Vietnam Era and Vietnam Combat Veterans among the Homeless gong
IMS.
r-nn-n4g.k
Robert Rosenheck MD, Peggy Gallup, PhD, and Cathenne A. Leda, MPH, MSN
Introducton
Methods
Surveys of the homeless have indicated that 43 percent to 50 percent of homeless male veterans served in the mulitary during the Vietnam Era (August, 5, 1964-May 7, 1975),1-3 compared to only 29 percent of veterans in the general population.4 During the 1980s, reports of high percentages of Vietnam Era veterans among the homeless appeared virtually simultaneously with a growing body of literature reporting significant post-war readjustment problems among Vietnam combatveterans5,6 and suggested that veterans who served in Vietnam may be at particularly high risk for homelessness. Three important shortcomings of these initial studies were: 1) the numbers of Vietnam Era veterans studied were small (53-88 per study); 2) the potentially confounding influence of age was not addressed (Vietnam Era veterans fall into the age cohort that is most at risk for homelessness)7 and 3) data were not presented on exposure to the presumed combat stressors, whether service in the Vietnam theater of war or exposure to lifethreatening combat fire. In 1987-88, the Department of Veterans Affairs (VA) Homeless Chronically Mentally Ill Veterans Program conducted intake assessments on 10,524 homeless veterans, of whom 5,287 (50 percent) reported service during the Vietnam Era. In this paper, demographic, military service and clinical assessment data on these veterans, and published data on Vietnam Era veterans in the general population, are used to examine: 1) whether Vietnam Era veterans are disproportionately represented among homeless veterans, when age is taken into consideration; 2) whether homeless Vietnam Era veterans are more likely to have served in Vietnam or to have been exposed to combat fire in Vietnam than Vietnam Era veterans in the general population; and 3) whether homeless veterans who served in Vietnam or who were exposed to combat fire there have more frequent medical, psychiatric or substance abuse problems as compared to a reference group ofhomeless veterans who did not serve in Vietnam.
Subjects The Homeless Chronically Mentally Ill (HCMI) Veterans Program was implemented in May 1987, at 43 VA Medical Centers across the country. Sites were selected on the basis of the estimated number of homeless persons in their service area, their capacity to conduct outreach to the homeless and the presence of a coalition of agencies assisting the homeless in their area. Homeless veterans were contacted through several routes: 52.7 percent were contacted through community outreach efforts in which social workers and nurses visited shelters, soup kitchens and other places frequented by the homeless, seeking out veterans in need ofassistance; 26.1 percent came to VA facilities on their own; 13.3 percent were referred by non-VA programs for the homeless; and 7.9 percent came through unspecified routes. Veterans were offered intake assessments if they were judged to be eligible for VA benefits, lacked a conventional place to sleep, and expressed interest in VA health care services or other benefits.
Procedures A standardized intake form recording data gathered through a structured interview, and clinicians' observations of major psychiatric symptoms, was completed on veterans assessed during the first 10.5 months of program operation (May 15, 1987-March 30, 1988). The interview addressed self-reported age, gender, ethnicity, duration of the current episode of homelessness, dates of admission and discharge from military service, receipt of combat pay, exposure to fire during comFrom the Northeast Program Evaluation Center, VA Medical Center, West Haven, CT (all authors); and the Yale University Department of Psychiatry (Rosenheck). Address reprint requests to Robert Rosenheck, MD/182, Northeast Program Evaluation Center, Veterans Administration Medical Center, 950 Campbell Avenue, West Haven, Cf 06516. This paper, submitted to the Journal May 2, 1990, was revised and accepted for publication September 19, 1990.
