Identification of cardiovascular risk factors in homeless adults

BACKGROUND: Cardiovascular disease is an important health problem among homeless adults; however, the common cardiac risk factors present in this population are unknown. This study was undertaken to identify the reversible cardiovascular risks present in the homeless. METHODS: A retrospective chart review was performed randomly on 100 patients who were seen at a homeless clinic in New Orleans, Louisiana. These patients were compared with 200 matched nonhomeless patients who attended an inner-city primary care clinic. Each chart from the 2 groups was reviewed for the presence of hypertension, diabetes mellitus type 2, cigarette smoking, and hypercholesterolemia. Statistical comparisons were made between the homeless and the control subjects. RESULTS: Hypertension was present in 65% of the homeless but only 52% of the nonhomeless [P < 0.05; odds ratio 1.78 (CI, 1.09 to 2.9)]. Smoking was far more common in the homeless than the nonhomeless, 75 versus 57%, respectively [P < 0.005; odds ratio 2.22 (CI, 1.27 to 3.88)]. There was no difference in the prevalence of diabetes or total cholesterol. Compared with national data hypertension, smoking and diabetes seem to be represented excessively in the homeless population. CONCLUSIONS: Smoking and hypertension are significantly more prevalent in the homeless population than in a matched cohort. Educational and preventive programs are needed to reduce the prevalence of cardiovascular disease and reduce the overutilization of expensive healthcare resources.     

Demographic differences in health status of homeless adults

OBJECTIVE: To determine how the physical health of homeless adults varies by the demographic characteristics of age, gender, ethnicity, lifetime length of homelessness, and work status. PARTICIPANTS: A community-based sample of 529 homeless adults. STUDY DESIGN: In multivariate analyses, the authors studied the independent contributions of five demographic groups to variations in 12 physical health measures (based on self-reports from face-to-face interviews, screening physical examinations, and venous blood samples). MEASUREMENTS AND MAIN RESULTS: Older persons were more likely to have a functional disability (p < 0.001), chronic disease (p < 0.001), and greater risk of dying (p < 0.001), but less likely to abuse substances (p < 0.001). Men were more likely than women to be substance users (p < 0.001) and to have a greater risk of dying (p < 0.001). Whites and blacks were less likely than respondents in other ethnic groups to have an abnormal blood test (p < 0.001). Persons homeless longer were more likely to be substance users (p < 0.001) and to have experienced trauma (p < 0.001). Working for pay was not related to any of our health measures. CONCLUSIONS: Age and gender contributed most to the understanding of differences in health status among homeless adults. Since the homeless have a wide variety of physical, mental, social, and substance-abuse problems, primary care providers are in the best position to provide the broad-based care needed by such persons.     

Differences in health status between older and younger homeless adults

The Institute of Medicine has placed a priority on determining the special health-care needs of elderly homeless persons. As part of a community-based study of 521 homeless adults in two beach communities of Los Angeles, we compared the demographic characteristics and health of older (age rangek 50-78, n = 61) and younger (age range, 18-49, n = 460) homeless individuals. Compared with younger adults, older adults were more likely to be white (85% versus 61%), veterans (59% versus 27%), retired (36% versus 3%), and living in a vehicle (21% versus 8%). Older adults were more likely to report having a chronic disease (69% versus 49%), functional disabilities, no informal social contacts during the previous month (49% versus 27%), observed high blood pressure (42% versus 22%), elevated creatinine (11% versus 2%), and elevated cholesterol (57% versus 36%). Older adults were less likely to have a toothache (3% versus 30%), report psychotic symptoms (25% versus 42%), and to be illegal drug users (15% versus 55%). Although they are chronologically younger, the constellation of health and functional problems of older homeless adults resemble those of geriatric persons in the general population. We suggest that geriatricians could play a significant role in training other primary-care providers to evaluate and treat socially isolated older homeless adults in a more comprehensive way than is currently standard in practice (e.g., interdisciplinary team care and emphasis on functional status, rehabilitative medicine, and assessment for sensory impairment).     

