Morbidity and mortality in a prospective cohort of people who were homeless during the COVID-19 pandemic.

Introduction: Certain living conditions, such as homelessness, increase health risks in epidemic situations. We conducted a prospective observational cohort study to investigate the impact of the COVID-19 pandemic on morbidity and mortality in adult people who were homeless. Methods: The study population comprised around 40% of the entire population experiencing homelessness in Marseille. They were enrolled at 48 different locations during the first pandemic wave (June to August 2020) and were followed up 3 and 6 months later. Rapid serological screening for SARS-CoV-2 was performed by community outreach teams at each follow-up, who also conducted interviews. Death registers and hospital administrative databases were consulted. Results: A total of 1,332 participants [mean age 40.1 years [SD 14.2], women 339 (29.9%)] were enrolled in the cohort. Of these, 192 (14.4%) participants were found positive for COVID-19 and were propensity score matched (1:3) and compared with 553 non-COVID-19 cases. Living in emergency shelters was associated with COVID-19 infection. While 56.3% of the COVID-19-infected cohort reported no symptoms, 25.0% were hospitalized due to the severity of the disease. Presence of three or more pre-existing comorbidities was associated with all-cause hospitalization. Among COVID-19 cases, only older age was associated with COVID-19 hospitalization. Three deaths occurred in the cohort, two of which were among the COVID-19 cases. Conclusion: The study provides new evidence that the population experiencing homelessness faces higher risks of infection and hospitalization due to COVID-19 than the general population. Despite the efforts of public authorities, the health inequities experienced by people who are homeless remained major. More intensive and appropriate integrated care and earlier re-housing are needed.

Cumulative incidence of SARS-CoV-2 infection within the homeless population: insights from a city-wide longitudinal study.

OBJECTIVES: The aim of this study was to determine the risk factors associated with SARS-CoV-2 infection in a cohort of homeless people using survival analysis. Seroprevalence in the homeless community was also compared with that of the general population. DESIGN: Cohort study. SETTING: Data were collected across two testing sessions, 3 months apart, during which each participant was tested for anti-SARS-CoV-2 antibodies and completed a face-to-face survey. PARTICIPANTS: All homeless adults sleeping rough, in slums or squats, in emergency shelters or transitional accommodation in Marseille were eligible. PRIMARY OUTCOME MEASURES: Occurrence of a seroconversion event defined as a biologically confirmed SARS-CoV-2 infection. Local data from a national seroprevalence survey were used for comparison between homeless people and the general population. RESULTS: A total of 1249 people were included. SARS-CoV-2 seroprevalence increased from 6.0% (4.7-7.3) during the first session to 18.9% (16.0-21.7) during the second one, compared with 3.0% (1.9-4.2) and 6.5% (4.5-8.7) in the general population. Factors significantly associated with an increased risk of COVID-19 infection were: having stayed in emergency shelters (1.93 (1.18-3.15)), being an isolated parent (1.64 (1.07-2.52)) and having contact with more than 5-15 people per day (1.84 (1.27-2.67)). By contrast, smoking (0.46 (0.32-0.65)), having financial resources (0.70 (0.51-0.97)) and psychiatric or addictive comorbidities (0.52 (0.32-0.85)) were associated with a lower risk. CONCLUSION: We confirm that homeless people have higher infection rates than the general population, with increased risk in emergency shelters. There is growing evidence that, in addition to usual preventive measures, public policies should pay attention to adapt the type of accommodation and overall approach of precariousness. TRIAL REGISTRATION NUMBER: NCT04408131.

Health status of recently arrived asylum seekers in their host country: results of a cross-sectional observational study.

