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Access to primary health care among homeless adults in Toronto, Canada: results from the Street Health survey.

https://arctichealth.org/en/permalink/ahliterature131318
Source
Open Med. 2011;5(2):e94-e103
Publication Type
Article
Date
2011
Author
Erika Khandor
Kate Mason
Catharine Chambers
Kate Rossiter
Laura Cowan
Stephen W Hwang
Author Affiliation
Toronto Public Health, Toronto, Ontario, Canada.
Source
Open Med. 2011;5(2):e94-e103
Date
2011
Language
English
Publication Type
Article
Keywords
Adult
Attitude of Health Personnel
Chronic Disease - epidemiology
Communication Barriers
Cost of Illness
Family Practice - statistics & numerical data
Female
Health Care Costs
Health Services Accessibility - economics - statistics & numerical data
Health Status Disparities
Health Surveys
Homeless Persons - psychology - statistics & numerical data
Humans
Male
Middle Aged
Ontario - epidemiology
Primary Health Care - economics - statistics & numerical data
Risk factors
Sexual Behavior - statistics & numerical data
Substance-Related Disorders - epidemiology
Abstract
Despite experiencing a disproportionate burden of acute and chronic health issues, many homeless people face barriers to primary health care. Most studies on health care access among homeless populations have been conducted in the United States, and relatively few are available from countries such as Canada that have a system of universal health insurance. We investigated access to primary health care among a representative sample of homeless adults in Toronto, Canada.
Homeless adults were recruited from shelter and meal programs in downtown Toronto between November 2006 and February 2007. Cross-sectional data were collected on demographic characteristics, health status, health determinants and access to health care. We used multivariable logistic regression analysis to investigate the association between having a family doctor as the usual source of health care (an indicator of access to primary care) and health status, proof of health insurance, and substance use after adjustment for demographic characteristics.
Of the 366 participants included in our study, 156 (43%) reported having a family doctor. After adjustment for potential confounders and covariates, we found that the odds of having a family doctor significantly decreased with every additional year spent homeless in the participant's lifetime (adjusted odds ratio [OR] 0.91, 95% confidence interval [CI] 0.86-0.97). Having a family doctor was significantly associated with being lesbian, gay, bisexual or transgendered (adjusted OR 2.70, 95% CI 1.04-7.00), having a health card (proof of health insurance coverage in the province of Ontario) (adjusted OR 2.80, 95% CI 1.61-4.89) and having a chronic medical condition (adjusted OR 1.91, 95% CI 1.03-3.53).
Less than half of the homeless people in Toronto who participated in our study reported having a family doctor. Not having a family doctor was associated with key indicators of health care access and health status, including increasing duration of homelessness, lack of proof of health insurance coverage and having a chronic medical condition. Increased efforts are needed to address the barriers to appropriate health care and good health that persist in this population despite the provision of health insurance.
Notes
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PubMed ID
21915240 View in PubMed
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Active tuberculosis among homeless persons, Toronto, Ontario, Canada, 1998-2007.

https://arctichealth.org/en/permalink/ahliterature136298
Source
Emerg Infect Dis. 2011 Mar;17(3):357-65
Publication Type
Article
Date
Mar-2011
Author
Kamran Khan
Elizabeth Rea
Cameron McDermaid
Rebecca Stuart
Catharine Chambers
Jun Wang
Angie Chan
Michael Gardam
Frances Jamieson
Jae Yang
Stephen W Hwang
Author Affiliation
St. Michael's Hospital, Toronto, Ontario, Canada. khank@smh.ca
Source
Emerg Infect Dis. 2011 Mar;17(3):357-65
Date
Mar-2011
Language
English
Publication Type
Article
Keywords
Adult
Emigrants and Immigrants - statistics & numerical data
Female
Homeless Persons - statistics & numerical data
Humans
Male
Middle Aged
Ontario - epidemiology
Risk factors
Tuberculosis - diagnosis - epidemiology - mortality
Abstract
While tuberculosis (TB) in Canadian cities is increasingly affecting foreign-born persons, homeless persons remain at high risk. To assess trends in TB, we studied all homeless persons in Toronto who had a diagnosis of active TB during 1998-2007. We compared Canada-born and foreign-born homeless persons and assessed changes over time. We identified 91 homeless persons with active TB; they typically had highly contagious, advanced disease, and 19% died within 12 months of diagnosis. The proportion of homeless persons who were foreign-born increased from 24% in 1998-2002 to 39% in 2003-2007. Among foreign-born homeless persons with TB, 56% of infections were caused by strains not known to circulate among homeless persons in Toronto. Only 2% of infections were resistant to first-line TB medications. The rise in foreign-born homeless persons with TB strains likely acquired overseas suggests that the risk for drug-resistant strains entering the homeless shelter system may be escalating.
Notes
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PubMed ID
21392424 View in PubMed
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Age- and sex-specific income gradients in alcohol-related hospitalization rates in an urban area.

