Vulnerable Puerto Rican Homeless

*Himilce Vélez Almodóvar, MS; *Miguel E. Marrero- Medina, MPH, DEA;

**Francisco Rivera, MA *Ponce School of Medicine & Health Science, Public Health Program, **Coalición de Coaliciones

Learning Objectives 1.  Describe a data collection process for

gathering information to identify vulnerable population among homeless.

2.  Develop a mechanism to prioritize population within housing first strategy.

3.  Outline steps to translate data to policy changes.

Public Policy in Puerto Rico •  "The phenomenon of homelessness and homelessness is not

new in Puerto Rico and there is evidence of this problem since the nineteenth century" (Martinez, 1997).

•  "The problem of homelessness is conceptualized from a health

approach that address the areas that are considered as barriers to the rehabilitation and social integration of rough sleepers, such as services related to health, housing, physical psychological rehabilitation programs "(exhibit num Act 392 of 2004).

•  The Department of the Family is who is responsible for coordinating the work relating to Public Policy Relating to the Diambulantes and submit requests for funds.

Public Policy; Laws & Acts •  Act to create the Commission for the Implementation of

Public Policy on Homeless Persons ▫  Act No. 250 of August 18, 1998.

•  Mental Health Act of Puerto Rico, ▫  Act No. 408 of October 2, 2000.

•  Multisectoral Council to Support Homeless Population, ▫  Act No. 130 of September 27, 2007.

▫  Act No. 277 of August 31, 2000.

▫  Act No. 29 January 11, 1998.

INTRODUCTION

•  Despite their higher burden of illness, homeless adults are less likely than the general adult population to use primary health care services and often rely on emergency departments or ambulatory care settings for their health care needs (Gelbert, 2000).

•  The numerous barriers they face in accessing and maintaining appropriate health care services aggravate the poor health condition among this vulnerable group (Bagett, et al. 2010).

PROBLEM • Even though homelessness has been studied

thoroughly in the United States; there are limited studies that provide descriptions of the homeless population in Puerto Rico, specifically in the southern area of the island.

•  The insufficiency of studies as well as the increase prevalence of homeless individuals in Puerto Rico suggests the necessity to recognize and characterize this population.  

IN THE RESEARCH FIELD… • Most studies have been performed by the service

providers in the island. • Academic - Theses and dissertations ▫  Studies have searched for:

  Identify the population   Identify the number of people affected   Identify the needs of the same.

THE PUERTO RICO HOMELESS

SOCIODEMOGRAPHIC & HEALTH SURVEY

Miguel E. Marrero- Medina, MPH, DEA; Osward Carrasquillo, MPH, MDc; Gabriel Altieri, MDc; Marvin Argüello, MPH, MDc; Karen Diaz, MPH, MDc; Salamilet Jordán, MPH, MDc; Arelis Villot, MPH

Ponce School of Medicine & Health Science, Social Medicine & Community Health Association

METHODS •  Design: Cross-sectional study •  Sample ▫  99 - homeless people (83 men and 16 women), who at the time of

the study where more than 21 years old, not pregnant & agreed to participate voluntarily.

•  Sampling method: Non probabilistic convenience sample •  Data Recollection Technique ▫  A short questionnaire (that could be completed in 5 to 8 minutes)

was design and culturally adapted for the Puerto Rican homeless population to identify socio-demographic and health characteristics, habits, health care use, needs for health services and other uniqueness of the homeless population. ▫  Health survey / Interview

•  Statistical Analysis: Frequency Distributions

SOCIO-DEMOGRAPHIC & HEALTH VARIABLES

RESULTS

•  The study revealed that the average age of the homeless, was 47.67, for a sample of 99 people, consisting of 83 men and 16 women.

•  92.9% of study participants were Puerto Ricans, and

the remaining born in the continental United States. •  As for schooling, only 28% complete their high

school achievement, which means that 72% can be classified as dropouts.

The health conditions that most affect homeless people are…

CONCLUSION •  The five most prevalent illnesses are: depression

(31.3%), hypertension (24.2%), liver diseases (19.2%), respiratory problems (16.2%), and heart diseases (15.2%).

•  The reasons most often contributed to cause the abandonment of their homes were: drug use (62.6%) and family problems (54.5%).

•  Other features that describe the profile of the respondents are that the majority (89%) receive financial aid, and do not abuse of alcohol, although the majority (62.6%), recognized to be drug users.

.

CONCLUSION It is important to continue obtaining data in the most lagging zones in Puerto Rico, especially outside of the San Juan Metropolitan area where there are less programs to help this type of population. Creating a profile of homeless people will be of benefit to create projects that will help with their main problems.

“CONTEO BORICUA”

*Himilce Velez Almodovar, MS; *Miguel E. Marrero- Medina, MPH, DEA; Ponce School of Medicine & Health Science, Public Health Program

PLANNING PHASE

Coalición de

Coaliciones

Ponce School of Medicine & Health Science

“Conteo Boricua”

2013

QUESTIONNAIRE SECTIONS

Conteo Boricua 2013

PIT

Vulnerability Index

Health Profile

“PIT” – Point-in-Time

•  The "(PIT) Point-in-Time" ▫  is a count of sheltered and unprotected homeless

in a single night during the month of January.

