Multimorbidity and Social Drivers of Homelessness and Health: Introduction to This Special Issue : Medical Care

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Multimorbidity and Social Drivers of Homelessness and Health

Introduction to This Special Issue

Tsai, Jack PhD*,†,‡; King, Ben PhD, MPH§; Elder, Jen MSc

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doi: 10.1097/MLR.0000000000001518
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While preparation for this special issue began before the onset of the coronavirus disease 2019 (COVID-19) pandemic, the pandemic was in full bloom while the issue was being developed. The COVID-19 pandemic has underscored the importance of the problems of homelessness and multimorbidity, perhaps more than ever before. A large number of evictions, unemployment, and behavioral health problems are occurring and are expected to continue in the aftermath of the pandemic due to morbidity and mortality related to the virus. In addition, measures taken to reduce virus transmission such as closing of businesses and stay-at-home orders have had negative secondary consequences for the economy, mental and physical health, and overall well-being.

Homelessness has been a public health problem for several decades despite longstanding efforts to prevent and end the condition. Successes have been made in numerous areas, but the work needs to continue to keep the problem at bay. At the same time, there is a rising rate of multimorbidity as the obesity crisis continues, large generations of adults are becoming older, and we face new challenges with sedentary work and lifestyle. It was no more than 2 decades ago that there was elevated focus on “dual diagnosis,” which usually meant a mental health disorder with a comorbid substance use disorder. But that term has become nearly outdated as it has become recognized that having multiple medical, mental health, and substance use disorders is common and a dyad category of morbidity may be overly simplistic in the universe of multiple existing categories. Thus, this special issue focuses on the intersection of homelessness, morbidities, and related social factors.

Over the past years, a spotlight has been turned on the health inequities across racial and ethnic communities. As recognition of the issues has grown, providers and researchers are digging deeper into the mechanisms behind such gaps and increasing our understanding of how interventions might reverse this legacy of health and social disparities. As we look forward and beyond the pandemic, we hold out hope for progress in this work, which is reflected in the studies produced herein. The solutions that will be developed will require rigorous impartial science, diversity of perspectives, and collective, unified efforts from different stakeholders and groups.

This special issue of Medical Care on homelessness highlights original research related to adolescents, the aging population, and Veterans, as well as those with medical and behavioral health conditions such as tuberculosis, HIV, and opioid use disorder. In 2 studies, researchers assessed sleep problems among transition-aged youth experiencing homelessness and among formerly homeless adults. In 2 other studies, researchers evaluated socioeconomic factors, such as strategies to address unemployment for Veterans who are criminal justice-involved and the intersections of financial strain, mental illness, and homelessness. The issue also features longitudinal studies from Boston, Massachusetts, Illinois, Minnesota, and Ontario, Canada that analyze trimorbidity, health care utilization, and outcomes of permanent supportive housing programs. Collectively, these research studies are not intended to comprehensively cover the complex problems related to homelessness. But rather, these studies together highlight some important pressing issues related to multimorbidity, social drivers of homelessness and health, and areas in need of development and intervention in vulnerable populations.

This special issue also includes 2 editorials. One editorial reflects on the historical response to homelessness in the United States, the reemergence of social medicine, and creation of the social determinants of health framework. The development of supported housing was a pivotal turning point in demonstrating that meeting an individual’s housing needs alongside providing clinical care and case management reduces costs as well as homelessness. This context leads us to the present era of the Housing First model, with interventions grounded in the understanding that socioeconomic realities and medical needs are inextricably linked. The second editorial is a consensus statement by The Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup, which outlines critical steps that the VA has implemented to reduce suicide deaths including universal suicide screening and Suicide Prevention Gatekeeper Training. They also highlight the need for increased community partnerships to reach Veterans who do not access VHA health care and for further research on risk factors for suicide to inform evidence-based practices.

This special issue came together through a partnership between the co-editors representing the US Department of Veterans Affairs (VA) National Center on Homelessness Among Veterans and the American Public Health Association (APHA) Caucus on Homelessness. This issue is a VA-sponsored supplement, and we are grateful for the support and the opportunity to showcase a wide array of researchers working on homelessness, including VA researchers. The VA operates the largest integrated health care system in the United States, and there are hundreds of local VA homeless programs working with various community partners throughout the country. Although the VA offers free or low-cost comprehensive health care to millions of eligible Veterans, homelessness among Veterans remains an issue, and the VA serves tens of thousands of Veterans experiencing homelessness annually. This special issue illustrates the complex realties of homelessness but also the progress that has been made and the continued efforts and gaps in knowledge that need work.

The APHA Caucus on Homelessness helped conceptualize this special issue and involved stakeholders from the National Health Care for the Homeless Council and the National Alliance to End Homelessness to solicit submissions. The Caucus was founded in 1990 and incorporated in 2019, and is affiliated with APHA but exists as an independent entity. The Caucus engages a membership within and beyond the APHA and maintains a broad focus on discussions and showcasing the evidence-base at the intersection of public health and homelessness. The organization serves as a voice for these issues within the APHA and a convening ground for public health experts across the wide range of fields needed to match the complexity of this issue. All 3 co-editors of this special issue have served as Chair of the Caucus.

In closing this introduction to the special issue, we want to thank all the authors who submitted their work for this special issue as well as all the homeless and at-risk individuals who participated in the research to contribute to our understanding. We also want to underscore the need for continued funding and resources to conduct rigorous research and science dedicated to homelessness so knowledge and practices can evolve. Lastly, we all need to maintain continued vigilance and encourage society’s participation in addressing homelessness as it affects us all, one way or another.


homelessness; housing instability; multimorbidity; Veterans; poverty; healthcare

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