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Background: Homelessness is associated with enormous health inequalities, including shorter life expectancy, higher morbidity and greater usage of acute hospital services. Viewed through the lens of social determinants, homelessness is a key driver of poor health, but homelessness itself results from accumulated adverse social and economic conditions. Indeed, in people who are homeless, the social determinants of homelessness and health inequities are often intertwined, and long term homelessness further exacerbates poor health. Aggregated health service data can mask this, and case histories thus provide important insights. Methods: This paper presents three case histories of homeless patients seen at an inner city public hospital in Perth, Western Australia. The case histories draw on several data sources: hospital data, information collected from rough sleepers and clinical observations. Estimates of the cost to the health system of the observed hospital usage by the three patients are included. Findings: The case histories illustrate the interplay of social determinants of health in homelessness that help explain the high level of hospital usage by rough sleepers. The cumulative healthcare costs for the three individuals over a 33 months period were substantial. Hospital attendance plummeted even in the short term when housing needs were addressed. Conclusions: Treating homelessness as a combined health and social issue is critical to improving the abysmal health outcomes of people experiencing homelessness. In addition, the enormous economic costs of hospital care for people who are homeless can be reduced when housing and other social determinants are taken into account.

Introduction While there has been a decline in smoking prevalence and an increase in quit attempts among the general U.S. adult population, this information is unknown for the population who receive housing assistance from the U.S. Department of Housing & Urban Development (HUD). Methods We used National Health Interview Survey (NHIS)-HUD linked data to explore how the prevalence of cigarette smoking and past-year quit attempts has changed from 2005 to 2018 among HUD-assisted adults. Changes in the prevalence of outcome measures were examined over time for all HUD programs and by HUD program type. We created logistic regression models to assess the odds of being a current smoker or having a past-year quit attempt as a function of sociodemographic characteristics overall and by HUD program type. Results The final study population consisted of 15,117 HUD-assisted adults aged 18 and older. Between 2005 and 2009 and 2015–2018, the smoking prevalence of HUD-assisted adults significantly declined from 33.9 to 25.4%. The proportion of HUD-assisted smokers with past-year quit attempts significantly increased from 45.6 to 55.5% between 2005 and 2009 and 2010–2014 and remained stable in 2015–2018. Rates of smoking in 2015–2018 were highest among Housing Choice Voucher (HCV) program recipients at 26.6%; though there was a significant decrease in smoking prevalence and increase in past-year quit attempts for HCV program participants over time. For the public housing and the Multifamily Housing (MF) programs, declining trends in smoking rates and increasing trends in past-year quit attempts did not reach statistical significance. Conclusions Among HUD-assisted adults, smoking prevalence has decreased, and past-year quit attempts have increased. While progress has been made, increased efforts to support smoking cessation are needed for HUD-assisted adults.

Substance use is disproportionately high among people who are homeless or vulnerably housed. We performed a systematic overview of reviews examining the effects of selected harm reduction and pharmacological interventions on the health and social well-being of people who use substances, with a focus on homeless populations. We searched MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute EBP, Cochrane Database of Systematic Reviews and DARE for systematic reviews from inception to August 2019. We conducted a grey literature search and hand searched reference lists. We selected reviews that synthesized evidence on supervised consumption facilities, managed alcohol programs and pharmacological interventions for opioid use disorders. We abstracted data specific to homeless or vulnerably housed populations. We assessed certainty of the evidence using the GRADE approach. Our search identified 483 citations and 30 systematic reviews met all inclusion criteria, capturing the results from 442 primary studies. This included three reviews on supervised consumption facilities, 24 on pharmacological interventions, and three on managed alcohol programs. Supervised consumption facilities decreased lethal overdoses and other high risk behaviours without any significant harm, and improved access to care. Pharmaceutical interventions reduced mortality, morbidity, and substance use, but the impact on retention in treatment, mental illness and access to care was variable. Managed alcohol programs reduced or stabilized alcohol consumption. Few studies on managed alcohol programs reported deaths. Substance use is a common chronic condition impacting homeless populations. Supervised consumption facilities reduce overdose and improve access to care, while pharmacological interventions may play a role in reducing harms and addressing other morbidity. High quality evidence on managed alcohol programs is limited.

This study analyzes the necessary components to managing a successful systems change by considering the processes of housing people experiencing homelessness across a range of geographic locations in the United States. Utilizing Michael Lipsky's notion of street-level bureaucracy, a nonprofit organization called RE!NSTITUTE™ challenges social service agencies to a \"100-Day Challenge™\" by granting front-line workers ownership of improving their work free from oversight from their administrators, which results in improved outcomes. This paper also gives legitimacy to existing models on systems change by using novel mathematical predictive modeling through using principles of conditional probability to recognize the best \"recipe\" for systems change. This quantitative approach achieves three key goals. Firstly, it confirms the existence of a hierarchy that suspects transformative change is the most crucial to bring about, followed by relational or mental changes, and imparts a data-driven concreteness to the theoretical model, revealing varying shares within each broad level. We innovate alternate quasi-periodic visuals whose impacts are lasting. Next, it offers (even under partial knowledge of the predictors) correlational guarantees that one may use while designing future studies: when changes in relationship, practice, and power dynamics are sure, for instance, changes in mental structures often follow with 50% chance. Finally, we point out, through change-point analysis, how shifts in the rate of reducing homelessness may be attributed to assignable causes such as understaffing, which can hamper successes and workers' ability to maintain consistent attendance. We quantify the impact of those shifts. Several instances of 100-Day Challenges™ across various regions of the U.S. are analyzed to unearth commonalities. Thefindings we offer stress that while variables such as changes in resources (or funding) are often emphasized to achieve social change, changes in practices and relationships (networking) are the most influential ingredients to achieve transformative systems change. The sustainment of workers in their positions is a key driver in maintaining growth in successfully relocating individuals experiencing homelessness.

