Capella University Health Care Utilization in Homeless Youth Discussion

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ORIGINAL PAPER
Health Care Utilization in Homeless Youth
Yolanda N. Evans • Sara M. Handschin •
Ann E. Giesel
Published online: 19 November 2013
Springer Science+Business Media New York 2013
Abstract To examine common reasons for utilization of
health care services at a free homeless youth clinic. This is
a retrospective chart review for visits over a 1 year period.
Data on age, gender, and up to 3 chief complaints per visit
were collected from the electronic medical record. Of the
744 clinical encounters, the mean age of youth was
18.8 years and 53.2 % involved female patients. The most
common reasons for utilizing services include screening
and treatment of sexually transmitted infections (STI)
14.3 %, physical exam for housing 13.7 %, dermatologic
complaints 13.5 %. Chief complaints were different for
males and females (p B 0.001). Females were more likely
to receive laboratory testing for STI than males
(p B 0.001). Females were most likely to seek care for
sexual and reproductive health needs and males were more
likely to come for acute concerns. These differences can
inform providers working with this vulnerable population.
Keywords Homeless youth Adolescent
Reproductive health Health care utilization
Introduction
It is estimated that between 1.6 and 2.8 million youth in the
USA runaway or are thrown away each year and youth
ages 12–17 are at higher risk for homelessness than adults
[1]. In Washington State, the 2010 Annual One Night
Count of people who are homeless in King County found
that of the 6,236 people staying in emergency shelters or
transitional housing on the night of the count, 1,009 (16 %)
were between the ages of 13–25 years [2].
Homeless youth acknowledge the need for help in
maintaining their physical well-being. They are more likely
to report poorer overall health, more emotional disturbances, and have higher rates of traumatic stress than nonhomeless children from middle income families. In order to
survive on the streets, they may resort to dangerous
behaviors, such as drug use and sex industry work. Even if
not permanently homeless, chronic periods of homelessness have been associated with survival sex, increased HIV
rates, and sexual victimization [3].
Homeless youth identify access to reproductive health
services as a fundamental need [4, 5] and value being
offered allopathic and complementary medicine services
[6, 7]. Youth have reported that peers provide anecdotal
remedies for ailments and may discourage seeking help
from medical professionals [5]. Those who do attempt to
access mainstream healthcare may be without health
insurance. If they have insurance, they may refuse to make
use of it for reasons such as not wanting to provide a real
name or contact information. They may also be ineligible
for services as a minor who is unaccompanied by a consenting adult. Therefore, medical drop-in services that are
based on a sliding scale fee for income or free of charge are
invaluable and depended upon by this population [8].
The purpose of this study is to describe service utilization at a free clinic for homeless youth in Seattle, Washington. Specific aims include: determining the common
reasons for seeking services and a comparison of patterns
of use by males and females. This drop in clinic provides
acute care, preventive care, reproductive health care, and
Y. N. Evans A. E. Giesel
Department of Pediatrics, University of Washington, Seattle,
WA, USA
Y. N. Evans (&) S. M. Handschin A. E. Giesel
Division of Adolescent Medicine, Seattle Children’s Hospital,
4540 Sand Point Way NE, Suite 200, Seattle, WA 98105, USA
e-mail: yolanda.evans@seattlechildrens.org
123
J Community Health (2014) 39:521–523
DOI 10.1007/s10900-013-9789-3
limited medications for homeless youth between the ages
of 12–23 years free of charge. In addition, youth are often
referred for temporary housing, meals, clothing, alternative
drop-in school, case management, employment training,
and mental health and substance use counseling. Alongside
allopathic medical services, complimentary medicine in the
form of acupuncture and/or massage is available. There are
two paid staff members, the clinic manager and an
attending physician. The remainder of the staff are volunteers or trainees (medical students, Pediatric and Family
Medicine residents, and fellows in Adolescent Medicine).
Methods
A retrospective chart review of electronic medical records
(EMR) at the Country Doctor Free Teen Clinic was performed by the two co-investigators, Y. Evans and S.
