Search

BackgroundContinuity of primary care (CPC) is associated with reduced mortality and improved health status. This study assessed the level of CPC and changes in CPC over 6 years among adults with experience of homelessness and mental illness who received a Housing First intervention.MethodsParticipants were adults (≥18 years old) with a serious mental disorder and experiencing chronic homelessness enrolled between October 2009 and June 2011 in the Toronto site of the Canadian At Home/Chez Soi study and followed until March 2017. Participants were randomized to Housing First with intensive case management (HF-ICM), Housing First with assertive community treatment (HF-ACT), or treatment as usual. For this report, 280 intervention group participants (HF-ICM, n = 193 and HF-ACT, n = 87) were analysed using data from health records. The main outcome was CPC measured by the Continuity of Care Index as a continuous and categorical variable among participants during 3 consecutive 2-year periods.ResultsMost HF-ICM participants had low levels of CPC, with 68%–74% of this group having low CPC across all time periods. Similarly, most HF-ACT participants had low levels of CPC, with 63%–78% of this group having low CPC across all time periods.ConclusionsAmong this group of individuals with mental illness who were experiencing homelessness, CPC remained low over 6 years of follow-up. This study highlights that housing and mental health interventions may need to place greater emphasis on improving CPC using effective strategies that are specifically geared towards this important goal among their clients.

We assessed the effects of the Toronto Site Housing First (HF) intervention on hospitalizations and emergency department (ED) visits among homeless adults with mental illness over 7 years of follow-up. The Toronto Site is part of an unblinded multi-site randomized pragmatic trial of HF for homeless adults with mental illness in Canada, which followed participants up to 7 years. Five hundred seventy-five participants were recruited and classified as having high (HN) or moderate need (MN) for mental health support services. Each group was randomized into intervention (HF) and treatment as usual groups, and 567 (98.6%) consented to link their data to health administrative databases. HF participants received a monthly rent supplement of $600 (Canadian) and assertive community treatment (ACT) support or intensive care management (ICM) support based on need level. Treatment as usual (TAU) participants had access to social, housing, and health services generally available in the community. Outcomes included all-cause and mental health-specific hospitalization, number of days in hospital, and ED visit. We used GEE models to estimate ratio of rate ratios (RRR). The results showed HF with ACT had no significant effect on hospitalization rates among HN participants, but reduced the number of days in hospital (RRR = 0.32, 95% CI 0.16-0.63) and number of ED visits (RRR = 0.57, 95% CI 0.34-0.95). HF with ICM resulted in an increase in the number of hospitalizations (RRR = 1.69, 95% CI 1.09-2.60) and ED visit rates (RRR = 1.42, 95% CI 1.01-2.01) but had no effect in days in hospital for MN participants. Addressing the health needs of this population and reducing acute care utilization remain system priorities. Trial registration: http://www.isrctn.com/identifier: ISRCTN42520374

Purpose To conduct a multi-dimensional and time-patterned analysis to identify distinct well-being trajectory profiles over a 6-year follow-up period among adults experiencing homelessness and mental illness. Methods Data from 543 participants of the At Home Chez Soi study’s Toronto site were examined over a 6-year follow-up period, including measures of quality of life, community functioning, housing stability, and substance use. Well-being trajectories were identified using Group-Based Trajectory Modelling. Multinomial regression was used to identify predictor variables that were associated with each well-being trajectory profile. Results Four well-being profiles were identified: low well-being, moderate well-being, good well-being, and high well-being. Factors associated with a greater likelihood of following a better well-being profile included receiving Housing First, reporting female gender and non-white ethnicity, having post-secondary studies, and reporting a high resilience level. Concurrently, factors associated with a lower likelihood of better well-being profiles were having a history of chronic homelessness, experiences of discrimination in the healthcare setting, having comorbid mental disorders and a high level of symptom severity, and reporting a history of traumatic brain injury and childhood adversity. Conclusions Individuals experiencing homelessness follow distinct well-being profiles associated with their socio-demographic characteristics, health status, trauma history, resilience capabilities, and access to housing and support services. This work can inform integrated housing and support services to enhance the well-being trajectories of individuals experiencing homelessness. Trial registration At Home/Chez Soi trial was registered with ISRCTN, ISRCTN42520374, http://www.isrctn.com/ISRCTN42520374.

Objective: The associations between adverse childhood experiences (ACEs) and psychopathology have been well-established in the general population. Research on ACEs in the homeless population has been limited. This study examined whether ACE exposure is associated with specific mental health outcomes among a national sample of homeless adults with mental illness and whether this association varies according to ACE dimension and gender. Methods: This cross-sectional study utilized data from a national sample of 2,235 homeless adults with mental illness in Canada to evaluate their sociodemographic characteristics, exposure to ACEs, and mental health outcomes. Exploratory and confirmatory factor analyses were conducted to identify and confirm ACE dimensions (maltreatment, sexual abuse, neglect, divorce, and household dysfunction) from individual ACE items. Multivariable logistic regression was used to examine the associations between total ACE score and ACE dimensions with mental illness diagnoses and psychopathology severity. Results: The mean total ACE score among all study participants was 4.44 (standard deviation [ SD]: 2.99). Total ACE score was positively associated with several mental illness diagnoses and psychopathology severity. Unique associations were found between specific ACE dimensions and poor mental health outcomes. The prevalence of almost all ACEs was significantly higher among women. Yet, associations between several ACE dimensions and poor mental health outcomes existed uniquely among men. Conclusions: There are unique and gender-specific associations between specific ACE dimensions and mental health outcomes among homeless adults. Better understanding of the mechanisms underlying these associations is needed to inform screening, prevention, and treatment efforts, particularly given the very high prevalence of ACEs among this vulnerable and marginalized population.

