Use of contraceptive methods among homeless women for protection against unwanted pregnancies and sexually transmitted diseases: prior use and willingness to use in the future.

Lifetime contraceptive use as reported by a representative sample of 764 homeless women in Los Angeles was examined overall and for different age and ethnic subgroups and contrasted with expressed willingness to use specific methods. Over 80% of the women reported condom use. However, less than 5% had ever used female condoms, although 38% of the overall sample and 73% of the teenagers said they were willing to try them. Similar gaps between reported use and endorsement were found for other particular methods. Native Americans had relatively low use of virtually all contraceptive methods, and over 80% of African-Americans rejected implants. Our findings suggest that age-related factors and ethno-cultural perceptions may deter some homeless women from using contraception. In any case, gaps between realized use and willingness to use may represent missed opportunities to prevent the high rates of unintended pregnancies and sexually transmitted infections found among homeless women.

Homeless women's gynecological symptoms and use of medical care.

Information is lacking on homeless women's gynecological symptoms and use of medical care for symptoms. This paper documents and explains gynecological symptoms and conditions and use of medical care in a probability sample of 974 reproductive-age (15-44) homeless women. Two-thirds of women reported symptoms during the previous year; 71 percent of those received medical care for their gynecological symptoms. Pregnancy, drug dependence, more episodes of homelessness, and general physical health symptoms were positively associated with a number of gynecological symptoms. Gynecological symptoms, younger age, better perceived health, and insurance coverage were positively associated with medical care; women reporting recent drug use and rape received less care. These findings support the importance of medical care and other treatment and support services for homeless women, including expanded care during pregnancy and substance abuse treatment. Health insurance coverage and an interruption in the cycle of homelessness also appear vital to women's health.

Hepatitis B among homeless and other impoverished US military veterans in residential care in Los Angeles.

Findings are presented for a cross-sectional study of serological markers of hepatitis B virus (HBV) infection in an underserved population-impoverished veterans of the US armed forces in a Veterans Administration (VA) residential program in the US. We examine the demographic, background, and risk factors associated with HBV infection in this high-risk population. This paper presents a secondary analysis of cross-sectional survey and clinical data for 370 male veterans who were residents of a domiciliary care program for homeless veterans in Los Angeles, using chi(2), Fisher's Exact, and logistic regression analysis. About one-third (30.8%) of the sample tested positive for current or past HBV infection (ie, seropositive for either the HBV core antibody or surface antigen). After multivariate analysis, rates of HBV were significantly higher among veterans who were older, non-white, or who had a history of regular heroin use (a proxy measure for injection drug use), drug overdose, or drug detoxification treatment. The rate of current or past HBV infection among veterans in this sample (30.8%) was high compared to an estimated 5% to 8% of the general US population. Also, 3% of the sample were currently infected with HBV. Strategies for intervention include broader screening, immunization, and treatment interventions with this high-risk group.

Reliability of homeless women's reports: concordance between hair assay and self report of cocaine use.

BACKGROUND: To assess the concordance of homeless women's self-reported drug use with objective data. OBJECTIVE: To determine whether objective data (e.g., hair assays) are necessary supplements to self reports in assessing homeless women's cocaine use. METHOD: Self reports of cocaine use by 1,037 homeless women were compared to objective data based on radioimmunoassay of hair; independent correlates of cocaine use and underreporting were assessed using logistic regression. RESULTS: Forty-two percent of the women self-reported cocaine use in the past 6 months, whereas 49% had positive hair assays. Over 25% underreported cocaine use; however, underreporting decreased as hair cocaine levels increased. Predictors of underreporting included being Latino, younger and living primarily in shelters. Nevertheless, independent predictors of self-reported cocaine use and positive hair assays were identical. CONCLUSION: Homeless women's self-reports of cocaine use are fairly accurate. Objective data are particularly critical for assessing cocaine use among subgroups who are fearful of sanctions or use cocaine relatively infrequently or in smaller amounts.

Is food insufficiency associated with health status and health care utilization among adults with diabetes?

