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Patients experiencing homelessness represent a disproportionate share of emergency department (ED) visits due to poor access to primary care and high levels of unmet health care needs. This is in part due to the difficulty of communicating and following up with patients who are experiencing homelessness.
To determine the prevalence and types of “new media” use among ED patients who experience homelessness.
This was a cross-sectional observational study with sequential enrolling of patients from three emergency departments 24/7 for 6 weeks. In total, 5788 ED patients were enrolled, of whom 249 experienced homelessness. Analyses included descriptive statistics, and unadjusted and adjusted odds ratios.
70.7% (176/249) of patients experiencing homelessness own cell phones compared to 85.90% (4758/5539) of patients in stable housing (
This study is unique in its characterization of new media ownership and use among ED patients experiencing homelessness. New media is a powerful tool to connect patients experiencing homelessness to health care.
Patients who are homeless experience high levels of unmet health needs [
New media refers to on-demand access to content anytime, anywhere, using a digital device that includes interactive user feedback, creative participation, and community formation around the media content [
Connectivity, identified by mHealth researchers, is crucial between patients, providers, and the system of care [
We must address issues of homelessness because they constitute a particularly vulnerable population of patients [
The realization that new media might serve a powerful function in the care and well-being of patients who are homeless has been described more recently in a handful of studies [
This study was an observational cross-sectional survey that continuously enrolled sequential patients in three EDs 24 hours per day, 7 days per week for 6 weeks (July-August 2012).
Patients were enrolled from three urban, high-volume EDs (Connecticut, USA) at Yale-New Haven Hospital (n=1922), Bridgeport Hospital (n=1900), and Hospital of St. Raphael (n=1966) for a total of 5788 patients.
Patients were excluded if they were under 18 years of age; presented as a trauma activation; presented with alcohol or other substance intoxication; spoke a language other than English or Spanish; presented with active psychosis, suicidal, or homicidal ideation; were in police custody, unable to consent due to life-threatening events or cognitive impairment; were in isolation for infectious concerns until cleared by provider; or were unable/unwilling to consent (
Patient flow diagram.
Our analysis included descriptive statistics, bivariate data analysis, and unadjusted and adjusted odds ratios.
Patients were asked a series of questions on homelessness: (1) how many nights they spent in their own home during the last week, (2) how many nights they spent at somebody else’s house, in a motel, in a half-way house, in transitional housing, in an institution, in jail, in shelter, and outdoors, and (3) where else they stayed in the past week (to rule out vacations or family and friend visits that were recreational vs shelter seeking). After reviewing the different potential options, we asked also patients to (4) estimate the number of times they had been homeless in the past year. We used a broad definition of homelessness, which included patients living “doubled up” with family or friends, or in some other transitional living arrangement such as staying in a motel, at their place of work, in a church, or a car in addition to including patients who were living in shelters or on the streets or other public places not meant for nighttime residence. This definition is consistent with that used by the US Health Resources and Services Administration (HRSA) in providing guidance to Health Care for the Homeless centers [
Patients were also asked (5) if they owned a cell phone, (6) what their cell phone was used for, including phone calls, text messaging, emailing, surfing the Internet, watching videos, listening to music, playing games, applications, and other, (7) what type of phone, provider, phone plan they had, and (8) frequency of use. Patients were asked about new media behaviors such as (9) seeking health information, and (10) tracking and managing health through a personal health record (PHR) or other application. Patients were asked about (11) use of computers, access, where accessed, and ownership. They were also asked about (12) accessing the Internet through cell phone, laptop, desktop, tablet; frequency of use; duration of use per day; purposes of use; social networking; and chatting; and (13) if would they be interested in receiving health information via each type of media about a variety of health issues. We included open-ended questions where patients could suggest other health topics of interest outside of those listed in the survey. The study ended with (14) the collection of demographics, health issues, access to health care, and insurance status.
