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

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.