Evaluating knowledge and utilization of community health resources to promote autonomous decision-making among people experiencing homelessness in New Orleans

ABSTRACT

People experiencing homelessness encounter barriers to self-directed community health resource use that may limit autonomous decision-making. Tailored educational material is needed to increase knowledge, promote well-informed resource access, and improve community health system navigability. This study aimed to 1) assess homeless individuals' baseline knowledge and utilization of community health resources and 2) evaluate use of a pocket-sized resource guide. Participants (N = 103) were recruited at a no-cost medical clinic in New Orleans to complete pre- and post-surveys assessing knowledge and utilization of community health resources listed on the guide. Over a third (38.8%) of participants indicated having low knowledge of resources at baseline. Utilization of resources varied substantially, ranging from a majority (66.7%) to a select few (6.9%) participants reporting attendance at sites. Among participants who completed the follow-up survey, self-rated knowledge of resources significantly increased (p = 0.029); however, the number of resources used in the past month slightly declined. These results may speak to participants who used the resource guides having an improved ability to selectively access resources for their specific needs. Interventions to improve health resource knowledge can, thus, aid more efficient and autonomous decision-making and are needed to improve community health system accessibility for populations experiencing homelessness.

KEYWORDS:

• Homelessness
• knowledge
• decision-making
• community health
• utilization

Introduction

People experiencing homelessness (PEH) face a complex, multileveled set of barriers to achieving adequate health and wellbeing. The daily inconsistencies of food, shelter, and safety – combined with personal and systemic neglect – exacerbate disease, interfere with treatment, and enhance mortality rates (Auerswald et al., 2016). These disparities in health and resource access are often further heightened by concomitant declines in mental health, substance use, and marginalization from the healthcare system (Aldridge et al., 2019; Kertesz et al., 2014; Wagner et al., 2014). A study of nearly 1,000 PEH found that 73% had an unaddressed health concern, including physical and mental medical care, prescriptions, vision, and dental care (Baggett et al., 2010). This varying range of unmet needs experienced by PEH – defined here as persons residing in emergency shelter, homeless transitional housing, or places not meant for human habitation for any length of time (UNITY of Greater New Orleans., 2019) – necessitates an interconnected, comprehensive, and accessible system of community health resources.

Deficits in accessible information about the available resources within a community health system may limit health resource use by diminishing knowledgeable and self-directed decision-making among PEH. A majority of PEH, for example, do not have a consistent location to access healthcare services and often rely on several health organizations to obtain the variety and specificity of resources they need (Dickins et al., 2019). Health and social care service systems for PEH, however, have been found to be largely disconnected from each other and, consequently, are ill-suited to communicate the availability of resource offerings across their network to meet a multi-faceted range of needs (Omerov et al., 2020). Inconvenient physical locations, inflexible bureaucracy, and stigmatizing practices within an organization may also serve as structural barriers to health resource access (Ha et al., 2015; Omerov et al., 2020). Integrating health care and community resources can improve system navigability; homeless and economically-disadvantaged individuals, for example, are more likely to access health services if participating in a shelter or housing program (Parsell et al., 2018). People experiencing homelessness who regularly visit a community clinic also have better health outcomes, and by accessing community health systems, their healthcare needs are more consistently met (Dickins et al., 2019; White & Newman, 2015). Integrating autonomy and agency-centered approaches to health knowledge promotion is essential to these efforts and has been associated with health improvements and life satisfaction among PEH (Parsell et al., 2018).

In New Orleans, Louisiana, limited knowledge of available services for the homeless population among both PEH and health service providers has been identified as an important determinant of health resource utilization (Louisiana Public Health Institute., 2017). Local housing unaffordability is the most decisive determinant of homelessness in the city. The aftereffects of Hurricane Katrina – which resulted in the destruction of 70% of the city’s housing, dismantled extended family and neighborhood networks, and resulted in declines in physical and mental health – also continues to be an important factor in deciding homelessness risk (UNITY of Greater New Orleans., 2019). The proportion of unsheltered PEH in New Orleans (43%), considered the most life-threatening living situation experienced in homelessness, is among the highest in the United States, particularly when compared to the larger sizes of non-homeless populations in other cities (UNITY of Greater New Orleans., 2019). The multifactorial drivers of homelessness in New Orleans reinforces the need for targeted health support structures that offer medical services and integrate shelter, housing assistance, employment opportunities, and social support as resources.

