Barriers to Care

Hypertension is a major health issue affecting Americans of all socioeconomic backgrounds. The number of Americans afflicted by hypertension has risen by 30% in the last decade, now with a total number of 73 million adults classified as having high blood pressure [1]. Most dangerously, chronic hypertension is a ‘silent killer,’ as hypertension symptoms are often unnoticeable until they cause major organ damages. It is estimated that 20 - 30% of people affected by hypertension are unaware that they have it [1]. Uncontrolled hypertension can lead to heart attacks, strokes, kidney failures, and eye damages. In the homeless population, hypertension is a particularly significant health issue. Second only to alcohol abuse, hypertension is the most common chronic healthcare issue afflicting homeless populations, affecting 14 – 25% of the homeless [2-5]. Compared with the housed counterparts, homeless adults are two-to-four times more likely to have hypertension and other cardiovascular diseases, at younger ages [6,7,8]. Poor diet, excessive use of alcohol, nicotine and other drugs are among the factors that increase their risks of developing and exacerbating high blood pressure [9].

Management of chronic hypertension in the low-income and homeless populations is particularly challenging. Despite the high prevalence of hypertension and cardiovascular diseases among the homeless, the homeless population experiences vast barriers to and a critical lack of preventive health care. Studies have consistently observed that the homeless underutilize preventive medical services such as primary care and outpatient services, thereby creating a much higher risk for developing more severe illnesses before seeking treatment, and overutilize emergency department for nonemergency care [10-14]. Increasingly, the emergency department has become the safety-net health resource of last resort for the homeless [15]. The over-use of emergency rooms leads to fragmented and crisis-mode health care management of chronic illness and does not provide preventive medical care [16]. As a result, chronic illness such as hypertension remains untreated until critical end-organ damages occur. Moreover, emergency departments are considerably more costly than outpatient services, creating significant nonreimbursed costs for hospitals and extreme financial burdens on the homeless [16]. In order to link the homeless population with preventive health care services, it is crucial to examine and eliminate the barriers they face to access primary health care. Here, we review the major barriers inhibiting adequate access to primary care for the homeless population.

Economic struggles constitute the most frequently discussed barrier to regular health care [16]. The homeless frequently lack insurance to make appointments at a primary care clinic or even to register at many walk-in clinics [14]. Without insurance, the cost of medication can be prohibitive; without storage facilities and regular access to drinking water, storing and administering medicines can be difficult [14].The economic struggles experienced by the homeless also prevent them from managing chronic hypertension in other ways. While life style changes, dietary adjustments, and weight reduction are necessary for hypertensive individuals to lower their blood pressure, the homeless frequently cannot afford fresh vegetables and fruits, and food served in shelters and soup kitchens is typically high in sodium, fat, and carbohydrates which contribute to elevated blood pressure. As a result, proper diet is exceedingly difficult to maintain [17]. Vigorous exercises may be difficult for the homeless due to the lack of comfortable walking shoes and socks or common musculoskeletal problems caused by arthritis or injury [18]. Lastly, the homeless frequently lack means of transportation to reach health care facilities [19], and they lack the telephones to schedule health care appointments [14]. The lack of access to telephones also makes it difficult for health care providers to contact the patient to monitor chronic illness and schedule follow-up care [14].

The homeless also experience perceptual and awareness barriers to preventive care for chronic hypertension. A homeless person may have higher priorities of obtaining adequate food, shelter, clothing, and safety than health care [20-23]. Until the basic survival needs are met, it is difficult for a homeless person to prioritize health care for chronic illness. Drug and alcohol abuse problems further complicate patient access to primary care. One in three homeless Americans has a substance use disorder, compared to one in five adults in the general population; the rate of alcohol abuse is over 50% in the homeless population [24]. Alcohol and drug abuses thus present competing needs against primary health care. Despite the competing priorities, studies have shown that homeless persons are willing to seek care for chronic illness if they believe such care is necessary [25]. However, it is often difficult for the homeless persons to realize the importance of treating chronic hypertension, given that the condition often remains asymptotic before causing life-threatening, end-organ damages. Thus, the lack of educational awareness about the dangers of untreated hypertension further contributes to the delay and failure in homeless persons’ attempts to seek primary care. Lastly, even when homeless individuals are motivated to seek preventive health care, they often lack knowledge of existing, available services and experience challenges in complying with long-term medication and treatment plans typical for hypertension [26].

In addition to the individual/internal barriers discussed above, the homeless population experiences many external/systematic barriers to preventive care for hypertension. The homeless’ lack of health insurance presents an economic burden on the health care institutions, many of which hesitate or refuse to provide services to people without health insurance. As a result, patients without insurance are “shoved to the bottom of the pile” [16]. Another significant external barrier stems from some health care professionals’ insensitivity toward the homeless person’s multiple social and health problems and a lack of respect for the homeless patient as a person [16]. The label “homeless” often stigmatizes patients; language barriers and cultural differences in values, beliefs, and behaviors often divide between the homeless patients and health professionals [16]. Systematic and bureaucratic barriers also lead to decreased access to care. Homeless persons experience greater difficulty in obtaining Medicaid than poor persons with stable housing [4]. Without a permanent mailing address, many homeless individuals are ineligible to apply for Medicaid and cannot receive mail notices of clinic appointments, laboratory test results, or Medicaid application updates [16]. The red tape and bureaucratic paperwork associated with Medicaid application discourage many from applying for insurance [16]. Consequently, homeless persons very often fear, distrust, and avoid bureaucratic institutions and the ‘system’ because of prior negative experiences [27]. Even when a homeless person obtains insurance, clinic hours that do not meet the needs of homeless persons [27] and transportation barriers present further challenges for them to attend clinical appointments. Long appointment waiting times [28] also lead to poor appointment attendance rates, given that the homeless tend to migrate frequently.

To reduce the use of the emergency departments by the homeless, it is crucial to overcome the homeless’ barriers to primary health care services [29-31]. Moreover, given that hypertension is a chronic condition, it is crucial to establish long-term, cost-effective community-based health care that promotes the homeless’ behaviors to maintain self-management of their chronic illness [32-35]. In order to establish such community-based health care programs, it is necessary to first understand the health care needs and utilization patterns of the homeless population. Evidence of the needs of the homeless population will provide basis for developing effective and specific strategies to address patient barriers to care.


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