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BMC Public Health. 2019 Jul 24;19(1):994
The Author(s).
Gordon, S. J.
Grimmer, K.
Bradley, A.
Direen, T.
Baker, N.
Marin, T.
Kelly, Mary T.
Gardner, S.
Steffens, M.
Burgess, T.
Hume, C.
Oliffe, John Lindsay
Background: Homelessness is increasing globally. It results in poorer physical and mental health than age matched people living in permanent housing. Better information on the health needs of people experiencing homelessness is needed to inform effective resourcing, planning and service delivery by government and care organisations. The aim of this review was to identify assessment tools that are valid, reliable and appropriate to measure the health status of people who are homeless. Methods: Data sources: A systematic literature search was conducted in PubMed (and Medline), PsychInfo, Scopus, CINAHL and ERIC from database inception until September 2018. Key words used were homeless, homelessness, homeless persons, vagrancy, health status, health, health issues, health assessment and health screening. The protocol was registered with PROSPERO. The National Health and Medical Research Council of Australia (NHMRC) hierarchy of evidence was applied; methodological quality of included articles was assessed using the McMaster critical appraisal tools and psychometric properties of the tools were appraised using the International Centre for Allied Health Evidence Ready Reckoner. Results: Diverse tools and measures (N = 71) were administered within, and across the reviewed studies (N = 37), with the main focus being on general health, oral health and nutrition. Eleven assessment tools in 13 studies had evidence of appropriate psychometric testing for the target population in domains of quality of life and health status, injury, substance use, mental health, psychological and cognitive function. Methodological quality of articles and tools were assessed as moderate to good. No validated tools were identified to assess oral health, chronic conditions, anthropometry, demography, nutrition, continence, functional decline and frailty, or vision and hearing. However, assessments of physical constructs (such as oral health, anthropometry, vision and hearing) could be applied to homeless people on a presumption of validity, because the constructs would be measured with clinical indicators in the same manner as people living in permanent dwellings. Conclusions: This review highlighted the need to develop consistent and comprehensive health assessment tools validated with, and tailored for, adults experiencing homelessness.
RESEARCH ARTICLE Open AccessHealth assessments and screening tools foradults experiencing homelessness: asystematic reviewS. J. Gordon1* , K. Grimmer1,2, A. Bradley1, T. Direen1, N. Baker1, T. Marin1, M. T. Kelly5, S. Gardner3, M. Steffens3,T. Burgess4, C. Hume4 and J. L. Oliffe5AbstractBackground: Homelessness is increasing globally. It results in poorer physical and mental health than age matchedpeople living in permanent housing. Better information on the health needs of people experiencing homelessnessis needed to inform effective resourcing, planning and service delivery by government and care organisations.The aim of this review was to identify assessment tools that are valid, reliable and appropriate to measure thehealth status of people who are homeless.Methods: Data sources: A systematic literature search was conducted in PubMed (and Medline), PsychInfo, Scopus,CINAHL and ERIC from database inception until September 2018. Key words used were homeless, homelessness,homeless persons, vagrancy, health status, health, health issues, health assessment and health screening. Theprotocol was registered with PROSPERO. The National Health and Medical Research Council of Australia (NHMRC)hierarchy of evidence was applied; methodological quality of included articles was assessed using the McMastercritical appraisal tools and psychometric properties of the tools were appraised using the International Centre forAllied Health Evidence Ready Reckoner.Results: Diverse tools and measures (N = 71) were administered within, and across the reviewed studies (N = 37),with the main focus being on general health, oral health and nutrition. Eleven assessment tools in 13 studies hadevidence of appropriate psychometric testing for the target population in domains of quality of life and healthstatus, injury, substance use, mental health, psychological and cognitive function. Methodological quality of articlesand tools were assessed as moderate to good. No validated tools were identified to assess oral health, chronicconditions, anthropometry, demography, nutrition, continence, functional decline and frailty, or vision and hearing.However, assessments of physical constructs (such as oral health, anthropometry, vision and hearing) could beapplied to homeless people on a presumption of validity, because the constructs would be measured with clinicalindicators in the same manner as people living in permanent dwellings.Conclusions: This review highlighted the need to develop consistent and comprehensive health assessment toolsvalidated with, and tailored for, adults experiencing homelessness.Keywords: Homeless adults, Health assessment, Screening, Review, Homelessness© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.* Correspondence: Sue.gordon@finders.edu.au; sue.gordon@flinders.edu.au1College of Nursing and Health Sciences, Flinders University, Bedford Park,South Australia5042Full list of author information is available at the end of the articleGordon et al. BMC Public Health (2019) 19:994 https://doi.org/10.1186/s12889-019-7234-yBackgroundHomelessness is a serious global problem [1] that affectsadults of all ages [2]. National assessments of homeless-ness vary in the definition of homelessness that is applied,making direct comparisons between countries difficult. Inthe European Union, it is estimated that 4.1 million peoplehave a homeless episode in a year [3] while, based on shel-ter use, an estimated 150,000–300,000 people experiencehomelessness in Canada in a year [4].The definitions of homelessness from the AustralianBureau of Statistics’ (ABS) [5] used in this review were; a person living in streets or without a shelter thatwould fall within the scope of living quarters, [if aperson has] no place of usual residence who movefrequently between various types of accommodation(including dwellings, shelters or other living quarters)or [if a person is] usually