There are no known studies to date that evaluate the relationship between self-rated knowledge and utilization of community resources in the population of PEH. Self-rated knowledge is an important metric in healthcare utilization (Hwang et al., 2016; van Dongen et al., 2019) and is associated with higher empowerment and autonomous decision-making among patients (Köpke et al., 2009; Lenz et al., 2012; Shankar et al., 2019). In order to address the needs of this population and the dearth of existing literature, this study aimed to (1) assess baseline knowledge and utilization of available community resources and (2) determine the necessity and efficacy of a laminated, pocket-sized resource guide in promoting knowledge and utilization among PEH.

Methods

Study design and patient recruitment

Surveys and resource guide evaluation were conducted in a convenience sample of 103 PEH residing in New Orleans, Louisiana from October 2019 through February 2020. All patients aged 18 years or older who presented to the no-cost clinic of a homeless shelter were eligible to participate. Participant recruitment occurred in the clinic’s waiting area. Patients were approached with study information and screened for eligibility. All PEH and individuals in need of basic services, without discrimination, were eligible to receive care at the Ozanam Inn and associated no-cost clinics; therefore, there were no disqualifying criteria for individuals presenting to the clinic. All individuals approached (n₁ = 103) agreed to participate and were enrolled into the study. To ensure complete anonymity, a unique patient identifier number was assigned to each participant; no personal identifying information was recorded. Trained research assistants administered a baseline survey to assess participant’s demographic characteristics, self-rated knowledge and utilization of community resources in the Greater New Orleans area, and the perceived need for a portable resource guide. A follow-up survey was administered approximately one month later to the participants who re-presented to the clinic. The institutional review board at Louisiana State University Health Sciences Center approved this study (IRB #19-1298). All participants provided written informed consent.

Community partnership

Ozanam Inn is a homeless shelter in New Orleans that has an established partnership with the research institution and their no-cost clinics. The shelter offers a variety of services to PEH at little to no-cost, including healthcare, financial assistance, and basic needs. Informal conversations with stakeholders, including the shelter’s chief executive officer and management team, and medical practitioners at the Ozanam Inn revealed a need to increase knowledge and utilization of the available community health resources. Information on the variety of resources offered throughout the community network was identified as difficult to access. Stakeholders discussed the need to understand patterns of resource use among PEH to diminish system fragmentation and maximize resource utility in the community.

Portable resource guide

To address deficits in accessible information, a portable resource guide was developed for distribution among PEH. The resource guide was a laminated sheet of paper, folded accordion-style into a dollar bill size for transportability in a wallet or pocket. The guide included information on ten community health resources in the Greater New Orleans area, including their names, addresses, phone numbers, operational hours, and list of services offered. The resources were categorized by type of services offered and had corresponding symbols next to their name as visual literacy supports. Literature has demonstrated the efficacy of using communication tools, such as portable resource guides, in increasing knowledge of community resources (Freimuth & Quinn, 2004). The community health resources on this guide were purposefully selected for their range of services (Table 1) and allowed for facilitated evaluation of which services were most and least often sought out in the community. Resources were also selected based on their proximity from the homeless shelter and clinic (Figure 1).

Figure 1. Map of community health resources in the Greater New Orleans area which were provided on the portable resource guide. Resource numbers correspond to the order in which they are listed in Table 1.

Table 1. Information of community health resources included in a portable resource guide for persons experiencing homeless in New Orleans, Louisiana.

