Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
Lancet. 2023 Nov;402 Suppl 1:S18. doi: 10.1016/S0140-6736(23)02075-5.
Trauma is an experience (physical or emotional) that is life-threatening, harmful, or out of the ordinary and has lasting effects on mental health and wellbeing. Much of the information about trauma within homeless populations focuses on events in childhood. Using coproduction principles, we aimed to synthesise qualitative evidence exploring the impact of trauma during adulthood homelessness on mental health, including substance use.
In this qualitative systematic review, we searched ASSIA, CINAHL, Cochrane, EMBASE, MEDLINE, Proquest theses and dissertations, PsychInfo, Scopus, and Web of Science for studies published from inception until Sept 6, 2022, alongside grey literature from relevant websites. Search terms were developed based on the PICO framework. No language, date, or geographical limits were applied. Any qualitative research reporting experiences of trauma and its impact on mental health during homelessness in adults was eligible. We extracted relevant data (eg, methodology, sample characteristics, homelessness, and findings). People with lived experience of homelessness were provided with bespoke training by the lead researcher. They contributed to refining the review aims, screening, coding, and theme development. Quality was assessed using the CASP Qualitative Studies Checklist.
We included 26 qualitative papers, including 876 adults experiencing homelessness between ages 18 and 70 years (448 [51%] women and 428 [49%] men). All papers focused on urban settings. Eight papers were from the USA, five from Canada, four from the UK and Australia, three from Brazil, and one from Ethiopia and Iran. A framework synthesis of these 26 papers identified three preliminary themes. People experiencing homelessness make sense of trauma in three ways: internalised understanding, relationality to others, and with a survival lens. Coping strategies for managing feelings of fear, anxiety, and depression included substance use, self-rationalisation, and strategies to feel safe. Finally, when people experienced repeated trauma, they became either dissociated, and accepted their situation, or resilient, wishing to change their circumstances.
Further evidence is needed in rural or coastal regions, where people experiencing homelessness may face greater isolation. Trauma rarely takes place in isolation, and often previous experiences of trauma shape how people experiencing homelessness make sense of trauma and cope with it. Support to address coping with the effects of trauma should focus on ensuring people do not become desensitised and prevent deterioration of mental health and substance use. The strength of this review is its coproduction with people with lived experience. Single person data extraction with secondary checks was a limitation.
National Institute for Health and Care Research (NIHR) School for Primary Care Research as part of the Three NIHR Research Schools Mental Health Programme.
创伤是一种危及生命、有害或异常的经历（身体或情感上的），会对心理健康和幸福感产生持久影响。在无家可归人群中，大多数关于创伤的信息都集中在儿童时期的事件上。我们运用共同生产原则，旨在综合定性证据，探索成年期无家可归期间创伤对心理健康的影响，包括物质使用。
在本次定性系统评价中，我们检索了 ASSIA、CINAHL、Cochrane、EMBASE、MEDLINE、Proquest 论文和学位论文、PsychInfo、Scopus 和 Web of Science，检索时间为从建库开始至 2022 年 9 月 6 日，同时检索了相关网站的灰色文献。检索词基于 PICO 框架制定，未设定语言、日期或地理限制。任何报告成年期无家可归者经历创伤及其对心理健康影响的定性研究均符合纳入标准。我们提取了相关数据（如方法学、样本特征、无家可归和发现）。有过无家可归经历的人由首席研究员提供专门培训。他们参与了审查目的的细化、筛选、编码和主题开发。使用 CASP 定性研究清单评估质量。
我们纳入了 26 篇定性论文，包括 18 至 70 岁之间的 876 名经历无家可归的成年人（448[51%]名女性和 428[49%]名男性）。所有论文均聚焦于城市环境。8 篇论文来自美国，5 篇来自加拿大，4 篇来自英国和澳大利亚，3 篇来自巴西，1 篇来自埃塞俄比亚和伊朗。对这 26 篇论文进行框架综合分析，确定了三个初步主题。经历无家可归者有三种方式理解创伤：内化理解、与他人的关系以及生存视角。管理恐惧、焦虑和抑郁等情绪的应对策略包括物质使用、自我合理化和感到安全的策略。最后，当人们经历反复创伤时，他们要么变得麻木不仁，接受自己的处境，要么变得坚韧不拔，希望改变自己的处境。
需要在农村或沿海地区进一步提供证据，因为那里的无家可归者可能面临更大的孤立。创伤很少单独发生，而且通常以前的创伤经历会影响无家可归者对创伤的理解和应对方式。解决创伤影响的应对支持应重点确保人们不会变得麻木不仁，防止心理健康和物质使用恶化。本综述的优势在于它与有过生活经历的人共同制作。单人数据提取和二次检查是一个局限性。
英国国民健康保险制度（NHS）和Care Research 学院作为三个 NHS 研究学院精神健康计划的一部分。