BACKGROUND: The World Health Organization (WHO) considers that the heterogeneity of concepts and definitions of migrants is an obstacle to obtaining evidence to inform public health policies. There is no recent data on the health status of only asylum seekers who have recently arrived in their Western host country. The purpose of this study was to determine the health status of asylum seekers and search for explanatory factors for this health status. METHODS: This cross-sectional observational study screened the mental and somatic health of adult asylum seekers who had arrived in France within the past 21 days and went to the Marseille single center between March 1 and August 31, 2021. In order to study the explanatory factors of the asylum seekers' health status, a multivariate analysis was performed using a logistic regression model to predict the health status. Factors taken into account were those significantly associated with outcome (level < 0.05) in univariate analysis. RESULTS: In total, 419 asylum seekers were included and 96% CI95%[93;97.3] had at least one health disorder. Concerning mental health, 89% CI95% [85.1;91.4] had a mental disorder and in terms of somatic health exclusively, 66% CI95% [61.4;70.6] had at least one somatic disorder. Women were more likely to have a somatic disease OR = 1.80 [1.07; 3.05]. We found a statistically significant association between the presence of at least one disorder and sleeping in a public space OR = 3.4 [1.02;11.28] p = 0.046. This association is also found for mental disorders OR = 2.36 [1.16;4.84], p = 0.018. CONCLUSIONS: Due to the high prevalence of health disorders our study found, asylum seekers are a population with many care needs when they arrive in their host country. The main factors linked to a poor health status seem to be related to a person's sex, geographical origin and sleeping in a public space.

Effect of Psychiatric Advance Directives Facilitated by Peer Workers on Compulsory Admission Among People With Mental Illness: A Randomized Clinical Trial.

Importance: Reducing the use of coercion in mental health care is crucial from a human rights and public health perspective. Psychiatric advance directives (PADs) are promising tools that may reduce compulsory admissions. Assessments of PADs have included facilitation by health care agents but not facilitation by peer workers. Objective: To determine the efficacy of PADs facilitated by peer workers (PW-PAD) in people with mental disorders. Design, Setting, and Participants: A multicenter randomized clinical trial was conducted in 7 French mental health facilities. Adults with a DSM-5 diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who had a compulsory admission in the past 12 months and the capacity to consent were enrolled between January 2019 and June 2020 and followed up for 12 months. Interventions: The PW-PAD group was invited to fill out a PAD form and meet a peer worker who was trained to assist in completing and sharing the form with relatives and psychiatrists. Main Outcomes and Measures: The primary outcome was the rate of compulsory admission at 12 months after randomization. The overall psychiatric admission rate, therapeutic alliance, quality of life, mental health symptoms, empowerment, and recovery outcomes were also investigated. Results: Among 394 allocated participants (median age, 39 years; 39.3% female; 45% with schizophrenia, 36% bipolar I disorder, and 19% schizoaffective disorder), 196 were assigned to the PW-PAD group and 198 to the control group. In the PW-PAD group, 27.0% had compulsory admissions compared with 39.9% in the control group (risk difference, -0.13; 95% CI, -0.22 to -0.04; P = .007). No significant differences were found in the rate of overall admissions, therapeutic alliance score, and quality of life. Participants in the PW-PAD group exhibited fewer symptoms (effect size, -0.20; 95% CI, -0.40 to 0.00), greater empowerment (effect size, 0.30; 95% CI, 0.10 to 0.50), and a higher recovery score (effect size, 0.44; 95% CI, 0.24 to 0.65), compared with those in the control group. Conclusions and Relevance: Peer worker-facilitated PADs are effective in decreasing compulsory hospital admissions and increasing some mental health outcomes (self-perceived symptoms, empowerment, and recovery). Involving peer workers in the completion of PADs supports the current shift of mental health care from substitute decision-making to supported decision-making. Trial Registration: ClinicalTrials.gov Identifier: NCT03630822.

Un modèle innovant d'intervention, de dépistage et de prise en charge mobile de la COVID-19 chez les personnes sans-abri à Marseille.

INTRODUCTION: Homeless people are particularly at risk of becoming infected with COVID-19 because their precarious living conditions make prevention measure difficult. OBJECTIVE: We describe an innovative approach with the aim of implementing testing and monitoring adapted to the needs of the homeless people of Marseille (inhabitants of slums, squats or those living on the street). RESULTS: The intervention included 1) the coordination of 18 support organizations for homeless people, 2) the training and the provision of rapid serological and antigenic tests, 3) a mobile outreach team with community mediators in order to provide tests, including COVID-19 PCR on point of care, prevention and monitoring of positive cases. Acceptability of the intervention by participants, field organization was good. The lack of adapted places of accommodation was an important restricting factor for optimal care and support. CONCLUSION: The emergence of COVID-19 has highlighted discontinuities in health care among homeless people. Specific mobile outreach teams could limit the impact on this high-risk population.

Residential Mobility of a Cohort of Homeless People in Times of Crisis: COVID-19 Pandemic in a European Metropolis.