In total, 5788 subjects were enrolled in the study. Of these, 249 (4.30%) patients reported episodes of homelessness in the past year. Patients who had experienced homelessness were more likely to be male (54.6%, 136/249), younger (mean age 40 vs 46 years), African American (38.6%, 96/249) or Latino (25.3%, 63/249), and have lower income and less education than stably housed patients (
Patients with a history of homelessness reported similar types of new media use as stably housed patients in terms of making phone calls, text messaging, emailing, surfing the Internet, social networking, using PHRs, and looking up health information (
Among those who owned a cell or smartphone, patients experiencing homelessness were slightly more likely to look up health information (64%, 52/81 vs 59.81%, 1317/2202) or track and manage their health using a PHR (20%, 16/81 vs 18.26%, 402/2202); however, these differences were not statistically significant (
Regardless of media use, we questioned patients about their need and desire for health information.
Demographics—Emergency Department Media Study, July 12-August 30, 2012.
Characteristics | Participants who were homeless ≥1 times in last year (n=249), |
Participants who were not homeless in last year (n=5539), |
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Men | 136 (54.6) | 2270 (40.98) |
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Women | 113 (45.4) | 3269 (59.02) |
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18-29 | 78 (31.3) | 1431 (25.83) |
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30-49 | 100 (40.2) | 1939 (35.01) |
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50-64 | 59 (23.6) | 1106 (19.97) |
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65+ | 12 (4.8) | 1063 (19.19) |
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White, non-Hispanic | 90 (36.1) | 2320 (41.88) |
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Black, non-Hispanic | 96 (38.6) | 1855 (33.49) |
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Hispanic | 63 (25.3) | 1295 (23.38) |
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Less than $30,000/yr | 193 (91.9) | 2691 (62.64) |
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$30,000-$59,999 | 10 (4.8) | 818 (19.04) |
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$60,000-$89,999 | 4 (1.9) | 436 (10.15) |
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$90,000+ | 3 (1.4) | 352 (8.19) |
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No high school diploma | 93 (37.3) | 752 (13.58) |
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High school grad | 97 (39.0) | 2353 (42.48) |
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Some college | 39 (15.7) | 1350 (24.37) |
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College+ | 20 (8.0) | 1084 (19.57) |
aParticipants who reported being homeless one or more times in the last year.
bParticipants who reported not being homeless at any time in the last year.
Media usage by ED patients experiencing homelessness.
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Homeless ≥1 times in last year (n=249), |
Not homeless in last year (n=5539), |
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176 (70.7) | 4758 (85.90) | <.001 | ||
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Making phone calls (% of cell users) | 175 (99.4) | 4717 (99.14) | 1 | |
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Text messaging (% of cell users) | 126 (71.6) | 3469 (72.91) | .7 | |
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81 (46.0) | 2202 (46.27) | .95 | |
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Look up health information (% of cell phone surfers) | 52 (64.2) | 1317 (59.81) | .43 |
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Track or manage health with app (% of cell phone surfers) | 16 (19.8) | 402 (18.26) | .73 |
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Emailing (% of cell users) | 74 (42.0) | 2007 (42.18) | .97 | |
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Social networking (% of cell users) | 67 (38.1) | 1836 (38.59) | .89 | |
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Listening to music (% of cell users) | 65 (36.9) | 1503 (31.59) | .14 | |
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Playing games (% of cell users) | 61 (34.7) | 1355 (28.48) | .08 | |
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Using apps (% of cell users) | 57 (32.4) | 1436 (30.18) | .53 | |
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Watching online videos (% of cell users) | 48 (27.3) | 1294 (27.20) | .98 | |
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Smartphone ownership (% of cell users) | 76 (43.2) | 2424 (50.95) | .043 | |
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<.001 | |||
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Android | 53 (69.7) | 1064 (43.89) |
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iPhone | 13 (17.1) | 1080 (44.55) |
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Blackberry | 7 (9.2) | 171 (7.05) |
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Windows | 3 (3.9) | 52 (2.15) |
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Other | 0 (0.0) | 57 (2.35) |
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<.001 | ||
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Contract plan with unlimited minutes | 66 (37.5) | 2380 (50.02) |
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Pay-as-you-go plan | 58 (33.0) | 941 (19.78) |
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Contract plan with limited minutes | 35 (19.9) | 1239 (26.04) |
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Medicaid phone | 16 (9.1) | 197 (4.14) |
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Other | 1 (<1.0) | 1 (<1.00) |
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147 (59.0) | 3767 (68.00) | .003 | ||
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Email use (% of Internet users) | 113 (76.9) | 3173 (84.23) | .017 | |
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Social networking use (% of Internet users) | 102 (69.4) | 2606 (69.18) | .96 |
Desire for health information by ED patients experiencing homelessness (% of adults in each group with desire for various health information).
