The medical care of street youth

Our clinical contacts with street youth support the view that their numbers are growing and that their medical needs are largely neglected. We describe our experience in providing medical care to street youth in Seattle, with attention to their medical presentations and patterns of health care utilization. We address aspects of adolescent street life that are unique to that particular mode of living or importantly formative in the lives of persons drawn to it.     

A risk profile comparison of homeless youth involved in prostitution and homeless youth not involved

All initial visits (n = 620) of runaway/homeless youths to an outpatient medical clinic over a 12-month period (July 1988-June 1989) were analyzed. Of these visits, 467 made by youth not involved in prostitution were compared with 153 visits by youth who were involved. According to the data from an adolescent risk profile interview, homeless youth involved in prostitution are at greater risk for a wide variety of medical problems and health-compromising behaviors, including drug abuse, suicide, and depression. The implications for public health and social policy are discussed.     

Homeless and runaway youth mental health issues: No access to the system

Data from a center for homeless and runaway youth are presented in order to summarize the major mental health problems faced by these youth. This article also identifies indicators related to behavioral and environmental variables that may help in the development of intervention and prevention strategies for this population.     

Service utilization among homeless and runaway youth in Los Angeles, California: rates and reasons

Purpose: To describe the service utilization patterns of homeless and runaway youth in a “service-rich” area of Los Angeles, California; identify demographic and other correlates of utilization; and contextualize the findings with qualitative data.

Method: During Phase 1 of this study, survey data were collected from an ethnically diverse sample of 296 youth aged 13–23 years, recruited from both service and natural “hang-out” sites using systematic sampling methods. During Phase 2, qualitative data were collected from 46 youth of varying ethnicities and lengths of time homeless.

Results: Drop-in centers and shelters were the most commonly used services (reported by 78% and 40%, respectively). Other services were used less frequently [e.g., medical services (28%), substance abuse treatment (10%) and mental health services (9%)]. Utilization rates differed by ethnicity, length of time in Los Angeles, and city of first homeless episode (Los Angeles versus all others). Shelter use was strongly associated with use of all other services. Despite youths’ generally positive reactions to services, barriers were described including rules perceived to be restrictive, and concerns youth had about confidentiality and mandated reporting. Youth suggested improvements including more targeted services, more long-term services, revised age restrictions, and more and/or better job training and transitional services to get them off the streets.

Conclusions: Because shelters and drop-in centers act as gateways to other services and offer intervention potential for these hard-to-reach youth, it is vital that we understand the perceived barriers to service utilization.     

Service utilization among homeless and runaway youth in Los Angeles, California: rates and reasons.

PURPOSE: To describe the service utilization patterns of homeless and runaway youth in a "service-rich" area (Los Angeles, California); identify demographic and other correlates of utilization; and contextualize the findings with qualitative data. METHOD: During Phase 1 of this study, survey data were collected from an ethnically diverse sample of 296 youth aged 13-23 years, recruited from both service and natural "hang-out" sites using systematic sampling methods. During Phase 2, qualitative data were collected from 46 youth of varying ethnicities and lengths of time homeless. RESULTS: Drop-in centers and shelters were the most commonly used services (reported by 78% and 40%, respectively). Other services were used less frequently [e.g., medical services (28%) and substance abuse treatment (10%) and mental health services (9%)]. Utilization rates differed by ethnicity, length of time in Los Angeles, and city of first homeless episode (Los Angeles vs. all others). Shelter use was strongly associated with use of all other services. Despite youths' generally positive reactions to services, barriers were described including restrictive rules, confidentiality and reporting problems, and negative interactions with staff members. Youth suggested improvements including more targeted services, more long-term services, revised age restrictions, and more and/or better job training and transitional services to get them off the streets. CONCLUSIONS: Because shelters and drop-in centers act as gateways to other services and offer intervention potential for these hard-to-reach youth, it is vital that barriers to use of these services are eliminated.     

Providers of primary care to homeless women in Los Angeles County

Little is known about the access barriers homeless women face at the sites where they are most likely to receive primary health care. To investigate this issue, we administered a mail survey to administrators and clinicians at clinic sites that were actual or potential providers of primary health care to homeless women in Los Angeles County in 1997. The response rate was 65%. Ninety percent of the homeless women seen by responding sites were seen at only 34% of those sites (designated as "major providers"). Deficiencies were identified in several structural and process characteristics that enhance access to and quality of care for homeless women, including clinician training in care for homeless persons; formal screening for homeless status and associated risk factors; and on-site provision of comprehensive health services, including mental health, substance abuse, reproductive health, and ancillary services. Some, but not all, deficiencies were less severe at major providers. Our results suggest that, although providers of care to homeless women share challenges faced by many safety net providers, there are several policy interventions that could improve access to and quality of care for homeless women.     

