• Bonin E, Brammer S, Brehove T, Hale A, Hines L, Kline S, Kopydlowski MA, Misgen M, Obias ME, Olivet J, O'Sullivan A, Post P, Rabiner M, Reller C, Schulz B, Sherman P, Strehlow AJ, Yungman J. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2003. 22 p. [35 references]

This is the current release of the guideline.

The following diseases/conditions in homeless patients:

• Unintended pregnancies
• Risky sexual behaviors
• Sexually transmitted diseases

Diagnosis
Evaluation
Management
Prevention
Treatment

Family Practice
Infectious Diseases
Internal Medicine
Obstetrics and Gynecology

Advanced Practice Nurses
Health Care Providers
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers
Students
Substance Use Disorders Treatment Providers

To recommend adaptations in standard clinical practices to assist primary care providers in delivering better reproductive health care to homeless patients

Homeless patients of reproductive age

Diagnosis/Evaluation

1. History, including living conditions, sexual history, patient's need and desire for contraception, behavioral health history (mental health, substance use including smoking), medical history, medications, immunizations, menstrual history, spiritual/cultural history, history of domestic/interpersonal violence, insurance status
2. Physical examination, including sensitivity toward concerns and fears of patient with a history of sexual abuse, genital exam for males and females according to standard clinical guidelines, nonjudgmental attitude
3. Diagnostic tests, including sexually transmitted diseases (STD) screening; urine pregnancy test (UCG); routine health care maintenance (Papanicolaou [Pap] smear and mammogram for women and testicular self-examination and prostate examination for men)

Management/Treatment/Prevention

1. Education and self-management, including educating patient about hygiene, contraceptive methods, medication/contraceptive side effects, STD protection, risk reduction, and smoking cessation; partner education; preconception counseling; educating about health care maintenance, storage and expiration of condoms and birth control pills, and possible effects of pregnancy on co-existing medical conditions
2. Medications and contraceptive devices, such as easy-to-use contraceptive methods and on-site dispensing, dual use of barrier and hormonal methods, injectable contraception for patients who cannot adhere to daily regimen, birth control pills, transdermal methods, female condoms, folate and calcium supplements, additional contraceptive method or a higher dose of oral contraceptive pill for women taking anti-seizure medication
3. Recognizing and managing associated problems and complications, such as medical and personal risks of pregnancy, housing problems, post-traumatic stress disorder, financial barriers to reproductive health care, lack of safe storage place
4. Strategies to encourage follow-up for monitoring of any contraceptive side effects, including appointment cards (worn in pouch around neck) and voice mail reminders, positive reinforcement, confirmation of contact information at every visit, allowing walk-ins, education of staff about contraceptive options

• Access to cancer screening: Pap smear, mammogram/breast examination, prostate examination (if indicated)
• Use of contraceptives, including barrier devices
• Access to prenatal care
• Health disparities between homeless and general U.S. populations:
  • Incidence/prevalence cancer of reproductive organs
  • Incidence/prevalence of sexually transmitted diseases
  • Complications of pregnancy

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Searches of MEDLINE, SocABS, and PsycInfo databases were performed. Bibliographies compiled by the Bureau of Primary Health Care’s Homeless Information Resources Center were also searched.

This guideline is adapted from five primary sources.

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

The Network Steering Committee and other primary health care providers, representing Health Care for the Homeless (HCH) projects across the United States, devoted several months during 2002–03 to developing special recommendations on reproductive health care for patients who lack stable housing. These recommendations reflect their collective experience in serving homeless adults and adolescents.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Clinical Validation-Pilot Testing
External Peer Review
Internal Peer Review

The guideline developer's Advisory Committee identifies, in the original guideline document, the clinicians who reviewed and commented on the draft recommendations prior to publication, including experienced Health Care for the Homeless practitioners and medical experts in reproductive health care. The guideline was field tested by clinicians in designated Health Care for the Homeless projects during the summer of 2003. Evaluation criteria included clarity, flexibility and ease of use; relevance to the care of homeless clients or those at risk of becoming homeless; inclusion of strategies to promote outreach and case management and ensure follow-up; sufficiently detailed to ensure that similar practitioners would offer similar treatment in the same circumstances; and sufficiently complete to enable new clinicians to use them for homeless clients. Evaluators found that the guideline met all of these criteria and recommended future development of "short forms" of this and other adapted clinical guidelines to facilitate use in a variety of clinical settings.

