Lisa Arangua

Access to women's health care: A qualitative study of barriers perceived by homeless women

ABSTRACT Homelessness is an escalating national problem and women are disproportionately affected. Nevertheless, few studies have focused on the special circumstances associated with being a homeless woman. For instance, while both genders experience serious barriers to obtaining health care, homeless women face an additional burden by virtue of their sexual and reproductive health needs. The current study was conducted as the first stage of a qualitative/quantitative investigation of homeless womens access and barriers to family planning and womens health care. We interviewed 47 homeless women of diverse ages and ethnic backgrounds. A qualitative approach was initially taken to explore the factors homeless women themselves perceive as barriers to their use of birth control and womens health services, and factors they believe would facilitate their use. Key findings are that health is not a priority for homeless women, that transportation and scheduling can be particularly burdensome for homeless women, and that being homeless leads some to feel stigmatized by health care providers. Despite being homeless, having children was extremely important to the women in our study. At the same time, those interested in contraception confronted significant barriers in their efforts to prevent pregnancies. We conclude with suggested interventions that would make general, gynecological, and reproductive health care more accessible to homeless women.

Health and Health Care Disparities Among Homeless Women

While disparities in health and health care between vulnerable (e.g., minorities, low-income) and majority populations are well documented, less is known about disparities within these special populations that are large and diverse. Such knowledge is essential to determine the neediest within these generally needy populations, and to plan interventions to reduce their health and health care disparities. With data from 1,331 women residing in Los Angeles County California, in one of the largest, most comprehensive studies of the health of homeless women to date, this study examined the health and health care disparities among homeless African American, Latina, and white women. This study further explored if race/ethnicity and other factors that predispose homeless women to poor health, or enable them to obtain better health care, were associated with their unmet need for medical care. The study found that white, non-Latina women were more likely to report unmet need than African Americans and Latinas, and women suffering from drug abuse, violence, or depression were most in need of care. These findings should be considered in targeting and addressing the special needs of homeless women of different racial/ethnic groups.

Prevalence, distribution, and correlates of hepatitis C virus infection among homeless adults in Los Angeles.

Objective. We documented the prevalence, distribution, and correlates of hepatitis C virus (HCV) infection among urban homeless adults. Methods. We sampled a community-based probability sample of 534 homeless adults from 41 shelters and meal programs in the Skid Row area of downtown Los Angeles, California. Participants were interviewed and tested for HCV, hepatitis B, and HIV. Outcomes included prevalence, distribution, and correlates of HCV infection; awareness of HCV positivity; and HCV counseling and treatment history. Results. Overall, 26.7% of the sample tested HCV-positive and 4.0% tested HIV-positive. In logistic regression analysis, independent predictors of HCV infection for the total sample included older age, less education, prison history, and single- and multiple-drug injection. Among lifetime drug injectors, independent predictors of HCV infection included older age, prison history, and no history of intranasal cocaine use. Among reported non-injectors, predictors of HCV infection included older age, less education, use of non-injection drugs, and three or more tattoos. Sexual behaviors and snorting or smoking drugs had no independent relationship with HCV infection. Among HCV-infected adults, nearly half (46.1%) were unaware of their infection. Conclusions. Despite the high prevalence of HCV infection, nearly half of the cases were hidden and few had ever received any HCV-related treatment. While injection drug use was the strongest independent predictor, patterns of injection drug use, non-injection drug use, prison stays, and multiple tattoos were also independent predictors of HCV. Findings suggest that urgent interventions are needed to screen, counsel, and treat urban homeless adults for HCV infection.

The Health Circumstances of Homeless Women in the United States

Women have become the fastest growing segment of the homeless population in the United States, yet very little is known about their sociodemographic profile, health status, use of health services, or the relation between their homeless condition to these social and health factors. This study draws on descriptive statistics and the multivariate results from nine major papers produced using data from the UCLA Homeless Womens Health Study to provide one of the first comprehensive profiles of the social, economic and health circumstances of homeless women in the United States. Homeless women are a highly vulnerable subgroup of the homeless population. The findings from the analysis of this large representative sample of homeless women indicates that the severity of the homeless condition itself is strongly associated with poor health and inadequate use of health services among these women. Findings also indicate that white women are especially vulnerable to adverse health and have limited access to various forms of health care. With the feminization of homelessness, it has become increasingly more important to target effective service linkages among providers of womens health services, substance abuse and mental health treatment and primary care to address the special needs of homeless women.

Project QUIT (Quit Using Drugs Intervention Trial): a randomized controlled trial of a primary care‐based multi‐component brief intervention to reduce risky drug use