Runaway and Pregnant: Risk Factors Associated with Pregnancy in a National Sample of Runaway/Homeless Female Adolescents

PURPOSE: Homeless youth are at particularly high risk for teen pregnancy; research indicates as many as 20% of homeless young women become pregnant. These pregnant and homeless teens lack financial resources and adequate health care, resulting in increased risk for low-birth-weight babies and high infant mortality. This study investigated individual and family-level predictors of teen pregnancy among a national sample of runaway/homeless youth in order to better understand the needs of this vulnerable population. METHODS: Data from the Runaway/Homeless Youth Management Information System (RHY MIS) provided a national sample of youth seeking services at crisis shelters. A sub-sample of pregnant females and a random sub-sample (matched by age) of nonpregnant females comprised the study sample (N = 951). Chi-square and t tests identified differences between pregnant and nonpregnant runaway females; maximum likelihood logistic regression identified individual and family-level predictors of teen pregnancy. RESULTS: Teen pregnancy was associated with being an ethnic minority, dropping out of school, being away from home for longer periods of time, having a sexually transmitted disease, and feeling abandoned by one's family. Family factors, such as living in a single parent household and experiencing emotional abuse by one's mother, increased the odds of a teen being pregnant. CONCLUSIONS: The complex problems associated with pregnant runaway/homeless teens create challenges for short-term shelter services. Suggestions are made for extending shelter services to include referrals and coordination with teen parenting programs and other systems of care.     

Medical care capacity for influenza outbreaks,Los Angeles

In December 1997, media reported hospital overcrowding and "the worst [flu epidemic] in the past two decades" in Los Angeles County (LAC). We found that rates of pneumonia and influenza deaths, hospitalizations, and claims were substantially higher for the 1997-98 influenza season than the previous six seasons. Hours of emergency medical services (EMS) diversion (when emergency departments could not receive incoming patients) peaked during the influenza seasons studied; the number of EMS diversion hours per season also increased during the seasons 1993-94 to 1997-98, suggesting a decrease in medical care capacity during influenza seasons. Over the seven influenza seasons studied, the number of licensed beds decreased 12%, while the LAC population increased 5%. Our findings suggest that the capacity of health-care systems to handle patient visits during influenza seasons is diminishing.     

Health and access to care: perspectives of homeless youth in Baltimore City, U.S.A

Homeless youth suffer from high rates of health problems, yet little is known about their perceptions of or context for their own health issues. In this study, a combination of qualitative techniques from participatory rural appraisal and rapid assessment procedures was used to investigate the perceptions of health needs of shelter-based youth in Baltimore, MD in the U.S.A. The most common youth-identified health problems included STDs, HIV/AIDS, pregnancy, depression, drug use and injuries. These correlate well with more objective health status data for the same youth. The youth spoke of environmental safety threats of violence and victimization by adults, as well as racism and sexism in their lives. Youth reported that trusted adult figures such as grandmothers are important sources of health advice. Many homeless youth from less than ideal family situations remain in contact with and continue to seek advice from parents and other family members. Health interventions with urban street youth need to acknowledge the primacy of the social context for these youth, as well as the reality of violence as a daily health threat.     

Sociodemographic and substance use characteristics associated with typologies and composition of social support networks among youth experiencing homelessness in Los Angeles,USA

Youth experiencing homelessness are a vulnerable population with increased behavioural health risks. Social networks are a consistent correlate of youths’ substance use behaviours. However, less is known about the reciprocal relationships among these constructs. This study classified youth experiencing homelessness according to their social support network type (e.g. instrumental, emotional, service) and composition (e.g. family, peers, service staff) and linked their membership in these social network classes to sociodemographic and substance use characteristics. Four waves of cross‐sectional data were collected between October 2011 and June 2013 from youth experiencing homelessness, ages 14–29, at three drop‐in centres in Los Angeles, CA (N = 1,046). This study employed latent class analysis to identify subgroups of youth experiencing homelessness according to the type and composition of their social support networks. Multinomial logistic regression analyses were then conducted to identify the sociodemographic and substance use characteristics associated with social support network class membership. Five latent classes of youths’ social support networks were identified: (a) high staff emotional and service support; (b) high home‐based peer and family emotional, service and instrumental support; (c) moderate street‐ and home‐based peer emotional support; (d) low or no support and (e) high home‐based peer and family emotional and instrumental support. Multinomial logistic regression models indicated that race/ethnicity, gender, sexual orientation, literal homelessness, former foster care experience, depression, heroin and marijuana use were significant correlates of social support network class membership. Results indicate distinct classes of social support networks among youth experiencing homelessness, with certain sociodemographic and substance use characteristics implicated in youths’ social networks.     

Health and health needs of homeless and runaway youth A position paper of the Society for Adolescent Medicine

The experience of runaway and homeless youth in the United States is not entirely unique and should be viewed in an international context. The youth in this country do have some unique characteristics and needs. Homeless youth in affluent societies such as ours are often on the streets for different reasons than those of their counterparts in developing countries. Nonetheless, life on the streets brings with it hazards for all homeless young people. Homeless youth are at risk for a number of serious physical and mental health problems, some resulting in pain and discomfort, others in disability and death.

