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Rebecca S. Bernstein, MD, MS, Linda N. Meurer, MD, MPH, Ellen J. Plumb, MD, and Jeffrey L. Jackson, MD
SYSTEMATIC REVIEW
Diabetes
OR homeless*.mp] AND
[Diabetes mellitus OR diabetes mellitus.mp OR
Hypertension
Chronic disease
Health status
METHODS
This study adhered to Preferred
Reporting Items for Systematic
Reviews and Meta-Analyses
(PRISMA) recommendations for
reporting on systematic reviews.40
Search Strategy
We conducted a systematic
search of published articles with
Medline, PsychINFO, Cumulative
Index to Nursing and Allied
Health Literature, Cochrane, and
Science Citation Index. Search
terms varied slightly on the basis
of controlled vocabulary for all
databases except Science Citation
Index (which lacks a controlled
vocabulary). We chose the search
terms following a review of Medical Subject Heading terms used
in a variety of articles known to
meet inclusion criteria. As a representative example, the Medline
search strategy is shown in Table
1. (A complete list of search
strategies for all databases is provided in Table A, available as a
supplement to the online version of
this article at http://www.ajph.org.)
TABLE 2Adapted Quality Assessment Tool for Systematic Review of Hypertension and Diabetes Prevalence in Homeless Adults in the United
States, 19802014
Questions
Are the study methods valid?
Loney41Prevalence of Dementiaa
Are the study design and sampling method appropriate for the
research question?
Is the sampling frame appropriate?
Are objective, suitable, standard methods used for the measurement of the
health outcome?
Is the health outcome measured with the same method for all participants?
Is the response rate adequate? Are those who refused or were not included
described?
What is the interpretation
of the results?
What is the applicability of the results?
SYSTEMATIC REVIEW
FIGURE 1Systematic review search results and reasons for exclusions: diabetes and hypertension
prevalence in homeless adults in the United States, 19802014.
SYSTEMATIC REVIEW
Population (n = 53)
53 (100)
Prospective
41 (77.4)
Retrospective
Sample selection (n = 53)
TABLE 3Continued
17 (32.1)
Probability
13 (24.5)
Convenience
16 (30.2)
Not specified
7 (13.2)
48 (90.6)
Rural only
1 (1.9)
Both
3 (5.7)
Unclear
1 (1.9)
12 (22.6)
Census
Urban only
5 (9.4)
Older adults
7 (13.2)
Veterans
9 (17.0)
Chronically homeless
2 (3.8)
31 (58.5)
200399
400599
9 (17.0)
4 (7.6)
600799
1 (1.9)
800999
2 (3.8)
10001999
1 (1.9)
20002999
2 (3.8)
30003999
1 (1.9)
4000
2 (3.8)
22
Medical clinic
18
Meal program
11
11
Day shelter
Transitional housing
2
2
Mobile outreach
Hospital
13 (23.6)
19901999
20002010
13 (23.6)
24 (43.6)
2011
5 (9.1)
US region (n = 53)
Northeast
19 (35.9)
Midwest
9 (17.0)
South
9 (17.0)
West
10 (18.9)
6 (11.3)
Continued
Analysis
Study description and synthesis of
results. We used descriptive statistics to summarize the number
and percentage of studies with
various characteristics, including
types of study design, sample selection, sample recruitment locations, year of data collection, and
study region. We also described
sample characteristics, including
denition of homelessness used,
prevalence of chronic homelessness, sample age, race, gender,
employment status, veteran status,
and insurance status.
We calculated prevalence estimates for hypertension and diabetes by using a random effects
model with study-level prevalence
estimates, and we used the Wilson
method to calculate 95% condence intervals for those estimates.46 We used the same
methods to calculate prevalence
estimates for mental health diagnoses, substance use disorders,
and other medical conditions.