Most vulnerable individuals are particularly affected by the COVID-19 pandemic. This study takes place in a large city in France. The aim of this study is to describe the mobility of the homeless population at the beginning of the health crisis and to analyze its impact in terms of COVID-19 prevalence. From June to August 2020 and September to December 2020, 1272 homeless people were invited to be tested for SARS-CoV-2 antibodies and virus and complete questionnaires. Our data show that homeless populations are sociologically different depending on where they live. We show that people that were living on the street were most likely to be relocated to emergency shelters than other inhabitants. Some neighborhoods are points of attraction for homeless people in the city while others emptied during the health crisis, which had consequences for virus circulation. People with a greater number of different dwellings reported became more infected. This first study of the mobility and epidemiology of homeless people in the time of the pandemic provides unique information about mobility mapping, sociological factors of this mobility, mobility at different scales, and epidemiological consequences. We suggest that homeless policies need to be radically transformed since the actual model exposes people to infection in emergency.

Factors associated with SARS-CoV2 infection and care pathways among the most vulnerable populations living in Marseille: a case control study.

BACKGROUND: The Covid-19 pandemic has led to substantial and unexpected increases in morbidity and mortality in France. Vulnerable populations housed in accommodation centres have a greater risk of infection because collective housing and their dependence on social support services mean it is more difficult to apply preventive measures. They are also at greater risk of developing severe forms of Covid-19 and waiting longer before seeking healthcare (for Covid-19 or other) treatment. We aimed to identify the factors associated with SARS-CoV2 infection in the most vulnerable populations in the city of Marseille. METHODS: The study sample comprised users of various services provided by the association AAJT in Marseille, France, some presenting symptoms suggestive of Covid-19 and others not. All had routine health surveillance provided by AAJT's dedicated healthcare team between March 2020 and May 2020. Using univariate and multivariate analyses, we studied the influence of several variables on morbidity associated with Covid-19. RESULTS: The study included 64 participants, 29 of whom tested positive for Covid-19 and 35 control subjects. Median age was 21.16 years old. Individuals in the 'Covid-19 case' group (p < 0.005) - which included persons testing positive and those suspected of being infected - were younger. The study sample's male/female ratio was seven. In our multivariate analyses, living in a shared apartment and poor adherence to social distancing measures were factors associated with Covid-19 infection. Furthermore, mental health problems - such as anxiety disorder - were very frequent in the study sample. CONCLUSIONS: Allocating more and specific housing units to structures providing accommodation services to the most vulnerable people would seem to be a decisive factor in controlling the spread of SARS-CoV2, and deserves more attention from public authorities.

Seroprevalence of SARS-CoV-2 antibodies among homeless people living rough, in shelters and squats: A large population-based study in France.

BACKGROUND: Overcrowded housing, as well as inadequate sanitary conditions, contribute to making homeless people particularly vulnerable to the SARS-CoV-2 infection. We aimed to assess the seroprevalence of the SARS-CoV-2 infection among people experiencing homelessness on a large city-wide scale in Marseille, France, taking into account different types of accommodation. METHODS: A consortium of outreach teams in 48 different locations including streets, slums, squats, emergency or transitional shelters and drop-in centres participated in the inclusion process. All participants consented to have a validated rapid antibody assay for immunoglobulins M (IgM) and G (IgG) and to answer a questionnaire on medical health conditions, comorbidities, and previous COVID-19 symptoms. Information on their housing conditions since the COVID-19 crisis was also collected from the participants. RESULTS: From June 01 to August 05, 2020, 1,156 homeless participants were enrolled in the study and tested. The overall seroprevalence of SARS-CoV-2 IgG/IgM antibodies was 5.6% (95%CI 2.3-7.0), ranging from 2.2% in people living on the streets to 8.1% in people living in emergency shelters (P = 0.009). Around one third of the seropositive participants reported COVID-19 symptoms. Compared to the general population in Marseille (3.6%), the homeless population living in the same urban area experienced a significantly increased risk of SARS-CoV-2 infection (|z| = 3.65 > 1.96). CONCLUSION: These findings highlight the need for regular screening among the homeless to prevent clustering in overcrowded or inadequate accommodations. It is also necessary to provide essential resources to keep homeless people healthy, the vast majority of whom have cumulative risk factors for SARS-CoV-2 infection.

