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Functional status, physical activity, homeless adults, homelessness
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Kiernan S, Mockler D, Ní Cheallaigh C and Broderick J. Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.12688/hrbopenres.13011.2)
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Systematic Review
Revised
Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review
[version 2; peer review: 2 approved]
PUBLISHED 01 Mar 2021
OPEN PEER REVIEW
REVIEWER STATUS
Abstract
Corresponding author:
Julie Broderick
Competing interests:
No competing interests were disclosed.
Grant information:
Health Research Board Ireland [APA-2017-029]
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2021 Kiernan S et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Kiernan S, Mockler D, Ní Cheallaigh C and Broderick J. Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.12688/hrbopenres.13011.2)
First published: 16 Apr 2020, 3:14 (https://doi.org/10.12688/hrbopenres.13011.1)
Latest published: 01 Mar 2021, 3:14 (https://doi.org/10.12688/hrbopenres.13011.2)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Revised Amendments from Version 1
The authors revised this work in response to valuable comments from reviewers. The main aspects addressed were as follows; In the introduction section, specific detail in relation to study objectives was added. In the methods section, more detail was added in relation to the subject expert, data extraction instrument and date of the search. A greater distinction was made between physical focused outcomes and physical activity focused outcomes in Table 1. In the Results section, the number of quantitative and qualitative studies was clarified, details about participant co-morbidities was included, Biological sex replaced the word gender as a column heading. In the discussion section, more interpretation in relation to biological sex, ethnicity of participants, and application of results community services was added.
See the authors' detailed response to the review by Cilia Mejia-Lancheros
See the authors' detailed response to the review by Jo Dawes
Introduction
The number of people experiencing homelessness is significant and increasing, with estimates of 307,000 people in the UK1, 550,000 in the USA2 and 235,000 in Canada3 at any one point, based on data from 2017, 2016 and 2017 respectively. A ‘person experiencing homelessness’ is someone without stable housing who may live on the streets, in a shelter, in temporary accommodation, or in some other unstable or non-permanent situation4.
Life expectancy is greatly reduced among people who are homeless. Recent data from the UK reports a mean age of death among people who died homeless of 45 years among men and 43 years among women, which compares with 76 and 81 years respectively, in the general population5. In Ireland the median age at death for people experiencing homelessness in Dublin is devastatingly low at 44 years for males and 36 years for females6. Contributing factors to lowered mortality levels are complex. People who are homeless people experience a ‘tri-morbidity’ of mental ill health, physical ill health, and addiction as well as complex interwoven factors related to social exclusion, higher rates of accidental, violent death and poor access to healthcare7.
Common chronic diseases such as chronic obstructive pulmonary disease, asthma, epilepsy, heart disease and stroke are substantially more prevalent among people experiencing homelessness compared to stably housed individuals8. External factors as well as chronic diseases have a multi-system effect with reported accelerated ageing9 and early onset of geriatric conditions10. Reflective of disease prevalence and other factors related to extreme socioeconomic deprivation, people who are homeless present for acute hospital care disproportionally compared to housed individuals11.
The benefits of physical activity are well known and recent guidelines12 have highlighted additional benefits of physical activity in terms of cognitive health health-related quality of life, mental health and sleep which has largely been explored in healthy populations. Information on physical activity levels among individuals who are homeless is not well known13.
Physical performance and functional limitation measures may provide an insight into early signs of disability, poor health, hospitalization and increased death risk9,12. These measures give an indication of a person’s ability to perform everyday tasks making them good indicators of overall ability to live independently as ageing occurs9. To date there has been no prior effort to characterize the overall physical status of people experiencing homelessness. Improved understanding of physical functioning and physical activity is important, as this may guide the development of screening tools to identify, and interventions to attenuate declines in people experiencing homeless. This will also help direct research as well as future systematic reviews in this topic area.
The protocol was developed and peer-reviewed locally and then registered in the PROSPERO database (CRD42019124306). In order to address the breadth of this area however, a scoping review rather than a ‘pure’ systematic review14 was conducted. Although some consider a scoping review a form of systematic review15, subtle differences are, for example, the breadth of the research question and the lack of risk of bias assessment14,15.
