Housing instability and incident hypertension in the CARDIA cohort.

Housing instability, a growing public health problem, may be an independent environmental risk factor for hypertension, but limited prospective data exist. We sought to determine the independent association of housing instability in early adulthood (year 5, 1990-1991) and incident hypertension over the subsequent 15 years of follow-up (years 7, 10, 15, and 20) in the Coronary Artery Risk Development in Young Adults (CARDIA) study (N = 5,115). Because causes of inadequate housing and its effects on health are thought to vary by race and sex, we hypothesized that housing instability would exert a differential effect on incident hypertension by race and sex. At year 5, all CARDIA participants were asked about housing and those free of hypertension were analyzed (N = 4,342). We defined housing instability as living in overcrowded housing, moving frequently, or living doubled up. Of the 4,342 participants, 8.5 % were living in unstable housing. Across all participants, housing instability was not associated with incident hypertension (incidence rate ratio (IRR), 1.1; 95 % CI, 0.9-1.5) after adjusting for demographics, socioeconomic status, substance use, social factors, body mass index, and study site. However, the association varied by race and sex (p value for interaction, <0.001). Unstably housed white women had a hypertension incidence rate 4.7 times (IRR, 4.7; 95 % CI, 2.4-9.2) that of stably housed white women in adjusted analysis. There was no association among white men, black women, or black men. These findings suggest that housing instability may be a more important risk factor among white women, and may act independently or as a marker for other psychosocial stressors (e.g., stress from intimate partner violence) leading to development of hypertension. Studies that examine the role of these psychosocial stressors in development of hypertension risk among unstably housed white women are needed.

Case management is associated with improved antiretroviral adherence and CD4+ cell counts in homeless and marginally housed individuals with HIV infection.

BACKGROUND: Case management (CM) coordinates care for persons with complex health care needs. It is not known whether CM is effective at improving biological outcomes among homeless and marginally housed persons with human immunodeficiency virus (HIV) infection. Our goal was to determine whether CM is associated with reduced acute medical care use and improved biological outcomes in homeless and marginally housed persons with HIV infection. METHODS: We conducted a prospective observational cohort study in a probability-based community sample of HIV-infected homeless and marginally housed adults in San Francisco, California. The primary independent variable was CM, defined as none or rare (any CM in 25% but 75%). The dependent variables were 3 self-reported health service use measures (receipt of primary care, emergency department visits and hospitalizations, and antiretroviral therapy adherence) and 2 biological measures (increase in CD4(+) cell count of >or=50% and geometric mean HIV load of or=50% improvements in CD4(+) cell count. CM was not associated with geometric HIV load <400 copies/mL when antiretroviral therapy adherence was included in the model. Study limitations include a lack of randomization. CONCLUSION: CM may be a successful method to improve adherence to antiretroviral therapy and biological outcomes among HIV-infected homeless and marginally housed adults.

Factors associated with the health care utilization of homeless persons.

CONTEXT: Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective. OBJECTIVE: To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons. DESIGN AND SETTING: Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients. SUBJECTS: A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996. MAIN OUTCOME MEASURES: Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year. RESULTS: Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75). CONCLUSIONS: In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.