Diagnosis and Evaluation

History

• Living conditions. Ask where patient lives; assess for residential stability, access to drinking water and food (particularly when needed to take medications), bathing facilities, a safe place to keep medications (including those requiring refrigeration) and hygiene items.
• Sexual history. Ask about sexual identity, orientation, behaviors, partners, pregnancies, and sexually transmitted diseases (STDs) including hepatitis B. Assess STD risk in considering intra-uterine device (IUD) use.
• Desire for contraception. Assess patient's need and desire for contraceptive services. Ask about history of contraceptive use. Offer reproductive health services to all patients, regardless of gender.
• Substance abuse/ mental health. Assess patient's ability to take pills daily or remember to return for follow-up.
• Medical history. Elicit best possible history of ongoing medical problems or prior history of significant conditions such as hypertension, liver disease, or thromboembolic events. This can be difficult in homeless patients who seek medical care from multiple providers in multiple sites.
• Smoking history. Given higher incidence of smoking in homeless population, weigh risk factors for using estrogen-containing methods with risk of pregnancy.
• Medications. Ask female patient about medications she may be taking, especially psychiatric and anti-seizure drugs, which may require careful regulation if taken in conjunction with birth control pills.
• Immunizations. Ask whether patient has been vaccinated against measles-mumps-rubella (MMR) and hepatitis. Women of childbearing age should receive MMR vaccine if not pregnant. Patients engaging in high-risk sexual behaviors may be at risk for hepatitis B and should be vaccinated as necessary. Men who have sex with men (MSM) are at risk for hepatitis A and should be vaccinated.
• Menstrual history. If history of irregular cycles, obtain additional information such as relationship to weight gain or loss, substance use, and galactorrhea (abnormal milk production, a common side effect of some psychiatric medications, sometimes seen in substance abusers).
• Spiritual/ cultural history. Ask about spiritual and cultural beliefs, values, and practices of patient and partner affecting their use of contraception.
• Domestic/ interpersonal violence. Ask explicitly about history of physical/sexual abuse. This may be one of few opportunities patient has to talk about these issues without partner present.
• Insurance status/ resources. Assess patient's ability to pay for various contraceptive methods.

Physical Examination

• May be postponed. Communicate willingness to initiate contraception (e.g., birth control pills or injectable contraception) without a physical exam (Stewart et al., 2001). Do not tell patient that exam is prerequisite to beginning contraceptive method unless IUD, unexplained bleeding, or other pelvic symptoms warrant immediate evaluation.
• Sexual abuse. Be sensitive to concerns, fears, and safety needs of patient with a history of sexual abuse, who may be reluctant to have a pelvic exam. Understand the paradigm of traumatic experience. Respect patient's physical space; ask permission to touch and to perform each exam.
• Genital exam recommended as part of reproductive health care for males and females, according to standard clinical guidelines. Also do breast exam to address preventive care needs. Provider should be extremely sensitive to patient with a history of sexual abuse. See patient with clothes on first; carefully explain genital exam; ask permission to examine; never leave female patient alone in stirrups.
• Nonjudgmental attitude. Make every effort to convey openness to patient decisions regarding sexual behavior, desire to use contraception, and plans regarding present or future childbearing. When a patient is currently experiencing homelessness and trying to achieve pregnancy, this can be particularly challenging.

Diagnostic Tests

• STD screening. Concurrently assess for and treat sexually transmitted diseases, recognizing higher incidence and need for more frequent screening if engaging in risky sexual behaviors. Sexually active homeless women should receive same priority for STD screening as an initial prenatal patient. Test for gonorrhea, chlamydia, syphilis, human immunodeficiency virus (HIV) (following local regulations regarding patient consent), hepatitis B antigen, trichomonas, bacterial vaginosis, and monilia. When pelvic examination is refused, urine gonorrhea and chlamydia screening combined with self-administered vaginal swab for saline and potassium hydroxide (KOH) preparations may be useful screening tools. Don't neglect possibility of infection of multiple orifices in men and women, considering sexual practices.
• Pregnancy test. urine pregnancy test (UCG)
• Routine health care maintenance. For female: annual Papanicolaou (Pap) smear if age 17 or older (younger if sexually active), mammogram if indicated (baseline mammogram between ages 35 and 40; every 1 to 2 years ages 40 to 49; and every year, age 50 and above). For male: monthly testicular self-examination, 15 and older; annually per clinician; prostate examination: both digital rectal exam and prostate specific antigen (PSA) test annually, age 50 and older (age 40 and older for African American men and men with family history of prostate cancer) (Agency for Health Care Research and Quality [AHRQ], 1998).
• Tests for other concurrent conditions - e.g., anemia screening if at risk, urinalysis if symptomatic.