https://arctichealth.org/en/permalink/ahliterature177156
Source
Ann Epidemiol. 2005 Jan;15(1):56-63
Publication Type
Article
Date
Jan-2005
Author
Stephen W Hwang
Mohammad M Agha
Maria I Creatore
Richard H Glazier
Author Affiliation
Inner City Health Research Unit, St. Michael's Hospital, Toronto, Ontario, Canada. hwangs@smh.toronto.on.ca
Source
Ann Epidemiol. 2005 Jan;15(1):56-63
Date
Jan-2005
Language
English
Publication Type
Article
Keywords
Adult
Age Factors
Aged
Alcohol-Related Disorders - economics - epidemiology
Female
Hospitalization - statistics & numerical data
Humans
Income
Male
Middle Aged
Ontario - epidemiology
Residence Characteristics
Social Class
Urban Health - statistics & numerical data
Abstract
This study examines the effects of age and sex on the relationship between neighborhood income and alcohol-related hospitalization rates in a large urban area.
Adults in Toronto, Canada, who were hospitalized with an alcohol-related condition between 1995 and 1998 were identified using discharge diagnoses. Income quintiles were determined based on area of residence. Annual rates of hospitalization for alcohol-related conditions per 10,000 individuals were calculated.
Rates of hospitalization with a primary diagnosis of an alcohol-related condition were similar among men age 20 to 39 in all incomes quintiles, but were inversely associated with income among men age 40 to 64 (28.8 and 13.3 per 10,000 in the lowest and highest income quintiles). Among women age 40 to 64, the lowest income quintile had the highest hospitalization rate (12.1 per 10,000), but women in all other income quintiles had relatively low hospitalization rates (5.9 to 7.7 per 10,000). As age increased above 65 years, rates of hospitalization with a primary diagnosis of an alcohol-related condition decreased or stabilized in both men and women.
The inverse association between income level and alcohol-related hospitalization rates becomes apparent after age 40. A gradient in hospitalization rates is seen in men across all income levels, but in women a prominent effect is seen only in those with the lowest income.
PubMed ID
15571994 View in PubMed
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The assessment of food security in homeless individuals: a comparison of the Food Security Survey Module and the Household Food Insecurity Access Scale.

https://arctichealth.org/en/permalink/ahliterature133107
Source
Public Health Nutr. 2011 Dec;14(12):2254-9
Publication Type
Article
Date
Dec-2011
Author
Anna C Holland
Matthew C Kennedy
Stephen W Hwang
Author Affiliation
Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
Source
Public Health Nutr. 2011 Dec;14(12):2254-9
Date
Dec-2011
Language
English
Publication Type
Article
Keywords
Adult
Canada
Cross-Sectional Studies
Diet Surveys
Family Characteristics
Female
Food Supply - statistics & numerical data
Guidelines as Topic
Homeless Persons
Humans
Male
Middle Aged
Questionnaires
Software
United States
Abstract
To compare the Household Food Insecurity Access Scale (HFIAS), the US Food Security Survey Module (US FSSM) and a modified version of the US FSSM in which references to buying food were changed to references to getting food, in terms of their classification of food security levels among homeless individuals, and to determine which of these instruments was most preferred by homeless individuals.
A cross-sectional survey.
Recruitment of participants took place at seven shelters and from three drop-in programmes that serve homeless individuals in Toronto, Canada.
Fifty individuals who were =18 years of age, able to communicate in English and currently homeless.
The modified US FSSM assigned 20% of participants to a lower ordinal food security category compared with the US FSSM, and only 8% to a higher food security category. The HFIAS assigned 30% of participants to a lower food security category compared with either the US FSSM or the modified US FSSM, and only 10-16% of participants to a higher food security category. When asked to compare all three instruments, the majority of respondents (62%) selected the HFIAS as the best instrument for people who are homeless.
A majority of homeless individuals selected the HFIAS as the best food security instrument for people who are homeless. Our findings suggest that the HFIAS is a more appropriate instrument than the US FSSM for measuring food security in the homeless population.
PubMed ID
21740619 View in PubMed
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Attitudes towards homeless people among emergency department teachers and learners: a cross-sectional study of medical students and emergency physicians.

