Randall Kuhn

Applying Cluster Analysis to Test a Typology of Homelessness by Pattern of Shelter Utilization: Results from the Analysis of Administrative Data

This study tests a typology of homelessness using administrative data on public shelter use in New York City (1988–1995) and Philadelphia (1991–1995). Cluster analysis is used to produce three groups (transitionally, episodically, and chronically homeless) by number of shelter days and number of shelter episodes. Results show that the transitionally homeless, who constitute approximately 80% of shelter users in both cities, are younger, less likely to have mental health, substance abuse, or medical problems, and to overrepresent Whites relative to the other clusters. The episodically homeless, who constitute 10% of shelter users, are also comparatively young, but are more likely to be non-White, and to have mental health, substance abuse, and medical problems. The chronically homeless, who account for 10% of shelter users, tend to be older, non-White, and to have higher levels of mental health, substance abuse, and medical problems. Differences in health status between the episodically and chronically homeless are smaller, and in some cases the chronically homeless have lower rates (substance abuse in New York; serious mental illness in Philadelphia). Despite their relatively small number, the chronically homeless consume half of the total shelter days. Results suggest that program planning would benefit from application of this typology, possibly targeting the transitionally homeless with preventive and resettlement assistance, the episodically homeless with transitional housing and residential treatment, and the chronically homeless with supported housing and long-term care programs.

The co-occurrence of AIDS and homelessness: results from the integration of administrative databases for AIDS surveillance and public shelter utilisation in Philadelphia

STUDY OBJECTIVE Administrative databases from the City of Philadelphia that track public shelter utilisation (n=44 337) and AIDS case reporting (n=7749) were merged to identify rates and risk factors for co-occurring homelessness and AIDS. DESIGN Multiple decrement life tables analyses were conducted, and logistic regression analyses used to identify risk factors associated with AIDS among the homeless, and homelessness among people with AIDS. SETTING City of Philadelphia, Pennsylvania, USA. MAIN RESULTS People admitted to public shelters had a three year rate of subsequent AIDS diagnosis of 1.8 per 100 person years; nine times the rate for the general population of Philadelphia. Logistic regression results show that substance abuse history (OR = 3.14), male gender (OR = 2.05), and a history of serious mental disorder (OR = 1.62) were significantly related to the risk for AIDS diagnosis among shelter users. Among people with AIDS, results show a three year rate of subsequent shelter admission of 6.9 per 100 person years, and a three year rate of prior shelter admission of 9%, three times the three year rate of shelter admission for the general population. Logistic regression results show that intravenous drug user history (OR = 3.14); no private insurance (OR = 2.93); black race (OR = 2.82); pulmonary or extra-pulmonary TB (OR = 1.43); and pneumocystis pneumonia (OR = 0.56) were all related to the risk for shelter admission. CONCLUSIONS Homelessness prevention programmes should target people with HIV risk factors, and HIV prevention programmes should be targeted to homeless persons, as these populations have significant intersection. Reasons and implications for this intersection are discussed.

Predictors of Exit and Reentry among Family Shelter Users in New York City

This study explores the process of exit from and reentry to public family shelters for homeless families in New York City. A Cox proportional-hazards model was developed to identify the effects of demographic, family structure, reason for homelessness, and time-related variables on the hazard rates for different types of shelter discharge and shelter reentry. The study specifically explores the significance of type of housing placement as a predictor variable for shelter reentry. Various demographic and family structure attributes are linked with shelter exit and reentry, including race and ethnicity, family size, age of family head, pregnancy status, and public assistance recipiency status. Although there is a trade-off between length of shelter stay and type of housing placement at shelter discharge, procuring subsidized housing is associated with a substantially lower probability of shelter readmission. Policy implications of these findings and future directions for research on the dynamics of family homelessness are discussed.

Patterns and determinants of public shelter utilization among homeless adults in New York City and Philadelphia

Administrative data on public shelter utilization among homeless adults from New York City (1987–1994) and Philadelphia (1991–1994) are analyzed to identify the relative proportion of shelter users by length of stay and rate of readmission, and to identify the characteristics that predict an exit from shelter. Survival analyses reveal that half of adult shelter users will stay fewer than 45 days over a two-year period (combined stays), and that approximately one half of men and one third of women will experience a readmission within two years of the first admission. Results also document the size and relative resource consumption of a long-term sheltered population, finding that 18.2 percent of New York shelter users stay 180 days or more in their first year, consuming 53.4 percent of the system days for first-time shelter users. Discrete-time logistic hazard regression analyses reveal that, in general, being older, of black race, having a substance abuse or mental health problem, or having a physical disability, significantly reduces the likelihood of exiting shelter. In both cities, people entering shelter in later years are staying longer, although individuals have shorter episodes on subsequent admissions. The implications of this study for the analysis and management of emergency shelter system utilization are discussed.

Trends in Compulsory Licensing of Pharmaceuticals Since the Doha Declaration: A Database Analysis

Reed Beall and Randall Kuhn describe their findings from an analysis of use of compulsory licenses for pharmaceutical products by World Trade Organization members since 1995.

