The individual and beyond: a socio-rational choice model of service participation among homeless adults with substance abuse problems

The homeless population during the COVID-19 syndemic: Inequities, practices of social resilience, and social reintegration strategies

This paper analyses the amplification of social insecurity and the social misrecognition of the homeless during the COVID-19 syndemic. The research was carried out in the city of Bergamo (IT), which has been severely affected by the COVID-19 syndemic since the early months of 2020; the research was developed in two phases. The first one analyses the practices of social resilience activated during the COVID-19 syndemic by the socio-educational staff and the coordination figures who work in the support services. The second phase analyses the different social dynamics that can improve the wellbeing and social reintegration of the homeless from a long-duration perspective. During the first months of 2020, the public authorities failed to pay attention to homeless people who slept on the streets and who lived in communities or found support in night shelters. The support services had to activate immediate emergency response strategies and subsequently had to produce and purchase protective devices for operators, guests and those who remained on the street. Faced with this process of social misrecognition, the support services for homeless people reacted by activating practices of social resilience. These practices have investigated the dimensions of daily interactions and the symbolic and value configurations connected to them. However, directly conversing with the homeless, it emerges that to achieve full social reintegration and to prevent new forms of social misrecognition, in the event of future social or health crises, the relationship with a non-stigmatized social community is fundamental. Consequently, the primary objectives that the support network for homeless people should set for future projects should involve the local community through project participation activities and raise awareness of the phenomenon of poverty.

"If you're gonna help me, help me": Barriers to housing among unsheltered homeless adults

Despite a legally-mandated right to shelter and extensive outreach efforts, an estimated 3,675 homeless individuals were living on the streets of New York City in 2018. Through interviews with 43 unsheltered homeless individuals in the borough of Manhattan (age range 21-74 years), this qualitative study examined barriers they face in accessing housing and other services as well as experiences surviving on the street. Through thematic analysis of the interview data, the most common barriers found were obtaining required identification documents, lack of accessibility of shelters amid complex healthcare needs, waiting as part of the process, and exclusion of pets from shelters and housing options. Themes capturing survival on the street included sleeping safe, avoiding shelters, and meeting daily needs. Virtually all barriers street homeless New Yorkers face stem from bureaucratic policies that, however well-intentioned, do not address their diverse needs. Thus, long delays and poor communication, combined with crowded, unsafe shelters, lead to frustration and alienation. While homelessness is ultimately the result of a severe and chronic shortage of affordable housing, creating accessible, safe, pet-friendly shelter and safe haven options and instituting a smoother, more transparent process for moving from the streets could substantially reduce street homelessness.

Health service preferences among veterans in supported housing in relation to needs expressed and services used

BACKGROUND

Understanding consumer service preferences is important for recovery-oriented care.

AIMS

To test the influence of perceived service needs on importance attached to treatment for alcohol, drug, mental health, and physical health problems and identify the influence of service needs and preferences on service use.

METHODS

Formerly homeless dually diagnosed Veterans in supported housing were surveyed in three waves for 1 year, with measures of treatment interests, health problems, social support, clinician-assessed risk of housing loss, and sociodemographics. Multiple regression analysis was used to identify independent influences on preferences in each wave. Different health services at the VA were distinguished in administrative records and baseline predictors for services used throughout the project were identified with multiple regression analysis.

RESULTS

Self-assessed problem severity was associated with the importance of treatment for alcohol, drug, mental health, and physical health problems. Social support also had some association with treatment interest for alcohol abuse, as did baseline clinician risk rating at the project's end. Preferences, but not perceived problem severity, predicted the use of the corresponding health services.

CONCLUSIONS

The health beliefs model of service interests was supported, but more integrated service delivery models may be needed to strengthen the association of health needs with service use.

