Creating a Science of Homelessness During the Reagan Era

Policy Points:

• A retrospective analysis of federally funded homeless research in the 1980s serves as a case study of how politics can influence social and behavioral science research agendas today in the United States.
• These studies of homeless populations, the first funded by the National Institute of Mental Health, demonstrated that only about a third of the homeless population was mentally ill and that a diverse group of people experienced homelessness.
• This groundbreaking research program set the mold for a generation of research and policy characterizing homelessness as primarily an individual-level problem rather than a problem with the social safety net.

Context

A decade after the nation''s Skid Rows were razed, homelessness reemerged in the early 1980s as a health policy issue in the United States. While activists advocated for government-funded programs to address homelessness, officials of the Reagan administration questioned the need for a federal response to the problem. In this climate, the National Institute of Mental Health (NIMH) launched a seminal program to investigate mental illness and substance abuse among homeless individuals. This program serves as a key case study of the social and behavioral sciences’ role in the policy response to homelessness and how politics has shaped the federal research agenda.

Methods

Drawing on interviews with former government officials, researchers, social activists, and others, along with archival material, news reports, scientific literature, and government publications, this article examines the emergence and impact of social and behavioral science research on homelessness.

Findings

Research sponsored by the NIMH and other federal research bodies during the 1980s produced a rough picture of mental illness and substance abuse prevalence among the US homeless population, and private foundations supported projects that looked at this group''s health care needs. The Reagan administration''s opposition to funding “social research,” together with the lack of private-sector support for such research, meant that few studies examined the relationship between homelessness and structural factors such as housing, employment, and social services.

Conclusions

The NIMH''s homelessness research program led to improved understanding of substance abuse and mental illness in homeless populations. Its primary research focus on behavioral disorders nevertheless unwittingly reinforced the erroneous notion that homelessness was rooted solely in individual pathology. These distortions, shaped by the Reagan administration''s policies and reflecting social and behavioral scientists’ long-standing tendencies to emphasize individual and cultural rather than structural aspects of poverty, fragmented homelessness research and policy in enduring ways.     

Health research funding agencies' support and promotion of knowledge translation: an international study

CONTEXT: The process of knowledge translation (KT) in health research depends on the activities of a wide range of actors, including health professionals, researchers, the public, policymakers, and research funders. Little is known, however, about health research funding agencies' support and promotion of KT. Our team asked thirty-three agencies from Australia, Canada, France, the Netherlands, Scandinavia, the United Kingdom, and the United States about their role in promoting the results of the research they fund. METHODS: Semistructured interviews were conducted with a sample of key informants from applied health funding agencies identified by the investigators. The interviews were supplemented with information from the agencies' websites. The final coding was derived from an iterative thematic analysis. FINDINGS: There was a lack of clarity between agencies as to what is meant by KT and how it is operationalized. Agencies also varied in their degree of engagement in this process. The agencies' abilities to create a pull for research findings; to engage in linkage and exchange between agencies, researchers, and decision makers; and to push results to various audiences differed as well. Finally, the evaluation of the effectiveness of KT strategies remains a methodological challenge. CONCLUSIONS: Funding agencies need to think about both their conceptual framework and their operational definition of KT, so that it is clear what is and what is not considered to be KT, and adjust their funding opportunities and activities accordingly. While we have cataloged the range of knowledge translation activities conducted across these agencies, little is known about their effectiveness and so a greater emphasis on evaluation is needed. It would appear that "best practice" for funding agencies is an elusive concept depending on the particular agency's size, context, mandate, financial considerations, and governance structure.     

Rapid review of five years of Aboriginal and Torres Strait Islander health research in Australia – persisting under‐representation of urban populations

Objective : To review how published Aboriginal and Torres Strait Islander health research reflects the geographical distribution of the Indigenous population of Australia. Methods : Rapid review using Lowitja Institute Lit.search tool for PubMed indexed Indigenous health research papers (January 2013 to January 2018). Geographic location, participant age, study type and recruitment site were identified for each paper. Results : A total of 1,258 research papers were identified: 190 (15%) focused exclusively on Indigenous people living in urban areas; 563 (45%) in rural/remote areas; and 505 (40%) spanned urban and rural/remote areas. Despite similar burdens of disease, three times as many papers were published per 1,000 DALYs for rural/remote areas than urban areas. Conclusions : Indigenous health research publications have more than doubled since 2010. However, research focusing on the health needs of urban Indigenous people remains low relative to disease burden and population. Implications for public health : More research to address the health needs of Indigenous people living in urban areas is required although this should not be at the expense of research for rural and remote areas. Increased funding quarantined for Indigenous health research, coupled with self‐determination of the research agenda and reporting on the geographic representativeness of research, may help address geographical inequities in research outputs.     

