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Varley AL, Hoge A, Riggs KR, deRussy A, Jones AL, Austin EL, Gabrielian S, Gelberg L, Gordon AJ, Blosnich JR, Montgomery AE, Kertesz SG. What do Veterans with homeless experience want us to know that we are not asking? A qualitative content analysis of comments from a national survey of healthcare experience. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e5027-e5037. [PMID: 35866310 PMCID: PMC9942008 DOI: 10.1111/hsc.13918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 06/15/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
Surveys of people who experience homelessness can portray their life and healthcare experiences with a level of statistical precision; however, few have explored how the very same surveys can deliver qualitative insights as well. In responding to surveys, people experiencing homelessness can use the margins to highlight health and social concerns that investigators failed to anticipate that standard question batteries miss. This study describes the unprompted comments of a large national survey of Veterans with homeless experiences. The Primary Care Quality-Homeless Services Tailoring (PCQ-HOST) survey presented 85 close-ended items to solicit social and psychological experiences, health conditions, and patient ratings of primary care. Amongst 5377 Veterans responding to the paper survey, 657 (12%) offered 1933 unprompted comments across nearly all domains queried. Using a team-based content analysis approach, we coded and organised survey comments by survey domain, and identified emergent themes. Respondents used comments for many purposes. They noted when questions called for more nuanced responses than those allowed, especially 'sometimes' or 'not applicable' on sensitive questions, such as substance use, where recovery status was not queried. On such matters, the options of 'no' and 'yes' failed to capture important contextual and historical information that mattered to respondents, such as being in recovery. Respondents also elaborated on negative and positive care experiences, often naming specific clinics or clinicians. This study highlights the degree to which members of vulnerable populations, who participate in survey research, want researchers to know the reasons behind their responses and topics (like chronic pain and substance use disorders) that could benefit from open-ended response options. Understanding patient perspectives can help improve care. Quantitative data from surveys can provide statistical precision but may miss key patient perspectives. The content that patients write into survey margins can highlight shortfalls of a survey and point towards future areas of inquiry. Veterans with homeless experience want to provide additional detail about their lives and care experiences in ways that transcend the boundaries of close-ended survey questions. Questions on substance use proved especially likely to draw comments that went beyond the permitted response options, often to declare that the respondent was in recovery. Respondents frequently clarified aspects of their care experiences related to pain, pain care, transportation and experiences of homelessness.
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Affiliation(s)
- Allyson L Varley
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
| | - April Hoge
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
| | - Kevin R Riggs
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Aerin deRussy
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
| | - Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Erika L Austin
- University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA
| | - Sonya Gabrielian
- VA Greater Los Angeles, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Lillian Gelberg
- VA Greater Los Angeles, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Ann Elizabeth Montgomery
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
- University of Alabama at Birmingham School of Public Health, Birmingham, Alabama, USA
| | - Stefan G Kertesz
- Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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deRussy AJ, Jones AL, Austin EL, Gordon AJ, Gelberg L, Gabrielian SE, Riggs KR, Blosnich JR, Montgomery AE, Holmes SK, Varley AL, Hoge AE, Kertesz SG. Insights for Conducting Large-Scale Surveys with Veterans Who Have Experienced Homelessness. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2021; 32:123-134. [PMID: 37234355 PMCID: PMC10208227 DOI: 10.1080/10530789.2021.2013013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/15/2021] [Accepted: 11/27/2021] [Indexed: 05/27/2023]
Abstract
Surveys of underserved patient populations are needed to guide quality improvement efforts but are challenging to implement. The goal of this study was to describe recruitment and response to a national survey of Veterans with homeless experience (VHE). We randomly selected 14,340 potential participants from 26 U.S. Department of Veterans Affairs (VA) facilities. A survey contract organization verified/updated addresses from VA administrative data with a commercial address database, then attempted to recruit VHE through 4 mailings, telephone follow-up, and a $10 incentive. We used mixed-effects logistic regressions to test for differences in survey response by patient characteristics. The response rate was 40.2% (n=5,766). Addresses from VA data elicited a higher response rate than addresses from commercial sources (46.9% vs 31.2%, p<.001). Residential addresses elicited a higher response rate than business addresses (43.8% vs 26.2%, p<.001). Compared to non-respondents, respondents were older, less likely to have mental health, drug, or alcohol conditions, and had fewer VA housing and emergency service visits. Collectively, our results indicated a national mailed survey approach is feasible and successful for reaching VA patients who have recently experienced homelessness. These findings offer insight into how health systems can obtain perspectives of socially disadvantaged groups.