Less dramatic, but just as critical, is the role that homelessness plays in disrupting an adolescent's healthy development. Many of the youth who become homeless come from dysfunctional families where physical and sexual abuse, neglect, and substance abuse are common.

Homelessness and the experiences associated with homelessness further negatively impact youths' physical, emotional, psychologic, and social development. As a result, most do not develop a healthy sense of self, nor do they establish healthy, supportive peer relationships. The majority of homeless youth drop out of school during their early teens. Thus, they miss the opportunity to develop the kinds of problem-solving and intellectual skills required for securing and maintaining employment as adults.

Homeless youth involved in alcohol and other drug abuse are even more likely to have significant deficits and may be more irresponsible and emotionally immature. Thus, a vicious cycle is established. Rather than acquiring the types of enriching experiences and skills that would enable them to develop into healthy adults, homeless youth become over time more alienated from society. As a result, many will become chemically dependent and chronically homeless adults.     

Risk factors for carriage of meningococcus in the Los Angeles County men's jail system

Ten cases of meningococcal meningitis in the Los Angeles County men's jail system in 1986 were the first known reported cases in this population. New cases have continued into 1990. Nineteen of 21 symptomatic cases identified by serogroup from the men's jail occurring through 1988 had serogroup C. The prevalence of meningococcal carriage and potential risk factors were studied in 1988 among 150 men booked to enter the jail, 350 inmates being released, and 100 jail staff. The prevalence of meningococcal carriage among releases, bookings, and staff were 25.4%, 18.7%, and 5.0%, respectively. Among releases, imprisonment longer than a threshold of 28 days increased carriage of serogroup C 10.0 times (95% confidence interval (CI) 4.6-21.6). Among bookings, household crowding increased serogroup C carriage 8.2 times (95% CI 1.5-45.3). Direct and passive smoking at home increased carriage of any serogroup 5.2 (95% CI 1.2-47.5) and 2.5 (95% CI 1.1-5.8) times, respectively. Feasible potential interventions include banning smoking in the jail and immunization with quadrivalent meningococcal vaccine of booked men sentenced for one month or more.     

The crisis of the Los Angeles County public hospital system: a harbinger for the nation.

The public hospital system in Los Angeles County, California, is in the midst of a major fiscal crisis that has already led to a serious reduction of capacity and could continue to worsen. Given the importance of the public system in a county where 30 percent of the population is uninsured and private hospitals provide very little uncompensated care, what happens in L.A. County is a harbinger for other cities and counties in the United States. This article highlights the issue of the extent to which local taxpayers, as opposed to state or federal taxpayers, are responsible for the continued operation of public hospitals and safety-net facilities in their communities.     

上海市闸北区社区卫生服务管理体制改革研究概述

论述了上海市闸北区社区卫生服务改革实施的背景、可行模式、改革内容及程序；对改革进行阶段性评估的内容、方法以及阶段性评估的初步结论。以管理体制改革为出发点，选择了授权管理经营的改革模式，围绕“两权分离、三权下放”的基本思路，从卫生局和社区卫生服务中心两个层面推开。专家外部阶段性评估认为实施授权管理经营改革有利于内部运行机制的创新，有利于社区卫生服务的改善，有利于经济补偿能力的增强，但同时也存在一些问题需要解决。     

The AIDS-related experiences and practices of primary care physicians in Los Angeles: 1984-89.

Telephone interviews of random samples of Los Angeles primary care physicians in 1984, 1986, and 1989 obtained information about their AIDS-related practice experiences, and sexual history taking. Data from mid-1989 reveal almost 74 percent have worked up at least one patient for AIDS or HIV infection in the past six months and 39.5 percent are caring for at least one patient with AIDS or AIDS-related complex. Self-reported use of appropriate sexual history questions has improved substantially over this five-year period.     

糖尿病管理质量评价指标体系构建与应用

目的以高质量整合型服务提供为导向, 以糖尿病为例, 构建出一套基于整合糖尿病管理模式、全面和具有可操作性的基层糖尿病管理质量评价指标体系。方法利用文献法提取整合相关指标, 以donabedian卫生评估模型和以患者为中心的照料模式为框架构建指标体系, 层次分析法为指标赋权, TOPSIS法评价比较。结果最终形成了包含3个一级指标、17个二级指标、30个三级指标的糖尿病管理质量评价指标体系, 测量广西两县6个乡镇的糖尿病管理质量, 并对其进行排序, 同时, 发现目前糖尿病管理质量存在的主要问题是基层医疗机构管理能力弱, 规范化程度低。结论本研究以糖尿病管理中整合和以患者为中心为立足点, 结合国际理念与地区现状构建了糖尿病管理质量评价指标体系; 通过应用发现该指标体系信度良好, 能反应调查地区糖尿病管理质量总体水平, 并能帮助识别地区糖尿病管理中的问题。