Federal Expenditures on Maternal and Child Health in the United States

The goals of this study are to estimate federal maternal and child health (MCH) expenditures and identify their sources. This analysis is intended to provide a broad view of MCH funding appropriations and a basis for discussion of whether funds could be better utilized for the benefit of the population served. Data on federal maternal and child health expenditures for fiscal year (FY) 2006 were derived from examining federal legislation, department/agency budgets, and various web-based program documents posted by federal agencies. Based on selected criteria, we identified programs targeting children under 21 or pregnant/parenting women within the United States. The funding levels of agency programs for maternal and child health activities were determined and the programs briefly summarized. The identifiable funding for maternal and child health programs in FY 2006 approached $57.5 billion dollars. Funding sources for maternal and child health were concentrated within the U.S. Department of Health and Human Services, but spread across several different agencies within the department and in the Departments of Defense, Education, Agriculture, Housing and Urban Development, and the Environmental Protection Agency. Multiple agencies and offices often funded related activities, without evidence of a common underlying strategy. Federal maternal and child health funding mechanisms may lead to a fragmentation in maternal and child health activities. The funding and service delivery apparatus would benefit from an integrative MCH infrastructure approach to pediatric research, service delivery, and data collection/access that incorporates life-course and social/environmental determinants perspectives.     

NIH and USDA funding of dietary supplement research, 1999-2007

Over one-half of U.S. adults use dietary supplements, so federally supported research into the safety and effectiveness of these compounds is important for the health of many Americans. Data collected in the Computer Access to Research on Dietary Supplements database, which compiles federally sponsored dietary supplement-related research, are useful to scientists in determining the type of dietary supplement research that federal agencies are currently funding and where research gaps exist. This article describes the dietary supplement-related research funded by the NIH and the USDA. Between fiscal years 1999 and 2007, the number of research projects and funding for dietary supplement research more than doubled. During that period, NIH funded 6748 dietary supplement-related projects at a cost of $1.9 billion and the USDA funded 2258 projects at a cost of $347 million. The top funded dietary supplement ingredient categories were vitamins and minerals, botanicals, phytochemicals, and fatty acids. Cancer was by far the most frequent health outcome in dietary supplement research funding, nearly double the next closest health outcome category. Other health outcomes with the greatest funding were cellular and molecular mechanisms, cardiovascular health, women's reproductive health, and immune function. The greatest number of dietary supplement research projects are funded by the NIH National Cancer Institute, the NIH National Center for Complementary and Alternative Medicine, the NIH Office of Dietary Supplements, and the USDA Agricultural Research Service.     

State agency policy and program coordination in response to the co-occurrence of HIV,chemical dependency,and mental illness

The co-occurrence of HIV infection, chemical dependency, and mental illness challenges federal and state governments to develop flexible and coordinated health policy and financing for public health services. State agencies play a critical role in the organization and support of these services at the local level. With emerging stress upon state government budgets and concomitant increasing need for publicly funded services, state agency coordination may be an important policy safety net to assure services for populations at the margins of health systems. Despite this important potential role, nothing is known about the degree to which state HIV, substance abuse, and mental health agencies coordinate policies and/or programs in response to these co-morbid conditions. OBJECTIVE: This study sought to establish a conservative and initial understanding of state HIV, substance abuse, and mental health agency coordination of policy and program in response to the co-occurrence of HIV, chemical dependency, and mental illness. METHOD: Estimation of coordination was accomplished through the comparison of three surveys conducted among state substance abuse directors (1998), state AIDS directors (1999), and state mental health directors (2000). Data from 38 states were reviewed. RESULTS: The most frequently reported state agency activities included coordinating funding, engaging in integrative planning activities, and conducting staff cross-training. When compared for association with state characteristics, coordination among state agencies was found to be associated with Early Intervention Services (EIS) designation, higher rates of AIDS generally, higher rates of AIDS among African Americans, and higher rates of AIDS among Hispanic populations. Given the limitations of comparing three disparate surveys, we determined the estimate of interagency coordination to be conservative and preliminary. CONCLUSION: While this study was useful as an initial step toward identifying state interagency policy and program coordination in response to the co-occurrence of HIV, chemical dependency, and mental illness, there were methodological challenges that should be addressed in future studies of state agency coordination. Several recommendations were advanced.     