OBJECTIVES: Preliminary studies have shown that among adults with diabetes, food insufficiency has adverse health consequences, including hypoglycemic episodes and increased need for health care services. The purpose of this study was to determine the prevalence of food insufficiency and to describe the association of food insufficiency with health status and health care utilization in a national sample of adults with diabetes. METHODS: We analyzed data from adults with diabetes ( n =1,503) interviewed in the Third National Health and Nutrition Examination Survey. Bivariate and multivariate analyses were used to examine the relationship of food insufficiency to self-reported health status and health care utilization. RESULTS: Six percent of adults with diabetes reported food insufficiency, representing more than 568,600 persons nationally (95% confidence interval, 368,400 to 768,800). Food insufficiency was more common among those with incomes below the federal poverty level (17% vs 4%, P < or = .001). Adults with diabetes who were food insufficient were more likely to report fair or poor health status than those who were not (63% vs 43%; odds ratio, 2.2; P=.05). In a multivariate analysis, fair or poor health status was independently associated with poverty, nonwhite race, low educational achievement, and number of chronic diseases, but not with food insufficiency. Diabetic adults who were food insufficient reported more physician encounters, either in clinic or by phone, than those who were food secure (12 vs 7, P<.05). In a multivariate linear regression, food insufficiency remained independently associated with increased physician utilization among adults with diabetes. There was no association between food insufficiency and hospitalization in bivariate analysis. CONCLUSIONS: Food insufficiency is relatively common among low-income adults with diabetes and was associated with higher physician utilization.

Assessing use of primary health care services by very low-income adults in a managed care program.

OBJECTIVE: To assess the effect of providing free health care services to low-income adults. METHODS: We measured access to primary care services by enrollees with 4 chronic medical conditions in the General Relief Health Care Program (GRHCP), a program designed for adults receiving General Relief (GR). Implemented by the Los Angeles County Health Department in October 1995, the GRHCP is composed of private and public health care facilities. As adults registered for GR, they were asked to complete a baseline health survey, were enrolled in the GRHCP, and assigned a health care provider. A total of 8520 surveys were completed between September and November 1996 (98% response rate). The analyses of this article are limited to individuals (N = 2164) who reported a history of hypertension, diabetes mellitus, a nonresolving cough, or substance dependence. We reviewed medical records to determine whether new GR recipients had visited their designated GRHCP provider within 4 months of enrollment and used multivariate logistic regression to assess the effect of individual patient factors on the use of free health care. RESULTS: A total of 17% of individuals visited their assigned GRHCP provider within 4 months of enrollment. In multivariate analysis, patients were more likely to have made a visit if they were younger than 50 years, were female, were Asian/Pacific Islander, reported needing to see a physician, or had seen a physician within 12 months. CONCLUSIONS: It is not sufficient to merely supply the name and address of a health care provider to this population. More aggressive efforts should be attempted to increase utilization of services for patients with medical conditions responsive to ambulatory care.

How will family physicians care for the patient in the context of family and community?

Difficulties caring for patients in the context of family and community stem from problems of power and vulnerability. Patients are disempowered in relation to physicians and to the medical care system. Physicians are disempowered in their ability to provide comprehensive relationship-centered care to individuals and families because of economic constraints on medical care and limits on continuity of care. Individual patients are also vulnerable to abuses of power within their families because of physical and sexual abuse; the recognition of such abuses and appropriate interventions for them requires awareness of the gender ideology that underlies interpersonal abuses of power. Families and communities can be disempowered because of vulnerabilities related to race, ethnicity, poverty, and homelessness. The additive effects of these vulnerabilities have created health disparities that are a hallmark of inequities in our country's medical system. Opportunities to teach students to recognize and address these disparities abound within medical education. Participatory training and educational action projects can prepare learners to lead us toward a more just and egalitarian medical system with the potential to change the context of family and community in which we care for patients. However, systematic commitment from educational programs is necessary to produce activated clinicians, teachers, and researchers to achieve these changes.

A diabetes-specific measure of patient desire to participate in medical decision making.