resident in long-term sheltersor similar arrangements for the homeles (pp. 5); OR a person living “in a dwelling that is inadequate; orhas no tenure, or if their initial tenure is short andnot extendable; or does not allow them to have controlof, and access to space for social relations” (pp. 11), orThese are broad definitions that include people experien-cing homelessness in different ways, such as a sofa surferor someone with insecure housing tenure. The definitionsthus reflect the variability and changing circumstances ofpeople who experience homelessness. Applying this defin-ition, the Australian census found 116,000 people werehomeless on Census night in 2016, representing 50 home-less people per 10,000 [5].The recent Rough Sleeping Statistics (Autumn 2017)for England [6] counts: People sleeping, about to bed down (sitting on/in orstanding next to their bedding) or actually beddeddown in the open air (such as on the streets, intents, doorways, parks, bus shelters orencampments), and People in buildings or other places not designed forhabitation (such as stairwells, barns, sheds, carparks, cars, derelict boats, stations, or “bashes”which are makeshift shelters, often comprised ofcardboard boxes).These definitions do not include people in hostels orshelters, people in campsites or other sites used forrecreational purposes or organised protest, squatters ortravellers [6]. This may explain why the single nightsnapshot for England was 4751 people or 20 per 10,000[6], was so much lower than Australian Figs. [5]. Whatis concerning is that irrespective of the definition used,the rate of homelessness in Australia had increased by4.6% between 2011 and 2016 [5], whilst in England therewas an 18% increase in London and a 14% increase inthe rest of England between 2016 and 2017, of peoplesleeping rough [6].The state of being homeless impacts significantly onhealth [7], resulting in higher rates of premature mortal-ity [4], with the average age of death for men andwomen experiencing homelessness in England being 47and 43 years respectively [7]. In Canada and the USA,the current mean age of people experiencing homeless-ness is approximately 50 years [8–10].Consequently, many people experiencing homelessnessalso present with age-related declining physical and cogni-tive functions [4, 9, 10]. Compared to the general popula-tion, people experiencing homelessness have higher levelsof mental illness [8], drug and alcohol use [4], infectiousdiseases, including influenza, tuberculosis, human im-munodeficiency virus (HIV), hepatitis, and sexually trans-mitted infections [11], oral cancer and other dentalproblems [7, 8], injury and assault and skin problems(often related to cold exposure) [11]. Approximately 40%adults experiencing homelessness report having at leastone chronic health condition, which is often poorly con-trolled [7, 12]. Compounding poor health is the transientnature of homelessness, which often precludes sustainedmanagement of these health conditions [7]. For instance,people experiencing homelessness typically attend acutecare services, such as hospital emergency departments,when they experience health crises, rather than accessingplanned, preventative models of care [13].Appropriate assessment tools are needed to identifythe health needs of adults experiencing homelessness.Appropriate assessments can inform the development ofpolicies and practices to provide effective prevention ofhealth problems, and interventions that improve health.Appropriate in this context means that the assessmentshould use language, items, and constructs which arerelevant to homelessness. For instance, many validatedtools are available to evaluate sleep quality, nutrition andhygiene in the general population. These tools oftenhave questions worded in a manner that assume that re-spondents sleep in a bed, and have access to food prep-aration and storage services, as well as bathroom andtoilet facilities. As this is may not be the case for manypeople experiencing homelessness, it is important thathealth screening tools are properly validated and appro-priate for specific circumstances of homelessness.The usefulness of health screening and assessmenttools to collect relevant information on particular indi-viduals, and/or a specific target population is typicallyexpressed in terms of validity, reliability and utility ofapplication. Testing for validity establishes that thehealth screening or assessment tool captures all the con-structs (or elements) that it purports to measure [14],Gordon et al. BMC Public Health (2019) 19:994 Page 2 of 14and that the scores compare with other similar measures[14]. Reliability is about understanding variability anderror in repeated measurement [14]. Health, as a con-struct for people experiencing homelessness, has beenoverlooked in a hard-to-reach group who do not easilyengage with traditional services until there is a crisis.The identification of valid and reliable tools is the firststep towards developing proactive health assessmentsthat will be relevant and acceptable to people experien-cing homelessness.This overall aim of this review was to identify healthscreening and assessment tools that have been developed for,or used with adults experiencing homelessness. The review: critiqued papers for methodological quality determined which health screening and assessmenttools were validated or specifically developed foradults experiencing homelessness, and described the psychometric properties and utility ofthose tools.MethodsThe review proposal was registered with PROSPERO(CRD42017068769). The conduct and reporting of thereview findings follow the PRISMA guidelines [15].Search strategyA preliminary database search identified common keywords and MeSH terms that were then applied to themain search. The keywords included: homeless, home-lessness, homeless persons, vagrancy, health status,health, health issues, health assessment and healthscreening. Where required, truncations (*) and MeSHterms were used in individual databases.Library databases were searched in May 2017 andupdated in September 2018. They included PubMed (andMedline), PsychInfo, Scopus, CINAHL and ERIC. Thesearch was restricted to human studies published in Eng-lish, and was not limited by date or type of article. Poten-tially-relevant articles were also identified through hand-searching of references cited in the reviewed articles. Thesewere then screened according to the review method. Thesearch strategy is provided in Additional file 1.Review