American Journal of Public Health 643
Public Health Briefs
bat service, and past history of psychiatric and substance abuse hospitalization. Alcohol and drug abuse problems were identified through a combination of patient self-reports (e.g., "Doyou have a problem with alcohol dependency now?") and clinician observations. Major psychiatric problems were assessed with a 10-item summed Psychiatric Problem Index (PPI), consisting of three self-report items and seven clinical observations, (Cronbach's alpha = 0.71). On a sub-sample of 1,318 veterans asssessed in this Program, a PPI of two or more was associated with a major DSM-llI psychiatric disorder (schizophrenia or other psychosis, bipolar disorder or depressive disorder), as determined by a psychiatrist's examination, with a sensitivity of80.1 percent and a specificity of 58.0 percent. A score of two or more on the PPI was thus considered evidence of significant psychiatric disorder. Military service during the Vietnam Era was categorized as follows. All veterans who served between August 7, 1964 and May 5, 1975 are officially classified by VA as Vetnam Era veterans. Within this group, Vetnam Era Only veterans (those who did not serve in Vietnam, and who were not exposed to warzone stress) were distinguished from Vetnam Theater veterans. Within the group of Vietnam Theater veterans, noncombat exposed veterans (those who served in Vietnam but were not under fire) were distinguished from combat ex-
posed veterans. Published data on veterans in the general population were used for compar644 American Journal of Public Health
ison purposes and included the Census Bureau's 1987 civilian population estimates4 and the Third Survey ofVeterans,8 a 1987 survey of a national sample of 9,442 veterans. Comparisons were made between the proportions of homeless veterans in various age and military service categories and estimated proportions of veterans in the general population in those categories. In addition, health status indicators for noncombat-exposed and combat-exposed Vietnam Theaterveteranswere compared with health status indicators for veterans who did not serve in Vietnam. Measurement precision was expressed as the 95 percent confidence interval of differences in percentages.
Rems Veteran Charactensis Age Distiibution: All Service Eras: The median age among all veterans in the HCMI Program was 40.1 years; 54.3 percent were 30-44 years old (Table 1). Homeless veterans in this program were thus similar in age to other homeless Americans, who have a median age of36.1 years.7 In contrast, the median age among veterans in the general veteran population in 1987 was 54.4 years; only 26 percent were 30-44 years old. Among veterans, as in the general population,7 the largest percentages of the homeless are in their 30s and early 40s. Vietnam Era Service: Over half of all veterans in the HCMI Veterans Program
served during the Vietnam Era, compared to only 29 percent in the general veteran population. However, within matched five-year age cohorts, the percentages of Vietnam Era veterans in the HCMI Veterans Program were generally similar to those in the general veteran population, although among the homeless, greater percentages of Vietnam Era veterans were found within younger age cohorts (Table 2). Among both homeless veterans and veterans in the general population, over 80 percent of 3044 year-olds were Vietnam Era veterans (87 percent in the HCMI Veterans Program; 81 percent in the general veteran population). Charactenstics of Vietnam Era Veterans: Vietnam Era veterans were 99 percent male; 54.6 percent White; 36.8 percent Black; 6.9 percent Hispanic; and 1.7 percent other. The racial distribution was similar to that reported in other studies of the homeless.7 The duration ofthe current episode of homelessness was less than one month for 25.8 percent, from one month to one year for 43.9 percent and more than one year for 30.3 percent. Vetnam Theater Service: Among Vietnam Era veterans assessed by the HCMI Veterans Program 44.9 percent reported service in the Vietnam Theater; 40.5 percent reported exposure to combat and 4.4 percent reported no combat exposure. These proportions are quite similar to those of Vietnam Era veterans in the general population, among whom 48.7 percent report service in the Vietnam Theater; 38.4 percent report exposure to combat and 10.3 percent report war zone service but no combat exposure.8 The percentage of White homeless Vietnam Era veterans who reported service in the Vietnam Theater was somewhat greater than that of other racialethnic groups (46.2 percent vs 42.4 percent). In contrast, in the general population of veterans 48.0 percent of Whites report service in the Vietnam Theater compared to 52.1 percent of other racialethnic groups. Clinical Assessment of Homeless Vetnam Era Veterans: Among homeless Vietnam Theater combat veterans who were not white, current medical, psychiatric and alcohol problems, as well as past histories of psychiatric hospitalization, were more common than among noncombat homeless veterans of similar raceethnicity (Table 3). While the same trends were apparent among Whites, they were of lesser magnitude.