Mortality in homeless people enrolled in the French housing first randomized controlled trial: a secondary outcome analysis of predictors and causes of death.

BACKGROUND: Homeless people face large excess mortality in comparison with the general population, but little is known about the effect of housing interventions like Housing First (HF) on their mortality. AIMS OF THE STUDY: 1) to explore 2-years mortality among homeless people with severe mental illness (SMI) included in French HF randomized controlled trial (RCT). 2) To examine causes of death among homeless participants. METHODS: For 703 participants of HF RCT: 353 in experimental group (HF) and 350 in control group (Treatment As Usual - TAU), any proof of life or death and causes of death were collected with a thorough retrospective investigation among relatives, institutions and administrative databases. Data collection took place from March to June 2017. RESULTS: 4.8% (n = 34) of the study participants died over the study period. Mean age of death was 40.9 (+/- 11.4) years. The overall 2-years mortality rate was 0.065 in the HF group (n = 23) versus 0.034 in the TAU group (n = 11). Mortality was associated with medications for opioid use disorder in multivariate Cox analysis (HR: 2.37, 95%CI 1.15-5.04, p = 0.025). Those in HF group seem to be more at risk of death compared to TAU group, mainly during the first 6 months of being housed, although the difference did not reach significance (HR: 0.49, 95%CI 0.24-1.01, p = 0.054). Violent deaths occurred in 52.2% of HF group's deaths versus 18.2% of TAU group's deaths, this excess being explained by 34.8% (n = 8) deaths by overdoses in HF group versus none in TAU group. LIMITATIONS: 1) 8.7% (n = 2) people in HF group died before HF intervention but were analyzed in intention-to-treat. 2) No proof of life or death has been found for only 0.6% in HF group (n = 2) but for 9.5% people in TAU group (n = 33) that could be anonymous deaths. 3) Undetermined causes represented 8.7% of deaths in HF group versus 36.4% in TAU group. 4) The small number of events (deaths) in the study population is a limitation for statistical analysis. CONCLUSIONS: Due to important limitations, we cannot conclude on HF effect on mortality, but our results nevertheless confirm that the vulnerability of long-term homeless people with SMI persists after accessing independent housing. Earlier intervention in the pathways of homelessness should be considered, alongside active specific support for addictions. TRIAL REGISTRATION: Ethics Committee Sud Mediterrannée V n° 11.050: trial number 2011-A00668-33: 28/07/2011. Clinicaltrials ID NCT01570712 : 4/4/2012.

"Locked down outside": Perception of hazard and health resources in COVID-19 epidemic context among homeless people.

While social inequality is widely recognised as being a risk factor for COVID-19 infection or serious forms of the disease, many questions still remain concerning the perception of hazard and protective measures by the most vulnerable populations. This mixed-methods study aimed (1) to describe the self-perceived health and protective measures linked to COVID-19 of homeless people in one of the largest and poorest cities in France, and (2) to assess which skills and resources they used to address the COVID-19 pandemic. The quantitative survey addressed these questions among a sample of 995 homeless people living either on the streets, in homeless shelters or in squats/slums, whereas the qualitative survey was constructed from 14 homeless interviewees. Both data collections were carried out between June and July 2020. Results showed that COVID-19 infection was clearly perceived by homeless people as a risk, but the experience of being homeless placed this risk among several others. Different practices of protection were observed according to the type of living place. Lockdown of the general population severely impacted the survival systems of the populations furthest from housing, with alarming rates of people without access to water or food. 77% of homeless participants reported that they encountered significant financial difficulties. All interviewees were particularly attentive to their health, with awareness and even a familiarity with the risks of infectious diseases long before the pandemic. Using a capability framework, our study showed a predominant lack of external health-related resources for homeless people, while internal health-related resources were more developed than expected. None of the places and lifestyles studied was favourable to health: collective shelters due to a greater restriction of people's choices, slums and street life due to a greater lack of basic resources.

SARS-CoV-2 rapid serological tests for field-based healthcare workers in homeless communities: A mixed-methods exploratory analysis.