Based upon the PCC (Population, Concept and Context) elements16, the overall aim of this scoping review was to evaluate the magnitude and scope of literature pertaining to the overall physical status of adults experiencing homelessness. Specific objectives were to evaluate the quantitative and qualitative literature on the following topics (i) physical functioning in adults experiencing homelessness, (ii) physical activity in adults experiencing homelessness, (iii) related secondary outcome measures such as frailty and cardiovascular fitness. In addition a further objective was (iv) to evaluate measurement methods of physical outcomes in included studies.
Methods
This review was informed by the Joanna Briggs Institute’s (JBI) methodology for scoping reviews14 and guided by the original framework of Arksey and O’ Malley16, and enhancements proposed by Levac et al.17. This review was checked against the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist18 (see reporting guidelines19).
Data sources and searches
A comprehensive search strategy was developed collaboratively with a skilled research librarian (D.M.) and a subject expert (C.N.C.) was consulted. The subject expert was a medical consultant who developed an inclusion health service for adults experiencing homelessness and is the clinical lead for service provision for people experiencing homelessness admitted to a large acute inner-city hospital in Dublin, Ireland. The following electronic databases were searched without date restrictions; MEDLINE/PubMed, EMBASE, PEDro, AMED, CINAHL, PsycINFO, SCOPUS (see extended data19). A grey literature search using Google Scholar and WorldCat search engines was performed; government reports were searched using the Google search engine and a combination of key word text from inception to 16.01.19.
Physical focused definitions employed in this review
We employed Nagi’s20 definition of functional limitations as restrictions in the basic performance of the person such as limitations in the performance of locomotor tasks, such as the person’s gait, and basic mobility. Although not the specific focus of this review, factors that relate to physical functioning limitations such as, but not limited to, frailty, physical symptom burden and cardiovascular fitness were included if reported in studies sourced. Physical activity was defined as any bodily movement produced by skeletal muscles that results in energy expenditure21 and was considered any type of physical training or movement, including any form of exercise, physical fitness or therapeutic movement. The full search strategy is available in Supplementary File 2.
Inclusion/exclusion criteria
This review included English language studies only. To meet the objective of the scoping review questions in this study, both qualitative and quantitative study designs were included. Studies that examined physical functioning or physical activity (separate searches for each were conducted and later combined) among homeless adults (>18 years) as a primary or secondary outcome measure were included. The following criteria for homeless from the European Typology for Homelessness and Housing Exclusion (ETHOS) criteria22: roofless, houseless, living in insecure housing, living in inadequate housing was employed in this review.
Selection of studies
Duplications were removed and relevant studies were imported into Covidence for title and abstract screening which took place independently by two reviewers (J.B. and S.K.). Both authors then conducted a full-text evaluation of selected studies. If necessary, any discrepancies were resolved by consensus by including a third author (C.N.C.).
Data extraction
Two reviewers (S.K. and J.B.) independently extracted data using a specifically designed data extraction sheet. The data extraction instrument collected the following data relating to included studies (author, year of publication, country of study origin, inclusion criteria, living arrangements, physical focused outcomes measured, participant characteristics (number of participants, age, biological sex, race/ethnicity, percentage with less than high school education, co-morbid conditions), physical focused variables (physical variable measured, type of measure, total number of studies, authors, results), physical activity/sedentary behavior focused measures (author, type of measure, measure subscale, main results). Any differences were resolved by consensus discussion. A third author (C.N.C) was available if disparities emerged between reviewers.
Results
Studies identified
After the removal of duplicates, 2832 studies were identified. After excluding studies which did not containing data relevant to physical functioning limitations or physical activity specific to adults who were homeless, a total of 15 studies were deemed eligible for inclusion in this reviewAfter excluding studies which did not containing data relevant to physical functioning limitations or physical activity specific to adults who were homeless, a total of 15 studies were deemed eligible for inclusion in this review. The PRISMA flow chart23 summarizes the search strategy (Figure 1). Quantitative (n=13) studies predominated and the remaining were qualitative in design (n=2). Over 2000 participants were included in this review (n=2,018). Over 70% of participants were male. A formal operational definition of homeless was included in one study only24. The living arrangement of participants was outlined in the recruitment strategy and/or eligibility criteria of remaining studies. The majority of studies included participants in shelter accommodation. Four studies were limited to male only participants24–27, while only two were female only28,29. Characteristics of the included studies are shown in Table 1. The majority of studies took place in North America (12/15) with the remainder in Australia (n=1) and Denmark (n=2).
