Reflection

Bringing Health Equity to the World’s Largest Health Survey

MPH student Megan Jones reflects on her summer group practicum, in which she and students Juliana Blodgett, Jiayue Chen, Julia Kane, and Lindsey Stevens helped the Boston Public Health Commission conduct a survey to better understand the health of people experiencing homelessness.

This summer, a team of School of Public Health students assisted the Boston Public Health Commission (BPHC) with a novel, community-engaged research project called “Unhoused and Uncounted: The Health of Boston Survey of People Experiencing Homelessness.”

To capture the unhoused’s stories, the students traded classrooms for shelters. Recruitment for the survey, a collaboration of SPH and the BPHC’s Homeless Services Bureau (HSB), took place at the bureau’s Southampton Street Shelter for men, Woods Mullen Shelter for women, and the Engagement Center. The shelters are just a few minutes’ walk from the SPH campus, located a few blocks apart straddling the intersection of Massachusetts Avenue and Melnea Cass Boulevard.

Better known as “Mass and Cass,” the intersection is the epicenter of the city’s homelessness and substance use crises. Over the past two years, the COVID-19 pandemic has exacerbated both issues and led to a surge in the number of encampments in the area. To prepare, student interviewers were briefed in health survey administration, human subject research ethics, harm reduction, trauma-informed care, and overdose prevention. With each interview, they documented unhoused individual’s responses to questions on health topics ranging from chronic disease to adverse childhood experiences.

These one-on-one, face-to-face interviews were made possible with funding from the SPH Practice Innovation Award. The award focuses on the “do” of SPH’s mission to “Think. Teach. Do.” offering pilot funding for advocacy projects that, in the words of the award announcement, “strengthen the School’s commitment to effecting change to improve the conditions that promote health in local communities.” HOB SPEH secured the award and with it the funding to hire a team of practicum student survey administrators, including Jones, Juliana Blodgett, Jiayue Chen, Julia Kane, and Lindsey Stevens.

“This is the first time in the School’s history that a group practicum has been offered,” says Daniel Brooks, associate professor of epidemiology and one of HOB SPEH’s principal investigators.

Lack of safety, infections, and discrimination

After more than 300 hours of interviews over six weeks, the health challenges of homelessness were laid bare during the data gathering for the survey. When students asked, “How safe from crime do you consider your neighborhood to be?” time and again respondents would say, “Out there? Extremely unsafe.” Many of those interviewed endorsed getting inadequate, frequently-interrupted sleep—perhaps a reflection of the security of their built environment. One respondent reported as little as two hours on average, providing an explanation for why her student interviewer had to repeatedly shout her name and reread the questions after she dozed off. Students heard from more than one young person who wore dentures after losing all their teeth to infection. Although exposure to the elements was not addressed in the survey, a student noticed the shoulders of one female respondent were angrily blistering, severely sun-burned from long, hot days in the streets. A young man lamented to his interviewer that he is frequently discriminated against for looking homeless and one of his major frustrations is having to carry a duffle bag of all his belongings everywhere he goes; he believes it has prevented him from being seriously considered for jobs.

It is too early in the analysis to draw conclusions from the survey data, but observations made by the student interviewers are already having an effect. Students expressed surprise at the numerous respondents who reported no sources of income, not even food stamps, and were at times unable to afford to eat. In response, HSB prioritized the installation of computer kiosks in each of its shelters to allow guests to more quickly and easily navigate the process of applying for public assistance.

HSB sees over 3,000 guests each year and together its shelters offer over 600 beds every night. The bureau strives to provide more than shelter; it also offers job training, behavioral health, and transitional and permanent housing support services. In connection with BPHC’s Recovery Services Bureau, HSB runs the Engagement Center (EC), a low-threshold day center providing respite to those on the streets. At all its sites, HSB offers its guests access to healthcare through partnership with the Boston Healthcare for the Homeless Program (BHCHP).

In his book “Stories from the Shadows: Reflections of a Street Doctor,” BHCHP founder and physician Dr. James O’Connell writes, “Health care for the disenfranchised is predicated upon a one-to-one relationship made possible only by the investment of time and by a willingness to venture beyond office and exam rooms to unfamiliar turf.” At the end of one interview in the Health of Boston Survey of People Experiencing Homelessness (HOB SPEH), a student recalls the respondent disclosing to her that he had never told anyone some of the sensitive things the survey prompted him to share. The experience was evocative for him and he accepted the student’s offer to connect him with supportive services for these issues. 

HOB SPEH is unique in more ways than one. “[HOB SPEH] is a novel approach to surveying [the homeless] population,” says Dan Dooley, director of BPHC’s Population Health and Research Office (PHAR) and one of the project’s principal investigators. Dooley would know: he has 24 years of experience with the health survey HOB SPEH is based on, the Behavioral Risk Factor Surveillance System (BRFSS). With a sample size of over 400,000 adults from all fifty states, the District of Columbia, and two U.S. territories, the BRFSS is the largest health survey in the world. Since it was established nearly four decades ago by the Centers for Disease Control and Prevention (CDC), the BRFSS has emerged as the gold standard in behavioral surveillance and nearly two thirds of states use BRFSS data to support health-promoting legislation.

