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The homeless population is aging; older homeless adults may be at high risk of experiencing violent victimization. To examine whether homelessness is independently associated with experiencing physical and sexual abuse, we recruited 350 adults, aged 50 and older in Oakland, California, who met criteria for homelessness between July 2013 and June 2014. We interviewed participants at 6-month intervals for 3 years in Oakland about key variables, including housing status. Using generalized estimating equations, we examined whether persistent homelessness in each follow-up period was independently associated with having experienced physical or sexual victimization, after adjusting for known risk factors. The majority of the cohort was men (77.4%) and Black American (79.7%). At baseline, 10.6% had experienced either physical or sexual victimization in the prior 6 months. At 18-month follow-up, 42% of the cohort remained homeless. In adjusted models, persistent homelessness was associated with twice the odds of victimization (adjusted odds ratio [AOR] = 2.01; 95% confidence interval [CI]: [1.41, 2.87]). Older homeless adults experience high rates of victimization. Re-entering housing reduces this risk. Policymakers should recognize exposure to victimization as a negative consequence of homelessness that may be preventable by housing.

Background/Objectives: Older homeless-experienced adults have low rates of advance care planning (ACP) engagement despite high rates of morbidity and mortality. To inform intervention development, we examined potential barriers and solutions to ACP engagement. Design: Cross-sectional qualitative study. Setting: We recruited adults who were homeless in the prior three years and ≥50 years of age in the San Francisco Bay Area, and recruited clinical stakeholders from a national meeting of homeless providers. We analyzed qualitative data using thematic analysis. Measurements: We conducted semistructured interviews with homeless-experienced older adults (n = 20) and focus groups with clinical stakeholders (n = 24) about perceived barriers and solutions to ACP engagement. Results: Participants considered ACP important, reflecting on deaths of people in their networks who had died. Participant-identified barriers to ACP included poor ACP knowledge, lack of familial ties and social isolation, competing priorities, avoidance and lack of readiness, fatalism and mistrust, and lack of ACP training for clinical and nonclinical staff. They identified solutions that included framing ACP as a way to provide meaning and assert choice, providing easy-to-read written documents focused on the populations' unique needs, tailoring content and delivery, initiating ACP in nonclinical settings, such as permanent supportive housing, and providing incentives. Conclusions: Both older homeless-experienced adults and clinical stakeholders believe that ACP is important, but acknowledge multiple barriers that impede engagement. By focusing on potential solutions, including capitalizing on opportunities outside of health care settings, focusing on the period after housing, and tailoring content, there are opportunities to improve ACP uptake.

ObjectivesTo describe the prevalence of and factors associated with oral health measures in a sample of older homeless adults in Oakland, CA.MethodsWe conducted a cross-sectional analysis of data from a population-based study of 350 homeless adults aged ≥50 in which trained researchers conducted structured interviews using validated questions regarding sociodemographics, health-related behaviors, healthcare utilization, and health status. We assessed self-reported tooth loss, oral pain, and unmet need for dental care. We used multivariable logistic regression to examine factors associated with missing half or more teeth.ResultsOver half 201/350 (57.4 percent) of participants were missing at least half of their teeth. Half 191/350 (54.6 percent) reported oral pain in the past 6 months; 101/350 (28.9 percent) reported that oral pain prevented them from eating and 73/350 (20.9 percent) reported that pain prevented sleeping. Almost half, 141/350 (40.3 percent), had not seen a dentist in over 5 years, and over half 190/350 (54.3 percent) reported being unable to obtain needed dental care. In multivariate models, increased age (AOR = 1.09, 95 percent CI 1.04-1.14), moderate-to-high risk alcohol use (AOR = 2.17, CI = 1.23-3.84), moderate-to-high risk cocaine use (AOR = 1.72, CI = 1.03-2.88), and ever smoking (AOR = 2.87, CI = 1.59-5.18) were associated with an increased odds of having lost half or more teeth.ConclusionsTooth loss and oral pain are highly prevalent in older homeless adults. Increasing age, alcohol, drug, and tobacco use are associated with tooth loss.

AimsTo examine the prevalence of and factors associated with unmet need for mental health and substance use treatment in older homeless adults.MethodsAmong 350 homeless adults aged ≥50, we examined prevalence of mental health and substance use problems and treatment. Using logistic regression, we examined factors associated with unmet treatment need.ResultsAmong those with a mental health problem, being aged ≥65 was associated with an increased odds, while having a regular healthcare provider and case manager were associated with a decreased odds of having unmet need for mental health treatment. A first homelessness episode at age ≥50 was associated with increased, while spending time in jail/prison or having a case manager was associated with decreased odds of unmet needs for substance use treatment.ConclusionOlder homeless adults have a high prevalence of unmet behavioral health treatment need. There is a need for targeted services for this population.

