Health Care Delivery

Homeless people are willing to obtain health care if they believe it is important

About one-third of homeless adults living in Los Angeles have impaired vision, skin/leg/foot problems, or tuberculosis (TB). Many have been in prison or been the victim of a crime. Most have been homeless for several years and suffer from chronic mental illness, alcoholism, or drug addiction. Fortunately, these homeless individuals can be motivated to seek medical care for conditions they consider serious, despite mental illness or substance abuse problems. This requires case identification and referral to a community physician for care, notes Lillian Gelberg, M.D., M.S.P.H., of the University of California, Los Angeles.

In a study supported in part by the Agency for Healthcare Research and Quality (HS06696), Dr. Gelberg and her colleagues tested a behavioral model of access to care that is particularly applicable to vulnerable populations. They analyzed data from the UCLA Homeless Health Study to determine factors that influence whether a homeless person will see a clinician for one of four conditions prevalent among the homeless—vision impairment, skin/leg/foot problems, high blood pressure, and positive tuberculosis (TB) skin test—and the impact of that care on their health status. The researchers interviewed 363 homeless people in Los Angeles and gave them a limited physical examination and TB skin test. Those found to have any one of the four study conditions were contacted every 4 months (up to 8 months) to see if they had sought medical care and to assess whether they still had the condition(s).

The majority of study participants had no regular source of care (only 4 percent used a private doctor), and only one-third were covered by health insurance. Homeless people were more apt to seek care for conditions that had a less immediate but longer term effect, such as high blood pressure and TB skin test positivity, than for symptomatic conditions of their skin and vision. They may have been coping or at least getting by. Or, they may have felt that they could treat such conditions on their own, for example, by obtaining reading glasses from a local store. However, use of care didn't always affect outcome, perhaps due to the harshness of their environment and the current state of health care available to these homeless individuals.

The researchers point out that residential history, mental health, substance abuse, history of victimization, and competing needs affect the use of health services and clinical outcomes. They recommend that the model tested in this study—the Behavioral Model for Vulnerable Populations—be considered in future research on the health of disadvantaged populations.

For more information, see "The behavioral model for vulnerable populations: Application to medical care use and outcomes for homeless people," by Dr. Gelberg, Ronald M. Andersen, Ph.D., and Barbara D. Leake, Ph.D., in the February 2000 Health Services Research 34(6), pp. 1273-1314.

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