Understanding Health Concerns and Barriers to Accessing Care Among Underserved Populations

Findings from HOP’s 2012-13 National Needs Assessment

‘Underserved populations’ is a broad term that is used to describe groups of people that face social, economic, and cultural barriers to accessing health care and social services. Community health centers (CHCs) provide care to underserved populations, but also receive additional funding to serve special populations.  The Health Resource and Services Administration (HRSA) designates special populations as migrant and seasonal farmworkers, people experiencing homelessness, public housing residents, and Native Hawaiians. In 2012, according to the Uniform Data Systems (UDS), CHCs served:

• 909,089 migrant and seasonal farmworkers,
• 1,121,037 individuals experiencing homelessness,
• 219,220 public housing residents,
• And more than 6,600 Native Hawaiians. [i]

As findings from Health Outreach Partners’ 2013 National Needs Assessment showed, the CHCs surveyed receive specific funding to serve farmworkers, but often end up also providing outreach services to other specific underserved populations. While there are some similarities in demographics, common health concerns, and barriers to accessing health care services, it is important to keep in mind that each population is unique. This article explores the health concerns and challenges faced among three underserved populations, and the role that outreach plays in removing barriers to accessing care.

People Experiencing Homelessness

Homelessness occurs when people or households are unable to acquire or maintain affordable, stable housing.[ii]  Further, a homeless individual is defined as a person who lacks permanent housing, and who may stay on the streets, in shelters, transitional housing, abandoned buildings, vehicles or any non-permanent or unstable housing situation.[iii]  The contributing factors to homelessness can include many social and economic issues, but in the end, research shows that the inability to find affordable housing is the primary cause of homelessness.[iv]

According to the 2012 U.S. Department of Housing and Urban Development (HUD) point-in-time count of homelessness, there are 633,782 people experiencing homelessness on any given night in the United States.[v]  Those experiencing homelessness are comprised of a variety of individuals and families from different backgrounds and situations.  However, those who are at a higher risk of experiencing homelessness include: 1) veterans; 2) those that are “doubled up”[vi]; 3) those that have been formerly incarcerated; 4) youth who age out of foster care; and 5) the uninsured.

Poor health can be both the cause and result of homelessness. People experiencing homelessness are three to six times more likely to become ill than housed people.[vii]  For CHC’s serving people experiencing homelessness, the top five diagnoses in 2011 were the following: 1) hypertension; 2) depression and other mood disorders; 3) diabetes; 4) other mental disorders (excludes drugs and alcohol dependence); and 5) asthma.  The average life expectancy in the homeless population is estimated between 42 and 52 years, compared to 78 years in the general population.

People experiencing homelessness are extremely vulnerable to poor health. Many people experiencing homelessness use emergency rooms as their primary source of health care.  However, this type of care is problematic for the following reasons: 1) it usually indicates that symptoms have reached severe stages; 2) there is little opportunity to promote preventative measures; and 3) it is costly for hospitals and the government. Providing a continuum of care is a challenge for people experiencing homelessness due to the instability of their lives and their vulnerability to social and environmental hazards.

Migrant and Seasonal Farmworkers

More than 3 million farmworkers are estimated to be in the United States.[viii]  Migrant and seasonal farmworkers are defined as individuals who engage in farm work which includes all of the processes involved in growing and packaging any commodities grown in the land. Farmworkers are classified in two ways: migrant and seasonal.  Migrant farmworkers seek annual employment and follow the harvest season from region to region. Seasonal farmworkers remain in one location for work and are often employed for a few seasons out of the year (or their responsibilities change throughout the year).

Given that agricultural work is one of the top hazardous occupations in the United States, migrant and seasonal farmworkers are at a higher risk for poor health than the general population. Further, long work days, unsafe working conditions, and low pay are contributing factors to the health problems of farmworkers.  Farmworkers work an average of 42 hours per week, with twenty-five percent (25%) working between 41 and 49 hours, and twenty-five percent (25%) working 50 hours or more.[ix]  For migrant health centers, the top five diagnoses in 2011 were the following: 1) hypertension; 2) diabetes; 3) otitis media and Eustachian tube disorder (ear-related); 4) overweight and obesity; and 5) asthma.  The average life expectancy of the farmworker population is estimated at 49 years[x], compared to 78 years in the general population.

Most farmworkers do not have access to affordable health care services much less health insurance. Only eight percent (8%) of migrant farmworkers reported having employer-based health insurance and five percent (5%) for seasonal farmworkers.[xi]  An estimated 15 to 20 percent of farmworkers use the services at migrant and community health centers.[xii] Thus, farmworkers may put off seeking care until their symptoms have reached a severe level and end up in the emergency room to address their health problems.  Again, the use of emergency rooms has its limitations as continuity of care and follow-up is extremely difficult and it is costly to the patient, hospital, and government.

