Grant Roy, Shapiro Alan, Joseph Sharon, Goldsmith Sandra, Rigual-Lynch Lourdes, Redlener Irwin
The Children's Health Fund, 215 West 125th Street, New York, NY 10027, USA.
Adv Pediatr. 2007;54:173-87. doi: 10.1016/j.yapd.2007.03.010.
To the extent that representative data are available for specific health conditions (eg, under-immunization, asthma prevalence), the authors' data suggest that the gap between the health status of homeless children and housed children in minority, low-income families is narrowing. Studies of the health status of homeless children allow a window into the health status of medically underserved children whose needs may not be readily documented because of their lack of access to the health care system. Although prevalence rates of most of the health conditions discussed in this article exceeded national norms, they were generally consistent with rates characteristic of health disparities based on race-ethnicity and income. It must be emphasized that in most instances, children were seen for their first pediatric visit within weeks of entering the homeless shelter system. The health conditions identified were often present before the child and family became homeless. The high prevalence of asthma among homeless children should therefore be a matter of concern to health providers and payors, because the authors' data strongly suggest that this is not confined to children in homeless shelters as a special population. Similarly, childhood obesity predates homelessness (or at least the episode of homelessness during which health care was provided) and as such the authors' data may indicate the extent of this problem more generally among medically underserved children in the communities of origin. These conditions seem to be exacerbated by the specific conditions associated with homeless shelter life. Asthma care, assuming it was previously available, is disrupted when housing is lost, and shelter conditions may have multiple asthma triggers. Nutrition often suffers as a result of inadequate access to nutritious food and cooking facilities in shelters, as indicated by the high rate of iron-deficiency anemia among very young children. It is clear that homeless children in shelters require enhanced access to primary and specialist care. Shelter placement necessarily disrupts prior health care relationships (if any), while simultaneously placing additional stress on the child's physical and emotional well being. A medical home model is strongly recommended to allow for continuous, culturally competent care. Developmental and mental health problems are also more prevalent among homeless children. These conditions may jeopardize life successes. The overcrowding associated with homeless shelters and the housing conditions that frequently precede episodes of homelessness are associated with the higher prevalence of otitis media found among young children. This in turn is associated with developmental delay. Also contributing to the developmental risk associated with homelessness is exposure to DV, which is also frequently an antecedent of homelessness. Developmental surveillance for young, homeless children, monitoring of school attendance and academic performance, and assessment of mental status for homeless adolescents are recommended to facilitate early identification of problems and delivery of necessary interventions. For young children, providers of health care to the homeless should be well networked into the Early Intervention and Preschool Special Education programs in their locality. Given the multiplicity of needs for homeless families, which of course includes help finding affordable housing, health care providers serving this population should also develop linkages with community agencies, including those that can help parents develop the skills necessary for economic self-sufficiency and long-term ability to sustain independent housing.
就特定健康状况(如免疫接种不足、哮喘患病率)有代表性数据可用的程度而言,作者的数据表明,少数族裔低收入家庭中无家可归儿童与有家可归儿童的健康状况差距正在缩小。对无家可归儿童健康状况的研究为了解医疗服务不足儿童的健康状况提供了一个窗口,这些儿童由于无法获得医疗保健系统的服务,其需求可能难以得到充分记录。尽管本文讨论的大多数健康状况的患病率超过了全国标准,但总体上与基于种族和收入的健康差距特征率一致。必须强调的是,在大多数情况下,儿童在进入无家可归者收容所系统后的几周内就进行了首次儿科就诊。所发现的健康状况往往在儿童及其家庭无家可归之前就已存在。因此,无家可归儿童中哮喘的高患病率应引起医疗服务提供者和付款人的关注,因为作者的数据有力地表明,这并不局限于作为特殊人群的无家可归者收容所中的儿童。同样,儿童肥胖在无家可归之前(或至少在提供医疗保健的无家可归期间)就已存在,因此作者的数据可能更普遍地表明了这一问题在原籍社区医疗服务不足儿童中的程度。这些状况似乎因与无家可归者收容所生活相关的特定条件而加剧。如果以前有哮喘护理,住房丧失时护理就会中断,而且收容所条件可能有多种哮喘诱发因素。由于在收容所中难以获得营养食品和烹饪设施,营养状况往往受到影响,这从幼儿中铁缺乏性贫血的高发病率就可以看出。显然,收容所中的无家可归儿童需要更多地获得初级和专科护理。进入收容所必然会中断以前的医疗保健关系(如果有的话),同时给儿童的身心健康带来额外压力。强烈建议采用医疗之家模式,以提供持续的、具有文化能力的护理。发育和心理健康问题在无家可归儿童中也更为普遍。这些状况可能危及人生成就。与无家可归者收容所相关的过度拥挤以及无家可归事件之前经常出现的住房条件与幼儿中耳炎患病率较高有关。这反过来又与发育迟缓有关。与无家可归相关的发育风险的另一个因素是接触家庭暴力,而家庭暴力也是无家可归的常见先兆。建议对年幼的无家可归儿童进行发育监测、监测上学出勤和学业成绩,并对无家可归青少年进行心理状态评估,以便尽早发现问题并提供必要的干预措施。对于幼儿,为无家可归者提供医疗保健的人员应与当地的早期干预和学前特殊教育计划建立良好的联系。鉴于无家可归家庭有多种需求,当然包括帮助寻找经济适用房,为这一人群提供服务的医疗保健提供者还应与社区机构建立联系,包括那些可以帮助父母培养经济自给自足所需技能和长期维持独立住房能力的机构。