Homelessness: a ‘cause of the causes’ of cardiovascular disease?

Cardiovascular disease management and healthcare delivery for people experiencing homelessness: a scoping review

BACKGROUND

People experiencing homelessness have increased prevalence, morbidity, and mortality of cardiovascular disease (CVD), attributable to several traditional and non-traditional risk factors. While this burden is well-known, mainstream CVD management plans and healthcare delivery have not been developed with people experiencing homelessness in mind nor tailored to their unique context. The overall objective of this work was to explore and synthesize what is known about CVD management experiences, programs, interventions, and/or recommendations specifically for people experiencing homelessness.

METHODS

We conducted a scoping review to combine qualitative and quantitative studies in a single review using the Arksey and O'Malley framework and lived experience participation. We performed a comprehensive search of OVID Medline, Embase, PsychINFO, CINAHL, Web of Science, Social Sciences Index, Cochrane, and the grey literature with key search terms for homelessness, cardiovascular disease, and programs. All dates, geographic locations, and study designs were included. Articles were analyzed using conventional content analysis.

RESULTS

We included 37 articles in this review. Most of the work was done in the USA. We synthesized articles' findings into 1) barriers/challenges faced by people experiencing homelessness and their providers with CVD management and care delivery (competing priorities, lifestyle challenges, medication adherence, access to care, and discrimination), 2) seven international programs/interventions that have been developed for people experiencing homelessness and CVD management with learnings, and 3) practical recommendations and possible solutions at the patient encounter level (relationships, appointment priorities, lifestyle, medication), clinic organization level (scheduling, location, equipment, and multi-disciplinary partnership), and systems level (root cause of homelessness, and cultural safety).

CONCLUSIONS

There is no 'one-size-fits all' approach to CVD management for people experiencing homelessness, and it is met with complexity, diversity, and intersectionality based on various contexts. It is clear, however, we need to move to more practically-implemented, community-driven solutions with lived experience and community partnership at the core. Future work includes tackling the root cause of homelessness with affordable housing, exploring ways to bring cardiac specialist care to the community, and investigating the role of digital technology as an avenue for CVD management in the homeless community. We hope this review is valuable in providing knowledge gaps and future direction for health care providers, health services research teams, and community organizations.

Describing the characteristics and symptom profile of a group of urban patients experiencing socioeconomic inequity and receiving palliative care: a descriptive exploratory analysis

Background

Individuals experiencing socioeconomic inequity have worse health outcomes and face barriers to palliative and end-of-life care. There is a need to develop palliative care programs tailored to this underserved population.

Objectives

To understand the characteristics and symptom profiles of a group of urban patients experiencing socioeconomic inequity and receiving palliative care.

Design

Descriptive exploratory analysis of a patient dataset. The patient dataset was generated through a pilot research study with patients experiencing socioeconomic inequity and life-limiting illness who received a community-based palliative care intervention.

Methods

The intervention took place over 1 year in the Palliative Care Outreach and Advocacy Team, a community-based urban palliative care clinic in Edmonton, Alberta, Canada, serving persons experiencing socioeconomic inequity. Participants had to be at least 18 years of age, be able to communicate in English, require palliative care for a life-limiting illness, and be able to consent to inclusion in the study.

Results

Twenty-five participants were enrolled. Participants predominantly identified as male and Indigenous, experienced poverty and housing instability, and had metastatic cancer. Our participants rated their pain, shortness of breath, and anxiety as more severe than the broader community-based palliative care population in the same city. Most patients died in inpatient hospices (73%).

Conclusion

Our analysis provides an in-depth picture of an understudied, underserved population requiring palliative care. Given the higher symptom severity experienced by participants, our analysis highlights the importance of person-centered palliative care. We suggest that socioeconomic inequity should be considered in patients with life-limiting illnesses. Further research is needed to explore palliative care delivery to those facing socioeconomic inequity.

Associations between Duration of Homelessness and Cardiovascular Risk Factors: A Pilot Study

Cardiovascular disease (CVD) in the United States disproportionally affects people who are homeless. This disparity is a critical concern that needs to be addressed to improve the health of individuals who are homeless. The connections between a history of homelessness, i.e., its duration and frequency, and CVD risk are not well understood. The present study sought to investigate how a history of homelessness is correlated with CVD risk factors in a sample of homeless persons in the Deep South. This study recruited participants who were homeless from two local adult homeless shelters in Birmingham, AL. Participants (n = 61) underwent interviews, physical measurements, and a capillary blood draw. Their mean age was 47 years, and 82% were men. Results showed the duration of homelessness was positively associated with several CVD risk factors (diabetes mellitus, total cholesterol, and low-density lipoprotein). However, there was no significant association between frequency of homelessness and any CVD risk factors. To get the more accurate estimate of CVD risk in this population, future research should incorporate additional risk factors related to homelessness and seek to develop a robust strategy to collect an accurate history of homelessness.