Background information
According to the United Nations, homelessness has become “an increasing social and public health problem worldwide”. There are various states of homelessness. Absolute homelessness refers to “conditions of persons without physical shelter”. Relative homelessness refers to a state in which one has some form of physical shelter but the shelter does not meet the required health and safety standards. For instance, it has poor sanitation and access to water is limited or non-existent. Estimates reveal that over 100 million individuals are homeless worldwide. In the United States of America, the US Department of Housing and Urban Development estimates that about 650,000 people were homeless per night. About 62% of these individuals were living in shelters and less than 2% were classified as “chronically homeless”. It is also estimated that in the period between September 2009 and October 2010, about 1.59 million people in the United States of America were housed in a shelter or transitional housing unit for at least one night. According to the Department of Urban Development and Housing, the number of homeless families increased by 20% in the period between the years 2007 and 2010. In the period between 2006 and 2010, one out forty children was homeless. 40% of the children who were homeless were under the age of six.
Being homeless is associated with several health problems in addition to poor access to health care services. Some of the medical conditions that the homeless are likely to encounter include: mental illnesses, respiratory conditions, neurological conditions and cardiovascular disease. The homeless often sleep on the streets, in abandoned buildings, vehicles and other places that are considered inappropriate for human habitation. Their living conditions are characterized by harsh weather conditions such as the rain and snow in addition to overcrowding. As a result, they are prone to contracting respiratory illnesses such as bronchitis and pneumonia . The situation is aggravated by the fact that the homeless have poor access to health care services. Thus when they contract respiratory illnesses, they receive treatment inconsistently or do not receive treatment at all.
Statement of the problem
Homelessness is a significant problem in the United States of America. Living on the streets and spending nights in places such as park benches, abandoned vehicles and buildings in addition to the streets can have a significant impact on an individual’s health. The living conditions of the homeless are characterized by exposure to harsh environmental problem such as the rain and snow. The homeless individuals are also prone to abusing substances such as cigarettes. Their nutritional status is also poor hence they lack the essential nutrients that would enable them to have an immune system capable of resisting illnesses. These factors combined or in isolation predispose the homeless to respiratory illnesses . The homeless have higher incidences of chronic obstructive lung diseases such as bronchitis and asthma as compared to individuals who are housed. The prevalence and the severity of these conditions is aggravated by the fact the homeless often experience great challenges when in comes to accessing health care services.
Significance of the problem
Given that the homeless are at a higher risk of contracting chronic lung disease, the prevalence and occurrence of diseases such as asthma and pneumonia are not well documented. It remains an area that has been ignored by the research community in spite the fact chronic lung diseases are among the leading causes of death in the United States of America. Therefore, I designed a study to study the prevalence of chronic obstructive lung disease among the homeless in Boston metropolitan area of the state of Massachusetts.
The biological connection between sleeping rough and respiratory illness
The homeless face unique challenges as a result of their living conditions. More often than not, they have to live in overcrowded shelters. They often sleep in abandoned buildings, vehicles, park benches, pavements and subways. They often lack the appropriate clothes that would protect them from the harsh weather elements that they are exposed to. Research has shown that the overcrowded living conditions of the homeless contribute to pneumonia infections. Streptococcus pneumonia is spread from one person to another through droplets. A typical cough can result in the production of thousands of particles that cause pneumonia. The particles can be transmitted from the infected individual through the air or contact. In the homeless shelters, the homeless have to share amenities in addition to bed space hence the pneumococcal infections are easily spread.
Asthma is known to be triggered by several elements that are present in the environment such as toxins, pollutants and industrial chemicals. The homeless brave windy and dusty conditions which predisposes them to asthmatic triggers. As a result, statistics indicate that the incidences of asthma among the homeless are likely to be four times higher than those among housed individuals. The rates of asthma occurrences among children have been found to be six times higher than those among children who are housed. Winter in USA is marked by harsh weather conditions which further aggravate the occurrence of respiratory illnesses among the homeless. Most of them spend nights in damp abodes that act as breeding ground for bacteria that cause illnesses such as pneumonia and bronchitis.
The ambient humidity of the habitations of the homeless also contributes to the occurrences of respiratory illness.The homeless are often exposed to a variety of pathogens at a given time. The respiratory system undergoes marked changes in addition to the immune system. The changes may result in the weakening of the respiratory system those results in the inability to resist infection with other pathogens that cause respiratory illness.
Literature review
While the occurrence of chronic pulmonary disease is prevalent among the homeless, research on the prevalence remains scarce. However, there are several studies that have been done in different parts of the United States of America regarding respiratory illnesses such as asthma and bronchitis. For instance, in a survey involving 68 homeless adults, it was found that a significant number of those who participated in the study had indications of some form of respiratory illness. Among those who participated in the study, 24% had been diagnosed with asthma, 19% had been diagnosed with bronchitis while 14% had chronic obstructive pulmonary disease. It was also evident that the participants already exhibited symptoms of obstructive lung disease such as wheezing, expulsion of phlegm and coughing . Based on the study, the researchers speculated that there could be a link between the occurrence of respiratory illness and homelessness as a result of the exposure to environmental elements and the poor access to treatment.
