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      Experiences With and Attitudes Toward Death and Dying Among Homeless Persons

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          Abstract

          Background

          Homeless persons face many barriers to health care, have few resources, and experience high death rates. They live lives of disenfranchisement and neglect. Few studies have explored their experiences and attitudes toward death and dying. Unfortunately, studies done in other populations may not apply to homeless persons. Exploring these experiences and attitudes may provide insight into life, health care, and end-of-life (EOL) concerns of this population.

          Objective

          To explore the experiences and attitudes toward death and dying among homeless persons.

          Design

          Qualitative study utilizing focus groups.

          Participants

          Fifty-three homeless persons recruited from homeless service agencies.

          Measurements

          In-depth interviews, which were audiotaped and transcribed.

          Results

          We present seven themes, some of which are previously unreported. Homeless persons described many significant experiences with death and dying, and many participants suffered losses while very young. These encounters influenced participants’ attitudes toward risks and risky behavior: e.g., for some, these experiences provided justification for high-risk behaviors and influenced their behaviors while living on the streets. For others, they may be associated with their homelessness. Finally, these experiences informed their attitudes toward death and dying as well as EOL care; homeless persons believe that care will be poor at the EOL.

          Conclusions

          Findings from this study have implications for addressing social services, health promotion, prevention, and EOL care for homeless persons, as well as for others who are poor and disenfranchised.

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          Most cited references48

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          A Guide to Conducting Consensual Qualitative Research

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            The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people.

            (1) To present the Behavioral Model for Vulnerable Populations, a major revision of a leading model of access to care that is particularly applicable to vulnerable populations; and (2) to test the model in a prospective study designed to define and determine predictors of the course of health services utilization and physical health outcomes within one vulnerable population: homeless adults. We paid particular attention to the effects of mental health, substance use, residential history, competing needs, and victimization. A community-based probability sample of 363 homeless individuals was interviewed and examined for four study conditions (high blood pressure, functional vision impairment, skin/leg/foot problems, and tuberculosis skin test positivity). Persons with at least one study condition were followed longitudinally for up to eight months. Homeless adults had high rates of functional vision impairment (37 percent), skin/leg/foot problems (36 percent), and TB skin test positivity (31 percent), but a rate of high blood pressure similar to that of the general population (14 percent). Utilization was high for high blood pressure (81 percent) and TB skin test positivity (78 percent), but lower for vision impairment (33 percent) and skin/leg/foot problems (44 percent). Health status for high blood pressure, vision impairment, and skin/leg/foot problems improved over time. In general, more severe homeless status, mental health problems, and substance abuse did not deter homeless individuals from obtaining care. Better health outcomes were predicted by a variety of variables, most notably having a community clinic or private physician as a regular source of care. Generally, use of currently available services did not affect health outcomes. Homeless persons are willing to obtain care if they believe it is important. Our findings suggest that case identification and referral for physical health care can be successfully accomplished among homeless persons and can occur concurrently with successful efforts to help them find permanent housing, alleviate their mental illness, and abstain from substance abuse.
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              Competing priorities as a barrier to medical care among homeless adults in Los Angeles.

              The role of competing priorities as a barrier to the utilization of physical health services was assessed in a subset (n = 363) of a probability sample of homeless adults in Los Angeles. Unadjusted odds of four measures of health services utilization were calculated for those with frequent difficulty in meeting their subsistence needs. These odds were then adjusted for a range of characteristics assumed to affect the utilization of health services among the homeless. Before and after adjustment, those with frequent subsistence difficulty were less likely to have a regular source of care (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.16, 0.53) and more likely to have gone without needed medical care (OR = 1.77, 95% CI = 1.04, 3.00). Subsistence difficulty had no impact on the likelihood of having an outpatient visit or having been hospitalized. Conclusions remained the same after adjustment. Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults.
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                Author and article information

                Contributors
                +1-612-6248936 , +1-612-6249108 , songx006@umn.edu
                Journal
                J Gen Intern Med
                Journal of General Internal Medicine
                Springer-Verlag (New York )
                0884-8734
                1525-1497
                18 January 2007
                April 2007
                : 22
                : 4
                : 427-434
                Affiliations
                [1 ]Center for Bioethics, University of Minnesota, N504 Boynton Hall, 410 Church Street S.E., Minneapolis, MN 55455 USA
                [2 ]Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN USA
                [3 ]Division of Chronic Diseases, City of Philadelphia Department of Public Health, Philadelphia, PA USA
                [4 ]Office of Clinical Research, Academic Health Center, University of Minnesota, Minneapolis, MN USA
                Article
                45
                10.1007/s11606-006-0045-8
                1829422
                17372788
                1393a41e-9025-4746-87f9-f40c9522da07
                © Society of General Internal Medicine 2007
                History
                Categories
                Original Article
                Custom metadata
                © Society of General Internal Medicine 2007

                Internal medicine
                poverty,focus groups,homelessness,end-of-life care,death
                Internal medicine
                poverty, focus groups, homelessness, end-of-life care, death

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