Services Receipt Following Veteran Outpatients' Positive Screen for Homelessness

INTRODUCTION

The Veterans Health Administration seeks to reduce homelessness among Veterans by identifying, and providing prevention and supportive services to, patients with housing concerns. The objectives of this study were to assess the proportion of Veterans Health Administration patients who received homeless or social work services within 6 months of a positive screen for homelessness or risk in the Veterans Health Administration and the demographic and clinical characteristics that predicted services utilization.

METHODS

Data were from a cohort of 27,403 Veteran outpatients who screened positive for homelessness or risk between November 1, 2012 and January 31, 2013. During 2013, AORs were calculated using a mixed-effects logistic regression to estimate the likelihood of patients' receipt of VHA homeless or social work services based on demographic and clinical characteristics.

RESULTS

The majority of patients received services within 6 months post-screening; predictors of services utilization varied by gender. Among women, diagnosis of drug abuse and psychosis predicted receipt of services, being unmarried increased the odds of using services among those screening positive for homelessness, and a diagnosis of post-traumatic stress disorder increased the odds of receiving services for at-risk women. Among men, being younger, unmarried, not service-connected/Medicaid-eligible, and having a medical or behavioral health condition predicted receipt of services.

CONCLUSIONS

Receipt of housing support services among Veterans post-homelessness screening differs by patient demographic and clinical characteristics. Future research should investigate the role that primary and secondary prevention interventions play in Veterans' resolution of risk for homelessness and experience of homelessness.

Does experiencing homelessness affect women's motivation to change alcohol or drug use?

BACKGROUND AND OBJECTIVES

Homeless women are at high risk of drug and alcohol dependence and may receive less opportunity for treatment. Our objective was to examine the association between experiencing homelessness and motivation to change drug or alcohol use.

METHODS

Women (n = 154) participants in a study of substance dependence at an urban medical center (69 with some homeless days in the last 90 days; 85 continuously housed at baseline) completed six items rating motivation to change alcohol or drug use (ie, importance, readiness, and confidence) at baseline and in 3-, 6-, and 12-month follow-up interviews. Unadjusted and longitudinal analyses controlling for covariates (eg, demographics, insurance status, substance use consequences, mental health status, and participation in treatment) were conducted.

RESULTS

There were no significant differences between women experiencing homeless days versus continuously housed women in the odds of reporting high motivation to change alcohol or drug use, either in unadjusted baseline analyses or longitudinal analyses adjusted for covariates. Covariates that were significantly associated with high importance, readiness or confidence to change behavior were higher life time consequences of substance use, and participation in 12-step programs.

DISCUSSION AND CONCLUSIONS

The findings suggest that clinicians should not make assumptions that homeless women have low motivation to change their substance use.

SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS

The same opportunities for addiction treatment should be offered to homeless as to housed women.

Predictors of substance abuse treatment need and receipt among homeless women

Many homeless women do not receive needed treatment for substance abuse. This study identified social network and other predisposing factors associated with perceived need for and receipt of substance abuse treatment among 273 homeless women who screened positive for past-year substance abuse. Perceived treatment need was more likely among women with drug-using sex partners, a denser network, and an arrest history but less likely for those with a minor child and a longer history of homelessness. Receiving treatment was more likely among women who received informational support from their sex partners and who had an arrest history but less likely among those who had a more street-based social network, had a minor child, considered themselves homeless, and recently needed mental health treatment. Treatment services researchers should attend more closely to social contextual factors, as well as the more traditional individual factors, to understand access and barriers to treatment.