We examine the long-term housing trajectories of 543 program participants at the Toronto site of the At Home/Chez-Soi project, a randomized controlled trial of a Housing First (HF) intervention for adults with mental disorders. The average follow-up period for our study was 5.5 years. We find that the HF approach, which includes housing subsidies and support services, was strongly associated with rapid transitions to sustained housing (70.4 percent of HF participants vs. 27.9 percent of treatment as usual participants). Mood disorders with psychotic features and primary psychotic disorders were negatively associated with the rapid and sustained housing trajectory, and alcohol use disorders were positively associated with a rapid then declining housing trajectory. We argue that to understand the long-term impacts of housing programs, research needs to better explore comprehensive and personalized care to support individuals with severe mental disorders.

This study identifies time-patterned trajectories of housing stability among homeless and vulnerably housed individuals who participated in a multisite four-year longitudinal study in Canada. Findings show four distinct trajectories for the homeless and vulnerably housed: high levels of sustained housing stability, improving levels over time leading to high levels of housing stability, decreasing levels of housing stability over time, and low levels of housing stability over time. The presence of resources rather than risk factors differentiated the trajectories of participants who achieved housing stability from those who had low levels of housing stability. Participants who had better housing stability were more likely to live in subsidized housing. Findings highlight the need for programs and policies directed at addressing the housing affordability problem through income support strategies and the creation of affordable housing.

The effects of the coronavirus disease-2019 (COVID-19) pandemic on the lives of underserved populations are underexplored. This study aimed to identify the impacts of the COVID-19 pandemic and associated public health responses on the health and social well-being, and food security of users of Housing First (HF) services in Toronto (Canada) during the first wave of the COVID-19 pandemic. This qualitative descriptive study was conducted from July to October 2020 in a subsample of 20 adults with a history of homelessness and serious mental disorders who were receiving HF services in Toronto. A semi-structured interview guide was used to collect narrative data regarding health and social well-being, food security and access to health, social and preventive services. A thematic analysis framework guided analyses and interpretation of the data. The COVID-19 pandemic and response measures had a variable impact on the health, social well-being and food security of participants. Around 40% of participants were minimally impacted by the COVID-19 pandemic. Conversely, among the remaining participants (impacted group), some experienced onset of new mental health problems (anxiety, stress, paranoia) or exacerbation of pre-existing mental disorders (depression, post-traumatic stress disorder and obsessive-compulsive disorder). They also struggled with isolation and loneliness and had limited leisure activities and access to food goods. The pandemic also contributed to disparities in accessing and receiving healthcare services and treatment continuity for non-COVID-19 health issues for the negatively impacted participants. Overall, most participants were able to adhere to COVID-19 public health measures and get reliable information on COVID-19 preventive measures facilitated by having access to the phone, internet and media devices and services. In conclusion, the COVID-19 pandemic and associated response measures impacted the health, social well-being, leisure and food security of people with experiences of homelessness and mental disorders who use supportive social and housing services in diverse ways.

espanolEn este trabajo se intentan definir los factores asociados a la desnutricion cronica de los ninos y ninas de 6 a 24 meses en Haiti y al descenso de la desnutricion en el periodo 1994-2017. Con este fin, se utilizan los datos de las Encuestas de Mortalidad, Morbilidad y Utilizacion de Servicios (Enquete Mortalite, Morbidite et Utilisation des Services (EMMUS)) que abarcan dicho periodo. En terminos metodologicos, se aplica un modelo de regresion lineal multiple y un modelo de descomposicion para encontrar, respectivamente, los factores relacionados con la desnutricion cronica y la contribucion de cada uno de ellos a la reduccion de la desnutricion cronica en el pais. Entre los resultados mas relevantes, se destaca que la escolaridad de la madre, el numero de hijos que haya tenido y el numero de consultas prenatales que haya recibido durante el embarazo son los factores que tienen un mayor peso en el descenso de la desnutricion cronica de los ninos en Haiti durante este lapso EnglishThis paper sets out to identify the factors associated with chronic malnutrition among children aged 6–24 months in Haiti and the reduction in the rate of malnutrition between 1994 and 2017. Data are obtained from the Mortality, Morbidity and Service Utilization Surveys (Enquete Mortalite, Morbidite et Utilisation des Services–EMMUS) covering that period. A multiple linear regression model is applied to identify the factors associated with chronic malnutrition in the country; and a decomposition model is used to identify each factor’s contribution to reducing it. The key findings include the fact that the mother’s education, the number of children she has had and the number of antenatal check-ups she attended during pregnancy are among the factors that best explain the decrease in chronic malnutrition among Haitian children during this period.

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.