In this Perspective, we build on social justice and emancipatory traditions within the field of health education, and the field’s long-standing commitment to building knowledge and shared power to promote health equity, to examine lessons and opportunities for health education emerging from the COVID-19 pandemic. Examining patterns that emerged as the pandemic unfolded in Metropolitan Detroit, with disproportionate impacts on African American and low-income communities, we consider conditions that contributed to excess exposure, mortality, and reduced access to critical health protective resources. Using a life course framework, we consider enduring impacts of the pandemic for health equity. Finally, we suggest several strategic actions in three focal areas—environment, occupation, and housing—that can be taken by health educators working in partnership with community members, researchers, and decision makers, using, for example, a community-based participatory research approach, to reduce adverse impacts of COVID-19 and promote long-term equity in health.

Housing conditions have been an enduring focus for public health activity throughout the modern public health era. However, the nature of the housing and health challenge has changed in response to an evolution in the understanding of the diverse factors influencing public health. Today, the traditional public health emphasis on the type and quality of housing merges with other wider determinants of health. These include the neighbourhood, community, and “place” where a house is located, but also the policies which make access to a healthy house possible and affordable for everyone. Encouragingly, these approaches to policy and action on housing have the potential to contribute to the “triple win” of health and well-being, equity, and environmental sustainability. However, more effective housing policies (and in public health in general) that adopt more systemic approaches to addressing the complex interactions between health, housing, and wider environment are needed. This paper illustrates some of the key components of the housing and health challenge in developed countries, and presents a conceptual model to co-ordinate activities that can deliver the “triple win.” This is achieved by offering a perspective on how to navigate more effectively, inclusively and across sectors when identifying sustainable housing interventions.

abstract Addressing patients' social needs is key to helping them heal from coronavirus disease 2019 (COVID-19), preventing the spread of the virus, and reducing its disproportionate burden on low-income communities and communities of color. New York City Health + Hospitals is the city's single largest health care provider to Medicaid and uninsured patients. In response to the COVID-19 pandemic, NYC Health + Hospitals staff developed and executed a strategy to meet patients' intensified social needs during the COVID-19 pandemic. NYC Health + Hospitals identified food, housing, and income support as patients' most pressing needs and built programming to quickly connect patients to these resources. Although NYC Health + Hospitals was able to build on its existing foundation of strong social work support of patients, all health systems must prioritize the social needs of patients and their families to mitigate the damage of COVID-19. National and local leaders should accelerate change by developing robust policy approaches to redesign the social and economic system that reinforces structural inequity and exacerbates crises such as COVID-19.

Recent decades have seen a rapid increase in the share of non-European immigrants in public housing in Europe, which has led to concern regarding the rise of ghettos in large cities. Using French census data over three decades, we examine how this increase in public housing participation has affected segregation. While segregation levels have increased moderately, on average, the number of immigrant enclaves has grown. The growth of enclaves is being driven by the large increase in non-European immigrants in the census tracts where the largest housing projects are located, both in the housing projects and the surrounding nonpublic dwellings. As a result, contemporary differences in segregation levels across metropolitan areas are being shaped by the concentration of public housing within cities, in particular the share of non-European immigrants in large housing projects constructed before the 1980s. Nevertheless, the overall effect of public housing on segregation has been ambiguous. While large projects have increased segregation, the inflows of non-European immigrants into small projects have brought many immigrants into census tracts where they have previously been rare and, thus, diminished segregation levels.

In 2023, approximately 650,000 people experienced homelessness (PEH) nightly in the United States, the highest number recorded in the country’s history. This alarming statistic has made homelessness a key issue in the 2024 elections, especially with the White House’s goal to reduce homelessness by 25% by 2025. Despite efforts and investments, homelessness remains a persistent public health challenge. The recent inclusion of street medicine services in Center for Medicare and Medicaid Services (CMS) billing codes represents a significant step forward. Street medicine, defined by CMS as healthcare provided in non-permanent locations to unsheltered individuals, now qualifies for Medicare reimbursement. This policy change, alongside state-level initiatives, aims to improve healthcare access for the unhoused, particularly older adults. However, challenges remain in establishing adequate fee schedules and integrating care management. Despite these obstacles, the integration of healthcare and housing services is crucial for addressing homelessness effectively, promoting stability, and improving health outcomes for PEH. This manuscript explores the history, practical guidance, and potential impacts of these developments on homelessness and public health.

Transgender women (i.e., persons who were assigned male sex at birth but who live and identify as female) experience forms of discrimination that limit their access to stable housing and contribute to high rates of incarceration; once incarcerated, the approaches used to assign them housing within the jail or prison place them at risk for abuse, rape, and other outcomes. Yet, a paucity of studies explores the implications of carceral housing assignments for transgender women. Whether the approaches used to assign housing in jails and prisons violate the rights of incarcerated transgender persons has been argued before the US federal courts under Section 1983 of the US Constitution, which allows persons who were raped while incarcerated to claim a violation of their Eighth Amendment rights. Reforms and policy recommendations have been attempted; however, the results have been mixed and the public health implications have received limited attention.