“If we offered you free health information, which topics would you be interested in receiving?”(Check all that apply) | Homeless ≥1 timesa, |
Homeless 0 timesa, |
OR | 95% CI |
Healthy weight / nutrition / weight loss | 156 (62.7) | 3626 (65.56) | 0.88 | 0.67-1.14 |
Mental health | 125 (50.2) | 1755 (31.73) | 2.16 | 1.68-2.79 |
Smoking | 106 (42.6) | 1101 (19.91) | 2.98 | 2.30-3.86 |
Alcohol | 54 (21.7) | 719 (13.00) | 1.85 | 1.35-2.53 |
Pregnancy | 39 (15.7) | 639 (11.55) | 1.42 | 1.00-2.02 |
Drugs / substance abuse | 59 (23.7) | 553 (10.00) | 2.79 | 2.06-3.79 |
Domestic violence | 47 (18.9) | 490 (8.86) | 2.39 | 1.72-3.33 |
Managing chronic disease | 119 (47.8) | 2518 (45.53) | 1.09 | 0.84-1.41 |
aParticipants were asked: “How many times have you been homeless in the last year?”
This study provides the first estimates of new media use among ED patients experiencing homelessness. Surprisingly, overall new media ownership by ED patients is similar to that in the general population and only slightly higher than the media ownership by ED patients experiencing homelessness [
Importantly, patients experiencing homelessness were similar to stably housed patients in types of new media use, modes of media, and frequency of use, defying popular assumptions of a large “digital divide” for patients who are homeless. This finding is consistent with prior research showing that young adults who were homeless versus non-homeless had very similar uses of social network technology [
Finally, ED patients experiencing homelessness were significantly more likely to want information on chronic health and social problems such as mental health, smoking cessation, alcohol and other substance abuse, pregnancy, and domestic violence than their stably housed counterparts. Negative consequences of these conditions are often treated in the ED, and preventative interventions may in fact decrease ED visits, health care costs, and improve health.
One limitation of our study is that patients who were intoxicated for long periods of time and/or actively psychotic were unable to give informed consent. This may have resulted in certain subsegments of ED patients who are homeless to be excluded from the study. In particular, patients who are chronically homeless suffer from disproportionately high levels of substance abuse and mental health disorders and thus may be underrepresented in the current study.
In summary, ED patients experiencing homelessness have high rates of cell phone ownership and are equal in new media use to stably housed patients adjusting for ownership. They are more likely to engage in all forms of mHealth. Our expanded knowledge about the desire for connectivity by patients who are homeless informs opportunities for prevention and intervention to improve the health of this vulnerable population and potentially decrease the cost of health care.
emergency department
Health Resources and Services Administration
personal health record
Research assistants were Maxx Amendola, Brian Biroscak, Landon Cally, Charlotte Cally, Steven Carusone, Pasquale Cicarella, Dikembe Blackwell, Christopher Covington, Alex Forte, Amalia Harvey, Rebecca Joseph, David Lam, Jessica Moffett, Stephen Post, Matthew Rosner, Simone Schneegans, Diane Schroeder, Raphael Szymanski, Patrick Welch, Katie Yanagisawa, and Michael Yanagisawa.
Emergency Medicine Chairs were Michael Werdmann, MD, Bridgeport ED and David Harriman, MD, Hospital of Saint Raphael ED (now called Yale-New Haven Hospital Saint Raphael Campus).
This study was funded entirely by the Department of Emergency Medicine and Yale University School of Medicine.
None declared.