Community health resource	Services offered
Ozanam Inn	Shelter, food, medical care, mental health/substance abuse, dental care, HIV/Hepatitis/STI, case management, career planning, housing support
New Orleans Mission	Shelter, food, medical care, mental health/substance abuse, HIV/Hepatitis/STI, case management
Housing Authority of New Orleans	Housing support
Lantern Light Ministry	Food, case management, career planning, emergency financial assistance, Medicaid, legal services
Louisiana Workforce Commission	Case management, career planning
Crescent City Vision	Eye care
Odyssey House	Medical care, mental health/substance abuse, case management, career planning, housing support
CrescentCare	Medical care, dental care, HIV/Hepatitis/STI, LGBTQ services, harm reduction
Daughters of Charity	Medical care, dental care, HIV/Hepatitis/STI, case management, Medicaid, legal services, smoking cessation
Covenant House	Shelter, medical care, mental health/substance abuse, case management

Preliminary conversations were conducted with a subsample of seven participants to assess the perceived utility, necessity, and comprehensibility of the portable resource guide and baseline survey. Participants were administered a four-item questionnaire with a prototype of the pocket-sized, laminated resource guide. For the first two questions, participants indicated whether they would use (“yes”/“no”) and thought they needed (“yes”/“no”) the resource guide they received. The third question was a five-point Likert-scale item that assessed the perceived need of the resource guide, with a response of one indicating “not needed at all” and a five indicating “extremely needed.” The last question, an open-ended item, asked participants to indicate resources, other than the guide, they would have preferred. Out of the seven participants who completed the preliminary interviews, five (71%) indicated they would use the resource guide. All participants indicated that the resource guides were “extremely needed” in the community. The seven participants then took part in an exploratory test of the baseline survey and indicated whether they understood each survey item by using an adapted health literacy measurement tool (Arozullah et al., 2007). Based on these feedback, two questions on the baseline survey were modified to improve clarity.

Baseline survey

The baseline survey was adapted from an instrument used for assessing community health resource knowledge and utilization, which has been previously validated in a study population of rural minorities (Crockett, 2006). For the current survey, 16 items were used. These included a generalized self-rated knowledge of resources assessed by asking participants, “What is your current knowledge level of community resources in New Orleans?” and having a five-point Likert-scale response ranging from “low” to “high” knowledge. This item is similar to other validated measures of self-rated knowledge of health resources designed for rapid use in a community setting, which have been proven reliable in associating self-rated knowledge with healthcare encounters and health behaviors (Hwang et al., 2016; van Dongen et al., 2019). The number of community health resources used in the past month was also assessed, accompanied by an open-ended item allowing participants to list which resources were used. Additionally, use of the ten community health resources included in the resource guide was assessed by asking participants to indicate their knowledge and/or use of each resource through the following response options: “You use the service regularly,” “Have used the service sometimes,” “Have heard of the service but never used it,” and “Have never heard of or used the service.” The four items evaluated in the preliminary questionnaire as well as demographic characteristics, including age, race/ethnicity, and gender, were collected.

Follow-up resource guide evaluation

The follow-up survey was administered to participants who represented to the no-cost clinic before pandemic restrictions were added to clinic protocols; thus, follow-up was limited due to COVID-19 procedures regarding patient contact. Data were collected at approximately one month following resource guide distribution. Survey items included reassessing participants’ self-rated knowledge of community health resources as well as their use of the resources on the guide with the same items as the pre-survey. Additionally, participants were asked if they still possessed the laminated resource guide (“yes’/“no”) and how many times they used the guide “in the past month.” At the end, participants were asked to provide feedback on the resource guide using an open-ended item.