Risk of bias. We appraised study
quality with the adapted standardized tool. We averaged scores
from both reviewers to yield an
overall quality rating for each
study. We determined a cut-off
point for a binary division between lower- and higher-quality
scores by visual analysis of score
Los Angeles, CA
Los Angeles, CA
PA
San Diego, CA
Fort Worth, TX
200077
Cronley 201381
Lansing, MI
Craft-Rosenberg et al.
Kansas City, MO
New York, NY
Ferenchick 199265
Boston, MA
Drake 199232
Multiplenational
Burt 199979
Providence, RI
Women-only rural
Boston, MA
Dellon 199552
Richmond, VA
New York, NY
NA
NA
NA
Mental illness
NA
Women
NA
NA
NA
NA
Older adults
NA
NA
Boston, MA
Bowdler 198951
Brickner et al. 199264
Medicaid-insured
Women
Older adults, veterans
Los Angeles, CA
Special Population
Greensboro, NC
Location
McGuire 201376
Ballard 2009
61
transitional housing
Convenience, shelter
service agency
Convenience, homeless
agencies
Census, shelter
apartments
flophouses, slum
method, street,
Unspecified sampling
agency
homeless assistance
shelter
Clinic
Transitional shelter
Convenience, shelter
Sampling Method
Both
HTN
HTN
Both
Both
Both
Both
DM
Both
Both
HTN
Both
Both
HTN
HTN
Both
Both
Both
HTN or DM Prevalence
self-report
HTN: self-report or BP
Self-report
Unspecified physical
examination
Chart review
Chart review
Self-report
Self-report
Self-report
Self-report
Self-report
medicines
Measured BP 140/90 mm
Hg or antihypertensive
Self-report
Self-report
Hg
Chart review
Measured BP > 140/90 mm
Self-report
Self-report
Diagnostic Method
33.3
38.1
51.4
34.3
24.2
38
48.7
35.5
62
56
28.7
45.5
74
42
TABLE 4Sample and Study Characteristics of Included Studies on Diabetes and Hypertension Prevalence in Homeless Adults in the United States, 19802014
measured
Continued
531
363
94
181
96
102
97
31
281
252
2938
247
90
5436
6494
59
No. of Participants
New York, NY
MultipleMid-Atlantic
San Francisco, CA
Philadelphia, PA
Los Angeles, CA
Nashville, TN
Multiplenational
Honolulu, HI
New York, NY
Phoenix, AZ
New York, NY
Johnson City, TN
Chattanooga, TN
Urbana-Champaign, IL
MultiplePennsylvania
Providence, RI
Providence, RI
Birmingham, AL
Larson 200286
Notaro 201355
region
Los Angeles, CA
TABLE 4Continued
Veterans
NA
Veterans
NA
NA
NA
Men
NA
NA
homeless
Unsheltered, chronically
Micronesian
Chronically unsheltered
NA
NA
Americans
Men
NA
NA
NA
NA
Veterans
NA
programs, street
Medical clinic
Probability, shelters, meal
Census, shelter
medical clinic
transitional housing,
Street
houses, street
Unspecified sampling
method, shelter
Probability, homeless
homeless services
Probability, shelter
Census, homeless veteran
programs
Convenience, VA homeless
Both
HTN
Both
HTN
DM
Both
Both
Both
Both
DM
Both
Both
Both
Both
Both
Both
Both
Both
DM
HTN
Both
provider diagnosis
Self-report
provider diagnosis
Self-report
further specified
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
Self-report
BP 140/90 mm Hg
report, medicines, or
Self-report
Self-report
Self-report
Self-report
Self-report
self-report
agencies
HTN: self-report or BP
160/90 mm Hg; DM:
Both
51.2
33.4
51.8
43.2
41
52.5
47
46.2
37.4
53
42.4
41.1
42.1
35.5
46
34
941
1716
2335
3595
112
127
100
177
194
122
95
100
Continued
55 DM; 96 HTN
260
47
1093
618
145
53
measured
128
Notes. BP = blood pressure; DM = diabetes mellitus; HTN = hypertension; ICD-9 = International Classification of Diseases, Ninth Revision; NA = not applicable; SRO = single-room occupancy; VA = Veterans Affairs.