Summary Background Adverse childhood experiences (ACEs) are strong risk factors for homelessness and poor health and functioning. We aimed to evaluate the lifetime prevalence of ACEs and their associations with health-related and functioning-related outcomes among homeless adults. Methods In this systematic review and meta-analysis, we searched from database inception to Nov 11, 2020, for original and peer-reviewed studies in English that documented lifetime prevalence of ACEs or associations between ACEs and health-related or functioning-related outcomes. We selected studies if they included a definable group of homeless adults and measured at least four ACE categories. We calculated pooled estimates of lifetime prevalence of one or more ACEs and four or more ACEs with random-effects models. We used the leave-one-out method in sensitivity analyses and studied meta-regressions to explore potential moderators of ACE prevalence. We also did a narrative summary of associations between ACEs and health-related and functioning-related outcomes, as there were too few studies on each outcome for quantitative meta-analysis. This study is registered with PROSPERO, CRD42020218741. Findings We identified 2129 studies through systematic search, of which 29 studies (16 942 individuals) were included in the systematic review, 20 studies (10 034 individuals) were included in the meta-analysis for one or more ACEs, and 15 studies (5693 individuals) were included in the meta-analysis for four or more ACEs. Studies included samples of adults experiencing homelessness in the USA, Canada, and the UK; participants in the included studies were predominantly male (65·2%) and mean ages ranged between 18·3 and 58·1 years, but many studies did not report race, ethnicity, and sexual and gender minority data. Lifetime prevalence of one or more ACEs among homeless adults was 89·8% (95% CI 83·7–93·7) and the lifetime prevalence of four or more ACEs was 53·9% (45·9–61·7). Considerable heterogeneity was identified in both meta-analyses (I2>95%). Of the potential moderators analysed, the ACE measurement tool significantly moderated the estimated lifetime prevalence of one or more ACEs and four or more ACEs, and age also significantly moderated the estimated lifetime prevalence of four or more ACEs. In the narrative synthesis, ACEs were consistently positively associated with high suicidality (two studies), suicide attempt (three studies), major depressive disorder (two studies), substance misuse (two studies), and adult victimisation (two studies). Interpretation The lifetime prevalence of ACEs is substantially higher among homeless adults than among the general population, and ACE exposure might be associated with prevalence of mental illness, substance misuse, and victimisation. Policy efforts and evidence-based interventions are urgently needed to prevent ACEs and address associated poor outcomes among this population. Funding Rhodes Trust and Canadian Institutes of Health Research.

ObjectivesPeople 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.DesignPragmatic randomised trial.Participants381 participants in the Toronto site of the At Home/Chez randomised trial.InterventionHF 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 measuresPrimary 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.ResultsAmong 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)).ConclusionHF may be a useful intervention to reduce the burden of TBI due to physical violence among homeless individuals with mental illness.Trial registration numberISRCTN42520374.

To examine the effect of a Housing First (HF) intervention and health-related risk factors on incarceration among adults with experiences of homelessness and mental illness.Participants (N = 508) were recruited at the Toronto site of the At Home/Chez Soi study. The outcome was incarceration in Ontario from 2009 to 2014. Exposures were intervention group (HF vs. treatment as usual), Axis I mental health diagnoses, emergency department (ED) visit, and history of traumatic brain injury (TBI). Logistic regression was used to examine the association between exposures and incarceration.Of 508 participants, 220 (43.3%) were incarcerated at least once during the study period. Among those incarcerated, 81.9% were male, 52.7% had been diagnosed with alcohol dependence/abuse, 60.9% had been diagnosed with substance dependence/abuse, 65.1% reported having visited an ED within the last 6 months, and 66.4% had a history of TBI. After adjusting for demographic covariates, substance dependence/abuse (aOR: 2.06; 95% CI: 1.40, 3.03), alcohol dependence/abuse (aOR: 1.52, 95% CI: 1.04, 2.22), ED visit (aOR: 1.54; 95% CI: 1.02, 2.32), and history of TBI (aOR: 2.60; 95% CI: 1.75, 3.85) were associated with incarceration. We found no significant effect of the HF intervention on incarceration outcome (aOR: 1.08; 95% CI: 0.76, 1.55).Among adults with experiences of homelessness and severe mental illness, those with substance and alcohol dependence/abuse disorders, history of TBI, and recent ED visits were at increased odds of incarceration. Strategies are needed to prevent and reduce incarceration for this population, including treatment of mental illness in the community.RéSUMé: OBJECTIF: Examiner l’effet d’une intervention de Logement d’abord (LD) et de facteurs de risque liés à la santé sur l’incarcération d’adultes ayant vécu des épisodes de sans-abrisme et de maladie mentale. MéTHODE: Les participants (N = 508) ont été recrutés sur le site torontois de l’étude At Home/Chez-Soi. L’issue à l’étude était l’incarcération en Ontario entre 2009 et 2014. Les expositions étaient le groupe d’intervention (LD vs. traitement habituel), les diagnostics de troubles de santé mentale de l’axe I, les visites aux services d’urgence (SU) et les antécédents de traumatisme cranio-cérébral (TCC). Nous avons procédé par régression logistique pour examiner l’association entre les expositions et l’incarcération. RéSULTATS: Sur 508 participants, 220 (43,3 %) avaient été incarcérés au moins une fois durant la période de l’étude. Chez les personnes incarcérées, 81,9 % étaient des hommes, 52,7 % avaient un diagnostic de dépendance à l’alcool ou d’abus d’alcool, 60,9 % avaient un diagnostic de dépendance à des substances ou d’abus de substances, 65,1 % ont dit avoir visité les SU au cours des 6 mois antérieurs, et 66,4 % avaient des antécédents de TCC. Après ajustement en fonction des covariables démographiques, la dépendance aux substances/l’abus de substances (rapport de cotes ajusté [RCa] : 2,06; IC de 95 % : 1,40, 3,03), la dépendance à l’alcool/l’abus d’alcool (RCa : 1,52, IC de 95 % : 1,04, 2,22), les visites aux SU (RCa : 1,54; IC de 95 % : 1,02, 2,32) et les antécédents de TCC (RCa : 2,60; IC de 95 % : 1,75, 3,85) étaient associés à l’incarcération. Nous n’avons observé aucun effet significatif de l’intervention de LD sur l’issue d’incarcération (RCa : 1,08; IC de 95 % : 0,76, 1,55). CONCLUSIONS: Chez les adultes ayant vécu des épisodes de sans-abrisme et de maladie mentale grave, ceux qui avaient des troubles de dépendance/d’abus de substances et d’alcool, des antécédents de TCC et qui avaient visité les SU récemment présentaient une probabilité accrue d’incarcération. Il faut des stratégies pour prévenir et réduire l’incarcération dans cette population, y compris des stratégies de traitement des maladies mentales hors du milieu carcéral.