A study involving sample population in Atlanta Georgia revealed that the prevalence of pneumonia particularly among the homeless is quite high. The high prevalence rates of pneumonia among the homeless in addition to the resulting high mortality rates are linked to the high rates of tobacco abuse, exposure to harsh living conditions and poor access to medical care. The winter season proved to be quite a difficult time for the homeless as it is marked by an increase in the prevalence rates of pneumonia among the homeless. The overcrowded living conditions exacerbate the problem further therefore leading to an increase in the transmission of pneumococcal infections. The finding in this study revealed that at least 19% of those who were surveyed suffered from asthma while 46% of them suffered from at least one chronic illness . The results are almost similar to a study that was conducted in New York which revealed that 17% of the participants had asthma at the time of the survey.
A survey by the Institute for the Outcomes of Research for the Hartford Community Health Partnership revealed that the homeless are three times more likely to likely to suffer from chronic bronchitis and emphysema than those individuals who are housed. 22.7% of those who were surveyed either suffered from chronic bronchitis and emphysema. The results of the study further indicated that the treatment of the homeless individuals is further exacerbated by poor nutrition and access to treatment.
Studies among specific populations among the homeless have also been done. For instance, a study involving a sample of 4- 7 year olds revealed that the prevalence of asthma was higher among homeless children. As a result, the children were more likely to be absent from school, to be hospitalized as a result of asthma exacerbations and to have poor performance in school. The condition is made worse by the fact that the management of the condition is likely to be worse among homeless children hence increasing the severity of the condition. The survey revealed that only 12-15% of the homeless children who are suffering from asthma were receiving the appropriate medication to control the symptoms of asthma . In addition to that, it was found that 27.9% of the participants were suffering from asthma. These rates are three times higher than the national prevalence rates within the same group. However these rates may not be a reflection of the prevalence of the condition among the homeless children given that the condition is often under-diagnosed and under treated. Evidence of the poor treatment and diagnosis of asthma is further provided by a study which involved 740 homeless children living in three shelters in New York. 12.9% of the children had asthma but had never been diagnosed by a physician before. As a result of the overcrowded living conditions, they experienced frequent asthma attacks which were rarely treated therefore making the condition worse.
Recent climatic changes in North America indicate that there is a significant impact of the changes on the health of the population. The homeless in particular remain a vulnerable group of people hence since they are periodically or constantly exposed to harsh weather elements. The cases of chronic bronchitis, emphysema and asthma that are reported among the homeless have been reported twice as many as those that are reported among the housed individuals. There are indications that the rates of asthma attacks among the homeless children are six times higher than those of their housed counterparts. Air pollutants have been known to have an impact on the severity of respiratory illness. The impact of air pollutants is particularly significant among those who spend their time outdoors as in the case of the homeless. Incidences of asthma, bronchitis and chronic obstructive pulmonary disease therefore continue to rise among the homeless as a result of the exposure to the increasing amounts of air pollutants.
Streptococcus pneumonia has been identified as the most common cause of pneumonia among the homeless. Pneumococcal infections have been known to be common among the homeless because of the following reasons: to begin with, shelters for the homeless are often overcrowded thus making it easy for pneumococcal infections to be spread from one person to another. The homeless also have limited resources therefore have to share beds and utensils which further aggravate the spread of pneumonia. In one study involving 39 homeless individuals living in a shelter, it was found that 23% had a history of chronic pneumonia. The spread of pneumonia was attributed to the overcrowded conditions at the shelter which made it easy for pneumonia to spread through droplets. The fatality rates as a result of pneumococcal infections were found to be 4% during the study.
Methodology
A retrospective study involves the use of research that has already been done. There are several types of retrospective studies that could be done: case series, case control and case report study. A case control study is a retrospective study that includes a control group. When carrying out a case control, two groups of individuals are identified: those who have a given condition such as pneumonia and those who do not suffer from the condition. The degree of exposure to the risk factor associated with the condition is then compared. There are two main assumptions that are made when conducting a case control study: it is assumed that the only difference between the cases and the controls is in having the disease. It is also assumed that exposure is equally distributed among the cases and the controls if the risk factor is indeed a cause of the condition.
