Equity is one of three key principles of the Department of Health strategy document.1 The pursuit of equity, it recommends, should extend to the examination of the health status of certain groups. Specifically, it states that disadvantaged groups should be given special attention.
The homeless provide an example of such a disadvantaged group whose health is profoundly affected by their homelessness or by the factors that caused them to become homeless. Anecdotal and empirical observations from around the world have confirmed this to be the case.2-5 What is also known is that the utilisation of health and related services is influenced by being homeless and by the presence of many barriers which limit equality of access to, and outcome from, encounters with these services.2,6,7
This is the first study that has examined the health of the adult homeless population of Dublin. Its objectives are as follows: to describe the size and composition of the adult homeless population of Dublin; to describe health related behaviour; to determine health status by enquiring about health and current morbidity; to determine the use of services by the homeless; and, to identify barriers to the use of such services.
The study was a four day census and questionnaire interview of homeless people in Dublin who met the definition of homelessness that was used which included residents of hostels, temporary private accommodation and those sleeping on the streets. It was estimated in advance of the study that 900-1000 people might meet the definition. The population was estimated during the course of the study by recording the number of people registered in the various institutions. In the case of those sleeping rough, the denominator was the average number of people seen by the soup run each night.8
Each hostel, bed and breakfast, guesthouse, food centre and "soup run" catering for the homeless in the Dublin area was contacted initially by post and subsequently by telephone to seek their support and participation.
The study was carried out by interviewer administered questionnaire. The questionnaire was anonymous and confidential and this was stressed to all potential interviewees. The questionnaire was divided into four sections: demography; experience and patterns of homelessness; health status and lifestyle; and, utilisation of health services.
Thirty three interviewers (medical and social policy students and voluntary workers) were recruited to carry out the interviews on a voluntary basis over a one week period. In order to reduce observer variation the interviewers were trained in administration of the questionnaire.
A pilot study was carried out six weeks in advance of the study which led to some changes in the questionnaire. The data collection was carried out in March 1997. Data were analysed using EpiInfo version 6.9
Five hundred and two questionnaires were completed. The population recorded using the method outlined above during the course of the study was 780 and this was used as the denominator giving a response rate of 64.4% (502/780).
Sixty five per cent of the group were under the age of 45 while eight per cent were over the age of 65. 85% of the population of homeless were male. The age distribution of this group was similar to the total homeless population. 77% of the female homeless population were under the age of 45 while 14% of them were over the age of 65.
Seventy eight per cent were current smokers and 29% were found to drink beyond recommended limits.10 The average weekly consumption of alcohol was 49.8 units. Twenty nine percent of respondents said that they had used illegal drugs.
Sixty eight per cent of people complained of at least one physical or psychiatric problem, including skin, foot and dental problems. Forty one per cent reported a previous diagnosis of one of the chronic physical diseases shown in Table 1 while 37% of people reported a previous diagnosis of one of the psychiatric problems listed. These prevalences are based on the proportion of responders to a question about a given condition.
Table 1 Estimated prevalence of physical and psychiatric problems among homeless adults Condition Number with condition Prevalence %
Chronic Physical Disease
|Peptic ulcer disease||65||13.7|
Chronic Psychiatric Problems
There was no sex difference in the overall prevalence of chronic disease but older respondents (over 45 years) were more likely to report at least one chronic disease (RR 1.4; p<0.001). The long-term homeless (more than one year) were also more likely to report at least one chronic disease (RR 1.4; p=0.016). Females were more likely to report a psychiatric disease (RR 1.5; p=0.002).
Smokers were more likely to report a chronic disease (RR 1.9; p<0.001), psychiatric disease (RR 3.3; p=0.009) and skin problems (RR 1.2; p=0.004). Alcohol consumption was greater in those with a chronic disease (42.2 vs 21.0 units per week, p=0.008) or psychiatric disease (39.0 vs 24.8 units per week, p=0.029). Although chronic disease was no more prevalent among those taking illicit drugs, psychiatric disease was more likely (RR 1.4; p=0.008).
The long-term homeless were more likely to report arthritis (RR 2.8; p<0.001), heart disease (RR 3.0; p=0.009), tuberculosis (RR 4.1; p=0.019), depression (RR 1.6; p<0.001) and anxiety disorder (RR 1.5; p=0.003). The effect of long-term homelessness on the prevalence of depression is only seen in younger respondents (under 45 years).
