HOMING IN ON THE HOMELESS - ASSESSING THE PHYSICAL HEALTH OF HOMELESSADULTS IN LOS-ANGELES-COUNTY USING AN ORIGINAL METHOD TO OBTAIN PHYSICAL-EXAMINATION DATA IN A SURVEY
Lc. Kleinman et al., HOMING IN ON THE HOMELESS - ASSESSING THE PHYSICAL HEALTH OF HOMELESSADULTS IN LOS-ANGELES-COUNTY USING AN ORIGINAL METHOD TO OBTAIN PHYSICAL-EXAMINATION DATA IN A SURVEY, Health services research, 31(5), 1996, pp. 533-549
Objective. Public policy that decreases the funding for social service
s may combine with the ascendancy of corporate managed care to increas
e the health care deficit. Assessing the health impact of these policy
changes on various populations is a fundamental challenge for health
services research. Disadvantaged populations, such as the homeless, ar
e likely to be affected disproportionately. Research quality data on t
he physical health of such populations are difficult and expensive to
obtain. In particular, physical examination data have not been availab
le and self-reports are insufficient. Our objective: to develop and ut
ilize a structured physical exam system enabling lay survey researcher
s to report reliably physical findings related to six tracer condition
s in a disadvantaged population. Study Setting. A field survey of home
less adults in Los Angeles County, California. Respondents were 363 ho
meless adults representing a subsample of a probability sample of the
county's homeless adult population. Study Design. We integrated existi
ng measures with expert clinical opinion and original means of data co
llection into a structured physical exam enabling lay interviewers to
identify the prevalence of vision problems, significant skin disorders
, peripheral vascular disease of the lower extremities, selected pedia
tric disorders, hypertension, and tuberculosis in a sample of homeless
adults. Principal Measures. We describe lay interviewer performance i
n terms of mastery of the necessary material based on written and prac
tical exams and in terms of the number of respondents successfully fol
lowed. We base our description of the instrument on the time necessary
to complete it, and on the proportion of each component successfully
completed during the field survey, as well as on interrater reliabilit
y. We report the prevalence of the various clinical conditions accordi
ng to self-report and according to the structured limited physical exa
m, as well as the marginal proportion of respondents who were identifi
ed by the physical exam and not by self-report. Principal Findings. In
terviewers performed the exam successfully under field conditions. Res
pondent acceptance of the instrument was high. Interrater agreement wa
s 100 percent regarding the need for referral on the basis of blood pr
essure and vision. Kappa statistics for skin, foot, and edema findings
were .67, .71, and .81, respectively. Adjusted for sampling weights,
60 percent of this population required referral for at least one of th
e specified conditions. For those portions of the survey for which bot
h self-report and physical exam data were available, lay interviewers
made significant percentages of referrals on the basis of physical fin
dings alone. Conclusions. High blood pressure, poor vision, peripheral
vascular diseases of the feet and legs, and significant skin conditio
ns are prevalent among the homeless in Los Angeles County. Without phy
sical exam data, estimates of the prevalence of these conditions will
be incorrect. Researchers can use laypersons to collect reliable and v
alid physical exam data on disadvantaged populations. This represents
a new tool for assessing and monitoring the health of these population
s.