https://arctichealth.org/en/permalink/ahliterature107882
Source
BMC Med Educ. 2013;13:112
Publication Type
Article
Date
2013
Author
Alison G Fine
Tony Zhang
Stephen W Hwang
Author Affiliation
Department of Family Medicine, University of Manitoba, Winnipeg, MN, Canada. Finea3@myumanitoba.ca.
Source
BMC Med Educ. 2013;13:112
Date
2013
Language
English
Publication Type
Article
Keywords
Attitude of Health Personnel
Cross-Sectional Studies
Emergency Medicine
Emergency Service, Hospital
Faculty, Medical
Homeless Persons
Humans
Ontario
Questionnaires
Students, Medical - psychology
Abstract
Medical students' attitudes and beliefs about homeless people may be shaped by the attitudes of their teachers and one of the most common sites for learning about homeless patients is the emergency department. The objective of this study was to determine if medical students in the preclinical and clinical years and emergency medicine faculty and residents have different attitudes and beliefs about homeless people.
The Health Professional Attitudes Toward the Homeless Inventory (HPATHI), was administered to all medical students, and emergency medicine physicians and residents at a large academic health sciences center in Canada. The HPATHI examines attitudes, interest and confidence on a 5-point Likert scale. Differences among groups were examined using the Kruskal Wallis test and Pearson's chi-square test.
The HPATHI was completed by 371 individuals, for an overall response rate of 55%. Analysis of dichotomized median and percentage results revealed 5/18 statements were significant by both methods. On the attitudes subscales physicians and residents as a group were more negative for 2/9 statements and on the confidence subscale more positive for 1/4 statements. The interest subscale achieved overall statistical significance with decreased positive responses among physicians and residents compared to medical students in 2/5 statements.
This study revealed divergences in attitudes, interests and beliefs among medical students and emergency medicine physicians and residents. We offer strategies for training interventions and systemic support of emergency faculty. Emergency medicine physicians can examine their role in the development of medical students through both formal and informal teaching in the emergency department.
Notes
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PubMed ID
23968336 View in PubMed
Less detail

Bed bug infestations in an urban environment.

https://arctichealth.org/en/permalink/ahliterature175260
Source
Emerg Infect Dis. 2005 Apr;11(4):533-8
Publication Type
Article
Date
Apr-2005
Author
Stephen W Hwang
Tomislav J Svoboda
Iain J De Jong
Karl J Kabasele
Evie Gogosis
Author Affiliation
Centre for Research on Inner City Health, St. Michael's Hospital, Toronto, Ontario, Canada. hwangs@smh.toronto.on.ca
Source
Emerg Infect Dis. 2005 Apr;11(4):533-8
Date
Apr-2005
Language
English
Publication Type
Article
Keywords
Animals
Bedbugs
Housing - standards
Humans
Insect Control - methods
Ontario
Public Health - standards
Urban health
Abstract
Until recently, bed bugs have been considered uncommon in the industrialized world. This study determined the extent of reemerging bed bug infestations in homeless shelters and other locations in Toronto, Canada. Toronto Public Health documented complaints of bed bug infestations from 46 locations in 2003, most commonly apartments (63%), shelters (15%), and rooming houses (11%). Pest control operators in Toronto (N = 34) reported treating bed bug infestations at 847 locations in 2003, most commonly single-family dwellings (70%), apartments (18%), and shelters (8%). Bed bug infestations were reported at 20 (31%) of 65 homeless shelters. At 1 affected shelter, 4% of residents reported having bed bug bites. Bed bug infestations can have an adverse effect on health and quality of life in the general population, particularly among homeless persons living in shelters.
Notes
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PubMed ID
15829190 View in PubMed
Less detail