Statistical analysis

Statistical analyses included all participants who completed the baseline survey (n₁ = 103) and, separately, the subset (n₂ = 12) who completed the follow-up survey. Responses to the baseline and follow-up survey item assessing self-rated knowledge of community resources were combined into two categories for interpretability; participants who marked 1–3 on the Likert scale were classified as having “low” self-rated knowledge while those endorsing responses four or five have “high” self-rated knowledge. Descriptive statistics of demographic characteristics at baseline were calculated, and differences across categories of self-rated knowledge were detected using a t test for continuous variables or Fisher’s exact test for categorical variables to account for small cell counts. Proportions of knowledge and utilization of ten community health resources at baseline were measured. To increase statistical power and to more accurately reflect overall irregular resource utilization among our research participants, “regular” and “sometimes” use of each community health resource were collapsed into one category to capture any frequency of utilization, referred to as “use;” the other response options are referred to as “know of” and “do not use/know.” Differences in resource use and knowledge across categories of self-rated knowledge were calculated, with statistical significance detected using Fisher's exact test. Finally, changes in self-rated knowledge and number of resources used in the past month in the subset of participants who completed the follow-up survey were evaluated using an asymptotic Wilcoxon-Pratt signed-rank test for paired data, a non-parametric approach that is conservative and appropriate for small sample sizes; it can handle zero differences and does not assume data are normally distributed. Significance was prespecified at an alpha level of 0.05 for all tests. All analyses were carried out in R version 4.0.2.

Findings

Baseline survey

A total of 103 patients presenting to Ozanam Inn completed the baseline survey and were provided with the resource guide. According to the United States Department of Housing and Urban Development’s Homeless Point in Time (PIT) Count, an annual survey of all persons in emergency shelter, homeless transitional housing, and in places not meant for human habitation within one 24-hour period (UNITY of Greater New Orleans., 2019), this sample size represents 8.7% of the total 1,179 PEH residing in the Greater New Orleans area in 2019. The majority of study participants identified as male (93.2%) and Black (59.2%) in the baseline survey, with a mean age of 51.7 (SD = 11.7) years (Table 2). This demographic distribution is consistent with the 2019 PIT Count, which documented 890 (75.5%) male and 721 (61.2%) Black PEH in New Orleans (UNITY of Greater New Orleans., 2019). Of the total sample, 40 (38.8%) indicated having “low” self-rated knowledge of community health resources while 63 (61.2%) indicated “high” self-rated knowledge. Participants with high self-rated knowledge of community health resources had a differing distribution of race/ethnicity (p = 0.036), with a greater proportion identifying as Black; all other demographic characteristics were balanced across self-rated knowledge. The subset of participants who completed the follow-up survey all identified as male. Half (50.0%) identified as White and one-quarter (25.0%) as Black, with a mean age of 49.6 (SD = 12.8) years.

Table 2. Demographic characteristics by self-rated knowledge in a purposeful sample of persons experiencing homelessness in New Orleans, Louisiana.

		Self-rated knowledge
	All (N = 103)	Low (n = 63)	High (n = 40)	P^‡	Follow-up (n = 12)
Age, years (SD)	51.7 (11.7)	51.3 (11.6)	52.3 (12.0)	0.67	49.6 (12.8)
Male	96 (93.2%)	60 (95.2%)	36 (90.0%)	0.53	12 (100%)
Race/ethnicity				0.036
Black	61 (59.2%)	31 (49.2%)	30 (75.0%)		3 (25.0%)
White	30 (29.1%)	23 (36.5%)	7 (17.5%)		6 (50.0%)
Native American	4 (3.9%)	3 (4.8%)	1 (2.5%)		1 (8.3%)
Asian	3 (2.9%)	1 (1.6%)	2 (5.0%)		1 (8.3%)
Other^†	5 (4.9%)	5 (7.9%)	0 (0.0%)		1 (8.3%)

^† Includes self-identified Hispanic/Latino, Muslim, Middle Eastern, and multiracial.

^‡ Statistical significance for differences between categories of self-rated knowledge determined by two-sided t test or Fisher’s exact test.

Knowledge and utilization of community health resources at baseline varied by organization (Figure 2). All participants reported use of Ozanam Inn, the site of data collection; thus, accurate reporting for all resources on this item was expected. The majority of participants (66.7%) also reported using New Orleans Mission. Otherwise, resource use throughout the city was relatively low, ranging from a quarter of participants (24.5%) using the Housing Authority of New Orleans to 6.9% using Covenant House. The majority of participants did not know of or use many resources, including Lantern Light Ministry (72.5%), the Louisiana Workforce Commission (72.5%), Daughters of Charity (69.6%), or Crescent City Vision (68.6%). A substantial proportion of participants had known about Covenant House (41.2%) and Odyssey House (32.4%); however, use of these resources was relatively low.