Objective:This review summarises and synthesises the existing literature on the relationship between food insecurity (FS) and mental health conditions among adult individuals experiencing homelessness.Design:Scoping review. Papers published between 1 January 2008 and 2 November 2018, searched in PubMed, Web of Science, Scopus, PsycINFO, Cochrane Library and CINAHL, using homelessness, food security and mental health keywords.Setting:Global evidence.Participants:Homeless adults aged 18 years or more.Results:Nine articles (eight cross-sectional and one longitudinal) were included in the present review. FS was measured using the Household Food Insecurity Access Scale, the United States Department of Agriculture Household Food Security Survey Module, as well as single-item or constructed measures. Depression and depressive symptoms were the most common mental health conditions studied. Other mental health conditions assessed included alcohol and substance use, emotional disorders, mental health problems symptoms severity and psychiatric hospitalisations. Composite measures such as axis I and II categories and a cluster of severe mental conditions and mental health-related functioning status were also analysed. FS and mental health-related problems were considered as both exposure and outcome variables. The existing evidence suggests a potential association between FS and several mental health conditions, particularly depression, mental health symptoms severity and poor mental health status scores.Conclusions:This review suggests the potential association between some mental health conditions and FS among homeless adults. However, there is a need for more longitudinal- and interventional-based studies, in order to understand the nature and directionality of the links between FS and mental health in this population group.

Theoretically, disease syndemics are hyper-localized in the forms they take, but little empirical data show how localization manifests. We present a comparison across three sites in Haiti, from data collected in June–august 2017 testing for localizations of risks across three communities: rural farming, border town, and in a high gang-activity urban zone. First, we modeled survey responses collected from heads of 4055 geographically-sampled households via linear regression, considering additive and interaction effects of food insecurity, crime exposure, and discrimination on depression and anxiety levels. Exposure to food insecurity, crime exposure, and discrimination were each associated with more depression and anxiety symptoms. For those living in the urban zone, there was weak evidence of possible interactional risks between the three vulnerabilities, suggesting little meaningful localized syndemic patterning. Second, we conducted thematic and word-based semantic network analysis to identify if people themselves cognitively connected vulnerabilities of hunger/poverty, crime, and suffering/discrimination using 7321 text blocks from 95 semi-structured interviews/focus groups. Network visualization suggested people commonly connect these domains. While the patterns were localized, crime concerns were central to all networks. The domain connections expressed through people's own words were more complexly inter-related than was evident from the modeled survey data, and suggested counter-intuitive influences. The quantitative approach to modeling syndemic interactions suggests no apparent practical benefits to layering or combining local anticrime, anti-hunger, and anti-discrimination programming. However, the qualitative network analysis suggests that programming could none-the-less leverage the perceived connections across domains for more meaningful and effective interventions. For the broader study of syndemics, incorporating novel qualitative approaches clarifies that constituent processes are not just potentially localizing suffering, but are also extremely important in how people cognitively understand and organize their everyday lives.

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).

