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Failing a generation: the impact of culture on the health and well-being of youth.

Trends in suicide, mental disorders, drug abuse and crime suggest western industrial societies are becoming increasingly harmful to psychological and social well-being. These trends are usually explained in personal, social and economic terms; problems in personal relationships, poverty, family conflict and breakdown, unemployment, homelessness, education pressures and demographic changes. The contribution of the culture of western societies to our worsening predicament, most evident among our youth, may be seriously under-estimated because it is more difficult to assess. Yet modern western culture arguably fails to meet the most fundamental requirements of any culture: to provide a sense of belonging and purpose, and so a sense of meaning and self-worth, and a moral framework to guide our conduct. This cultural failing may be more apparent in Australia, and other 'new' western nations because they are young, heterogeneous peoples, without a long, shared cultural heritage or a strong sense of identity.

Adolescent↗

Partnership for health care. An academic nursing center in a rural community college.

Academic nursing centers, owned and administered by schools of nursing, provide ambulatory care in settings in which nurses are both health care providers and clinic managers. Such centers are growing in number within the United States (1,2). In contrast to academic health centers that are based on a medical model, they "give the client direct access to professional nursing services ... using nursing models of health" (3). Academic nursing centers provide accessible and affordable health care services to a variety of clients, including women and children, the elderly, the homeless, minorities, and low-income and underserved persons. They are based in diverse settings--schools of nursing, senior or neighborhood centers, public housing projects, storefronts, churches, schools, and mobile vans--and in some instances, they serve as home care providers (4). They have in common their ownership by schools of nursing.

Adolescent↗

Youth health: street kids in an inner suburb of Melbourne.

This study has investigated a primary medical care service established within a Community Health Centre aimed at young homeless people. The study shows the service clearly reaches the target group, and indicates other young people are also prepared to access this service. The results illustrate to some extent the collective disadvantages faced by this group of young people, not only because of their homelessness, but in terms of their needs regarding personal and financial support. In particular, the study confirms substance abuse as a major problem in this population, and indicates the need for further examination of the use of health care services by this group, particularly in relation to women's health issues.

Adolescent↗

Rapid hiv testing in urban outreach: a strategy for improving posttest counseling rates.

In 1998, 48% of persons who had HIV testing at publicly funded sites in the United States failed to return for test results and posttest counseling. Opportunities for timely HIV therapy were lost; valuable resources were wasted. This study tested the hypothesis that rapid HIV testing enables a high percentage of high-risk outreach clients to learn their serostatus. We did on-site counseling and rapid HIV testing at community-based organizations (e.g., chemical dependency programs, homeless shelters) in North Minneapolis. The project tested 735 persons. All but one (99.9%) learned their HIV serostatus. African Americans made up 79% of subjects. Rapid testing has a role to play in HIV outreach. It is useful in populations who are at high risk of HIV infection, who currently are not accessing HIV testing, and who have high failure to return rates. Future developments in rapid testing technology will make this testing option more convenient and cost-effective.

AIDS Serodiagnosis↗

Training in community psychiatry: new opportunities.

The authors describe the impact on training that accompanied an assignment of senior (PGY-4) residents to work one-half day each week for a six month period at a community-based agency concerned with the care of persons with severe and persistent mental illness who were formerly homeless. As the goals and methods of psychiatric training are rethought and adapt to programmatic shifts and economic pressures, new opportunities open up to move treatment and training to the "front lines" in the community where an innovative therapeutic armamentarium for persons with severe and chronic mental illness is developing.

Community Mental Health Services↗

Becoming and remaining homeless: a qualitative investigation.

This article reports the qualitative findings of a multimethod study of the homeless population in Toronto, Canada. The qualitative component sought to identify how people become homeless and why some individuals remain homeless for an extended period of time or cycle in and out of homelessness (the chronically homeless). In-depth, semistructured interviews were conducted with 29 homeless adults. The findings suggest that people both become and remain homeless due to a combination of macro level factors (poverty, lack of employment, low welfare wages, lack of affordable housing) and personal vulnerability (childhood abuse or neglect, mental health symptoms, impoverished support networks, substance abuse). Chronically homeless individuals often reported experiences of severe childhood trauma and tended to attribute their continued homelessness to a substance abuse problem. It is concluded that both macro and individual level factors must be considered in planning programs and services to address the issue of homelessness in Canada.