methodArticles identified through the library database searchwere exported into EndNote v7 [16]. Duplicate articleswere removed, and remaining articles were independ-ently screened by title and abstract (AB and TD). Poten-tially-relevant articles were then screened in full text.Comparisons were made between reviewers at eachscreening phase and a third reviewer (SJG) resolveddiscrepancies.Exclusion criteriaThis review did not include research about children andadolescents (younger than 18 years) experiencing home-lessness, or studies that assessed health services forpeople experiencing homelessness, or studies that de-scribed tools that aimed to diagnose health conditions.Inclusion criteriaA two-step inclusion criteria was applied. Firstly, articleswere included when they described the application ofhealth screening or assessment tools for health issues re-lated to adults experiencing homelessness (aged 18 yearsand over). Included articles also explicitly described thestudy sample as experiencing homelessness as per thoseproposed by the Australian Bureau of Statistics’ (ABS)definition of homelessness and provided in the introduc-tion of this paper [5].Secondly, the assessment and screening tools reportedin these articles were aggregated to identify a sub-set,for which claims had been made about being developedfor or with, and/or validated with people sufferinghomelessness. Where necessary, additional developmen-tal literature for each tool was sourced for informationon whether, and how the tool had been validated for thetarget population. This was completed by initially check-ing the reference lists and/or undertaking an independ-ent literature search for additional material on the toolitself. Studies that used tools which had not been vali-dated for the target population were noted, but no fur-ther analysis of methodological quality was undertaken.Data extractionData were extracted to detail all the articles by author,publication year, study population, setting, purpose, tooldescriptions, condition/s assessed, primary outcomes,and tool psychometric properties (if applicable). Authorswere contacted for further information when there was alack of detail regarding the tool.Hierarchy of evidenceThe hierarchy of evidence of the articles reporting onvalidated tools was assessed based on the NationalHealth and Medical Research Council of Australia(NHMRC) recommendation [17]. The NHMRC hier-archy of evidence is internationally used in evidence re-views. It is based on the CEBM hierarchy model inwhich the hierarchy of evidence for diverse researchquestions contains different types of research designs (fitfor purpose). It was appropriate for this review becauseof the likely heterogeneity of research designs.Critical appraisalThis took two forms.Gordon et al. BMC Public Health (2019) 19:994 Page 3 of 141. Two reviewers independently appraised themethodological quality of the articles usingvalidated tools relevant to the study design. Thesewere 1) McMaster University Quantitative CriticalReview Form [18], 2) McMaster UniversityQualitative Critical Review Form [19] or 3) theLeeds Evaluative Tool for Mixed Method Studies[20]. A third reviewer (SJG) arbitrated ondiscrepancies between reviewers, when required.Seven individuals conducted paired appraisals (AB,TD, SG, NB, MK, TB, CH). The McMaster criticalappraisal instruments (designed for quantitative andqualitative designs) provided a ubiquitous approachto scoring methodological quality, without the needto use different tools for different designs (forinstance the CASP suite). The McMaster criticalappraisal tool provided a standardised way ofcomparing methodological quality across diverseresearch designs.2. To assess the psychometric properties of the tools forwhich claims had been made regarding validation inthe target population, the International Centre forAllied Health Evidence (iCAHE) Ready Reckoner wasused. This is a structured checklist of psychometricproperties and utility of application, developed forassessment and outcome measures [21]. The ReadyReckoner allows structured standardised comparisonof psychometric properties of assessmentinstruments. It requires reviewers to identify thedevelopmental literature on assessment instruments,and extract information on what psychometricproperties were tested (and how), and whatinformation is provided on utility. To gain a point foreach category in the Ready Reckoner, instrumentsneeded to have tested for, and reported on, the valuesfor each psychometric test. The values themselvesare not reported in the Reckoner, as the Reckoner issimply a way of summarising the amount and type oftesting to which an instrument has been subjectedduring developmental phases. Moreover, as values areoften dependent on sampling strategies, sample sizeand comparison instruments, it generally requires agreat deal more information to interpret a value, thusreporting a value on its own can be misinterpreted.As completion of the Ready Reckoner requires accessto the developmental references, these are cited, andreaders interested in exploring more about aninstrument can access further information efficientlyto make their own judgements.Data synthesisTools were categorized to; 1) health screening or 2)health assessment.ResultsSearch resultsThe database search and screening process is summa-rized in the PRISMA flow diagram (Fig. 1).Potentially-relevant studies and the tools they reportedonOf 2122 identified studies, 37 were identified as poten-tially-relevant (Table 1). These studies reported on 73health screening or health assessment tools, across 11domains: oral health [22–32]; health related quality oflife, and health status [9, 33–48]; nutrition [49–56]; psy-chological and cognitive function [9, 22, 34, 35, 41, 42,44, 56–59]; substance use [28, 33–36, 51, 57]; injury [29,30, 36, 58]; chronic conditions [33, 44, 45, 60, 57]; dem-ography and anthropometry [34–40, 44, 49, 51–55, 60];functional decline and frailty [9, 37, 38, 54]; hearing andvision [9, 36, 61]; and pelvic floor health [9].Description of tools validated for people experiencinghomelessnessEleven assessment tools (reported in 13 articles) hadbeen developed for, and/or validated in people experien-cing homelessness. These tools addressed domains ofhealth-related quality of life and health status, substanceuse, injury, mental health and psychological and cogni-tive function. They comprised: Addiction Severity Index (ASI) [33] Beck Depression Index (BDI II) [35, 45] Brain Injury Screening