This chapter presents the budget estimates and program justifications for the Department of Housing and Urban Development (HUD). HUD’s core mission is to promote adequate and affordable housing, economic opportunity and a suitable living environment free from discrimination. The 2001 Budget for HUD reflects the successful implementation of a multiyear comprehensive reform effort which has helped restore the effectiveness and financial integrity of the Department’s critical affordable housing and economic development initiatives. Building on the success of these reforms, Congress and the Administration have provided significant increases in key HUD programs over the past two years. The 2001 Budget will continue these historic successes by providing the Department with the tools to fulfill its fundamental strategic goals: increasing the availability of decent, safe and affordable housing in American communities (including the enhancement of homeownership opportunities, especially for minorities and first-time homebuyers, the transformation of public housing and the expansion of housing assistance to alleviate severe housing needs); ensuring equal housing opportunity; promoting self-sufficiency and asset development of families and individuals (including moving homeless families to self-sufficiency through locally-developed continuum of care strategies and contributing to the success of welfare-to-work efforts); and improving community quality of life and economic vitality through locally-driven initiatives and programs. The 2001 budget provides increases for two successful block grant programs which serve HUD’s fundamental affordable housing and economic development missions—the Community Development Block Grant (CDBG) and the HOME Investment Partnerships programs. These programs provide states and localities with formula funding pursuant to locally-developed consolidated plans for a wide variety of activities which benefit low and moderate-income families. The Community Development Loan Guarantee program (under Section 108 of the Housing and Community Development Act of 1974) will be continued with level funding and a slightly increased loan guarantee limitation. The Economic Development Initiative will also be maintained. Grants for Urban Empowerment Zones will continue support for ten-year plans to provide new job opportunities and community revitalization in 15 urban areas. The Rural Housing and Economic Development program will be continued at an increased level. HUD’s Homeless Assistance programs will be funded at an increased level to enable communities to continue their development and implementation of comprehensive coordinated continuum of care systems to address the needs of homeless people and families. This funding includes 18,000 rental assistance vouchers designed to provide affordable permanent housing for formerly homeless individuals and families in order to provide a stable living environment, a critical necessity for maintaining access to needed services and providing access to employment opportunities. HUD’s Continuum of Care approach recently received the prestigious 1999 Innovations in Government award from the Harvard University’s John F. Kennedy School of Government and the Ford Foundation. The 2001 Budget maintains the Federal commitment to replacing distressed and obsolete public housing with attractive, mixed-income communities and creating new economic opportunities for residents. Consistent with this commitment and with a special focus on replacing projects that have been determined to be non-viable, the HOPE VI program will receive a significant increase from last year’s enacted level. The 2001 Budget provides $3,192 million for the Public Housing Operating Fund, which helps to maintain good quality housing, and provides a slight increase for the Public Housing Capital Fund, which helps modernize and improve the housing stock. The 2001 budget includes 120,000 incremental vouchers that will help address the severe housing needs of low-income households. These vouchers are necessary to address the continued increase in the number of families nationwide which have worst case needs for housing assistance, including extremely-low income families currently paying more than half their income for rent or living in severely inadequate living conditions. The Administration reaffirms its long-held commitment to renew all expiring Section 8 contracts, to protect residents from displacement by substantially increasing funding for Section 8 renewals, to provide Section 8 tenant-based assistance for displaced families, and for the replacement of affordable housing due to opt-outs from the project-based Section 8 program. The Administration also continues its support for the Department’s successful Housing for Persons With HIV/AIDS program (HOPWA) by providing increased funding to prevent thousands of persons with HIV/AIDS from becoming homeless. This increase is necessary to continue to provide stable housing and services in existing local programs and fund new jurisdictions as they become eligible for formula funding due to the continued increase in the number of AIDS cases. Building on last year’s successful adoption of the Housing Security Plan for Older Americans, the Housing for the Elderly program (under Section 202 of the Housing Act of 1959) will receive a substantial increase, including an increase in capital funding to convert existing housing to assisted living with services and an increase for construction of new affordable assisted living. The Housing for Persons with Disabilities (under Section 811 of the National Affordable Housing Act of 1990) will receive additional funding. In support of the Administration’s strong commitment to increase homeownership opportunities, the 2001 budget includes major support to help lowand moderate-income American families become homebuyers. The budget will increase the Federal Housing Administration’s (FHA) maximum mortgage loan limits, allowing Single Family insurance to cover loans up to the same level as the Fannie Mae and Freddie Mac (GSEs) limits. (Currently FHA can insure home mortgages only up to 87 percent of the GSE limits in high cost areas and only up to 48 percent in low-cost areas, including approximately 2,200 rural counties throughout the Nation). In addition, the budget authorizes FHA to develop new adjustable rate mortgage products. These provisions will provide much-needed assistance to first-time homebuyers, minorities, and other underserved populations. Increased funding for the Fair Housing Assistance and Fair Housing Initiatives programs (FHAP and FHIP) will strengthen the ability of public and private fair housing groups, and partnerships between them, to enforce the laws protecting all Americans against illegal housing discrimination. In order to ensure the effective implementation of its programs, the Department’s Office of Policy Development and Research (PD&R) will be provided with a budget increase. These additional funds are necessary to ensure timely provision of data, research and analysis of national housing and economic conditions, and to measure the performance of pro-