Handschin. Permission to access the electronic medical
records was granted by the Director of Operations at the
Country Doctor Community Health Center, the facility
where the Country Doctor Free Clinic operates. The entire
study was approved by the University of Washington
Human Subjects Division. The medical records were
reviewed to gather eleven different items for each patient
encounter: patient stated age, stated gender, up to three
chief complaints (or reasons for visiting the clinic that
evening), whether or not a urine HCG was obtained (if
female), sexually transmitted infection (STI) laboratory
studies [including gonorrhea, chlamydia, HIV, or rapid
plasma reagin (RPR)], contraception dispensed including
oral contraceptive pills, NuvaRing, Ortho Evra Patch, Depo
Provera injections, or Plan B emergency contraception (if
female), the use of complimentary and alternative medicine
(CAM), discharge diagnosis, and medications dispensed.
For the purposes of this study we focused our descriptive
analysis on the following variables: stated age, stated
gender, chief complaints, urine HCG, STI laboratory
studies, contraception dispensed.
The Country Doctor Free Teen Clinic previously used
hand written notes to document patient encounters without
a standardized template. In February 2010, the clinic converted to the use of electronic medical records. Review of
the EMR for this study included reading hand written paper
notes that had been scanned into the EMR. Information
from the patient encounter notes was entered into Excel
spreadsheets. To confirm that the two co-investigators
recorded the same variables after reading the scanned hand
written documents, 10 patient encounters were separately
reviewed by each co-investigators, with agreement on 106
out of 110 variables recorded (96.4 %).
Data was transferred directly from Excel into STATA
version 10. Analyses included descriptive summaries of
stated age, stated gender, chief complaints, urine HCG, STI
laboratory studies, contraception dispensed. Patient
encounters were stratified by gender and Chi2 analysis was
used to compare the reasons for clinic visits and STI
screening tests performed between males and females.
Results
All patient encounters that occurred between January 5,
2009 and January 5, 2010 were included in the chart review.
Patients who left without being seen or charts with missing
information on the items of interest were excluded from the
study. A total of 31 encounters were excluded. A total of 744
patient encounters met inclusion criteria with 371 individual
patients utilizing the clinic during this time frame.
Study results are summarized in Table 1. The average
number of visits per patient over the study period was two.
The mean age of patients served was 18.8 years with 53 %
reporting female gender and 47 % reporting male gender.
Among the overall sample, the most common reasons for
visiting the clinic were for STI testing (14.3 %), the need
for physical exam to obtain housing (13.7 %), and a dermatologic complaint (13.5 %). The chief complaints were
different for males and females (p B 0.001).
For females, the most common reasons for visiting the
clinic included STI testing (18.2 %), contraception
(17.5 %), and a physical exam for housing (12.4 %). There
were a total of 222 screening STI tests performed among
females. Females were more likely to receive laboratory
testing for STI than males (p B 0.001) For males, the most
common reason for visiting the clinic was a dermatologic
complaint (16.4 %), a physical exam for housing (15.2 %),
and upper respiratory infection symptoms (12.2 %). There
were 122 STI screening tests performed among males.
Discussion
Screening and treatment of STIs was the most common
reason for homeless youth to access health services in our
study. There were differences by gender. Young women
were most likely to seek care for sexual and reproductive
health needs and had a higher proportion of visits for these
concerns. Young men had higher proportions of visits for
acute concerns including URI symptoms, dermatologic and
musculoskeletal complaints. Our findings are consistent
with previously documented health needs in this population, where homeless youth requested reproductive health
and STI screening [9, 10].
One reason for the gender difference could be the
requirement of many shelters in the Seattle metro to require
a physical examination prior to admission. This requirement
522 J Community Health (2014) 39:521–523
123
may increase the number of teens, especially males, seeking
care. Males are less likely to seek health services overall
[11], yet our study found nearly equal numbers of males and
females utilizing the homeless teen clinic. Another explanation for the gender difference could involve the provision
of reproductive health (contraception) and STI screening
offered at our site. Homeless females have been found to
request and seek out services for contraception and STI
screening and treatment [10]. Because our clinic is known
by local youth to offer these services, it is not unexpected
that a high proportion of homeless females would request
them.
Our findings indicate that homeless youth will seek
contraception and commonly prescribed methods include
combination birth control pills and Depo Provera. However, long acting reversible contraception, such as the
implantable rod or intra-uterine device, were not available.
Condoms were offered, but provision to patients was not
routinely documented in the EMR and was therefore
excluded from analyses.
The findings of this study are unique to this particular
clinic and can not be generalized to other populations. Our
results do not reflect services that were declined or patients
who did not receive services because they were recently
conducted elsewhere, such as through another clinic,
shelter or the juvenile justice system. Nor do they reflect
the number of patients who received health education
regarding STIs or contraceptive counseling, but declined
any of the options.
