General Health Care
It must not be forgotten that homeless people are affected by all of the same health care problems that affect the general population. It is true that certain conditions are more common amongst homeless populations (such as mental health problems, hepatitis C and tuberculosis, for example) but homeless people also develop common chronic health conditions such as diabetes, heart disease, lung disease and cancers. Homelessness creates an added complexity when it comes to managing these common chronic conditions because there as so many extra barriers to achieving a god clinical outcome. For example, if finding food, warmth, money and dealing with your mental health are your immediate priorities then attending for a flu vaccine or a review of your inhalers may be much lower on your list of things to do.
Here we will briefly focus on the issues to consider when managing diabetes, COPD and infectious diseases in homeless patients.
Diabetes
It is difficult to give precise statistics about diabetes in homeless populations but in the UK, the link between socio-economic disadvantage and diabetes has been identified, with people in the lowest socio-economic groups being 2.5 times more likely to develop the condition (because of higher rates of smoking, obesity, high blood pressure and poor diets) and 3.5 times more likely to develop complications from diabetes (Weng, 2002).
Studies with groups of homeless people with diabetes in America found that 72% reported difficulties in managing their condition (Hwang, 2000) and the All Parliamentary Group for Diabetes with Diabetes UK identified some common problems faced by homeless patients with diabetes:
COPD
Chronic respiratory conditions, smoking (the biggest risk factor for respiratory illness) and death from respiratory illnesses are all much more common in homeless populations than in the general population (Hwang 2000, Health Protection Agency 2004, O'Connell 1991). COPD might be more difficult to diagnose and manage with homeless patients as GP's will be more used to having a background of frequent infections, access to chest X-rays and perhaps spirometry results over a series of consultations. With homeless patients there may be no background history available (or no medical records at all) and patients may be less likely to attend appointments arranged at the hospital or with the practice nurse.
At the risk of seeming repetitive, it is useful to remember here that attending appointments in unfamiliar or far away places might be a real barrier for some homeless patients. The fewer places a homeless patient has to travel to for care, the more likely successful engagement should logically be. Another reason why the mainstream primary care team is potentially so well placed to provide excellent quality health care for this group of patients is how they can provide so much of the basic care and support regarding diabetes and COPD (and others) in one single place. Granted, retinopathy and podiatry checks might not be possible but screening, diagnosis, education, treatment and monitoring can be.
So, when dealing with chronic respiratory conditions in homeless patients, you might want to consider relying more on the clinical picture and history to make your diagnosis. Patients should, of course, still be offered spirometry in the normal way. Consider treating exacerbations aggressively in this group, as outcomes are so much poorer and remember to continue being active in the offer of smoking cessation advice and therapies.
Infectious Disease (Flu & TB)
Flu
Homelessness itself is not included in the list of special risk groups for influenza, however, Public Health England state that:
"the medical practitioner should apply clinical judgement to take into account the risk of influenza exacerbating any underlying disease that a patient may have, as well as the risk of serious illness from influenza itself. Influenza vaccine should be offered in such cases even if the individual is not in the clinical risk groups specified above."
Even though homelessness is not a clinical risk category itself the following facts are known:
With these facts in mind, and the flexibility afforded in the Public Health Guidance, it seems that targeted vaccination for homeless groups is easily justified.
TB
In 2010 there were over 8,483 cases of TB in England. 39% of these were in London and 73% of cases were in people born outside of the U.K.(HPA, 2011). The activity of tuberculosis is heavily affected by social factors and the groups at the highest risk of developing TB are:
Treatment for TB usually lasts at least 6 months and homeless groups are at high risk of having incomplete treatment (Story et al, 2007). Incomplete treatment, in turn, makes drug resistance more likely. When you put these things together we see a situation where:
For more information, the NICE Guidance on identifying and managing TB amongst heard to reach groups from 2012 gives a very clear summary of the evidence. There is also a TB leaflet for workers in the homeless sector produced by the government.
Here we will briefly focus on the issues to consider when managing diabetes, COPD and infectious diseases in homeless patients.
Diabetes
It is difficult to give precise statistics about diabetes in homeless populations but in the UK, the link between socio-economic disadvantage and diabetes has been identified, with people in the lowest socio-economic groups being 2.5 times more likely to develop the condition (because of higher rates of smoking, obesity, high blood pressure and poor diets) and 3.5 times more likely to develop complications from diabetes (Weng, 2002).
