Running head: HEALTHCARE DISPARITIES

Healthcare Disparities in Chronically Homeless Adults Andrea Mygrants Ferris State University

HEALTHCARE DISPARITIES Abstract Being homeless in the US is a daily reality for many people. According to the executive summary, State of Homelessness in America, At a point in time in January 2012, 633,782 people were experiencing homelessness. This issue is important to nursing because this is a population of people that face an increase in health problems and disparities. These disparities are especially high in those people who are chronically homeless. In looking at what disparities they face along with policies and social stigma, nurses can better understand and care for chronically homeless adults.

HEALTHCARE DISPARITIES Healthcare Disparities in Chronically Homeless Adults The purpose of this paper is to highlight some of the issues that are facing chronically homeless adults in the United States. In particular interest to nursing is the question of what health disparities the homeless face. To answer this question, the definition and population of homelessness will be examined, health disparities will be identified, and contributing factors such as policies and attitudes toward homelessness will be also be looked at. Population and Disparity Population Homeless people are defined as those without a permanent nighttime residence. This can be people who spend the night on the street, in shelters, in tents, or any other non-permanent shelter. People that are doubled up, or staying with a friend or relative are considered homeless. People are also considered homeless if they are in nonpermanent housing such as a motel, or are being evicted from their home. (National Health Care for the Homeless Council, 2013) There are many types of people who become homeless, and the reasons for their homelessness also vary. Men, women, children, and entire families can become homeless. People may also become temporarily homeless or chronically homeless.

While chronically homeless people only make up about 27% of all homeless people, they are often at the most at risk for health disparities. Most chronically homeless people are also adults, and they make up about 88% of the homeless population. (SAMSHA, 2011) Due to their increased vulnerability, the focus of this paper will be on chronically homeless adults.

HEALTHCARE DISPARITIES Disparity Chronically homeless adults face many health disparities. The Journal of the American Medical Association (JAMA) published a study that looked at the death rates and causes of death for homeless adults. Their findings were that, Compared with Massachusetts adults, mortality disparities were most pronounced among younger individuals, with rates about 9-fold higher in 25- to 44-year-olds and 4.5-fold higher in 45- to 64-year-olds. (Baggett et al., 2013) The leading cause of death found for homeless adults 25-44 years old was found to be drug overdose, with opiate overdose implicated in 81% of these deaths. The leading cause of death for homeless adults aged 45-65 was found to be heart disease and cancer. (Baggett et al., 2013) According to a study in the Journal of Community Health, homeless adults have been shown to have higher rates certain illnesses such as tuberculosis, hepatitis and mental illness. Other identified disparities in the homeless population are race, 49% of homeless adults in the US are African American vs. Caucasian (35%) and Hispanic (13%). Less education, and increased risk of trauma are also higher in homeless adults. (Notaro, Khan, Kim, Nasaruddin & Desai, 2012) Social Determinants Poverty To say that homelessness is related to poverty seems obvious, but why has this become an increasing issue in the US? According to the National Coalition for the Homeless, Poor people are frequently unable to pay for housing, food, childcare, health care, and education. Difficult choices must be made when limited resources cover only

some of these necessities. Often it is housing, which absorbs a high proportion of income

HEALTHCARE DISPARITIES that must be dropped. If you are poor, you are essentially an illness, an accident, or a paycheck away from living on the streets. (National Coalition for the Homeless, 2009)

This is then exacerbated by high unemployment rates and jobs that are part time or do not pay a living wage, lack of affordable housing, and decreased funding to social assistance programs. (National Coalition for the Homeless, 2009) Mental Illness Mental illness is disproportionally higher in homeless adults than it is in the general US adult population. According to SAMSHA survey done in 2010, 26.2% of sheltered homeless adults had a serious mental illness versus a National Institute of Mental Health figure of 6% of adults overall having a serious mental illness. (SAMSHA, 2011), (National Institute of Mental Health, nd). Mental illness can also effect decision making skills, interpersonal relationships, and the ability to maintain employment which all increase a persons risk of becoming or staying homeless. Substance Abuse As mentioned before, homeless adults face a much higher mortality rate from substance abuse. Substance abuse may be a cause of homelessness, or occur afterward as a coping mechanism. Substance abuse may also occur in conjunction with mental illness and make it difficult to enter treatment programs that are designed to only treat substance abuse, or only treat mental illness. Substance abuse problems also make it difficult for homeless adults to find even temporary shelter, as most homeless shelters do not allow people to stay if they are intoxicated. Substance abuse problems are also harder to treat in homeless adults, as they are often more consumed with daily survival needs, and are

HEALTHCARE DISPARITIES therefore less motivated to address personal problems. (National Coalition for the Homeless, 2009) Criminal Record According to a study by Psychiatry Services, federal legislation enacted in