Difficulty performing activities of daily living ("functional impairment") is common in homeless adults aged 50 and older. However, little is known about the trajectory of these impairments, nor the extent to which these trajectories are similar to those of older adults in the general population. We identified trajectories of functional impairment in homeless adults aged 50 and older, and risk factors for differing trajectories. We conducted a prospective cohort study of 350 homeless adults, aged 50 and older, recruited via population-based sampling in Oakland, California and interviewed at 6-month intervals for up to 3 years. We assessed functional trajectories based on self-reported difficulty performing 5 activities of daily living. We used multivariable multinomial logistic regression to identify baseline risk factors for each trajectory. At baseline, participants' mean age was 58 years (SD, 5.3), 24.1% were women, 80.9% were African American, and 38.6% had difficulty performing 1 or more activities of daily living. We identified 4 distinct functional trajectories: minimal impairment in 136 participants (41.1%); persistent impairment in 81 (25.4%); partial improvement in 74 (23.5%); and decline in 28 (10.0%). Risk factors for persistent impairment included falls in the 6 months before baseline, depressive symptoms, and low physical performance. Although functional impairment improved in some homeless adults, it persisted or worsened in many others. These findings suggest that, similar to older adults in the general population, functional impairment among older homeless persons is not a transient phenomenon, but instead a chronic issue requiring long-term solutions.

BackgroundThe median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults.ObjectiveThis study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years.MethodsWe recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies.ResultsOf the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72).ConclusionsOlder homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.

ContextThe homeless population is aging. Older homeless adults experience premature development of age-related conditions and an elevated symptom burden. Little is known about symptom experience among older homeless adults.ObjectivesTo characterize the experience, understanding, and management of physical, psychological, social (e.g., loneliness), and existential (e.g., regret, loss of dignity) symptoms among older homeless adults.MethodsWe conducted semistructured interviews from June 2016 to March 2017 with a purposive sample of participants from the Health Outcomes of People Experiencing Homelessness in Older Middle Age cohort, a longitudinal study of homeless adults aged 50 and older. We analyzed data between June 2016 and December 2017 using thematic analysis.ResultsWe found four main themes: 1) nonphysical symptoms are interwoven with, and as distressing as, physical symptoms; 2) individuals attribute symptoms to childhood abuse, manual labor, the conditions of homelessness, and aging; 3) symptoms interfere with daily functioning, causing negative changes in personality, energy, and motivation; and 4) individuals cope with symptoms through religion, social support, and substance use.ConclusionHomelessness causes and exacerbates physical and psychological distress. Interventions should address multiple interconnected dimensions of suffering. Health systems that care for homeless patients should adapt palliative care practices using a stepwise approach. Homeless shelters should adopt policies and modifications that increase privacy and autonomy while promoting community building. Housing interventions should promote community building. All who work with people experiencing homelessness should avoid stigmatizing language and recognize homeless individuals' sources of strength and coping.

Older homeless-experienced adults have low engagement in advance care planning (ACP) despite high morbidity and mortality. We conducted a cross-sectional analysis of a cohort of 350 homeless-experienced adults aged 50 and older in Oakland, California. We assessed the prevalence of potential surrogate decision-makers, ACP contemplation, discussions, and ACP documentation (surrogate designation, advance directives). We used multivariable logistic regression to examine factors associated with ACP discussions and documentation. The median age of the cohort was 59 (range 52-82), 75.2% were male, and 82.1% were black. Sixty-one percent reported a potential surrogate, 21.5% had discussed ACP, and 19.0% reported ACP documentation. In multivariable models, having 1 to 5 confidants versus none (adjusted odds ratio (aOR)=5.8, 95% confidence interval (CI)=1.7-20.0), 3 or more chronic conditions versus none (aOR=2.3, 95% CI=0.9-5.6), and a recent primary care visit (aOR=2.1, 95% CI=1.0-4.4) were associated with higher odds of ACP discussions and each additional 5 years of homelessness (aOR=0.7, 95% CI=0.5-0.9) with lower odds. Having 1 to 5 confidants (aOR=5.0, 95% CI=1.4-17.5), being black (aOR=5.5, 95% CI=1.5-19.5), and having adequate versus limited literacy (aOR=7.0, 95% CI=1.5-32.4) were associated with higher odds of ACP documentation and illicit drug use (aOR=0.3, 95% CI=0.1-0.9) with lower odds. Although the majority of older homeless-experienced adults have a potential surrogate, few have discussed or documented their ACP wishes; the odds of both were greater with larger social networks. Future interventions must be customized for individuals with limited social networks and address the instability of homelessness, health literacy, and the constraints of safety-net healthcare settings.

