Helsinkiläisten asunnottomien terveys, myöhempi asumistilanne ja terveyspalvelujen käyttö

Being homeless is a stressful life-situation that complicates everyday life in many ways. Previous studies from other countries have shown that homelessness is associated with increased morbidity and mortality, as well as increased use of hospital and emergency department services. Yet, the health situation of the homeless in Finland has not been extensively studied before. The aim of this study was to examine the housing situation, morbidity, mortality and healthcare service use of the homeless shelter population in Helsinki, Finland. By combining data from both local and national registers three cohorts of shelter users (in total 1458 persons) were followed for up to ten years. The housing situation, morbidity and overall as well as cause-specific mortality and health care service use were assessed and compared with an age-matched control group from the general population. The results show that homeless shelter users had high morbidity compared with the control group, and that especially psychiatric morbidity was high. During the ten-year follow-up period about half of those who had stayed in shelter died, which means a fivefold risk of death for the homeless compared with the controls. The risk of death from diseases and medical conditions was more than threefold compared with the control group, and the risk of death from external causes was over tenfold. The large majority of those still alive at the end of the ten year follow-up were staying in supported housing, with only a small group being still or again homeless. Six per cent of the homeless were independently housed. Compared with controls, the homeless had over 40 times more hospital days in psychiatric hospitals, 10 times more hospital emergency department visits and over six times more medical/surgical hospital days. Also those who had stayed only temporarily in shelter had a high use of emergency department and hospital services. Mental disorders were strongly associated with primary healthcare service use. The homeless visited primary care for mental health- and substance use-related problems, traumas and infections, but undertreatment of chronic conditions such as hypertension and diabetes was detected. This study shows that, also in the Finnish setting, having experienced homelessness is strongly associated with adverse health outcomes and that the prognosis for the homeless in shelters is poor both in terms of being independently housed and mortality. The high use of hospital and emergency services and relatively low use of outpatient care, as well as undertreatment of chronic conditions, indicate that access to timely and appropriate care is insufficient, leading to high use of specialized care. Better, targeted healthcare services are needed to prevent avoidable hospitalizations, ill health and premature death.Asunnottoman henkilön arki on monella tapaa hankalaa ja stressaavaa. Aiempi kansainvälinen tutkimus on osoittanut, että asunnottomuuteen liittyy kohonnut sairastavuuden ja kuolleisuuden riski, sekä lisääntynyttä päivystys- ja sairaalapalvelujen käyttöä. Asunnottomien terveydentilaa ei ole Suomessa aiemmin selvitetty perusteellisesti. Tämän väitöstutkimuksen tavoitteena oli tuottaa tietoa pääkaupunkiseudun ensisuojissa yöpyneiden asunnottomiensairastavuudesta, kuolleisuudesta, terveyspalvelujen käytöstä ja myöhemmästä asumistilanteesta. Yhdistelemällä rekisteritietoja monesta eri rekisteritietokannasta tutkimuksessa seurattiin kolmea ensisuojassa yöpyneiden ryhmää (yhteensä 1458 henkilöä) pisimmillään kymmenen vuoden ajan. Heidän asumistilannettaan, sairastavuuttaan, kuolleisuuttaan ja terveyspalvelujen käyttöään verrattiin ikävakioituun verrokkiryhmään. Tutkimuksen tulokset osoittivat, että asunnottomat olivat verrokkeja selvästi sairaampia, koskien erityisesti mielenterveyshäiriöitä. Kymmenen vuoden seurannan aikana noin puolet ensisuojassa yöpyneistä asunnottomista kuoli, mikä tarkoittaa noin viisinkertaista kuolemanriskiä verrokkiryhmään nähden. Seurannan lopussa elossa olleista tutkittavista valtaosa asui tuetun asumisen piirissä ja vain pieni joukko oli yhä tai jälleen asunnottomina. Kuusi prosenttia alkuperäisestä asunnottomien ryhmästä asui itsenäisesti. Verrokkiryhmään nähden asunnottomilla oli yli nelikymmenkertaisesti sairaalapäiviä psykiatrisessa sairaalahoidossa, kymmenkertaisesti sairaalapäivystyskäyntejä ja yli kuusinkertaisesti sairaalapäiviä somaattisessa erikoissairaanhoidossa. Myös he, joiden ensisuojassa yöpyminen oli tilapäistä ja lyhytaikaista, käyttivät paljon sairaala- ja päivystyspalveluja. Mielenterveysongelmista kärsiminen oli vahvasti yhteydessä perusterveydenhuollon käyttöön. Asunnottomat henkilöt kävivät perusterveydenhuollon lääkärin vastaanotolla mielenterveys- ja päihdeongelmien, traumojen sekä infektioiden takia, sen sijaan krooniset taudit olivat alihoidettuja. Tämä tutkimus osoittaa, että myös Suomessa asunnottomuuteen liittyy hyvin usein terveysongelmia ja selvästi kohonnut kuolemanriski. Runsas sairaala- ja päivystyspalvelujen käyttö sekä suhteellisen pieni polikliinisten palvelujen käyttö viittaavat siihen, että oikea-aikaisen ja asianmukaisen hoidon saatavuus on asunnottomilla riittämätöntä, mikä johtaa suureen erikoissairaanhoitopalvelujen käyttöön. Tarvittaisiinkin parempia, erityisesti asunnottomille kohdistettuja terveyspalveluja vähentämään ennaltaehkäistävissä olevia sairaalajaksoja, huonoa terveyttä ja kohonnutta ennenaikaisen kuoleman riskiä