Figure 1. PRISMA flow diagram of selection for review.
Table 1. Study characteristics.
Participant characteristics are shown in Table 2. Despite the relatively low mean/median age of participants [2nd decade (n=2 studies), 3rd decade (n=2 studies), 4th decade (n=5 studies), 50th decade (n=5 studies), 60th decade, (n=2 studies), participants experienced a high burden of physical and mental conditions. From data presented in included studies, rates of hypertension ranged from 20.4% to 59%, arthritis from 16.8% to 46.8%, diabetes from 14% to 18.3% and depression from 34% to 59.6%.
Table 2. Details of participant characteristics.
| Citation | Number of participants | Age mean (SD) | Biological Sex | Race/ Ethnicity | <High school education | Comorbid conditions |
|---|---|---|---|---|---|---|
| Ballard, 2009 | 126 | 41.99 ± 9.42 years | Female only M:0 F:126 | African American (54%) White (32.5%) American Indian (4.8%) Mixed race (4.8%) Asian (1.6%) Other/unsure (4.4%) | 31.8% | High blood pressure: 41.1% Asthma: 26.8% Arthritis: 25% STDs: 22.4% |
| Bazari et al. 2018 | 20 | 62 years | Male= 65% M:13 F:7 | African American (85%) | NS | NS |
| Brown et al. 2012 | 247 | 56 years | Male= 92% M:187 F:60 | White (39.7%) | 26.1% | Hypertension (59%), arthritis (44.9%), depression (59.6%) |
| Brown et al. 2017 | 350 | 58 (54–61 years)a | Male= 77.1% | African American (79.7%), White (10.9%) Latino (4.6%), Other (4.9%) | 25.7% | Hypertension (56%) Coronary artery disease or myocardial infarction (9.1%) Congestive heart failure (7.1%) Diabetes (14%) Stroke (11.2%) Respiratory disease (26.3%) Arthritis (44.6%) HIV/AIDS (5.5%) |
| Chau et al. 2002 | 221 | 46.7 years | Male=54% M:120 F:101 | African-American (57%) Caucasian (26%) Other (17%) | 60% | NS |
| Gadermann et al. 2014 | 100 | 43.3 +/- 11.9 years | Male= 69% M:69 F:31 | White (55%), Aboriginal (30%) Other (15%) | 27.2% | Arthritis/rheumatism, joint problems (43.9%), Hepatitis C (31.6%), Migraines (28.6%), Mental health conditions (52.5%), Substance abuse (40.2%), Depression (34%), Substance dependence (26.6%), GAD (15.6%), PTSD (12.5%) |
| Gregg and Bedard 2016 | 18 | 41.05 ± 11.32 years | Male = 100% M:18 F:0 | NS | NS | NS |
| Kendzor et al. 2015 | 57 | 49.4 +/- 7.7 years | Male = 66.6% | African-American (54.4%) Latino (3.5%) Mixed race(5.3%) | NS | NS |
| Marmolejo et al. 2018 | 40 | 21.4 ± 2.3 years | Male = 67.5% M:27 F:13 | White (30%) Hispanic (27.5%) African American (20%) American Indian/ Alaska Native 3(7.5%) Native Hawaiian /Pacific Islander 1(2.5%) Missing (12.5%) | 15% | NS |
| Pantalawa et al. 2017 | 283 | 59 (51–82)a | Male=75.6% M:214 F:69 | African American (82.4%) White (9.6%) Other (21.9%) | 21.9% | Heart related (17.2%) Respiratory related (23.7%) Diabetes (18.3%) Arthritis (46.8%) Cirrhosis/liver disease (21.0%) Kidney disease (5.4%) Cancer (5.9%) HIV/AIDS (6.2%) |
| Quine et al. 2004 | 32 | 66 years | Male = 100% M:32, F:0 | Australian born (66%) Born overseas (33%) | NS | ‘Significant’ health difficulties (66%) |
| Randers et al. 2010 | 15 | 29 ± 2 years | Male = 100% M:15,F:0 | NS | NS | NS |
| Randers et al. 2012 | 22 | 37 ± 10 years | Male = 100% M:22, F:0 | NS | NS | NS |
| Raven et al. 2017 | 350 | 58 (54–61)a | Male = 77.1% M:270 F:80 | African American (79.7%) Non-African American (20.3%) | 74.3% | Chronic illness (23.9%), Acute illness (21.6%), Pain (19.2%) PTSD (32.6%) Depression (53.3%) |