Plan and Management

Education, Self-Management

• Hygiene. Discourage use of harsh cleansing products, bath water additives, vaginal perfumes, and douches. Assist client in finding ways to keep clean, given limited access to bathing facilities, menstrual hygiene items, and/or clean underwear.
• Contraceptive methods. Describe each method in a way that is understandable to patient; take into account primary language, literacy, and possible cognitive deficit. Give simple instructions for contraceptive method selected. Always ask if there is any barrier to complying with the plan of care and if anything about it is unclear. Supplement your discussion with simple and effective brochures (multilingual, if possible).
• Side effects. During every visit, reinforce education about medication/contraceptive side effects (e.g., irregular bleeding with depo-medroxyprogesterone acetate). Discuss what to report to health care provider and when to seek medical evaluation.
• STD protection. Explain that many contraceptives (including birth control pills) do not protect against sexually transmitted diseases. Recommend condom use even with other contraceptive method. Provide information on availability of male and female barrier methods, either on site or elsewhere. Provide information about vaginal creams, gels, and suppositories containing spermicides that will prevent pregnancy and may decrease risk of some STDs.
• Risk reduction. Counsel at-risk clients to adopt safer sexual behaviors. Use interactive counseling that focuses on preventing unwanted pregnancy and transmission of disease, including description of risky behaviors and preventive methods. Counseling should be nonjudgmental, client-centered, and appropriate to client's age, sex, sexual orientation, and developmental level. Promote abstinence, reduction in numbers of sexual partners, and use of condoms, but use a risk reduction approach. For patients involved in injection drug use or other serious drug use, offer referral to substance abuse treatment and for access to clean needles when available.
• Smoking cessation. Use opportunity to encourage smoking cessation; assess readiness to change smoking behavior in female who prefers birth control pills.
• Partner education. If possible, include partner in discussion of contraceptive alternatives.
• Preconception counseling. Discuss nutrition, mental health, and substance abuse nonjudgmentally. Explain risks of pregnancy for patient and fetus related to alcohol, drug, and nicotine use. Also explain risks of psychiatric medications or other prescribed medications during pregnancy. Encourage folate-containing vitamin supplements in women of childbearing age. Educate client desiring pregnancy about advantages of and contraindications to breastfeeding.
• Health care maintenance. Encourage monthly breast/testicular self-exam and teach client how to perform exam.
• Storage/expiration of condoms, birth control pills. Educate patient about proper storage of condoms and birth control pills; advise not to use beyond expiration date.
• Co-existing medical conditions. Educate patient about possible effects of pregnancy on chronic medical conditions (e.g., diabetes, asthma, seizures, psychiatric disorders). This information will help male or female patient in decisions regarding family planning or contraceptive use.