Questionnaire (BISQ) [58] Brief Instrumental Functioning Scale [9] Colorado Coalition for Homelessness ConsumerOutcome Scale [34] Delighted-Terrible Faces Scale (DTFS) [40] Rural Homelessness Interview Schedule [35] Life Fulfilment Scale (LFS) [44] Nottingham Health Profile [44] Short Form Survey-12 (SF-12) and/or Short FormSurvey-36 (SF-36) [39, 60, 41] World Health Organization Quality of Life 100(WHOQoL 100) and/or World Health OrganizationQuality of Life BREF (WHOQoL-BREF) [26, 42, 43]Fifty-five other assessment and screening tools were po-tentially-relevant to persons experiencing homelessness,but no evidence was found that validity had been estab-lished with this target population. Potential relevance wasassessed in terms of generalizability or transferrable con-structs between the population with which they had beendeveloped and tested, and people experiencing homeless-ness. This was defensible for measures which are commonto the general adult population, such as anthropometryand demography; oral health; continence; vision andGordon et al. BMC Public Health (2019) 19:994 Page 4 of 14hearing but not risk factors. Other potentially-relevant toolswere found for conditions which could well be experiencedby people who were homeless, including substance use, men-tal health issues, inadequate diet, poverty, injury and chronicillness. There were a further five tools for which little couldbe found in terms of psychometric properties or utility.Table 1 lists the tools, the studies in which they were re-ported, the populations with which the tools had been de-veloped or validated (where available), and references foradditional literature providing evidence that the tool wasvalid for people experiencing homelessness. These studiesare highlighted for ease of identification. The characteristicstable for all included studies is provided in Additional file 2.Hierarchy of evidenceOf the 13 studies that used validated tools for the targetpopulation, three were classified as NHMRC III-1 [34, 35,44] (prospective observational cohort studies). Two studiesinvolved the development and validation of new assessmenttools [34, 35] and the third [44] tested previously validatedoutcome measures in a pre-post study of the impact of casemanagement for people experiencing homelessness. Theremaining studies were classified as NHMRC III-2 as theywere all cross-sectional studies reporting on surveys ormeasurements taken at a single time point.Methodological quality of included studiesMethodological quality of the included studies ranged from57.1% [38] to 90.9% [9, 34, 39]. For the NHMRC III-1 stud-ies the median quality score was 72.7% (25th % 64.9-75th %81.8), whilst for the NHMRC III-2 studies the median qual-ity score was 81.8% (25th % 72.7- 75th % 90.9). The individ-ual quality appraisal items for each potentially-relevantarticle are provided in Additional file 3.Ready reckoner scoresThe psychometric properties and utility of the validatedtools are summarized in Table 2. As all tools had beenFig. 1 PRISMA flow diagram detailing the search and selection processGordon et al. BMC Public Health (2019) 19:994 Page 5 of 14Table 1 Assessment instruments reported in the included literature, developmental reference(s) for the instrument (DRI) if relevantto homeless populations, and population(s) on which the instrument had been developed or validated. Shaded tools are validatedor developed with people experiencing homelessnessInstrument and citation DRI Validation populationsDomain 1: Oral healthWHO Oral health assessment guidelines [29, 30] Adults and children worldwideRelevant to homeless, but not specifically validatedDecay (cavitation and visual dentine caries) andmissing permanent teeth (D3CVMFT) [29, 30]Children worldwideRelevant to homeless, but not specifically validatedEllis standard classification [29] Adults and children worldwide, relevant to homeless,but not specifically validatedShortened Oral Health Impact Profile (OHIP-14 tool)(inc oral health-related quality of life interview) [22]Adults 60+ years, relevant to homeless, but not validatedCommunity Periodontal Index (CPI) [23, 24, 29, 30] Adults and children worldwide, relevant to homeless, butnot specifically validatedDental health measure [35] No available information on instrumentModified Dental Anxiety Scale (MDAS) [22, 23] Adults, validated in many languages. Relevant to homeless,but not specifically validatedOral hygiene level - the plaque index [32] No available information on process or reference to testThe Adult Dental Health Survey (ADHS) [24] Minimum information on process or reference to test. Informationextracted from NHS website on the survey (geography, sex, age,ethnic group, household details, general and dental health, experienceof dental services and treatments, dental examination for tooth andgum health.The Geriatric Oral Health Assessment Index (GOHAI)[27]Older adult populations internationally, relevant to homeless, butnot specifically validatedGlobal Self-Rated Oral Health [27] Adult populations internationally. Relevant to homeless, but notspecifically validatedDomain 2: Quality of Life and health statusThe Medical Outcomes Study (MOS) 12 Item ShortForm Survey (SF-12) [33, 39, 60] derived from MOS SF-36[48, 62] Validated on international adult populations including homelessWorld Health Organisation’s Quality of Life – shortversion (WHOQOL-BREF) [41] derived from WHOQOL-100[26, 43][43, 63] Validated on international adult populations including homelessRural Homelessness Interview Research Instrument[35][35] Developed for homeless rural women and children MidwesternUnited States of AmericaNottingham Health Profile [44] [64–66] Validated on international populations including homelessDelighted-Terrible Faces Scale (DTFS) [44] [66] Visual quality of life health outcome measure relevant to all ages.Reported to have been validated on homeless people in a PhD thesisEQ-5D [40, 46] Adult quality of life health outcome measure, relevant to, but notspecifically validated on, homeless peopleGeneral health status tool [37] Limited information available on process, or referencesGlobal Self-Rated General Health [27] Developed for adult populations, relevant to, but not specificallyvalidated for, homelessLife Fulfilment Scale (LFS) [44] [66] Developed for people with epilepsy, reported as validated for homelesspopulations in a PhD thesisQuality of Life Scale [38] Developed on a diverse adult population (incl ethnic minorities, olderpeople, low income people) and