In This Issue:
- Homeless Families with Children: Programmatic Responses of Five Communities
- Adolescent Health
- Rising Health Care Costs: Causes, Implications, and Strategies
- HIV Disease in Correctional Facilities
HOMELESS FAMILIES WITH CHILDREN: PROGRAMMATIC RESPONSES OF FIVE COMMUNITIES
Prior to the 1980s, the profile of a homeless person was a middle-aged, single man with a chronic alcohol problem, frequently found sleeping on a park bench or a grate. In the past decade, though, the ranks of the homeless have grown to include families, usually composed of young mothers with preschool children and infants. According to the best estimates available, between 25 percent and 41 percent of all homeless individuals are members of homeless families; and between 10 percent and 15 percent of all homeless households are homeless families with children. A 1989 report by the General Accounting Office (GAO) estimates that 68,000 children and youth age 16 and younger are members of homeless families. Data on unaccompanied youth are scarce; however, GAO suggests as many as 208,000 youth may be unaccompanied and homeless each year.
The extent and rapid growth of homelessness among families with children have demanded a response beyond the capabilities of local emergency shelter systems. Consequently, government programs, legislative initiatives, and private efforts have sought to prevent homelessness by bolstering the self-sufficiency of individuals and families at risk, in addition to ameliorating the immediate effects of homelessness by providing emergency food and shelter.
The report, Homeless Families with Children: Programmatic Responses of Five Communities, documents an exploratory study that examined the ways in which existing programs or service delivery systems have adapted to meet the needs of homeless families with children. The report describes the specialized needs of homeless families and provides insights into the prevalence of this population and factors contributing to family homelessness. It identifies and examines in-depth programs in Atlanta, Baltimore, Boston, Minneapolis, and Oakland that were designed to meet the needs of homeless families and that are widely regarded as model approaches. The report also identifies policy issues and barriers affecting programs for homeless families.
Findings primarily relate to the coordination and comprehensiveness of services. At the public agency level, little coordination was found among agencies handling homeless families' problems. The programs established to help these families often lack integrated service delivery, services planning such as case management, follow-up of families that leave the service system, and outcome evaluation.
Regarding comprehensiveness of services, the cities visited do not have in place a true housing continuum that includes emergency shelter, transitional housing, and services-enriched permanent housing. As a result, homeless families are often left to navigate the system on their own and consequently may not receive the services they need to achieve independence.
Preschool programs including Head Start serve only a minority of homeless preschool-age children; inadequate child care for families that leave the homeless service system is one of the most common obstacles to independent living. On the positive side, homeless school-age children do have access to the public school system. Also, homeless families are routinely provided eligibility screening and application assistance for the Special Supplemental Food Program for Women, Infants, and Children (WIC) and for major entitlement programs such as Aid to Families with Dependent Children (AFDC), Medicaid, and Food Stamps.
The federal Interagency Council on the Homeless has been briefed on the findings of the study and is addressing its recommendations.
The study was conducted under contract by Macro Systems, Inc., for the Office of the Assistant Secretary for Planning and Evaluation. The study's project officer, Laura Feig, can be reached on 202-690-5938. Copies of the final report, #4068, are available from PIC.
Adolescents are commonly regarded as among the healthiest of Americans and among the least in need of health services. However, recent data suggest that, when considering biomedical, behavioral, and social health, one out of five of today's 31 million adolescents have at least one serious health problem. Even more disturbing, American adolescents often face formidable barriers when trying to obtain basic health care.
The report, Adolescent Health, reviews the physical, emotional., and behavioral health status of contemporary American adolescents. The study focused on both males and females aged 10 through 18 of various socioeconomic backgrounds and geographic areas. The report identifies risk and protective factors for adolescent health problems. It also evaluates options in the organization of health services and technologies available to adolescents (including accessibility and financing), assesses options to improve collecting adolescent health statistics, and identifies gaps in research on the health and behavior of adolescents.
Adolescents as a group have among the lowest mortality rates in the United States, with the leading causes of death being injuries, including accidents, suicide, and homicide. The study identified the major adolescent health problems as being related to family life (such as abuse and neglect); schooling (such as boredom); lack of recreational opportunities; chronic physical illness (especially acute respiratory illness, which is the leading cause of absence from school); nutrition and fitness; dental and oral hygiene; AIDS and other sexually transmitted diseases; pregnancy and parenting; mental health; alcohol, tobacco, and illicit drug abuse; delinquency; and homelessness.
The study found differences in the types of health problems experienced by males and females, older and younger adolescents, and different racial and ethnic groups. The study also found that preventive efforts (such as using seat belts and contraception, acquiring training, etc.) that change the environment, provide some form of protection, or improve skills are more effective than didactic, education-based interventions. Also, preventive efforts that use comprehensive approaches involving multiple systems and addressing multiple issues may be more effective than traditional single-issue, single-focus approaches. In many cases such as suicide and drug abuse, early intervention with appropriate clinical services may be both more feasible and more effective than primary prevention.
