HEALTH PROMOTION PROGRAM

Health Promotion Program

Health Promotion Program

Introduction: The problem

It is estimated that from 500,000 to 700,000 people in the United States are homeless on any one night (National Law Center on Homelessness and Poverty, 1999). A nationwide U.S. telephone survey revealed that an estimated 13.5million people have been homeless sometime in their lives (Link, Susser, Phelan, Moore, & Struening, 1994).

The definition of homelessness as having spent more than seven consecutive nights in a shelter or other nondwelling (Homeless Assistance Act, 1987) is well accepted and was used for this study. Although the number of persons who are homeless fluctuates with the economic situation in the United States, the homeless are one of the most rapidly expanding segments of the medically underserved (Crane, 1991; US Conference of Mayors, 1998). Although morbidity in homeless persons is well documented (Bottomley, 2001; Ferenchick, 1992; Gelberg, Linn, Usatine, & Smith, 1990), and most cities provide ongoing preventative health care, no study has explored the process used by homeless persons to decide whether or not to access disease-detection health services. The purpose of this study was to describe the factors reported by homeless persons as influencing their decisions to utilize or reject a public health tuberculosis (TB)-detection service. The research question guiding the study was: What are the factors that homeless persons report as influencing their decisions to accept or reject a public health TB-detection effort?

Vulnerable population and setting

The objective physical and mental health of the U.S. homeless population has received considerable study. Health problems in homeless persons are disproportionately higher than health problems in the general population— higher rates of drug and alcohol abuse and mental illness have been reported (Fischer & Breaky, 1991; Gill, Melzer, & Hinds, 1996; Wenzel et al., 2001). Incidence of injuries, fractures, dental, and gynecologic problems exceed the incidence in the housed population (Ferenchick, 1992; Wright & Weber, 1997). High rates of respiratory tract disease, peripheral vascular disease, hypertension, liver disease including hepatitis C, foot pain, severe vision problems, dermatologic problems, and communicable diseases have been reported (Gelberg et al., 1990; Hibbs et al., 1994; Nyamathi, Dixon, Robbins, Longshore, & Gelberg, 2002; Power & Hunter, 2001). Communicable diseases are more prevalent in the homeless, because of impaired immune status related to poor nutrition and exposure to weather, high rates of drug addiction and human immunodeficiency virus (HIV), and crowded conditions in shelters (Krieger & Higgins, 2002; Oliveira & Goldberg, 2002; Sundwall & Tavani, 1991). When compared to low-income housed mothers, homeless sheltered mothers were more likely to have experienced severe physical and sexual assault, major depressive disorder, posttraumatic stress disorder, and substance-abuse problems (Bassuk et al., 1996). Approximately 20-25% of the homeless population is affected by mental disorders (Sullivan, Burman, & Koegel, 2002), although the stereotypic long-term seriously ill, antisocial people comprise less than 10% of homeless persons (Sundwall & Tavani, 1991). The need for homeless persons to receive ongoing preventative health care and treatment for acute and chronic illness is not ...