To investigate the magnitude and distribution of the main causes of death, disability, and risk factors in Haiti.We conducted an ecological analysis, using data estimated from the Global Burden of Disease Study 2017 for the period 1990-2017, to present life expectancy (LE), healthy life expectancy (HALE) at under 1-year-old, cause-specific deaths, years of life lost (YLLs), years lived with disability (YLDs), disability adjusted life-years (DALYs), and risk factors associated with DALYs.LE and HALE increased substantially in Haiti. People may hope to live longer in 2017, but in poor health. The Caribbean countries had significantly lower YLLs rates than Haiti for ischemic heart disease, stroke, lower respiratory infections, and diarrheal diseases. Road injuries were the leading cause of DALYs for people aged 5-14 years. Road injuries and HIV/AIDS were the leading causes of DALYs for men and women aged 15-49 years, respectively. Ischemic heart disease was the main cause of DALYs for people older than 50 years. Maternal and child malnutrition were the leading risk factors for DALYs in both sexes.Haiti faces a double burden of disease. Infectious diseases continue to be an issue, while non-communicable diseases have become a significant burden of disease. More attention must also be focused on the increase in worrying public health issues such as road injuries, exposure to forces of nature and HIV/AIDS in specific age groups. To address the burden of disease, sustained actions are needed to promote better health in Haiti and countries with similar challenges.Investigar la magnitud y la distribución de las principales causas de muerte, discapacidad y factores de riesgo en Haití.Se llevó a cabo un análisis ecológico con datos estimados a partir del estudio Carga Global de Morbilidad 2017 para el período 1990-2017 para presentar la esperanza de vida (LE), la esperanza de vida saludable (HALE), la mortalidad por causas específicas, los años de vida perdidos (YLL), los años vividos con discapacidad (YLD), los años de vida ajustados por discapacidad (DALY), y los factores de riesgo asociados a los DALY.La LE y la HALE aumentaron sustancialmente en Haití. En 2017, la población puede esperar vivir más, pero con mala salud. Los países del Caribe tuvieron tasas de YLL significativamente más bajas que Haití en cuanto a cardiopatías isquémicas, accidentes cerebrovasculares, infecciones respiratorias bajas y enfermedades diarreicas. Las lesiones debidas a accidentes de tránsito fueron la principal causa de DALY para las personas de 5 a 14 años. Las lesiones debidas a accidentes de tránsito y el VIH/sida fueron las principales causas de DALY en hombres y mujeres de 15 a 49 años de edad, respectivamente. Las cardiopatías isquémicas fueron la principal causa de DALY para las personas mayores de 50 años. Las desnutriciones materna e infantil fueron los principales factores de riesgo de DALY en ambos sexos.Haití se enfrenta a una doble carga de enfermedad. Las enfermedades infecciosas siguen siendo un problema, mientras que las enfermedades no transmisibles se han convertido en una carga significativa de enfermedad. También debe prestarse más atención al aumento de problemas de salud pública preocupantes, como las lesiones por accidentes de tránsito, la exposición a fenómenos naturales y el VIH/sida en grupos etarios específicos. Para hacer frente a la carga de morbilidad es necesario adoptar medidas sostenidas para promover una mejor salud en Haití y en los países con desafíos similares.

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.

Le suicide est un enjeu majeur de santé publique au Canada. Si les facteurs individuels et démographiques influent sur le taux de suicide, la qualité des services de santé a également un impact. Dans un système public de soins comme celui du Canada ou celui du Royaume-Uni, la qualité des soins se manifeste à trois niveaux : individuel, programmatique et systémique. L'examen des suicides sert à évaluer les services de santé quant au décès par suicide et, au niveau agrégé, à évaluer ces services à l’échelle des programmes et du système. Les grandes bases de données médico-administratives constituent une autre source de données utile à la prise de décisions sur l’ensemble de la population à l’échelle systémique, programmatique et individuelle et portant sur les services en santé mentale susceptibles d'avoir une influence sur le risque de suicide. Cet article décrit un projet mené à l’Institut national de santé publique du Québec (INSPQ) utilisant le Système intégré de surveillance des maladies chroniques du Québec (SISMACQ), en collaboration avec des collègues du pays de Galles (Royaume-Uni) et de l’Institut norvégien de santé publique. Cette étude décrit l’élaboration d’indicateurs de la qualité des soins à ces trois niveaux et les stratégies connexes d’analyse statistique. Nous proposons 13 indicateurs de soins de santé pouvant être créés à partir d’un système de surveillance des maladies chroniques : déterminant systémique, déterminants démographiques, soins primaires, soins spécialisés, équilibre entre les secteurs de soins, consultation à l’urgence et budgets en santé mentale et toxicomanie.

ObjectivesViolent deaths classified as undetermined intent (UD) are sometimes included in suicide counts. This study investigated age and sex differences, along with socioeconomic gradients in UD and suicide deaths in the province of Ontario between 1999 and 2012.MethodsWe used data from the Institute for Clinical Evaluative Sciences, which has linked vital statistics from the Office of the Registrar General Deaths register with Census data between 1999 and 2012. Socioeconomic status was operationalised through the four dimensions of the Ontario Marginalization Index. We computed age-specific and annual age-standardised mortality rates, and risk ratios to calculate risk gradients according to each of the four dimensions of marginalization.ResultsRates of UD-classified deaths were highest for men aged 45–64 years residing in the most materially deprived (7.9 per 100 000 population (95% CI 6.8 to 9.0)) and residentially unstable (8.1 (95% CI 7.1 to 9.1)) neighbourhoods. Similarly, suicide rates were highest among these same groups of men aged 45–64 living in the most materially deprived (28.2 (95% CI 26.1 to 30.3)) and residentially unstable (30.7 (95% CI 28.7 to 32.6)) neighbourhoods. Relative to methods of death, poisoning was the most frequently used method in UD cases (64%), while it represented the second most common method (27%) among suicides after hanging (40%).DiscussionThe similarities observed between both causes of death suggest that at least a proportion of UD deaths may be misclassified suicide cases. However, the discrepancies identified in this analysis seem to indicate that not all UD deaths are misclassified suicides.