a
n = 226 for reported DM and 168 for reported HTN, but n = 286 for measured DM and 287 for measured HTN.
outreach van
78
46
41
Self-report
Self-report
DM
Both
Convenience, mobile
Convenience, shelter
NA
NA
San Francisco, CA
Atlanta, GA
Wiersma et al. 201059
123
49.7
Self-report, chart review,
best available
Both
clinic, meal program
Census, multiservice
housing first program
Mental illness,
Chronically homeless
Philadelphia, PA
Weinstein et al. 201358
Detroit, MI
Washington 200575
African Americans
60
100
52.6
43.4
Chart review, any source
Self-report
Both
Both
Transitional shelter
Boston, MA
Viron et al. 201497
Mental illness
Convenience, shelter,
37.9
Self-report
Both
New York, NY
201278
Women
room
Probability, shelter
Vijayaraghavan et al.
329
64 091
DM
Medical clinic, emergency
Veterans
National
Tsai et al. 201396
method
Multiplenational
Tsai et al. 201395
NA
Unspecified sampling
Both
Self-report
45.5
51.8
725
351
method, shelter
shelter
Unspecified sampling
Newly homeless
New York, NY
Schanzer et al. 200771
Cincinnati, OH
St Paul, MN
Savage et al. 200657
Schaffer et al. 200094
NA
NA
Both
HTN
Both
Self-report
Self-report
Self-report
43
37
31.5
Self-report
Both
program, inpatient psych,
NA
36.9
110
101
413
269
37.45
Self-report
Both
programs, street
TABLE 4Continued
SYSTEMATIC REVIEW
5 (9.4)
20%39.9%
1 (1.9)
40%59.9%
60%79.9%
6 (11.3)
22 (41.5)
80%100%
19 (35.9)
Age, yb (n = 45)
43.3 69.0
Age, yc (n = 39)
41.1 66.7
22 (41.5)
31 (58.5)
0.44 60.26
White (n = 44)
0.40 60.23
0.47 60.24
Other (n = 36)
0.20 60.22
Employed (n = 21)
0.20 60.14
Veterans (n = 18)
0.49 60.34
0.58 60.28
RESULTS
We identied a total of 1837
unduplicated articles with our
Description of Studies
Included
The 53 included studies had
considerable heterogeneity in
their individual study aims. Many
described the health status of a local
homeless population,14,21,51---60
whereas others examined health
behaviors or health risks.61---63
Although the search strategy
targeted studies that included the
prevalence of hypertension or
diabetes, some studies had broad
Participant Characteristics
Participant characteristics are
detailed in Table 5. The average
age was 43.3 years (SD = 9.0), and
69% of the sample was male.
However, 6 studies were predominantly female. Forty percent
of study participants were White,
and 47% were African American.
SYSTEMATIC REVIEW
were high, and nearly three quarters of the homeless smoked. Rates
of mental health diagnoses and
drug and alcohol abuse were also
high. Studies were too variable in
their individual denitions of
overall mental illness or substance
abuse to present prevalence that
was not diagnosis-specic.
50
40
30
Risk of Bias
20
1980
1990
2000
2010
2020
Year
95% CI
Fitted values
Age
Note. CI = confidence interval. Studies of older adults were excluded. For trend, P < .001.