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Affiliation(s)
| | - Audrey L Jones
- VA Salt Lake City Health Care System
- University of Utah School of Medicine
| | - Erika L Austin
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Public Health
| | - Adam J Gordon
- VA Salt Lake City Health Care System
- University of Utah School of Medicine
| | - Lillian Gelberg
- VA Greater Los Angeles Healthcare System
- University of California Los Angeles
| | - Sonya E Gabrielian
- VA Greater Los Angeles Healthcare System
- University of California Los Angeles
| | - Kevin R Riggs
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Medicine
| | - John R Blosnich
- VA Pittsburgh Healthcare System
- Suzanne Dworak-Peck School of Social Work, University of Southern California
| | - Ann Elizabeth Montgomery
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Public Health
| | | | - Allyson L Varley
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Medicine
| | | | - Stefan G Kertesz
- Birmingham Veterans Affairs Medical Center
- University of Alabama at Birmingham School of Public Health
- University of Alabama at Birmingham School of Medicine
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Baggett TP, Liauw SS, Hwang SW. Cardiovascular Disease and Homelessness. J Am Coll Cardiol 2019; 71:2585-2597. [PMID: 29852981 DOI: 10.1016/j.jacc.2018.02.077] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 02/09/2018] [Accepted: 02/11/2018] [Indexed: 01/14/2023]
Abstract
Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts
| | - Samantha S Liauw
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stephen W Hwang
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada.
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Health status of the homeless in Dublin: does the mobile health clinic improve access to primary healthcare for its users? Ir J Med Sci 2018; 188:545-554. [PMID: 30178074 DOI: 10.1007/s11845-018-1892-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 08/17/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Homeless people experience substantially higher rates of illness and significant barriers to accessing health services. The mobile health clinic (MHC), staffed by trainee general practitioners, targets and provides homeless people in Dublin with free and easy access to primary healthcare services. AIMS To explore and determine the specific health reasons for attending the mobile health unit and to investigate whether the MHC improves access to primary healthcare for homeless people. METHODS Interviewer-administered questionnaire addressed demographic characteristics, physical and mental health status. RESULTS Forty-two participants were recruited in this study. The majority were male (90%), single (74%), Irish (81%) and in the 25-44 age group (71%). Risky health behaviour was common: tobacco use (93%; 39/42), illicit drug use (60%; 25/42) and alcohol use (45%; 19/42). Most participants described their health status as fair (48%) or good (31%). There were high rates of physical and mental health conditions. Hepatitis C (29%; 12/42) and depression (43%; 18/42) were prevalent. Dental disease was present in 79%. Compared with MHC, most health conditions were diagnosed and treated at other healthcare facility (OHF) [134 vs 27]. Report of physical health symptoms, such as coughs (61%) and migraine headache (46%), was also high, an average of five per person/year. CONCLUSION While the findings of this study are limited by the small sample size, they nevertheless indicate that the MHC promotes access to primary care service. Results also highlight the need to expand the healthcare approaches on the MHC to adequately meet the health needs of its target population.
