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Family Health Center
21 Grand Street
Hartford, Connecticut 06106
Contact: Jamilah Ali, PA
Phone: (860) 550-7500
Key words: cardiovascular disease; cocaine
use; patient education; risk reduction
The purpose of this study was two-fold
and included the following major activities:
1) screening to determine the
prevalence of cardiovascular risk factors
among clients and 2) development and evaluation
of a patient education pamphlet.
METHODS
A cardiovascular (CV) risk assessment
was offered to patients at homeless shelters
and soup kitchens in Hartford, Connecticut.
No incentives were offered for participation.
Fifty-five patients, 18 years of age and
older, volunteered for a CV assessment
during a 7 month period in 1997. Information
regarding the purpose of the study, CV
disease, and consent forms were provided
to volunteers as part of the registration
process. Relevant health and medical history
information was obtained from the participants.
The cohort of 55 reflected the following
demographics (note-due to rounding, some
percentages may not add up to 100 percent):
Gender
Males 74%
Females 25% |
Race/Ethnicity
Black 67%
Shelter 29%
White 7%
Hispanic 24% |
Housing Status
Transitional 25%
Doubled up 20%
Other 24% |
Beginning with the clients first visit,
culturally appropriate intervention materials
regarding behaviors that increase the
risk of CV disease were provided and blood
samples were taken. Whether or not blood
samples were taken at each subsequent
visit depended on the results of the previous
visit. At the start of the study, staff
intended to test the level of highdensity
lipoprotein (HDL) on individuals with
a cholesterol level exceeding 200 as well
as obtain a glycohemoglobin on individuals
with glucose levels exceeding 140. However,
HDL levels were not tested on the majority
of participants due to their inaccessibility
for follow-up.
Data obtained from the screening evaluations
was applied to the First Heart Attack
Risk Test, developed by the American Heart
Association (AHA), using their definition
of risk parameters (e.g., smoking status,
weight, cholesterol). This AHA assessment
uses a threshold of four points to indicate
that a person has an increased risk of
a heart attack as compared to the general
population. In part because of the prevalence
of substance abuse among homeless individuals
and the dangers of cocaine use, a question
regarding cocaine use was added to the
AHA assessment. A self-assessment was
also requested of participants, using
a four point scale, ranging from Excellent
to Poor. The second phase of this study
involved the evaluation of a pamphlet
(Cocaine and its Effects on Your Heart)
developed by a staff physician at the
request of program staff. Evaluation of
the pamphlet was done through the use
of a survey distributed at two shelters.
The survey consisted of five questions
that requested information regarding the
following: the respondents history of
cocaine use; whether or not the pamphlet
was in fact read by the participant; how
much of the pamphlet was read; how good
the respondent thought the pamphlet was;
and whether or not the pamphlet led to
a change in attitude about cocaine use.
Regarding the First Heart Attack Risk
Test, the frequency of each variable and
its assigned number of points was analyzed.
The mean score was 3.964, with a standard
deviation of 2.325. Two-thirds of the
participants scored four or less points
on the Test, while one-third were found
to be at increased risk for a myocardial
infarction (MI), having a score of four
or more points. The maximum score was
ten points. The four most common risk
factors indicated by participants were
smoking--63 percent; being more than twenty
pounds above ideal body weight (IBW)--38
percent; any history of cocaine use; and
having a first degree relative with an
MI prior to age 60--25 percent. Participants
rated their health in the following manner
when asked to do a self-assessment: Excellent
14 percent; Goodm 58 percent; Fair 18
percent; and Poor 9 percent. Fifty-one
individuals completed surveys regarding
the Cocaine and its Effects on Your Heartn
pamphlet. Seventy-one percent of the respondents
read the pamphlet; 55 percent indicated
that they had used cocaine before and
15 percent stated they had used cocaine
within the last year. Fifty-three percent
rated the pamphlet as excellent and 67
percent indicated that it changed the
way they thought about cocaine. Reasons
given for not reading the pamphlet included
that it contained too many hard words;
respondents vision was too poor; respondent
was not interested; and respondent needed
it in Spanish.
A number of patients were found to be
at high risk for heart disease. One reason
for the number of individuals found to
be at risk was the high number of smokers
in the group (63 percent), strikingly
higher than the 1995 prevalence of smoking
among blacks and whites in the general
population (i.e., 26 percent). Also noteworthy
was the fact that 38 percent of the group
was more than 20 pounds over their ideal
weight, while only 5 percent had a significantly
elevated level of cholesterol. This observation
may reflect some effects of the soup kitchen
diet, which probably includes a great
deal of inexpensive carbohydrates such
as pasta and rice. In general, common
shortcomings of screening programs include
selection bias, over diagnosis, and lead
time bias. Selection bias was a problem
in this study. Randomization was attempted
at the start of this study, but was unsuccessful
for three major reason: 1) clients_ objections
to services being made available to some,
but not everyone; 2) insufficient time
for clinicians to invite potential participants
to join the study while providing acute
or primary care in the shelters or soup
kitchens; and 3) lack of clinical supplies
or patient education materials at certain
times. All of the above prevented the
targeted sample population of 150 from
being realized. Over diagnosis and lead
time bias were less likely to have occurred.
If anything was likely to occur, it was
underdiagnosing rather than over diagnosing,
primarily because of difficulty experienced
in trying to obtain follow-ups for all
participants. Because so many CV risk
factors are modifiable, lead time bias
is less likely to have been a problem.
Regarding the pamphlet evaluation, although
the results appear to have been positive,
there were indications of problems with
it as well. One problem is the length.
For example, during the evaluation, some
respondents clearly did not read the pamphlet
thoroughly; some _finished_ reading long
before even a highly literate or educated
individual would have.
Because of the shortage of time, finances,
and personnel, studies on homeless clients
are very difficult. Difficulties experienced
during this study underscore the importance
of a well-planned study. More studies
should be done regarding the risk for
CV disease among homeless people as well
as more attention paid to developing (and
evaluating) programs that can help homeless
persons find ways to reduce their risk
of CV disease despite their extremely
difficult lifestyles.
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