FIGURE 2Trends in homeless adult mean sample age for included studies: United States, 19802014.
a combined sample of 284 participants; again, we found no signicant difference in diabetes
TABLE 6Behavioral Health and Medical Disease Prevalence in Homeless Adults in the United States, 19802014
Diagnosisa
Hypertension
I 2, %
Q (df)
869.35 (42)
95.2
Diabetes
84.5
245.93 (38)
Asthma
COPD
80.5
99.3
112.70 (22)
2452.57 (18)
Cirrhosis
97.9
188.83 (4)
Cancer
96.1
407.56 (16)
CVA
92.8
179.83 (13)
56.0
15.92 (7)
Dental disease
99.5
2648.66 (12)
Hepatitis
96.6
353.96 (12)
HIV
Hyperlipidemia
95.3
90.6
360.41 (17)
64.16 (6)
Depression
99.3
2579.47 (19)
Anxiety
99.0
815.31 (8)
PTSD
99.7
2019.12 (7)
Bipolar disorder
99.0
776.69 (8)
Schizophrenia
98.1
527.04 (10)
Substance abuse
Alcohol abuse
Drug abuse
99.1
99.4
2859.60 (25)
3024.27 (18)
96.5
395.84 (14)
Notes. CI = confidence interval; COPD = chronic obstructive pulmonary disease; CVA = cerebrovascular accident (stroke); df = degrees of
freedom; PTSD = posttraumatic stress disorder.
a
All diagnoses by self-report.
Heterogeneity Analyses
We observed a high degree of
heterogeneity in the pooled prevalence rates of diabetes and
hypertension. The impacts of
study-level characteristics are
shown in Table 8. We found mean
sample age and year of study to
be signicantly associated with
increasing prevalence of both diabetes and hypertension, and together to account for 18.5% of the
variation in diabetes prevalence
and 47% of the variation in hypertension prevalence. In addition,
having health insurance was associated with increased prevalence
of diabetes (P < .001); however,
SYSTEMATIC REVIEW
15
Frequency
insurance status was not signicantly associated with hypertension prevalence (P = .12).
We did not nd prevalence of
alcohol abuse (P = .47 and P = .65
for diabetes and hypertension,
respectively) and tobacco use
(P = .63 and P = .58, respectively)
to be signicantly associated with
change in prevalence of either
disease, nor were gender (P = .51
and P = .51, respectively) or
African American race (P = .53
and P = .92, respectively). Proportion of the sample with depression
was signicantly associated with
increased prevalence of diabetes
(P = .02) but not signicantly
associated with hypertension
prevalence (P = .42). There was
a marginally signicant association
between anxiety and increased
prevalence of hypertension
(P = .05), but it was not associated
with diabetes prevalence (P = .42).
Bipolar disorder (P = .84 and
P = .91 for diabetes and hypertension, respectively) and schizophrenia rates (P = .97 and P = .87,
respectively) did not signicantly
change the prevalence of either
disease.
10
0
0
DISCUSSION
Among homeless American
adults, approximately 27% have
hypertension and 8% have diabetes
mellitus. Our sample included an
overrepresentation of men and
African Americans, mirroring the
general homeless population in the
United States.30 There is evidence
that the prevalence of both diseases
Coefficient (SE)
Diabetes
Probability sample
-0.038 (0.019)
.054
Sampling frame
-0.042 (0.019)
.033*
Sample size
-0.034 (0.023)
.152
Diagnostic methods
0.023 (0.041)
.573
Consistent methods
Response rate
-0.019 (0.045)
-0.003 (0.029)
.679
.908
Statistical methods
-0.048 (0.028)
.096
Subgroups
-0.020 (0.023)
.407
Applicability
-0.053 (0.020)
.011*
Probability sample
-0.116 (0.046)
.015*
Sampling frame
-0.055 (0.049)
.273
Sample size
Diagnostic methods
-0.040 (0.066)
0.049 (0.099)
.545
.619
Consistent methods
0.150 (0.081)
.072
Response rate
-0.100 (0.061)
.106
Statistical methods
0.029 (0.065)
.658
Hypertension
Subgroups
-0.016 (0.055)
.770
Applicability
-0.097 (0.051)
.062
*P < .05.