OBJECTIVES: The high risk of SARS-CoV-2 transmission in homeless communities requires adapted prevention strategies for field-based healthcare workers (HCWs). Rapid serological tests (RSTs) could be an invaluable tool for HCWs to control COVID-19 transmission. This study assesses the benefits of RSTs for HCWs in Marseille, France. STUDY DESIGN: Mixed-methods exploratory analysis. METHODS: A mixed-methods approach was used, combining quantitative and qualitative data, to prospectively analyse acceptability of RSTs, prevalence of SARS-CoV-2 antibodies and prevention behaviours in 106 HCWs from 18 non-governmental organisations (NGOs) and health or social institutions in Marseille from June 1 to July 31, 2020. For the qualitative dimension, semi-structured individual interviews were conducted with 21 HCWs from 7 of 18 NGOs and institutions. RESULTS: Most of the 106 HCWs in the quantitative study reported better prevention measures at work than in their homes. Despite this, the majority reported that they felt unsafe at work in terms of COVID-19 infection risk. SARS-CoV-2 antibody seroprevalence among the study population was 6.1%. Only four HCWs refused to have an RST.The 21 qualitative interviews highlighted that HCWs were not afraid of RSTs or of any possible stigma associated with a positive serological status, although they were sometimes suspicious about RST validity. Downplaying their risk of infection was a coping strategy to keep both a sense of control and remain motivated at work. CONCLUSIONS: RSTs should be adopted as an additional tool in the strategy to protect both HCWs and healthcare service users. Additional follow-up of these observational findings is needed, especially with the increasing prevalence of vaccination in HCWs.

Europeans' willingness to pay for ending homelessness: A contingent valuation study.

The purpose of this study is to assess the utility value European citizens put on an innovative social program aimed at reducing homelessness. The Housing First (HF) model involves access to regular, scattered, independent and integrated housing in the community with the support of a multidisciplinary team. Currently, HF is not implemented by most European countries or funded by healthcare or social plans, but randomised controlled trials have stressed significant results for improved housing stability, recovery and healthcare services use. The broader implementation of HF across Europe would benefit from a better understanding of citizens' preferences and "willingness to pay" (WTP) for medico-social interventions like HF. We conducted a representative telephone survey between March and December 2017 in eight European countries (France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain, and Sweden). Respondent's WTP for HF (N = 5631) was assessed through a contingent valuation method with a bidding algorithm. 42.3% of respondents were willing to pay more taxes to reduce homelessness through the HF model, and significant differences were found between countries (p < 0.001); 30.4% of respondents who did not value the HF model were protest zeros (either contested the payment vehicle-taxes- or the survey instrument). Respondents were willing to pay €28.2 (±11) through annual taxation for the HF model. Respondents with higher educational attainment, who paid national taxes, reported positive attitudes about homelessness, or reported practices to reduce homelessness (donations, volunteering) were more likely to value the HF model, with some countries' differences also related to factors at the environmental level. These findings inform key stakeholders that European citizens are aware of the issue of homelessness in their countries and that scaling up the HF model across Europe is both feasible and likely to have public support.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial - DAiP study.

BACKGROUND: Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France. METHODS: A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis. SETTING: Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews. PARTICIPANTS: 400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French. INTERVENTIONS: The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care. MAIN OUTCOMES AND MEASURES: The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs. DISCUSSION: Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

Lifetime, 5-year and past-year prevalence of homelessness in Europe: a cross-national survey in eight European nations.

OBJECTIVES: To examine the lifetime, 5-year and past-year prevalence of homelessness among European citizens in eight European nations. DESIGN: A nationally representative telephone survey using trained bilingual interviewers and computer-assisted telephone interview software. SETTING: The study was conducted in France, Ireland, Italy, the Netherlands, Poland, Portugal, Spain and Sweden. PARTICIPANTS: European adult citizens, selected from opt-in panels from March to December 2017. Total desired sample size was 5600, with 700 per country. Expected response rates of approximately 30% led to initial sample sizes of 2500 per country. MAIN OUTCOME MEASURES: History of homelessness was assessed for lifetime, past 5 years and past year. Sociodemographic data were collected to assess correlates of homelessness prevalence using generalised linear models for clustered and weighted samples. RESULTS: Response rates ranged from 30.4% to 33.5% (n=5631). Homelessness prevalence was 4.96% for lifetime (95% CI 4.39% to 5.59%), 1.92% in the past 5 years (95% CI 1.57% to 2.33%) and 0.71% for the past year (95% CI 0.51% to 0.98%) and varied significantly between countries (pairwise comparison difference test, p<0.0001). Time spent homeless ranged between less than a week (21%) and more than a year (18%), with high contrasts between countries (p<0.0001). Male gender, age 45-54, lower secondary education, single status, unemployment and an urban environment were all independently strongly associated with lifetime homelessness (all OR >1.5). CONCLUSIONS: The prevalence of homelessness among the surveyed nations is significantly higher than might be expected from point-in-time and homeless service use statistics. There was substantial variation in estimated prevalence across the eight nations. Coupled with the well-established health impacts of homelessness, medical professionals need to be aware of the increased health risks of those with experience of homelessness. These findings support policies aiming to improve health services for people exposed to homelessness.