This study provides further evidence that homeless
youth do seek health care and will utilize vital services,
such as acute care and reproductive health care, when
offered. Though males and females may seek care for
different reasons, these clinic visits provide the opportunity
for important screening and preventive care. Care providers
should be educated and competent in sexual and reproductive and be prepared to provide such services to this
vulnerable population.
Acknowledgments The authors would like to acknowledge Mavis
Bonnar and the staff at the Country Doctor Community Clinic for
their support on this project.
Conflict of interest The authors have no conflicts of interest to
disclose.
References
1. Youth noise (Internet): YouthNoise Homelessness Archive.
(2010). cited 10/20/2010. Available from: http://www.youthnoise.
com/page.php?page_id=6144.
2. Seattle king County Coalition on Homelessness. (2012). 2012
annual one night count of people who are homeless in king
county, Seattle, WA. http://www.homelessinfo.org/what_we_do/
one_night_count/2012_results.php.
3. Marshall, B. D. L. (2008). The contextual determinants of sexually transmissible infections among street-involved youth in
North America. Culture, Health & Sexuality, 10(8), 787–799.
4. Ensign, B. J. (2006). Perspectives and experiences of homeless
young people. Journal of Advanced Nursing, 54(6), 647–652.
5. Ensign, J., & Panke, A. (2002). Barriers and bridges to care:
Voices of homeless female adolescent youth in Seattle, WA,
USA. Journal of Advanced Nursing, 37(2), 166–172.
6. Ensign, J. (2004). Quality and improvement. Quality of health
care: The views of homeless youth. Health Services Research,
39(4), 695–707.
7. Breuner, C., Barry, P., & Kemper, K. (1998). Alternative medicine use by homeless youth. Archives of Pediatric Medicine,
152(11), 1071–1075.
8. De Rosa, C., Montgomery, S., Kipke, M. D., Iverson, E., Ma, J.,
& Unger, J. (1999). Service utilization among homeless and
runaway youth in Los Angeles. Journal of Adolescent Health,
24(3), 190–200.
9. Ensign, J., & Santelli, J. (1998). Health status and service use.
Comparison of adolescents at a school-based health clinic with
homeless adolescents. Archives of Pediatrics Adolescent Medicine, 152(1), 20–24.
10. Ensign, J. (2000). Reproductive health of homeless adolescent
women in Seattle, WA, USA. Women & Health, 31(2–3),
133–151.
11. Marcell, A. V., Klein, J. D., Fischer, I., Allan, M. J., & Kokotailo,
P. K. (2002). Male adolescent use of health care services: Where
are the boys? Journal of Adolescent Health, 30(1), 35–43.
Table 1 Summary of demographics and chief complaints
Male Female Sample total
Total encounters (N) 348 (46.8 %) 396 (53.2 %) 744 (100 %)
Mean age in years (SD) 19.2 (2.3) 18.4 (2.5) 18.8 (2.4)
Chief complaint (%) Dermatologic 16.4 STI testing 18.2 STI testing 14.3
Physical exam for housing 15.2 Contraception 17.5 Physical exam for housing 13.7
Respiratory/URI symptoms 12.2 Physical exam for housing 12.4 Dermatologic 13.5
Musculoskeletal 11.4 Dermatologic 11.0 Respiratory/URI symptoms 10.7
Other 11.0 Respiratory/URI symptoms 9.5 Other 9.8
STI testing 9.8 Other 8.8 Contraception 9.5
Test results 5.8 Test results 6.1 Musculoskeletal 7.7
STI sexually transmitted infection, URI upper respiratory infection
J Community Health (2014) 39:521–523 523
123
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
attachment_2

ORIGINAL PAPER
Cell Phone Utilization Among Foreign-Born Latinos: A Promising
Tool for Dissemination of Health and HIV Information
Lorena Leite • Megan Buresh • Naomi Rios •
Anna Conley • Tamara Flys • Kathleen R. Page
Published online: 26 February 2013
Springer Science+Business Media New York 2013
Abstract Latinos in the US are disproportionately affected
by HIV and are at risk for late presentation to care. Between
June 2011 and January 2012, we conducted a cross-sectional
survey of 209 Baltimore Latinos at community-based venues
to evaluate the feasibility of using information communication technology-based interventions to improve access to
HIV testing and education within the Spanish-speaking
community in Baltimore. Participants had a median age of
33 years interquartile range (IQR) (IQR 28–42), 51.7 %
were male, and 95.7 % were foreign-born. Approximately
two-thirds (63.2 %) had been in the US less than 10 years
and 70.1 % had been previously tested for HIV. Cell phone
(92.3 %) and text messaging (74.2 %) was used more than
Internet (52.2 %) or e-mail (42.8 %) (p.01). In multivariate analysis, older age and lower education were associated with less utilization of Internet, e-mail and text
messaging, but not cell phones. Interest was high for
receiving health education (73.1 %), HIV education
(70.2 %), and test results (68.8 %) via text messaging.