Mortality and causes of death among homeless in Finland : a 10-year follow-up study

Background Homelessness is associated with increased mortality, and some predictors of mortality have been previously identified. We examined the overall and cause-specific mortality among homeless men in Helsinki and the associations of social background and health service use with mortality. Methods To assess cause-specific mortality in a competing risks framework, we performed a register-based, case-control study of 617 homeless men and an age-matched control group of 1240 men from the general population that were followed for 10 years between 2004 and 2014. Cox proportional hazards model was used to calculate HR for death and a competing risks model to calculate sub-HRs (sHR) for cause-specific death. Results During the follow-up, 45.0% of the homeless died compared with 10.5% of controls (HR 5.38, 95% CI 4.39 to 6.59). The risk of death was particularly elevated for the homeless aged Conclusions Homelessness is associated with a fivefold mortality compared with the controls, and especially homeless agedPeer reviewe

Mental disorders and the use of primary health care services among homeless shelter users in the Helsinki metropolitan area, Finland

Background: Homelessness is associated with increased morbidity, mortality and health care use. The aim of this study was to examine the role of mental disorders in relation to the use of 1) daytime primary health care services and 2) after hours primary health care emergency room (PHER) services among homeless shelter users in the Helsinki Metropolitan Area, Finland. Methods: The study cohort consists of all 158 homeless persons using the four shelters operating in the study area during two selected nights. The health records were analyzed over a period of 3 years prior to the sample nights and data on morbidity and primary health care visits were gathered. We used negative binomial regression to estimate the association between mental disorders and daytime visits to primary health care and after hours visits to PHERs. Results: During the 3 years the 158 homeless persons in the cohort made 1410 visits to a physician in primary health care. The cohort exhibited high rates of mental disorders, including substance use disorders (SUDs); i.e. 141 persons (89%) had a mental disorder. We found dual diagnosis, defined as SUD concurring with other mental disorder, to be strongly associated with daytime primary health care utilization (IRR 11.0, 95% CI 5.9-20.6) when compared with those without any mental disorder diagnosis. The association was somewhat weaker for those with only SUDs (IRR 4.9, 95% CI 2.5-9.9) or with only other mental disorders (IRR 5.0, 95% CI 2.4-10.8). When focusing upon the after hours visits to PHERs we observed that both dual diagnosis (IRR 14.1, 95% CI 6.3-31.2) and SUDs (11.5, 95% CI 5.7-23.3) were strongly associated with utilization of PHERs compared to those without any mental disorder. In spite of a high numbers of visits, we found undertreatment of chronic conditions such as hypertension and diabetes. Conclusions: Dual diagnosis is particularly strongly associated with primary health care daytime visits among homeless persons staying in shelters, while after hours visits to primary health care level emergency rooms are strongly associated with both dual diagnosis and SUDs. Active treatment for SUDs could reduce the amount of emergency visits made by homeless shelter users.Peer reviewe

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Asunnottomuuteen liittyy suuria terveysriskejä [pääkirjoitus]

Kodittomuuden haasteet tulisi huomioida myös terveydenhuollossa