Self-prompted communication books were used in combination with conversational peer orientation to increase conversational interactions of verbal high school students with autism or autistic-like behavior with their peers without disabilities. Previous investigators have used communication books only with students with autism or intellectual disability with limited or no verbal or reading skills. The six high school participants in this study could read and were verbal. We sought to determine whether the communication books would be accepted by peers without disabilities in general education classrooms or whether the books would stigmatize the students with disabilities. Finally, we assessed the effects of having a peer with a learning disability as the teacher of conversational interaction skills. We interpreted our results to conclude that the communication book package was associated with increased conversational interactions for all participants with their general education peers and that communication books were viewed positively by conversational partners.

A functional assessment-based intervention (FABI) was designed and implemented to increase the on-task behavior of David, a second-grade student in a general education classroom. David attended an elementary school that used a comprehensive, integrated, three-tiered (CI3T) model of prevention. The school's principal nominated David for Project FUNCTION after consulting with his classroom teacher. David's teacher, Ms. Jones, stated that David demonstrated high rates of off-task behavior including leaving the assigned instructional area, disrupting peers, and using materials inappropriately during morning instructional activities. When project liaisons were first introduced to David, his guardian was navigating a medical referral process to obtain a formal attention-deficit hyperactivity disorder (ADHD) diagnosis and treatment for David. Previous interventions attempted by the school's pre-referral intervention team had been unsuccessful at increasing David's level of academic engagement. Functional assessment data were used to generate the Function Matrix and the subsequent hypothesis regarding the function of David's off-task behavior. Then, the Function-Based Intervention Decision Model was used to guide the intervention design. Ms. Jones and project liaisons collaborated to determine intervention components that would address the function of David's behavior and were feasible to implement during morning instructional activities. This article outlines the processes used to devise and implement the FABI, which include: (1) procedures to conduct the functional assessment; (2) completion of the Function Matrix and Function-Based Intervention Decision Model to determine the maintaining function of the student's behavior and the appropriate intervention model; (3) implementation of intervention components; and (4) evaluation of intervention outcomes. The practicality and ease of implementation of self-monitoring to address the dual function of David's off-task behavior are documented. (Contains 4 tables and 2 figures.)

Although numerous studies have documented the long-term effects of childhood victimization on mental health in adulthood, few have directly examined potential mediators and moderators of this association. Using data from the Welfare, Children, and Families project (1999)--a probability sample of 2,402 predominantly black and Hispanic low-income women with children living in Boston, Chicago, and San Antonio--we predict psychological distress in adulthood with measures of physical assault and sexual coercion before age 18. Building on previous research, we test the mediating and moderating influences of emotional support, instrumental support, and self-esteem. Although we observe no indirect effects of physical assault, the effect of sexual coercion is partially mediated by instrumental support and self-esteem. We also find that the effects of physical assault and sexual coercion are moderated (buffered) by emotional support and self-esteem. (Contains 4 tables.)

Objectives. We examined the long-term health consequences of relationship violence in adulthood. Methods. Using data from the Welfare, Children, and Families project (1999 and 2001), a probability sample of 2402 low-income women with children living in disadvantaged neighborhoods in Boston, Massachusetts; Chicago, Illinois; and San Antonio, Texas, we predicted changes in the frequency of intoxication, psychological distress, and self-rated health over 2 years with baseline measures of relationship violence and a host of relevant background variables. Results. Our analyses showed that psychological aggression predicted increases in psychological distress, whereas minor physical assault and sexual coercion predicted increases in the frequency of intoxication. There was no evidence to suggest that relationship violence in adulthood predicted changes in self-rated health. Conclusions. Experiences with relationship violence beyond the formative and developmental years of childhood and adolescence can have far-reaching effects on the health status of disadvantaged urban women. (doi:10.2105/AJPH.2008.151498)