Innovative cell phone-based communication interventions
have the potential to link Latino migrants to HIV prevention,
testing and treatment services.
Keywords HIV Cellular phone Technology
Latino health Migrants
Introduction
Latinos are the largest and fastest growing ethnic minority
in the United States, with a total population of 50.5 million
in 2010 [1]. During the last decade, the Latino population
of Baltimore City increased by 135 %, primarily due to
recent migration of individuals born in Central America
and Mexico [2, 3]. As in other rapid-growth regions, such
as the southeastern US, Latinos living in Baltimore are
more likely to be young, male, foreign-born and in the US
for less than 15 years, compared to those from states with
well-established Latino communities such as New York,
Florida, and California [4]. Demographic changes have
resulted in high demand for culturally competent services,
which may not be readily available in rapid growth states.
Lack of services sensitive to the needs of migrants can
exacerbate disparities in quality and access to health care.
Latinos living in the US are disproportionately affected
by HIV, and have an estimated lifetime risk (ELR) of
infection 3.2 times higher than for Whites [5]. From 1997
to 2006, rates of AIDS cases in Baltimore City decreased
40 % among non-Hispanic Blacks and 23 % among nonHispanic Whites, but nearly doubled among Latinos (from
40.8 to 80.0 cases/100,000 people), and mortality due to
AIDS among Latinos was twice that of non-Latino Whites
[6]. Furthermore, Latinos are often diagnosed in the later
stages of disease [7–11]. Late diagnosis is associated with
high mortality, and unrecognized infection increases HIV
transmission in the community [12].
Foreign-born Latinos are at particularly high risk for late
presentation, with a shorter interval from HIV diagnosis to
AIDS when compared with US-born Latinos [9]. CDC data
shows that Latinos born in Mexico or Central America are
more than twice as likely to be diagnosed late with HIV
than Latinos born in the US [11]. Non-English speaking
Lorena Leite and Megan Buresh contributed equally to this
manuscript.
L. Leite M. Buresh N. Rios T. Flys K. R. Page (&)
Johns Hopkins University School of Medicine, 600 N. Wolfe St.
Phipps 524, Baltimore, MD 21287, USA
e-mail: kpage2@jhmi.edu
A. Conley
Washington University, St. Louis, MO, USA
123
J Immigrant Minority Health (2014) 16:661–669
DOI 10.1007/s10903-013-9792-x
Latinos in Los Angeles county are almost three times more
likely to present late to care than English-speaking Latinos
[13]. In North Carolina, a state that has experienced a rapid
increase in the Latino foreign-born population, Latinos
present to HIV care with a lower CD4 count than African
Americans (186 vs. 302 cells/mm3
) and account for a
majority of serious opportunistic infections in the clinic,
including tuberculosis and histoplasmosis which are likely
acquired in their country of origin [10, 14]. Therefore,
immigrants have a particular need for targeted interventions to provide earlier access to HIV testing.
Foreign-born Latinos are also vulnerable to factors that
have been shown to impact access to HIV services, such as
self-awareness of risk, immigration status, cultural background, isolation, and disruptions of social and family relationships [15–17]. Stigma is also a major barrier to accessing
HIV services among foreign-born Latinos [18, 19]. In 2008,
the Baltimore City Health Department (BCHD) established a
Latino Outreach Program to provide culturally-sensitive,
Spanish-language HIV education, testing, and linkage to
care services for Latino migrants. Program evaluation has
shown over 95 % of clients served by the Latino Outreach
program are foreign-born Latinos and that HIV testing rates
in this population have increased from 37 to 62 % in the
2 years since the program was established [20, 21]. While
traditional community-based outreach has improved access
to testing for Latinos in Baltimore, novel approaches should
be evaluated to complement these services and further
improve HIV testing rates.