Adolescent↗

The closing of Central State Hospital: long-term outcomes for persons with severe mental illness.

This study examined the clinical/community functioning of long-stay patients following closing of a large state psychiatric hospital. Two overlapping samples were followed: (1) the tracking project collected information on patient location, treatment provision, legal contacts, and level of functioning (LOF) and followed all discharged patients and (2) the research study subsample, drawn from the final group of discharged patients, gathered information on quality of life (QOL), LOF, and general physical and mental health. At follow-up, patients were functioning equal to or better than prior to discharge. There were consistent improvements in QOL (especially safety and occupational satisfaction) and LOF (especially housing and income/benefits). Fewer than 27% of patients discharged into the community were rehospitalized, and fewer than 4% were either in jail or homeless after 24 months. The study demonstrates that even persons who have been hospitalized for extremely long periods can do well in the community.

Adult↗

Mental health/mental illness of the elderly who are homeless.

In the United States, there are 6000 people who become 65 years of age each day becoming part of the thirteen percent of the U.S.A. population that is 65 or over, 30 million persons. The U.S. Census Bureau has estimated that, by the year 2050, more than 100 million will be 55 or older, and that 30 million will be older than 75 (American Association of Retired Persons [AARP], 1991). This article describes the recent research on the prevalence of the homeless elderly, with emphasis on their mental health/mental illness.

Aged↗

Characteristics and service use of long-term members of self-help agencies for mental health clients.

OBJECTIVE: This study examined the characteristics of long-term members of self-help agencies managed and staffed by mental health clients, why they sought help from the agencies, and how they differed from clients of community mental health agencies. METHODS: A survey and assessment instruments were used to obtain information on the service utilization of 310 long-term agency members as well as on their resources, history of disability, functional status, psychological disability, health problems, and DSM-III-R diagnosis. Data from management information systems of the self-help and community mental health agencies were used to compare service populations. RESULTS: The self-help agencies served a primarily African-American population (64 percent), many of whom were homeless (46 percent). Eighty-seven percent had confirmed DSM-III-R diagnoses, and 50 percent had dual diagnoses with moderate to severe substance or alcohol abuse or dependence. They had sought help from the self-help agencies primarily for resources such as food or clothing, for "a place to be," or because they were homeless. Obtaining counseling or help for substance or alcohol abuse was a less important reason for coming to the self-help agencies. CONCLUSIONS: A high proportion of the persons served by the self-help agencies in the study were homeless and had a dual diagnosis of mental disorder and substance abuse. The self-help agencies provided their clients with material resources while community mental health agencies provided psychotherapeutic and medical care.

Activities of Daily Living↗

Urban homelessness and poverty during economic prosperity and welfare reform: changes in self-reported comorbidities, insurance, and sources for usual care, 1995-1997.

Little is known of how homeless and other urban poor populations have fared during the robust economy and within structural changes in health care delivery and entitlement programs of the 1990s. This is important in determining the need for population-specific services during a vigorous economy with low unemployment and increasing Medicaid managed-care penetration. This study compared health insurance status and availability of a source for usual medical care, psychiatric and substance abuse comorbidities, and perceived causes of homelessness in homeless adults surveyed in 1995 and 1997. Cross-sectional, community-based surveys were conducted in 1995 and 1997 at sites frequented by urban homeless adults residing in Pittsburgh, Pennsylvania. Self-reported medical, mental health, and substance abuse comorbidities, health insurance, and source for usual care were measured. Compared to the 388 individuals surveyed in 1995, the 267 homeless adults surveyed in 1997 had more medical comorbidity (56.6% vs. 30.2%, P <.001) and mental health comorbidity (44.9% vs. 36.9%, P =.04) and required more chronic medication (52.1% vs. 30.3%, P <.001). More respondents in 1997 than 1995 reported having no health insurance (41.4% vs. 29.4%, P <.001). While there was no difference in the overall proportion reporting a source for usual care (78.3% in 1997 vs. 80.2% in 1995, P =.55), fewer persons reported use of the emergency department and more persons reported using a shelterbased clinic for usual care in 1997 compared with 1995. These findings suggest more need for medical care among homeless and urban poor persons in 1997 compared with 1995 and support the continued need for outreach and support services despite a vigorous economy.

Adolescent↗

Homeless veterans.

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Ill-Housed Persons↗