Access to Healthcare Among Homeless Populations of Cleveland - An Introspective Analysis

Access to Health Care among Homeless Populations of Cleveland: An Introspective Analysis


According to the National Law Center on Homelessness and Poverty “on any given night in America, anywhere between 700,000 to 2 million people are homeless (“Almanac of Policy,” 2000),” and approximately 36 percent of this population consists of families with children (“Almanac of Policy,” 2000). By far, Homelessness as one of America’s major social problems is not a newly-received ideology, for centuries social theorists have attempted to analyze psychosocial characteristics that seem to define populations of homeless individuals in efforts to devise subsequent mechanisms to alleviate, if not eliminate such poverty-induced destitution. To date, there have been innumerable of studies conducted to track the workings of community-based interventions, implemented to improve healthcare for homeless populations. To date, the number of studies designed to examine perceptions of health care amongst Cleveland’s homeless populations has been limited. In 2005, the U.S. Department of Housing and Urban Development (HUD) estimated an approximate 754,147 individuals to have been homeless on any given day in the United States of America (“Educate Yourself!-Homelessness,” 2005). Nonetheless the Mental Health Services for Homeless Persons, Inc. (MHS) approximates that 21,811 individuals of Cuyahoga County are expected to be homeless at some time in the course of a year (“How many are Homeless in Cuyahoga County Ohio,” 2005). The rate of homelessness is steadily increasing in most U.S. cities, to induce a complex, long-term social problem that plaques American society as a whole.

Because homelessness is a rather convoluted issue, consisting of a host of personal and social determinants that are often interconnected to cause one to experience severe poverty, there are no quick fixes to solve this problem. Disabilities that affect one’s mental or physical health are often substantially elevated among homeless populations. In Cuyahoga County for example, approximately 24% of homeless individuals have been reported to suffer from at least one mental illness (“How many are Homeless in Cuyahoga County Ohio,” 2005), which is roughly 4.1 percent higher than the national average of 19.9 respectively (“How many are Homeless in Cuyahoga County Ohio,” 2005). The influence of drugs and alcohol has also been implicated to contribute to the high incidence of poverty and homelessness, as the Substance Abuse and Mental Health Services Administration (2003) estimates: “38% of homeless people were dependent on alcohol and 26% abused other drugs (“National Coalition for,” 2009),” rates that are much higher than the national average of 7.5 and 9.1 respectively (“2003 National Survey,” 2008). While it is true that the quality of one’s mental health and duration of substance abuse does in fact contribute to homelessness, it is important to note that these characteristics alone do not cause individuals to become homeless. To accurately assess the problem of homelessness, it is mandatory to examine structural influences that impacts, and oftentimes sustains homelessness.

Poverty and Homelessness: The Intersectionality of Structural Determinants

In Structural Determinants of Homelessness in the United States, researchers Marta Elliot and Lauren Krivo identifies “four structural factors that are most commonly cited as the major causes of homelessness: (1) lack of low-cost housing, (2) high poverty rates, (3) poor economic conditions, and (4) lack of community mental health care facilities (Elliot, & Krivo, 1991).” While these factors seem to be documented as four distinct variables, there is a common element that links them together that is economic disparity. Despite many popular beliefs, the number of homeless individuals who partake in the U.S. job market as paid full-time or temporary workers is ever-increasing. Although many homeless citizens are active contributors to the U.S. economy, with approximately 44 percent reportedly engaged in the labor market (“Almanac of Policy,” 2000), individuals who are homeless tend to experience discrimination at greater rates than the non-homeless, which contributes to further socioeconomic inequalities for the homeless and hinders their opportunities for upward economic mobility. According to a 1996 National Survey of Homeless Assistance Providers and Clients (NSHAPC) “single homeless individuals in 1996 reported an average income of $348 during the last 30 days, about 51 percent of the 1996 federal poverty level of $680/month for one person (“Almanac of Policy,” 2000),” thus homeless individuals tend to earn far less than the lowest-wage earners in mainstream American society. Just as discrimination based on race and gender has been implicated to induce sustained economic inequalities for subgroups of Americans, one’s relative housing status, or lack thereof, has been correlated with one’s capacity to gain employment. It is a paradox, to obtain a job one must have a home address and a personal telephone number, yet without a substantial income it is nearly impossible to afford adequate housing, therefore if one lacks a permanent location for residence the chance that he or she will become gainfully employed is slim to none and such a cycle of poverty causes one to become embedded into a state of chronic, or persistent homelessness. In America, chronic homelessness applies to “one who has either been continuously homeless for a year or more, or has had at least four episodes of homelessness in the past three years (“10-year plan to,” 2010).” Historically, ethnicity has been correlated with sustain poverty and chronic homelessness in America. “In the 2004 Status Report on Hunger and Homelessness, the U.S. Conference of Mayor’s found that people of color make up (65%) of all homeless persons staying in shelters and transitional housing programs nationwide, and yet comprise only 31% of the U.S. population(“Racial Equality and Homelessness,” 2007).”