• HUD requires conducting a homeless count unprotected home every two years (odd years).

Vulnerability Index

The Vulnerability Index is a tool for the identification and prioritization of the

homeless housing according to the fragility of their health.

VULNERABILITY INDEX •  The instrument identifies specific health conditions that

can cause that certain homeless are at increased risk of death in the street.

•  For people who have been homeless for at least six months, one or more of the following indicators place them at increased risk of mortality:

  More than three hospitalizations or emergency room visits in a year   More than three visits to the emergency room in the previous three

months   60 and over   Cirrhosis of the liver   End-stage renal disease - 5   History of frostbite, immersion foot, or hypothermia   + HIV / AIDS   Tri-morbidity: co-occurring psychiatric, substance abuse, and chronic

medical conditions

Instrument Development process

Leaders evaluate the instrument and training them to use it.

Recommendation for logistics and structure/

Experst panel suggest cultural adaptation and modifications

Consult suggested changes with the creator of the instrument

Translation

Original Instruments

Point in Time & Vulnerability Index

QUESTIONNAIRES

Completed questionnaires  

1779

 Valid questionnaires after data quality control  

1654  

Homeless not housed and housed identified (PIT)  

2034  

Persons considered to estimate vulnerability and chronicity.  

1502  

PIT

• Of the 2,034 homeless counted in 2013, 87.4% were older than 24 years.

•    76.6% of the homeless housed did not slept in

the street or in a dwelling unfit during the night of February 25.

•  From non-housed people (1,559), 7.2% were

under 18 years.

Number of homeless persons identified in PIT (2009-2013)

0

500

1000

1500

2000

2500

2009 2010 2011 2012 2013

2295

536

1537

541

2034

Years

Demographic Profile •  Sex: A 24.6% homeless people were women •  Gender: ▫  987 – heterosexual ▫  24 – Bisexual ▫  24 – Homosexual ▫  3 – Transgender ▫  460 – Did not answer the question

•  Age: ▫  Average: 48.3 years ▫  The older person is 98 years old.

•  Ethnicity: Only 1.1% identified themselves as non-Latino

•  Others income sources identify (less than 3%): pension, social security and recycling .

•  Sexual workers was a source of income for 23 interviewees

•  Drug traffic was a source of income for 6 interviewees

Food stamps 545 (36.3%)

Informal work 360 (24.0%)

Panhandling 106 (7.1%)

Government economical assistance

93 (6.2%)

Income sources

HEALTH INSURANCE

641 (42.6%) NO

835 (55.6%) Public health

insurance

Risk indicador for vulnerability in homeless Risk Indicator Number Percentage

Tri‐Morbidity: Co‐occurring psychiatric, substance abuse, and chronic medical condition

633 42.1

More than three hospitalizations or emergency room visits in past year

53 3.5

More than three emergency room visits in the previous three months

113 7.5

Aged 60 years or older 217 14.5 HIV/AIDS 95 6.3 Cirrhosis of the liver 151 10.1 End-stage renal disease 61 4.1 Climate related diseases 140 9.3

Vulnerable 895 (59.8%)

Chronic 1097 (73.0%)

YEARS LIVING AS HOMELESS PERSON

VULNERABLE

Average: 7.19 years as homeless person 25% of the interviews indicate living more than 9 years as homeless person

NON VULNERABLE

Average: 3.96 years as homeless person 25% of the interviews indicate living more than 5 years as homeless person

HOMELESS HEALTH CONDITIONS, CONTEO BORICUA, PUERTO RICO, 2013

0 2 4 6 8 10 12 14 16

Hepatitis C

Asma

Diabetes

Enfermedad del Corazón

Cancer

Enfisema

Tuberculosis

Percentage

Substance Abuse

• 49.6% indicate substance or alcohol abuse sometime in their life.

• 17.1% indicate daily-use of alcohol in the the past 30 days.

• 22.8% report use of inyectable drugs sometime in their life

• 28.2% indicate be treated for substance abuse sometime in their life.

Mental Health

• 23.4% had receive mental health treatment

• 8.5% have been in the hospital against their will by mental reasons

VETERAN HOMELESS

43 Veterans (2.9%)

55% of those are vulnerable

Average 9.8 years being homeless

VIOLENCE

• Since they are homeless, 15.5% indicate being victim of violence

SUSBSTITUE HOME • 10.3% homeless people lived in a

substitute home. • Of those (155) … ▫ Vulnerable - 77% ▫ Chronic – 80%.

Common factors in studies •  The homelessness - mostly men. •  It is consistent in being a problem for adults

  (under 49 years).

• Homelessness is associated with other problems such as: ▫  Addiction to substances ▫  Low Schooling ▫  Mental disorders ▫  Lack of employment and economic resources

CALL TO ACTION: STRATEGIES