The Effects of Children’s Migration on Elderly Kin’s Health: A Counterfactual Approach

Recent studies of migration and the left-behind have found that elders with migrant children actually experience better health outcomes than those with no migrant children, yet these studies raise many concerns about self-selection. Using three rounds of panel survey data from the Indonesian Family Life Survey, we employ the counterfactual framework developed by Rosenbaum and Rubin to examine the relationship between having a migrant child and the health of elders aged 50 and older, as measured by activities of daily living (ADL), self-rated health (SRH), and mortality. As in earlier studies, we find a positive association between old-age health and children’s migration, an effect that is partly explained by an individual’s propensity to have migrant children. Positive impacts of migration are much greater among elders with a high propensity to have migrant children than among those with low propensity. We note that migration is one of the single greatest sources of health disparity among the elders in our study population, and point to the need for research and policy aimed at broadening the benefits of migration to better improve health systems rather than individual health.

Understanding Interhousehold Transfers in a Transition Economy: Evidence from Russia

This article uses data from the Russian Longitudinal Monitoring Survey to describe the patterns and determinants of private interhousehold transfers. Russian households have experienced large reductions in income during the post‐Soviet transition period, with a particularly severe decline occurring in the fall of 1998. Sharply declining fertility, increasing mortality, and past demographic catastrophes have left a population that is both young (few elderly) and old (one of the oldest working‐age populations in the world). Informal networks in Russia are likely to take on distinctive characteristics as the country’s economic institutions are underdeveloped and there is a very limited social safety net, while household structure closely resembles that found in much wealthier countries. Although it is often assumed that the elderly in Russia are a highly vulnerable economic group, we actually find that transfers flow strongly from elderly and “empty‐nest” households to households in the early part of the life course. This is especially true for older households in rural areas. Descriptive statistical models show a tendency toward increasing net transfer outflow as households age, expressed first through declining transfer receipt and later through increased giving of transfers. Although the tendency toward net transfer outflow slows down for the elderly, we also find that elderly pension income, which proved more consistent through the initial posttransition period than wages or other public transfers, are redistributed to younger households.

Projections of global health outcomes from 2005 to 2060 using the International Futures integrated forecasting model

OBJECTIVE To develop an integrated health forecasting model as part of the International Futures (IFs) modelling system. METHODS The IFs model begins with the historical relationships between economic and social development and cause-specific mortality used by the Global Burden of Disease project but builds forecasts from endogenous projections of these drivers by incorporating forward linkages from health outcomes back to inputs like population and economic growth. The hybrid IFs system adds alternative structural formulations for causes not well served by regression models and accounts for changes in proximate health risk factors. Forecasts are made to 2100 but findings are reported to 2060. FINDINGS The base model projects that deaths from communicable diseases (CDs) will decline by 50%, whereas deaths from both non-communicable diseases (NCDs) and injuries will more than double. Considerable cross-national convergence in life expectancy will occur. Climate-induced fluctuations in agricultural yield will cause little excess childhood mortality from CDs, although other climate-health pathways were not explored. An optimistic scenario will produce 39 million fewer deaths in 2060 than a pessimistic one. Our forward linkage model suggests that an optimistic scenario would result in a 20% per cent increase in gross domestic product (GDP) per capita, despite one billion additional people. Southern Asia would experience the greatest relative mortality reduction and the largest resulting benefit in per capita GDP. CONCLUSION Long-term, integrated health forecasting helps us understand the links between health and other markers of human progress and offers powerful insight into key points of leverage for future improvements.

Identities in motion: Social exchange networks and rural- urban migration in Bangladesh

Expanding on work that demonstrates the importance of rural resources (land, manpower) on rural-urban migrant success in Bangladesh, the article incorporates the role of an expanding network of village-based social connections in perpetuating the flow of migration and ensuring migrant success. As kin groups, lineages, and entire villages shift from their home settings to major cities, identities that had little meaning in the local context are mobilised to create trust between past and future migrants. Identity- based migration opportunities function as a new source of capital in a society with severe constraints on formal credit and insurance markets, allowing small landholders to pre serve their livelihood in exchange for allegiance to an increasingly influential group of urban gatekeepers. This fluid notion of identity often bends to more traditional social and economic concerns, however, generating a network whose membership is determined as much by pre-existing social relationships, spatial proximity and resource holdings, as by a potential migrants skills, honesty or effort. Thesefindings raise critical concerns over the inherent risks and social costs built into the rural-urban migration process.

The impact of family members on the self-reported health of older men and women in a rural area of Bangladesh

The purpose of this study is to examine whether the co-residence of spouses and children affects self-reported general health among older men and women in a rural area of Bangladesh. Binary logistic regression has been used to explore the impact of spouses and children on self-reported health with particular attention to the gender of children and interactions with chronic disease. The data are from the Matlab Health and Socio-Economic Survey. A sample of 765 women and 979 men aged 60 or more years with at least one surviving child was available. The principal result is that for an older woman optimum self-reported health is most likely when a spouse and at least one son and one daughter are present. Any deviation from this family pattern (either no spouse or children of only one sex) leads to a significantly increased risk of poor self-reported health. On the other hand among other men there were no differences in self-reported health among the various spouse-child combinations. The relationship between a balanced gender distribution of children and optimum self-reported health among older women may explain the levelling out of fertility at roughly three children per women despite intensive family planning promotion in the area. Further reductions in fertility (an important policy concern) may depend on improving the substitutability of sons and daughters in the support of their elderly mothers. (authors)