Abstract
Based on current demographic counts at countless homeless clinics, homeless people are subject to a disparagingly high rate of illnesses compared to the public. What’s even worse, medical programs offered to the homeless appear not effective enough at stopping this disparity, which implies that current methods are missing a key factor in tackling the homeless crisis in both the San Francisco Bay Area and other communities: housing. Housing viewed in a sense as healthcare may be the solution. San Francisco, a place with the third largest number of homeless individuals in the country, serves as the perfect location to test if housing truly is healthcare. An experiment such as the one proposed here would provide a valuable look into the impact that housing can have on homeless health.
Introduction
Literature Review
The focus of this research proposal is on low-income homeless individuals and their health. San Francisco, in particular, faces the problem of caring for its homeless community. In the United States, a homeless individual is defined as lacking “a fixed, regular, and adequate nighttime residence,” and with rising housing prices and living expenses, a low-income person in San Francisco is classified as making less than $82,200 per year ( U.S. Department of Housing and Urban Development, 2019; Poverty in San Francisco, City Performance Scorecards, 2018). In comparison, the United States Department of Health and Human Services declares that the 2021 Poverty Guidelines is only $26,500 for a household of 4 people for the District of Columbia, which shows how difficult it may be for a low-income person to be able to afford living in San Francisco. About 70% of homeless respondents in the San Francisco Homeless Count reported living in San Francisco before becoming homeless (Applied Survey Research (ASR), 2019). The Mission and Tenderloin neighborhoods are areas known for high homeless concentrations within the city, with African Americans accounting for the greatest percentage (37%) of the homeless population.
Homelessness presents unique challenges to one’s health which can be divided into two: upstream causes and downstream causes. Upstream causes are systemic barriers such as poverty or discrimination which worsen “downstream medical causes of high morbidity and mortality of homeless people,” and downstream causes are illnesses and diseases (Liu & Huang, 2021). For example, excessive drinking is a common upstream cause of homelessness, which can also exacerbate downstream causes as homelessness perpetuates depression and liver disease. As a homeless individual is deprived of assistance and treatment, the cycle of upstream and downstream causes can lead one into crippling poverty and thus deteriorating quality of health.
One may wonder what can be done to aid homeless people in escaping this vicious cycle? Some solutions are various programs operating in San Francisco which seek to assist the homeless, such as the UCSF Homeless Clinic. The UCSF team aims to provide urgent care assistance to the homeless and enter them into the healthcare system. Clinics like this can be found in other parts of the US as well. USF in Tampa Bay offers similar services and also conducts studies on the health of homeless patients which are vital in understanding the relationship between homelessness and illness. While clinics are undoubtedly vital in administering necessary care to the homeless in need, even “the best, most coordinated medical services are not very effective if the patient’s health is continually compromised” (National Health Care for the Homeless Council, 2019). This means that if a homeless person is expected to go back to the streets or crowded shelters, the effectiveness of their medical treatment declines. If, however, a homeless patient were provided stable housing along with medical care, it’s likely that their health quality would improve.
Healthcare for Homeless People is a program designed to highlight the intersectional challenges homeless people face in their pursuit of medical treatment. It addresses research pertaining to the unique lengths required to treat patients dually afflicted with various chronic illnesses and homelessness. The team’s approach to identifying the medical situation for homeless patients was by mapping out upstream and downstream causes of morbidity and mortality for homeless people. An upstream cause could be extreme poverty or past trauma, while a downstream cause could be mental illness or HIV/AIDS. Juxtaposed to these causes in the article is a diagram of the proper interventions needed to care for patients.
The topic covered by Liu and Huang undoubtedly serves to improve the healthcare experience for homeless patients. This paper serves as a broad, general overview of the challenges faced in many facets of the homeless experience. In comparison, the other papers are more focused on specific areas of homeless health challenges. While touching briefly on the need for housing, there lacks an extensive analysis of the health benefits of housing for homeless populations.
Chronic Disease Burden of the Homeless is a study done by students at the University of South Florida (Pribish et al., 2019). The study details their reporting about the prevalence of chronic diseases within the homeless population of Tampa Florida. The research confirmed pre-existing suppositions that homeless populations are at higher risk for chronic diseases than the general population. The team in this paper conducted retrospective chart reviews on the adult homeless population at two clinic sites. This paper highlights the need for more substance abuse and mental health programs targeted towards vulnerable groups like the homeless. While this paper overlaps with Liu and Huang’s research in regards to chronic illness within the homeless community, this paper goes more in depth with the documentation of the chronic health disparities between the general and homeless population. Unlike the previous research done, however, this paper provides valuable insight on how we need more data collection on the effectiveness of housing in solving this disparity.