Health services utilization between older and younger homeless adults

PURPOSE: Our purpose in the current study was to examine the relationship between health services utilization delivered by means of the Homeless Outreach Medical Services (HOMES) program and health services utilization delivered by means of the Parkland emergency room and inpatient units among a sample of older and younger homeless adults being served by the Parkland Health and Hospital System. DESIGN AND METHODS: The HOMES program uses two 40-ft-long mobile medical units and a fixed-site outpatient clinic to provide primary health care on a walk-in, no-charge basis to individuals who are homeless. We used a quasi-experimental design, and we randomly selected health services utilization data from 293 male (50.4%) and 288 female (49.6%) homeless patients from among the 14,876 homeless patients aged 20-64 years who used HOMES and the Parkland Health and Hospital System between June 1, 1992, and June 30, 1999. The dependent variables were measurements of inpatient and outpatient utilization of psychiatric, substance abuse, and musculoskeletal services by homeless patients. Inpatient and outpatient utilization patterns by age were assessed. Data were analyzed using a split-plot repeated measures multivariate analysis of variance (MANOVA), one-way analysis of variance (ANOVA), and simple linear regression. RESULTS: Older homeless individuals utilized the HOMES more than inpatient services for substance abuse and musculoskeletal conditions, but they utilized inpatient services the most for psychiatric-related conditions. IMPLICATIONS: This level of inpatient utilization is perhaps a result of greater severity or progression of mental illness among older homeless adults. The level of outpatient utilization is probably because the HOMES program mitigates many of the barriers that prevent homeless individuals from obtaining primary medical care.     

Substance use and labor force participation among homeless adults

OBJECTIVES: We measured the proportion of homeless adults in the labor force and examined the impact of substance use on labor force participation. METHODS: A county-wide probability sample of 397 homeless adults was interviewed three times in a 15-month period. RESULTS: Almost 80% of homeless adults were employed or looking for work at one point in time; however, only 47.7% remained in the labor force over the 15-month study period. Recent drug users were only 5% as likely as other homeless adults to be in the labor force; and consistent public entitlement recipients were only 18% as likely as other homeless adults to be in the labor force. CONCLUSIONS: Recent illicit drug use posed a deterrent to labor force participation among homeless adults, but heavy alcohol use did not. Most homeless adults were not consistently in the labor force and those who were, did not receive public entitlement benefits. This finding poses an interesting dilemma since previous studies indicated that homeless adults, who are consistent public entitlement recipients, were more likely to get housed than those who are not.     

Substance use and labor force participation among homeless adults

Objectives: We measured the proportion of homeless adults in the labor force and examined the impact of substance use on labor force participation. Methods: A county-wide probability sample of 397 homeless adults was interviewed three times in a 15-month period. Results: Almost 80% of homeless adults were employed or looking for work at one point in time; however, only 47.7% remained in the labor force over the 15-month study period. Recent drug users were only 5% as likely as other homeless adults to be in the labor force; and consistent public entitlement recipients were only 18% as likely as other homeless adults to be in the labor force. Conclusions: Recent illicit drug use posed a deterrent to labor force participation among homeless adults, but heavy alcohol use did not. Most homeless adults were not consistently in the labor force and those who were, did not receive public entitlement benefits. This finding poses an interesting dilemma since previous studies indicated that homeless adults, who are consistent public entitlement recipients, were more likely to get housed than those who are not.     

