpist right political paranoia with reference to the assimilating capability of immigrants. [ABSTRACT FROM AUTHOR]

There is a growing attention to neoliberal policies and practices as they relate to climate change and housing within academic literature. However, the combined effects of neoliberal political and economic decisions on the interaction between climate change and displaced and homeless populations have not been substantially explored. In this paper, we identify and focus on three key re-emerging themes prevalent within neoliberal discourses: economic considerations, individualization, and short-termism. To examine the intersecting influence of climate change and these themes on vulnerable populations, the following case studies are discussed: displaced populations in the Middle East and North Africa (MENA) region, refugees in Kenya, and tiny homes programs in the U.S. and Canada. The diversified contexts and levels of analysis allow for more nuanced understanding of the variety of ways in which neoliberal influences and climate-induced events impact the most vulnerable populations. We argue for the need to change the framing of these issues, which are often presented in neoliberal terms and are driven by neoliberal logic. We then present potential avenues for resolving the identified issues, such as through systemic changes, development of long-term solutions, and focusing on community-based adaptation (CBA) programs. [ABSTRACT FROM AUTHOR]

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Background: Peer workers are individuals who draw on their personal experiences in a professional capacity to support clients. Existing research on the role of peer workers in mental health, homelessness, and substance use services has primarily focused on their impact on client outcomes. This paper describes the development of peer workers as they transition into, through, and beyond this role. Utilising data from the Supporting Harm Reduction through Peer Support (SHARPS) study, where Peer Navigators supported people experiencing homelessness and substance use challenges, this paper explores the sense-making involved in an intensive peer support worker role, adaptation to organisational culture, and engagement with opportunities for professional advancement. Methods: Semi-structured interviews with three Peer Navigators were conducted by two SHARPS study researchers at four time points in 2018 and 2019 corresponding with the beginning, middle, and end of the intervention. These data were analysed along with entries from the three Peer Navigators' reflective diaries. Analysis followed a multi-stage approach to thematic analysis utilising both inductive and deductive processes. The Peer Navigators' personal reflections have also been incorporated into the recommendations. Results: The foundational training provided to the Peer Navigators before taking up their role helped to ensure readiness and build confidence. This training illuminated the dynamics of supporting individuals with complex health and social challenges. Integrating into diverse organisational environments, the Peer Navigators adapted to new professional expectations and consistently advocated for harm reduction and psychologically informed approaches, sometimes encountering resistance from other professionals. Establishing effective relationships with participants and professionals was essential and involved dealing with challenges such as overcoming personal biases and navigating systemic obstacles. the Peer Navigators benefitted from the specially designed training to support career progress with personal and professional development opportunities which enabled successful transitions beyond the SHARPS study. Conclusions: Pre-work training, coupled with support and adherence to key principles, enabled the Peer Navigators to integrate effectively into diverse organisations. Quality relationships were vital in achieving client outcomes and supporting the professional growth of the Peer Navigators. These findings are important for services employing peer workers and underscore the importance of a commitment to training and continuing professional development. [ABSTRACT FROM AUTHOR]

Adolescents in vulnerable living contexts (e.g., foster care, juvenile justice facilities, and experiencing homelessness) may be at increased risk of adolescent dating violence victimization (ADV) due to unstable environments and trauma exposure. They may also experience different protective factors. Yet, research is limited on ADV in these contexts. This study assessed differences in ADV experiences among adolescents (10–21 years) in vulnerable contexts compared to adolescents at home utilizing data from a sexual health education program serving communities facing health inequities in California. Descriptive analyses compared adolescents in vulnerable contexts (n = 1,951) with those living at home (n = 10,682). Multivariable logistic regression was used to estimate the odds of experiencing past year physical and/or sexual ADV by context, controlling for sociodemographic variables. We also examined two potential protective factors: meaningful communication with a parent/guardian and pro-social friendships. Significantly more adolescents in vulnerable contexts than at home identified as male (65.6% vs. 51.6%), 18 years or older (16.5% vs. 8.7%), non-Hispanic Black or African American (14.4% vs. 5%), and LGBTQ+ (15.3% vs. 10.8%). Among adolescents who dated in the past year, 21% in vulnerable contexts reported experiencing physical and/or sexual ADV, compared to 15% of those at home, and reported lower levels of protective factors. Adolescents experiencing homelessness/unstable housing and those in juvenile justice facilities had greater adjusted odds of ADV compared to adolescents at home (56% and 54% higher odds, respectively). It is critical to address systemic factors, which disproportionately impact the most marginalized and disadvantaged adolescents, in approaches for ADV prevention. [ABSTRACT FROM AUTHOR]