All is not lost, however. San Francisco Homeless Count and Report aims to increase more data collection by comprehensively studying the lives of the Bay Area homeless population. The report contains relevant information on the number of homeless people within the Bay Area as well as their individual health. Judging off of the 1054 person sample for survey data, the health situation is dire for citizens within the Bay Area who lack housing. The survey took place within a 16 day window and was designed to yield qualitative data with respect to family, duration of homelessness, health, nighttime accommodations, etc. Similarly to the Tampa Bay study, this report clarifies the need for the additional allocation of resources to the homeless community. Most importantly, since the report was conducted within the geographical area of the proposed experiment, the data collected may possibly inform us of the expected health data for the subjects in our experiment prior to finding permanent housing as well as provide insight for further data collection, which will be detailed in this research proposal.
Rationale
Current literature in academia in the realm of health and homelessness is mainly focused on the negative correlation between homelessness and quality of health. While certainly helpful in giving a better idea of the health challenges the homeless face, there still remains a need for increasing research on the effectiveness of housing in improving the health of homeless individuals. San Francisco must desperately address the homeless problem in the city. The most likely solution, housing, must be tested and examined to see the scale of benefit it brings not just to the homeless, but to the city as a whole.
Objectives
For the vulnerable homeless population in San Francisco, housing could be healthcare. It is crucial that research in this topic goes beyond identifying the health of the homeless, and into the permanent solutions that can be enacted to heal them. The experiment will be about documenting the health quality of formerly homeless residents residing in San francisco permanent supportive housing planned to combat homelessness. They will self-report their health from before they received housing and their current situation. The results will be analyzed to determine whether there is a solid case to be made for housing as a means of ending the cycle of upstream and downstream causes for homeless individuals.
Design & Methodology
Duration and Location
The experiment will be conducted at a pending permanent supportive housing (PSH) location in San Francisco. It would take approximately a 5 minute call per person involved in the experiment. Total time that it would take is estimated to be 4-8 hours, considering the variation in population of different PSH buildings. The most likely PSH organization to contact would be Bayview Access Point Catholic Charities. Their program serves to provide shelter and housing for families. We would contact their phone number (415) 430-6320 and introduce them to the proposal. A request would be made for access to phone numbers of likely candidates for the survey within the PSHs that the organization runs. It will be explained that the phone numbers are needed for approximately 5 minute phone calls with previously homeless residents in order to assess the quality of housing and healthcare in San Francisco.
Survey Questions
In our survey, research volunteers would ask each subject the questions on the following topics and record them in our database:
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Annual income prior to receiving housing
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Current income
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Job prior to receiving housing
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Current job
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Monthly health care expenses prior to receiving housing
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Current monthly health care expenses
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Monthly health care needs prior to receiving housing
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Current monthly health care needs
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Health issues (illnesses, infections, diseases, etc…) prior to receiving housing
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Current health issues
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Reduction or increase in overall health satisfaction since being homeless till now
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Any current government assistance
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Is patient in need of more help
Subjects
In this study, we will be collecting self-reported health information from people who are considered homeless in the state of California and who live in San Francisco County. The location of the experiment is still pending as the location of PSHs are not easily accessible. We are interested in any PSH within the San Francisco City and County.
Potential PSHs in San Francisco:
2111 Jennings Street, San Francisco, CA 94124
123 10th Street, San Francisco, CA 94103
1021 Franklin st, FL 2, San Francisco, CA 94109
3270 18th Street, San Francisco, CA 94110
37 Grove Street, San Francisco, CA 94104
1641 LaSalle Avenue, San Francisco, CA 94124
Data Analysis
In order to properly assess how the subjects are doing health-wise, we will employ a series of questions around any illness(es) that the subject has had or continues to have. Data collected will involve the subject’s health status prior to attaining permanent housing, in comparison to their health status after the attainment of permanent housing. Questions will also involve the patient’s testimony of the quality and quantity of visits to a medical provider or clinic both before and after receiving housing.
The independent variable in the situation is the housing situation (whether in permanent housing or not), and its effect on the patient’s health. Which makes the patient’s health the dependent variable. The measurement of the independent variable is simply whether the patient has access to a permanent housing solution or not. The effect of housing on the dependent variable would be measured by the patient’s reduction or increase in visits to medical providers after housing, combined with the patient's self-reported increase or decrease in health ( symptoms and pain due to illnesses).
My hypothesis for this experiment is that the data will reflect a significant improvement in the health of the subjects after they acquired permanent housing. The data will be stored by subject, and once all subjects have been surveyed, the answers will be charted in a bar graph. A graph like this could be presented to a city planner as a visual for how housing is either assisting or harming the homeless. With quantified data on the number of subjects that either improve or decline in health during their stay in housing, city planners can get a much better idea as to if there should be more permanent supportive housing built.
The study is designed in a way that engages local high schoolers to familiarize themselves with fellow members of the community. The students have a new way of communicating with their neighbors of San Francisco which they might otherwise not meet. While surveying subjects, the high schoolers can spread helpful resources that are being held in our local area, for the benefit of the subjects. Clinics, free and/or subsidized food, and workshops are all invaluable resources that the students can play a part in sharing with the members of our community who need it.