Alcohol’s harms to others (AHTO) has gained increased research and policy attention, yet little information is available on different social relationships involved in such harms or consequences of harms perpetrated by various types of drinkers. Using data from the 2014 to 2015 US National Alcohol Survey (N= 5,922), we present analyses comparing frequency and impacts of eight past-year harms from other drinkers. In this sample (53% female; 66% White/Caucasian, 13% Black/African American, and 15% other race; 15% Hispanic/Latino of any race; mean age = 47 years), 19% reported at least one harm in the prior 12 months, 8% reported more than one harm, 4.9% reported a family perpetrator, 3.5% a spouse perpetrator, 6.1% a friend perpetrator, and 8.1% a stranger perpetrator. Controlling for basic demographics, the number of harms in the past year and harms perpetrated by known others (but not strangers) were significantly associated with recent distress. When comparing specific harms, financial problems due to a family member’s or a spouse/partner’s drinking each were associated with significantly greater distress, as were feeling threatened or afraid of family members, spouses/partners, or friends who had been drinking. These new data shed light on possible intervention points to reduce negative impacts of AHTO in the United States. [ABSTRACT FROM PUBLISHER]

Background: Little is known about how drinking in different contexts is associated with harms from someone else’s drinking, including marital problems, financial problems, and assault. We examined how drinking in four different contexts was associated with alcohol’s harm from others (AHFO).Methods: We utilized the landline sample of the 2010 US National Alcohol Survey (n= 5885) to examine associations between drinking context and AHFO using weighted binary logistic regression.Results: For women, drinking when friends dropped over was positively associated with assault and financial troubles due to someone else’s drinking. Drinking when friends dropped over was negatively associated with assault for men. For men, drinking at a bar, party, or during a quiet evening at home were each significantly associated with more assault by someone who had been drinking. Bar drinking among women was significantly associated with more marital problems, whereas drinking at a party at someone else’s home was associated with significantly less marital problems.Conclusions: Context-specific drinking has differential associations with specific types of harms from someone else’s drinking for men and women. Additional research on drinking context, relationship to the harmer, and violence experienced by men and women is needed. [ABSTRACT FROM PUBLISHER]

Introduction and Aims: Study aims were to examine: (i) how physical and sexual victimisation in early life are associated with alcohol's harm from others; and (ii) whether respondents' current drinking is a mediator of the association between early life victimisation and alcohol's harm from others among men and women.Design and Methods: Data were from national computer-assisted telephone interviews, using the landline sample (3335 men and 3520 women ages ≥18) from the 2010 US National Alcohol Survey. Harms from someone else's drinking included family/marital problems, financial troubles, assault and vandalism in the past 12 months. Victimisation was measured with severe physical abuse or sexual assault before age 18.Results: Severe physical or sexual victimisation before age 18 was reported by 3.4% of men and 8.1% of women. Significantly more men (5.2%) than women (2.4%) reported assault by other drinkers, and significantly more women reported family/marital (5.3%) and financial problems (2.8%) than did men (2.6 and 1% respectively). Severe early life victimisation was robustly associated with a greater likelihood of experiencing past-year harms from other drinkers for both men and women. Men's drinking partially mediated associations between early life victimisation and recent assaults and vandalism by other drinkers.Discussion and Conclusions: Early life victimisation may increase risk of harms from someone else's drinking. Health services and interventions that screen for histories of victimisation may help decrease risk of later harms from others' drinking. Reductions in drinking among men with histories of victimisation also could help reduce their exposure to such harms. [Kaplan LM, Greenfield TK, Karriker-Jaffe KJ. Examination of associations between early life victimisation and alcohol's harm from others. [ABSTRACT FROM AUTHOR]

Various harms from others' drinking have been studied individually and at single points in time. We conducted a US population 15-year trend analysis and extend prior research by studying associations of depression with combinations of four harms - family/marriage difficulties, financial troubles, assault, and vandalism - attributed to partners or family members. Data come from four National Alcohol Surveys conducted by telephone in 2000, 2005, 2010, and 2015 (analytic sample = 21,184). Weighted logistic regression models estimated time trends adjusting for victim characteristics (gender, age, race/ethnicity, marital status, poverty, employment, family history of alcohol problems, and drinking maximum). The 2015 survey asked the source of the harm; we used similar models to examine characteristics, including anxiety and depression, associated with various combinations of family/marriage, financial, and assault harms due to partner's/spouse's/family members' drinking. A significant upward trend (P <0.001) from 2000 to 2015 was seen for financial troubles but not for other harms due to someone else's drinking. In 2015, depression and/or anxiety were strongly associated with exposures to harms and combinations of harms identified as stemming from drinking spouse/partner and/or family members. The results shed new light on 15-year trends and associations of harms with personal characteristics. A replicated finding is how the victim's own heavy drinking pattern is implicated in risks for exposures to harms from someone else's drinking. Documenting risk factors for and mental health impacts is important for interventions to reduce alcohol's harm to others.