validated on healthy adults, and adultswith a range of health issues (incl Post Traumatic Stress syndrome).Relevant to, but not specifically validated for, homelessRAND Current Health Scale [36] Adolescents and adults internationally, relevant to, but not specificallyvalidated on, homeless peopleRosenberg Self-Esteem Instrument [27] Adolescents and adults internationally, relevant to, but not specificallyvalidated on, homeless peopleThe New General Self-Efficacy Scale [38] Adult self-efficacy measure, relevant to, but not specifically validated on,homeless peopleGordon et al. BMC Public Health (2019) 19:994 Page 6 of 14Table 1 Assessment instruments reported in the included literature, developmental reference(s) for the instrument (DRI) if relevantto homeless populations, and population(s) on which the instrument had been developed or validated. Shaded tools are validatedor developed with people experiencing homelessness (Continued)Instrument and citation DRI Validation populationsColorado Coalition for the Homeless(CCH)Consumer Outcome scale [34][34] Outcome measure developed specifically for homelessVeterans Research and Development (RAND)12-Item Health Survey [27]Adult quality of life health outcome measure developed fromSF-36 for veterans, relevant to, but not specifically validated on,homeless people. Tested for people with depression, and alcoholaddictionBrief Instrumental Functioning Scale [10] [69] Validated on international adult populations including homelessSF36 Italian version [40] Validated in Italy with healthy groups, chronic obstructive pulmonarydisease, myocardial infarction, migraine and dialysis populations(Apolone cref in Lav)Health and Lifestyle Questionnaire [51] Formulated for people experiencing homelessness, yes/no responsesabout appetite meal frequency, money spent on food no validation.Domain 3: Substance UseAddiction Severity Index (ASI) [9, 33] [67, 68] Validated on international adult populations including homelessBehavior and Symptom IdentificationScale (BASIS-32) [34, 35]Adult mental health outcome measure, not in the public domain,elevant to, but not validated on, homeless peopleCut Down, Annoyed, Guilty and Eye Opener(CAGE) alcoholism screening test [36, 57]General screening tool relevant to adolescents and adults, relevantto homeless but not specifically validatedDrug Abuse Screening Test (DAST) [34, 35] Adolescents and adults internationally, correlates with MAST, relevantto homeless but not specifically validatedMichigan Alcohol Screening Test (MAST) [34, 35] Adolescents and adults internationally, validated for mental healthconcerns, sexual misdemeanours, alcohol abuse, relevant to homelessbut not specifically validatedDomain 4: InjuryBrain Injury Screening Questionnaire (BISQ) [58] [70] Child, adolescent and adult internationally, validated on homeless persons,individuals with HIV seeking vocational rehabilitation, youth in the juvenilejustice system, public schoolchildren, substance users, intercollegiate athletes,and other community-based samplesDomain 5: Chronic ConditionsAmerican Thoracic Society guidelines forspirometry assessment [60]Adult populations internationally. Relevant to homeless, but not specificallyvalidatedChronic pain Grade Questionnaire (7-item) [57] Adult populations internationally. Relevant to homeless, but not specificallyvalidatedDomain 6: Demography, anthropometry, risk factorsAnthropometry [34, 36–39, 44, 46, 53–55, 60] Adult populations internationally. Relevant to homeless, but not specificallyvalidatedBiochemical analysis [49, 52, 54, 55] Adult populations internationally. Relevant to homeless, but not specificallyvalidatedDartmouth improve your Medical Care [39] Adult populations internationally. Relevant to homeless, but not specificallyvalidatedRAND Serious Symptom Index [36] Adult populations internationally. Relevant to homeless, but not specificallyvalidatedRAND Minor Symptom Index [36] Adult populations internationally. Relevant to homeless, but not specificallyvalidatedDomain 7: Functional Decline and frailty10-Item modified Barthel Index [56] Older adult populations (or younger adults with disability) internationallyRelevant to homeless, but not specifically validatedFried criteria [9] Older adult populations internationally, relevant to homeless, but notspecifically validatedModified Katz Activities of Daily Living Scale [9] Older adult populations internationally, Relevant to homeless, but notspecifically validatedGordon et al. BMC Public Health (2019) 19:994 Page 7 of 14Table 1 Assessment instruments reported in the included literature, developmental reference(s) for the instrument (DRI) if relevantto homeless populations, and population(s) on which the instrument had been developed or validated. Shaded tools are validatedor developed with people experiencing homelessness (Continued)Instrument and citation DRI Validation populationsRAND Functional status [37] Adult populations internationally. Relevant to homeless, but notspecifically validatedDomain 8: Vision and hearingSnellen Chart [9] Children, adolescents, adults internationally. Relevant to homeless,but not specifically validatedRetinal camera, ophthalmoscope, air puff tonometer [61] Adult populations internationally, relevant to homeless, but notspecifically validatedDomain 9: Mental health, psychological and cognitive functionBoston Naming Test (BNT) [59] Originally developed for individuals with aphasia or other languagedisturbance caused by stroke, Alzheimer’s disease, or other dementingdisorder, now available for children. Relevant to homeless, but notspecifically validatedCentre for Epidemiological Studies Depression Scale [22] Children, adolescents and adults worldwide, relevant to homelessbut not specifically validatedColor Trails test [59] Children, adolescents and adults worldwide, relevant to homelessbut not specifically validatedControlled Oral Word Association Test (FAS) [59] Adolescents and adults worldwide, relevant to homeless but notspecifically validatedGeriatric Depression Scale (GDS-12R) [56] Older adults, validated on healthy, medically ill and mild to moderatelycognitively impaired older adults, relevant to homeless but not specificallyvalidatedGrooved Pegboard Test [59] Children, adolescents, adults, validated on many conditions, relevant tohomeless but not specifically validatedMini Mental State Examination (MMSE) [10] Adults worldwide, relevant to homeless but not specifically validatedNeuropsychological Assessment Questionnaire [59] Adults