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Baggett TP, Yaqubi A, Berkowitz SA, Kalkhoran SM, McGlave C, Chang Y, Campbell EG, Rigotti NA. Subsistence difficulties are associated with more barriers to quitting and worse abstinence outcomes among homeless smokers: evidence from two studies in Boston, Massachusetts. BMC Public Health 2018; 18:463. [PMID: 29631559 PMCID: PMC5891993 DOI: 10.1186/s12889-018-5375-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/26/2018] [Indexed: 02/07/2023] Open
Abstract
Background Three-quarters of homeless people smoke cigarettes. Competing priorities for shelter, food, and other subsistence needs may be one explanation for low smoking cessation rates in this population. We analyzed data from two samples of homeless smokers to examine the associations between subsistence difficulties and 1) smoking cessation readiness, confidence, and barriers in a cross-sectional study, and 2) smoking abstinence during follow-up in a longitudinal study. Methods We conducted a survey of homeless smokers (N = 306) in 4/2014–7/2014 and a pilot randomized controlled trial (RCT) for homeless smokers (N = 75) in 10/2015–6/2016 at Boston Health Care for the Homeless Program. In both studies, subsistence difficulties were characterized as none, low, or high based on responses to a 5-item scale assessing the frequency of past-month difficulty finding shelter, food, clothing, a place to wash, and a place to go to the bathroom. Among survey participants, we used linear regression to assess the associations between subsistence difficulty level and readiness to quit, confidence to quit, and a composite measure of perceived barriers to quitting. Among RCT participants, we used repeated-measures logistic regression to examine the association between baseline subsistence difficulty level and carbon monoxide-defined brief smoking abstinence assessed 14 times over 8 weeks of follow-up. Analyses adjusted for demographic characteristics, substance use, mental illness, and nicotine dependence. Results Subsistence difficulties were common in both study samples. Among survey participants, greater subsistence difficulties were associated with more perceived barriers to quitting (p < 0.001) but not with cessation readiness or confidence. A dose-response relationship was observed for most barriers, particularly psychosocial barriers. Among RCT participants, greater baseline subsistence difficulties predicted less smoking abstinence during follow-up in a dose-response fashion. In adjusted analyses, individuals with the highest level of subsistence difficulty had one-third the odds of being abstinent during follow-up compared to those without subsistence difficulties (OR 0.33, 95% CI 0.11–0.93) despite making a similar number of quit attempts. Conclusions Homeless smokers with greater subsistence difficulties perceive more barriers to quitting and are less likely to do so despite similar readiness, confidence, and attempts. Future studies should assess whether addressing subsistence difficulties improves cessation outcomes in this population. Trial registration ClinicalTrials.gov: NCT02565381.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA. .,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA. .,Department of Medicine, Harvard Medical School, Boston, MA, USA. .,Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, MA, USA.
| | - Awesta Yaqubi
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA
| | - Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Sara M Kalkhoran
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Claire McGlave
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Eric G Campbell
- Department of Medicine, Harvard Medical School, Boston, MA, USA.,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA.,Tobacco Research & Treatment Center, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA.,Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, MA, USA
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Expanded Medicaid Provides Access to Substance Use, Mental Health, and Physician Visits to Homeless and Precariously Housed Persons. J Community Health 2017; 43:207-211. [DOI: 10.1007/s10900-017-0405-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Baggett TP, Campbell EG, Chang Y, Rigotti NA. Other tobacco product and electronic cigarette use among homeless cigarette smokers. Addict Behav 2016; 60:124-30. [PMID: 27128808 DOI: 10.1016/j.addbeh.2016.04.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 04/08/2016] [Accepted: 04/14/2016] [Indexed: 01/29/2023]
Abstract
OBJECTIVE We determined the prevalence and correlates of other tobacco product and electronic cigarette (e-cigarette) use in a clinic-based sample of homeless cigarette smokers. METHODS In April-July 2014, we used time-location sampling to conduct a cross-sectional, in-person survey of 306 currently homeless adult cigarette smokers recruited from 5 clinical sites at Boston Health Care for the Homeless Program. We assessed past-month use of large cigars, little cigars, smokeless tobacco, and e-cigarettes. Among those who had used e-cigarettes, we assessed the reasons for doing so. We used logistic regression analysis to identify the participant characteristics associated with the use of each product. RESULTS Eighty-six percent of eligible individuals participated in the survey. In the past month, 37% of respondents used large cigars, 44% used little cigars, 8% used smokeless tobacco, 24% used an e-cigarette, and 68% used any of these products. Reasons for e-cigarette use included curiosity (85%) and to help quit conventional cigarettes (69%). In multivariable regression analyses, homeless smokers with greater subsistence difficulties were more likely to use little cigars (p=0.01) and less likely to use e-cigarettes (p=0.001). Non-Hispanic black (p=0.01), Hispanic (p<0.001), and rough-sleeping (p=0.04) participants were more likely to use large cigars. Readiness to quit was not associated with other tobacco product use but was significantly associated with e-cigarette use to help quit smoking (p=0.02). CONCLUSIONS Health care providers who serve homeless people should consider routine screening for the use of other tobacco products and e-cigarettes to help guide smoking cessation discussions and tobacco treatment planning.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States; Boston Health Care for the Homeless Program, Boston, MA, United States.