Medications/Contraceptive Devices

• Dispense on site if possible, instead of giving patient a prescription or referring elsewhere. Recommend contraceptive methods that are easiest to use. For patient desiring contraception, initiate some contraceptive method immediately. Consider patient preference for dosage form (injection versus pills or patch) and encourage dual use of barrier and hormonal method.
• Injections. Consider injectable contraception if patient cannot adhere to daily regimen (for birth control pills), especially if risks associated with pregnancy are high. If pregnancy test is negative and likelihood of pregnancy before next visit is high, consider initiating injection beyond five-day onset of menses. Counsel patient regarding theoretic and very small risk to fetus if hormonal method is given inadvertently in early pregnancy. It may be desirable in some cultural or social situations for the female to have access to a contraceptive method of which her partner is not aware. Injections offer some benefit in these situations.
• Birth control pills. Determine number of pill packs to prescribe at one time based on patient's access to medications and ability to adhere to prescribed regimen. Make calendar for patient to use. For patients with mental health problems, consider prescribing only one pill pack at a time.
• Transdermal methods offer the advantage of convenience for some homeless clients, but may be expensive. Provider should also consider patient's occupation when prescribing contraceptive patches. Conspicuous forms of birth control (such as contraceptive patches, implants, etc.) may present an occupational disadvantage to some individuals (e.g., dancers in clubs - a common source of employment for homeless people in some areas).
• Female condom. Easy to use and as effective as the male condom in preventing pregnancy and protecting against sexually transmitted disease, this method may offer homeless clients another alternative for birth control. It is inexpensive and sold over-the-counter, but not always available.
• Initiation of contraception. After discussion of contraceptive alternatives, patient may wish to sign consent and begin contraceptive method immediately. Plans for voluntary surgical sterilization may also be initiated, but a temporary method should be considered until this can be accomplished.
• Vitamins. Prescribe folate supplement to all women of childbearing age (to prevent neural tube defects in fetus). Vitamins are usually appealing to homeless women, who have inadequate diets. Recommend calcium supplement (e.g., Tums) to patient on medroxyprogesterone acetate to counteract demineralization of bone caused by progesterone-only method.
• Contraindications. Estrogen-containing methods are not recommended for women 35 years of age or older who smoke. (Higher prevalence of smoking has been documented among homeless adults than in the general population.) IUDs are contraindicated for women with high STD risk (true of many homeless women).
• Anti-seizure medication. Careful regulation of anti-seizure medication required if taken in conjunction with birth control pills. Women with seizure disorders may require an additional contraceptive method or a higher dose of oral contraceptive pills than women who are not on anti-seizure medications. This is especially important to avoid an unintended pregnancy while taking a seizure medicine that may be teratogenic. Include in discussion issue of deleterious side effects of epileptic medications in pregnancy.

Associated Problems/Complications

• Pregnancy. Counsel patient on medical and personal risks of pregnancy. May encounter refusal of birth control, desire for pregnancy at a very unstable time of life (e.g., because of loss of other children to state custody, belief that partner will be more faithful if patient is pregnant, to get sympathy/benefits). Some females try to achieve pregnancy while actively using drugs and alcohol. Many drug users don't have regular menses and consider birth control unnecessary. Help patient to understand risks of pregnancy related to irregular menses, drug and alcohol abuse.
• Housing problems. Recognize that lack of housing may be even more of a problem once client becomes pregnant.
• Post-traumatic Stress Disorder (PTSD). Recognize that many homeless women and men are survivors of physical/sexual assault, with associated risks of psychological trauma and sexually transmitted disease, which both complicate and enhance their need for reproductive health services.
• Financial barriers. Limited resources for medications and lack of affordable health insurance for impoverished adults unaccompanied by children may present barriers to reproductive health care for both women and men.
• Lack of safe storage place. Many homeless people don't have a safe place to store condoms, barrier devices, or medications. Store contraceptive devices and medications for patient and provide ready access to them.

Follow-Up

• Frequent follow-up is recommended to deal with any side effects of prescribed contraceptive method. Mention reproductive health to patient at each visit. Make plan to ensure return one month after initial visit.
• Reminders. Appointment cards kept in pouches, worn around neck, are useful to remind patient when to return to clinic for next prescription or injection. Use of voicemail reminders and outreach workers can also facilitate follow-up care.
• Positive reinforcement. Thank patient for showing up, even if late, and for any attempt to follow plan of care. Don't scold.
• Contact information. Re-confirm at every visit where patient is staying, address, phone number, cell phone, emergency contact number(s) where message can be left, case manager's name (if seen in clinic), clinic numbers (if seen in shelter).
• Drop-in policy. Be flexible. Encourage appointments but allow walk-ins, to promote better follow-up care and increase access to reproductive health services.
• Educate staff, co-workers to increase their knowledge of contraceptive options and comfort level with homeless patients.

None provided

Overall benefits:

• Improved sexual and reproductive heath in homeless individuals

Specific benefits:

• Injectable contraception offers some benefits in situations when it is desirable for the female to have access to a contraceptive method of which her partner is not aware.
• Female condom is easy to use and as effective as the male condom in preventing pregnancy and sexually transmitted diseases; it is inexpensive, but not always available

Estrogen-containing methods are not recommended for women 35 years of age or older who smoke

Intra-uterine devices are contraindicated for women with high risk of sexually transmitted diseases

The information and opinions expressed in the guideline are those of the Advisory Committee for the Adaptation of Clinical Guidelines on Reproductive Health Care for Homeless Patients, not necessarily the views of the U.S. Department of Health and Human Services, the Health Resources and Services Administration, or the National Health Care for the Homeless Council, Inc.

