Objective: Previous studies have established a link between childhood abuse and dissociation. Other work has shown childhood abuse increases the likelihood of violent victimization in adulthood. ...Although it has been posited that dissociation may mediate childhood abuse and adult violent victimization, research investigating this hypothesis is sparse, particularly for extremely vulnerable populations such as homeless and unstably housed individuals. investigated the relationship between childhood abuse and dissociation on violent victimization in a cohort of homeless and unstably housed women. We also assessed whether dissociation mediated childhood abuse and violent victimization in this sample. Method: Participants were asked at an initial assessment and a 6-month follow-up to report any physical or sexual violence experienced in the previous 6 months. Questionnaires recording history of specific types of childhood abuse, dissociation, and other factors were also recorded at the initial assessment. Results: Hierarchical logistic regression models revealed that childhood sexual abuse (Odds ratio OR = 3.10, p < .01) and severe dissociation (OR = 1.99, p < .01) were significantly associated with recent physical violence, and childhood sexual abuse (OR = 3.88, p < .01) and dissociation (OR = 1.87, p < .05) were also associated with recent sexual violence. Dissociation mediated neither childhood abuse on recent physical violence or recent sexual violence. Conclusion: Developing approaches that effectively identify and treat dissociation as a part of an overall framework of trauma-informed care in homeless and unstably housed women may be an effective way to decrease future physical violence in this vulnerable population.
The COVID-19 pandemic caused dramatic upsurges in stress and anxiety across the United States, as well as increased substance use to cope with pandemic-related stress. Few studies have focused ...exclusively on extremely disadvantaged individuals who are already at risk for substance use. We sought to understand factors associated with increased alcohol and cannabis use during the first 10 months of the COVID-19 pandemic among unsheltered and unstably housed women.
Between July and December 2020, we conducted phone surveys with San Francisco unhoused and unstably housed women regarding substance use, health, and health services use since the beginning of the pandemic (March 2020).
Among 128 participants, increased use of alcohol and cannabis were reported by 15% and 23%, respectively. The odds of increased use of both substances were 4 times higher in participants who also had increased difficulties managing symptoms of a chronic medical condition during the pandemic.
An intentional and comprehensive approach to managing the health of particularly vulnerable individuals during the COVID pandemic could help alleviate its exacerbating influences. Such an approach should include resources, tools and interventions for managing substance use, as well as chronic, non-COVID medical conditions, which are common and strongly tied to substance use in unhoused and unstably housed women.
This study examined the relationship between different forms of childhood violence (emotional, physical, and sexual) and these same forms of violence in adulthood, using a crosssectional baseline ...survey of 298 homeless and unstably housed women in San Francisco, California. We also examined other related factors, including mental illnesses diagnosis, sex exchange, jail time, HIV status, and sociodemographic information. Regression analysis indicated that although several of these factors were associated with experiences of violence as an adult, specific types of child violence (e.g., sexual violence) predicted instances of that same type of violence as an adult but not necessarily other types. Thus, risk of adult violence among low-income women may be better predicted and addressed through histories of same-type childhood violence, despite years of intervening exposures and stressors.
HIV/HCV coinfected patients are a priority for direct acting antiretroviral (DAA) treatment, yet barriers to treating vulnerable patients persist. This study surveyed safety net clinic patients and ...providers to quantify their preferences for DAA treatment and prioritize modifiable barriers. Preferences were assessed using best-worst scaling. General linear mixed models were used to determine whether attributes differed in importance and whether patients and providers valued attributes differently. 158 HIV/HCV coinfected patients and 49 providers participated. Patients and providers had strong preferences for treatment within the medical homes where patients receive HIV care. Support such as reminders and advice numbers were also important, but were more important to providers than patients. Providers identified lack of insurance coverage for DAA as the most significant barrier. Providers rated HIV primary care providers as best suited to deliver DAA to HIV+ patients. Addressing structural barriers is essential for increasing DAA treatment in safety net settings.