Influence of Materials on Teacher Adoption of Abstinence-Only- Until-Marriage Programs

BACKGROUND: Given the growing scientific evidence against abstinence-only-until-marriage education, health educators are supporting an evidence-based approach to teaching sexuality education. However, there is still an abundance of federal support and funding streams allocated to sustain abstinence-only programs. This study assessed indicators that influence the adoption of abstinence-only-until-marriage education as well as school teachers' likelihood of adopting such programs.
METHODS: Predictors included relative advantage, compatibility, complexity, and observability and were assessed with a self-administered, validated questionnaire. Additional questions were asked related to demographics, professional history, and abstinence-only-until-marriage education policies and funding. The relationships were tested with multiple regression analysis.
RESULTS: A trend became apparent in which most teachers would allow a state- or federally funded program to be offered and presented in their schools, but most did not know if their school received funding to support abstinence-only-until-marriage education. Attendance at religious services, complexity of abstinence-only-until-marriage programs, and abstinence-only-until-marriage curriculum emerged as important predictors of the likelihood to adopt abstinence education.
CONCLUSIONS: Trends in political agendas, policy development, and state and federal funding have supported abstinence-only-until-marriage education programs. In order to ensure an understanding about the inclusion of sexuality education in the classroom, insight into the teacher's role in the integration of sexuality education in the classroom is important.     

Violence, mental health, substance abuse-problems for women worldwide

The objective of this paper is to bring attention to the epidemic proportions and the burden of disease from the overlapping health and social problems of violence, psychiatric or psychological distress, and substance abuse. Research is needed to prevent, alleviate, and treat these global problems, particularly for women because, although these problems affect the entire population, there are more problems for women. An overview from diverse national and international literature on the three areas is presented. Among health care professionals--physicians, nurses, and others--there is a great need for increased awareness of the problems and culturally sensitive research to understand better the interrelations among violence and anger and mental disorders and substance abuse, not only in high-risk subgroups of the population such as inner-city youths, but also among women and others in the general population globally.     

The Massachusetts HIV, hepatitis, addiction services integration (HHASI) experience: responding to the comprehensive needs of individuals with co-occurring risks and conditions

Categorical funding mechanisms traditionally used to fund public health programs are a challenge to providers serving individuals with complex needs that often span multiple service areas. Integration--a formalized, collaborative process among service systems--responds to the challenge by decreasing fragmentation of care and improving coordination. In 2000, the Massachusetts Department of Public Health (MDPH) received a one-year planning grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to evaluate opportunities for integrating HIV/AIDS programs and substance abuse treatment programs. The project was later expanded to include viral hepatitis programming. Outcomes include the development of a strategic plan, joint procurement initiatives, and an ongoing commitment to sustain inter-bureau integration efforts, even in the face of substantial budget reductions. Integrated approaches can promote greater efficiency, improving communication and coordination among clients, providers, and government funding agencies.     

Health, housing, and public policy

With federal funding of affordable housing declining, health care and housing organizations must work together to advocate sound policy and reasonable funding in this realm. Federal agencies like the U.S. Department of Housing and Urban Development (HUD) and the U.S. Department of Agriculture traditionally have been the primary source of low income housing funds. But key housing programs like HUD's Section 8 have lost a significant amount of funding. Through advocacy efforts, health care and housing organizations can urge legislators to retain or restore these vital programs. They also can support the preservation of affordable housing units in order to counterbalance the trend of these homes being "lost to the market." Also, health care and housing agencies can partner to enhance housing services. Vulnerable populations-such as the elderly, individuals at risk for homelessness, those with disabilities, and the mentally ill-can benefit greatly from the supportive services that health care organizations can offer.     

Clients with substance abuse and mental health concerns: A guide for conducing intake interviews

Although comorbidity (co-occurrence of a psychiatric and substance use disorder) is a common phenomenon at both mental health and substance abuse treatment agencies, rarely do such agencies thoroughly assess for both types of diagnoses during their standard intake interview. This article describes the development of an intake form designed to guide a comprehensive assessment of both mental health and substance abuse concerns. The form guides intake interviewers toward documenting administrative and demographic information, substance use and mental health concerns, and variables needed for compliance with grant funding sources. Use of the protocol can provide a clinical foundation for treatment planning and continuity of care for clients, while also providing error-free agency data that can be used for administrative, program planning, outcome assessment, and research purposes.     

