Paul Koegel

Competing priorities as a barrier to medical care among homeless adults in Los Angeles.

OBJECTIVES The role of competing priorities as a barrier to the utilization of physical health services was assessed in a subset (n = 363) of a probability sample of homeless adults in Los Angeles. METHODS Unadjusted odds of four measures of health services utilization were calculated for those with frequent difficulty in meeting their subsistence needs. These odds were then adjusted for a range of characteristics assumed to affect the utilization of health services among the homeless. RESULTS Before and after adjustment, those with frequent subsistence difficulty were less likely to have a regular source of care (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.16, 0.53) and more likely to have gone without needed medical care (OR = 1.77, 95% CI = 1.04, 3.00). Subsistence difficulty had no impact on the likelihood of having an outpatient visit or having been hospitalized. Conclusions remained the same after adjustment. CONCLUSIONS Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults.

Childhood Risk Factors for Homelessness Among Homeless Adults

OBJECTIVES This effort used data from the Course of Homelessness study and comparative secondary data on the general population to identify negative childhood and family background experiences that may increase risk for adult homelessness. METHODS Frequencies of negative childhood experiences were examined among a probability sample of 1563 homeless adults. Differences in risk for such experiences were calculated by sex, age cohort, and racial/ethnicity status. Where possible, rates of negative childhood experiences among the homeless were compared with the general population. RESULTS Substantial numbers of this sample experienced multiple problems as children across several domains: poverty, residential instability, and family problems. Women and Whites disproportionately reported experiences suggestive of personal or family problems; non-Whites disproportionately reported experiences suggestive of personal or family problems; non-Whites disproportionately reported experiences suggestive of poverty. Homeless adults were at increased risk of childhood out-of-home placement, tenure in public housing, and homelessness, but not at greater risk for physical abuse. Women appeared to be at greater risk for sexual abuse. CONCLUSIONS The problems that homeless individuals experience as adults have very clear analogs in their childhoods. Vulnerability to homelessness stems from factors unevenly distributed across age, sex, and race/ethnicity groups.

Antecedents of physical and sexual victimization among homeless women: a comparison to homeless men.

Homeless women experience extensive health risks including physical and sexual victimization. Few studies that have gathered information on homeless persons have reported results separately for women or have compared them directly with men. Research that both investigates antecedents of victimization among homeless women and compares them to those for men is necessary to determine whether prevention efforts must be different for each group. We investigated potential antecedents of recent (past 30 days) physical and sexual victimization in a probability sample of 394 homeless women and compared findings to those for 1159 homeless men. As hypothesized, mental disorder, substance dependence, and engaging in economic survival strategies significantly predicted victimization among homeless women. With few dissimilarities, these characteristics also predicted victimization among homeless men. Although differences in the needs and experiences of homeless women and men must be recognized, both women and men require assistance to establish and maintain safe residences, treatment of any substance use and mental disorder, and alternatives to economic survival strategies that place them at risk for victimization.

Utilization of Mental Health and Substance Abuse Services Among Homeless Adults in Los Angeles

OBJECTIVES Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors of mental health and substance abuse treatment among a community-based probability sample of homeless adults. METHODS The data analyzed here were collected through face-to-face interviews with 1,563 homeless individuals. Bivariate analyses examined differences between homeless men and women in (1) the prevalence of major mental illnesses and substance dependence and (2) utilization of inpatient and outpatient treatment services for those with specific diagnoses. Logistic regression analyses identified predictors of mental health treatment among those with chronic mental illness and substance abuse treatment among those with recent substance dependence. RESULTS Two-thirds of these homeless adults met criteria for chronic substance dependence, whereas 22% met criteria for chronic mental illness, with substantial overlap between those two disorders: 77% of those with chronic mental illness were also chronic substance abusers. Only one-fifth of each of those two groups reported receiving treatment for those disorders within the last 60 days. Mental health service utilization was predicted largely by factors related to need (eg, diagnosis, acknowledgment of a mental health problem), whereas substance abuse service utilization was predicted by myriad additional factors, reflecting, in part, critical differences in the organization and financing of these systems of care. CONCLUSIONS More attention must be directed at how to better deliver appropriate mental health and substance abuse services to homeless adults.