The Department of Housing and Urban Development

Methods We searched PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature for studies of the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless populations. We also searched bibliographic indices, scanned reference lists, and corresponded with authors. W e explored potential sources of heterogeneity in the estimates by metaregression analysis and calculated prevalence ratios to compare prevalence estimates for homeless people with those for the general population. Findings We identifi ed 43 eligible surveys with a total population of 63 812 (59 736 homeless individuals when duplication due to overlapping samples was accounted for). Prevalences ranged from 0·2% to 7·7% for tuberculosis, 3·9% to 36·2% for hepatitis C virus infection, and 0·3% to 21·1% for HIV infection. We noted substantial heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus infection, and HIV infection (all Cochran’s χ² signifi cant at p<0·0001; I²=83%, 95% CI 76–89; 95%, 94–96; and 94%, 93–95; respectively). Prevalence ratios ranged from 34 to 452 for tuberculosis, 4 to 70 for hepatitis C virus infection, and 1 to 77 for HIV infection. Tuberculosis prevalence was higher in studies in which diagnosis was by chest radiography than in those which used other diagnostic methods and in countries with a higher general population prevalence than in those with a lower general prevalence. Prevalence of HIV infection was lower in newer studies than in older ones and was higher in the USA than in the rest of the world. Interpretation Heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus, and HIV suggests the need for local surveys to inform development of health services for homeless people. The role of targeted and populationbased measures in the reduction of risks of infectious diseases, premature mortality, and other adverse outcomes needs further examination. G uidelines for screening and treatment of infectious diseases in homeless people might need to be reviewed.

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Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis.

This article presents the findings of a methodical examination of how well one school of nursing was meeting its goal of addressing diversity through its pedagogy. The underlying assumption was that a school’s curriculum both shapes and reflects a climate of valuing diversity. This mixed-method evaluation study was conducted in four steps, including a content analysis of all syllabi in the School of Nursing’s (SON) curriculum, comparison of the content analysis to students’ evaluation of diversity in their education, a survey of the 2006 graduates, and an analysis of faculty responses to the findings. The findings are being used to guide the SON in the development of training and to bring about forums for formal dialogue. These will assist faculty to effectively integrate diversity in their teaching and interaction with students and to move toward the long-term goal of preparing culturally humble and sensitive clinicians, educators, and researchers.

A Mixed Method Study

Assessing measurement in health: Beyond reliability and validity.

One method of gaining knowledge, skills, and experience with different cultures for nurses and nursing students is through an international immersion program of training in language, culture, and community nursing. This article presents a qualitative and quantitative research study of the influence of a 2-week service-learning medical experience of a nursing student group who traveled abroad to Belize, Central America.

Influence of international service-learning on nursing student self-efficacy toward cultural competence.

This article describes a qualitative study that explored the perceptions of graduating students from a northeast baccalaureate nursing program regarding their life experiences with cultural diversity. Thirteen students were interviewed using an interview guide, and interviews were recorded on audiotape. Information obtained included participants' cultural heritage, life experiences before entering a nursing program, educational and clinical experiences in the nursing program, knowledge about cultural competence, and the students' reflections on their ability to provide culturally competent care. Primarily qualitative methods were used to gather and analyze data. This article focuses on one of the major themes that emerged: defining life experiences related to cultural diversity. Data were reanalyzed focusing on this theme, and three life patterns emerged: positive, neutral, and conflicted. These patterns affected the students' interest and desire to provide culturally competent care. Implications for further research and nursing education are discussed.

Perceptions of graduating nursing students regarding life experiences that promote culturally competent care

HIV screening: beliefs and intentions of the homeless.

In this paper, we describe the development and psychometric properties of the Fogg Intent-to-Screen for HIV questionnaire (ITS HIV), which measures peoples' beliefs and intentions toward HIV screening. The ITS HIV was developed using the Theory of Planned Behavior as the framework for a developmental process that included qualitative interviews, a validation phase, two pilot tests, and a field test of the final 55-item questionnaire. The field test involved 312 homeless persons from five New England states. Cronbach alphas of the direct measures scales ranged from .72 to .90. Findings from a path analysis verified the construct validity. The psychometric estimates from these analyses suggest the ITS HIV questionnaire is appropriate for use in clinical practice or to evaluate the effectiveness of interventions.

Development of the Fogg Intent-to-Screen for HIV (ITS HIV) questionnaire.

ABSTRACT Background: Colorectal cancer (CRC) is a leading cause of death from cancer in the United States, despite the availability of high-quality screening options. Multiple barriers to CRC screening have been identified, including cost (noninsured), younger age, racial or ethnic minority, recent immigration to the United States (non-English speaking), fear or distrust of the health care system, and rural residence. Local Problem: The mean CRC screening rate for the designated Federally Qualified Health Center (FQHC) was 33.7% for the 5 months preceding this quality improvement (QI) project. The benchmark target for CRC screening was 60.1%. Methods: The Model for Improvement and Plan-Do-Study-Act cycle created the framework for the CRC screening targeted interventions used in this FQHC patient population. Interventions: Multiple targeted interventions were implemented over a 4-month period that emphasized a strong provider recommendation, a team-based approach to identify and offer CRC screening options to the overdue patient. A chart audit was followed by a mailed fecal immunochemical test (FIT) and colonoscopy reminder letter initiative. Results: The performance metric for CRC screening reached 40% within 4 months. A second chart audit confirmed the CRC screening rate improved to 41.5% among patients aged 50–75 years. An overall 55% return rate was achieved with the mailed FIT initiative within 2 months. Conclusions: Continued quality improvement initiatives are needed to achieve the benchmark target for this FQHC. These team-based interventions can be used by the primary care nurse practitioner to improve health equity for CRC screening in other underserved populations.

Catherine J. Fogg

Papers

Perceptions of graduating nursing students regarding life experiences that promote culturally competent care

HIV screening: beliefs and intentions of the homeless.

Development of the Fogg Intent-to-Screen for HIV (ITS HIV) questionnaire.

Addressing barriers to colorectal cancer screening in a federally qualified health center