worldwide, relevant to homeless but not specifically validatedRepeatable Battery for Assessment of NeuropsychologicalStatus (RBANS) [58]Developed for adults with dementia, now validated on many conditions,and for children & adolescents, relevant to homeless but not specificallyvalidatedRey-Osterrieth Complex Figure Design (Rey-O) [41] Children, adolescents, adults worldwide, tested for dementia, relevantto homeless but not specifically validatedRuff Figural Fluency Test (RFFT) [59] Adolescents and adults worldwide, relevant to homeless, but notspecifically validatedStroop Color Word test [59] Children and adolescentsThe Beck Depression Inventory-II, BDI-II [35, 45] [71] Adolescents and adults worldwide, validated for homeless menThe Elderly Cognitive Assessment Questionnaire (ECAQ)[56]Adults worldwide, tested for older adults, relevant to homeless,but not specifically validatedTrail Making Test [59] Adults worldwide, tested for older adults and those with dementia,relevant to homeless, but not specifically validatedTrail Making Test Part B (TMT-B) [10]Wechsler Adult Intelligence Scale, Third Edition (WAIS-III)[59]Adults worldwide, tested for older adults, relevant to homeless, butnot specifically validatedWechsler Memory Scale, Third Edition (WMS-III) [59] Adults worldwide, tested for older adults, relevant to homeless, butnot specifically validatedWisconsin Card Sorting Test (WCST) [59] Adults worldwideRelevant to homeless, but not specifically validatedDomain 10: Nutrition24-h diet recall [50] Adults and children worldwide, relevant to homeless, but notspecifically validatedDETERMINE Your Nutritional Health Checklist [56] Older adults worldwide, relevant to homeless, but not specificallyvalidatedFood frequency questionnaire [50] Adults and children worldwide, relevant to homeless, but notspecifically validatedGordon et al. BMC Public Health (2019) 19:994 Page 8 of 14specifically validated and developed for people experien-cing homelessness, the question on relevance was de-leted. The best performing tool for the target populationwas the WHOQoL 100 or WHOQoL BREF (scoring100%), followed by BDI II, SF-12 and SF-36, and thenthe ASI (all scoring 94%). The Colorado Coalition forHomeless Consumer Outcomes scale ranked best of thepurpose-built tools (82%), with the Rural HomelessnessInterview Schedule (RHI) scoring poorest (56%).DiscussionThis systematic review is the first that we know of, that hascollated information on the validity of health screening andassessment tools used for people experiencing homeless-ness. Accurate information on health needs can only beobtained by the use of psychometrically-sound tools applic-able to this population. While 73 health screening and as-sessment tools were reported as having been used to collectinformation on a range of issues in people experiencinghomelessness, only 11 had published evidence of psycho-metric testing applicable to this target population. Thesetools captured information regarding quality of life, healthstatus, substance use, injury, and psychological and cogni-tive function.No validated tools were identified that assessed oral health,chronic conditions, anthropometry, demography, nutrition,continence, functional decline and frailty, or vision and hear-ing. However, assessments of physical constructs (such asoral health, anthropometry, vision and hearing) could beapplied to homeless people on a presumption of validity,because the constructs would be measured clinically in thesame manner as for people living in dwellings.On the basis of the findings of this review, informationreported on chronic health conditions, demography, func-tional decline and frailty, nutrition and pelvic floor healthin people experiencing homelessness, may not be valid in-dicators of their health. For instance, it cannot be assumedthat someone ‘living rough’ is a ‘community dweller’, whichwas a common description of the population for whichthe non-validated tools for people experiencing homeless-ness had been developed or tested [9] (See Table 1).The iCAHE Ready Reckoner summarises common in-terpretations of validity and reliability as extracted fromthe developmental literature, as a way of demonstratinghow well and thoroughly, a tool has been tested [21]. How-ever, it is important to view testing in terms of the realworld experienced by the target population, as findingsmay be constrained by the capacity of individuals to inter-pret and complete assessments. For example, issues con-cerning literacy and memory recall (due to substanceabuse, illness or dementia) may affect acceptability of thetool and the quality of data collected with it. Thus, toolutility for the target population also needs to be consideredin terms of its language and literacy levels, how long ittakes to complete the items, and how many items the toolincludes. Other aspects which assessors may need to con-sider are whether the tool is freely available and whetherthere are population norms for comparison.Human health research must align with the ethical princi-ples of beneficence, non-maleficence, health maximization,efficiency, and respect for autonomy, justice and propor-tionality [72]. People experiencing homelessness are a par-ticularly vulnerable population, therefore assessment toolsshould enable efficient collection of representative data,relevant to the individual, and be delivered with minimumintrusion and maximum likelihood of doing good [1, 7, 72].The health screening and assessment tools identified inthis review contained 60 individual measures, of which 55had available developmental material suggesting that withfurther research, the tool might be made relevant to peopleexperiencing homelessness (See Table 1). Assessments ofphysical constructs (such as oral health, anthropometry,muscle strength, balance) appear to have been applied tothe study population on a presumption of validity, becausethe constructs would be measured in the same manner aspeople living in permanent dwellings. The importance oforal health assessment of the target population washighlighted by the 11 different oral health tools identified inthis review (of which nine had evidence of developmentand application). Whilst none had been validated withpeople experiencing homelessness, two warrant further de-velopment in this population; the Shortened Oral HealthImpact Profile (OHIP-14 tool incorporating oral health-re-lated quality of life interview) [22] and the Geriatric OralHealth Assessment Index (GOHAI) [27]. Both had beendeveloped