Because discriminatory housing practices has been fairly common for many centuries in America, not officially barred until the latter 20th century, African Americans and other ethnic-minorities have been systematically denied housing or subjugated to unfair leasing policies. As a result of unfair housing practices, it is plausible to assume that the rate of poverty and homelessness is correlated with institutional discrimination. In fact discrimination is still a major barrier in modern housing practices “in 2004, Hispanic households were two times as likely as African-American households were three times as likely as white households to have a sub-prime loan (“Racial Equality and Homelessness,” 2007). In all, both personal and structural characteristics are highly impactful in the onset of homelessness in U.S. society. To understand the diverse causes of homelessness without an examination of long-term implications is quite futile; therefore, an analysis of relative health and economic outcomes as a result of sustained poverty is necessary.

Health Implications Associated with Chronic Homelessness

“Recent studies on the health status of homeless persons report that being without a home is associated with excess morbidity and mortality, may increase communicable diseases, injuries, hypothermia, and malnutrition; and may exacerbate existing conditions (Robertson, & Cousineau, 1986).” In addition, “Homeless adults also suffer several medical problems due to under-nutrition. Common problems include anemia, dental problems, gastric ulcers, other gastrointestinal complaints, cardiovascular disease, hypertension, hypercholesterolemia, acute and chronic infectious diseases, diabetes, and malnutrition (Vickery, 2004-2010).” If these health outcomes do not seem to be a wakeup call, let’s consider the long-term health implications for children who suffer from chronic homeless: “homeless children suffer several medical problems due to under-nutrition, including chronic and recurring physical ailments, and higher rates of fever, cough, colds, diarrhea, and obesity. In addition, a greater incidence of infections, fatigue, headaches, and anemia, as well as impaired cognitive development and visual motor integration, has been documented in homeless children (Vickery, 2004-2010).” In addition, children who belong to families that are chronically homeless are at a high risk to develop cognitive impairments (Vickery, 2004-2010). Aside from diseases that result from nutritional deficiencies, the homeless are at greater risks to suffer from prolonged or untreated injuries and infectious agents than the U.S. general population. Several studies have indicated that the use of health care among the homeless is rather frequent; however, these individuals tend to utilize emergency medical services as the sole basis to attain health care, which often negates the use of preventive care due to an inability to afford needed checkups with medical professionals.

Economics of Poverty and Homelessness

The use of preventive health care among populations of homeless Americans is severely poor compared to that of mainstream society as a whole. As result of infrequent screenings and checkups, “homeless people are admitted to hospital up to five times more often than the general population and stay in hospital longer other low-income patients. These prolonged stays in hospital result in significant excess health care costs (Vickery, 2004-2010).” The current expenditure for health care in the United States of America is approximately “$2.3 trillion in 2008, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980 (Kimbuende, 2010).” One of the major contributors to the rise in healthcare expenditures over the past two decades has been attributed to American society’s increased reliance on emergency medical services to treat chronic illnesses that were largely symptomatic and preventive in early stages. As the Henry J. Kaiser Family Foundation states “the burden of chronic disease, such as diabetes and cardiovascular disease, has risen dramatically; both of these chronic conditions are known to be correlated with obesity, smoking, and diet, and are very expensive to treat over prolonged periods of time (Kimbuende, 2010).” The cost to sustain the current health care system that is primarily based on the treatment of chronic diseases that were once preventable is a highly ineffective model. Not only does this model sacrifice the quality of life-years for millions of American citizens, but the overall productivity of this nation is greatly diminished as a result of elevated rates of preventable morbidity and mortality.

