Characteristics and Risk Behaviors of Homeless Black Men Seeking Services from the Community Homeless Assistance Plan -- Dade County, Florida, August 1991

The number of homeless persons in the United States has been estimated to range from 600,000 (1) to 3 million (Dr. Barbara Cohen, The Urban Institute, personal communication, 1991), with higher concentrations of these persons in several large urban centers. Because of the circumstances of homelessness, neither the health status nor the public health needs of these persons are well defined. In Dade County (which includes incorporated Miami), Florida (1990 population: 1.9 million), the average daily number of persons who are homeless is estimated to be 6000; during a 1-year period, approximately 10,000 persons are homeless at some time (Dr. Andrew Cherry, Barry University, Miami, personal communication, 1991). This report presents findings from a survey conducted in August 1991 to assess the health risks of homeless persons in Dade County seeking services from the Community Homeless Assistance Plan (CHAP), a pilot case-management project that places homeless persons into housing, jobs, and appropriate social services.

During the 2-week intake period for the CHAP pilot program in August 1991, a University of Miami research team conducted face-to-face interviews at the CHAP site (three mobile office trailers located within an encampment of homeless persons beneath the Interstate 395 bridges in downtown Miami). For sampling stability and homogeneity, interviewees were selected from among black male clients, the modal subpopulation served by CHAP. Prospective interviewees were approached individually by a researcher, who briefly described the health assessment and invited participation. The investigator read an informed consent statement emphasizing that the survey was anonymous; that CHAP services were not contingent upon participation in the survey; and that survey information would facilitate the development of outreach/intervention programs to reduce health risks among persons on the street. Of approximately 130 men who were approached, 113 agreed to participate.

The survey used the Risk Behavior Assessment (RBA) questionnaire developed by the National Institute on Drug Abuse (2) for multisite national studies. RBA items include demographics; use of alcohol and other drugs during the 30 days preceding the interview or ever; history of injecting-drug use; sexual history for the 30 days preceding the interview; history of sexually transmitted diseases (STDs), including acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV)-seropositivity; and arrest records for the 30 days preceding the interview and ever. The RBA previously had been established to be reliable and valid for current drug users. For this assessment, four questions from the Adult Use of Tobacco Survey (3) were added to the RBA to assess prevalence of cigarette smoking. Demographics

Of the 113 men who were interviewed, most (92 (81%)) were aged 25-44 years. Although 39 (35%) had less than a high school education, 31 (27%) had received some level of college or technical education (Table 1). Sixty-two (55%) were never married; 42 (37%) were separated or divorced. Substance Use

Ninety-three (82%) men reported smoking cigarettes during the 30 days preceding the survey (Figure 1) (almost three times the 29% prevalence rate for black men aged 18-49 years in Florida in 1989 (CDC, unpublished data)); three men were classified as former smokers. Combining alcohol and all illicit drugs, 97 (86%) reported use of one or more of these substances during the 30 days preceding the interview. All persons in the sample had used alcohol during their lifetime, and 86 (76%) reported use during the 30 days preceding the interview. Crack cocaine was the most common street drug in current use and was reported to have been used by 64 (57%) men during the 30 days preceding the interview. Although 105 (93%) reported ever using marijuana, 34 (30%) had smoked marijuana in the 30 days preceding the interview. Similarly, ever using cocaine (other than crack) was reported by 80 (71%) men, and 17 (15%) reported use during the 30 days preceding the interview. Although 21 (19%) men reported ever using heroin and 18 (16%) reported ever using speedball (heroin and cocaine mixed), none of those interviewed reported use of either substance during the 30 days preceding the interview.