Cervical cancer screening among urban immigrants by region of origin: a population-based cohort study.

https://arctichealth.org/en/permalink/ahliterature140183
Source
Prev Med. 2010 Dec;51(6):509-16
Publication Type
Article
Date
Dec-2010
Author
Aisha K Lofters
Stephen W Hwang
Rahim Moineddin
Richard H Glazier
Author Affiliation
Department of Family & Community Medicine, University of Toronto, Toronto, Canada. Aisha.lofters@utoronto.ca
Source
Prev Med. 2010 Dec;51(6):509-16
Date
Dec-2010
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Asia, Southeastern - ethnology
Cohort Studies
Emigrants and Immigrants
Female
Healthcare Disparities
Humans
Middle Aged
Multivariate Analysis
Ontario - epidemiology
Poverty Areas
Urban health
Uterine Cervical Neoplasms - diagnosis - epidemiology - ethnology - prevention & control
Vaginal Smears
Young Adult
Abstract
We compared the prevalence of appropriate cervical cancer screening among screening-eligible immigrant women from major geographic regions of the world and native-born women.
We determined the proportion of women who were screened during the three-year period of 2006-2008 among 2.9 million screening-eligible women living in urban centres in Ontario, Canada. In multivariate analyses, we adjusted for numerous variables including age, neighbourhood-level income, and prenatal visits during the study period.
61.3% of women were up-to-date on cervical cancer screening. Screening rates were lowest among women from South Asia when compared to the referent group (Canadian-born women and immigrants who arrived before 1985) (adjusted rate ratio 0.81, 95% CI [0.80-0.82] among women aged 18-49 years, adjusted rate ratio 0.67 [0.65-0.69] among women aged 50-66 years). Of the older South Asian women living in the lowest-income neighbourhoods and not in a primary care enrollment model, 21.9% had been appropriately screened. In contrast, among Canadian-born women living in the highest-income neighbourhoods and in a primary care enrollment model, 79.0% had been appropriately screened.
Efforts to reduce cervical cancer screening disparities should focus on women living in the lowest-income neighbourhoods and women from South Asia.
PubMed ID
20932995 View in PubMed
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Cognitive interviewing methods for questionnaire pre-testing in homeless persons with mental disorders.

https://arctichealth.org/en/permalink/ahliterature129424
Source
J Urban Health. 2012 Feb;89(1):36-52
Publication Type
Article
Date
Feb-2012
Author
Carol E Adair
Anna C Holland
Michelle L Patterson
Kate S Mason
Paula N Goering
Stephen W Hwang
Author Affiliation
Department of Community Health Sciences and Psychiatry, University of Calgary, Calgary, AB, Canada. ceadair@ucalgary.ca
Source
J Urban Health. 2012 Feb;89(1):36-52
Date
Feb-2012
Language
English
Publication Type
Article
Keywords
Adult
Aged
Canada
Female
Homeless Persons - psychology
Humans
Interview, Psychological - methods
Male
Mental Disorders - diagnosis
Middle Aged
Psychometrics - instrumentation
Questionnaires
Abstract
In this study, cognitive interviewing methods were used to test targeted questionnaire items from a battery of quantitative instruments selected for a large multisite trial of supported housing interventions for homeless individuals with mental disorders. Most of the instruments had no published psychometrics in this population. Participants were 30 homeless adults with mental disorders (including substance use disorders) recruited from service agencies in Vancouver, Winnipeg, and Toronto, Canada. Six interviewers, trained in cognitive interviewing methods and using standard interview schedules, conducted the interviews. Questions and, in some cases, instructions, for testing were selected from existing instruments according to a priori criteria. Items on physical and mental health status, housing quality and living situation, substance use, health and justice system service use, and community integration were tested. The focus of testing was on relevance, comprehension, and recall, and on sensitivity/acceptability for this population. Findings were collated across items by site and conclusions validated by interviewers. There was both variation and similarity of responses for identified topics of interest. With respect to relevance, many items on the questionnaires were not applicable to homeless people. Comprehension varied considerably; thus, both checks on understanding and methods to assist comprehension and recall are recommended, particularly for participants with acute symptoms of mental illness and those with cognitive impairment. The acceptability of items ranged widely across the sample, but findings were consistent with previous literature, which indicates that "how you ask" is as important as "what you ask." Cognitive interviewing methods worked well and elicited information crucial to effective measurement in this unique population. Pretesting study instruments, including standard instruments, for use in special populations such as homeless individuals with mental disorders is important for training interviewers and improving measurement, as well as interpreting findings.
Notes
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PubMed ID
22109879 View in PubMed
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A community-based intervention to increase screening mammography among disadvantaged women at an inner-city drop-in center.