Figure 2. Proportion of participants experiencing homelessness’ knowledge and utilization of various community health resources in New Orleans, Louisiana. Percentages may not add up to 100 due to rounding.

Community health resource knowledge and utilization at baseline was relatively balanced across levels of self-rated knowledge, with a few exceptions (Table 3). Those with high self-rated knowledge were more likely to know of, and use, the Housing Authority of New Orleans (p = 0.0030) and Crescent City Vision (p = 0.0046) as compared to those with low knowledge. Participants with high self-rated knowledge also used a significantly higher number of community health resources in the past month than those with low knowledge (3.5 vs. 2.8 resources, respectively; p = 0.033).

Table 3. Proportion of participants experiencing homelessness’ knowledge and utilization of various community health resources by level of self-rated knowledge in New Orleans, Louisiana

	Self-rated knowledge and use
	Low (n = 63)	High (n = 40)	P^†
Number of resources used in past month, mean (SD)	2.8 (1.6)	3.5 (1.8)	0.033
Ozanam Inn
Use	63 (100%)	40 (100%)	–
New Orleans Mission			0.29
Use	38 (61.3%)	30 (75.0%)
Know of	9 (14.5%)	5 (12.5%)
Do not use/know	15 (24.2%)	5 (12.5%)
Housing Authority of New Orleans			0.0030
Use	11 (17.7%)	14 (35.0%)
Know of	11 (17.7%)	14 (35.0%)
Do not use/know	40 (64.5%)	12 (30.0%)
Lantern Light Ministry			0.065
Use	15 (24.2%)	7 (17.5%)
Know of	1 (1.6%)	5 (12.5%)
Do not use/know	46 (74.2%)	28 (70.0%)
Louisiana Workforce Commission			0.10
Use	8 (12.9%)	12 (30.0%)
Know of	5 (8.1%)	3 (7.5%)
Do not use/know	49 (79.0%)	25 (62.5%)
Crescent City Vision			0.0046
Use	8 (12.9)	12 (30.0)
Know of	4 (6.5)	8 (20.0)
Do not use/know	50 (80.6)	20 (50.0)
Odyssey House			0.38
Use	11 (17.7%)	7 (17.5%)
Know of	17 (27.4%)	16 (40.0%)
Do not use/know	34 (54.8%)	17 (42.5%)
CrescentCare			0.20
Use	9 (14.5%)	7 (17.5%)
Know of	9 (14.5%)	11 (27.5%)
Do not use/know	44 (71.0%)	22 (55.0%)
Daughters of Charity			0.50
Use	6 (9.7%)	7 (17.5%)
Know of	11 (17.7%)	7 (17.5%)
Do not use/know	45 (72.6%)	26 (65.0%)
Covenant House			0.26
Use	3 (4.8%)	4 (10.0%)
Know of	23 (37.1%)	19 (47.5%)
Do not use/know	36 (58.1%)	17 (42.5%)

^† Statistical significance for differences between categories of self-rated knowledge determined by two-sided t test or Fisher’s exact test.

Follow-up resource guide evaluation

Self-rated knowledge of community health resources significantly increased after receiving the portable resource guide in the subset of participants (n₂ = 12) who completed the follow-up survey (p = 0.029), with a shifted mode response of two on the Likert scale (low knowledge) at baseline to three and five (high knowledge) at follow-up (Figure 3). In contrast, the number of resources used in the past month did not significantly change (p = 0.29). A mode of three resources used at baseline and two resources at follow-up were observed (Figure 4).

Figure 3. Distribution of self-rated knowledge before and after receiving a portable resource guide among persons experiencing homelessness in New Orleans, Louisiana (n₂= 12).