Links with Other Projects
The University of Pennsylvania ran a study measuring the use of public services by homeless people, and the decrease in use when they were placed in supportive housing. They found major decreases in the total amount of “days that tenants spent in shelters (61 percent), inpatient psychiatric hospitals (61 percent) … [and] public hospitals (21 percent)” (National Symposium on Homelessness Research, 2007). This study is similar to our current experiment proposal in that it’s analyzing the relationship between health and homelessness. However, the study’s goal is largely to investigate whether the use of public services like hospitals can decrease when the homeless are given housing. In our experiment proposal, public services usage is only a partial factor in assessing the health difference between subjects being homeless or housed.
Anticipated Problems
One of the biggest challenges in measuring the variables at play is determining the extent to which one person’s pain is reduced or increased. Since the patient is reporting it to us themselves, there is no way to accurately quantify the change in pain.
Before we can even reach the patients, communication must be made with the organizations who run the PSHs in San Francisco. This can either be done directly or via the UCSF homeless clinic. It is crucial that contact is established with one of these organizations so that phone numbers of potential subjects can be obtained. If there is no success in receiving the phone numbers of the residents, then the experiment proposal can not be carried out.
Even if contact has been made successfully with an organization who runs a PSH, with the nature of the PSHs that are available, there is no guarantee that an ample number of residents willing to be surveyed will have had or currently have illnesses. If there is only a fraction of residents who experienced illnesses while homeless, then the data cannot be considered reliable since the set would be too restricted to tell an accurate picture of the relationship between homelessness, health, and housing in San Francisco.
Expected Outcomes
Our expected outcomes will be a visual representation of the answers that we collect from our subjects. There will be a pie chart with three parts, each part’s size corresponding to the percentage of people who are part of that category. For every surveyed person who’s monthly health care expenses are higher now than before they were homeless, there would be one portion of the pie which indicates their composition of the population (for example, if 40% of our population says that their expenses are now higher, 40% of the pie would be colored). Similarly, we have our second and third parts of the pie corresponding for every surveyed person who’s monthly health care expenses are lower now than before they were homeless and if the monthly health care expenses remain unchanged by $1,000. There will be another pie chart with three parts, which instead compares monthly health care needs currently and prior to receiving housing. For the question regarding a reduction or increase in overall health satisfaction, there will be a pie chart that is divided into two sections, one for those who have a worse view and another for an improved view.
When processing information regarding the individual medical histories of the subjects, challenges arise in how to chart it. For example, it is difficult to represent the data of the question regarding current health issues and health issues prior to receiving housing, as this information will be drastically different for each patient. This work requires walking a fine line of grouping results into efficient groupings of data while managing not to completely overwrite the unique health experience that each subject has gone through. Further consultation and information from medical professionals is needed.
Bibliography
Applied Survey Research (ASR), Kwak, Y., Petry, L., Gallant, J., Lee, K., Connery, P., & Green, S. (2019). San Francisco HOMELESS COUNT & SURVEY COMPREHENSIVE REPORT. https://hsh.sfgov.org/wp-content/uploads/2020/01/2019HIRDReport_SanFrancisco_FinalDraft-1.pdf
Liu, M., & Huang, S. W. (2021, January 14). Health care for homeless people. Nature Reviews Disease Primers. https://www.nature.com/articles/s41572-020-00241-2?error=cookies_not_supported&code=17fcb1cc-f2e0-4d5f-bffd-8ec200a9e7fa
National Health Care for the Homeless Council. (2019, February). Homelessness & Health: What’s the Connection? https://nhchc.org/wp-content/uploads/2019/08/homelessness-and-health.pdf
National Symposium on Homelessness Research. (2007). Toward Understanding Homelessness: The 2007 National Symposium on Homelessness Research. People Who Experience Long-Term Homelessness: Characteristics and Interventions. ASPE. https://aspe.hhs.gov/reports/toward-understanding-homelessness-2007-national-symposium-homelessness-research-people-who-0
Poverty in San Francisco | City Performance Scorecards. (2018). SfGov.Org. https://sfgov.org/scorecards/safety-net/poverty-san-francisco#:%7E:text=For%20example%2C%20HUD%20defined%20%E2%80%9CLow,for%20a%20family%20of%20four.
Pribish, A., Khalil, N., Mhaskar, R., Woodard, L., & Mirza, A. S. (2019, April). Chronic Disease Burden of the Homeless: A Descriptive Study of Student-Run Free Clinics in Tampa, Florida. PubMed. https://pubmed.ncbi.nlm.nih.gov/30324539/
U.S. Department of Housing and Urban Development. (2019). Requirements for Definition of Homeless. https://files.hudexchange.info/resources/documents/HomelessDefinition_RecordkeepingRequirementsandCriteria.pdf
