Publication Date

Winter 12-11-2024

Item Type

Image; StillImage

Executive Summary

Nursing Leadership Executive Summary

The unhoused population in Washington State increased by 12% from January 2022 to January 2023, underscoring a growing regional crisis (Washington State Department of Commerce, 2024). To serve this population, we partnered with an agency in Western Washington. In collaboration with the agency’s health services administrative director, we developed a multilingual handout on healthcare and insurance options to improve health literacy.

Our project involved a windshield survey, demographic analysis, evidence-based research, and collaboration with translators to ensure accessibility. This paper outlines the project’s development, research process, creation of the handout, and its intended impact.

Background

A windshield survey was conducted to observe the demographics and environmental factors surrounding the agency, aiming to identify unmet needs and develop strategies to better serve its population. Following a tour of the agency, a discussion with the health services administrative director highlighted the need to increase knowledge and awareness of healthcare access and insurance options among the agency’s clients. We decided to create a handout that would enhance health literacy between the options of primary, urgent, telehealth, and emergency care. The handout also included information on how to obtain insurance. The handout is available in eight languages which will allow the agency to reach its clientele more effectively.

Population Served

The agency primarily serves women, children, and their families. Of those served, 88% are people of color, mainly from Spanish-, Portuguese-, French-, Lingala-, Marshallese-, Amharic-, and Tigrinya-speaking countries. In 2023, the agency reported 270,173 overnight stays, served 836,937 meals and assisted 1,355 families in moving to or maintaining stable housing (Agency, personal communication, October 9, 2024).

Health Needs and Risk Factors

Numerous social equity factors impact the unhoused population, including the disproportionate representation of people of color, who make up half of all unhoused individuals in the United States (Fowle, 2021). This diverse group often includes non-English speakers, further complicating access to healthcare. During the 2018–2019 school year, 16% of unhoused students required English language assistance, compared to 10% of the total student population—a clear overrepresentation (U.S. Department of Education, 2022). In King County, families with children accounted for 32% of the unhoused population (All Home, 2020).

Additionally, a lack of insurance significantly limits access to healthcare. In 2015, 20% of uninsured adults in the U.S. went without medical care due to cost, and by 2016, two-thirds of uninsured individuals reported worse care compared to those with private insurance (Blazer et al., 2018). Uninsured individuals also experienced higher rates of chronic conditions like hypertension and diabetes, often exacerbated by financial barriers to treatment adherence (Blazer et al., 2018, pp. 23–30).

Health Literacy

Health literacy refers to an individual’s ability to understand, obtain, and apply health information to make informed health decisions (Odoh et al., 2019). Research shows that among the unhoused population, higher health literacy correlates with greater confidence in overall health, while lower health literacy is linked to reduced confidence (Odoh et al., 2019). With the agency’s guests consisting of parents and children, research suggests that improving health literacy can enhance children’s resilience to the challenges of being unhoused (Edie et al., 2024).

This background research was instrumental as the facility we partnered with focuses on supporting unhoused families and children. Understanding the potential language barriers and the predominance of families within this population, we developed a multilingual handout to improve health literacy. It was apparent that bridging the language barrier in healthcare and increasing insurance information is imperative in minimizing disparities among this population.

Activities

The project centered on creating an educational pamphlet for unhoused individuals, offering clear and accessible information about healthcare options, including emergency departments, urgent care, primary care, telehealth, and health insurance. The team researched common barriers to healthcare access, such as limited health literacy and unfamiliarity with available services. The pamphlet design incorporated color coding to represent different levels of care—blue for telehealth and primary care, yellow for urgent care, red for emergency department, and green for insurance—based on research indicating that color usage can improve health outcomes and understanding (Ghamari & Amor, 2016).

Translations were conducted using a combination of translation tools and bilingual speakers following the modified Brislin model and back-translation methods for accuracy (Son, 2018). Google Translate was used initially, with translators verified by native speakers.

