By Virginia Johnson

What do you see?

PhotoP – Problem of homelessness. As the economy took a downturn, more people struggled to pay their bills and many ultimately became homeless.

H – Housing, lack of affordable housing. More line up daily for beds in shelters. Those who sleep on the streets risk harm from violence and the elements.

O – Ostracized, feelings of rejection drive the homeless further underground making it difficult to provide ongoing healthcare.

T – Tuberculosis (TB)thrives amongst the homeless. Latent TB is a particular problem of the homeless. Cramped settings in shelters make spread of the infection difficult to control.

O – Obscurity. I chose this picture because the first impression is of a majestic tree standing in a parking lot. It is only when you look closely under the trees that you see, what looks like, a pile of old clothes or trash. They are the homeless, huddled in sleeping bags early one Sunday morning.

Assessment

Annually TB accounts for more than 2,000,000 deaths worldwide (Maurer & Smith, 2013)

TB amongst the homeless is 100 times greater than that of the general population, within the USA(Feske, Teeter, Musser, & Graviss, 2013)

Homelessness is associated with inadequate nutrition, substance abuse, HIV, poor health, lack of sleep and overcrowding leaving the homeless vulnerable to infection. (Proudfoot, 2005)

The homeless are at high risk for latent TB and have a history of incomplete TB treatment(Craig et al., 2007).

Monitoring and treatment of the homeless is made more difficult by their inconsistency and failure to comply with medication regimens, along with the need for extended periods of treatment - 6-9 months ("Trends in Tuberculosis," 2004)

Assessment

Arkansas has one of the lowest incidence rates of TB in the United States of America ("ASTHO," 2013).

July 2012, the Arkansas Department of Health (ADH) converted from “TB skin tests to blood tests” for those at high risk of contracting the disease. ("ASTHO," 2013).

Arkansas implemented the “new latent TB regimen of 2 pills per week for 12 weeks”. This has improved compliance ("ASTHO," 2013).

Unfortunately, only people who reside in shelters for more than fourteen days are required to be tested for TB . There is a deficiency in detection of TB in the homeless who do not stay in one shelter for more than 14 days.

Plan

Meet with interested parties, e.g. community leaders, Pulaski County Health Department, public health/community nurses, physicians and local business people to develop a strategy for testing the homeless who reside in shelters < 14 days.

Fundraiser to cover expenses of food and gifts for participants – seek out local venders who are willing to donate items.

Salvation Army Shelter selected for 21 day trial.

Plan

Educate homeless on signs and symptoms of TB – use pictures to demonstrate e.g droplet spread of disease.

Perform blood tests on all volunteer shelter residents in the selected shelter.

Educate homeless on need to return for test results and follow treatment plan if they test positive.

Establish method of monitoring compliance with 12 week follow up plan. Implement direct observation technique (DOT) for medication administration.

Implementation

4 weeks before trial - recruit volunteers from nursing schools, churches and the community to draw blood and collect patient data during the trial. Arrange for meeting with them and shelter staff to ensure unity of effort.

2 weeks prior to testing place posters announcing the program including dates, times and benefits for the participants.

Be personally available to assist at each session of the 21 day trial.

Provide a healthy hot meal and snacks for all who attend a short presentation and have blood drawn.

Implementation

Notify each participant when they will need to return for their results. Stress importance of this and stimulate compliance with meal and gift (e.g. sleeping bag, socks, underwear) when they return.

When participants return, reinforce signs and symptoms of TB prior to meal and gift.

Ensure those who test positive for TB are transferred to a local facility to begin treatment.

Educate those who test positive that it is crucial they complete the 12 weeks of treatment.

EvaluationParticipants will return for results

Participants will be able to identify signs and symptoms of TB.

Participants who test positive will be compliant with 12 week course of treatment.

If outcomes are statistical significant, then plan to repeat process in shelters city wide.

SWOT AnalysisStrengths:

• Based on testing and treatment methods supported by evidence based practice.

• Collaboration between diverse group of community providers and leaders leading to an increased impetus for success.

• Use of volunteers to lower costs. • Use of established shelter in which

participants feel relatively comfortable.

•Opportunities:

• If trial significant and cost effective can replicate at other facilities

• Participants are captive audience for other educational opportunities.

• Opportunity for volunteers to spend time with the homeless and learn more about this sector of the population – may stimulate more volunteering in this field.

Weaknesses:

• Population very mobile and often unreliable-potential problem with follow up for test results and treatment.

• Potential for inadequate funding to provide for all participants.

• Ostracized – many of homeless feel ostracized and do not go to shelters. This leaves a whole category of people who are still not reached.

• Threats:

• Lack of local support – trial could be seen in negative light – bringing people into business area of Little Rock who are potential carriers of TB.

• Use of drugs and alcohol, along with failure to take psychiatric medications could pose a threat to completion of the project. This would create inadequate data for future planning of TB monitoring efforts.

ReflectionMy CIP contains problems inherent in the homeless population. These are related to feelings of inadequacy and inferiority in the potential clientele. Establishing trust is crucial to the success of this plan. Also, there are the issues of drugs, alcohol and mental illness that can affect compliance.

Eradication of TB among the homeless in Little Rock would be the ideal long term goal for this project. Realistically, if the pilot is successful it would need to be reproduced throughout the city and repeated cyclically throughout the year to ensure maximum capture within the homeless population.

ReferencesArkansas takes steps to combat tuberculosis. (2013). Retrieved from www.astho.org

Craig, G. M., Booth, H., Story, A., Hayward, A., Hall, J., Goodburn, A., & Zumla, A. (2007, January 27). The impact of social factors on tuberculosis management. Journal of Advanced Nursing, 58(5), 418-24.

Feske, M. L., Teeter, L. D., Musser, J. M., & Graviss, E. A. (2013, March 14). Counting the homeless:A previously incalculable tuberculosis risk and its social determinants. American Journal of Public Health, 103(5), 839-48. http://dx.doi.org/10.2105/AJPH.2012.300973

Homelessness & health: what’s the connection. (2011). Retrieved from www.nhchc.org

Maurer, F. A., & Smith, C. M. (2013). Community/public health nursing practice: Health for families and populations (5th ed.). St Louis, MO.: Elsevier Saunders.

Proudfoot, C. (2005, March). Tuberculosis and homeless people. Primary Health Care, 15(2), 16-9.

Trends in tuberculosis. (2004). Retrieved from http:www.cdc.gov/mmwr/preview/mmwrhtml/mm5410a2.htm