May 1991, Vol. 81, No. 5
Public Health Briefs
Dscssion Several methodological limitations of this study require comment. Although the data were collected in a national program, theywere not gathered through a systemic sampling procedure and findings cannot be confidently generalized to the national population of homeless Vietnam Era veterans. Both sampling and reporting biases may influence our findings. First, data were collected through a VA clinical program, in which an over-representation of combat-stressed veterans might be expected. Second, because the data were gathered in a VA program, veterans may have tended to overreport their combat experiences, assuming that such reports would improve their access to VA health care services and financial benefits. On the other hand, many Vietnam veterans have been critical of VA services,9 and some have been reluctant to use them,10 possibly biasing the representation of Vietnam Theater veterans downward. In our view, Vietnam service is more likely to have been overcounted in this study than undercounted. The data presented suggest that the large percentage of Vietnam Era veterans among homeless veterans is best explained by the specific vulnerability of men in their 30s and early 40s to homelessness.7 Neither Vietnam Era service, Vietnam Theater service, nor exposure to combat fire appear to be unexpectedly common among homeless veterans studied. This conclusion is consistent with findings from the National Vietnam Veterans Readjustment Study (NVVRS),6 conducted in 1987. The NVVRS did note, however, that veterans who met diagnostic criteria for Posttraumatic Stress Disorder (15.2 percent of all Vietnam Theater veterans) were far more likely to have been homeless than those who did not. While Vietnam service, by itself, does not appear to be a major risk factor for homelessness, those veterans who were most affected by combat may be at greater risk for homelessness than others. Vietnam veterans in the HCMI Veterans Program who were not White and who were exposed to combat have more frequent psychiatric, medical and alcohol problems than those veterans who are not White who did not serve in Vietnam. These findings are consistent with those of the NVVRS which found substantial differences in health status measures between veterans who were exposed to high
levels of combat and those not exposed, and a considerably higher prevalence of
May 1991, Vol. 81, No. 5
Posttraumatic Stress Disorder among those who are not White than among Whites.6 The absence of significant differences in health status measures among Whites may reflect the limited specificity of our screening instruments, although further research is needed to clarify the meaning of these findings. While not overrepresented among homeless veterans, homeless Vietnam combat veterans, like
Vietnam combat veterans examined in other studies, appear to face more frequent medical and psychiatric problems and may require special services. El
Acknowledgments We thank Paul Errera, MD, Boris Astrachan, MD, and Alan Fontana, PhD, for their assistance. The evaluation of the Homeless Chroni-
American Journal of Public Health 645
Public Health Bnefs
cally Mentally Ill Veterans Program was funded by the US Department of Veterans Affairs. This paper is based on presentations at the annual meeting ofthe Society for Traumatic Stress Studies, San Francisco, CA, October25, 1989, and the annual meeting of the American Psychiatric Association, New York, NY, May 15, 1990.
References 1. Farr RK, Koegel P, Bumam A: A Study of Homelessness and Mental Illness in the Skid Row Area of Los Angeles. Los Angeles, CA: Los Angeles County Department of Mental Health, 1986. 2. Gelberg L, Linn LS, Leake: Mental health, alcohol and drug use and criminal history among homeless adults. Am J Psychiatry 1988; 145:191-196.
3. Streuning EL, Pittman J, Rosenblatt A: Characteristics of homeless veterans in the New York City shelter system. In: Rosenblatt A (ed): Homelessness. Albany, NY: Rockefeller Institute of Government (in press). 4. Department of Veteran Affairs: Annual Report 1987. Washington DC: Department of Veterans Affairs, 1989. 5. Laufer R, Frey Wouters E, Yager T: Postwar trauma, social and psychological problems of Vietnam veterans in the aftermath of the Vietnam War. In: Legacies of Vietnam, Comparative Adjustment of Veterans and Their Peers. Washington DC: US Govt Printing Office, 1981. 6. Kulka R, Schlenger W, Fairbank J, Hough R, Jordan B, Marmar C, Weiss D: National
7.
8. 9.
10.
Vietnam Veterans Readjustment Study. Research Triangle Park, NC: Research Triangle Institute, 1988. Rossi P: Down and Out in America, The Causes of Homelessness. Chicago, IL: University of Chicago Press, 1989. Department of Veteran Affairs: 1987 Survey of Veterans. Washington DC: Department of Veterans Affairs, 1989. Myths and Realities: A Study of Attitudes toward Vietnam Era Veterans. Report submitted by the Veterans Administration to the Committee on Veterans Affairs, US Senate, Washington, DC, 1980. Lifton RJ: Home from the War: Vietnam Veterans, Neither Victims nor Executioners. New York: Simon and Schuster, 1973.
Determinants of Late Stage Diagnosis of Breast and Cervical Cancer: The Impact of Age, Race, Social Class, and Hospital Type ...