This guideline has been distributed to 161 Health Care for the Homeless (HCH) grantees across the United States and to several academic programs that train primary care providers. These and other recommended clinical practice adaptations to optimize care for homeless persons are also being used in workshops at national and regional conferences, including the National HCH Conference sponsored by the Bureau of Primary Health Care/HRSA/HHS.

Getting Better
Staying Healthy

Effectiveness
Patient-centeredness

• Bonin E, Brammer S, Brehove T, Hale A, Hines L, Kline S, Kopydlowski MA, Misgen M, Obias ME, Olivet J, O'Sullivan A, Post P, Rabiner M, Reller C, Schulz B, Sherman P, Strehlow AJ, Yungman J. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2003. 22 p. [35 references]

2003

Health Care for the Homeless (HCH) Clinician's Network - Medical Specialty Society
National Health Care for the Homeless Council, Inc. - Private Nonprofit Organization

The Bureau of Primary Health Care, Health Resources and Services Administration, U.S. Department of Health and Human Services

Advisory Committee for the Adaptation of Clinical Guidelines on Reproductive Health Care for Homeless Patients

Committee Members: Edward Bonin, MN, FNP-C, RN, Tulane University Health Sciences Center, Adolescent Drop-In Health Services, New Orleans, Louisiana; Sharon Brammer, FNP, H.E. Savage Health Care for the Homeless, Mobile, Alabama; Theresa Brehove, MD, Venice Family Clinic, Venice, California; Abby Hale, PA-C, Homeless Healthcare Project, Community Health Center of Burlington, Burlington, Vermont; Lorna Hines, CMA, The Outreach Project, Primary Health Care, Inc., Des Moines, Iowa; Susan Kline, MN, ARNP, Public Health - Seattle and King County, Seattle, Washington; Mary Ann Kopydlowski, BSN, RN, Boston Health Care for the Homeless Program, Jamaica Plain, Massachusetts; Mike Misgen, MA, LPC, Colorado Coalition for the Homeless, Stout Street Clinic, Denver, Colorado; Maria Elisa Obias, MSN, CNS, RN, Care Alliance, Cleveland, Ohio; Jeffrey Olivet, MA, Albuquerque Health Care for the Homeless, Inc., Albuquerque, New Mexico; Adele O’Sullivan, MD, Maricopa County Dept. of Public Health, Phoenix, Arizona; Mark Rabiner, MD, Saint Vincent’s Hospital & Medical Center, New York, New York; Christine Reller, MSN, RN, Hennepin County Community Health Dept., Health Care for the Homeless Project, Minneapolis, Minnesota; Betty Schulz, CPNP, RN, Mercy Children's Health Outreach Project, Baltimore, Maryland; Peter Sherman, MD, New York Children’s Health Project, New York, New York; Aaron Strehlow, PhD, FNP-C, RN, UCLA School of Nursing Health Center at the Union Rescue Mission, Los Angeles, California; Jeffrey Yungman, MSW, Crisis Ministries’ Health Care for the Homeless Project, Charleston, South Carolina

The Health Care for the Homeless (HCH) Clinicians' Network has a stated policy concerning conflict of interest. First, all transactions will be conducted in a manner to avoid any conflict of interest. Secondly, should situations arise where a Steering Committee member is involved in activities, practices or other acts which conflict with the interests of the Network and its Membership, the Steering Committee member is required to disclose such conflicts of interest, and excuse him or herself from particular decisions where such conflicts of interest exist.

No conflicts of interest were noted during preparation of this guideline.

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on May 24, 2004. The information was verified by the guideline developer on June 24, 2004. This summary was updated by ECRI on October 4, 2006 following the new FDA advisory on Ortho Evra. This summary was updated by ECRI Institute on February 4, 2008 following the new U.S. Food and Drug Administration advisory on Ortho Evra Contraceptive Transdermal Patch.

All material in this document is in the public domain and may be used and reprinted without special permission. Citation as to source, however, is appreciated. Suggested citation: Bonin E, Brammer S, Brehove T, Hale A, Hines L, Kline S, Kopydlowski MA, Misgen M, Obias ME, Olivet J, O'Sullivan A, Post P, Rabiner M, Reller C, Schulz B, Sherman P, Strehlow AJ, Yungman J. Adapting your practice: treatment and recommendations on reproductive health care for homeless patients. Nashville (TN): Health Care for the Homeless Clinicians' Network, National Health Care for the Homeless Council, Inc.; 2003. 22 p.