Funding: This study was funded by a Canadian Institutes for Health Research Operating Grant (FRN-142498). LR is supported by a Canada Research Chair in Population Health Analytics. Background: Homicide - a lethal expression of violence - has garnered little attention from public health researchers and health policy makers, despite the fact that homicides are a cause of preventable and premature death. Identifying populations at risk and the upstream determinants of homicide are important for addressing inequalities that hinder population health. This population-based study investigates the public health significance of homicides in Ontario, Canada, over the period of 1999-2012. We quantified the relative burden of homicides by comparing the socioeconomic gradient in homicides with the leading causes of death, cardiovascular disease (CVD) and neoplasm, and estimated the potential years of life lost (PYLL) due to homicide. Methods: We linked vital statistics from the Office of the Registrar General Deaths register (ORG-D) with Census and administrative data for all Ontario residents. We extracted all homicide, neoplasm, and cardiovascular deaths from 1999 to 2012, using International Classification of Diseases codes. For socioeconomic status (SES), we used two dimensions of the Ontario Marginalization Index (ON-Marg): material deprivation and residential instability. Trends were summarized across deprivation indices using age-specific rates, rate ratios, and PYLL. Results: Young males, 15-29 years old, were the main victims of homicide with a rate of 3.85 [IC 95%: 3.56; 4.13] per 100,000 population and experienced an upward trend over the study period. The socioeconomic neighbourhood gradient was substantial and higher than the gradient for both cardiovascular and neoplasms. Finally, the PYLL due to homicide were 63,512 and 24,066 years for males and females, respectively. Conclusions: Homicides are an important cause of death among young males, and populations living in disadvantaged neighbourhoods. Our findings raise concerns about the burden of homicides in the Canadian population and the importance of addressing social determinants to address these premature deaths. Publisher PDF

OBJECTIVES: Lack of wealth (poverty) impacts almost every aspect of human biology. Accordingly, many such studies include its assessment. In almost all cases, approaches to assessing poverty are based in lack of success within cash economies (e.g., lack of income, employment). But this operationalization deflects attention from alternative forms of poverty that may have the most substantial influence on human wellbeing. We test how a multidimensional measure of poverty that considers agricultural assets expands the explanatory power of the construct of household poverty by associating it with one key aspect of wellbeing: symptoms of mental health. METHODS: We use the case of three highly vulnerable but distinctive communities in Haiti—urban, town with a rural hinterland, and rural. Based on survey responses from adults in 4,055 geographically sampled households, linear regression models were used to predict depression and anxiety symptom levels controlling for a wide range of covariates related to detailed measures of material poverty, including cash-economy and agricultural assets, income, financial stress, and food insecurity. RESULTS: Household assets related to the cash economy were significantly associated with lower (i.e. better) depression scores (-0.3, [95% CI: -0.6 to, -0.0]) but unrelated to anxiety scores (-0.04 [95% CI: -0.39 to 0.30]).). Agricultural wealth was significantly – and more strongly - associated with both reductions in depression symptoms (-0.8 [95% CI: -1.6 to -0.2]) and anxiety symptoms (-0.9 [95% CI: -1.6 to -0.2]). These associations were consistent across the three sites, except in the fully urban site in Port-au-Prince where level of depression symptoms was not significantly associated with household agricultural wealth. CONCLUSIONS: Standard measures of poverty based on success in the cash economy can mask important associations between poverty and wellbeing, in this case related to household-level subsistence capacity and crucial food-producing household assets.

The Haitian health system includes a public and a private sector. The public sector comprises the Ministry of Health and Population (MSPP) and a social security institution (Ofatma). The private sector includes private insurance agencies and providers. MSPP provides health services to the non-salaried population, while Ofatma provides services to the salaried population. Health expenditure in Haiti in 2016 was 5.4% of gross domestic product. Expenditure per capita in health was 38 American dollars. There is a great dependency on foreign resources. The MSPP is in charge of most stewardship functions. The main challenge faced by the Haitian health system is the provision of comprehensive health services with financial protection to all the population. This goal will not be met without additional financial resources, mostly public, and an effort to strengthen health institutions.El sistema de salud haitiano se conforma por un sector público y un sector privado. El primero está compuesto por el Ministerio de Salud Pública y Población (MSPP) y la Caja de Seguro de Accidentes de Trabajo, Enfermedades y Maternidad (Ofatma). El sector privado incluye a los seguros y prestadores de servicios de salud privados. El MSPP ofrece servicios básicos a la población no asalariada (95% de la población total), mientras que la Ofatma ofrece seguros contra accidentes de trabajo, enfermedades y maternidad a los trabajadores del sector formal privado y público. El gasto total en salud enmHaití representó 5.4% del producto interno bruto en 2016 y el gasto en salud per cápita fue de 38 dólares estadunidenses. Hay una enorme dependencia de los recursos externos. El MSPP es el responsable de la mayor parte de las actividades de rectoría. El mayor reto que enfrenta el sistema de salud de Haití es ofrecer servicios integrales de salud con protección financiera a toda la población. Esta meta no podrá alcanzarse sin mayores recursos financieros, sobre todo públicos, y sin un importante esfuerzo de fortalecimiento institucional.

