A study by Song, Bartels, and Ratner published early in 2007 was the first to canvass these concerns in a systematic way. The study, "Dying on the Streets: homeless persons' concerns and desires about end of life care," asked homeless clients at a half dozen facilities in the Twin Cities to describe a good death and asked such questions as, "What kinds of services would you say would be needed so that homeless people might die in comfort and dignity?"

The answers elicited by these queries often surprised the researchers.

"Homeless persons' level of sophistication and understanding of end-of-life concerns and the threats they face living in the streets was a revelation to me," admits Bartels, whose background is in nursing and family social science. "Because death is so pervasive in their everyday life, they know what they do and don't want. A number have already appointed someone to serve as their advocate. You'd think that if they didn't know where they were going to sleep tonight, they probably wouldn't have a living will — but some do."

Over and over again, the homeless individuals interviewed for the study emphasized two things: They wanted to die with dignity if possible — no machines keeping them alive — and they wanted their bodies tended to and their lives commemorated in some way after they are gone.

With this research in hand, Song's team convened a conference and invited homeless individuals, service providers for the homeless, end-of-life care experts, and representatives from the Medical Examiner's office to ask what they thought would be an effective intervention study. "They came up with the same recommendation we did," says Song: "living wills."

"Homeless people tend not only to be sicker than the rest of us but also to suffer the greatest disparities in health care, with poor access to treatment and even poorer outcomes," Song observes. "Advance directives may be their one practical means of preserving their voice when they no longer are able to speak for themselves."

The tools to quit smoking

Kolawole Okuyemi, M.D., M.P.H., associate professor in the Department of Family Medicine and Community Health on the University's Twin Cities campus, is also challenging assumptions about homeless populations.

"There's a general feeling that quitting smoking should not be a priority for homeless people and that, in fact, it's an okay way of dealing with the stress of homelessness," Okuyemi observes. "There's also a presumption that because of competing demands for food and shelter, the homeless are in no position to quit smoking."

Okuyemi, who came to the University in 2006 to create and direct the Medical School's Program in Health Disparities Research, is out to prove both assumptions wrong. Not only is smoking a top health concern for homeless people, but a pilot research program he conducted at the University of Kansas has already shown that homeless people want to quit smoking and can, if given the tools to do so.

Although trauma of one kind or another — accidents and homicides — ranks much higher as a cause of death among the homeless than among the general population, the reality is that, just like everyone else, homeless people are most likely to die of chronic illness — cancer, cardiovascular disease, diabetes, and AIDS. Smoking, of course, is a major contributor to at least two of those illnesses. Meanwhile, smoking among the homeless is much more common than among the general population. An estimated 70 percent of this country's 4 million homeless smoke cigarettes, as opposed to 25 percent of the population at large, and homeless smokers on average consume more cigarettes per day than other smokers.

"Smoking is perhaps the leading preventable cause of disease among the homeless," Okuyemi says. "And part of the tragedy of this tobacco use is that these are the people who can least afford it."

In the Kansas pilot program, Okuyemi's team conducted six focus groups with 62 homeless individuals to find out why they smoked, whether they wanted to quit, and what kind of program they would like, and be willing, to participate in. His methodology was informed by one of his fundamental principles of working with underserved communities: to conduct research with these communities and not on them by enrolling participants in studies as collaborators rather than as passive subjects for study. Okuyemi used findings from the focus groups to design a pilot intervention with a six-month follow-up. Although the sample size was relatively small — 50 participants — the results were highly encouraging.

"Contrary to expectations, the people who agreed to be part of the program showed up for their appointments, and about 70 percent of those enrolled finished the program — the same completion rate as that for the general population," Okuyemi says. By study's end, the success rate — the proportion who quit smoking — among homeless participants was identical to that of the general population.

"It was mind-boggling," Okuyemi says.

Now he's using those results to launch a major research study/intervention to see whether they hold true with more subjects over a longer time period. He's confident that they will. So is the NIH, which recently awarded Okuyemi and his research team a four-year, $2.8 million grant to find out.

The new study will be based in Twin Cities homeless shelters. Already several organizations that serve the homeless, including the Dorothy Day Center, Listening House, People Serving People, and Healthcare for the Homeless, have signed on to the project. Okuyemi is planning to enroll some 400 homeless individuals in the study, which differs from the pilot project because, in addition to offering a traditional smoking-cessation program that includes the use of nicotine patches, it will provide participants with motivational interviewing counseling, which Okuyemi calls "a special kind of counseling that encourages individuals' inner motivation to drive their decision-making."

Of his new research, he says, "This is the first full-scale study of its type anywhere in the world. If, as we are hoping, about 20 to 25 percent of the participants quit smoking long-term, the policy implications are significant. It would serve as a model for shelters and agencies around the country to offer programs to their homeless clients who are interested in quitting smoking."   

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