1. Health, Employment Status, and Urban Homelessness American Public Health Association (APHA) Tuesday, November 6, 2007 Nadra Tyus, DrPH Urban Health Institute (UHI) Johns Hopkins University Dept. of Population, Family, and Reproductive Health

2. Introduction l Scientific data suggest that homeless populations suffer disproportionately from disease and poor access to care l Little data exists regarding characteristics of homeless populations as well as actual health status and healthcare utilization patterns among homeless adults

3. Objective To examine the relationship between homelessness, employment, and health status among a low-income, urban population from East Baltimore, Maryland.

4. Study Design From January 2005 to December 2006, a 62-item questionnaire was administered to over 1300 adults in East Baltimore

5. Methods l Study Design: Nonrandom/convenience sample » Survey administered by CHWs as part of outreach initiatives (i.e. UHI clinic, soup kitchens, drug detox facilities, community-based health centers, markets, and door to door outreach, etc.) l Survey items: Socio-demographics, chronic disease risk factors, health behaviors, and healthcare utilization factors l Blood pressures also taken and recorded by CHWs

6. Analyses l Frequencies » Demographics, Health Status, Health Behaviors and Healthcare Utilization Patterns l Bivariate Analysis » Crosstabs between Homeless and Employment Status regarding aforementioned variables

7. Results l Total Sample N = 1346 l 18% of respondents self-reported as being currently homeless (n=246)

8. Demographics of Homeless Population l Race » 205 (83%) – African-American » 37 (15%) - White » 1 (0.4%) – Hispanic » 2 (1.0%) – Native American/Alaska Native l Ages ranged from 19-88 (mean 41.6)

9. l Gender » Male - 63.4% l Less than High School Education – 48% l Marital Status » 66.7% Single » 15.9% Separated » 7.3% Married » 6.9% Divorced l Insurance Status » 30.1% Insured (n=74) l Type of Insurance » 16% Medicaid/Primary Adult Care » 6% Medicare » 6% Other » 2% Employment-based » 2% Military Care » 0.4% Private Demographics of Homeless Population

10. l Current Smokers – 77% » US rate – 21.6% l Elevated Blood Pressure (> 120/80) – 54% » US rate – 20% l Current Substance abuse problem – 49% » US rate – 2.9% l Current Alcohol abuse problem – 16% » US rate – 7.7% Health Behaviors and Status of Homeless Population

11. Body Mass Index l Overweight (BMI = 25-29.9) » 28.7% l Obese (BMI = 30+) » 21% » US rate – 32%

12. Most important health concern (Chief Complaint) –Substance abuse – 40% –High Blood Pressure - 5% –Insurance – 7% Health Concerns of Homeless Population

13. Self-Reported Health Issues l Current » None – 35% » High Blood Pressure – 12% » Depression/Stress/Anxiety/Mental Health – 8% » Asthma/Respiratory – 8% l Past » None – 64% » High Blood Pressure – 4%

14. Sexual Health l Sexually Active - 73% l Currently Pregnant? » 5 women l Current or Past STDs - 36% l Which STDs? (n=191) » Gonorrhea – 21% » Chlamydia – 3% » HIV – 3% » Syphilis – 2% » Other – 5%

15. Healthcare Utilization Patterns Among Homeless Population l How many times in the past year have you been to the ER? » At least once – 63% l How many times…been to a private doctor? » At least once – 28% l How many times…been to a clinic? » At least once – 53%

16. l Delayed seeking treatment in last year – 79% l Reasons for delay » No insurance - 53% » Could not afford Treatment – 18% » Other – 20% Healthcare Utilization Patterns Among Homeless Population

17. l Do you have a regular doctor or healthcare provider? (n=57) » Yes – 23% l How satisfied are you with him/her? » Not satisfied – 4% » Satisfied – 13% » Very Satisfied – 6% Healthcare Utilization Patterns Among Homeless Population

18. Homeless and Employment Status Analyses

19. Homeless Population Employed – 38% » Full time – 17% » Part time – 10% » Self-employed – 2% » Retired – 9%

20. Demographics *

21. Homeless and Employment: Insurance Status

22. Homeless and Employment: Health Status

23. Current & Previous Health Issues Unemployed and Homeless l Current Concern » 45% Substance Abuse » 5% High BP l Previous Health Issues » 12% High BP » 10% Depression/Mental Health » 7% Asthma/Respiratory Employed and Homeless l Current Concern » 30% Substance Abuse » 8% High BP l Previous Health Issues » 13% High BP » 8% Depression/Mental Health

24. Diabetes

25. Health Behaviors

26. Health Care Utilization Unemployed Employed

27. Main Reason for Delaying No Insurance or Could not Afford Treatment!!!

28. Regular Healthcare Provider

29. Conclusion

30. Overall Demographics l Homeless population was mostly single, males l 30% of Homeless were insured l 38% of Homeless were working » But not necessarily insured

31. Overall Health Status l Very high prevalence of smoking behaviors and STDs l High rates of Hypertension l Extremely high rates of Substance abuse l Many were seeking help with High Blood Pressure, Depression/Mental Health, and Asthma/Respiratory problems

32. Conclusions (Homeless and Employment) l Significant proportion of Homeless are also working – 38% l A larger proportion of Homeless who are employed are uninsured vs. those who are unemployed (74% vs. 69%)

33. Homeless and Employment Comparisons l Employment does not appear to confer any health benefits: » High rates of overweight/obesity, High Blood Pressure, and Diabetes risk in both groups » Similar rates of Depression/Mental Health Issues l Employment did not appear to influence healthier behaviors: » High rates of substance abuse, smoking, and STDs in both groups

34. Homeless and Employment: Healthcare Utilization Issues l Although employed respondents reported using private physicians and healthcare clinics more often, the delay to seek treatment was almost the same for both groups l Main reason for delaying treatment was associated with insurance/payment issues for both the employed and unemployed

35. Discussion l This study suggests that: » Demographics of the Homeless population are largely becoming a significant proportion of the working poor » Overall, the working poor have no health status, health insurance, or healthy behavior benefit when compared to populations who are not working

36. Implications for Employers l Results indicate a serious need to assist the working homeless/poor with achieving an improved health status and quality of life » Health promotion programs or incentives in the workplace l Having employees who are chronically ill and engaging in unhealthy behaviors have serious implications for costs and productivity for urban employers » Absenteeism and presenteeism » Effect on co-workers; infectious diseases

37. Implications for the Healthcare System l Health insurance does not guarantee improved health status » But, why not? l Numerous policies and healthcare administration structures must be changed in order to improve the health status of already marginalized populations l Increasing need to improve the access to and quality of preventive care for all populations

38. Limitations l Not representative (Generalizability) » Area where respondents live represent a primarily urban, low-income population » Non-random sample l Self-reported data (reliability)

39. Acknowledgements l M. Christopher Gibbons, MD, MPH UHI Associate Director l Greg Cundiff, CHW Coordinator l All the wonderful CHWs!

40. THANK YOU!