https://arctichealth.org/en/permalink/ahliterature173606
Source
Women Health. 2005;41(1):21-31
Publication Type
Article
Date
2005
Author
Robert K Heyding
Angela M Cheung
Eva J M Mocarski
Rahim Moineddin
Stephen W Hwang
Author Affiliation
Leaside Health Centre and the Department of Family and Community Medicine, Toronto, ON, M4G 4E4, Canada.
Source
Women Health. 2005;41(1):21-31
Date
2005
Language
English
Publication Type
Article
Keywords
Aged
Breast Neoplasms - prevention & control - radiography
Community Health Centers - statistics & numerical data - utilization
Female
Homeless Persons - statistics & numerical data
Humans
Mammography - utilization
Mass Screening - utilization
Middle Aged
Ontario - epidemiology
Outcome Assessment (Health Care)
Patient Acceptance of Health Care - statistics & numerical data
Poverty - statistics & numerical data
Preventive Health Services - standards
Retrospective Studies
Urban Health Services - statistics & numerical data - utilization
Urban Population - statistics & numerical data
Women's health
Women's Health Services - statistics & numerical data - utilization
Abstract
To determine the effectiveness of a community- based intervention to increase the use of screening mammography among disadvantaged women at an inner-city drop-in center.
This study involved women 50 to 70 years old who were clients of an inner-city drop-in center in Toronto, Canada, during the years 1995-2002 (N = 158 in 1995-2001 and N = 89 in 2002). In 2002, the drop-in center and a nearby hospital initiated a collaborative breast cancer screening project in which a staff member of the drop-in center accompanied small groups of women for mammography visits at a weekly pre-arranged time. Interrupted time series analysis was used to examine the effect of this intervention on the annual rate of screening mammography, as determined by review of medical records.
More than half of the women 50 to 70 years old who used the drop-in center in 2002 had been diagnosed with a major mental illness, and one-third were either homeless or living in supportive housing. In the 7 years before the introduction of the intervention, annual mammography rates among women using the drop-in center averaged 4.7%. During the intervention year, 26 (29.2%) of 89 women underwent mammography (p = 0.0001 for the change from pre-to post-intervention).
The introduction of accompanied small-group visits was associated with significantly increased use of mammography in a group of disadvantaged women who were clients of an inner-city drop-in center. This approach may be useful to promote breast cancer screening among women affected by mental illness or homelessness who have contact with community-based agencies.
PubMed ID
16048866 View in PubMed
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A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance.

https://arctichealth.org/en/permalink/ahliterature106553
Source
Am J Public Health. 2013 Dec;103 Suppl 2:S294-301
Publication Type
Article
Date
Dec-2013
Author
Stephen W Hwang
Catharine Chambers
Shirley Chiu
Marko Katic
Alex Kiss
Donald A Redelmeier
Wendy Levinson
Author Affiliation
Stephen W. Hwang, Catharine Chambers, and Shirley Chiu are with the Centre for Research on Inner City Health, part of the Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario. Marko Katic and Alex Kiss are with the Department of Research Design and Biostatistics, Sunnybrook Health Sciences Centre, Toronto. Donald A. Redelmeier is with the Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, Toronto. Wendy Levinson is with the Department of Medicine, University of Toronto.
Source
Am J Public Health. 2013 Dec;103 Suppl 2:S294-301
Date
Dec-2013
Language
English
Publication Type
Article
Keywords
Adult
Ambulatory Care - utilization
Canada - epidemiology
Cohort Studies
Emergency Service, Hospital - utilization
Female
Health Services - utilization
Homeless Persons - statistics & numerical data
Hospitalization - statistics & numerical data
Humans
Male
Middle Aged
Socioeconomic Factors
United States - epidemiology
Universal Coverage
Abstract
We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system.
We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs).
Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations.
In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.
PubMed ID
24148051 View in PubMed
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