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Risk Factors and Public Assistance Role in Hypertension among Homeless Population: A Cohort Study

Homelessness is defined as a condition of people living without
any regular nighttime residence [1]..

communicable diseases and substance abuse [3][4][5]. Since there is a strong correlation between socioeconomic status and health, it is not surprising that homeless individuals are facing a heavy disease burden, which requires a distinctive approach to fulfill their health care needs [6]. Among the most common chronic illnesses affecting homeless people is cardiovascular disease [7]. However, the risk factors associated with its manifestations are generally unidentified [3]. Most of homeless people are lacking health insurance, which results in deadly consequences of cardiovascular disease specifically [3]. For instance, hypertension is estimated to affect between 18% to 41% of the homeless population [8].
Hypertension has been found to be a leading risk factor for death worldwide [9,10]. Consequently, homeless individuals have an average life expectancy of 42 to 52 years old, almost 30 years less than the average American [8].
This study was designed to determine the prevalence of hypertension among the homeless community of downtown Orlando area, where 1500 individuals are estimated to be homeless.
Additionally, we wanted to identify certain risk factors inducing the development of hypertension among these individuals. Ultimately, this could help educating the public about this issue, which will potentially assist the city to develop more effective and efficient solutions, that they might not have been considered earlier.

Enrollment of Study Participants
All participants in this study were self-identified as homeless adults residing in Orlando Downtown, Florida. All participants have consented to be enrolled in the study following an approved Institutional Review Board from the University of Central Florida (IRB00001138). All participants were interviewed and selected for the study following approved inclusion/exclusion criteria defined in the IRB protocol and the consent form. Exclusion criteria includes those who were under the age of 18 years old, pregnant women, had permanent housing, had received mastectomies, and had consumed alcohol on that day. Additionally, we conducted a brief visual check to ensure that participants' left arm were not amputated and that they were not suffering from any present ablations or cuts that may lead to complications if the blood pressure was measured. To conduct the study effectively, we aimed to recruit a sizeable and

Statistical Analysis
First, we quantified the responses to each survey question, which indicated the prevalence of certain factors, behaviors, or characteristics within the sample that effectively represents the Orlando homeless community. Data are expressed as mean ± standard error of the mean by using graphpad prism ® . Two tailed student's t-test was used. The difference between samples and controls was considered statistically significant at a level of *P<0.05.
In order to compare between the homeless population and the nonhomeless population (derived from other studies), a Z-Test for two population proportions was conducted to determine if there was a statistically significant difference.

Presence of Hypertension Among Homeless Population
Of over 200 individuals were interviewed, 167 agreed to participate in this study. Demographics of study participants are listed in Table 1. The average age of participants was 42.3 ± 11 years, and 83% were men. Physical and social characteristics of study participants are listed in Table 2. Evaluated based on a mean systolic blood pressure of higher than 130 mm Hg or a mean diastolic blood pressure of higher than 80 mm Hg, 52% (87 out of 167) of homeless individuals had hypertension. Additionally, 33 (20%) individuals were in a prehypertension stage (SBP 120-129 and DBP <80 mm Hg). Surprisingly, only 7 individuals (4%) out of those were aware of their hypertension and currently taking antihypertensive medication. The prevalence of hypertension among individuals who reported to be homeless over one year was 73% (38 out of 52), which is significantly higher than individuals who were homeless for less than a year (51.3%) ( Figure 1A).

Effects of Diabetes, Smoking, Bmi And Age on Hypertension Prevalence
The prevalence of self-reported diabetic patients among the homeless population was 12% (20 out of 167), 70% (14 out of 20) of those patients were found to have hypertension ( Figure 1B).  Figure 1C). Individuals    Hypertension was significantly prevalent among individuals receiving no assistance (75.67%) compared to individuals receiving both financial and social assistance (47.61%). However, financial assistance had a major effect on lowering hypertension prevalence in comparison to social assistance, since it was 58.62% and 74.41%, respectively ( Figure 3).

Figure 3:
Prevalence of hypertension among homeless individuals receiving financial or social assistance.

Discussion
Several research studies have focused on elucidating the socioeconomic discrepancies in prevalence of risk factors leading to cardiovascular disease [11,12,13]. Nevertheless, a small attention has been paid to study those risks among the homeless population, which represents the most socioeconomic underprivileged community in the United States [14,15]. This study, which is one of the first to assess risk factors of hypertension among homeless individuals in Orlando metropolitan area, demonstrates high prevalence of major risks in this community. We should also bear in mind that financial and social assistance play a major role in decreasing the prevalence of hypertension in this population as our results indicate. Overall, Hypertension is prevalent among the Orlando homeless metropolitan community, which surpasses the national average. This observation might be attributed to high prevalence of main cardiovascular risk factors such as smoking and drug abuse among homeless individuals, in addition to hurdles to overcome those factors [16,17]. Furthermore, the diet of homeless individuals is usually high in saturated fats and insufficient in essential nutrients, which leads to abnormalities in their lipid panel [7,18]. The study shows that social and financial services seem to lower hypertension prevalence among homeless individuals receiving the benefits. The study supports data from other countries offering affordable and accessible health care services. Specifically, our study provides a trend like data reported in Canada where hypertension prevalence was found to be only 35% among homeless population in the city of Toronto [19].
Canada provides affordable and accessible health care services to all residents including homeless individuals. We strongly believe that the prevalence of hypertension is much higher in other major cities especially those with harsher climate conditions. We plan to do a larger scale study on homeless communities residing in other major metropolitan cities and during different times of the year.
Our study renews the call for more resources to help the homeless communities including development of more intervention programs to reduce smoking, and alcohol and substance abuse.

Significance for Public Health
Hypertension is found to be prevalent among Orlando homeless community and it has exceeded the national average in the United States. Additionally, social and financial aids seem to decrease the prevalence of hypertension among homeless individuals receiving these benefits. The outcome of the study supports data from other countries offering affordable and accessible health care services, and certainly, it renews the call for more resources to help the homeless communities.