A student essay for Clare Winnicott Essay Competition. A societal critique of the ongoing issues and complications for those experiencing homelessness in modern times, which applies both Stuart Hall’s Theory of Representation (1997) and peer reviewed research on social stigmas, to identify the effectiveness of relationship-based practice within the homeless sector. [ABSTRACT FROM AUTHOR]

AbstractWhile there are an abundance of studies evaluating the effectiveness of Housing First programs, there is a recent surge in critical social science research that situates Housing First within broader debates about contemporary neoliberal homelessness governance. This paper provides clarity to this evolving and somewhat fragmented work by highlighting three main conceptualisations of critical Housing First research. First, it is interpreted as a technocratic global fast policy that, while appealing to policymakers and government officials, ultimately fails to address the structural causes of housing insecurity and homelessness. Second, it is viewed as an economic tool that prioritises housing for a narrow cohort of ‘chronic homeless’ that incur a high cost to scarce public resources. Third, it is seen as a disciplinary tactic that ignores people’s alternative expressions of home and compels them to abide by the norms of ‘independent living’ and the private rental market. We conclude with an assessment of this critical literature. Whilst acknowledging its key insights, we contend that its treatment of Housing First as yet another form of neoliberal homelessness governance and overreliance on Anglophone-country case studies risks reifying HF’s worst aspects and failing to adequately recognise its transformative potential. [ABSTRACT FROM AUTHOR]

Background: The concurrence of homelessness and alcohol use disorder (AUD) has negative consequences in affected individuals. Managed alcohol programs (MAPs), a harm reduction strategy based on providing regular doses of alcohol to individuals with AUD, have emerged as a potential solution to reduce alcohol-related harms.Objectives: This study examined the impact of a MAP implemented in Barcelona on patterns of alcohol and other psychoactive substance use, health, and quality of life among people who use drugs and were experiencing homelessness. The research also incorporated a gender perspective and focused on individuals who had accessed a residential center.Methods: A descriptive qualitative design was used, employing semi-structured interviews with eight participants who were enrolled in the MAP (three women, five men) and four program professionals. Thematic analysis was used to analyze the resulting data.Results: The domains guiding the study appeared as outcome themes: patterns of use of alcohol and other substances, health, quality of life and impact on female-identified participants. Participants reported improved health due to reduced consumption of alcohol and other substances, better anxiety management, and reconnection to health services. The participants reported enhanced quality of life, including feeling safer, and better use of time, which had been spent on meeting their basic needs. Women reported that a key benefit of the program was living in a sexism-free environment.Conclusion: These results appear to demonstrate that harm reduction strategies prioritizing basic needs and adopting a gender-sensitive perspective can positively impact the health and quality of life of people experiencing homelessness with AUD. [ABSTRACT FROM AUTHOR]

The AHURI Final Report No. 429 delves into the evolving landscape of homelessness in Australia from 2001 to 2021, shedding light on the disparities in rates across capital cities and remote regions, particularly in the Northern Territory. It underscores the critical need for evidence-based policies to tackle homelessness effectively, emphasizing the importance of affordable rental housing and culturally sensitive approaches, especially for First Nations communities. The report's data-driven analysis reveals the intricate web of demographic, housing, and socioeconomic factors influencing homelessness rates, advocating for targeted interventions to bridge the gap between service capacity and homelessness prevalence. [Extracted from the article]