Cardiovascular disease (CVD) and heart failure (HF) are major causes of mortality in low-income populations and differ by sex. Risk assessment that incorporates cardiac biomarkers is common. However, ...research evaluating the utility of biomarkers rarely includes controlled substances, which may influence biomarker levels and thus influence CVD risk assessment.
We identified the effects of multiple substances on soluble "suppression of tumorigenicity 2" (sST2), a biomarker of adverse cardiac remodelling, in 245 low-income women. Adjusting for CVD risk factors, we examined associations between substance use and sST2 over six monthly visits.
Median age was 53 years and 74% of participants were ethnic minority women. An sST2 level > 35 ng/mL (suggesting cardiac remodelling) during ≥1 study visit was observed in 44% of participants. In adjusted analysis, higher sST2 levels were significantly and positively associated with the presence of cocaine (Adjusted Linear Effect ALE:1.10; 95% CI:1.03-1.19), alcohol (ALE:1.10; 95% CI:1.04-1.17), heroin (ALE:1.25; 95% CI:1.10-1.43), and the interaction between heroin and fentanyl use.
Results suggest that the use of multiple substances influences the level of sST2, a biomarker often used to evaluate cardiovascular risk. Incorporating substance use alongside cardiac biomarkers may improve CVD risk assessment in vulnerable women.
While substance use is known to influence cardiovascular health, most prior studies only consider one substance at a time. We examined associations between the concurrent use of multiple substances ...and left ventricular mass index (LVMI) in unhoused and unstably housed women.
Between 2016 and 2019, we conducted a cohort study of unstably housed women in which measurements included an interview, serum/urine collection, vital sign assessment, and a single transthoracic echocardiogram at baseline. We evaluated independent associations between 39 separate substances confirmed through toxicology and echocardiography-confirmed LVMI.
The study included 194 participants with a median age of 53.5 years and a high proportion of women of color (72.6%). Toxicology-confirmed substance use included: 69.1% nicotine, 56.2% cocaine, 28.9% methamphetamines, 28.9% alcohol, 23.2% opioid analgesics, and 9.8% opioids with catecholaminergic effects. In adjusted analysis, cocaine was independently associated with higher LVMI (Adjusted linear effect: 18%; 95% CI 9.9, 26.6). Associations with other substances did not reach levels of significance and did not significantly interact with cocaine.
In a population of vulnerable women where the use of multiple substances is common, cocaine stands out as having particularly detrimental influences on cardiac structure. Blood pressure did not attenuate the association appreciably, suggesting direct effects of cocaine on LVMI. Routinely evaluating stimulant use as a chronic risk factor during risk assessment and preventive clinical care planning may reduce end organ damage, particularly in highly vulnerable women.
ABSTRACT
Background
Well-tolerated, highly effective HCV treatment, known as direct-acting antivirals (DAAs), is now recommended for all people living with HCV, providing the tools for HCV ...elimination. We sought to understand treatment barriers among low-income HIV/HCV coinfected patients and providers with the goal of increasing uptake.
Methods
In 2014, we conducted 26 interviews with HIV/HCV co-infected patients and providers from a San Francisco clinic serving underinsured and publically-insured persons to explore barriers impacting treatment engagement and completion. Interview transcripts were coded, and a thematic analysis was conducted to identify emerging patterns.
Results
Conditions of poverty—specifically, meeting basic needs for food, shelter, and safety—undermined patient perceptions of self-efficacy to successfully complete HCV treatment programs. While patient participants expressed interest in HCV treatment, the perceived burden of taking daily medications without strong social support was an added challenge. This need for support contradicted provider assumptions that, due to the shorter-course regimens, support is unnecessary in the DAA era.
Conclusions
Interferon-free treatments alone are not sufficient to overcome social-structural barriers to HCV treatment and care among low-income HIV/HCV co-infected patients. Support for patients with unmet social needs may facilitate treatment initiation and completion, particularly among those in challenging socioeconomic situations.