The concept that social determinants often interlink to induce prolonged problems in society is evident yet again by the relationship between poverty, homelessness, and health in the United States of America. For example, if one is homeless it becomes relatively difficult to obtain a job, due to a lack of telephone and home address that is often required when one applies for employment, if he is then unable to secure a job is it highly unlikely that he will be able to afford the necessary health insurance to main proper health, as a consequent of the inability to maintain wellness he is more likely to become ill in the future. If one suffers from acute to chronic illness, it is more difficult to seek employment or to gain the skills that are necessary to advance his career. It is obvious that preventive care is essential for socioeconomic mobility, thus to continuously limit the amount of emphasis on preventive care for underserved populations of Americans will enable sustained poverty to ensue for many generations to come.

To increase health and wellness among the homeless it is imperative to understand the possible barriers that may hinder one’s ability to attain the health care that is needed, if we are able to identify such barriers it is plausible to create policies and community-based interventions that target these barriers and subsequently alleviate health disparities for populations of homeless Americans. As discussed previously, the greatest barrier to health care for homeless populations is the lack of economic power. Socioeconomic status is one of, if not, the greatest barrier for homeless populations who seek to improve personal health. In large, preventive health care is utilized most often by those of mid-to-upper middle socioeconomic backgrounds, as these citizens are better able to afford these services through private health care insurance. Nonetheless, the concept of socioeconomics is rather broad and may entail of a host of traits. The ability to identify and isolate specific factors that are intrinsic to the socioeconomic status paradigm may in fact alter one’s socioeconomic status as a whole. Socioeconomic status is best described as ‘“a discipline studying the reciprocal relationship between economic science on the one hand and social philosophy, ethics, and human dignity on the other” toward social reconstruction and improvement (“Social-Economic Impacts,” 2010),” thus this concept encompasses the intersection between society and economics with the theory that a change in one component will correspond to a change in the latter.

Perceptions of Access to Health Care among Homeless Populations of Cleveland: An Introspective Analysis (Present Study)

In recent years, a substantial number of surveys have been devised to chart perceptions of health care among homeless populations across the U.S. For the most part, these studies on homelessness have been very narrow and concentrate, with a focus on Chicago, Baltimore, Los Angeles, and New York, cities where the population density per capita tends to exceed that of the standard American city. While it is important to analyze and depict homelessness in cities that are more populous, the choice to divert attention to these regions alone will hinder the majority of cities across America, as distribution of donations and other funds will be largely unequal. Research on access to health care among homeless populations has been either unexamined for the vast majority of counties across the United States of America or the data that is available is dated to two or more decades ago. Aside from annual tabulations of demographic characteristics, no studies have been conducted in the last ten to fifteen years to analyze perceptions of access to preventive health care services for homeless populations in the City of Cleveland. Cleveland is the largest city of Cuyahoga County and currently stands as the second-poorest city in the United States (Smith, 2010), yet knowledge about access to healthcare for its underserved populations has been subpar, consequently community-based interventions to improve health, and plausibly decrease the rates of poverty and homelessness, has been constrained. In the present study I would like to study perceptions of : (1) access to health care, (2) treatment by medical professionals, (3) barriers that limit one’s ability to utilize preventive resources, (4) current interventions that have been employed to improve health, (5) and plausible health interventions that may effectively decrease barriers in healthcare.


Cross-sectional structural interviews will be the method that is employed to gain insight from homeless populations about their perceptions of healthcare. Participants for the study will be selected at random; however, all participants must speak the English language unless an interpreter is present for the purpose of translation. In addition, there is a strict age requirement that prohibits anyone who does not occupy the ages of seventeen to sixty-four from participation in the present study. Ideally, the goal is to survey individuals who are categorized as the ‘chronic homeless,’ but all who meet the basic age requirement will be included in this study. I will conduct face-to-face, thirty-minute interviews with willing participants, representative of 2-5 housing facilities located in the City of Cleveland, the data will then be subsequently coded and analyzed.

Participants: This will be a random sample of residents. To deduce results that are valid and applicable for most populations of homeless individuals in Cleveland, it is optimal to obtain a wide-range of participants, who represent diverse demographic backgrounds.