Background: Homeless-experienced adults smoke at rates 5 times that of the general adult population, and often have limited access to cessation treatments while homeless. Permanent Supportive Housing (PSH) can be a catalyst for cessation treatment utilization, yet little is known about use of these treatments following PSH entry, or how to tailor and implement cessation care that meets homeless-experienced adults' vulnerabilities. Methods: Using Department of Veterans Affairs (VA) administrative data, we assessed smoking status (ie, current, former, non/never) among a cohort of homeless-experienced Veterans (HEVs) housed in Los Angeles-based PSH. We compared cessation treatment use rates (ie, nicotine replacement therapies, cessation medications, psychosocial counseling) pre- and post-housing using Chi-square tests. Predisposing (ie, demographics), enabling (eg, primary care, benefits), and need characteristics (ie, health, mental health, substance use diagnoses) were examined as correlates of cessation treatment utilization pre- and post-housing in univariable and multivariable logistic regression models. Results: Across HEVs (N = 2933), 48.6% were identified as currently-smoking, 17.7% as formerly-smoking, and 14.0% as non/never smoking. Among currently- and formerly-smoking HEVs (n = 1944), rates of cessation treatment use post-housing were significantly lower, compared to pre-housing, across all treatment types. Health, mental health, and substance use was more prevalent among currently- and formerly-smoking HEVs compared to non/never-smoking HEVs, and most diagnoses were positively associated with utilization univariably. However, in multivariable models, cessation clinic referrals and primary care engagement were the only significant (P <.001) predictors of pre-housing and post-housing cessation treatment utilization. Conclusion: Among HEVs, we found high smoking rates and low cessation treatment utilization pre- and post-PSH entry. Efforts to educate providers about this population's desire to quit smoking, support primary care engagement, and increase cessation clinic referrals may bolster their utilization. For homeless-experienced adults, optimizing cessation treatment accessibility by embedding cessation services within PSH and homeless service settings may reduce utilization impediments. [ABSTRACT FROM AUTHOR]

Background: Social integration (i.e., reciprocal interactions with peers and community members) is a notable challenge for many homeless-experienced adults with serious mental illness (SMI). In this study, we examine a range of housing services offered to homeless-experienced adults with SMI and identify the impacts of supportive services on participants' social integration outcomes, with the goal of improving services in transitional and permanent housing settings for homeless-experienced adults with SMI. Methods: Through semi-structured interviews with homeless-experienced adults with SMI (n = 30), we examine the impacts of housing and service settings on participants' social integration. Participants received services in a variety of housing settings, including transitional housing with congregate/shared living (n = 10), transitional housing with individual quarters (n = 10), and permanent supportive housing (n = 10). Results: Participants expressed caution in developing social relationships, as these could pose barriers to recovery goals (e.g., substance use recovery). For many, social integration was secondary to mental and physical health and/or housing stability goals. Individual quarters gave individuals a place of respite and a sense of control regarding when and with whom they socialized. Meeting recovery goals was strongly related to connecting to and receiving a range of supportive services; interviews suggest that proximity to services was critical for engagement in these resources. Conclusions: Programs serving homeless experienced adults with SMI should seek to understand how individuals conceptualize social integration, and how social relationships can either support or hinder participants' recovery journey. [ABSTRACT FROM AUTHOR]

Background: Homeless-experienced veterans (HEVs) are an important but challenging group to care for in the U.S. Department of Veterans Affairs health care system, and there are opportunities to examine the potential of integrative and complementary medicine approaches. Methods: This observational study enrolled 33 HEVs in a one-group observational, prospective study of Battlefield Acupuncture (BFA) with a monthly follow-up for 3 months after initiating BFA. Results: Linear growth curve analyses revealed a significant improvement in overall pain scores and scores on the effects of pain on activity level, mood, and stress. Conclusions: These preliminary findings suggest the potential of BFA to improve pain among HEVs as an area for further research. [ABSTRACT FROM AUTHOR]

Introduction: Despite increased awareness of the detrimental relationship between homelessness and health, people experiencing homelessness remain an underserved population in health and social care research. Due to barriers affecting the accessibility of medicine and healthcare services, as well as reported competing priorities such as food and shelter, evidence has demonstrated that people experiencing homelessness are less likely to undergo routine examinations, receive diagnoses and adhere to prescribed medical treatments. To enhance service design and access for those experiencing homelessness, it is critical to better recognise, understand and address the barriers these individuals face. This meta‐ethnography aims to identify barriers, enablers and interventions to begin addressing this inequality gap. Methods: A systematic literature search was undertaken in October and re‐ran in December 2023 across four databases: MEDLINE, Embase, CINAHL and Scopus. Qualitative studies were included if they addressed barriers, enablers and interventions aimed at tackling medicines and health service inequalities among populations experiencing homelessness. Study quality was assessed using the Joanna Briggs Institute critical appraisal checklist. Data were synthesised using a meta‐ethnographic approach, as outlined by Noblit and Hare. The review was registered on PROSPERO (CRD42024511502) and performed according to PRISMA guidelines. Results: This meta‐ethnographic systematic review synthesised data from eight studies across multiple countries. Three overarching third‐order constructs (termed 'themes') were developed through reciprocal translation and centred around: recognising and acknowledging the discrimination, stigma and barriers experienced when using current services; exploring safe and practical use of medicines and the promotion of general health education and appreciating strategies to tackle inequalities, namely community outreach programmes designed for homeless communities. Conclusion: This work highlighted the barriers, enablers and interventions that sought to address the inequalities affecting people experiencing homelessness in accessing medication and healthcare services. Future research should utilise lived‐experience narratives and co‐design to further explore ways to tackle wider healthcare accessibility inequalities for this minoritised population. Trial Registration: Not applicable, as this is a systematic review. Patient or Public Contribution: Public contributors (minority research champions and one public health research champion, H.K.G. and T.G.) informed and shaped this project during study design and conceptualisation. They helped to ensure that the study was conducted, and the findings were reported with sensitivity. [ABSTRACT FROM AUTHOR]