Feasibility of completing an accelerated vaccine series for homeless adults

Summary.  Homeless adults are at high risk for hepatitis B virus (HBV) infection. In addition to culturally sensitive programmes designed to enhance vaccination compliance, accelerated HBV vaccination (three doses over 21 days) have also been suggested to improve compliance among high-risk groups. In this paper, we examined predictors of completers of two of three doses of a HAV/HBV vaccine series, normally delivered over a 6-month period, to simulate compliance with an accelerated series, dosed over 4 weeks. A convenience sample of 865 homeless adults was randomized into a nurse case-managed approach (NCMIT) vs standard programmes with (SIT) and without tracking (SI). Each group was assessed for completion of two of the three dose HAV/HBV vaccine series as well as the full three dose vaccine series. Sixty-eight percent of the NCMIT participants completed the three dose vaccination series at 6 months compared to 61% of SIT participants and 54% of SI participants. Eighty-one percent of the NCMIT participants completed two of the vaccinations compared to 78% of SIT participants and 73% of SI participants. The NCMIT approach resulted in greater numbers of completers of two of three doses and of the full three dose vaccine series. Predictors of completers of two doses and the full three dose vaccine series are provided. A greater number of homeless persons completed two doses across the three groups compared to the three dose vaccine series. The use of nurse case-management and tracking, coupled with an accelerated HAV/HBV vaccination schedule, may optimize vaccination compliance in homeless adults.     

Risk factors for hepatitis C virus infection among homeless adults

OBJECTIVE: To describe the prevalence of hepatitis C virus (HCV) infection in a sample of homeless and impoverished adults and examine risk factors for HCV infection in the overall sample and as a function of injection drug use. DESIGN: Assays were conducted on stored sera. Sociodemographic characteristics and risky sexual activity were measured by content-specific items. Substance use was measured by a structured questionnaire. HCV antibodies were tested by enzyme-linked immunosorbent assay; a confirmatory level was defined by recombinant immunoblot assay. SETTINGS: Shelters ( N = 36) and outdoor locations in Los Angeles. PARTICIPANTS: Eight hundred eighty-four homeless women and/or partners or friends. RESULTS: Among this sample of 884 homeless and impoverished adults, 22% were found to be HCV infected. Lifetime injection drug users (IDUs) (cocaine, crack, and methamphetamine) and recent daily users of crack were more likely than nonusers or less-frequent users of these drugs to be HCV-infected. Similar results were found for those who had been hospitalized for a mental health problem. Among non-injection drug users and persons in the total sample, those who reported lifetime alcohol abuse were more likely than those who did not to be HCV infected. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed IDUs have over 25 times greater odds of having HCV infection than non-IDUs. HCV infection was also predicted by older age, having started living on one's own before the age of 18, and recent chronic alcohol use. Males and recent crack users had about one and a half times greater odds of HCV infection when compared to females and non-chronic crack users. CONCLUSIONS: Targeted outreach for homeless women and their partners, including HCV testing coupled with referrals to HCV and substance abuse treatments, may be helpful.     

Community-based rapid HIV testing in homeless and marginally housed adults in San Francisco

BACKGROUND: Standard two-step HIV testing is limited by poor return-for-results rates and misses high-risk individuals who do not access conventional testing facilities. METHODS: We describe a community-based rapid HIV testing programme in which homeless and marginally housed adults recruited from shelters, free meal programmes and single room occupancy hotels in San Francisco received OraQuick Rapid HIV-1 Antibody testing (OraSure Technologies, Bethlehem, PA, USA). RESULTS: Over 8 months, 1614 adults were invited to participate and 1213 (75.2%) underwent testing. HIV seroprevalence was 15.4% (187 of 1213 individuals) overall and 3.5% (37 of 1063) amongst high-risk individuals reporting no previous testing, a prior negative test, or previous testing without result disclosure. All 1213 participants received their results. Of 30 newly diagnosed persons who received confirmatory results, 26 (86.7%) reported at least one contact with a primary healthcare provider in the 6 months following diagnosis. CONCLUSIONS: We conclude that community-based rapid testing is feasible, acceptable and effective based on the numbers of high-risk persons tested over a short period, the participation rate, the prevalence of new infection, the rate of result disclosure, and the proportion linked to care.     