"
"I'l-,"M 1'.1-K-'l,--,-3,l'l'l"
0
L
- -- - X-MML..I.
'U
%?:,-ee-
Jeanne Mandelblatt, MD, Howard Andrews, PhD, Jon Kemer, PhD, Ann Zauber, PhD, and Wdliam Bumetu, MD
Intrwoducton Age and race have each individually been associated with cancer stage.1-5 However, previous studies have not controlled for the effects of social class and health care setting. This paper presents findings from logistic regression analyses to quantify the individual and combined effects of age, race, socioeconomic class, and type of health care setting on breast and cervical cancer stage.
Metods Cancer Data-Tumor Registry The study sample consisted of all cases of breast and cervical cancer among New York City (NYC) residents that were
reported to the New York State Department of Health Tumor Registry between 1980 and 1985. More than 90 percent of incident cases are reported to the registry from NYC.6 In the study period, there were 22,111 breast cancer, 2,930 invasive cervical cancer, and 6,408 cervical carcinoma in-situ cases with known stages reported. Stage was unknown for 7.5 percent and 2.6 percent of the breast and cervical cases, respectively. Missing stage
was associated with age (p < .0001) and missing marital status (p < .01) for both cancers. Age was classified into five-year categories. Race was reported as either Black or White. There were insufficient data to include Hispanic origin in the analysis. Marital status was dichotomized as "ever"1 versus "never" married. Hospital type was classed as "public" for the 11 NYC municipal hospitals and "non-public" for the remaining facilities.
Demographic Vanables-Census Data Because individual information on socioeconomic class is not available in registry data, 1980 United States census Address reprint requests to Jeanne Mandelblatt, MD, Assistant Professor, Division of Cancer Control, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, Box 60, 1275 York Avenue, New York, NY 10021. Drs. Kerner and Zauber are also with that Department at the Cancer Center; Dr. Andrews is with New York State Psychiatric Institute, New York City; Dr. Burnett is Director, Tumor Registry, New York State Department of Health, Albany. This paper, submitted to the Journal July 12, 1990, was revised and accepted for publication December 5, 1990.
May 1991, Vol. 81, No. 5
IMS.
r-nn-n4g.k
Robert Rosenheck MD, Peggy Gallup, PhD, and Cathenne A. Leda, MPH, MSN
Introducton
Methods
Surveys of the homeless have indicated that 43 percent to 50 percent of homeless male veterans served in the mulitary during the Vietnam Era (August, 5, 1964-May 7, 1975),1-3 compared to only 29 percent of veterans in the general population.4 During the 1980s, reports of high percentages of Vietnam Era veterans among the homeless appeared virtually simultaneously with a growing body of literature reporting significant post-war readjustment problems among Vietnam combatveterans5,6 and suggested that veterans who served in Vietnam may be at particularly high risk for homelessness. Three important shortcomings of these initial studies were: 1) the numbers of Vietnam Era veterans studied were small (53-88 per study); 2) the potentially confounding influence of age was not addressed (Vietnam Era veterans fall into the age cohort that is most at risk for homelessness)7 and 3) data were not presented on exposure to the presumed combat stressors, whether service in the Vietnam theater of war or exposure to lifethreatening combat fire. In 1987-88, the Department of Veterans Affairs (VA) Homeless Chronically Mentally Ill Veterans Program conducted intake assessments on 10,524 homeless veterans, of whom 5,287 (50 percent) reported service during the Vietnam Era. In this paper, demographic, military service and clinical assessment data on these veterans, and published data on Vietnam Era veterans in the general population, are used to examine: 1) whether Vietnam Era veterans are disproportionately represented among homeless veterans, when age is taken into consideration; 2) whether homeless Vietnam Era veterans are more likely to have served in Vietnam or to have been exposed to combat fire in Vietnam than Vietnam Era veterans in the general population; and 3) whether homeless veterans who served in Vietnam or who were exposed to combat fire there have more frequent medical, psychiatric or substance abuse problems as compared to a reference group ofhomeless veterans who did not serve in Vietnam.