Three men reported injecting-drug use (cocaine) during the 30 days preceding the interview. Of the 76 men who reported use of illicit drugs during the 30 days preceding the interview, 29 (38%) reported histories of residential drug treatment; for these men, the cumulative lifetime duration of treatment averaged 14.8 weeks. Sexual Activity

Of 110 men who responded to questions about sexual activity during the 30 days preceding the interview, 33 (30%) men reported no sex partners, 34 (31%) reported sex with one partner, and 43 (39%) reported sex with two or more partners. Among 78 men who reported sexual activity during the 30 days preceding the interview, 13 (17%) reported having sex on one occasion, 38 (49%) on two to five occasions, and 27 (35%) on six or more occasions. Of these 78 sexually active men, 69 (88%) reported sex with women only, eight (10%) reported sex with men only, and one (1%) reported sex with both men and women. Nine men indicated that at least one sex partner during the 30 days preceding the interview was an injecting-drug user. More than half of the sexually active respondents (40/76 (53%)) reported use of alcohol before or during sex on one or more occasions; similarly, more than half (40/75 (53%)) reported use of crack cocaine before or during sex.

During the 30 days preceding the interview, almost half (38/78 (49%)) of the sexually active men indicated that they had used a condom on one or more occasions. Five (6%) men reported giving sex in exchange for drugs, 29 (37%) reported giving drugs in exchange for sex (27 of 29 gave crack), 11 (14%) reported exchanging sex for money, and 18 (23%) reported giving money for sex.

Of 109 men who responded to questions regarding STDs, 60 (55%) reported a previous diagnosis of gonorrhea, and 39 (36%) reported a previous diagnosis of syphilis; 11 (11%) of 96 who had received HIV test results indicated that they had been informed that they were HIV-antibody positive. Reported by: JM Shultz, PhD, NL Weatherby, PhD, CB McCoy, PhD, Comprehensive Drug Research Center, Dept of Epidemiology and Public Health; PJ Greer, MD, Dept of Medicine; P Branca, D O\'Connor, Univ of Miami School of Medicine; A Bock, JD, I Cabral, Miami. R Needle, PhD, Community Research Br, National Institute on Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administration.

Editorial Note

Editorial Note: The CHAP program provided a unique opportunity to describe the demographic and health characteristics of a sample of homeless persons who had self-selected to seek assistance services. Because of inherent constraints on sampling, the number of homeless persons in Dade County and other locations cannot be accurately estimated. Nonetheless, the findings from this health assessment indicate a high prevalence of substance use and a substantial prevalence of high-risk sexual behaviors among homeless black men who are seeking shelter and job-placement services in Dade County.

The findings from this survey suggest at least three levels for approaching the health risks and public health needs of homeless persons in Dade County and elsewhere. First, street-based interventions (e.g., community outreach counseling concerning sexual and drug-use behaviors and referral networks for health-care and service agencies) may be developed to minimize the health consequences of substance use and unprotected sexual activity; such services can be provided by community-based clinics, organizations that serve homeless persons, and university-based public health activities. The University of Miami researchers have conducted extensive outreach efforts for drug abuse and AIDS prevention among high-risk groups, including the homeless (4).

Second, case-management programs such as CHAP enable placement of homeless persons in housing and jobs and provide follow-up during the transition from street to independent living. In addition, CHAP staff provide several services, including initial placement in shelters, job referral, chemical dependency assessment and referral to treatment, referral to medical and social services in the community, and ultimately, long-term housing placement.

Finally, a multistrategy approach addressing the public health needs of the homeless will require an active, ongoing partnership between public, voluntary, private, and academic organizations. This approach may include establishing permanent facilities to provide intake, assessment, referral, and case-management services and targeting primary prevention education efforts concerning drug use and sexual risks among homeless persons.

References

1. Burt M, Cohen B. America's homeless. Washington, DC: The Urban Institute Press, 1989.

2. National Institute on Drug Abuse. Training manual for administering and coding the Risk Behavior Assessment (RBA) questionnaire. Rockville, Maryland: Community Research Branch, National Institute on Drug Abuse, Alcohol, Drug Abuse, and Mental Health Administration, 1991.

3. CDC. Tobacco use in 1986: methods and tabulations from Adult Use of Tobacco Survey. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1990; DHHS publication no. (OM)90-2004.

4. McCoy CB, Khoury EL. Drug use and the risk of AIDS. American Behavioral Scientist 1990;33:419-31.

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