Journal of urban health : bulletin of the New York Academy of Medicine
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Advance care planning is relevant for homeless individuals because they experience high rates of morbidity and mortality. The impact of advance directive interventions on hospital care of homeless individuals has not been studied. The objective of this study was to determine if homeless individuals who complete an advance directive through a shelter-based intervention are more likely to have information from their advance directive documented and used during subsequent hospitalizations. ⋯ Without reference to an advance directive, documentation of end-of-life care preferences occurred in 30.1 vs. 30.4 % of participants, respectively (p = 0.96), most often due to documentation of code status. There were no significant differences in resource utilization between admitted patients who completed and did not complete an advance directive. In conclusion, homeless men who complete an advance directive through a shelter-based intervention are more likely to have their detailed care preferences documented or used during subsequent hospitalizations.
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Neighborhood physical disorder-the visual indications of neighborhood deterioration-may inhibit outdoor physical activity, particularly among older adults. However, few previous studies of the association between neighborhood disorder and physical activity have focused on this sensitive population group, and most have been cross-sectional. We examined the relationship between neighborhood physical disorder and physical activity, measured using the Physical Activity Scale for the Elderly (PASE), in a three-wave longitudinal study of 3497 New York City residents aged 65-75 at baseline weighted to be representative of the older adult population of New York City. ⋯ However, physical disorder was not related to changes in PASE score over 2 years of follow-up. In this ethnically and socioeconomically diverse population of urban older adults, residents of more disordered neighborhoods were on average less active at baseline. Physical disorder was not associated with changes in overall physical activity over time.
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Three barriers investigators often encounter when conducting longitudinal work with homeless or other marginalized populations are difficulty tracking participants, high rates of no-shows for follow-up interviews, and high rates of loss to follow-up. Recent research has shown that homeless populations have substantial access to information technologies, including mobile devices and computers. These technologies have the potential both to make longitudinal data collection with homeless populations easier and to minimize some of these methodological challenges. ⋯ If this population of persons experiencing street homelessness can be successful with this method of data collection, perhaps other disenfranchised, difficult-to-track, or difficult-to-reach populations could be followed using web-based data collection methods. Local governments are striving to decrease the "digital divide," providing free or greatly discounted wi-fi connectivity as well as mobile computer lab access to low-income geographic areas. These actions, in combination with increased smart phone ownership, may permit vulnerable populations to connect and communicate with investigators.
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Urban populations disproportionately experience poor sexual outcomes, including high rates of teenage pregnancy and sexually transmitted infections. However, the contribution of substance use across adolescence to poor sexual outcomes in young adulthood has not been investigated in depth, despite offering opportunities for more targeted prevention. This study aimed to estimate joint trajectories of adolescent alcohol and marijuana use to determine if they relate differently to four sexual outcomes: multiple sexual partners, sex without a condom, teenage pregnancy, and contraction of a sexually transmitted infection in young adulthood (by age 25). ⋯ Applying longitudinal latent profile analysis to estimate joint trajectories of alcohol and marijuana use from grades 8-12, we identified four classes representing high dual use, moderate alcohol use, moderate alcohol use with increasing marijuana use, and non-use. Class membership differently predicted all four outcomes investigated with high dual users having the highest level of teenage pregnancy and the increasing marijuana trajectory having the highest risk of engaging with multiple sexual partners in the past month. Results suggest implications for both sexual risk and substance use prevention for urban youth.
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Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. ⋯ The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at $7573, with the bulk of this difference found in inpatient services. Cost differences resulted more from a higher probability of service use among those experiencing ongoing episodes of housing instability than from higher costs among service users. Our findings suggest that VA programmatic efforts aimed at preventing extended episodes of housing instability could potentially result in substantial cost offsets for the VA health care system.