Data Collection: Data will be collected during the face-to-face interview sessions, where the interviewee (researcher) will document the responses of each participant.

Coding and Analysis: SPSS and other statistical software will enable bi-variate and multivariate correlation analyses to be conducted.
Specific Aims for Present Introspective Analysis
The overall objective of the present study is to enhance knowledge about perceptions of health care and access to medical care from the direct insights of Cleveland’s homeless individuals.

I would like to track demographic characteristics to better understand how such determinants may impact one’s perception of access to medical treatment(s).

Some of the demographic characteristics of interest for the current study:


Race and ethnicity
Family size
Employment status
Duration of homelessness (in accord with federal definition for homelessness)
Geographic/spatial proximity to area hospitals with respect to location of residence
Current health conditions

It is significant to examine the current health care interventions that are common among most homeless facilities in Cleveland. it is imperative to understand how homeless individuals of Cleveland perceive health interventions, therefore one of the current objectives is to gain direct insights from the homeless about programs implemented by Cuyahoga County.

There are health interventions that have been implicated to increase the use of preventive health care among the homeless; therefore, I would like to study how homeless individuals of Cleveland view the efficacy of these models.

Preliminary Hypotheses
There are plausible correlations between race or ethnic-origin and incidence of homelessness in the United States of America.
According to PBS: Facts and Figures (2009):
“42% of Homeless Americans are African-American, although they account for roughly 11% of the general population.”
“13% are Hispanic (compared to 9% of the general population).”
“39% are non-Hispanic Whites (compared to 76% of the general population).”

The race of an individual may influence their perceptions of access to health care and the overall quality of medical treatments that are received. Whether perceptions about quality of care are based on direct personal experiences or the knowledge acquired from a friend or kin with of similar demographic backgrounds, to understand the basis of how health care is perceived among underserved populations is vital.

Hypothesis 1:

There is an insignificant correlation between race and perceptions of adequate health care among populations surveyed. It is presumed that African-Americans will entail of the largest ethnic group represented in the survey, but unless there are objective indicators of racial discrimination I do not believe most homeless individuals will attribute barriers in access to health to race or gender alone.

Hypothesis 1.2:

Duration of homelessness will be significantly correlated with one’s perception of personal health. Those who experience chronic homelessness will project a greater need for preventive health care and an increased dissatisfaction will quality of care as a whole.

Hypothesis 2.1:

It is plausible for homeless individuals to perceive current health and wellness interventions with relatively high satisfaction when such interventions involve: (1) interpersonal interactions between the homeless individual and medical professional, (2) a structured mechanism to address the personal health needs of the individual, (3) a structured course that entails of diverse resources (i.e. medical contacts, literature, etc.) to main proper health.

Implications of Future work

The scope of the present research is designed to enhance public awareness about the medical needs that are specific to homeless populations of Cleveland, Ohio. To bridge the growing disparities in health that affects millions of Americans, it is vital to examine possible barriers that may impede equality in the current healthcare system. My hope is to provide a foundation for medical professionals, social scientists, community organizers, and policy-makers to collaborate and address the needs of underserved citizens in the City of Cleveland.

Acknowledgements: I would like to thank my research advisor, Dr. Eva Kahana, and the directors of each accommodating housing facility, all of whom were especially helpful throughout the duration of this project. In addition, I would like to thank each and every resident who partook in an interview; to work with all of you on a weekly basis was a wonderful experience, Thank you once again.

Literature Cited

10-year plan to end chronic homelessness in sacramento county is now sacramento steps foward. (2010, March 19). Retrieved from

2003 national survey on drug use and health: detailed tables. (2008, June 03). Retrieved from

Almanac of policy issues: homelessness. (2000, December). Retrieved from

Educate yourself!-homelessness. (2005, January ). Retrieved from

Facts and figures: the homeless. (2009, June 26). Retrieved from

How many are homeless in cuyahoga county, ohio usa?. (2005). Retrieved from

Kimbuende, Eric. (2010, March). U.s. health care costs. Retrieved from

Racial equity and homelessness. (2007). Retrieved from

Smith, R. (2010, September 29). Census shows cleveland is the second-poorest city in the united states. Retrieved from

Social-economic impacts. (2010). Retrieved from

Vickery, P. (2004-2010). Homelessness. Retrieved from