| | - Eric G Campbell
- Department of Medicine, Harvard Medical School, Boston, MA, United States; Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, United States
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Harvard Medical School, Boston, MA, United States; Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, United States
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Baggett TP, Campbell EG, Chang Y, Magid LM, Rigotti NA. Posttraumatic Stress Symptoms and Their Association With Smoking Outcome Expectancies Among Homeless Smokers in Boston. Nicotine Tob Res 2015; 18:1526-32. [PMID: 26508393 DOI: 10.1093/ntr/ntv238] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 10/20/2015] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Cigarette smoking and traumatic life experiences are each common among homeless adults, but the prevalence and correlates of posttraumatic stress disorder (PTSD) symptoms among homeless smokers are not known. We assessed symptoms of PTSD and their association with smoking outcome expectancies in a sample of homeless smokers in Boston. METHODS We used time-location sampling to conduct an in-person survey of homeless adult smokers using Boston Health Care for the Homeless Program clinical services. We assessed symptoms of PTSD with the PTSD Checklist-Civilian version and considered scores at least 14 as positive. We used the Smoking Effects Questionnaire to assess positive and negative smoking outcome expectancies. We modeled the associations between PTSD screening status and smoking expectancies using design-adjusted linear regression. RESULTS Eighty-six percent of eligible individuals participated (N = 306). Sixty-eight percent of participants screened positive for PTSD. Screen-positive respondents were younger (P = .001), more likely to report fair/poor health (P = .01), chronic obstructive pulmonary disease (P = .02), and past-month hallucinations (P = .004), and had greater drug (P < .001) and alcohol (P < .001) use severity and cigarette dependence (P = .002). In analyses controlling for these confounders, PTSD screen-positive participants more strongly endorsed smoking to reduce negative affect (P = .01), smoking for social benefits (P = .002), and smoking for weight control (P = .03). Exploratory analyses suggested that these associations were driven by avoidance/numbing and re-experiencing symptoms. CONCLUSIONS Symptoms of posttraumatic stress are common among homeless smokers and strongly associated with positive smoking outcome expectancies. Tobacco cessation programs for this population should consider screening for PTSD and fostering a trauma-sensitive treatment environment. IMPLICATIONS In this study of homeless cigarette smokers in Boston, over two-thirds of participants screened positive for PTSD. PTSD screen-positive respondents more strongly endorsed multiple positive smoking outcome expectancies than screen-negative individuals. These findings suggest that the psychological sequelae of trauma may be a pervasive but under-recognized factor impacting the persistence of smoking among homeless people. Tobacco cessation programs for this population should consider screening for PTSD, fostering a trauma-sensitive treatment environment, and incorporating strategies that have shown promise in smokers with PTSD.
