For the purpose of national census statistics and for clarification of this discussion, a homeless person is defined as one living on the street, in deserted apartment buildings or one who spends nights at a homeless shelter. Due to the difficulty of counting the homeless, statistics in recent years have been variable. According to the U.S. Department of Housing and Urban Development, there were 643,067 sheltered and unsheltered homeless persons nationwide as of January 2008. (Preston, 2008). Another approximation stems from a study conducted by the National Law Center on Homelessness and Poverty, which estimates that 3.5 million people, 1.35 million of them children, are likely to experience homelessness in a given year. (2007). These numbers are likely underrepresentative because they rely heavily on data from homeless shelters, which do not account for people living in deserted apartments and public spaces. Health problems associated with homelessness are diverse and severe and carry serious implications not only for the homeless demographic but for the national health system as well. Many intervention programs have been established to address the health issues of the homeless. The objective of Healthy People 2010 is to guide these intervention programs by providing evidence-based 10-year objectives for treating specific diseases that afflict a large proportion of Americans.
Homeless families are at a higher risk for nearly every adverse physical and behavioral health outcome. According to a study conducted by Terry, Bedi and Patel, homeless youth have a higher incidence of trauma-related injuries, infections and nutritional deficiencies (2010). Furthermore, there is a proportionately higher prevalence of substance abuse, psychological illness, and sexual and emotional abuse. Common also for this demographic are upper respiratory infections from poor living conditions, genitourinary infections, sexually transmitted diseases, eye and skin infections, dental disease, and a higher incidence of chronic disease including asthma, epilepsy and diabetes. More significantly for treatment and prevention programs is the high incidence of debilitating mental health. The same study reports that 80% of youth included in the study experienced depression, 20% had a history of prior suicide attempt and the prevalence of anxiety disorders was three times the national average. (Terry, Bedi & Patel, 2010).
The most serious problem with homeless families is that the health problems are self-perpetuating. The lack of medical resources and education available leads children to repeat the high-risk behaviors of their parents. A study that examined health behaviors and infant health outcomes in homeless pregnant women in the United States suggest that homeless children are disadvantaged and at a higher risk of serious health complications from birth (Richards, Merrill & Baksh, 2011). Infants had lower births weights, a longer hospital stay and were more likely to require neonatal intensive care. Mothers were younger, uninsured, less educated, less likely to initiate and sustain breastfeeding and provide less prenatal care. They were also more likely to smoke cigarettes, and be underweight or have class III obesity. Infants therefore are born into high-risk families who are ill prepared to care for them.
Psychological instability and parental neglet early in life often leads to substance abuse later in life. The literature is replete with studies that show a high association between homelessness and substance abuse. According to one study, rates of drug use disorders for homeless adults are more than eight times higher than general population estimates (Robertson, Zlotnick, & Weesterfelt, 1997). Two-thirds of the study sample had a lifetime history of substance use disorder including alcohol dependence (52.2%), and other drugs (52.2%). Another study conducted a 6-months assessment and found that 56% of the study population used marijuana, 40% used crack and 38% used alcohol to intoxication (Rhoades et al., 2011). While the exact estimates undoubtedly vary nationally, the association between homelessness and drug abuse appears to be consistent. This finding is also consistent with other associative behavior of the homeless including a higher incidence of violence, higher rates of liver and cardiovascular disease, chronic obstructive pulmonary disease, and mental disability.
Considering the high incidence of disease and the extensive associative behaviors and health issues, homeless families are clearly a high-risk demographic. A cohort study of homeless adults in Philadelphia showed that the age-adjusted mortality rate is 3.5 times higher among the homeless than that of the general population (Hibbs et al., 1994). An international study examined the differential effect on cause-specific mortality and showed that among patients hospitalized for drug-related conditions, the homeless cohort experienced a seven-fold increase in risk of death from drugs compared with the rest of the population (Morrison, 2009). The hazard ratio of all-cause mortality in the homeless compared to the rest of the population was 4.4. These statistics vary according to city, level of crime and homeless services available.