AIMS To assess the effect of a multi-component primary care delivered brief intervention for reducing risky psychoactive drug use (RDU) among patients identified by screening. DESIGN Multicenter single-blind two-arm randomized controlled trial of patients enrolled from February 2011 to November 2012 with 3-month follow-up. Randomization and allocation to trial group were computer-generated. SETTING Primary care waiting rooms of five federally qualified health centers in Los Angeles County (LAC), USA. PARTICIPANTS A total of 334 adult primary care patients (171 intervention; 163 control) with RDU scores (4-26) on the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) self-administered on tablet computers. 261 (78%) completed follow-up. Mean age was 41.7 years; 62.9% were male; 37.7% were Caucasian. INTERVENTION(S) AND MEASUREMENT Intervention patients received brief (typically 3-4 minutes) clinician advice to quit/reduce their drug use reinforced by a video doctor message, health education booklet and up to two 20-30-minute follow-up telephone drug use coaching sessions. Controls received usual care and cancer screening information. Primary outcome was patient self-reported use of highest scoring drug (HSD) at follow-up. FINDINGS Intervention and control patients reported equivalent baseline HSD use at 3-month follow-up. After adjustment for covariates, in the complete sample linear regression model, intervention patients used their HSD on 3.5 fewer days in the previous month relative to controls (P<0.001), and in the completed sample model, intervention patients used their HSD 2.2 fewer days than controls (P < 0.005). No compensatory increases in use of other measured substances were found. CONCLUSIONS A primary-care based, clinician-delivered brief intervention with follow-up coaching calls may decrease risky psychoactive drug use.

Hepatitis C Among Clients of Health Care for the Homeless Primary Care Clinics

Objectives. To describe the prevalence, distribution and risk factors for hepatitis C virus (HCV) infection among homeless adults using eight Health Care for the Homeless (HCH) clinics nationally. Methods. Data were collected for 387 participants through blood draws, structured interviews, chart reviews. Results. Overall prevalence of HCV-antibody positivity was 31.0%, including 70.0% among injection drug users and 15.5% among reported non-injectors. Much HCV infection was hidden as the majority (53.3%) of HCV-antibody positive participants was unaware of their status. Independent risk factors for HCV among the total sample included injection drug use, prison, and tattoos; among injectors, risk factors included prison and three or more years of injection drug use; among reported non-injectors, risk factors included tattoos and prison. Conclusion. These HCH clinics serve high concentrations of HCV-infected injectors, making these and similar clinics priority intervention sites for aggressive screening, education, testing, and treatment for HCV and other blood-borne diseases.

Are homeless transitional shelters receptive to environmental tobacco control interventions

Despite a smoking prevalence approaching 70% among homeless adults in the US,1,2 little is known about ways to intervene on smoking behaviour in this marginalised population. Tobacco control advocates point to marketing by the tobacco industry and the pervasiveness and social acceptance of tobacco use in homeless settings as barriers to promoting effective cessation of smoking and smoke-free environments in this vulnerable population.3 They maintain that homeless service providers continue to hold apparently common assumptions that tobacco is a resource and that their clients have higher priority needs than to quit smoking.3–5 Recent studies, however, have begun to challenge these assumptions.2–6 In a series of focus groups and interviews exploring tobacco use behaviours among the homeless,2 up to 76% of homeless persons interviewed reported an intention to quit smoking in the next 6 months. Recent investigations in tobacco, alcohol and drug addiction have also demonstrated that rehabilitation programmes for misusers are commonly more effective when risky …

Hospitalizations Among Homeless Women: Are There Ethnic and Drug Abuse Disparities?

This paper explores associations among the vulnerabilities of being female, being a member of a minority group, and being a drug abuser in homeless women’s hospitalizations. It uses a 1997 probability survey of 974 homeless females age 15–44 in Los Angeles. In unadjusted analyses, whites were more likely than other ethnic minority groups to be hospitalized, and drug abusers were more likely to be hospitalized than non-drug abusers. Multiple logistic regression analyses indicated that factors associated with hospitalization differed considerably among the ethnic and drug-abuse subgroups. For example, ethnic disparities in inpatient health care were found for drug-abusing women, but not for those who did not abuse drugs. Pregnancy was the only important determinant of hospitalization in all subgroups (OR, 2.9–17.4). Preventing unintended pregnancy appears to be the most inclusive means of reducing hospitalization and attendant costs among homeless women.

Barriers to Drug Use Behavior Change Among Primary Care Patients in Urban United States Community Health Centers

In 2011 and 2012, 147 patients in urban United States Community Health Centers who misused drugs, but did not meet criteria for drug dependence, received a brief intervention as part of a National Institute on Drug Abuse-funded clinical trial of a screening and brief intervention protocol. Potential study participants were identified using the World Health Organization (WHO) Alcohol, Smoking, and Substance Involvement Screening Test. Data gathered during brief interventions were analyzed using grounded theory strategies to identify barriers patients believed inhibited drug use behavior change. Numerous perceived barriers to drug use behavior change were identified. Study implications and limitations are discussed.

Providers of primary care to homeless women in Los Angeles County.

Little is known about the access barriers homeless women face at the sites where they are most likely to receive primary health care. To investigate this issue, we administered a mail survey to administrators and clinicians at clinic sites that were actual or potential providers of primary health care to homeless women in Los Angeles County in 1997. The response rate was 65%. Ninety percent of the homeless women seen by responding sites were seen at only 34% of those sites (designated as “major providers”). Deficiencies were identified in several structural and process characteristics that enhance access to and quality of care for homeless women, including clinician training in care for homeless persons; formal screening for homeless status and associated risk factors; and on-site provision of comprehensive health services, including mental health, substance abuse, reproductive health, and ancillary services. Some, but not all, deficiencies were less severe at major providers. Our results suggest that, although providers of care to homeless women share challenges faced by many safety net providers, there are several policy interventions that could improve access to and quality of care for homeless women.