1996 required public housing authorities to enhance their screening of housing applicants so that more people with a criminal history would be excluded. Although housing authorities were required to reject applicants for only a few types of criminal offenses, typical implementations of the law followed rigid guidelines in excess of federal requirements. One analysis estimated that as many as 3.5 million Americans are currently ineligible for most federal housing assistance as a result of this law. (Malone, 2009) This exclusion of homeless people with a criminal record from housing assistance was then questioned by this study. The study looked to see what the rates of supportive housing success were between those with and without a criminal history, with housing success defined as retention of housing for two years, or moving to another appropriate living situation. The findings of the study showed that people with a criminal history did equally well with housing success as those who did not have a criminal history. (Malone, 2009) This difficulty with finding housing for homeless adults with a criminal background is only made worse by the fact that they often end up with further criminal charges for substance abuse, sleeping or defecating in public, or crimes related to mental illness exacerbation. Even for those homeless adults with a criminal record who do not have any substance abuse or mental illness problems, it can be difficult to find a home

HEALTHCARE DISPARITIES with no employment, and difficult to find employment without a home. This leads to cycle of homelessness and recidivism that is hard to escape. Policies

Federal policies are in place to help reduce homelessness. The US Department of Housing and Urban Development gives homeless assistance grants, and Supplemental Security Income (SSI) and Medicaid are granted to those with physical and mental disabilities. The Federal government also funds programs for homeless veterans through the Veterans Administration. While state and local policies vary greatly, most do have programs in place monitor and reduce homelessness. There are also a large number of private charity and non-profit organizations that work to provide shelter, food, and advocacy for homeless adults, children, and families. As shown in the previous sections, there also need to be some improvements and changes to policy to help reduce and eliminate homelessness. Policies at the federal, state, and local level should be focused on better mental health and substance abuse services, increased minimum wage laws, easier to navigate and non-discriminatory housing subsidies, and better assistance with housing and employment for people released from jail or prison. Contributing Factors Societal Views It is no mystery that homeless people are stigmatized in society. They way that they are forced to live their lives means they often violate important social mores about cleanliness, appropriate areas to sleep, and public intoxication. While people may have general sympathy or compassion for the poor or the needy, this sympathy may break

HEALTHCARE DISPARITIES down when faced with actual homeless people. In an NPR article about social views on homelessness in San Francisco, they cite people who are, tired of having to step over a sleeping or drunk homeless person just to get to the office. and want more aggressive action taken to get homeless people out of the street. (Gonzalez, 2007) Healthcare Worker Views

Attitudes toward homeless people by healthcare workers can make a difference in the care that they receive. In a report published by the Agency for Healthcare Research and Quality (AHRQ), they state findings that, Homeless individuals often report feeling unwelcome in health care settings, and they perceive their negative experiences to be the result of discrimination by health care providers on the basis of their homelessness or low social class. Intense emotional responses to these experiences can greatly decrease homeless individuals' desire to seek health care in the future. (Hwang & Henderson, 2010) Nurses and healthcare workers should seek to recognize this bias within them and actively work to decrease its impact on their patients.

HEALTHCARE DISPARITIES References

Baggett, T., Hwang, S., OConnell, J., Porneala, B., Stringfellow, E., Orav, E., Rigotti, N. (2013). Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. The Journal of the American Medical Association, 173(3), 189-195. doi: 10.1001/jamainternmed.2013.1604 Gonzalez, R. (2007, October 27). Attitude toward homeless shifts in San Francisco. Retrieved from http://www.npr.org/templates/story/story.php?storyId=15561430 Hwang, S., & Henderson, M. Agency for Healthcare Research and Quality, (2010). Health care utilization in homeless people: Translating research into policy and practice (Working Paper No. 10002). Retrieved from website: http://meps.ahrq.gov/mepsweb/data_files/publications/workingpapers/wp_10002. pdf Malone, D. (2009). Assessing criminal history as a predictor of future housing success for homeless adults with behavioral health disorders. Psychiatric Services, 60(2), 224-230. doi: 10.1176/appi.ps.60.2.224 National Coalition for the Homeless. (2009, July). Why are people homeless?. Retrieved from http://www.nationalhomeless.org/factsheets/why.html National Coalition for the Homeless. (2009, July), Substance Abuse and Homelessness. Retrieved from http://www.nationalhomeless.org/factsheets/addiction.pdf National Health Care for the Homeless Council. (2013). What is the official definition of homelessness?. Retrieved from http://www.nhchc.org/faq/official-definitionhomelessness/

HEALTHCARE DISPARITIES National Institute of Mental Health. (nd). The numbers count: Mental disorders in America. Retrieved from http://www.nimh.nih.gov/health/publications/thenumbers-count-mental-disorders-in-america/index.shtml Notaro, S., Khan, M., Kim, C., Nasaruddin, M., & Desai, K. (2012). Analysis of the

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health status of the homeless clients utilizing a free clinic. Journal of Community Health, 38(1), 172-177. doi: 10.1007/s10900-012-9598-0 Substance Abuse and Mental Health Services Administration (SAMHSA). (2011). Current statistics on the prevalence and characteristics of people experiencing homelessness in the United States. Retrieved from website: http://homeless.samhsa.gov/ResourceFiles/hrc_factsheet.pdf