PURPOSE: The goal of this study was to develop a diabetes-specific scale of patient desire to participate in medical decision making (DPMD) and examine its internal consistency reliability, stability, and validity (content, discriminant, convergent, and construct). METHODS: In a cross-sectional study, 65 patients with type 2 diabetes from a teaching hospital's general medical clinic were interviewed at baseline and 2 weeks later to measure their DPMD scores. Data were collected on demographic/clinical features, health value, social support, desire to make a final decision, and value of patient autonomy. RESULTS: Of the 11 DPMD items, 2 distinct factors emerged representing desire for discussion and desire for information. The DPMD scale had high internal consistency reliability, was stable over 2 weeks and demonstrated good content validity. DPMD scale items were more correlated with each other than with health value or social support. Overall, patients who obtained diabetes education reported greater desire to participate in decisions. Younger patients had a greater overall desire for discussion. The DPMD desire for discussion subscale correlated with patients' desire to make the final treatment decision but not with patients' value of autonomy. CONCLUSIONS: The DPMD is a brief, reliable, valid measure for assessing patient desire to participate in diabetes medical decision making.

Severity of homelessness and adverse birth outcomes.

Predictors and the prevalence of adverse birth outcomes among 237 homeless women interviewed at 78 shelters and meal programs in Los Angeles in 1997 were assessed. It was hypothesized that they would report worse outcomes than national norms, that African Americans would report the worst outcomes because of their greater risk in the general population, and that homelessness severity would independently predict poorer outcomes beyond its association with other adverse conditions. Other predictors included reproductive history, behavioral and health-related variables, psychological trauma and distress, ethnicity, and income. African Americans and Hispanics reported worse outcomes than are found nationally, and African Americans reported the worst outcomes. In a predictive structural equation model, severity of homelessness significantly predicted low birth weight and preterm births beyond its relationship with prenatal care and other risk factors.

Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women.

BACKGROUND: There is a dearth of validated information about lesbian and bisexual women's health. To better understand some of these issues, we used population-based data to assess variations in health behaviors, health status, and access to and use of health care based on sexual orientation. METHODS: Our study population was drawn from a population-based sample of women, the 1997 Los Angeles County Health Survey. Participants reported their sexual orientation and these analyses included 4697 women: 4610 heterosexual women, 51 lesbians, and 36 bisexual women. We calculated adjusted relative risks to assess the effect of sexual orientation on important health issues. RESULTS: Lesbians and bisexual women were more likely than heterosexual women to use tobacco products and to report any alcohol consumption, but only lesbians were significantly more likely than heterosexual women to drink heavily. Lesbians and bisexual women were less likely than heterosexual women to have health insurance, more likely to have been uninsured for health care during the preceding year, and more likely to have had difficulty obtaining needed medical care. During the preceding 2 years, lesbians, but not bisexual women, were less likely than heterosexual women to have had a Papanicolaou test and a clinical breast examination. CONCLUSIONS: In this first population-based study of lesbian and bisexual women's health, we found that lesbians and bisexual women were more likely than heterosexual women to have poor health behaviors and worse access to health care. These findings support our hypothesis that sexual orientation has an independent effect on health behaviors and receipt of care, and indicate the need for the increased systematic study of the relationship between sexual orientation and various aspects of health and health care. Arch Fam Med. 2000;9:1043-1051

Type of social support among homeless women: its impact on psychosocial resources, health and health behaviors, and use of health services.

BACKGROUND: Information about whether specific types of support are associated with poor psychosocial profiles, health behaviors, and positive use of medical care is critical for identifying homeless women at highest risk for negative outcomes. OBJECTIVES: This study aimed to examine the impact that various levels of support from substance users and nonusers have on homeless women's psychosocial profiles, health and health behaviors, and use of health services. METHODS: This cross-sectional survey used a sample of 1,302 sheltered homeless women. Using controls for potential confounders, outcomes were compared across four mutually exclusive subgroups of women reporting support from substance users only (n = 58), substance nonusers only (n = 439), both users and nonusers (n = 136), and no one (n = 669). Structured and psychometrically sound instruments measured social support, substance use, self-esteem, coping, and psychological symptoms. Additional instruments measured sociodemographic characteristics, sexual risk behavior, health status, and use of health services. RESULTS: As compared with those who have little or no support, women whose support included substance nonusers reported better psychosocial profiles and somewhat greater use of health services. Support from substance nonusers only was associated with better health behaviors and greater use of health services. Support from substance users only was essentially equivalent to not having support. CONCLUSION: Modifying the social networks of homeless women appears to be associated with improved mental health outcomes, less risky health behaviors, and greater use of health services.

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.

Sheltered versus nonsheltered homeless women differences in health, behavior, victimization, and utilization of care.