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Affiliation(s)
- Travis P Baggett
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Boston Health Care for the Homeless Program, Boston, MA;
| | - Eric G Campbell
- Department of Medicine, Harvard Medical School, Boston, MA; Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA
| | - Leah M Magid
- College of Health and Rehabilitation Sciences and School of Public Health, Boston University, Boston, MA
| | - Nancy A Rigotti
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA
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Abstract
Although homeless individuals often experience health problems requiring care, there are limitations to available research concerning the scale of their needs and the accessibility of safety net agencies to meet them. Traditional access-to-care surveys calculate unmet need among all persons queried (rather than persons needing care), making it difficult to calculate what percentage of persons requiring care actually obtain it. Additionally, no research has compared the relative accessibility of safety net programs to homeless persons in need. This cross-sectional, community-based survey assessed the prevalence of unmet need for several specific types of health care and compared the accessibility of agencies in Birmingham, AL. Substantial proportions of respondents reported unmet needs for general medical care (46 %), specialty care (51 %), mental health care (51 %), dental care (62 %), medications (57 %), and care of a child (23 %). The most commonly mentioned sites where care was sought included a federally funded Health Care for the Homeless (HCH) program (59 %), a religious free clinic (31 %), and a public hospital emergency department (51 %). The HCH program was most commonly cited as the location where care, once sought, could not be obtained (15 %), followed by the county hospital primary care clinics (13 %). In this survey, unmet need was common for all types of care queried, including primary care. Key components of the safety net, including a federally funded homeless health care program, had suboptimum accessibility.
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Palepu A, Patterson ML, Moniruzzaman A, Frankish CJ, Somers J. Housing first improves residential stability in homeless adults with concurrent substance dependence and mental disorders. Am J Public Health 2013; 103 Suppl 2:e30-6. [PMID: 24148035 DOI: 10.2105/ajph.2013.301628] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the relationship between substance dependence and residential stability in homeless adults with current mental disorders 12 months after randomization to Housing First programs or treatment as usual (no housing or support through the study). METHODS The Vancouver At Home study in Canada included 2 randomized controlled trials of Housing First interventions. Eligible participants met the criteria for homelessness or precarious housing, as well as a current mental disorder. Residential stability was defined as the number of days in stable residences 12 months after randomization. We used negative binomial regression modeling to examine the independent association between residential stability and substance dependence. RESULTS We recruited 497 participants, and 58% (n = 288) met the criteria for substance dependence. We found no significant association between substance dependence and residential stability (adjusted incidence rate ratio = 0.97; 95% confidence interval = 0.69, 1.35) after adjusting for housing intervention, employment, sociodemographics, chronic health conditions, mental disorder severity, psychiatric symptoms, and lifetime duration of homelessness. CONCLUSIONS People with mental disorders might achieve similar levels of housing stability from Housing First regardless of whether they experience concurrent substance dependence.
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Affiliation(s)
- Anita Palepu
- Anita Palepu is with the Department of Medicine, University of British Columbia, Vancouver, British Columbia. Michelle L. Patterson, Akm Moniruzzaman, and Julian Somers are with the Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia. C. James Frankish is with the School of Public and Population Health, University of British Columbia, Vancouver
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Palepu A, Gadermann A, Hubley AM, Farrell S, Gogosis E, Aubry T, Hwang SW. Substance use and access to health care and addiction treatment among homeless and vulnerably housed persons in three Canadian cities. PLoS One 2013; 8:e75133. [PMID: 24124470 PMCID: PMC3790780 DOI: 10.1371/journal.pone.0075133] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 08/07/2013] [Indexed: 11/25/2022] Open
Abstract
Introduction We examined the prevalence of substance use disorders among homeless and vulnerably housed persons in three Canadian cities and its association with unmet health care needs and access to addiction treatment using baseline data from the Health and Housing in Transition Study. Methods In 2009, 1191 homeless and vulnerably housed persons were recruited in Vancouver, Toronto, and Ottawa, Canada. Interviewer administered questionnaires collected data on socio-demographics, housing history, chronic health conditions, mental health diagnoses, problematic drug use (DAST-10≥6), problematic alcohol use (AUDIT≥20), unmet physical and mental health care needs, addiction treatment in the past 12 months. Three multiple logistic regression models were fit to examine the independent association of substance use with unmet physical health care need, unmet mental health care need, and addiction treatment. Results Substance use was highly prevalent, with over half (53%) screening positive for the DAST-10 and 38% screening positive for the AUDIT. Problematic drug use was 29%, problematic alcohol use was lower at 16% and 7% had both problematic drug and alcohol use. In multiple regression models for unmet need, we found that problematic drug use was independently associated with unmet physical (adjusted odds ratio [AOR] 1.95; 95% confidence interval [CI] 1.43–2.64) and unmet mental (AOR 3.06; 95% CI 2.17–4.30) health care needs. Problematic alcohol use was not associated with unmet health care needs. Among those with problematic substance use, problematic drug use was associated with a greater likelihood of accessing addiction treatment compared to those with problematic alcohol use alone (AOR 2.32; 95% CI 1.18–4.54). Conclusions Problematic drug use among homeless and vulnerably housed individuals was associated with having unmet health care needs and accessing addiction treatment. Strategies to provide comprehensive health services including addiction treatment should be developed and integrated within community supported models of care.
