Review and special articles
Interventions to Improve the Health of the Homeless: A Systematic Review

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Background

Homelessness is a widespread problem in the United States. The primary goal of this systematic review is to provide guidance in the development and organization of programs to improve the health of homeless people.

Methods

MEDLINE, CINAHL, HealthStar, PsycINFO, Sociological Abstracts, and Social Services Abstracts databases were searched from their inception through July 2004 using the following terms: homeless, homeless persons, and homelessness. References of key articles were also searched. 4564 abstracts were screened, and 258 articles underwent full review. Seventy-three studies conducted from 1988 to 2004 met inclusion criteria (use of an intervention, use of a comparison group, and the reporting of health-related outcomes). Two authors independently abstracted data from studies and assigned quality ratings using explicit criteria.

Results

Forty-five studies were rated good or fair quality. For homeless people with mental illness, case management linked to other services was effective in improving psychiatric symptoms, and assertive case management was effective in decreasing psychiatric hospitalizations and increasing outpatient contacts. For homeless people with substance abuse problems, case management resulted in greater decreases in substance use than did usual care. For homeless people with latent tuberculosis, monetary incentives improved adherence rates. Although a number of studies comparing an intervention to usual care were positive, studies comparing two interventions frequently found no significant difference in outcomes.

Conclusions

Coordinated treatment programs for homeless adults with mental illness or substance abuse usually result in better health outcomes than usual care. Health care for homeless people should be provided through such programs whenever possible. Research is lacking on interventions for youths, families, and conditions other than mental illness or substance abuse.

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

References (84)

  • D. Culhane et al.

    Public shelter admission rates in Philadelphia and New York Citythe implications of turnover for sheltered population counts

    Housing Policy Debate

    (1994)
  • B.D. Levy et al.

    Health care for homeless persons

    N Engl J Med

    (2004)
  • M.B. Kushel et al.

    No door to lockvictimization among homeless and marginally housed persons

    Arch Intern Med

    (2003)
  • M. Tanaka et al.

    Accidental hypothermia and death from cold in urban areas

    Int J Biometeorol

    (1991)
  • A.J. Stratigos et al.

    Medical and cutaneous disorders associated with homelessness

    Skinmed

    (2003)
  • A.R. Moss et al.

    Tuberculosis in the homeless. A prospective study

    Am J Respir Crit Care Med

    (2000)
  • M.J. Robertson et al.

    HIV seroprevalence among homeless and marginally housed adults in San Francisco

    Am J Public Health

    (2004)
  • R.C. Cheung et al.

    Viral hepatitis and other infectious diseases in a homeless population

    J Clin Gastroenterol

    (2002)
  • A.M. Nyamathi et al.

    Risk factors for hepatitis C virus infection among homeless adults

    J Gen Intern Med

    (2002)
  • E. Roy et al.

    Hepatitis B virus infection among street youths in Montreal

    CMAJ

    (1999)
  • E. Roy et al.

    Risk factors for hepatitis C virus infection among street youths

    CMAJ

    (2001)
  • S.W. Hwang et al.

    Barriers to appropriate diabetes management among homeless people in Toronto

    CMAJ

    (2000)
  • P. Vostanis et al.

    Mental health problems of homeless children and familieslongitudinal study

    BMJ

    (1998)
  • D.E. McLean et al.

    Asthma among homeless childrenundercounting and undertreating the underserved

    Arch Pediatr Adolesc Med

    (2004)
  • M.B. Kushel et al.

    Factors associated with the healthcare utilization of homeless persons

    JAMA

    (2001)
  • S.W. Hwang

    Mortality among men using homeless shelters in Toronto, Ontario

    JAMA

    (2000)
  • A.M. Cheung et al.

    Risk of death among homeless womena cohort study and review of the literature

    CMAJ

    (2004)
  • E. Roy et al.

    Mortality in a cohort of street youth in Montreal

    JAMA

    (2004)
  • E. Bonin et al.
    (2004)
  • McKinney-Vento Homeless Assistance Act (U.S.C. 11431 et seq), Title 1, Section 103,...
  • D.L. Shern et al.

    Serving street-dwelling individuals with psychiatric disabilitiesoutcomes of a psychiatric rehabilitation clinical trial

    Am J Public Health

    (2000)
  • R. Rosenheck et al.

    Effectiveness and cost of specific treatment elements in a program for homeless mentally ill veterans

    Psychiatr Serv

    (1995)
  • D.P. Culhane et al.

    Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing

    Housing Policy Debate

    (2002)
  • B. Dickey et al.

    Use of mental health services by formerly homeless adults residing in group and independent housing

    Psychiatr Serv

    (1996)
  • S.M. Goldfinger et al.

    Housing placement and subsequent days homeless among formerly homeless adults with mental illness

    Psychiatr Serv

    (1999)
  • L.J. Seidman et al.

    The effect of housing interventions on neuropsychological functioning among homeless persons with mental illness

    Psychiatr Serv

    (2003)
  • C. Clark et al.

    Outcomes of homeless adults with mental illness in a housing program and in case management only

    Psychiatr Serv

    (2003)
  • A.F. Lehman et al.

    A randomized trial of assertive community treatment for homeless persons with severe mental illness

    Arch Gen Psychiatry

    (1997)
  • G.A. Morse et al.

    An experimental comparison of three types of case management for homeless mentally ill persons

    Psychiatr Serv

    (1997)
  • G.A. Morse et al.

    Experimental comparison of the effects of three treatment programs for homeless mentally ill people

    Hosp Community Psychiatry

    (1992)
  • R.A. Rosenheck et al.

    Service systems integration and outcomes for mentally ill homeless persons in the ACCESS program. Access to Community Care and Effective Services and Supports

    Psychiatr Serv

    (2002)
  • R.J. Calsyn et al.

    Do consumers who have a choice of treatment have better outcomes?

    Community Ment Health J

    (2000)
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