Over the past decade, information and communication
technology (ICT), such as text messaging and Internet, have
been utilized to improve health care and education in various
settings. For example, interventions using cell phones and
text messaging have been used to increase HIV testing rates
[22], enhance medication adherence among HIV-positive
individuals [23–28] and access of minority youth to information about HIV/AIDS and referral to STD care [29, 30].
Text-messaging interventions have also been used to reduce
high-risk sexual behaviors and methamphetamine use
among men who have sex with men (MSM) [31] and instant
messaging has been used to counsel MSM about HIV in realtime. [32] When patients have been surveyed on their attitudes toward use of cell phones, text messaging and Internet
for HIV interventions, their response has been positive [33].
Cell phone-based interventions may therefore be an effective
means to disseminate health information to Latinos. While
there are disparities in technology use between native and
foreign-born Latinos, the digital divide is smaller for cellular
phones, with 72 % of foreign-born compared to 80 % of
native-born Latinos utilizing a cell phone [34]. According to
the Pew Internet and American Life project, African
Americans and Latinos are more likely than Whites to use
cell phones and mobile devices to access the Internet, use
instant messaging, visit social networking sites, look up
health information, and track or manage their health [35].
We conducted a cross-sectional survey study of Latinos
living in Baltimore to evaluate the feasibility of using communication technology-based interventions to improve
access to HIV testing and education within the Spanishspeaking community in Baltimore. We evaluated the relationship between age, gender, and education and ICT use.
We also assessed migrant-associated factors, such as country
of origin and time in the US, because differences in socioeconomic and educational attainment between migrants
from different countries could impact utilization of ICT [34,
36]. Identifying factors associated with communication
technology use and acceptability is important to understand
who may be reached by using technology-based interventions and what population may be missed due to the lack of
technology use, particularly among individuals who have
never been tested for HIV.
Methods
This was a cross-sectional survey of 209 Baltimore Latinos
conducted between June 2011 and January 2012.
Study Setting and Participants
The survey was conducted in selected street and community-based venues in Baltimore City. Several methods were
used to identify venues frequented by Latinos living in
Baltimore. We interviewed 10 key informants, including
outreach workers from the BCHD Latino outreach program, bar owners, bar clients, staff at community based
organizations, and social workers familiar with the Latino
community in Baltimore. Interview guides were developed
in collaboration with the BCHD Latino Outreach program
and included questions about barriers to HIV testing among
Latinos, appropriate incentives for participation, identification of local events for Latinos, and places with high
Latino presence. Once a list of venues was generated, we
observed locations at various time intervals to to evaluate
whether the target population could be assessed in sufficient numbers at each site. Eligibility for participation
included self-identification as Latino, age C18 years old,
ability to communicate in Spanish or English, and ability to
give oral consent.
The institutional review board of the Johns Hopkins
University School of Medicine approved this study.
Measures
We developed a 21-item survey querying: (1) demographics including age, gender, race, sex, education, years
662 J Immigrant Minority Health (2014) 16:661–669
123
in the US, primary language and country of origin, (2)
frequency of technology use, including cellular phone, text
messaging, email and Internet, and (3) interest in receiving
health information, HIV education and HIV testing results
by each of the three modalities.
Technology use was assessed using the following
questions: (1) Do you use a cell phone? (2) If so, how often
do you use it? (3) Is your cell phone a smartphone? (4) Do
you use short message service (SMS)/text messaging with
your cell phone? (5) If so, how often do you use it? (6) Do
you use the Internet? (6) If so, how often do you use it? (7)
Do you use e-mail? (8) If so, how often to you use it?
Frequency of use was assessed as ‘‘daily,’’ ‘‘weekly,’’ ‘‘less
than once per week,’’ or ‘‘never.’’
Interest in receiving health information by each of the
different technologies was assessed using the following
questions: (1) Would you be interested in receiving health
information by (text message/SMS, Internet or e-mail)? (2)
Would you be interested in receiving education about HIV by
(text message/SMS, Internet or e-mail)? (3) Would you be
interested in receiving HIV test results by (text message/SMS,
Internet or e-mail)? The items selected for inclusion in the
questionnaire were chosen based on review of the literature,
and consultation with focus groups and key informants.
Data Collection