| Wilson, 2004 | 137 | 36 years (range 18–60) | Female only M:0 F:137 | White (53%) African American (43.8%) | 22% | Physical diseases: Asthma: 27% Chronic bronchitis: 25.5% Hypertension: 20.4% Arthritis: 16.8% STD: 16.8% Ulcer: 15.3% |
The following physical variables were evaluated in studies included in this review; mobility status, frailty, flexibility, physical symptom burden, physical activity levels and exercise intensity achieved and fitness. Table 3 summarizes physical focused variables and Table 4 summarizes physical activity/sedentary behavior variables.
Table 3. Physical focused variables measured in systematic review studies.
Table 4. Physical activity/sedentary behaviour focussed measures.
Mobility status
Mobility status was evaluated in two studies. Overall results indicated that many people homeless experiencing homelessness have difficulty mobilizing. In two studies10,30 mobility was measured by self-reported difficulty walking. Brown et al. 201230 sampled 247 homeless adults, and found that 102 (41.3%) self-reported difficulty walking30. Brown et al. 2017 included 350 participants aged 50 or older and reported mobility impairments in over one quarter of participants (26.9%) and 33.7% reported one or more falls in the previous 6 months. Results of this study indicated that greater mobility impairments (defined as difficulty across a room) were found in participants < 50 years, compared to those ≥ 50 years.
Functional limitations
Raven et al. 2017 reported that over half (58.4%, n=204) of participants had limitations in lower extremity function measured by the Short Physical Performance Battery31. This study included participants with a median (IRQ) age of 58 (54–61) years.
Frailty
Frailty was evaluated in one study30. Frailty was measured using the Fried criteria32 in which more than 3 of 5 characteristics were present: unintentional weight loss, low physical activity, exhaustion, slow walking speed and weak handgrip. In total, 40 participants (16%) met frailty criteria, bearing in mind that participants were aged between 50 and 69.
Flexibility
Flexibility was assessed in two studies24,33 and compared to control groups. The Sit and Reach test34 was used which targets hamstring and lower back flexion. Other flexibility tests employed were the butterfly test (targets adductor muscles), the trunk flexibility test and shoulder stretch34. Mean (SD) results for the sit and reach test, butterfly test, left shoulder, right shoulder, left trunk twist and right trunk twist were 26.2 (9.01), 17.83 (7.29), 0.59 (9.55), 2.42 (7.54), 8.89 (7.96), 12.22 (8.23) respectively33. It was noted that participants who were homeless were less flexible (p<0.05) in four stretch tests compared to a control group of university students. Similar low values were reported for the Sit and Reach test in the Gregg and Bedard (2016)24 study of 24.32 ± 8.07cm.
Strength
Strength was measured in one study24 using a grip strength test35 which was reported to be mean (SD) 43.24 (6.79). Values from the homeless cohort age 41.05 ± 11.32 years were reported to be comparable to a reference population.
Physical health/symptom burden
Physical symptom burden was evaluated in three studies, assessed in 3 different ways. Patanwala et al. (2017) evaluated physical symptoms in homeless aged ≥ 50 years36 using the Patient Health Questionnaire-15 (PHQ-15)37. They reported that over one-third (34%, n= 96) had a moderate-high physical symptom burden. The most common physical symptoms were joint pain, fatigue, back pain and sleep difficulties.