Figure 4. Distribution of number of community health resources used in the past month before and after receiving a portable resource guide among persons experiencing homelessness in New Orleans, Louisiana (n₂= 12).

Discussion

This study offered a targeted, exploratory examination of community resource network use among PEH in the Greater New Orleans area, documenting which services are most and least often sought out in the community. Community health resource knowledge and use was generally low in this population. Potential barriers to utilization across several of these organizations include physical distance and/or lack of transportation, inconvenient operational hours, restrictive shelter rules, or stigma associated with the religious practices, among others (De Rosa et al., 1999; Garrett et al., 2008; Hauff & Secor-Turner, 2014; Omerov et al., 2020). Importantly, results revealed that some resources, despite participants having higher knowledge at baseline, were rarely used. These organizations offered similar services to others that were more frequently used among participants; thus, although visiting multiple healthcare sites is common in the general population (Bourgeois et al., 2010), mitigating redundancy in resource access could be an important driver of self-directed decision-making (Omerov et al., 2020). Since the resource landscape is largely ineffective in communicating across their network (Omerov et al., 2020), the population of PEH largely gain knowledge of services among peers and by word of mouth. Organizations may need to craft better community marketing strategies that involve directly speaking to the population about their resource offerings and availability.

High levels of resource knowledge effectively predicted resource use among PEH. Specifically, participants in this study with high self-rated knowledge at baseline used a significantly higher number of community health resources in the past month than those with low levels of knowledge. Additionally, resources with more specialized offerings, including Housing Authority of New Orleans and Crescent City Vision, were utilized significantly more by participants with high self-rated knowledge. This finding supports the current literature, which indicates that high self-rated knowledge can be beneficial for PEH in accessing services specific to their needs and for improving community network navigability (Hwang et al., 2016; Shankar et al., 2019; van Dongen et al., 2019).

Although our ability to evaluate the portable resource guide was tempered by a relatively high attrition rate at follow-up, in other studies, agency-centered interventions like these guides have been shown to increase knowledge of community health resources while still allowing PEH to make their own, autonomous decisions about their health (Freimuth & Quinn, 2004; Köpke et al., 2009; Lenz et al., 2012; Shankar et al., 2019). In the small group of participants evaluated at follow-up, self-rated knowledge significantly increased after receiving the portable resource guide. Interestingly, an increase in knowledge also marked a qualitative decline in resource use, suggesting more efficient decision-making, with PEH potentially relying on a lower number of community health resources for the variety of services needed. Other explanations are possible, and it is important to emphasize the need to for better retainment in future studies to confirm these results. However, implementation of similar, agency-based empowerment interventions has been previously associated with significant improvements in behavioral health and wellbeing (Shankar et al., 2019), including quantitative increases in physical health and life satisfaction related to a sense of autonomy and control among PEH (Parsell et al., 2018).

Prior research indicates that structuring the healthcare network as informed by marginalized populations is crucial for enabling autonomous decision-making as well as for meeting their physical health needs (Dwyer & Duckett, 2016; Entwistle et al., 2010; Marmot, 2011; Parsell et al., 2018; Robert et al., 2015). When organizations root themselves in their population’s own sense of meaning, their ability to shift their accessibility and availability to meet the current needs of the population becomes inconsequential (Shankar et al., 2019). Further, this encourages patient autonomy and empowers them to respond more efficiently in their constantly changing environment (Shankar et al., 2019). The results of the current study add to this increasing body of evidence, which favors interventions that promote autonomy in PEH to benefit their physical and behavioral health. Overall, integrating systems-based improvements with robust interventions at the population level are driving factors in determining how PEH experience and receive meaningful healthcare services.