Introduction: There is a paucity of research on and a limited understanding of patient and public involvement (PPI) in the context of research in homelessness and, in particular, direct involvement of people with lived and living experience of homelessness (PEH) as expert advisors. We aim to report on outcomes and reflections from lived experience advisory panel (LEAP) meetings and PPI activities, held throughout the study lifecycle of a pilot randomised‐controlled trial (RCT) focused on evaluating integrated health and practical support for PEH. Methods: Community Pharmacy Homeless Outreach Engagement Non‐medical Independent prescribing Rx (PHOENIx Community Pharmacy RCT) is an integrated health and social care intervention for people experiencing homelessness who present to community pharmacy. Intervention includes weekly support from a pharmacist prescriber and a third sector support worker for up to 6 months. PPI activities undertaken throughout the study were documented, including outcomes of LEAP meetings. Outcome reporting followed Guidance for Reporting Involvement of Patients and the Public 2 Short Form (GRIPP2‐SF). Results: In total, 17 members were recruited into the LEAP; six meetings (three in two study sites) were held. PPI input was also received through representation from homelessness third sector organisation staff as study co‐applicants and core membership in the trial steering committee. Together, the PPI activities helped shape the study proposal, design of study materials, data analysis and dissemination materials. LEAP panel members offered valuable input via their experience and expertise into the delivery and refinement of interventions. Although longitudinal input was received from some LEAP members, ensuring repeat attendance in the pre‐planned meetings was challenging. Conclusion: People who face social exclusion and marginalisation can provide highly valuable input as equal partners in co‐design and delivery of interventions seeking to improve their health and well‐being. Fluid membership and flexible methods of seeking and incorporating advice can offer pragmatic approaches to minimising barriers to continued involvement in research. Patient or Public Contribution: This study reports findings and learning relevant to involvement of people with lived and living experience of homelessness as advisors in a research study. It is important for researchers to offer fluid memberships and use diverse methods to receive input from lived experience members, as traditional PPI methodology may be insufficient to ensure inclusivity. Staff and volunteers from third sector organisations were important PPI partners who bring their experience based on frontline service provision, often as the first port of call for people experiencing severe and multiple disadvantage. Trial Registration: ISRCTN88146807. [ABSTRACT FROM AUTHOR]

This paper advances existing work on the geographies of homelessness by considering the phenomenon of sofa‐surfing—defined as the practice of living in a host's home, without a right to reside, in the absence of more permanent accommodation—as a distinctive, and until recently somewhat hidden, form of homelessness. Examining sofa‐surfing is important as it recognises the varied and intersecting spatial, temporal and mobility characteristics of vulnerable populations, often thought to be living at the margins of homelessness. Across the globe, the significant increase in sofa‐surfing since the 2010s, coupled with the unique, and frequently hidden, movements between 'host' homes, and the interrelationships that exist between sofa‐surfers and hosts, makes sofa‐surfing an essential lens through which to interpret the diverse geographies of 21st Century homelessness. To achieve this, we draw together work from a range of global contexts that examine the roots of stigmatised homeless identities and punitive public policies, alongside studies of homeless mobilities and performative homeless identities, to help understand the complex precarities associated with feelings of dislocation and (not) belonging. Investigating patterns of sofa‐surfing mobilities alongside sofa‐surfers' fluid performative identities matters, and this paper provides new ways of understanding how such unique interactions impact sofa‐surfers' felt capacities to belong within and between sofa‐surfing spaces. [ABSTRACT FROM AUTHOR]