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Affiliation(s)
- Anita Palepu
- Centre for Health Evaluation and Outcome Sciences, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- * E-mail:
| | - Anne Gadermann
- Centre for Health Evaluation and Outcome Sciences, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Anita M. Hubley
- Department of Education and Counseling Psychology and Special Education, University of British Columbia, Vancouver, BC, Canada
| | - Susan Farrell
- Department of Psychiatry, Royal Ottawa Health Care Group, University of Ottawa, Ottawa, ON, Canada
| | - Evie Gogosis
- Centre for Research on Inner City Health, Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
| | - Tim Aubry
- Centre for Research on Educational and Community Services, School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Stephen W. Hwang
- Centre for Research on Inner City Health, Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
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Hwang SW, Ueng JJM, Chiu S, Kiss A, Tolomiczenko G, Cowan L, Levinson W, Redelmeier DA. Universal health insurance and health care access for homeless persons. Am J Public Health 2010; 100:1454-61. [PMID: 20558789 DOI: 10.2105/ajph.2009.182022] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We examined the extent of unmet needs and barriers to accessing health care among homeless people within a universal health insurance system. METHODS We randomly selected a representative sample of 1169 homeless individuals at shelters and meal programs in Toronto, Ontario. We determined the prevalence of self-reported unmet needs for health care in the past 12 months and used regression analyses to identify factors associated with unmet needs. RESULTS Unmet health care needs were reported by 17% of participants. Compared with Toronto's general population, unmet needs were significantly more common among homeless individuals, particularly among homeless women with dependent children. Factors independently associated with a greater likelihood of unmet needs were younger age, having been a victim of physical assault in the past 12 months, and lower mental and physical health scores on the 12-Item Short Form Health Survey. CONCLUSIONS Within a system of universal health insurance, homeless people still encounter barriers to obtaining health care. Strategies to reduce nonfinancial barriers faced by homeless women with children, younger adults, and recent victims of physical assault should be explored.
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Affiliation(s)
- Stephen W Hwang
- Centre for Research on Inner City Health, St Michael's Hospital, Toronto, Ontario, Canada.
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Baggett TP, O'Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J Public Health 2010; 100:1326-33. [PMID: 20466953 DOI: 10.2105/ajph.2009.180109] [Citation(s) in RCA: 319] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed the prevalence and predictors of past-year unmet needs for 5 types of health care services in a national sample of homeless adults. METHODS We analyzed data from 966 adult respondents to the 2003 Health Care for the Homeless User Survey, a sample representing more than 436,000 individuals nationally. Using multivariable logistic regression, we determined the independent predictors of each type of unmet need. RESULTS Seventy-three percent of the respondents reported at least one unmet health need, including an inability to obtain needed medical or surgical care (32%), prescription medications (36%), mental health care (21%), eyeglasses (41%), and dental care (41%). In multivariable analyses, significant predictors of unmet needs included food insufficiency, out-of-home placement as a minor, vision impairment, and lack of health insurance. Individuals who had been employed in the past year were more likely than those who had not to be uninsured and to have unmet needs for medical care and prescription medications. CONCLUSIONS This national sample of homeless adults reported substantial unmet needs for multiple types of health care. Expansion of health insurance may improve health care access for homeless adults, but addressing the unique challenges inherent to homelessness will also be required.
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Affiliation(s)
- Travis P Baggett
- General Medicine Division, Massachusetts General Hospital, Boston, MA 02114, USA.
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