SYSTEMATIC REVIEW
Hypertension (Reported)
Coefficient (SE)
Coefficient (SE)
0.046 (0.035)
.193
-0.059 (0.061)
.34
Midwest
0.002 (0.040)
.958
-0.063 (0.069)
.372
South
0.012 (0.031)
.694
0.016 (0.077)
.835
West Coast
-0.014 (0.026)
.592
-0.004 (0.063)
.955
National
0.007 (0.040)
.84
-0.004 (0.080)
.957
0.010 (0.028)
.732
0.044 (0.062)
.48
Probability
-0.027 (0.026)
.321
0.010 (0.061)
.877
Unspecified
-0.010 (0.034)
.748
0.084 (0.081)
.307
0.005 (0.001)
<.001
0.011 (0.002)
<.001
Year of publicationa
0.002 (0.000)
<.001
0.004 (0.001)
.016
0.001 (0.001)
.382
0.002 (0.002)
.511
Male, % of sample
-0.024 (0.036)
.507
0.055 (0.083)
.511
Race/ethnicity, % of sample
African American
-0.035 (0.055)
.533
0.012 (0.126)
.924
White
-0.079 (0.056)
.171
-0.099 (0.120)
.419
Other
0.154 (0.061)
.018
0.037 (0.133)
.782
0.125 (0.029)
<.001
0.244 (0.149)
.12
0.076 (0.035)
.068
0.172 (0.182)
.365
Prevalence of depression
0.215 (0.079)
.018
0.195 (0.234)
.422
-0.112 (0.152)
.471
0.099 (0.211)
.645
-0.116 (0.070)
0.097 (0.198)
.119
.633
0.032 (0.202)
0.147 (0.255)
.877
.576
SYSTEMATIC REVIEW
Prevalence of Diabetes
0.15
0.1
0.05
0
1980
1990
2000
2010
2020
Year
Homeless, 95% CI
FIGURE 4Prevalence of self-reported diabetes in homeless and nonhomeless adults in the United
States: 19802014.
Prevalence of Hypertension
1990
2010
0.4
0.3
0.2
0.1
0
1980
2000
2020
Year
Homeless, 95% CI
FIGURE 5Prevalence of self-reported hypertension in homeless and nonhomeless adults in the United
States: 19802014.
SYSTEMATIC REVIEW
1830
3150
4.4
73.3
30.4
45.3
5161
17.8
20.2
4.4
4.1
Age, Years
62
a
Limitations
Participants in the meta-analysis
sample may be somewhat older
than the general homeless population, as captured in the 2012
Annual Homeless Assessment Report (Table 9). This difference lies
in the relative proportions of
adults aged 30 years and younger
versus those aged between 31 and
50 years in the meta-analysis
sample. As such, it is not affected by
the inclusion of 5 studies targeting
older adults. The proportion of
the homeless population aged 51
years and older in the meta-analysis
sample is actually slightly lower
than in the general population.
It is possible that the 16 clinicbased studies included skewed
the sample toward middle-aged
adults, who are more likely to have
medical conditions that cause them
to seek care. This may result in
higher pooled prevalence rates of
Conclusions
In this systematic review and
meta-analysis of the prevalence of
hypertension and diabetes in
homeless adults, we found that
both conditions have had increasing prevalence over the past 30
years. These differences are, to
a large extent, attributable to the
aging of the homeless population.
This study builds upon the existing
literature regarding this aging trend
by drawing from a broad sample
and directly linking aging trends to
chronic disease rates. With heterogeneity analyses, we identied
several other factors that contribute to variations in estimated
diabetes prevalence, including insurance status and depression.
Although the homeless population today has signicant unmet
health needs, which contribute to
devastatingly premature morbidity
Contributors
R. S. Bernstein originated and designed the
study, led data collection, performed data
analyses, and led the writing. L. N. Meurer
supervised the study, contributed to study
design, assisted in data collection, and
assisted with writing and revising. E. J.
Plumb assisted with data collection
and revised the article. J. L. Jackson
supervised the study, contributed to
study design, assisted in data collection,
supervised and assisted in analysis, and
assisted in writing and revising.
Acknowledgments
This project was supported by an Institutional National Research Service Award
SYSTEMATIC REVIEW
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