Subjects The Homeless Chronically Mentally Ill (HCMI) Veterans Program was implemented in May 1987, at 43 VA Medical Centers across the country. Sites were selected on the basis of the estimated number of homeless persons in their service area, their capacity to conduct outreach to the homeless and the presence of a coalition of agencies assisting the homeless in their area. Homeless veterans were contacted through several routes: 52.7 percent were contacted through community outreach efforts in which social workers and nurses visited shelters, soup kitchens and other places frequented by the homeless, seeking out veterans in need ofassistance; 26.1 percent came to VA facilities on their own; 13.3 percent were referred by non-VA programs for the homeless; and 7.9 percent came through unspecified routes. Veterans were offered intake assessments if they were judged to be eligible for VA benefits, lacked a conventional place to sleep, and expressed interest in VA health care services or other benefits.
Procedures A standardized intake form recording data gathered through a structured interview, and clinicians' observations of major psychiatric symptoms, was completed on veterans assessed during the first 10.5 months of program operation (May 15, 1987-March 30, 1988). The interview addressed self-reported age, gender, ethnicity, duration of the current episode of homelessness, dates of admission and discharge from military service, receipt of combat pay, exposure to fire during comFrom the Northeast Program Evaluation Center, VA Medical Center, West Haven, CT (all authors); and the Yale University Department of Psychiatry (Rosenheck). Address reprint requests to Robert Rosenheck, MD/182, Northeast Program Evaluation Center, Veterans Administration Medical Center, 950 Campbell Avenue, West Haven, Cf 06516. This paper, submitted to the Journal May 2, 1990, was revised and accepted for publication September 19, 1990.
American Journal of Public Health 643
Public Health Briefs
bat service, and past history of psychiatric and substance abuse hospitalization. Alcohol and drug abuse problems were identified through a combination of patient self-reports (e.g., "Doyou have a problem with alcohol dependency now?") and clinician observations. Major psychiatric problems were assessed with a 10-item summed Psychiatric Problem Index (PPI), consisting of three self-report items and seven clinical observations, (Cronbach's alpha = 0.71). On a sub-sample of 1,318 veterans asssessed in this Program, a PPI of two or more was associated with a major DSM-llI psychiatric disorder (schizophrenia or other psychosis, bipolar disorder or depressive disorder), as determined by a psychiatrist's examination, with a sensitivity of80.1 percent and a specificity of 58.0 percent. A score of two or more on the PPI was thus considered evidence of significant psychiatric disorder. Military service during the Vietnam Era was categorized as follows. All veterans who served between August 7, 1964 and May 5, 1975 are officially classified by VA as Vetnam Era veterans. Within this group, Vetnam Era Only veterans (those who did not serve in Vietnam, and who were not exposed to warzone stress) were distinguished from Vetnam Theater veterans. Within the group of Vietnam Theater veterans, noncombat exposed veterans (those who served in Vietnam but were not under fire) were distinguished from combat ex-
posed veterans. Published data on veterans in the general population were used for compar644 American Journal of Public Health
ison purposes and included the Census Bureau's 1987 civilian population estimates4 and the Third Survey ofVeterans,8 a 1987 survey of a national sample of 9,442 veterans. Comparisons were made between the proportions of homeless veterans in various age and military service categories and estimated proportions of veterans in the general population in those categories. In addition, health status indicators for noncombat-exposed and combat-exposed Vietnam Theaterveteranswere compared with health status indicators for veterans who did not serve in Vietnam. Measurement precision was expressed as the 95 percent confidence interval of differences in percentages.