Goals and Principles of Providers Working with People Experiencing Homelessness: A Comparison Between Housing First and Traditional Staircase Services in Eight European Countries.

The implementation and adaptation of the Housing First (HF) model represented profound changes the structure and delivery, goals, and principles of homeless services. These features of homeless services directly influence providers, their work performance and the clients' outcomes. The present research, conducted in eight European countries, investigated how social providers working in HF or TS (Traditional Staircase) describe and conceptualize the goals and the principles of their services. Data were collected through 29 focus group discussions involving 121 providers. The results showed that HF and TS had similar and different goals for their clients in the following areas: support, social integration, satisfaction of needs, housing, and well-being. HF providers emphasized clients' autonomy and ability to determine their personal goals, with housing being considered a start on the path of recovery, while TS were more focused on individual clients' basic needs with respect to food, health and finding temporary accommodations. HF providers privileged the person-centered approach and housing as a right, while TS providers were more focused on helping everyone. Implications of the results are discussed as suggestions both for practice and for research.

Victimization and posttraumatic stress disorder in homeless women with mental illness are associated with depression, suicide, and quality of life.

OBJECTIVE: This study aimed to determine the following: 1) the proportion of women in the homeless population with schizophrenia (SZ) or bipolar disorder (BD), in addition to the trajectory of their homelessness (ie, homelessness history, number of nights spent without home during the 180 past nights) and the characteristics of their illnesses compared to men (ie, illness severity, suicide risk, physical health status, and quality of life [QoL]); 2) whether these women were victimized more frequently than similarly situated men; 3) the impact of victimization on these women in terms of illness severity, suicide risk, physical health status, and QoL; and lastly 4) the differences and overlap of homeless women with SZ and BD. METHODS: This study employed data at baseline from a multicenter randomized controlled trial conducted in the following four large French cities: Lille, Marseille, Paris, and Toulouse. Mobile mental health outreach teams recruited SZ/BD homeless patients in the street, emergency shelters, hospitals, and jails from August 2011 to April 2014. Evaluations were performed during face-to-face interviews by psychiatrists and research assistants in the offices of mobile mental health outreach teams that were located in the downtown area of each city. The quantitative data were analyzed using descriptive analyses, chi-square and Student's t-tests, generalized estimating equation regression models, and path analysis. RESULTS: A total of 703 patients were included in this study. The proportion of women in the SZ/BD homeless population was 123/703 (17.5%). In this population, women were more likely than men to declare that they were subjected to physical or sexual assault during the past 6 months, that they had been diagnosed with posttraumatic stress disorder (PTSD), and that they had experienced more severe depressive symptoms. Moreover, these women presented a higher suicide risk, worse physical health status, and lower QoL than similarly situated men. Homeless women with BD were more vulnerable than women with SZ. A path analysis revealed that PTSD and violent victimization might explain the higher levels of depression and suicide risk and the lower levels of physical health status and QoL in homeless women. CONCLUSION: SZ/BD homeless women experience more PTSD and victimization than men, which are both associated with poor clinical outcomes. These results confirm the vulnerability of homeless women in this high need population and should be considered by public health policy.

Problems maintaining collaborative approaches with excluded populations in a randomised control trial: lessons learned implementing Housing First in France.