Outcomes

The outcome of the project is to increase understanding of the different levels of health care available and how to access insurance to cover health costs. Key objectives include: raising awareness of appropriate care options, enhancing awareness and adoption of telehealth services, reducing reliance on emergency services for non-urgent conditions, and how to apply for and find more information about health insurance in Washington State. Although challenges such as differing literacy levels and language comprehension arose, the use of translated materials and visual aids mitigated these barriers.

The long-term goals include reducing emergency department visits, increasing primary care visits, expanding telehealth utilization, and increasing the number of unhoused individuals with health insurance. Since the project has yet to be implemented, measuring actual outcomes is currently not feasible. Future evaluations could incorporate feedback from the health services administrative director and an analysis of local emergency department usage trends to gauge the project's impact.

Conclusion

This project addresses the knowledge gap regarding healthcare options among the unhoused population, which often leads to unnecessary emergency room visits. These visits strain the healthcare system and prevent individuals from accessing care tailored to their needs. The user-friendly pamphlet provides clear distinctions between healthcare services, telehealth resources, and steps for obtaining insurance. The initiative aims to empower the unhoused community to make informed healthcare decisions, improve health outcomes, and reduce avoidable medical visits. This project highlights the critical role of health literacy and the significant contributions nursing professionals can make in guiding individuals through the complexities of the healthcare system.

References

All Home. (2020). Seattle/King County Point-in-Time Count of Individuals Experiencing Homelessness. In KRCHA.org (pp. 53–68). KRCHA. https://kcrha.org/wp-content/uploads/2020/07/Count-Us-In-2020-Final.pdf

Blazer, D., Bazarian, J., Bogner, J., Fitzpatrick, A., Harrison, T., Harvey, P., Hernan, Mi., Hsia, R., Maestas, N., McKenzie, J., Mullen, K., Nguyen, L., Osbarhr III, A., Schulman, K., Seabury, S., & Taylor JR, D. (2018). Health-Care Utilization as a Proxy in Disability Determination (pp. 23–30). National Academies Press. https://doi.org/10.17226/24969

Edie, A., Carmody, K., & Jewel, S. (2024). Building resilience in families experiencing homelessness through integration of health, parenting and child development programs. Child Care Health and Development/Child, Care, Health and Development, 50(4), 1–2. https://doi.org/10.1111/cch.13290

Fowle, M. Z. (2022). Racialized Homelessness: A review of historical and contemporary causes of racial disparities in homelessness. Housing Policy Debate, 32(6), 940–967. https://doi.org/10.1080/10511482.2022.2026995

Ghamari, H., Amor, C.M. (2016). The role of color in healthcare environments, emergent bodies of evidence-based design approach. Sociology and Anthropology 4(11), 1020-1029. https://doi.org/10.13189/sa.2016.041109

King County Regional Homelessness Authority. (n.d.). Count us in 2020 Seattle/King County point-in-time count of individuals experiencing homelessness. https://kcrha.org/wp-content/uploads/2020/07/Count-Us-In-2020-Final.pdf

Odoh, C., Vidrine, J. I., Businelle, M. S., Kendzor, D. E., Agrawal, P., & Reitzel, L. R. (2019). Health literacy and self-rated health among homeless adults. Health Behavior Research, 2(4). https://doi.org/10.4148/2572-1836.1055

Son, J. (2018). Back translation as a documentation tool. Translation & Interpreting: The

International Journal of Translation and Interpreting Research, 10(2), 89–100. https://search.informit.org/doi/10.3316/informit.864953916346703

U.S. Department of Education. (2022). English Learners and Homelessness (pp. 1–2). Office of Language Acquisition. https://files.eric.ed.gov/fulltext/ED625650.pdf

Washington State Department of Commerce. (2024). Homelessness in Washington. Washington State Department of Commerce (pp. 1–31). Washington State Department of Commerce. https://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName=CommerceReports_2023_HD_Homelessness_in_Washington_24def55e-7087-43fc-ad0c-7894a56106ab.pdf

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