Review and special articlesInterventions to Improve the Health of the Homeless: A Systematic Review
Introduction
Homelessness is a widespread problem in the United States, with >800,000 individuals currently homeless.1 Earlier studies have estimated that 5 million to 8 million Americans experienced homelessness within the last 5 years,2 and about 1.0% of Philadelphians and 1.2% of New Yorkers stayed at a homeless shelter each year.3 Homelessness affects people of all ages: adolescents, adult men, adult women, and families with children account for 9%, 60%, 16%, and 15% of the U.S. homeless population, respectively.1
Homeless people often suffer from serious health conditions.4 In a cross-sectional study, 43% of homeless people in the United States had either a mental health or a substance use problem, and an additional 23% had concurrent mental health and substance use problems.1 Injuries, assault, cold exposure, and skin problems are common hazards of life on the street.5, 6, 7 Infectious diseases, including tuberculosis, HIV, hepatitis, and sexually transmitted diseases, occur at higher than average rates.8, 9, 10, 11, 12, 13, 14 Chronic medical conditions, including hypertension and diabetes, are often poorly controlled.15 Pregnancy is common among adolescent girls,16 and homeless children are at increased risk for asthma and behavioral disorders.17, 18 More than half of all homeless people in the United States lack health insurance and face major barriers to obtaining care.19 Not surprisingly, mortality rates among homeless people are greatly elevated.20, 21, 22 As a result of their complex health issues and lack of stable housing, homeless patients present serious challenges to healthcare providers.23
The development and support of programs to improve the health of homeless people should therefore be an important priority. However, an evidence-based approach is required to identify interventions that result in demonstrable health benefits. To date, no comprehensive and rigorous survey has been undertaken of the literature in this area.
The primary goal of this systematic review is to summarize the existing evidence on interventions to improve health-related outcomes in homeless people. This information will help guide healthcare and social service providers and government agencies as they seek to identify effective means to assist this population. Furthermore, this knowledge will reduce the likelihood of replicating previously unsuccessful efforts. Recognizing that the literature in this area varies widely in methodologic rigor, this review evaluates the quality of each study using explicit and well-validated criteria. Secondary goals of this review are to identify major gaps in the existing knowledge base of interventions for the homeless, and to provide insights into methodologic pitfalls that future researchers should seek to avoid.
Section snippets
Data Sources
MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless persons, homelessness, and homeless. Title and abstract of each article were reviewed and placed into a keep or reject database based on predetermined criteria. A second investigator reviewed these databases, a third investigator arbitrated disagreement, and consensus was reached after discussion. To
Quality and Categorization of Studies
The database search and study selection process is summarized in Figure 1. Of 73 included studies, 13 were rated as good quality, 32 were fair, and 28 were poor. The most common reasons for poor quality ratings were small sample size (<50 subjects per group) and low follow-up rates (<50% overall). Studies with a quality rating of good or fair are summarized in Table 1, categorized by the subpopulation targeted and the type of intervention examined.
Interventions for Homeless People with Mental Illness
Detailed information on these studies is given
Discussion
Of >4500 articles on homelessness, <2% met inclusion criteria for this systematic review. A relatively small number of good- and fair-quality controlled studies are available to guide the selection of interventions to improve the health of homeless people. The evidence is most plentiful with respect to the treatment of homeless single adults with mental illness or substance abuse. Studies have examined a heterogeneous group of interventions for these individuals, in part due to regional
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