Risk factors for cardiovascular disease among the homeless and in the general population

We described the distribution of risk factors for cardiovascular disease among homeless people living in the city of Porto, Portugal. Comparisons were made between subsamples of homeless people recruited in different settings and between the overall homeless sample group and a sample of the general population. All “houseless” individuals attending one of two homeless hostels or two institutions providing meal programs on specific days were invited to participate and were matched with subjects from the general population. We estimated sex, age and educationadjusted prevalence ratios or mean differences. The prevalence of previous illicit drug consumption and imprisonment was almost twice as high among the homeless from institutions providing meal programs. This group also showed lower mean systolic and diastolic blood pressure. Prevalence of smoking was almost 50% higher in the overall homeless group. Mean body mass index and waist circumference were also lower in the homeless group and its members were almost five times less likely to report dyslipidemia. Our findings contribute to defining priorities for interventions directed at this segment of society and to reducing inequalities in this extremely underprivileged population. Homeless Persons; Hypertension; Overweight; Obesity Introduction Homelessness is an essentially urban phenomenon linked to social discrimination affecting millions of people worldwide 1. Closely associated with individual factors (e.g. long term unemployment, family breakdown, mental illness, substance abuse) and societal factors (e.g. poverty, high housing costs, unfavorable labor market conditions), there has been an increasing tendency in homelessness in recent years, due to the economic and social crises that have affected many countries 2,3,4,5,6,7,8. This social condition is also an important determinant of health and has been associated with an increased risk of physical and mental disease9,10,11. In comparison with the general population, mortality rates are reported to be higher among the homeless and premature death is more common 9,10,11, especially due to cardiovascular disease 11,12. In addition to a high prevalence of diabetes and hypercholesterolemia, the increased risk of cardiovascular disease has been attributed essentially to a high prevalence of hypertension and substance abuse 12,13,14,15,16. Several studies reported prevalence of hypertension among the homeless ranging from 14% to 51% 14,15,17,18,19,20,21, and prevalence of tobacco and alcohol consumption of almost 80% and 30% respectively 12,14,22. Furthermore, the fact that the homeless population experiences difficulties in obtaining and maintaining stable sources of medical care has also been described as a barrier to appropriARTIGO ARTICLE Oliveira LP et al. 1518 Cad. Saúde Pública, Rio de Janeiro, 28(8):1517-1529, ago, 2012 ate healthcare 23,24,25 that contributes to a lack of awareness of these health problems and difficulties in adhering to treatment regimens 26. In Portugal, however, these factors are expected to have a lower impact on the health status of the homeless population because healthcare assistance is provided by the National Health Service which is universal, comprehensive and free of charge for individuals that do not have the financial means to support the relatively low fees 27. Epidemiological research that targets such “hard-to-reach” populations also faces important methodological challenges, both due to the variety of operational definitions of homelessness and to the difficulties in sampling a numerically small and widely dispersed population living in anonymity 2,28,29,30. To ensure a valid comparison of results obtained in different settings and define strategies for monitoring risk factors for cardiovascular disease among the homeless, it is necessary to understand the impact of different sampling techniques on estimates. To assess the effect of different recruitment settings on the estimate of the distribution of risk factors for cardiovascular disease, we evaluated two samples of homeless people: one assembled from homeless hostels and the other from institutions that run meals programs. We, then, compared these samples with the general population to quantify the association between homelessness and these determinants of health.