Determinants of Regular Source of Care Among Homeless Adults in Los Angeles

OBJECTIVES The authors explore the determinants of having a regular source of care in a community-based probability sample of homeless adults in Los Angeles. Results from this study should be more representative than those from previous studies of the homeless that are clinic- or shelter-based. In addition to those factors found to be barriers to regular sources of care in the general population, we hypothesized that psychosocial characteristics of the homeless and the homeless lifestyle would negatively impact their likelihood of having a regular source of care. METHODS The authors conducted a multiple logistic regression to predict regular source of care among the homeless, using an adaptation of the Behavioral Model of health services utilization as an analytic framework. RESULTS Fifty-seven percent of the sample reported that they had a regular source of care. Of those with a source of care, 30% reported a hospital outpatient department; 25% reported a community or homeless clinic; 23% reported a hospital emergency room; 14% reported a government clinic; and 9% reported a private physicians office as their source of care. Some factors found to be barriers to having a regular source of care in the general population (male, Hispanic, young age) also were barriers among homeless adults. Additional barriers in this sample included homelessness-related characteristics such as competing needs, long-term homelessness, and social isolation. Chronic mental illness and chronic substance dependence were not related to having a source of care among the homeless. Characteristics that increased the likelihood of having a regular source of care in the general population (poor health status, Medicaid) were not related to having a regular source of care among the homeless. CONCLUSIONS In a context of limited resources, the distribution of regular source of care among the homeless appears to be highly inequitable. Although some of the characteristics identifying those with a regular source of care suggest differential patterns of behavior across subgroups, others suggest differential advantage in access to care and a lack of fit between the needs of the homeless and the organization of health services.

Pathways to Homelessness Among the Mentally Ill

Abstract  Background: Persons with mental illness are over-represented among the homeless relative to the general population, and mental illness is most likely one of many vulnerabilities that confer risk for homelessness. Method: This paper elucidates the pathways to homelessness for persons with mental illness by comparing and contrasting groups of mentally ill homeless persons, non-mentally ill homeless persons, and housed mentally ill persons drawn from RANDs Course of Homelessness (COH) study and the Epidemiological Catchment Area (ECA) survey. Results: Homeless persons share childhood histories of economic and social disadvantage. The mentally ill homeless appear to have a “double dose” of disadvantage: poverty with the addition of childhood family instability and violence. Among the mentally ill homeless, those who became homeless prior to becoming mentally ill have the highest levels of disadvantage and disruption; while those who become homeless after becoming ill have an especially high prevalence of alcohol dependence. Conclusions: Mental illness may play a role in initiating homelessness for some, but is unlikely in and of itself to be a sufficient risk factor for homelessness. In addition to outreach and treatment programs for adult mentally ill homeless persons, emphasis should be placed on interventions with children and on addressing more pervasive causes of homelessness.

Enumerating Homeless People

Decisions about how inclusive one should be in attempting to sample and/or enumerate homeless populattons are best guided by information regarding what is sacrificed when different sampling choices are made. This article draws upon data from the Course of Homelessness Study to explore how three progressively less inclusive sampling frames affect understandings of the size and characteristics of homeless populations in two Los Angeles sites. Findings suggest that less inclusive sampling frames substantially affect populatton estimates, but do not consistently produce biased estimates of population characteristics. Whether, and the extent to which, such bias is introduced varies by site, by gender, and by the population characteristic in question.

Through a different lens: An anthropological perspective on the homeless mentally ill

Recent attempts to understand the emergence of a growing population of homeless mentally ill individuals have almost exclusively relied on epidemiological and clinical approaches, the result being an incomplete and even distorted perception of these people and their behavior. This paper describes gaps that currently exist in our understanding of the homeless mentally ill, focusing on the dearth of rich qualitative descriptions of lives in process, the overwhelming preoccupation with pathology and disaffiliation, the failure to view homeless mentally ill individuals in the broader socio-economic and situational contexts of their daily lives, the absence of a longitudinal perspective, and an over-reliance on self-report as a source of data. Data are offered from an ethnographic examination of the ongoing adaptation of 50 chronically mentally ill homeless adults in the downtown area of Los Angeles to suggest how research utilizing an anthropological perspective can fill some of these gaps. This discussion indicates by extension that anthropological research can provide policy-relevant insights in this critical area and that the study of homelessness and mental illness presents opportunities for anthropologists to pursue a variety of issues relevant to the field.

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, pre-homelessness 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.

Adherence to HIV antiretrovirals among persons with serious mental illness.

Despite the absence of empirical evidence, serious mental illness is assumed to be a high risk factor for nonadherence to HIV antiretroviral regimens. To assess antiretroviral adherence among persons with serious mental illness, we conducted a study in which adherence was observed over a 2-week period with electronic monitoring bottle caps and self-report. Forty-seven participants enrolled, with all but two (96%) completing the study. Psychiatric diagnoses included bipolar depression (n = 24), schizophrenia (n = 12), schizoaffective disorder (n = 5), and major depression with psychotic features (n = 6). Mean adherence (proportion of prescribed doses taken) was 66% (standard deviation [SD] = 34), as measured by electronic monitoring; 40% demonstrated at least 90% adherence, but 31% had less than 50% adherence. Self-reported adherence to psychotropics was moderately correlated with self-reported (r = 0.45, p < 0.05) and electronically monitored (r = 0.39, p < 0.05) antiretroviral adherence. Viral load (log(10)) was negatively correlated with electronically monitored (r = -0.28, p < 0.10) and self-reported (r = -0.39, p < 0.05) antiretroviral adherence, after controlling for the length of time on treatment. These findings suggest that many patients with serious mental illness are able to adhere very well to antiretroviral regimens, yet a substantial proportion of our sample displayed poor adherence, indicating the need for research to further assess the factors that influence adherence to antiretrovirals in this population.