Background: Current cancer screening guidelines for transgender individuals are guided primarily by expert opinion, and are extrapolated from guidelines for cisgender populations, despite the additional unique risks that transgender populations face in cancer risk and cancer care. Aims: We examined adherence to current recommended screening guidelines as well as drivers of cancer screening in 192 transgender and gender-nonbinary (TGNB) individuals participating in Project AFFIRM, a multi-site longitudinal cohort study of TGNB individuals. Methods: We used a chi-squared analysis to look for significant associations between predictors and adherence to breast, cervical, prostate and colon cancer screening. We analyzed predictors by 3 different categories: sex/gender identity, healthcare access, and socioeconomic status. Results: Screening rates were low for breast, cervical, prostate and colon cancer in TGNB populations compared to national rates for cisgender populations. Among several significant predictors, gender-affirming surgery (hysterectomy) (p-value = <0.0001) and telling others they are transgender at a younger age (< 18) (p-value = 0.0344) were associated with increased screening adherence, while having HIV was associated with decreased screening adherence (p-value = 0.0045). Discussion: Our results suggest that interacting with the healthcare system to obtain comprehensive cancer screening can be difficult to navigate among the other healthcare needs of TGNB individuals both on an individual and systems level. Future efforts to mitigate the barriers to screening adherence should be targeted at the healthcare system level. [ABSTRACT FROM AUTHOR]

In US literary history, the Great Depression stands as a wellspring of poetry and prose that imagines homelessness otherwise, that reads the embodiments and relationalities of homeless dispossession as an abolitionist horizon, cutting across the structural, epistemic violence of urban sociology, welfare bureaucracy, and the carceral state as well as practicing radical alternatives of relating to housing. Arguably influenced by discourses on subproletarian pathology, myriad Depression‐era writers regarded the homeless as bereft of futurity, and they understood the condition of unhoused immiseration as a state of social death that marked the homeless as kinless. This literary vein conceived of homelessness as a disgendering experience in which the homeless body becomes an aberration from the heteropatriarchal gender binary. Alongside this literature of homeless nonfuturity, this article locates a literary countercurrent that explores how homeless persons continue to build kinships and collective futures that manifest through and exceed their bare existence. In particular, the article examines the poem "Homeless but Not Motherless" (1935) and the novel The Girl (ca. 1939), finding in both a recognition not only of the disgendering violence of homelessness but also of the potentialities for forging kinship across exclusions from labor, housing, family, and civil society. [ABSTRACT FROM AUTHOR]

The major aim of this study was to understand the experience of resilience in adolescents and young adults within the context of a unitary caring science and to generate insights into ways to cultivate resilience in adolescents and young adults who have experienced adversity. Four major essences emerged and were synthesized into one statement. Maintaining hope and optimism for a promising future is acknowledging awareness and acceptance and experiencing connectedness while embracing power in the situation. The essences were interpreted within a theory of unitary caring. [ABSTRACT FROM AUTHOR]

Background: Government programs—targeting chronic disease patients with high health care costs—focus on clinical conditions, factors internal to the health care system, and individual patient education, not on addressing modifiable social determinants of health to reduce health care utilization. Objective: To evaluate differences in sociodemographic variables and health care utilization between patients with chronic obstructive pulmonary disease (COPD) who reported food insecurity and those who did not. Methods: This descriptive retrospective cross-sectional study used data from the electronic health records of a convenience sample of 854 participants with a discharge diagnosis of COPD or COPD with acute exacerbation, admitted via the emergency department of participating hospitals in Southern California. Chi-square (or Fisher's exact) tests and t tests were used to evaluate group differences, and multivariate (or Firth) logistic regression to identify factors that increased the odds of emergency department visits and hospitalizations. Results: Significant differences between groups were identified for food insecurity (sometimes or often vs never insecure) and age (P <.001), race (P =.022), medical insurance (P <.001), zip code (P =.022), homeless status (P <.001), smoking status (P <.001), and emergency department visits (P =.033). No significant differences were found for food insecurity and hospitalizations (P =.592). Conclusion: This study contributes to the growing body of research supporting the association of upstream social factors (food insecurity, homelessness, zip code) and downstream health outcomes (repeated emergency room visits), and how existing programs can be effectively utilized to impact downstream health outcomes such as health care utilization. [ABSTRACT FROM AUTHOR]