Treading Water: The No-Growth Investment in Health Services Research

There is a “perfect storm” brewing in the American healthcare system. Healthcare spending has grown faster than our economy for many years and is projected to double in as little as 10 years. In spite of what we spend on healthcare, research tells us that we only receive appropriate care half the time. We are simply not getting what we are paying for. Health services research provides the data and the evidence needed to make better decisions, design healthcare benefits, and develop effective policies to optimize healthcare financing, facilitate access to healthcare services, and improve healthcare outcomes. Despite what we know and what we can learn from health services research, federal funding for this important field continues to erode. This article provides a primer on the federal budget process and summarizes findings from the Federal Funding for Health Services Research 2007.Health services research (HSR) explores healthcare costs, quality, and access and seeks ways to improve healthcare delivery, safety, availability, and affordability. HSR has been defined as a “multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to healthcare, the quality and cost of healthcare, and ultimately our health and well-being.”1 In particular, HSR identifies what treatments work best when, for whom, and at what sites of service; it evaluates how best to finance healthcare and control spending; it helps inform healthcare benefit design; it translates the innovations from basic bench science into medical practice, allowing providers, health plans, and patients to make more informed health choices. HSR is the link between research and patient care.Since 2003, the Coalition for Health Services Research (coalition) has been tracking the federal government''s investment in HSR by collecting budgetary data from federal agencies that principally fund HSR. The coalition has been collecting annual budgetary data from the federal agencies that fund HSR. In the past 5 years, we have found that despite what we can learn from HSR, there has been an erosion of federal funding for this field, in part because of competing federal priorities, a constrained fiscal climate, and polarizing partisan politics. These trends have likely hindered the ability of the researchers to examine the healthcare system and identify innovative and effective solutions. If left unchecked, the declining investment in HSR may have further implications for the study of health and patient care in the future.This article provides a primer on the federal budget process and summarizes findings from Federal Funding for Health Services Research 2007, the fifth annual report of HSR expenditures.2Federal agencies have not developed or adopted a uniform definition for HSR or standard categories for collecting and reporting data about reimbursement and funding methodologies, health disparities, patient safety, and chronic disease management. Therefore, questions remain about the breadth and scope of activities included in the funding totals presented in this article. Investments in what any one agency has self-reported as “health services research” may not be equivalent to what is reported by another agency. For example, budget numbers can reflect entire agency budgets, including overhead costs or a rough estimate of dollars spent on HSR. Nevertheless, our data offer the best available estimate on the federal government''s investment in this area.     

Substance abuse treatment management information systems: Balancing federal,state, and service provider needs

There is increased interest in documenting the characteristics and treatment outcomes of clinets served with Alcohol, Drug Abuse, and Mental Health Block Grant funds. The evolution of federal client-based management systems for substance abuse treatment services demonstrates that data collection systems are important but require continued support. A review of the Massachusetts substance abuse management information system illustrates the utility of a client-based data set. The development and impelemntation of a comprehensive information system require overcoming organizational barriers and project delays, fostering collaborative efforts among staff from diverse agencies, and employing considerable resources. In addition, the need to develop mechanisms for increasing the reliability of the data and ongoing training for the users is presented. Finally, three applications of the management information system’s role in shaping policy are reviewed: developing services for special populations (communities of color, women, and pregnant substance abusers, and injection drug users), utilizing MIS data for evaluation purposes, and determining funding allocations.     

Ethical responsibilities of health research funders to advance global health justice

Research funders from high-income countries have an ethical obligation to support health research in low and middle-income countries that promotes justice in global health. Conceptual work from bioethics proposes funders should do so through their design of grants programs, investments, and grants management. That work has begun to specify the content of funders’ ethical responsibility with regards to health systems research, but it has thus far not been informed by their practice. As a first step to bridge that gap, this paper focuses on health systems research funders’ design of grants programs. It aims to test the content of funders’ proposed ethical responsibility against recent empirical work describing how they design their health systems research grants programs to help address global health disparities. Based on that analysis, recommendations are made for how to better articulate the content of health systems research funders’ obligation. Such recommendations may be pertinent to funders of other types of international research. The paper also provides an initial picture of how well health systems research grants programs’ designs may align with the ideals of global health justice.     