The health problems of the homeless are severe. The objective of Healthy People 2010 is to raise awareness of the different health issues afflicting them and to provide objectives for effective treatment and intervention. Homelessness is not identified as a specific 2020 topic on the Healthy People 2010 website because its health problems are too broad and incapsulate many of the specific topics that are listed (Healthy People, 2011). Topics that are applicable to the homeless include mental health and mental disorders, immunization and infectious diseases, HIV, injury and violence prevention, nutrition and weight status, oral health, respiratory diseases, sexually transmitted diseases and substance abuse. Studies have shown that risky health behavior that is especially high among the homeless develops during adolescence (Lawrence, Grootman & Sim, 2009). The Healthy People 2010 "Adolescent Health" topic specifically cites homelessness as one of the public health and social problems that start during these years of life.
The Healthy People 2010 intervention guidelines present several disease prevention objectives for adolescent health. The most significant of these is to increase the proportion of adolescents who have had a wellness checkup in the past 12 months. Currently 68.7% of adolescents aged 10 to 17 years have a wellness checkup in the past 12 months. The target is a ten percent improvement to 75.6% of adolescents. This would be a particularly effective way of screening homeless adolescents who generally do not have access to healthcare services. Many of the chronic diseases that the homeless develop over time result from neglect. Regular screening as proposed by this objective would help to remedy this shortcoming. Another serious problem of homeless adolescents is the lack of a reliable parental figure. Healthy People 2010 reports that 75.7% of adolescents aged 12 to 17 years have an adult in their lives with whom they could talk about serious problems. This statistics is likely much lower when isolated for adolescents in homeless families. The objective is to increase this percentage to 83.3%. A targeted intervention specifically for the homeless could be beneficial. Another objective applicable to the homeless is the reduction of minor and young adult perpetration of violent crimes. Currently 444.0 per 100,000 adolescents and young adults aged 10 to 24 years are arrested for criminal acts. The objective is a ten percent improvement to 399.6 arrests per 100,000 in this population.
One of the specific health problems that is consistently associated with homelessness and directly addressed by the Healthy People 2010 is substance abuse. Objectives to reduce this pendemic include increasing the number of admissions to substance abuse treatment for injection drug use, increasing the number of Level I and Level II trauma centers and primary care settings that implement evidence-based alcohol Screening and Brief Intervention, reducing drug-induced deaths, and reducing average annual alcohol consumption.
These objectives identify one of the key problems to the assessment and nursing intervention strategies for homeless families -- accessibility. Generally, homeless families are less willing to seek medical attention medical issues that are the product of their lifestyles. Respiratory disorders, mental problems, and sexually transmitted diseases, for example, are chronic problems that are products of the environment. The homeless are less likely to receive regular screening, counseling or education. According to a study that evaluates the costs of providing healthcare, homeless families tend to have longer hospitalizations than other low-income groups, many using the environment as a respite from living on the street (Terry, Bedi & Patel, 2010).
Nonetheless, effective nursing strategies and intervention programs have been identified. Two management programs have been identified through extensive research as particularly effective with homeless families especially with a co-occurrence of mental illness (Morse, 1999). Intensive case management (ICM) is grounded in the clinical principles of assertive and persistent outreach and active assistance in accessing needed resources. The underlying tasks include assessment of need, care planing, implementation and regular review (Rog, Holupka, McCombs-Thimton, Brito & Hambrick, 1996). Assertive Community treatment (ACT), which is often co-termed Continuous Treatment Teams, is a comprehensive, multi-disciplinary and longitudinal program that focuses on community involvement and tries to address the sources of the health problem rather than simply treating the symptoms once they arise. ACT has been shown to produce more patient contact, higher utilization of needed reources, higher patient satisfaction and…