Studies with groups of homeless people with diabetes in America found that 72% reported difficulties in managing their condition (Hwang, 2000) and the All Parliamentary Group for Diabetes with Diabetes UK identified some common problems faced by homeless patients with diabetes:
- difficulties in obtaining food – little choice available in shelters;
- difficulties in scheduling or managing their diabetes consistently due to lack of routine and lifestyle choices available;
- some shelters may forbid residents possessing needles. There could be other fears surrounding possible theft of syringes from those using syringes to support their drug taking habits;
- increased risk of hypoglycaemia due to alcohol abuse, lack of suitable remedies e.g.glucose, lack of awareness and training of those with whom they come into contact. Also, in the cold, damp weather, more carbohydrate may be needed to maintain their blood glucose levels;
- increased walking and poor footwear accentuate problems with peripheral neuropathy or foot problems; and
- they are more likely than others to present with a disease rather than at prevention or screening stages, and may use accident and emergency departments for their healthcare needs. They can feel alienated from health promotion materials, as these often require high levels of literacy. Although homeless people may be concerned about health related problems, low self esteem and low expectations prevent them from accessing healthcare (Diabetes UK, 2006).
COPD
Chronic respiratory conditions, smoking (the biggest risk factor for respiratory illness) and death from respiratory illnesses are all much more common in homeless populations than in the general population (Hwang 2000, Health Protection Agency 2004, O'Connell 1991). COPD might be more difficult to diagnose and manage with homeless patients as GP's will be more used to having a background of frequent infections, access to chest X-rays and perhaps spirometry results over a series of consultations. With homeless patients there may be no background history available (or no medical records at all) and patients may be less likely to attend appointments arranged at the hospital or with the practice nurse.
At the risk of seeming repetitive, it is useful to remember here that attending appointments in unfamiliar or far away places might be a real barrier for some homeless patients. The fewer places a homeless patient has to travel to for care, the more likely successful engagement should logically be. Another reason why the mainstream primary care team is potentially so well placed to provide excellent quality health care for this group of patients is how they can provide so much of the basic care and support regarding diabetes and COPD (and others) in one single place. Granted, retinopathy and podiatry checks might not be possible but screening, diagnosis, education, treatment and monitoring can be.
So, when dealing with chronic respiratory conditions in homeless patients, you might want to consider relying more on the clinical picture and history to make your diagnosis. Patients should, of course, still be offered spirometry in the normal way. Consider treating exacerbations aggressively in this group, as outcomes are so much poorer and remember to continue being active in the offer of smoking cessation advice and therapies.
Infectious Disease (Flu & TB)
Flu
Homelessness itself is not included in the list of special risk groups for influenza, however, Public Health England state that:
"the medical practitioner should apply clinical judgement to take into account the risk of influenza exacerbating any underlying disease that a patient may have, as well as the risk of serious illness from influenza itself. Influenza vaccine should be offered in such cases even if the individual is not in the clinical risk groups specified above."
Even though homelessness is not a clinical risk category itself the following facts are known:
- Homelessness is an independent risk factor for premature mortality (Morrison, 2009)
- Mortality from respiratory infections is 7 times higher in homeless populations (O'Connell, 1991)
- There are high rates of chronic respiratory illnesses, which are themselves a clinical risk group (Hwang, 2000)
- The high prevalence of chronic health problems combined with the effect of the congregate living standards in hostels means homeless groups there are more susceptible to vaccine preventable infectious disease (Rogers et al, 2004)
With these facts in mind, and the flexibility afforded in the Public Health Guidance, it seems that targeted vaccination for homeless groups is easily justified.
TB
In 2010 there were over 8,483 cases of TB in England. 39% of these were in London and 73% of cases were in people born outside of the U.K.(HPA, 2011). The activity of tuberculosis is heavily affected by social factors and the groups at the highest risk of developing TB are:
- the homeless - 788.1 cases per 100,000 people
- problem drug users - 354.3 cases per 100,000 people
- prisoners - 208.4 cases per 100,000 people (Story et al, 2007)
Treatment for TB usually lasts at least 6 months and homeless groups are at high risk of having incomplete treatment (Story et al, 2007). Incomplete treatment, in turn, makes drug resistance more likely. When you put these things together we see a situation where:
- TB is more common among homeless and hard to reach groups,
- these groups are less likely to access or complete treatment, thus increasing the likelihood of drug resistance and
- TB is more easily spread among these groups due to their living conditions.