When preventive interventions do not work, treatment is necessary. Unfortunately, many American adolescents needing treatment are faced with problems related to the accessibility and the appropriateness of the services. In addition, the effectiveness of treatment approaches for some highly visible problems such as drug abuse has not yet been adequately assessed. The study found one of the most promising recent innovations addressing health and related needs of adolescents is the school-linked services center. These centers offer adolescents confidential services at no expense. Blanket consent is usually obtained from parents before the adolescent seeks services.
The report concludes that a more sympathetic, suppoqive approach to adolescents is needed. It also urges the federal government to restructure and invigorate its role in researching adolescent health status and needs and in providing necessary services.
Copies of the executive summary, #4019, are available from PIC.
RISING HEALTH CARE COSTS
Although the United States is a leader in medical research and has the capability to deliver the highest quality health care in the world, criticisms of its health care system have grown throughout the past decade. Health care spending per person in the U.S. is very high compared with other industrialized countries and is increasing more rapidly than national income. In addition, many Americans are uninsured and ineligible for existing public health care programs. An aging population and more effective and costly medical technologies contribute to the high and rapidly rising costs. However, many observers suggest that a major reason is the failure of the normal discipline of the marketplace to limit the quantity of services supplied, resulting in part from consumers paying less than full price out of pocket for the services they purchase.
The report, Rising Health Care Costs: Causes, Implications, and Strategies, describes the factors responsible for rising health care costs in the United States and examines various cost-containment strategies and the extent to which they have been effective.
Comparisons of health care costs in the U.S., West Germany, Japan, and the United Kingdom show that the U.S. spends more per capita for health care than any other industrialized country and that in 1980 the U.S. spent 1 1 percent of its federal budget on health care. Trends identified as contributing to the increasing health care expenditures include the aging of our population, continuous development of effective but costly medical technologies, decreased out-of-pocket spending, which encourages consumers to purchase more services and higher quality services than if consumers were paying for them in full, and increased testing by physicians to prevent liability lawsuits and to conform with widely accepted practice guidelines. The report suggests the following cost-containment efforts: cost-sharing by consumers; managed care, which includes third-party payors' review of services to be provided and limitations on patients'choices of providers; and price controls. Regulatory strategies in the U.S. have included health planning and certificate-of-need programs, state all-payor rate-setting programs, and controls on expenditures. The report concludes that, by combining several cost-containment policies, the U.S. could better control health care spending.
Copies of the executive summary, #4020, are available from PIC.
HIV DISEASE IN CORRECTIONAL FACILITIES
The human immunodeficiency virus (HIV) epidemic has had a substantial impact at the nation's prisons and jails. Numerous studies have confirmed that the rate of HIV infection in correctional facilities is disproportionately high compared with the general population and is challenging the already marginally sufficient prison health care capabilities.
The report, HIV Disease in Correctional Facilities, discusses the special health care, human rights, and education issues that face the nation and its federal, state, and local correctional facilities in their management of detainees and prisoners living with HIV disease, i.e., the continuum of conditions that begins with seroconversion and ends with AIDS. The report reflects the testimony of numerous experts, health care professionals, prisoners' rights advocates, educators, correctional personnel, and former inmates and current prisoners living with HIV disease.
The numerous problems resulting from the inadequate health care and the overcrowded conditions in correctional facilities are documented in this report. To start, the report cites a 1987 study conducted by the Correctional Association of New York that suggests that prisoners with AIDS may be dying at twice the rate of nonprisoners with AIDS. The report addresses the issue that prisoners with HIV infection are rapidly acquiring tuberculosis and many more are at increased risk from the resurgent tuberculosis epidemic now pervading the nation's prisons. Because of the lack of privacy when inmates meet with medical personnel, the lack of privacy when the medication is distributed, and the segregation policies in many prisons, the confidentiality of HIV-infected inmates is often violated. Noninfected inmates and staff fear even casual contact with HIV-infected inmates. Often, doctors and dentists refuse to treat those individuals. The study also found that former prisoners are re-entering their communities with little or no knowledge about HIV disease and how to prevent its spread.
Recommendations include that (1) the Public Health Service develop guidelines for the prevention and treatment of HIV disease in the nation's prisons, take steps to control the tuberculosis epidemic, and increase its attention to women and adolescents in regard to these policies; (2) prison officials assess conditions of confinement, adequacy of health care delivery systems, HIV education programs, and the availability of HIV testing and counseling for prisoners; and (3) a program such as the National Health Service Corps be created to attract health care providers to work in correctional facilities.
The study was conducted by the National Commission on AIDS, Washington, D.C. Copies of the executive summary, #4027, are available from PIC.
SERVICES AVAILABLE FROM THE PIC
The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: http://aspe.hhs.gov/PIC/. Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at: email@example.com