Public Housing Residents

Public housing is the U.S. government’s program to assist low-income individuals and families, seniors and people with disabilities find and secure affordable housing.  Two types of government programs that offer housing assistance are public housing and housing vouchers (Section 8).  Public housing is government-based housing, where rent is based on a percentage of income developed by HUD.  Section 8 is private housing, where the individual pays rent with 30% of their income, and the voucher pays the remainder from the government.  As of December 31, 2012, there were over 2 million residents living in public housing, and another 4.6 million residents living in Section 8 Housing.[xiii] Approximately 46% of public housing residents remain for more than five years.

Research shows that public housing residents have the worst health of any population in the United States.[xiv]  The contributing factors that put public housing residents at the highest risk for poor health are connected to a variety of social and economic circumstances.  The average household income is $13,650, and 68% are classified under HUD’s “extremely low income” category with an income 30% below the national median.  Further, public housing is mostly located in heavily impoverished areas, where access to health and social services is limited.

HRSA’s Public Housing Primary Care (PHPC) Program provides primary care services to public housing residents through health centers that are located on the premises of public housing, or at locations immediately accessible to residents.  According to UDS 2011, top five diagnoses for public housing residents accessing public housing primary health centers are the following: 1) hypertension, 2) diabetes, 3) depression and other mood disorders, 4) asthma, and 5) other mental disorders (excluding drugs and alcohol dependence).

Barriers to Accessing Health Services Among Underserved Populations

In the 2012-13 National Needs Assessment, online survey respondents were asked about barriers to accessing care faced by all underserved populations served by their outreach programs. The cost of health services (57%) ranked first, followed by lack the lack of transportation (52%), lack of knowledge about available services (47%), and lack of insurance (44%).

Underserved populations face challenges accessing health and social services.  Evidence shows that underserved populations are at a high risk for poor health and show significantly worse health outcomes compared to the general population.  Outreach programs at CHC’s play a crucial role in providing access to health care services, yet not all outreach approaches are effective for each population.

Outreach Strategies to Reduce Barriers

As part of HOP’s 2012-13 National Needs Assessment, telephone interviews were conducted with experts in the field of outreach, in which they were asked to identify outreach strategies that are most effective for the specific communities they serve.  The following strategies emerged from the interviews:

• Hiring outreach workers from the community: Outreach workers that speak the same language and come from a similar cultural background can help build trust among patients and community members. One respondent who worked with public housing residents emphasized that the most effective way to connect with patients is to recruit current or former residents to be outreach workers.  
• Taking time to build trust:  Respondents acknowledged that trusting relationships are important in order to work effectively with individuals, families, and communities. One respondent who works with people experiencing homelessness emphasized that working to build trust takes time and patience.  One way to build strong and trusting relationships is to maintain a consistent, visible presence within the community. 
• Providing health services outside the health center: For many of the respondents, outreach provides the opportunity to conduct basic screenings and promote health education, and ultimately bring patients into the health center to access services.  Yet for others, health care services are delivered in the outreach setting rather than trying to bring the patients into the health center.  Mobile units were cited as a way to effectively reach mobile populations, such as people experiencing homelessness and farmworkers.
• Forming partnerships: A common theme that emerged from the respondents’ interviews is that outreach is most effective when organizations collaborate.  Many respondents cited the importance of both internal and external partnerships in expanding the scope of outreach.  In one example, a respondent who works with farmworkers and immigrants spoke about a partnership between the CHC and the Mexican government to promote health education.

Given the different characteristics and needs of underserved populations, there is no perfect way to conduct outreach and “one size does not fit all” in determining outreach strategies.  The most effective outreach strategies are those that take into account the social and economic conditions that people live in as well as understanding their cultural context.

Additional Resources (updated on January 22, 2016):

• National Outreach Guidelines: In 2012, HOP collaborated with four national partner organizations and an Advisory Panel to develop the current National Outreach Guidelines for Underserved Populations.  Learn more about the guidelines: https://outreach-partners.org/2012/05/29/national-outreach-guidelines/

• Other National Cooperative Agreements with information on underserved populations:
  • Agricultural Workers
    • Farmworker Justice
    • Health Outreach Partners
    • MHP Salud
    • Migrant Clinicians Network
    • National Association of Community Health Centers
    • National Center for Farmworker Health
  • Individuals and Families Experiencing Homelessness
    • National Healthcare for the Homeless Council
  • Asian American, Native Hawaiians, and Other Pacific Islanders
    • Association of Asian Pacific Community Health Organizations
  • Residents of Public Housing
    • Community Health Partners for Sustainability
    • National Center for Health in Public Housing
  • Lesbian, Gay, Bisexual, Transgender (LGBT) 
    • National LGBT Health Education Center