OBJECTIVE: To contrast sociodemographic characteristics, physical and mental health status, substance use, sexual behaviors, victimization, and utilization of health services between homeless women residing in sheltered and non-sheltered environments. DESIGN: Cross-sectional survey. A structured scale was used to measure mental health status. Physical health status, substance use, sexual behavior, history of adult victimization, and health services utilization were measured by content-specific items. SETTING: Shelters (N = 47) and outdoor locations in Los Angeles. PARTICIPANTS: One thousand fifty-one homeless women. RESULTS: Homeless women living on the streets were more likely than sheltered women to be white and longer-term homeless. Controlling for sociodemographic characteristics, multiple logistic regression analyses revealed that unsheltered women had over 3 times greater odds of fair or poor physical health, and over 12 times greater odds of poor mental health than sheltered homeless women. They were also more likely than sheltered women to report using alcohol or noninjection drugs, to have multiple sexual partners, and to have a history of physical assault. About half of the overall sample reported utilization of a variety of health services; however, unsheltered homeless women were less likely to utilize all of the health services that were assessed, including drug treatment. CONCLUSIONS: There is a critical need for aggressive outreach programs that provide mental health services and substance abuse treatment for homeless women on the streets. Comprehensive services that also include medical care, family planning, violence prevention, and behavioral risk reduction may be particularly valuable for homeless women, especially those living in unsheltered environments.

Predicting health services utilization among homeless adults: a prospective analysis.

This study expands on the Andersen-Newman health services utilization (HSU) model. In a community-based homeless sample (n = 363) baseline predisposing, enabling, and needs-based variables predicted hospitalization and ambulatory outpatient service utilization within 1 year after baseline. Standard predisposing and enabling variables were supplemented with latent constructs representing substance use, mental illness, poor housing status, social support, community support, and barriers to health care. Need is represented by baseline health status. Poor physical health, more barriers, drug use, African American ethnicity, less community support, and less education predicted hospitalization, the least desirable form of HSU. Poor health, female gender, a regular source of care, community support, drug use, and fewer alcohol problems predicted an office visit. Because outpatient visits for acute conditions provide an opportunity for generally neglected preventive services and health screenings, this study suggests convenient multiservice health-related programs for the homeless that include drug and alcohol treatment.

Health of homeless women with recent experience of rape.

There is limited understanding of the physical health, mental health, and substance use or abuse correlates of sexual violence against homeless women. This study documents the association of rape with health and substance use or abuse characteristics reported by a probability sample of 974 homeless women in Los Angeles. Controlling for potential confounders, women who reported rape fared worse than those who did not on every physical and mental health measure and were also more likely to have used and abused drugs other than alcohol. Results should serve to alert clinicians about groups of homeless women who may benefit from rape screening and treatment interventions.

The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people.

OBJECTIVES: (1) To present the Behavioral Model for Vulnerable Populations, a major revision of a leading model of access to care that is particularly applicable to vulnerable populations; and (2) to test the model in a prospective study designed to define and determine predictors of the course of health services utilization and physical health outcomes within one vulnerable population: homeless adults. We paid particular attention to the effects of mental health, substance use, residential history, competing needs, and victimization. METHODS: A community-based probability sample of 363 homeless individuals was interviewed and examined for four study conditions (high blood pressure, functional vision impairment, skin/leg/foot problems, and tuberculosis skin test positivity). Persons with at least one study condition were followed longitudinally for up to eight months. PRINCIPAL FINDINGS: Homeless adults had high rates of functional vision impairment (37 percent), skin/leg/foot problems (36 percent), and TB skin test positivity (31 percent), but a rate of high blood pressure similar to that of the general population (14 percent). Utilization was high for high blood pressure (81 percent) and TB skin test positivity (78 percent), but lower for vision impairment (33 percent) and skin/leg/foot problems (44 percent). Health status for high blood pressure, vision impairment, and skin/leg/foot problems improved over time. In general, more severe homeless status, mental health problems, and substance abuse did not deter homeless individuals from obtaining care. Better health outcomes were predicted by a variety of variables, most notably having a community clinic or private physician as a regular source of care. Generally, use of currently available services did not affect health outcomes. CONCLUSIONS: Homeless persons are willing to obtain care if they believe it is important. Our findings suggest that case identification and referral for physical health care can be successfully accomplished among homeless persons and can occur concurrently with successful efforts to help them find permanent housing, alleviate their mental illness, and abstain from substance abuse.