Some gender differences in the progression of human immunodeficiency virus (HIV) infection have been attributed to delayed treatment among women and the social context of poverty. Recent economic ...difficulties have led to multiple service cuts, highlighting the need to identify factors with the most influence on health in order to prioritize scarce resources. The aim of this study was to empirically rank factors that longitudinally impact the health status of HIV-infected homeless and unstably housed women. Study participants were recruited between 2002 and 2008 from community-based venues in San Francisco, California, and followed over time; marginal structural models and targeted variable importance were used to rank factors by their influence. In adjusted analysis, the factor with the strongest effect on overall mental health was unmet subsistence needs (i.e., food, hygiene, and shelter needs), followed by poor adherence to antiretroviral therapy, not having a close friend, and the use of crack cocaine. Factors with the strongest effects on physical health and gynecologic symptoms followed similar patterns. Within this population, an inability to meet basic subsistence needs has at least as much of an effect on overall health as adherence to antiretroviral therapy, suggesting that advances in HIV medicine will not fully benefit indigent women until their subsistence needs are met.
Homeless and unstably housed women living in an urban setting are at risk for sexually transmitted diseases, yet the seroprevalence and correlates of herpes simplex virus type 2 (HSV-2) specific to ...impoverished women are poorly understood.
Between April and October 2010, we conducted a cross-sectional analysis of sociodemographic, structural, and behavioral factors associated with prevalent HSV-2 infection (recent and historical infections) within a community-recruited cohort of homeless and unstably housed women. Logistic regression modeling was used to identify independent sociobehavioral correlates of HSV-2 infection.
Among 213 women (114 HIV positive and 99 HIV negative), the median age was 49, 48% were African American, and 63% had completed high school. HSV-2 seroprevalence was 88%, and only 17% of infected women were aware of their infection. In adjusted analysis, odds of HSV-2 infection were significantly higher for those reporting at-risk drinking (adjusted odds ratio AOR = 7.04; 95% confidence interval CI = 1.59, 67.91), heterosexual orientation (AOR = 4.56; 95% CI = 1.81, 11.69), and for those who were HIV positive (AOR = 3.64; 95% CI = 1.43, 10.30). Odds of HSV-2 infection decreased as current income increased (AOR for each $500 monthly increase = 0.90; 95% CI = 0.78, 0.997).
There is an extremely high seroprevalence of HSV-2 infection among homeless and unstably housed women, and most are unaware of their HSV-2 status. Screening all unstably housed women for HSV-2 infection, with additional counseling for sexual risk and alcohol use, may lead to the identification of more infections and be a first step in reducing additional disease transmission.
Abstract Purpose To examine correlates of emergency department (ED) use and hospitalizations in a community-based cohort of homeless and unstably housed women, with a focus on the role of physical ...health and pain. Methods We conducted a cross-sectional analysis of baseline survey results from a study of homeless and unstably housed women in San Francisco. Primary outcomes were any self-reported ED visit and inpatient hospitalization over the prior 6 months. Primary independent variables of interest were self-reported physical health status, as measured by the Short Form-12 (SF-12), and bodily pain. Other potential covariates were organized using the Gelberg-Andersen Behavioral Model for Vulnerable Populations. Standard bivariate and multivariable logistic regression techniques were used. Results Three hundred homeless and unstably housed women were included in the study, of whom 37.7% reported having an ED visit and 23.0% reported being hospitalized in the prior 6 months. Mean SF-12 physical health scores indicated poorer than average health compared with the U.S. norm. Most women (79.3%) reported at least some limitation in their daily activities owing to pain. In adjusted analyses, moderate and high levels of bodily pain were significantly correlated with ED visits (odds ratio OR, 2.92 and OR, 2.57) and hospitalizations (OR, 6.13 and OR, 2.49). As SF-12 physical health scores decreased, indicating worse health, the odds of ED use increased. Predisposing, enabling, and additional need factors did not mediate these associations. Conclusions Physical health and bodily pain are important correlates of ED visits and hospitalizations among homeless and unstably housed women. Interventions to reduce ED use among women who are homeless should address the high levels of pain in this population.
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