Relational systems change

This article describes the "relational systems change" model developed by the Institute for Health and Recovery, and the implementation of the model in Massachusetts from 1998-2002 to facilitate systems change to support the delivery of integrated and trauma-informed services for women with co-occurring substance abuse and mental health disorders and histories of violence and empirical evidence of resulting systems changes. The federally funded Women Embracing Life and Living (WELL) Project utilized relational strategies to facilitate systems change within and across 3 systems levels: local treatment providers, community (or region), and state. The WELL Project demonstrates that a highly collaborative, inclusive, and facilitated change process can effect services integration within agencies (intra-agency), strengthen integration within a regional network of agencies (interagency), and foster state support for services integration.     

Environmental justice at school: understanding research, policy, and practice to improve our children's health

BACKGROUND: No overarching federal agencies or policies are responsible for ensuring environmental health at schools in the United States, potentially allowing many inequities for low‐income and minority communities to persist. This article examines emergent research, policy, and practice‐based efforts that may be used to identify and address environmental justice at school. METHODS: A brief literature review was conducted to understand (1) major mental, behavioral, and physical outcomes associated with environmental risk for school‐aged children and (2) current research methods for assessing these relationships. Documents prepared by government agencies, school districts, and advocacy groups were also collected and synthesized to improve understanding of the state of planning and policies for maintaining or improving school environments. RESULTS: Environmental risk can manifest in diverse ways such as mold, poor air quality, poor community design, or contaminated playgrounds. Deeply rooted in national and state structures of school funding and planning, such risks can lead to outcomes including respiratory illness, poor performance in school, and reduced levels of physical activity. With growing attention to these concerns, methods for measuring environmental risks and underlying disparities have advanced tremendously in the last few decades, yet development of innovative research approaches may be necessary to further advance and evaluate appropriate interventions. CONCLUSIONS: Environmental injustice is generally unacknowledged during decision‐making in US school districts. Continued dialogue reflective of translatable science is necessary to support school districts with limited funding in ensuring safe, healthy environments for learning.     

Behavioral Disorders: The New Public Health Crisis

Behavioral health has become a public health crisis. No other public health crises are as widespread or contribute as much to the burden of illness in the U.S. as do behavioral health disorders. By 2020, mental and substance use disorders will surpass all physical diseases worldwide as major causes of disability. Yet state and federal governments continue to make steep cuts to funding for public behavioral health services. We cannot afford to wait for the next national tragedy to recognize that behavioral health disorders are a public health crisis deserving of our nation's attention and support.     

Community-based participatory research: implications for public health funding

Community-based participatory research (CBPR) increasingly is being recognized by health scholars and funders as a potent approach to collaboratively studying and acting to address health disparities. Emphasizing action as a critical part of the research process, CBPR is particularly consistent with the goals of "results oriented philanthropy" and of government funders who have become discouraged by the often modest to disappointing results of more traditional research and intervention efforts in many low income communities of color. Supporters of CBPR face challenging issues in the areas of partnership capacity and readiness, time requirements, funding flexibility, and evaluation. The authors suggest strategies for addressing such issues and make a case for increasing support of CBPR as an important tool for action-oriented and community-driven public health research.     

Funding agencies in low- and middle-income countries: support for knowledge translation

OBJECTIVE: The aim was to describe how selected health research funding agencies active in low- and middle-income countries promote the translation of their funded research into policy and practice. METHODS: We conducted inductive analysis of semi-structured interviews with key informants from a purposive sample of 23 national and international funding agencies that fund health research in Brazil, Colombia, India, the Philippines, South Africa and Thailand. We also surveyed web sites. FINDINGS: We found a commitment to knowledge translation in the mandate of 18 of 23 agencies. However, there was a lack of common terminology. Most of the activities were traditional efforts to disseminate to a broad audience, for example using web sites and publications. In addition, more than half (13 of 23) of the agencies encouraged linkage/exchange between researchers and potential users, and 6 of 23 agencies described "pull" activities to generate interest in research from decision-makers. One-third (9 of 23) of funding agencies described a mandate to enhance health equity through improving knowledge translation. Only 3 of 23 agencies were able to describe evaluation of knowledge translation activities. Furthermore, we found national funding agencies made greater knowledge translation efforts when compared to international agencies. CONCLUSION: Funding agencies are engaged in a wide range of creative knowledge translation activities. They might consider their role as knowledge brokers, with an ability to promote research syntheses and a focus on health equity. There is an urgent need to evaluate the knowledge translation activities of funding agencies.