Similarly, Gaderman et al. (2014) using the SF-1238, reported that the physical component summary scale was 43.6 (SD=11.0), which was ‘substantially lower’ than US population normative values39. In this study is was found that 87.9% (n=53) of participants suffered at least one physical health condition.
These findings concur with a qualitative study included in this review. Bazari et al. (2018) reported that physical symptoms experienced by homeless adults interfere with daily functioning40. They included 20 participants aged between 52 and 78 years (median age 62). It was found that daily challenges and physical conditions of homelessness caused and exacerbated symptoms.
“I can’t be active anymore like playing sports because I used to like to go play basketball or lift weights… but I can’t do nothing anymore…” (M, 63)
Some participants cited premature aging as the reason for their physical symptoms and decreased functional ability.
“It’s the arthritis…. Sometimes I feel I am carrying all my weight on my legs….I just feel like I’ve aged so quickly in my life” (F, 58)
Fatigue was also a factor.
‘’I guess every day that I have to walk I’m tired. I guess that’s the main thing: that I go from bench to bench and feel tired’’ (M, 58)
Physical activity levels
Physical activity levels were measured in six studies. Diverse methods were employed to assess this construct in each study. Insufficient physical activity levels among homeless adults were generally reported across studies (Table 4). Kendzor et al. (2015) examined modifiable health risk factors among homeless smokers (n= 57)41. The results showed that 26.3% did not meet recommended physical activity levels in the previous week. Chau et al. 2002 asked about exercise habits during an interview which mainly focused on cancer risk behaviours and screening. It was reported that 56% (n=125) performed daily exercise, but no details of the definition of exercise was supplied. Gregg and Bedard (2016) evaluated ‘regular exercise’ as per Courneya and Bobick, 200042 and reported that 44% (n=8) exercised ‘’at least three times per week, for at least 20–30 min in duration, and at least moderate-to-vigorous intensity’’. Wilson (2005) explored health-promoting behaviours of women who were living in shelter accommodation (n= 137)29. The study employed the Health-Promoting Lifestyle Profile II (HPLPII)43 and found that participants scored lowest in the physical activity subscale which is shown in Table 5 although overall it was reported that total levels of health-promoting behaviours were similar to another study of low income and homeless women44.
Table 5. Health-Promoting Lifestyle Profile - Physical activity subscale.
Quine et al. (2004)27 employed semi structured interviews and a number of facets of physical activity emerged. It found that some participants were until recently physically active. However, deterioration in their health had reduced their activity levels.
“I used to walk about a quarter of a mile up and around the block” (M, 86)
Physical activity was also undertaken as a necessity.
‘’It’s a good walk [to a meals centre] and they put on a hot breakfast’’ (M, 68)
Physical activity was also used as a time filler
‘’if there’s something on like a movie worthwhile I’ll watch that and if there’s not I’ll for out for a walk for an hour and come back’’ (M, 75).
Exercise capacity
Randers et al. (2010) reported VO2 max levels for 15 people experiencing homelessness who were engaging in a football training program. Reported VO2 max levels were 33.5 +/- 2.0 ml.kg.min-125. Similarly, Randers et al. 2012 reported VO2 max levels for 22 men experiencing homelessness before and after a 12 week soccer training program. Reported VO2 max levels were 36.7 +/- 7.6 ml.kg.min-1 which appeared higher than a control group (33.7 +/- 4.5)45. One further study evaluated fitness using the 1 mile walk test24 with a result of 16.48 +/- 2.42 minutes which was reported to be similar to reference values for age and gender.
Discussion
This review provided a snapshot of existing literature in the area of physical functioning limitations and physical activity levels in people experiencing homelessness. The scoping review methodology enabled a broad range of inter-related physical related variables (mobility status, functional levels, frailty, flexibility, physical symptom burden, physical activity levels and exercise capacity) to be usefully subsumed into one review which gives a broad overview of this topic area. It is clear from this review that the experience of homelessness negatively influences physical –focused parameters but the diversity of measures limited our ability to synthesize data for the purposes of this review.