There are limitations to this study. Due to pandemic-related restrictions during data collection, the sample size for those who completed the follow-up survey was low, limiting follow-up in this high-risk COVID-19 population. While there are no infallible methods for safe conduct of community-based research during a global pandemic, all efforts should be made to mitigate risk to participants and researchers alike. Various strategies to conducting community-based research safely during the COVID-19 pandemic specifically have been suggested, including infectious screening procedures before contact, maintaining face coverings and social distancing, minimizing exchange of materials, and virtual gatherings whenever possible (Rhodes & Sy, 2020; Velagaleti & Vasan, 2020). Among PEH and similar economically-disadvantaged populations, virtual research might become challenging; therefore, research teams should strictly abide by the other precautions in place. When the study environment is deemed safe, researchers might implement a phased reopening in a manner consistent with recommendations from state and local governing institutions (Rhodes & Sy, 2020). Recommendations by the Centers for Disease Control and Prevention (CDC) should also be consulted before local efforts to continue research during a global pandemic. A poor attrition rate in this study is also somewhat expected in studies performed among PEH due to innate instability in their living situations. As such, the efficacy of the portable resource guide cannot be fully determined in this study. Regardless, these study results do offer initial guidance on investigating knowledge around community health resources in this marginalized population; future studies can build upon these findings and explore similar, low-cost interventions and their value in improving resource utilization. Secondly, our participants represent a sample of convenience in a single data collection site. Although their demographic data is consistent with the 2019 Homeless PIT Count, there are few women and non-Black minorities enrolled in this study; hence, the interpretation of results is limited. The main strength of our study includes having the Ozanam Inn as a community partner, who provided insights to study results and opportunities for evidence-based interventions. In addition, although there is a vast amount of literature discussing the unmet health needs in the population of PEH, to the authors’ knowledge, this is the first study to evaluate self-rated knowledge and its implications for autonomous decision-making among PEH.

In conclusion, this study provides a preliminary framework for understanding how self-rated knowledge promotes autonomous decision-making among PEH. In cities with high rates of homelessness and fragmented resource networks, findings such as these are vital for healthcare professionals and community nonprofit organizations in order to improve the navigability of systems and limit barriers to access. Future studies are needed to evaluate the use of interventions, such as portable resource guides, and tools that increase knowledge and autonomous decision-making among PEH. Future studies should also include multiple community sites in various parts of the region to overcome sampling limitations.

Acknowledgements

We would like to acknowledge the Albert Schweitzer Fellowship for the full funding of this project and express our sincere gratitude for their continuous support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Albert Schweitzer Fellowship at Louisiana State University Health Sciences Center in New Orleans, Louisiana.

Notes on contributors

Olivia E. Gilbert

Olivia E. Gilbert is an MD candidate at Louisiana State University Health Sciences Center in New Orleans and an incoming Neurosurgery resident physician at University of North Carolina Chapel Hill. She serves as the Director of the Student Run Community Clinics at the Ozanam Inn, a homeless shelter in New Orleans, Louisiana.

Nicole A. Dominique-Branley

Nicole Dominique-Branley, MD, MPH is a Stanford Pediatrics resident physician at Lucile Packard Children's Hospital in Palo Alto, California.

Abrania Marrero

Abrania Marrero is a PhD candidate in Population Health Sciences, Nutritional Epidemiology at Harvard T.H. Chan School of Public Health. Her research investigates human and global environmental changes in small island food systems, including the impacts of dietary colonialism and climatic shocks on human health, nutrition security, and chronic disease risk.

Melinda S. Sothern

Melinda S. Sothern, PhD, CEP is a licensed clinical exercise physiologist and currently serves as Professor Emerita at the Louisiana State University Health Sciences Center, Schools of Medicine and Public Health in New Orleans, Louisiana. Her research focuses on pediatric exercise physiology, nutritional genomics, social determinants of health and behavioral counseling as it relates to the screening, diagnosis, design, implementation and evaluation of interventions to prevent and treat chronic diseases in childhood such as obesity, type 2 diabetes, asthma, musculoskeletal and emotional disorders.

Stephen Phillippi

Stephen Phillippi, PhD is the Chair of Behavioral & Community Health Sciences at the Louisiana State University Health Sciences Center's School of Public Health. As a full professor, with tenure, he is also the Director of the Institute for Public Health & Justice and Founding Director of the Center for Evidence to Practice, both working to bring evidence-based practices and supportive policies to states and local communities.