Fifty seven percent of respondents rated their health as good to excellent while the remainder rated it as either fair or poor. Males were significantly more likely than females to rate their health as good (RR 1.5; p=0.002).
Fifty five per cent of respondents stated that they had a current medical card. Medical card ownership was more likely in older people (RR 1.3; p<0.001) and those reporting a psychiatric disorder (RR 1.3; p=0.047) but not in those reporting at least one chronic disease. Possession of a medical card was found to increase general practitioner (GP) consultation rates (3.6 visits in previous six months vs 1.8, p<0.001).
The average number of GP (3.7 vs 1.8, p<0.001), accident and emergency (A&E) (0.6 vs 0.2, p<0.001) and outpatient (OPD) (3.2 vs 0.3, p<0.006) visits in the last 6 months was higher among those reporting at least one chronic disease. A number of factors, including demography, health problems and lifestyle were associated with greater use of health services in the previous 6 months. Rating of health had no effect on use of any of the health services examined.
The response rate of 64% achieved in this study is in keeping with or better than response rates in other studies of homeless people.2,11,12 One previous study in Dublin achieved a response rate of 34%.13 Many other studies avoid the difficulties relating to definition of homelessness or population denominator estimation and, therefore, do not quote response rates.3,4 Medical students have been successfully employed in this way in the past4 as they were in this study.
The homeless population is heterogeneous and very few would fit the demographic stereotype of a homeless person which is commonly perceived or expressed. The sex structure of the Dublin homeless population is almost identical to that of a Sheffield study which used a similar approach.3 The age breakdown of both populations is similar, although the Sheffield population appears to be somewhat older.3 In comparison to the overall Irish population, the homeless population contains a smaller proportion of people over the age of 65 (11.5% vs. 8.1%).14
The behavioural risk factors identified indicate that there is a considerable potential for benefit from health promotion initiatives.15 Seventy eight per cent of the homeless people in this study smoked cigarettes which is identical to a prevalence of 78% found in another comparable study.4 It compares to a prevalence of cigarette smoking of 31% of people aged 15 and over in the general Irish population.16
The prevalence of alcohol abuse at 29% compares to 27% for males and 21% for females in the general Irish population16 and was lower than might be expected.17 The prevalence of alcohol abuse reported in the literature among homeless people, however, has varied considerably according to the methods of measurement employed.5 Another study, using similar methods, found a prevalence of alcoholism of 28%.3 The lifetime prevalence of drug use of 28% found in this study was also lower than expected.5,18 Fear on the part of the interviewees that drug or alcohol abuse could result in expulsion from certain institutions could have lead to a reluctance to divulge details of current alcohol and drug taking habits. Further studies should be carried out using appropriate methods to ascertain the extent of alcohol and drug abuse in this population.
The prevalence of many chronic diseases and chronic problems was higher than would be expected from a sample of similar demographic composition drawn from the general population. The estimated prevalences of diabetes mellitus, hypertension, peptic ulcer disease, respiratory disease, depression and anxiety disorder were greater in the homeless population than would be expected.19
The combined prevalence of chronic physical diseases of 41% compares to reported prevalences between 30% to 40% for homeless populations elsewhere.6,7,20 Comparable prevalences for diabetes mellitus and hypertension in another study using self-reported morbidity were 2.7% and 20.5% compared to 2.5% and 12.7% in this study.4 A Sheffield study found similar prevalences to this study of epilepsy (4% vs. 5.3% in this study) and tuberculosis (3% vs. 2.7% in this study).3
The Sheffield study also found a similar prevalence of reported psychiatric illness to this study (34% vs. 36.9%).3 The prevalence of depression in this study was 32.5% which compares closely to an estimate of 29.5% in an American study of the urban homeless. However, the American study would indicate that this study may have overestimated the prevalence of anxiety disorder (27.6% vs. 17.6%).21 This may have occurred because less strict diagnostic criteria were used in this study. In order to define these issues more clearly, chronic physical and psychiatric health in the homeless requires further research attention.
Nearly half (44%) of all homeless people rated their health as either fair or poor. This compares to estimates of between 33% and 48% for homeless populations and 18% to 21% for the general population from other studies which have also used perceived health status to measure health among the homeless.22
The variation in attendance at A&E, GP and OPD found between different subgroups of the homeless population may reflect differences in the problems they experience, differences in their help-seeking behaviour or differences in their access to the various health services.