Preferences for sites of care among urban homeless and housed poor adults

OBJECTIVE: To describe sources of health care used by homeless and housed poor adults. DESIGN: In a cross-sectional survey, face-to-face interviews were conducted to assess source of usual care, preferred site of care for specific problems, perceived need for health insurance at different sites of care, and satisfaction with care received. Polychotomous logistic regression analysis was used to identify the factors associated with selecting non-ambulatory-care sites for usual care. SETTING: Twenty-four community-based sites (i.e., soup kitchens, drop-in centers, and emergency shelters) frequented by the homeless and housed poor in Allegheny County, Pa. PARTICIPANTS: Of the 388 survey respondents, 85.6% were male, 78.1% African American, 76.9% between 30 and 49 years of age, 59.3% were homeless less than 1 year, and 70.6% had health insurance. MAIN RESULTS: Overall, 350 (90.2%) of the respondents were able to identify a source of usual medical care. Of those, 51.3% identified traditional ambulatory care sites (i.e., hospital-based clinics, community and VA clinics, and private physicians offices); 28.9% chose emergency departments; 8.0%, clinics based in shelters or drop-in centers; and 2.1%, other sites. Factors associated with identifying nonambulatory sites for usual care included lack of health insurance (relative risk range for all sites [RR] = 3.1-4.0), homelessness for more than 2 years (RR = 1. 4-3.0), receiving no medical care in the previous 6 months (RR = 1. 6-7.5), nonveteran status (RR = 1.0-2.5), being unmarried (RR = 1. 2-3.1), and white race (RR = 1.0-3.3). CONCLUSIONS: Having no health insurance or need for care in the past 6 months increased the use of a non-ambulatory-care site as a place for usual care. Programs designed to decrease emergency department use may need to be directed at those not currently accessing any care.     

Can the poor adhere? Incentives for adherence to TB prevention in homeless adults.

SETTING: Community-based population of homeless adults living in San Francisco, California. OBJECTIVE: To compare the effect of cash and non-cash incentives on 1) adherence to treatment for latent tuberculosis infection, and 2) length of time needed to look for participants who missed their dose of medications. DESIGN: Prospective, randomized clinical trial comparing a 5 dollar cash or a 5 dollar non-cash incentive. All participants received directly observed preventive therapy and standardized follow-up per a predetermined protocol. Completion rates and amount of time needed to follow up participants was measured. RESULTS: Of the 119 participants, 102 (86%) completed therapy. There was no difference between the cash and non-cash arms. Completion was significantly higher among males (OR 5.65, 95%CI 1.36-23.40, P = 0.02) and persons in stable housing at study entry (OR 4.86, 95%CI 1.32-17.94, P = 0.02). No substance use or mental health measures were associated with completion. Participants in the cash arm needed significantly less follow-up to complete therapy compared to the non-cash arm (P = 0.03). In multivariate analysis, non-cash incentive, use of crack cocaine, and no prior preventive therapy were associated with more follow-up time. CONCLUSION: Simple, low cost incentives can be used to improve adherence to TB preventive therapy in indigent adults.     

Vulnerability factors for homelessness associated with substance dependence in a community sample of homeless adults

We studied a community probability sample of 1185 homeless individuals to examine substance dependence in relationship to other personal and social vulnerabilities linked to homelessness, including sociodemographics, childhood/adolescent factors, prehomelessness factors, multiple episodes of homelessness, and the quality of shelter in their current episode of homelessness. These vulnerability factors were significantly concentrated in homeless individuals with lifetime and recent substance dependence, especially among those with both alcohol and drug dependence. In addition, the profiles of the homeless with alcohol dependence alone were distinct from those with drug dependence alone or both, with older age, more males, longer histories of homelessness, and significantly poorer quality shelter during the previous 30 days. Therefore, homeless individuals with substance dependence have many vulnerabilities beyond their substance dependence that should be dealt with in treatment or other service settings before lasting housing can be achieved.