BACKGROUND: In 2006, a local collective combating homelessness set up an 'experimental squat' in an abandoned building in Marseille, France's second largest city. They envisioned the squat as an alternative to conventional health and social services for individuals experiencing long-term homelessness and severe psychiatric disorders. Building on what they learned from the squat, some then joined a larger coalition that succeeded in convincing national government decision-makers to develop a scientific, intervention-based programme based on the Housing First model. This article analyses the political process through which social movement activism gave way to support for a state-funded programme for homeless people with mental disorders. METHODS: A qualitative study of this political process was conducted between 2006 and 2014, using a hybrid theoretical perspective that combines attention to both top-down and bottom-up actions with a modified Advocacy Coalition Framework. In addition to document analysis of published and grey literature linked to the policy process, researchers drew on participant observation and observant participation of the political process. Data analysis consisted primarily of a thematic analysis of field-notes and semi-structured interviews with 65 relevant actors. RESULTS: A coalition of local activists, state officials and national service providers transformed knowledge about a local innovation (an experimental therapeutic squat) into the rationale for a national, scientifically based project consisting of a randomised controlled trial of four state-supported Housing First sites, costing several million euros. The coalition's strategy was two-pronged, namely to defend a social cause (the right to housing) and to promote a scientifically validated means of realising positive outcomes (housing tenure) and cost-effectiveness (reduced hospitalisation costs). CONCLUSION: Activists' self-agency, especially that of making themselves audible to public authorities, was enhanced by the coalition's ability to seize 'windows of opportunities' to their advantage. However, in contrast to the United States and Canadian Housing First contexts, which are driven by implementation science and related approaches, it was grassroots activists who promoted a scientific-technical approach among government officials unfamiliar with evidence-based practices in France. The windows of opportunity nevertheless failed to attract participation of those most in need of housing, raising the question of whether and how marginalised and/or subordinate groups can be integrated into collaborative research when a social movement-driven innovation turns into a scientific approach. TRIAL REGISTRATION: The current clinical trial number is NCT01570712 . Registered July 17, 2011. First patient enrolled August 18, 2011.

Bread and Shoulders: Reversing the Downward Spiral, a Qualitative Analyses of the Effects of a Housing First-Type Program in France.

This paper is a qualitative analysis of the effects of accompagnement, a support framework, on recovery trajectories of people with long-term homelessness and severe psychiatric disorders during 24 months in a Housing First-type program in France. A comprehensive methodology based on grounded theory was used to construct an interview guide, conduct multiple interviews with 35 Housing First participants sampled for heterogeneity, and produce memos on their trajectories before and after entering the program based on interview information. Thematic analysis of a representative subsample (n = 13) of memos identified 12 objective factors and 6 subjective factors key to the recovery process. An in-depth re-analysis of the memos generated four recovery themes: (1) the need for secure space favorable to self-reflexivity; (2) a "honeymoon" effect; (3) the importance of even weak social ties; (4) support from and hope among peers. Three challenges to recovery were identified: (1) finding a balance between protection and risk; (2) breaking downward spirals; (3) bifurcating the trajectory. This study provides new insight into the recovery process, understood as a non-linear transformation of an experience-the relationship between objective life conditions and subjective perception of those conditions-which reinforces protective support over risk elements.

Psychometric properties of the recovery measurement in homeless people with severe mental illness.

OBJECTIVE: The Recovery Assessment Scale (RAS) is one of the most widely used measurements of recovery in mental health research. To date, no data have been available concerning the psychometric characteristics of the RAS in homeless people with severe mental illness. The aim of this study was to provide new data regarding the psychometric properties of the RAS in homeless people with schizophrenia and bipolar disorder. METHODS: This multi-center study was conducted in 4 French cities. In addition to the RAS, data on sociodemographic information, disease severity using the Modified Colorado Symptom Index - MCSI, and the number of mental health comorbidities, care characteristics and quality of life (S-QoL-18) were collected. The RAS was tested for construct validity, reliability, external validity, sensitivity to change and acceptability. RESULTS: Six hundred fifty-eight homeless patients participated in this study. The five-factor structure was confirmed by confirmatory factor analysis (RMSEA = 0.043, CFI = 0.95, NFI = 0.94 and SRMR = 0.063). The internal item consistency (from 0.40 to 0.80) and reliability (Cronbach's alpha from 0.79 to 0.87) were satisfactory for all dimensions. External validity testing revealed that the dimension scores were correlated significantly with the MCSI and S-QoL 18 scores. Significant associations with age, disease severity, psychiatric comorbidities and care characteristics showed good discriminant validity. The percentage of missing data (< 14.4%) and sensitivity to change were satisfactory. CONCLUSIONS: Our study demonstrated the satisfactory acceptability and psychometric properties of the RAS, supporting its use as a mean of recovery measurement for homeless patients.