For more information, the NICE Guidance on identifying and managing TB amongst heard to reach groups from 2012 gives a very clear summary of the evidence. There is also a TB leaflet for workers in the homeless sector produced by the government.
References
All Parliamentary Group on Diabetes & diabetes UK. Diabetes and the disadvantaged: reducing health inequalities in the UK -http://www.diabetes.org.uk/Documents/Reports/Diabetes_disadvantaged_Nov2006.pdf
Health Development Agency: Homelessness, Smoking and Health. Health Development Agency; 2004.
Health Protection Agency (2011) Tuberculosis in the UK: 2011 report. London: Health Protection Agency
Hwang SW: Mortality among men using homeless shelters in Toronto, Ontario. JAMA 2000, 283(16):2152-7.
Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol. 2009. Available from: http://ije.oxfordjournals.org/content/early/2009/03/21/ije.dyp160
O’Connell J. Nontuberculous respiratory infections among the homeless. Semin Respir Infect 1991, 6(4):247-53.
Public Health England. Immunisation Against Infectious Disease: The Green Book 2014. Chapter 19 (Influenza).
Rogers MA, Wright JG, Levy BD: Influenza. In The Health care of Homeless Persons: A Manual of Communicable Diseases and Common Problems in Shelters and on the Streets. Boston: Boston Healthcare for the Homeless Program; 2004:67-71.
Stephen W. Hwang, Ann L. Bugeja Barriers to appropriate diabetes management among homeless people in Toronto. CMAJ 2000;163(2):161-5
Story A, Murad S, Roberts W et al. (2007) Tuberculosis in London: the importance of homelessness, problem drug use and prison. Thorax 62: 667–71
Health Development Agency: Homelessness, Smoking and Health. Health Development Agency; 2004.
Weng, C., Coppin, D.V. and Sonksen, P.H. (2002) Geographic and social factors are related to increased morbidity and mortality rates in diabetic patients. Diabetic Medicine 17(8): 612- 617
All Parliamentary Group on Diabetes & diabetes UK. Diabetes and the disadvantaged: reducing health inequalities in the UK -http://www.diabetes.org.uk/Documents/Reports/Diabetes_disadvantaged_Nov2006.pdf
Health Development Agency: Homelessness, Smoking and Health. Health Development Agency; 2004.
Health Protection Agency (2011) Tuberculosis in the UK: 2011 report. London: Health Protection Agency
Hwang SW: Mortality among men using homeless shelters in Toronto, Ontario. JAMA 2000, 283(16):2152-7.
Morrison DS. Homelessness as an independent risk factor for mortality: results from a retrospective cohort study. Int J Epidemiol. 2009. Available from: http://ije.oxfordjournals.org/content/early/2009/03/21/ije.dyp160
O’Connell J. Nontuberculous respiratory infections among the homeless. Semin Respir Infect 1991, 6(4):247-53.
Public Health England. Immunisation Against Infectious Disease: The Green Book 2014. Chapter 19 (Influenza).
Rogers MA, Wright JG, Levy BD: Influenza. In The Health care of Homeless Persons: A Manual of Communicable Diseases and Common Problems in Shelters and on the Streets. Boston: Boston Healthcare for the Homeless Program; 2004:67-71.
Stephen W. Hwang, Ann L. Bugeja Barriers to appropriate diabetes management among homeless people in Toronto. CMAJ 2000;163(2):161-5
Story A, Murad S, Roberts W et al. (2007) Tuberculosis in London: the importance of homelessness, problem drug use and prison. Thorax 62: 667–71
Health Development Agency: Homelessness, Smoking and Health. Health Development Agency; 2004.
Weng, C., Coppin, D.V. and Sonksen, P.H. (2002) Geographic and social factors are related to increased morbidity and mortality rates in diabetic patients. Diabetic Medicine 17(8): 612- 617