The barrier to service utilisation that results from the lack of a medical card is considerable. Almost half of the homeless population have no personal medical card. Those with chronic health problems were often more likely to use A&E services. The fact that they were no more likely to have a medical card may account for the greater likelihood of using A&E among those with on-going health needs. The type of health problems which were found to be associated with greater use of A&E would seem to provide further evidence of this inappropriate use of health services among homeless people. It is primary care services, such as GP, which are appropriate for the care of chronic and non-emergency problems. Without access to these services, there is no continuity of care for the homeless person within the health services.
The differences in health between homeless and non-homeless people appear not to be the actual health problems that they suffer from, but their greater health risks, the higher prevalence of certain health problems and their limited access to appropriate intervention when they are ill. Further studies, which include physical examination, history taking and clinical investigations should be conducted to examine the physical and psychiatric problems of the homeless in more detail and to allow comparison with non-homeless groups. A health service response to deal with the health problems which have been identified will require a strategic multidisciplinary approach focused on the needs and the potential for health and social gain in this vulnerable population.
I wish to acknowledge the help and support I received from
I also wish to thank for his statistical and methodological advice, comments and criticisms. Thanks are also due to
Dr Emer Feely,
Dr Howard Johnson,
Dr Anne O'Connor and
Dr Colin Doherty.
I received help from a number of agencies including the Homeless Initiative; Housing Section, Dublin Corporation; Homeless Section, Eastern Heaslth Board; Diocesan Social Justice Group; Trust; Salvation Army; Dublin Simon; Focus Ireland; Medical Students Voluntary Society (UCD).
Mr Gerry Kenny,
Ms Mary Higgins,
Mr Greg Maxwell,
Mr Sean Megahey,
The interviewers were
Finally, I wish to thank all the homeless people who participated without whose co-operation this work would not have been possible.
Ails N Carthaigh,
Tony W Holohan
Department of Public Health
Eastern Health Board
Tel: +353 (01) 6352073
Fax: +353 (01) 6710606
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- George SL, Shanks NJ, Westlake L. Census of Single Homeless People in Sheffield. BMJ 1991; 302: 1387-9.
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- Plumb JD. Homelessness: Care, Prevention and Public Policy. Ann Int Med 1997; 127: 973-5.
- Robertson MJ, Cousineau MR. Health Status and Access to Health Services among the Urban Homeless. Am J Public Health 1986; 76: 561-3.
- Dublin Simon. Dublin Simon Community, Annual Report, 1995-1996. Dublin: Dublin Simon, 1996.
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- Department of Health. A Health Promotion Strategy. Dublin: Department of Health, 1995.
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- Moore J. B&B in Focus. The Use of Bed and Breakfast Accommodation for Homeless Adults in Dublin. Dublin: Focuspoint, 1994.
- Central Statistics Office. Census 1996, Volume 2: Ages and Marital Status. Dublin Stationery Office, 1997.
- Power R, French R, Connelly J et al. Health, Health Promotion, and Homelessness. BMJ 1999; 318: 590-2.
- Friel S, Nic Gabhainn S, Kelleher C. The National Health and Lifestyle Surveys. Galway: Centre for Health Promotion Studies, National University of Ireland, 1999.
- McCarty D, Argeriou M, Huebner RB, Lubran B. Alcoholism, Drug Abuse and the Homeless. Am Psychol 1991; 46: 1139-48.
- Robertson MJ, Zlotnick C, Westerfelt A. Drug Use Disorders and Treatment among Homeless Adults in Alameda County, California. Am J Public Health 1997; 87: 221-8.
- Lyons RA, Carroll D, Doherty K et al. General Practice Estimates of the Prevalence of Common Chronic Conditions. IMJ 1992; 84: 22-4.
- Fleischman S, Farnham T. Chronic Disease in the Homeless. In: Wood D (ed.). Delivering Health Care to Homeless Persons: The Diagnosis and Management of Medical and Mental Health Conditions. New York: Springer Publishing Company, 1992.
- Koegel P, Burnam MA, Farr RK. The Prevalence of Specific Psychiatric Disorders among Homeless Individuals in the Inner City of Los Angeles. Arch Gen Psych 1988; 45: 1085-92.
- Jahiel RI. Health and Health Care of Homeless People. In: Robertson MJ, Greenblatt M eds. Homelessness: A National Perspective. New York: Plenum, 1991