AbCDC views population health as an interdisciplinary customizable approach that allows health

AbCDC views population health as an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes non-traditional partnerships among different sectors of the community – public health, industry, academia, health care, local government entities, etc. – to achieve positive health outcomes (cdc.gov). The Institute for Healthcare Improvement (IHI) embraced the Triple Aim of improving population health, improving patient experience and reducing the cost of care (Stiefel & Nolan, 2012). The purpose of this paper is to analyze disparities in health care for homeless population with cardiovascular disease (CVD). This paper mainly focuses on literature review and research on homeless population with cardiovascular disease. Margaret Whitehead’s proposed conceptual model of health equity and disparities was utilized as theoretical basis. In addition, nursing theory by Leininger was incorporated to include holistic and cultural approach to the selected problem. The data was analyzed to identify disparities, morbidity, mortality, health outcomes, disease prevention approaches, any risk factors the homeless population is facing as well as healthcare delivery and availability of healthcare. Per Center of Disease Control (CDC), CVD is a leading cause of death among homeless adults, way more prevailing than the same disease in nonhomeless people (Bragget et al., 2018). A number of complex factors contribute to this disparity. Per Bragget et al.’s (2018), in addition to expected risk factors such as smoking and uncontrolled comorbidities (ex., hypertension and diabetes), there are nontraditional risk factors of psychosocial nature that are contributing to CVD among homeless adults. They include chronic stress, depression, and substance abuse. The research conducted by Baggett et al. (2018) also points out to lack of health care access and challenges in cardiac diagnosis and testing that lead to delay in treatment. Keywords: homeless, cardiovascular disease, population health, health disparitiesPopulation Health: Disparity and Health Inequality of the Homeless Population with Cardiovascular DiseaseNumerous studies have been conducted on homeless population and their risk of developing CVD. In the United States, about 550,000 people are homeless on a given night (Henry et al., 2016), and an estimated 2.3 to 3.5 million people experience homelessness over the course of a year (Burt et al., 2012). In the United States, the homeless population is growing older, with a median age around 50 years. In addition, men, African-American, gender and sexual minorities are over-represented in homeless population (Davidson, 2014). Culhane et al. (2013) points out to multiple factors contributing to homelessness, such as poverty, incarceration, high housing cost, in addition to personal factors such as mental and behavioral issues, substance use disorders, and disability. Baggett et al. (2018) sited that homeless population is really diverse, but they all share common vulnerability of not having their own place to stay that is safe and reliable. Baggett et al. (2018) presented data specific to homelessness and cardiovascular mortality. According to their study, factors contributing to disparities in CVD mortality in homeless populations include “late presentation to care, fragmentation of care, competing psychosocial priorities, and a high burden of traditional and nontraditional CVD risk factors” (Baggett et al., 2018, p.14). As a result, these issues play major role in numerous difficulties in management of CVD in this vulnerable population. Theoretic/Model Foundation In Yamada et al.’s (2015) summary article reviewing population health and national surveillance of health disparities, they stated that it is important to properly select and identify the population group for the study to build a framework for national surveillance of health disparities. To identify and understand these disparities, a surveillance system must be able to provide data to analyze disparities in “incidence and prevalence, morbidity and mortality, functional health outcomes, primary and secondary prevention approaches, risk factors, and healthcare delivery” (Yamada et al., 2015, p.12). According to the Transcultural Nursing theory, nurses have a responsibility to understand the role of culture in the health of the patient. Leininger identified nursing decisions and actions that achieve culturally friendly care for the patient. This nursing theory would best support the population health problem for homeless people with CVD as they represent the common homelessness culture and each individual share their own unique culture that must be taken into consideration when approaching managing CVD in this population. Per Leininger’s theory, the nurse’s diagnosis of the patient should include any problems that may come up that involve the healthcare environment and the patient’s cultural background. In further support of the theory application to the project, Leininger emphasized that the nurse’s care plan should involve aspects of the patient’s cultural background. This is especially important since patient’s culture can greatly affect their health, as well as their reactions to treatments and care (McFarland & Wehbe-Alamah, 2018)Another applicable theory that was used in the study was Margaret Whitehead’s proposed conceptual model of health equity and disparities that offers a framework for examining the determinants of health disparities and provides a useful perspective to guide the development of a framework for CVD surveillance (Yamada et al., 2015). Whitehead’s seven determinants of health disparities are: “(1) natural biological variation; (2) health-damaging behavior that is freely chosen; (3) the transient health advantage of one group over another when one group is first to adopt health-promoting behavior (as long as other groups have the means to catch up fairly soon); (4) health-damaging behavior in which the degree of choice of lifestyles is severely restricted; (5) exposure to unhealthy, stressful living and working conditions; (6) inadequate access to essential healthcare services and other basic services; and (7) natural selection or health-related social mobility involving the tendency for sick people to move down the social scale” (cited by Yamada et al., 2015). All of these identified disparities are applicable to the population studied in this paper. Description of the