This review included 2,018 participants, of which females were underrepresented as over 70% of review participants were male. This reflects that 4 studies exclusively included males, whereas only 2 studies only included females, and relatively there was a higher proportion of males than females in the remaining studies. Less therefore appears to be known about the physical profile of females experiencing homelessness compared to males. Sex as a biological characteristic was reported in studies was reported rather than gender which is more a social and identity construct46. It is known that transgender people are disproportionally represented among homeless populations47 but this group were not represented in studies included in this review.
The majority of studies included in this review were quantitative in design (n=11), while 3 were qualitative. Almost 80% of studies were based in North America, with the rest of studies from other high income countries of Denmark and Australia. There appears to be a large evidence gap in the evaluation of physical variables among people in low and middle income countries.
In the US based studies 59.6% of participants were African American, while a lower proportion were white (29.8%). This reflects the high proportion of African Americans among homeless populations in the US48. Indigenous people are also over-represented among homeless populations49 which likely mirrors the proportion of Aboriginal people in a Canadian study42 included in this review. It is possible that in other studies this group may have been under-represented or not specifically reported. Out of 10 US based studies, one reported the proportion of American Indian participants was 4.8%, and another quoted that 10% of participants were American Indian/Alaska Natives/Native Hawaiian/Pacific Islanders. Most of the rest of the studies included categories of ‘other’ in which it was likely native populations were subsumed. Similarly, there may have been an under-representation of Latino people and people of mixed race heritage but absolute proportions of different ethnic groups among homeless populations are likely to be context specific.
Studies predominately appeared to include people in shelter accommodation. The proportion of people sleeping rough who were included in studies within this review was low and it is probable that their physical health variables may be worse than individuals living in sheltered accommodation. Despite the frequency of hospital visits and stays in this population11,50, no study profiled hospitalized homeless individuals. It is likely that this cohort may be especially vulnerable and debilitated and requires further evaluation with regard to physical focused variables.
Despite the disparity in measures, there generally appears to be a pattern of low physical functioning levels and poor physical activity levels among people experiencing homelessness compared to expected levels. A high physical symptom burden was also noted particularly in relation to joint pain, fatigue, back pain and sleep problems36. Flexibility levels were also significantly lower than control group findings33. This finding suggests a global decline or substandard level of physical fitness and function among homeless adults and an earlier onset of geriatric conditions which has been shown previously51, the reasons for which need to be further elucidated. In the study by Brown et al., 2017, it was noted that despite a median age of 58 years, participants had rates of geriatric conditions similar or equivalent to adults in the general population with a median age of nearly 80 years52,53. Similarly, the study by Raven et al. included participants with a median age of 58 years and reported that almost 60% had limitations in lower extremity function. This was also shown in the earlier study by Brown30 and provides more evidence for the need for geriatric style rehabilitation services needed for people experiencing homelessness10.
At odds with the majority of studies, two Danish studies25,26 which evaluated fitness in a population of people experiencing homelessness who were participating in street soccer showed comparable fitness levels to control group values but mean ages were in the 3rd decade in these studies. Gregg and Bedard also showed that fitness and strength were comparable to reference ranges among healthy populations54 in also a relatively young cohort with an average age of 41.05 +/- 11.32 years. It is possible that these groups are not representative of the population as a whole, nonetheless the diversity of people experiencing homelessness and spectrum of ability is important to consider. It is also possible that physical functioning limitations may develop after the 3rd and 4th decades for some people experiencing homelessness.
While reported physical activity levels varied between studies, a large proportion of participants experiencing homelessness appeared to have low physical activity levels33. Promoting physical activity may mitigate against some of the burden of physical and mental health issues suffered by people experiencing homelessness46. One study27 highlighted a nuanced view indicating that physical activity was undertaken not necessarily for health gain but by participants out of necessity to access meals and to fill in time.
The number of outcomes and measures suggests a lack of empirical data in the area to aid clinical decision makers and researchers about the overall physical health status of people experiencing homelessness. Physical focused measures included in this review were for the most part cursory in nature and were subsidiary to other study outcomes. While a diversity of outcomes were included in studies included in this review, self-report measures were predominantly used rather than more robust objective methods with the exception of two studies which employed a gold standard measure to evaluate V02 max32,33. Studies by Brown et al. (2011), Brown et al. (2017) and Raven et al. (2017) were the only studies to examine mobility impairment. Only one study used the Short Physical Performance Battery, a useful battery of physical performance tests to assess functional status47. Only one study evaluated frailty and falls (Brown et al. 2011). All studies which evaluated physical activity used self-report measures which lack reliability and are prone to inaccuracies48.
