Harvard Medical School, Boston, MA, USA; MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
Lancet Public Health. 2021 Nov;6(11):e836-e847. doi: 10.1016/S2468-2667(21)00189-4. Epub 2021 Sep 30.
Adverse childhood experiences (ACEs) are strong risk factors for homelessness and poor health and functioning. We aimed to evaluate the lifetime prevalence of ACEs and their associations with health-related and functioning-related outcomes among homeless adults.
In this systematic review and meta-analysis, we searched from database inception to Nov 11, 2020, for original and peer-reviewed studies in English that documented lifetime prevalence of ACEs or associations between ACEs and health-related or functioning-related outcomes. We selected studies if they included a definable group of homeless adults and measured at least four ACE categories. We calculated pooled estimates of lifetime prevalence of one or more ACEs and four or more ACEs with random-effects models. We used the leave-one-out method in sensitivity analyses and studied meta-regressions to explore potential moderators of ACE prevalence. We also did a narrative summary of associations between ACEs and health-related and functioning-related outcomes, as there were too few studies on each outcome for quantitative meta-analysis. This study is registered with PROSPERO, CRD42020218741.
We identified 2129 studies through systematic search, of which 29 studies (16 942 individuals) were included in the systematic review, 20 studies (10 034 individuals) were included in the meta-analysis for one or more ACEs, and 15 studies (5693 individuals) were included in the meta-analysis for four or more ACEs. Studies included samples of adults experiencing homelessness in the USA, Canada, and the UK; participants in the included studies were predominantly male (65·2%) and mean ages ranged between 18·3 and 58·1 years, but many studies did not report race, ethnicity, and sexual and gender minority data. Lifetime prevalence of one or more ACEs among homeless adults was 89·8% (95% CI 83·7-93·7) and the lifetime prevalence of four or more ACEs was 53·9% (45·9-61·7). Considerable heterogeneity was identified in both meta-analyses (I>95%). Of the potential moderators analysed, the ACE measurement tool significantly moderated the estimated lifetime prevalence of one or more ACEs and four or more ACEs, and age also significantly moderated the estimated lifetime prevalence of four or more ACEs. In the narrative synthesis, ACEs were consistently positively associated with high suicidality (two studies), suicide attempt (three studies), major depressive disorder (two studies), substance misuse (two studies), and adult victimisation (two studies).
The lifetime prevalence of ACEs is substantially higher among homeless adults than among the general population, and ACE exposure might be associated with prevalence of mental illness, substance misuse, and victimisation. Policy efforts and evidence-based interventions are urgently needed to prevent ACEs and address associated poor outcomes among this population.
Rhodes Trust and Canadian Institutes of Health Research.
不良的儿童经历（ACEs）是导致无家可归和健康状况及功能不佳的强烈危险因素。我们旨在评估无家可归成年人一生中 ACEs 的发生率及其与健康相关和功能相关结局的关联。
在这项系统评价和荟萃分析中，我们从数据库创建开始搜索，到 2020 年 11 月 11 日，以英文搜索原始同行评审研究，记录 ACEs 的终生发生率或 ACEs 与健康相关或功能相关结局之间的关联。如果研究包括可定义的无家可归成年人群体且测量了至少四个 ACE 类别，我们将选择研究。我们使用随机效应模型计算了一个或多个 ACE 和四个或更多 ACE 的终生发生率的汇总估计值。我们使用剔除一个研究的敏感性分析方法和研究荟萃回归来探索 ACE 发生率的潜在调节因素。我们还对 ACEs 与健康相关和功能相关结局之间的关联进行了叙述性总结，因为每个结局的研究数量太少，无法进行定量荟萃分析。本研究已在 PROSPERO（CRD42020218741）上注册。
我们通过系统搜索确定了 2129 项研究，其中 29 项研究（16942 人）被纳入系统评价，20 项研究（10034 人）被纳入一个或多个 ACE 的荟萃分析，15 项研究（5693 人）被纳入四个或更多 ACE 的荟萃分析。研究包括美国、加拿大和英国无家可归成年人的样本；纳入研究的参与者主要为男性（65.2%），平均年龄在 18.3 至 58.1 岁之间，但许多研究未报告种族、民族以及性少数群体和性别少数群体的数据。无家可归成年人一生中 ACEs 的发生率为 89.8%（95%CI 83.7-93.7），一生中 ACEs 发生率为 4 个或更多 ACEs 的发生率为 53.9%（45.9-61.7）。两个荟萃分析都存在显著的异质性（I>95%）。在分析的潜在调节因素中，ACE 测量工具显著调节了一个或多个 ACEs 和四个或更多 ACEs 的终生发生率，年龄也显著调节了四个或更多 ACEs 的终生发生率。在叙述性综合中，ACEs 与高自杀意念（两项研究）、自杀企图（三项研究）、重度抑郁症（两项研究）、物质使用障碍（两项研究）和成人受害（两项研究）呈持续正相关。
无家可归成年人一生中 ACEs 的发生率明显高于普通人群，ACE 暴露可能与精神疾病、物质使用障碍和受害的发生率有关。迫切需要采取政策措施和基于证据的干预措施，以预防 ACEs 并解决该人群的相关不良结局。
罗兹信托基金会和加拿大卫生研究院。