There are certain study biases that are unique to case studies. If the case control study is hospital based, the study involves the collection of clinical records of the cases and the controls from the hospital. The cases and the controls may have been admitted to the hospital on different dates: this type of bias is referred to as Berkson’s bias. For instance in a case control study of asthma, it often emerges that many asthma patients are treated and discharged from hospital. If the case control study is population based, the study entails the collection of subjects with the potential of becoming cases once they develop the disease. One of the most commonly used statistic ratio in case studies is the odds ratio. The odds ratio is defined as “the ratio between the odds of an outcome in an exposed group against the odds of the same outcome is a group that was not exposed. The case control retrospective studies have both their strengths and weaknesses. Case control study allows the researcher to conduct studies on the occurrence of rare diseases. For instance for respiratory illness, a case control study would be ideal for studying a disease such as cystic fibrosis. Case control studies also allow the researcher to conduct studies on disease that have a long incubation period between exposure and development of the disease. For instance, some individuals may be exposed to tuberculosis but the symptoms do not manifest until several months later. An individual may also be exposed to pneumonia but the symptoms do not manifest until several months later. For homeless individuals, a case control study would be ideal to study the prevalence of pneumococcal infections.
A case control study allows for the researcher to study a disease with multiple causes. For instance, asthma is caused by exposure to environmental pollutants, genetic factors, and prenatal factors such as exposure to tobacco smoke in addition to lifestyle induced factors such as being overweight. Through a case control study it would be possible to examine two or three causes of asthma among the cases and the controls that are the subject of the given study. It is also relatively inexpensive to conduct a case control study especially a retrospective study as compared to carrying out a cohort study.
Some of the weaknesses of retrospective case control studies include: it is often impossible to verify the credibility of the information given that is recorded by somebody else. Such information may therefore be subject to several biases hence compromising on the integrity of the data. One can only focus on one disease or condition when carrying out a case control study. In cases when the researcher is interested in carrying out research on a group of illnesses such as respiratory illness, a case control study might not be the appropriate tool to use. It is often difficult to choose an appropriate control group. For instance, if a researcher is interested in studying the occurrence of asthma among the homeless, it may be difficult to determine whether the right control group would be those who are temporarily homeless or those who are permanently housed. Research is often subject to variables that the investigator has absolutely no control over. It is therefore impossible for a retrospective case control study to take such factors into control. For a non-epidemiologist, the results of a retrospective case control study may be difficult to comprehend therefore difficult to comprehend.
The results from one case control study cannot be used to conclusively develop a link between an exposure and an outcome. It is therefore important that the information obtained is thoroughly scrutinized prior to drawing a conclusion on the association between an exposure and an outcome. A criterion that is often recommended for use by epidemiologists entails the examination of the results of a case control study based on the following premises: specificity, consistency, sequence of events, biological gradient, biological plausibility and consistency with what is known about the disease. The strength of association ought to be explicitly demonstrated in the results. If the exposure to a given risk factor elevates the occurrence of a condition to slightly moderate then it is possible to derive an association between the exposure as a cause and the condition.
Sample Size
The research study shall be conducted in the Boston metropolitan area of the state of Massachusetts in the United States of America. The study shall include a total of 100partcipants whereby 50 of the participants shall be homeless while the remaining number shall consist of sheltered citizens. Basically, the research shall focus on the respiratory disorders amongst the homeless whilst the sheltered citizens shall act as a control group. The research participants shall be selected randomly from at least 500homeless people who shall volunteer for the study. Ideally, one gender shall not comprise more than two-thirds of the entire sample size. In addition, the study shall be restricted to participants aged between 16 and 30 years of age.
Procedure of the Study
The objective of this study shall be basically to ascertain the degree to which exposure to environmental elements affects prevalence and severity of asthma attacks amongst the citizens of Boston metropolitan. Given the study is medical nature, primary data from the subjects shall be collected on a limited basis. In fact, the only data that is significant to the study that shall be collected directly from the participants is whether they are homeless or sheltered and the frequency of their medical check-ups. Almost all the data relevant to the study shall be collected through secondary. The study shall rely on patient medical records from community based clinics as well as shelter homes for the homeless in Boston metropolitan region for the period between the years 2011 and 2012. The purpose of these clinical records shall be to ascertain the housing status of the participants, status of their asthma and when it was diagnosed, and the frequency of medical checkups and hospitalization specifically related to the asthma attacks. In addition to this, the clinical records shall be instrumental in determining in which group the cases of asthma attacks are more prevalent and the role played by environmental elements in these cases. Finally, the study shall involve the use of the odds ratio method to determine the exact link between asthma attacks and environmental elements.
Assumptions to the Study
Given the nomadic lifestyle, the study assumes that most of the homeless citizens in the Boston metropolitan area have been constrained to the region of the study. To this effect, the research thus assumes that their clinical records are up to date. This is based on the assumption that most homeless people frequently get medical checkups. In addition, the research shall ignore the effects of other factors such as hereditary factors on asthma attacks. For the purposes of the study, it shall be assumed that all the participants are subject to similar predisposing factors with an exception of environmental factors.
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