for efficient application with older people, need-ing minimum physical assessment time and including ques-tions on oral health quality of life. Similarly, the validity ofTable 1 Assessment instruments reported in the included literature, developmental reference(s) for the instrument (DRI) if relevantto homeless populations, and population(s) on which the instrument had been developed or validated. Shaded tools are validatedor developed with people experiencing homelessness (Continued)Instrument and citation DRI Validation populationsNational Health and Nutrition Examination Survey [60] Adult population internationally, relevant to homeless bynot specifically validatedDomain 11: Pelvic Floor HealthInternational Consultation on IncontinenceQuestionnaire [9]Adult population internationally, relevant to homeless bynot specifically validatedGordon et al. BMC Public Health (2019) 19:994 Page 9 of 14objective measures such as anthropometry, vision and hear-ing could be readily applied in homeless populations, astesting would be presumed to be similar for any adult. Het-erogeneity of people experiencing homelessness supportsthe need for validated tools appropriate to specificsubgroups, for example; different sex-age groups, or peoplewith varying language and reading capabilities.Without evidence of validity, self-report tools of mostconcern regarding applicability to homeless populations in-clude those measuring health domains such as chronic con-ditions, functional decline and frailty, cognitive function,continence and nutrition. Not only could concerns beraised about the capacity and willingness of homelesspeople to complete written self-reports (because of literacy,vision or trust) but also question relevance to their circum-stances. Recalling information over a set time period is acommon element in most self-report tools, and this as-sumes that events of interest have occurred within thattime period, and that an individual’s memory allows themto be accurately recalled and expressed. This is particularlyproblematic in dietary intake tools where the types of foodsused to prompt memory may be inappropriate toTable 2 Ready Reckoner psychometric properties and utilityInstrument & studyrefs (see key)RHI [35] SF12 & 36[33, 39, 60]WHOQol[26, 43]NHP[44]ASI [9,33]CCH[34]BIFS[10]BISQ[58]BDI [35,45]DTFS[44]LFS[44]Validationreference(s)[35] [48, 62] [43, 63] [64–66] [67, 68] [34] [69] [70] [71] [66] [66]Validity face √ √ √ √ √ √ √ √ √ √ √content √ √ √ √ √ √ √ √ √ √ √construct √ √ √ √ √ √ √ √ √comparison √ √ √ √ √ √ √ √ √ √sensitivity √ √ √ √ √ √ √ √ √ √factors √ √ √ √ √ √Reliability inter-tester NA NA NA NA √ √ NA √ NA NA NAintra-tester √ √ √ √ √ √test-retest √ √ √ √ √ √ √ √internal consistency √ √ √ √ √ √ √ √ √ √Utility < 20 items √ √ √ √ √ √Number of items 8 12 26 13 200 42 6 119+ 21 1 20Manual scoring √ √ √ √ √ √ √ √ √ √< 15min admintimeNS √ NS √ √ √ √ √ √ √Estimated time(mns)NS 10 NS 10 60 12 5 12 10 2 12Norms √ √ √ √Cut off scores √ √ √No cost √ √ √ √ √ √ √ √ √ √No limitations onuse√ √ √ √ √ √ √ √ √Total 9 15 16 12 16 14 13 13 15 10 13Possibletotal16 16 16 16 17 17 16 17 16 16 16% total 56% 94% 100% 75% 94% 82% 81% 76% 94% 62% 76%Key to instrument references in included literaturea. RHI Rural Homelessness Interviewb. SF-12, SF-36 Medical Outcomes Study (MOS) (SF-12 derived from SF-36)c. WHOQOL_BREF derived from WHOQOL-100 World Health Organisation Quality of Lifed. NHP Nottingham Health Profilee. ASI Addiction Severity Index (ASI)f. CCH Colorado Coalition Homeless Consumer Outcome scaleg. BIFS Brief Instrumental Functioning Scaleh. BISQ Brain Injury Screening Questionnaire (BISQ)i. BDI II Beck Depression Index II)j. DTFS Delighted – Terrible Faces Scalek. LFS Life Fulfilment ScaleGordon et al. BMC Public Health (2019) 19:994 Page 10 of 14circumstances of homelessness, and frequency and locationof eating may be variable [50, 56, 60].Two tools were identified which had been developeddirectly for, and with input from, homeless people [34,35]. These tools had moderate to good study methodo-logical quality, but poor to moderate tool property qual-ity. The latter reflects the specific nature of the studypopulation, and includes additional testing for reliabilityand external generalizability. Both tools captured infor-mation leading to homelessness, employment options,education, children, housing options, and access to ben-efits. These constructs had been identified during inter-views with people experiencing homelessness, andwere included in the fit-for-purpose tools, rather thanexisting tools that had been adapted for homelesspopulations. Consulting with homeless adults appearsto be essential in designing sensitive, comprehensive,and multidimensional tools that capture the range ofhealth concerns of this specific population group [14,72, 73].The WHO global healthy ageing initiative promotesgood health for all adults, irrespective of country orcircumstance [73, 74]. People ‘living rough’ have beenshown to have symptoms of aging much earlier thanthe general population [4, 7, 9, 10]. Therefore, a lensmight be placed on comprehensive test batteries de-veloped for older people, to adapt them for peopleexperiencing homelessness. Concerns in the elderlysuch as poor balance, falls, vision loss, incontinence,arthritis, chronic pain and poor skin health may alsobe relevant to younger homeless people [2, 10]. How-ever, it will be necessary to engage homeless peoplein determine which criteria are important to them.Improving the quality and comprehensiveness ofscreening and assessment tools to quantify the preva-lence and impact of such conditions currently associ-ated with ageing, but which may also be found inhomeless populations will provide important new in-formation on the true impacts of homelessness. Add-itionally, this will provide an improved understandingof accelerated aging associated with poverty andsleeping rough.LimitationsThis review was conducted as comprehensively aspossible, using an in-depth search approach, that fo-cused on English-language health screening and as-sessment tools developed for, used in, or potentiallyapplicable to, homeless populations. It did not includearticles about assessment of the specific diseaseswhich may occur in people experiencing homelessness(for instance cardiac or respiratory diseases, mentalillnesses or infectious diseases). The findings have notbeen differentiated by age group, sex, location orgeography (which limits comparative insights intovariability by sex, and among homeless