BPHC recognized the utility of the BRFSS and adopted a version of its own in 1999. The Boston BRFSS informs the biennial Health of Boston report, notably the “HOB” of HOB SPEH. Former Boston Mayor Marty Walsh wrote in a preface to the most recent report from 2016-2017, “[HOB] provides residents with critical information on a range of health topics that affect our city, creating opportunity to improve health outcomes for many of our most vulnerable residents.” However, given its reliance on an active landline or cell phone for survey administration, past Boston BRFSS samples likely lacked representation from people experiencing homelessness. HOB SPEH marks the first time in Boston’s 20+ year history of using the BRFSS that its most vulnerable residents were deliberately included.

Analyzing social determinants of health

While the BRFSS has its origins in the assessment of individual determinants of health, like healthy behaviors, the most recent analysis of the Boston BRFSS focused on the social determinants of health. The social determinants of health are commonly defined as the conditions of our environment, the spaces where we live, learn, work, play, and age, that influence our health. While healthy choices contribute to good health, having a choice in the first place is a privilege dictated by the larger societal forces in a person’s life. To acknowledge health inequities, BPHC stratifies behavior data by demographic characteristics and socioeconomic status (HOB 2016-2017). HOB SPEH’s 300-person sample size, an estimated 10% of the homeless population, was designed to provide sufficient statistical power for analysis of smaller groups based on demographic characteristics. 

The importance of this approach is highlighted in the story of the BRFSS survey question: “Do you live in subsidized housing?” When this question was added to the Boston BRFSS in 2001, it unearthed glaring health disparities. One in three people living in subsidized housing ranked their health as fair or poor, compared to less than 10 percent of other city residents. This was reflected in higher rates of hypertension, diabetes, obesity, and asthma. Notably, one in four adults served by the Boston Housing Authority (BHA) had asthma, compared to less than 10 percent of other residents. The same year, a partnership formed to further research to address these disparities and the Partners in Health and Housing Prevention Research Center (PHH-PRC) was founded among BHA, BPHC, Boston University School of Public Health (BUSPH), and the Community Committee for Health Promotion.

With funding from the CDC, PPHH-PRC partnered with the city’s Inspectional Services Division (ISD) to pilot the Breathe Easy at Home (BEAH) program beginning in 2005. BEAH enables physicians to write referrals for housing inspections in order to address the living conditions that might be contributing to their patients’ asthma. The program proved both proactive and cost-effective; BEAH later received the 2008 Model Practice award from the National Association of County and City Health Officials.

These cross-sector alliances continue to fruitfully address public health challenges at the intersection of health and housing. In 2012, BHA became the first housing authority in the country to go smoke free in an effort to both save money on cleaning costs and cut down second-hand smoke exposure. In 2017, recognizing that 25% of their admitted patients are unhoused and 30% of their pediatric patients come from housing-insecure families, Boston Medical Center (BMC) announced their commitment to invest $6.5 million over five years in community partnerships to support affordable housing initiatives.

Twelve years after PPHH-PRC published “Use of a Population-Based Survey to Describe the Health of Boston Public Housing Residents” documenting their use of the Boston BRFSS to highlight the health disparities experienced by public housing residents, Brooks and Dooley asked the question: What if the BRFSS could do for Boston’s homeless population what it did for public housing residents? The idea for HOB SPEH was formed.

Counting the uncounted

In response to the increase in the homeless population in the area, Interim Mayor Kim Janey declared the situation at Mass and Cass a public health crisis on October 19th, 2021 and over the first two months of her term, Mayor Michelle Wu spearheaded a public-health-led effort to “increase access to services while ensuring safe and healthy streets.”

Eviction notices were posted and by the deadline 154 people formerly living in tents were placed in low-threshold housing at six temporary sites funded in part by grants from the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act and recovery funds from the 2021 American Rescue Plan. On January 12th, all the remaining encampments were cleared and the streets cleaned.

The move attracted significant media attention and was met with a mixed response. In an article titled “A Broken Promise,” GBH news reported that only those individuals surveyed at a single point in time in December were placed in housing and an estimated 100 others were given the option to either stay in one of BPHC’s congregate shelters or remain out in the cold. WBUR coverage from the day featured Tim Gallagan who left the tent he occupied for seven months to live in a supportive housing program set up in the nearby Roundhouse hotel. He said, “It’s a huge positive step.” According to the City, it is the first step in a larger vision, a vision shared by HSB, to “make experiences of unsheltered homelessness rare, brief, and non-recurring.”

“Nothing is more meaningful than getting someone successfully housed. [Homelessness] is a traumatizing event,” HSB Director Gerry Thomas says. To house the most people, she says the bureau must be data-driven, center those with lived experience, and include them in the planning process, hence their initiative to start HOB SPEH. To count the uncounted.