The general lack of robust data which extensively evaluates physical functioning and physical activity among people experiencing homelessness may be also partly due to concerns regarding vulnerability and potential or perceived ability to participate in research can result in exclusion from research. This can lead to a lack of evidence on which to base policies and design suitable housing services.
Strengths and limitations
This review appears to be the first attempt to systematically present literature pertaining to physical functioning limitations and physical activity levels in adults experiencing homelessness. The scoping review methodology employed in this review was suitably broad to bring together evidence from heterogeneous methodology sources including observational, mixed method and qualitative designs of the experience of physical limitations in people experiencing homelessness as well as the diverse reporting of outcomes55. This scoping review allowed various inter-related physical aspects such as frailty, cardiovascular fitness, and flexibility among others. This methodology was also useful to examine emerging evidence in this relatively new field of research. In a topic as broad as physical functioning limitations it has helped focus on where future research and eventual systematic reviews should be targeted.
A number of limitations pertained to this review, however. Firstly, studies lacked a consistent definition of homelessness. As diverse study designs were included in this review, this resulted in strong heterogeneity which precluded the ability to quantitatively analyse results. A formal assessment of methodological quality of the included studies was not performed as scoping reviews aim to include a broad overview of available evidence, irrespective of quality55. Finally, potentially relevant evidence from other languages may have been missed as this review only included English language papers.
As all studies included in this review were community based, the generally low level of physical functioning and physical activity of this population is relevant to a broad spectrum of community based services including housing, social health services. Housing services should bear accessibility in mind and social activities should incorporate a physical/exercise component where possible.
Bearing in mind the prevalence of physical functioning limitations, we would advocate that all clinicians should screen this population for physical deficits so appropriate rehabilitation or other services can be initiated. We appreciate however, that the non-uniformity of outcomes and measurement tools applied presents a challenge to clinicians. Recommendations on appropriate physical functioning and physical activity measures are needed which are suitable to use in this population to prevent waste of valuable healthcare resources49. Studies should focus on reliability, validity and responsiveness of physical functioning measures for people experiencing homelessness as a basis for more effective clinical assessment and management. Further research should determine a core outcomes set56 applicable to this population. Ideally this would be a quick standardized physical test battery so reliable consistent data can be collated to highlight at risk groups, inform clinical decision making and practice and advocate for better services. Further consistent primary research needs to be conducted before a comprehensive systematic review can be conducted. Factors possibly contributing to physical functioning limitations such as age, co-morbidities as well as a host of other factors also need further exploration.
Conclusion
This review shows that adults experiencing homelessness appear to suffer physical functioning limitations and low physical activity levels but the inconsistency in measurement methods limits our ability to extensively profile this population at this time. Given the low levels of physical functioning shown in people experiencing homelessness, greater prominence and robustness of measurement methods should be applied to fully interrogate this area. Further research is necessary so adequate rehabilitation regimes and support can be put in place for this vulnerable population. This scoping review will guide future research and systematic review development in this emerging area.
Data availability
Underlying data
All data underlying the results are available as part of the article and no additional source data are required.
Extended data
Open Science Framework: Physical functioning limitations and physical activity of people experiencing homelessness: A review. https://doi.org/10.17605/OSF.IO/7VGZP19
This project contains the following extended data:
Reporting guidelines
Open Science Framework: PRISMA-ScR checklist for ‘Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review’. https://doi.org/10.17605/OSF.IO/7VGZP19
Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).