Summary Background Housing First is increasingly implemented for homeless adults with mental illness in large urban centres, but little is known about its long-term effectiveness. The At Home/Chez Soi randomised controlled trial done in five cities in Canada showed that Housing First improved housing stability and other select health outcomes. We extended the At Home/Chez Soi trial at the Toronto site to evaluate the long-term effects of the Housing First intervention on housing and health outcomes of homeless adults with mental illness over 6 years. Methods The At Home/Chez Soi Toronto study was a randomised, controlled trial done in Toronto (ON, Canada). Here, we present the results of an extension study done at the same site. Participants were homeless adults (aged ≥18 years) with a serious mental disorder with or without co-occurring substance use disorder. In phase 1, participants were stratified by level of need for mental health support services (high vs moderate), and randomly assigned (1:1) using adaptive randomisation procedures to Housing First with assertive community treatment (HF-ACT), Housing First with intensive case management (HF-ICM), or to treatment as usual (TAU). Participants with moderate support needs were further stratified by ethnoracial status. Considering the nature of the Housing First intervention, study participants and study personnel were not masked to group assignment. Phase 1 participants could choose to enrol in the extension study (phase 2). The primary outcome was the rate of days stably housed per year analysed in the modified intention-to-treat population, which included all randomly assigned participants who had at least one assessment for the primary outcome. Participants contributed data to the study up to the point of their last interview. Multilevel multiple imputation was used to handle missing data. The trial was registered with ISRCTN, ISRCTN42520374. Findings Between Oct 1, 2009, and March 31, 2013, 575 individuals participated in phase 1 of the Toronto Site At Home/Chez Soi study (197 [34%] participants with high support needs and 378 [66%] with moderate support needs). Of the 378 participants with moderate support needs, 204 were randomly assigned to receive the HF intervention with ICM or with ethnoracial-specific ICM services (HF-ER-ICM; HF-ICM or HF-ER-ICM groups) and 174 were randomly assigned to TAU. Of the 197 participants with high support needs, 97 were randomly assigned to receive the HF intervention with ACT (HF-ACT treatment group) and 100 were randomly assigned to TAU group. Between Jan 1, 2014, and March 31, 2017, 414 (81%) of 575 phase 1 participants participated in the extended phase 2 study. The median duration of follow-up was 5·4 years (IQR 2·1–5·9). Among phase 2 participants, 141 had high support needs (79 participants in the HF-ACT group; 62 participants in the TAU group), and 273 had moderate support needs (160 participants in the HF-ICM or HF-ER-ICM group; 113 participants in the TAU group). 187 high support needs participants (93 participants in the HF-ACT group, 94 participants in the TAU group), and 361 moderate support needs participants (201 participants in the HF-ICM or HF-ER-ICM group, 160 participants in the TAU group) were included in the modified intention-to-treat analysis for the primary outcome. The number of days spent stably housed was significantly higher among participants in the HF-ACT and HR-ICM or HF-ER-ICM groups than participants in the TAU groups at all timepoints. For participants with moderate support needs, the rate ratio (RR) of days stably housed in the Housing First group, compared with TAU, was 2·40 (95% CI 2·03–2·83) in year 1, which decreased to 1·13 (1·01–1·26) in year 6. The RR of days stably housed for participants with high support needs, compared with TAU, was 3·02 (2·43–3·75) in year 1 and 1·42 (1·19–1·69) in year 6. In year 6, high support needs participants in the Housing First group spent 85·51% of days stably housed compared with 60·33% for the TAU group, and moderate needs participants in the Housing First group spent 88·16% of days stably housed compared with 78·22% for the TAU group. Interpretation Rent supplements and mental health support services had an enduring positive effect on housing stability for homeless adults with mental illness in a large, resource-rich urban centre, with a larger impact on individuals with high support needs than moderate support needs. Funding Mental Health Commission of Canada, Ontario Ministry of Health and Long-Term Care, and the Canadian Institute of Health Research.

Rationale Stigma and discrimination are negatively associated with social and health status. People who are homeless often experience systemic stigma and discrimination. Objective In this study, we analyze the longitudinal interrelationships between the trajectories of housing (housing stability) and well-being outcomes (i.e., recovery, quality of life, and community functioning) and the trajectories of discrimination and stigma in a sample of adults with mental illness and recent experiences of homelessness in Toronto, Canada. We also examined the effect of the Housing First (HF) intervention on these interrelationships. Method The Group-Based Trajectory Model was used to estimate the interrelationship (or intersections) between discrimination and stigma with housing stability, recovery, quality of life, and community functioning in 274 participants of the At Home/Chez Soi, phase 2, Toronto site randomized trial over a two-year follow-up period. Results Three distinct trajectory groups were observed for discrimination (Low,Moderate decrease, and moderate increase), stigma (Low, Moderate, and High), recovery (Low, Moderate, and High), and the quality of life (Low, Moderate, and High). Two-trajectory groups (Low and High) were identified for housing stability and community functioning. The analyses showed that the trajectory groups for discrimination and stigma are strongly and contemporaneously interrelated with thetrajectory groups for housing stability, recovery, quality of life, and community functioning ability. The HF intervention had a mitigating effect on the changes across select trajectory groups, particularly for members of the Low and High discrimination and stigma trajectories group. Conclusion Persistent mental health-related discrimination and stigma trajectories are longitudinally and contemporaneously interrelated with housing and well-being outcomes in persons experiencing mental illness and recent homelessness. These findings indicate the need for interventions and actions to reduce stigma toward thispopulation. Such interventions may improve housing stability, quality of life, mental health recovery, and community functioning.