Rems Veteran Charactensis Age Distiibution: All Service Eras: The median age among all veterans in the HCMI Program was 40.1 years; 54.3 percent were 30-44 years old (Table 1). Homeless veterans in this program were thus similar in age to other homeless Americans, who have a median age of36.1 years.7 In contrast, the median age among veterans in the general veteran population in 1987 was 54.4 years; only 26 percent were 30-44 years old. Among veterans, as in the general population,7 the largest percentages of the homeless are in their 30s and early 40s. Vietnam Era Service: Over half of all veterans in the HCMI Veterans Program
served during the Vietnam Era, compared to only 29 percent in the general veteran population. However, within matched five-year age cohorts, the percentages of Vietnam Era veterans in the HCMI Veterans Program were generally similar to those in the general veteran population, although among the homeless, greater percentages of Vietnam Era veterans were found within younger age cohorts (Table 2). Among both homeless veterans and veterans in the general population, over 80 percent of 3044 year-olds were Vietnam Era veterans (87 percent in the HCMI Veterans Program; 81 percent in the general veteran population). Charactenstics of Vietnam Era Veterans: Vietnam Era veterans were 99 percent male; 54.6 percent White; 36.8 percent Black; 6.9 percent Hispanic; and 1.7 percent other. The racial distribution was similar to that reported in other studies of the homeless.7 The duration ofthe current episode of homelessness was less than one month for 25.8 percent, from one month to one year for 43.9 percent and more than one year for 30.3 percent. Vetnam Theater Service: Among Vietnam Era veterans assessed by the HCMI Veterans Program 44.9 percent reported service in the Vietnam Theater; 40.5 percent reported exposure to combat and 4.4 percent reported no combat exposure. These proportions are quite similar to those of Vietnam Era veterans in the general population, among whom 48.7 percent report service in the Vietnam Theater; 38.4 percent report exposure to combat and 10.3 percent report war zone service but no combat exposure.8 The percentage of White homeless Vietnam Era veterans who reported service in the Vietnam Theater was somewhat greater than that of other racialethnic groups (46.2 percent vs 42.4 percent). In contrast, in the general population of veterans 48.0 percent of Whites report service in the Vietnam Theater compared to 52.1 percent of other racialethnic groups. Clinical Assessment of Homeless Vetnam Era Veterans: Among homeless Vietnam Theater combat veterans who were not white, current medical, psychiatric and alcohol problems, as well as past histories of psychiatric hospitalization, were more common than among noncombat homeless veterans of similar raceethnicity (Table 3). While the same trends were apparent among Whites, they were of lesser magnitude.
May 1991, Vol. 81, No. 5
Public Health Briefs
Dscssion Several methodological limitations of this study require comment. Although the data were collected in a national program, theywere not gathered through a systemic sampling procedure and findings cannot be confidently generalized to the national population of homeless Vietnam Era veterans. Both sampling and reporting biases may influence our findings. First, data were collected through a VA clinical program, in which an over-representation of combat-stressed veterans might be expected. Second, because the data were gathered in a VA program, veterans may have tended to overreport their combat experiences, assuming that such reports would improve their access to VA health care services and financial benefits. On the other hand, many Vietnam veterans have been critical of VA services,9 and some have been reluctant to use them,10 possibly biasing the representation of Vietnam Theater veterans downward. In our view, Vietnam service is more likely to have been overcounted in this study than undercounted. The data presented suggest that the large percentage of Vietnam Era veterans among homeless veterans is best explained by the specific vulnerability of men in their 30s and early 40s to homelessness.7 Neither Vietnam Era service, Vietnam Theater service, nor exposure to combat fire appear to be unexpectedly common among homeless veterans studied. This conclusion is consistent with findings from the National Vietnam Veterans Readjustment Study (NVVRS),6 conducted in 1987. The NVVRS did note, however, that veterans who met diagnostic criteria for Posttraumatic Stress Disorder (15.2 percent of all Vietnam Theater veterans) were far more likely to have been homeless than those who did not. While Vietnam service, by itself, does not appear to be a major risk factor for homelessness, those veterans who were most affected by combat may be at greater risk for homelessness than others. Vietnam veterans in the HCMI Veterans Program who were not White and who were exposed to combat have more frequent psychiatric, medical and alcohol problems than those veterans who are not White who did not serve in Vietnam. These findings are consistent with those of the NVVRS which found substantial differences in health status measures between veterans who were exposed to high
levels of combat and those not exposed, and a considerably higher prevalence of
May 1991, Vol. 81, No. 5
Posttraumatic Stress Disorder among those who are not White than among Whites.6 The absence of significant differences in health status measures among Whites may reflect the limited specificity of our screening instruments, although further research is needed to clarify the meaning of these findings. While not overrepresented among homeless veterans, homeless Vietnam combat veterans, like
Vietnam combat veterans examined in other studies, appear to face more frequent medical and psychiatric problems and may require special services. El
Acknowledgments We thank Paul Errera, MD, Boris Astrachan, MD, and Alan Fontana, PhD, for their assistance. The evaluation of the Homeless Chroni-
American Journal of Public Health 645
Public Health Bnefs
cally Mentally Ill Veterans Program was funded by the US Department of Veterans Affairs. This paper is based on presentations at the annual meeting ofthe Society for Traumatic Stress Studies, San Francisco, CA, October25, 1989, and the annual meeting of the American Psychiatric Association, New York, NY, May 15, 1990.