Problem ProjectCardiovascular disease (CVD) is a major cause of death among homeless people and a contributor to excess mortality in this population. The increase in comorbidities and adverse social circumstances seen frequently among homeless people makes the management of CVD in this population very challenging. As Yamada et al. (2015) suggested this would necessitate a flexible, creative, and multidisciplinary approach. This paper analysis an integrated framework for understanding the basis of CVD disparities in homeless people and offers practical management suggestions tailored to the needs of this population, with emphasis on coronary artery disease prevention, diagnosis, and treatment. (Yamada et al., 2015)It was found by Stiefel and Nolan (2012) that key measurement principles that apply to the Triple Aim is the need for a defined population which in this papers it is homeless population with CVD. Critical Appraisal of the EvidenceRisk Factor BurdenThe researchers found that homeless populations may be more likely to have an adverse profile of both traditional and nontraditional CVD risk factors. These risks can be considered under the categories of demographic, medical, substance use, psychiatric, and social factors (Baggett et al., 2018). In 2018, Baggett et al., stated that African-American and elderly experience higher CVD mortality rate. The prevalence of hypertension among homeless people is similar to that among nonhomeless people ( Bernstein et al., 2015). However, hypertension among homeless individuals often goes undiagnosed or untreated, contributing to poorer blood pressure control than that seen in the general population. Similarly, although the prevalence of diabetes among homeless individuals is comparable to that in the general population ( Bernstein et al., 2015), multiple barriers to effective glycemic management in the setting of homelessness result in generally worse disease control and greater complications. Several studies have suggested that overweight and obesity prevalence similar to that in the general population ( Baggett et al., 2018). In addition, limited access to exercise facilities and constrained dietary options that are frequently lacking in nutritional quality present considerable challenges to weight reduction efforts and may independently contribute to CVD risk ( Baggett et al., 2018). Studies of lipid profiles among homeless individuals have yielded mixed findings around the prevalence of hypercholesterolemia ( Bernstein et al., 2015). Although total cholesterol and triglyceride levels may be lower in some settings ( Bernstein et al., 2015), potentially reflecting inadequate diet, high-density lipoprotein levels may also be lower in this population ( Bernstein et al., 2015). Among those who qualify for lipid-lowering medications, few appear to be receiving them ( Bernstein et al., 2015). Finally, depending on the subpopulation sampled, an estimated 1.5% to 10.5% of homeless individuals are infected with human immunodeficiency virus ( Noska, 2017), and this may contribute to elevated CVD risk through a variety of mechanisms.The prevalence of cigarette smoking among homeless people is 68% to 80% ( Bernstein et al., 2015). An estimated 60% of ischemic heart disease deaths among homeless people are tobacco-attributable ( Bernstein et al., 2015), making smoking the single largest contributor to CVD mortality in homeless populations. Although light to moderate alcohol use may be protective against CVD, heavier drinking has been associated with multiple adverse cardiovascular outcomes, such as cardiomyopathy and congestive heart failure (CHF) ( Bernstein et al., 2015) and is seen more commonly in homeless populations. About one-quarter of homeless adults have a recent history of cocaine use ( Baggett et al., 2018), which has been linked to accelerated atherosclerosis, myocardial ischemia and infarction, and other cardiac complications such as aortic dissection and sudden cardiac death that may be related to dramatic drug-induced fluctuations in blood pressure ( Bernstein et al., 2015). In addition to the pharmacological effects of specific drugs, the use of any drug by injection—a practice more common among homeless individuals ( Baggett et al., 2018) and especially prevalent during the current opioid crisis that has disproportionately affected this population—increases the risk of infective endocarditis and associated valvular complications ( Baggett et al., 2018).Rates of depression, anxiety, and nonspecific psychological distress are high in homeless populations, and these psychiatric conditions may contribute to CVD ( Goodwin et al., 2009). Post-traumatic stress disorder, estimated to affect some 21% to 39% of homeless people ( Goodwin et al., 2009), has also been associated with higher risk for CVD. As many as one-fourth of homeless people have chronic serious mental illnesses such as schizophrenia, bipolar disorder, or severe depression, and these disorders may complicate the presentation and diagnosis of CVD by interfering with individuals’ reporting of symptoms, ability or motivation to seek care, and executive capacity for completing diagnostic testing. In addition, individuals with mental illness have generally high rates of smoking, and many psychotropic medications cause or exacerbate cardiometabolic risk factors for CVD, such as obesity, dyslipidemia, and diabetes ( Goodwin et al., 2009). These considerations have led to the development of a CVD risk prediction model specific to people with serious mental illness, although its applicability to homeless individuals without major psychiatric illness is uncertain. No comparable homeless-specific risk prediction models exist. ( Goodwin et al., 2009)A variety of social and environmental stressors commonly experienced by homeless people have been linked to a higher risk for CVD. They have difficulty meeting needs for shelter, food, clothing, and other basic necessities. In a study of 25 homeless men, those with high levels of life stress had a lower density of lymphocyte beta-adrenergic receptors ( Dimsdale et al., 1994), introducing a physiological pathway through which the stressful life circumstance of homelessness might impact cardiovascular functioning. Adding to these stressful life circumstances, poor diet and suboptimal sleep duration and quality are intrinsic to the experience of homelessness and may also contribute to CVD risk ( Dimsdale et al., 1994).

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