Three theories have been proposed to explain the relationship between suicide and economic fluctuations, including the Durkheim (nonlinear), Ginsberg (procyclical), and Henry and Short (countercyclical) theories. This study tested the effect of economic fluctuations, measured by unemployment rate, on suicide rates in Canada from 1926 to 2008. Autoregressive integrated moving average time-series models were used. The results showed a significant relationship between suicide and economic fluctuation; this association was positive during the contraction period (1926-1950) and negative in the period of economic expansion (1951-1973). Males and females showed differential effects in the period of moderate unemployment (1974-2008). In addition, the suicide rate of mid-adults (45-64) was most impacted by economic fluctuations. Our study tends to support Durkheim's theory and suggests the need for public health responses in times of economic contraction and expansion.

El sistema de salud haitiano se conforma por un sector público y un sector privado. El primero está compuesto por el Ministerio de Salud Pública y Población (MSPP) y la Caja de Seguro de Accidentes de Trabajo, Enfermedades y Maternidad (Ofatma). El sector privado incluye a los seguros y prestadores de servicios de salud privados. El MSPP ofrece servicios básicos a la población no asalariada (95% de la población total), mientras que la Ofatma ofrece seguros contra accidentes de trabajo, enfermedades y maternidad a los trabajadores del sector formal privado y público. El gasto total en salud en Haití representó 5.4% del producto interno bruto en 2016 y el gasto en salud per cápita fue de 38 dólares estadunidenses. Hay una enorme dependencia de los recursos externos. El MSPP es el responsable de la mayor parte de las actividades de rectoría. El mayor reto que enfrenta el sistema de salud de Haití es ofrecer servicios integrales de salud con protección financiera a toda la población. Esta meta no podrá alcanzarse sin mayores recursos financieros, sobre todo públicos, y sin un importante esfuerzo de fortalecimiento institucional.

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.

It is common in prior studies of the influence of neighbourhood characteristics on mental health to use participant-assessed neighbourhood exposures, which can lead to same-source bias since an individual’s mental health status may influence their judgement of their neighbourhood. To avoid this potential bias, we evaluated the use of individually assessed neighbourhood exposures to understand how they compare to collectively assessed measures (by aggregating multiple responses within the same neighbourhood). This would increase the validity of the measure by decoupling the neighbourhood measure from an individual’s mental health status. We conducted a stratified-randomised survey of 2411 adults across 87 census tracts in Toronto, Canada (mean of 28 per census tract) to investigate how self-reported (individually assessed) social environmental neighbourhood measures compared to aggregated, collectively assessed, measures for neighbourhood problems/disorder, safety, service quality, and linking, bonding and bridging social capital. The outcome, experience of major depression in the past 12 months, was measured using the Composite International Diagnostic Studies Depression Scale Short Form. (1) Individually assessed neighbourhood problems, (2) low (individually assessed) neighbourhood safety, (3) low (individually assessed) neighbourhood service quality, and (4) low (individually assessed) linking social capital were independently associated with depression (all at least p

Suicide is a major public health issue in Canada. The quality of health care services, in addition to other individual and population factors, has been shown to affect suicide rates. In publicly managed care systems, such as systems in Canada and the United Kingdom, the quality of health care is manifested at the individual, program and system levels. Suicide audits are used to assess health care services in relation to the deaths by suicide at individual level and when aggregated at the program and system levels. Large health administrative databases comprise another data source used to inform population-based decisions at the system, program and individual levels regarding mental health services that may affect the risk of suicide. This status report paper describes a project we are conducting at the Institut national de santé publique du Québec (INSPQ) with the Quebec Integrated Chronic Disease Surveillance System (QICDSS) in collaboration with colleagues from Wales (United Kingdom) and the Norwegian Institute of Public Health. This study describes the development of quality of care indicators at three levels and the corresponding statistical analysis strategies designed. We propose 13 quality of care indicators, including system-level and several population-level determinants, primary care treatment, specialist care, the balance between care sectors, emergency room utilization, and mental health and addiction budgets, that may be drawn from a chronic disease surveillance system.Le suicide est un enjeu majeur de santé publique au Canada. Si les facteurs individuels et démographiques influent sur le taux de suicide, la qualité des services de santé a également un impact. Dans un système public de soins comme celui du Canada ou celui du Royaume-Uni, la qualité des soins se manifeste à trois niveaux : individuel, programmatique et systémique. L'examen des suicides sert à évaluer les services de santé quant au décès par suicide et, au niveau agrégé, à évaluer ces services à l’échelle des programmes et du système. Les grandes bases de données médico-administratives constituent une autre source de données utile à la prise de décisions sur l’ensemble de la population à l’échelle systémique, programmatique et individuelle et portant sur les services en santé mentale susceptibles d'avoir une influence sur le risque de suicide. Cet article décrit un projet mené à l’Institut national de santé publique du Québec (INSPQ) utilisant le Système intégré de surveillance des maladies chroniques du Québec (SISMACQ), en collaboration avec des collègues du pays de Galles (Royaume-Uni) et de l’Institut norvégien de santé publique. Cette étude décrit l’élaboration d’indicateurs de la qualité des soins à ces trois niveaux et les stratégies connexes d’analyse statistique. Nous proposons 13 indicateurs de soins de santé pouvant être créés à partir d’un système de surveillance des maladies chroniques : déterminant systémique, déterminants démographiques, soins primaires, soins spécialisés, équilibre entre les secteurs de soins, consultation à l’urgence et budgets en santé mentale et toxicomanie.