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Kiernan S, Mockler D, Ní Cheallaigh C and Broderick J. Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.12688/hrbopenres.13011.2)
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Mejia-Lancheros C. Reviewer Report For: Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.21956/hrbopenres.14378.r29009)
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HOW TO CITE THIS REPORT
Mejia-Lancheros C. Reviewer Report For: Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.21956/hrbopenres.14378.r29009)
The direct URL for this report is:
https://hrbopenresearch.org/articles/3-14/v2#referee-response-29009
https://hrbopenresearch.org/articles/3-14/v2#referee-response-29009
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 1
VERSION 1
PUBLISHED 16 Apr 2020
Views
21
How to cite this report:
Mejia-Lancheros C. Reviewer Report For: Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.21956/hrbopenres.14104.r28429)
The direct URL for this report is:
https://hrbopenresearch.org/articles/3-14/v1#referee-response-28429
https://hrbopenresearch.org/articles/3-14/v1#referee-response-28429
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 07 Dec 2020
Approved with Reservations
VIEWS 21
Overview
The study assessed the existing evidence on physical functioning limitation and physical activity among homeless adults using the scoping review framework. The findings highlight that people who experience homelessness have a high level of physical functioning impairment and ... Continue reading
The study assessed the existing evidence on physical functioning limitation and physical activity among homeless adults using the scoping review framework. The findings highlight that people who experience homelessness have a high level of physical functioning impairment and ... Continue reading
CITE
HOW TO CITE THIS REPORT
Mejia-Lancheros C. Reviewer Report For: Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.21956/hrbopenres.14104.r28429)
The direct URL for this report is:
https://hrbopenresearch.org/articles/3-14/v1#referee-response-28429
https://hrbopenresearch.org/articles/3-14/v1#referee-response-28429
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseThe authors would like to sincerely thank the reviewer for their extremely insightful comments. We have numbered each comment and responded to each in turn as per below.
Overview
... Continue reading -
Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseDear Reviewer 2,
Thank you for your very insightful comments, in response to your comments; we have made the following changes to the review.
Each comment is listed, ... Continue reading
COMMENTS ON THIS REPORT
-
Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseThe authors would like to sincerely thank the reviewer for their extremely insightful comments. We have numbered each comment and responded to each in turn as per below.
Overview
... Continue reading -
Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseDear Reviewer 2,
Thank you for your very insightful comments, in response to your comments; we have made the following changes to the review.
Each comment is listed, ... Continue reading
Views
30
How to cite this report:
Dawes J. Reviewer Report For: Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.21956/hrbopenres.14104.r27323)
The direct URL for this report is:
https://hrbopenresearch.org/articles/3-14/v1#referee-response-27323
https://hrbopenresearch.org/articles/3-14/v1#referee-response-27323
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 01 May 2020
Approved
VIEWS 30
Introduction
The background and rationale for this scoping review was clearly described and explains the importance of it being undertaken. The authors do address the aims of the paper, but are not explicit about the objectives (although objectives are ... Continue reading
The background and rationale for this scoping review was clearly described and explains the importance of it being undertaken. The authors do address the aims of the paper, but are not explicit about the objectives (although objectives are ... Continue reading
CITE
HOW TO CITE THIS REPORT
Dawes J. Reviewer Report For: Physical functioning limitations and physical activity of people experiencing homelessness: A scoping review [version 2; peer review: 2 approved]. HRB Open Res 2021, 3:14 (https://doi.org/10.21956/hrbopenres.14104.r27323)
The direct URL for this report is:
https://hrbopenresearch.org/articles/3-14/v1#referee-response-27323
https://hrbopenresearch.org/articles/3-14/v1#referee-response-27323
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
-
Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseThe authors would like to sincerely thank the reviewer for their extremely insightful comments. For clarity we numbered each comment and responded to it in turn.
Introduction
R1 Comment ... Continue reading -
Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseDear Reviewer 1,
Thank you for your very insightful comments, in response to your comments; we have made the following changes to the review.
Each comment is listed, ... Continue reading
COMMENTS ON THIS REPORT
-
Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseThe authors would like to sincerely thank the reviewer for their extremely insightful comments. For clarity we numbered each comment and responded to it in turn.
Introduction
R1 Comment ... Continue reading -
Author Response 01 Mar 2021Julie Broderick, Discipline of Physiotherapy, Trinity College Dublin, the University of Dublin, Dublin, Ireland01 Mar 2021Author ResponseDear Reviewer 1,
Thank you for your very insightful comments, in response to your comments; we have made the following changes to the review.
Each comment is listed, ... Continue reading
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations -
A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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