Social Determinants of Health – Homelessness
Editorial Series Part I
Social Determinants of Health (SDoH) are the conditions under which people are born, grow, live, work and age1. They have a larger role on population health than more traditional factors like genetics, behavior and health care2. Examples include socioeconomic status, education, employment, social networks, racism, discrimination, residential location and housing security. These upstream factors create the structure for health inequalities. I wanted to start off this editorial series on SDoH with homelessness.
A homeless person is defined by the 2009 Homelessness Emergency Assistance and Rapid Transition to Housing (HEARTH) Act as “someone who lacks a fixed, regular, and adequate nighttime residence and who lives in a shelter or a place not designed for human habitation; people at imminent risk of housing loss within the next two weeks; and people fleeing from domestic violence with inadequate resources to obtain other permanent housing”3. Homelessness affects men, women, children and families of all races, ethnic groups and backgrounds. The National Alliance to End Homelessness 2018 report notes on any given night last year, more than 550,000 people were homeless, one-third of which were people in families with children. California accounted for nearly 150,000 of these4. The Greater Los Angeles “Point-In-Time” Count in 2019 noted approximately 59,000 and 36,000 homeless in Los Angeles County and the city of Los Angeles respectively 5.
Homelessness impacts mortality disparities, health conditions and health care utilization. A myriad of dermatologic, infectious and neurologic issues are more prevalent and chronic medical conditions tend to be uncontrolled and more advanced in this population. Hospitalization and emergency department visits are also higher6.
Evidence is growing that the provision of housing has health and social benefits for homeless people. Disparities in hospitalizations and mortality decrease. Community programs to address this in our nation include examples like Housing First and Health Care for the Homeless. Local initiatives such as the Skid Row Housing Trust and the Housing for Health Program at the Los Angeles County Department of Health Services also exist. As of the writing of this editorial, there are a couple of bills (SB-50 Planning and zoning: housing development: streamlined approval: incentives, and AB-1482 Tenancy: rent caps) in the 2019-2020 California Legislature regular season that try to address some of the issues that impact accessibility to affordable housing.
As Family Physicians we are on the front line to have an impact on these upstream issues. Of course, we should provide thoughtful trauma informed care to these often-marginalized patients and families. Care should follow evidence-based guidelines and adjusted as appropriate to the situation. That said, as physicians, we have opportunities and platforms to advocate for social reform on many local, state and national levels. We must serve as that voice for others who struggle.
- American Academy of Family Physicians. Social determinants of health policy. https://www.aafp.org/about/policies/all/social-determinants.html
- American Academy of Family Physicians. Advancing Health Equity by Addressing Social Determinants of Health in Family Medicine (Position Paper). https://www.aafp.org/about/policies/all/socialdeterminantofhealth-positionpaper.html
- Department of Housing and Urban Development. Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009. https://www.hudexchange.info/resource/1717/s-896-hearth-act/
- National Alliance to End Homelessness. https://endhomelessness.org/
- Los Angeles Homeless Services Authority. 2019 Greater Los Angeles Homeless Count – Total Point-In-Time Homeless Population By Geographic Areas. https://www.lahsa.org/documents?id=3467-2019-greater-los-angeles-homeless-count-total-point-in-time-homeless-population-by-geographic-areas.pdf
- UpToDate. Health care of homeless persons in the United States. https://www.uptodate.com/contents/health-care-of-homeless-persons-in-the-united-states/print?search=homeless&source=search_result&selectedTitle=1~107&usage_type=default&display_rank=1