A population-based survey of tuberculosis symptoms: how atypical are atypical presentations?

There is scant information on tuberculosis symptoms from a population-based perspective. We prospectively identified 526 tuberculosis cases reported in Los Angeles County over a 6-month period. Of 313 persons who completed our questionnaire, 72.7% had cough, 48.2% for >2 weeks, and 52.3% had fever, 29.4% for >2 weeks. Among those with pulmonary disease, only 52.4% had cough for >2 weeks. In a multivariate model, persons with significant symptoms typical of tuberculosis disease (defined as cough or fever for >2 weeks, weight loss, or hemoptysis) were associated with lack of medical insurance, negative tuberculin skin test, diagnosis during a process other than screening, and non-Asian race. In summary, classic symptoms of prolonged cough and fever are insensitive predictors of tuberculosis. Our data suggest that Asians may need to be added to the list of persons who present with tuberculosis atypically. We believe that the Infectious Diseases Society of America guidelines for community-acquired pneumonia should emphasize demographic features in addition to clinical symptoms when suggesting which patients require evaluation for Mycobacterium tuberculosis.

Predicting clinician injury prevention counseling for young children.

BACKGROUND: Injury is the primary cause of morbidity and mortality in children and an important topic for counseling. OBJECTIVE: To describe and explain clinicians' reported counseling behavior during the well-child examinations for children aged 5 years and younger on the following 4 injury prevention topics: motor vehicle crashes, toxic ingestion, drowning, and firearm injuries. METHODS: A random sample of 465 pediatricians, family physicians, and pediatric nurse practitioners in an urban setting received mailed questionnaires; 325 (69.9%) responded. Multivariate logistic regression predicting counseling on each injury prevention topic was performed. RESULTS: Most reported discussing motor vehicle occupant protection (66.2%) and toxic ingestion prevention (62.1%) during the well-child examination. Only 31.8% stated they counseled on drowning prevention and 15.7%, on firearm injury prevention. Knowledge of injury mortality and morbidity rates was not associated with counseling. For most topics, female respondents were more likely to counsel than male respondents (motor vehicle crash odds ratio [OR], 2.24 [P = .03]; toxic ingestion OR, 1.82 [P = .05]; drowning OR, 1.97 [P = .04]). Health maintenance organization settings predicted injury prevention counseling for most topics (motor vehicle crash OR, 2.52 [P = .04]; toxic ingestion OR, 2.77 [P = .01]; firearm injury OR, 2.97 [P = .001]). Clinicians placing lower importance on counseling were less likely to counsel on drowning and firearm injury (drowning OR, 0.73 [P = .006]; firearm injury OR, 0.58 [P<.001]). CONCLUSIONS: Clinicians' knowledge of local injury epidemiology did not influence their counseling on these topics. Clinicians and their patients might benefit by using programs such as The Injury Prevention Program to help them standardize their approach to injury prevention counseling during the routine well-child examination.

Sink or swim--clinicians don't often counsel on drowning prevention.

OBJECTIVE: Drowning is one of the leading causes of injury death for young children in the United States. This study examined primary care providers' knowledge of and counseling on drowning prevention. METHODS: A random sample of 465 Los Angeles County pediatricians, family physicians, and pediatric nurse practitioners who serve families with young children received mailed questionnaires; 325 (70%) responded. RESULTS: About two thirds of clinicians did not know that injury deaths attributable to drowning were more common than those attributable to toxic ingestions and firearm injuries in young children. Only one third of clinicians stated they counseled on drowning prevention. Counseling drowning prevention was positively associated with female gender (odds ratio: 1.97; 95% confidence interval: 1.64, 2.30) and negatively associated with an attitude that drowning prevention counseling was less important than other injury prevention topics (odds ratio:.73; 95% confidence interval:.61,.85). Clinician specialty, age, years out from training, proportion of well-child examinations in a typical week, having children, practice setting, and knowledge of drowning injury deaths were not significant in multivariate analysis. CONCLUSION: The belief of clinicians that it is less important to counsel on drowning prevention than other injury prevention topics poses a substantial challenge to their providing such education to families with young children.drowning, counseling, physician's role.