References 1. Farr RK, Koegel P, Bumam A: A Study of Homelessness and Mental Illness in the Skid Row Area of Los Angeles. Los Angeles, CA: Los Angeles County Department of Mental Health, 1986. 2. Gelberg L, Linn LS, Leake: Mental health, alcohol and drug use and criminal history among homeless adults. Am J Psychiatry 1988; 145:191-196.
3. Streuning EL, Pittman J, Rosenblatt A: Characteristics of homeless veterans in the New York City shelter system. In: Rosenblatt A (ed): Homelessness. Albany, NY: Rockefeller Institute of Government (in press). 4. Department of Veteran Affairs: Annual Report 1987. Washington DC: Department of Veterans Affairs, 1989. 5. Laufer R, Frey Wouters E, Yager T: Postwar trauma, social and psychological problems of Vietnam veterans in the aftermath of the Vietnam War. In: Legacies of Vietnam, Comparative Adjustment of Veterans and Their Peers. Washington DC: US Govt Printing Office, 1981. 6. Kulka R, Schlenger W, Fairbank J, Hough R, Jordan B, Marmar C, Weiss D: National
7.
8. 9.
10.
Vietnam Veterans Readjustment Study. Research Triangle Park, NC: Research Triangle Institute, 1988. Rossi P: Down and Out in America, The Causes of Homelessness. Chicago, IL: University of Chicago Press, 1989. Department of Veteran Affairs: 1987 Survey of Veterans. Washington DC: Department of Veterans Affairs, 1989. Myths and Realities: A Study of Attitudes toward Vietnam Era Veterans. Report submitted by the Veterans Administration to the Committee on Veterans Affairs, US Senate, Washington, DC, 1980. Lifton RJ: Home from the War: Vietnam Veterans, Neither Victims nor Executioners. New York: Simon and Schuster, 1973.
Determinants of Late Stage Diagnosis of Breast and Cervical Cancer: The Impact of Age, Race, Social Class, and Hospital Type ...
"
"I'l-,"M 1'.1-K-'l,--,-3,l'l'l"
0
L
- -- - X-MML..I.
'U
%?:,-ee-
Jeanne Mandelblatt, MD, Howard Andrews, PhD, Jon Kemer, PhD, Ann Zauber, PhD, and Wdliam Bumetu, MD
Intrwoducton Age and race have each individually been associated with cancer stage.1-5 However, previous studies have not controlled for the effects of social class and health care setting. This paper presents findings from logistic regression analyses to quantify the individual and combined effects of age, race, socioeconomic class, and type of health care setting on breast and cervical cancer stage.
Metods Cancer Data-Tumor Registry The study sample consisted of all cases of breast and cervical cancer among New York City (NYC) residents that were
reported to the New York State Department of Health Tumor Registry between 1980 and 1985. More than 90 percent of incident cases are reported to the registry from NYC.6 In the study period, there were 22,111 breast cancer, 2,930 invasive cervical cancer, and 6,408 cervical carcinoma in-situ cases with known stages reported. Stage was unknown for 7.5 percent and 2.6 percent of the breast and cervical cases, respectively. Missing stage
was associated with age (p < .0001) and missing marital status (p < .01) for both cancers. Age was classified into five-year categories. Race was reported as either Black or White. There were insufficient data to include Hispanic origin in the analysis. Marital status was dichotomized as "ever"1 versus "never" married. Hospital type was classed as "public" for the 11 NYC municipal hospitals and "non-public" for the remaining facilities.
Demographic Vanables-Census Data Because individual information on socioeconomic class is not available in registry data, 1980 United States census Address reprint requests to Jeanne Mandelblatt, MD, Assistant Professor, Division of Cancer Control, Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, Box 60, 1275 York Avenue, New York, NY 10021. Drs. Kerner and Zauber are also with that Department at the Cancer Center; Dr. Andrews is with New York State Psychiatric Institute, New York City; Dr. Burnett is Director, Tumor Registry, New York State Department of Health, Albany. This paper, submitted to the Journal July 12, 1990, was revised and accepted for publication December 5, 1990.
May 1991, Vol. 81, No. 5