populationsglobally). Future research might address these know-ledge gaps to better establish health screens and as-sessments specific to different types of homelessness,and different types of people experiencing it [6, 7].ConclusionsThe findings of this review confirm the complexities ofassessing, accurately representing and addressing thepotentially poor health of homeless populations. Fewstudies have reported on validated and reliable healthscreening and assessment tools, informed by input frompeople experiencing homelessness. Improving harm re-duction strategies and early identification of health con-ditions in adults experiencing homelessness is vital,recursively flowing to and from empirical evidence,government policies and targeted services to addressthese significant and long-standing health inequities.That said, if research is asking, and by extension report-ing on, the ‘wrong’ items and measures, there is signifi-cant potential for discord between what is espoused asneeded, versus what should be triaged, to advance thehealth of homeless people. Based on the findings of thecurrent review we recommend the development andconsistent use of a suite of measures informed by andvalidated for people experiencing homelessness. This isa vital first step to accurately capturing, reporting andaddressing the complex health needs of this vulnerablepopulation.Summary box for policy and practiceA large number of assessment and screening tools for issuespotentially related to the complex and varied health needs ofpeople suffering homelessness was identified in this review.However, very few had been co-designed with people sufferinghomelessness, and many used language, wording, or situationaldescriptors that were not relevant to the target population.There were no validated tools to assess issues such as oralhealth, chronic health conditions, anthropometry, demography,nutrition, continence, functional decline and frailty, vision orhearing.There is an urgent need to develop consistent andcomprehensive health assessment and screening tools specificto the needs and concerns of subgroups of people experiencinghomelessness. This will ensure that valid data is available toinform health policies and healthcare initiatives that are likely tobe effective.Gordon et al. BMC Public Health (2019) 19:994 Page 11 of 14Additional filesAdditional file 1: Search terms for the review (DOCX 13 kb)Additional file 2: Characteristics of included studies (n = 39) (DOCX 64kb)Additional file 3: Critical appraisal summaries (DOCX 28 kb)AbbreviationsABS: Australian Bureau of Statistics; ADHS: Adult Dental Health Survey;ASI: Addiction Severity Index; BASIS-32: Behavior and Symptom IdentificationScale; BDI II: Beck Depression Index; BIFS: Brief Instrumental FunctioningScale; BISQ: Brain Injury Screening Questionnaire; BNT: Boston Naming Test;CAGE: Cut Down, Annoyed, Guilty and Eye Opener; CCHCO: ColoradoCoalition Homeless Consumer Outcome scale; CPI: Community PeriodontalIndex; D3CVMFT: Decay (cavitation and visual dentine caries) and missingpermanent teeth; DAST: Drug Abuse Screening Test; DETERMINE: NutritionalHealth Checklist; DRI: Developmental reference instrument; DTFS: Delighted-Terrible Faces Scale; ECAQ: Elderly Cognitive Assessment Questionnaire; EQ-5D: Euro Quality of Life Group five dimensions survey (mobility, self-care,usual activities, pain/discomfort, and anxiety/depression); FAS: ControlledOral Word Association Test; GDS-12R: Geriatric Depression Scale;GOHAI: Geriatric Oral Health Assessment Index; HIV: Humanimmunodeficiency virus; iCAHE: international Centre for Allied HealthEvidence; LFS: Life Fulfilment Scale; MAST: Michigan Alcohol Screening Test;MDAS: Modified Dental Anxiety Scale; MMSE: Mini Mental State Examination;MOS: Medical Outcomes Study; NHMRC: National Health and MedicalResearch Council of Australia; NHP: Nottingham Health Profile; OHIP-14: Shortened Oral Health Impact Profile; RAND: Research ANd Development;RBANS: Repeatable Battery for Assessment of Neuropsychological Status; Rey-O: Rey-Osterrieth Complex Figure Design; RFFT: Ruff Figural Fluency Test;RHI: Rural Homelessness Interview; SF-12: Short Form Survey-12; SF-36: ShortForm Survey-36; TMT-B: Trail Making Test Part B; USA: United States ofAmerica; WAIS-III: Wechsler Adult Intelligence Scale, Third Edition;WCST: Wisconsin Card Sorting Test; WHO: World Health Organization;WHOQoL 100: World Health Organization Quality of Life 100; WHOQoL-BREF: World Health Organization Quality of Life BREF; WMS-III: WechslerMemory Scale, Third EditionAcknowledgementsNot applicable.Authors’ contributionsSJG and NB made substantial contributions to the conception and design ofthe work. AB and TD conducted the searches, retrieved studies and screenedfor inclusion via title and abstract with SJG as arbiter. AB, TD, SG, NB, MK, TB,CH, MS, TM were responsible for dual critical appraisal and data extraction.Where disagreement occurred SJG and JLO were arbiters. KG conducted theready reckoner work. AB, TD, TM, SJG and KG were responsible for draftingthe manuscript and all authors critically revised it for important intellectualcontent. All authors gave final approval to the finished manuscript and agreeto be accountable for all aspects of the work.FundingIn-kind funding was provided by Flinders, University, University of BritishColumbia and The University of Adelaide. Publication fees were contributedby The University of Adelaide. The funding bodies had no influence on thedesign of the study, or collection, analysis, and interpretation of data or inwriting the manuscript.Availability of data and materialsThe information accessed and included in this systematic review is availablevia the references provided.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Author details1College of Nursing and Health Sciences, Flinders University, Bedford Park,South Australia5042. 2Division of Physiotherapy, Faculty of Medicine andHealth Science, Stellenbosch Uni, Cape Town, South Africa. 3Adelaide DentalSchool, University of Adelaide, Adelaide, South Australia5000. 4School ofPublic Health, University of Adelaide, Adelaide, South Australia5000. 5Schoolof Nursing, University of British Columbia, Vancouver, Canada.Received: 7 December 2018 Accepted: 25 June 2019References1. Ortiz-Ospina E, Roser M. 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Health assessments and screening tools for adults experiencing homelessness: a systematic review
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