Methodological challenges in psychiatric treatment adherence research

Reflecting an increasing awareness of the importance of treatment adherence on outcomes in psychiatric populations, the National Institute of Mental Health (NIMH) convened a panel of treatment adherence researchers on September 27-28, 2007 to discuss and articulate potential solutions for dealing with methodological adherence research challenges. Panel discussions and presentations were augmented with targeted review of the literature on specific topics, with a focus on adherence to medication treatments in adults with serious mental illness. The group discussed three primary methodological areas: participants, measures, and interventions. When selecting patients for adherence-enhancing interventions (AEIs), a three-tier model was proposed that draws from the universal (targeting all patients receiving medication treatment for a specific condition, regardless of current adherence), selective (targeting patients at risk for nonadherence), and indicated (targeting patients who are currently nonadherent) prevention model and emphasizes careful patient characterization in relevant domains and appropriate matching of interventions to the selected population. Proposals were also made to reduce problematic selection biases in patient recruitment and retention. The panel addressed the pros and cons of various methods that can be used to measure adherence, and concluded that it is appropriate to use multiple measures whenever possible. Finally, the panel identified a broad range of intervention approaches, and conditions under which these interventions are likely to be most effective at reducing barriers to adherence and reinforcing adherence behavior.

Fundamental Causes of Housing Loss among Persons Diagnosed with Serious and Persistent Mental Illness: A Theoretically Guided Test

Previous research on housing loss among severely mentally ill persons who have been placed in housing after being homeless has been largely atheoretical and has yielded inconsistent results. We develop a theory of housing loss based on identifying fundamental causes-problems in motives, means and social situation-and test these influences in a longitudinal, randomized comparison of housing alternatives. As hypothesized, individuals were more likely to lose housing if they had a history of alcohol or drug abuse, desired strongly to live independently contrary to clinician recommendations, or were African Americans placed in independent housing. Deficits in daily functioning did not explain these influences, but contributed to risk of housing loss. Our results demonstrate the importance of substance abuse, the value of distinguishing support preferences from support needs, and the necessity of explaining effects of race within a social context and thus should help to improve comparative research.

Where do people go when they first become homeless? A survey of homeless adults in the USA

The longer a person is homeless, the more likely he or she is to experience poor health and be placed at higher risk for premature death. This makes interventions early in one's homelessness an important prevention strategy. However, little is known about where someone goes for help when they first become homeless and how well those sites are prepared to address the multitude of issues facing a homeless person. In order to address this question, we conducted a cross-sectional community-based survey in two US cities in 1997 using population proportionate sampling of homeless persons identified at 91 sites to identify 'first-stop' access sites and reasons for seeking help at those sites. A total of 230 persons participated in the face-to-face interview (93% response rate). From a list of 20 possible 'first-stop' sites, 105 (45.7%) reported going to a soup kitchen, 71 (30.9%) went to a welfare office, 64 (27.8%) sought admission to a detoxification centre, 60 (26.1%) met with a homeless outreach team, 57 (24.8%) went to a family member, and 54 (23.5%) went to an emergency room. Individuals with a chronic medical or mental health condition were significantly more likely to access a healthcare site (medical: 62.6% vs. 47.6%, P = 0.02; mental health: 62.4% vs. 38.8%, P < 0.01) or social service agency (medical: 64.0% vs. 43.3%, P = 0.02; mental health: 59.1% vs. 40.7%, P < 0.01). Those persons reporting a need for alcohol treatment were significantly more likely to first go to a healthcare site (46.4% vs. 29.1%, P < 0.01) and those with alcohol abuse/dependence were less likely to seek help from family or friends (66.7% vs. 81.9%, P < 0.01). Most respondents sought assistance for concerns directly associated with an immediate need as opposed to seeking care for issues causing their actual homelessness. These findings suggest the need to expand and integrate the availability of services at 'first-stop' access sites that facilitate early exits from homelessness.

The effect of individual, program, and neighborhood variables on continuity of treatment among dually diagnosed individuals

This study reviewed the medical charts of 271 patients diagnosed with co-morbid mental health and substance-use disorders who were discharged from a hospital acute inpatient unit to various outpatient treatment programs in Philadelphia. Geographic Information Systems (GIS) technology and logistic regression modeling were employed to investigate the effects of individual, neighborhood, and program-level variables on arrival to the first treatment appointment within 30 days of discharge. Four models are presented. The results of the study suggest that having had three or more treatment episodes prior to inpatient hospitalization, and living in a neighborhood in which temporary or transitional, and presumably, other low income housing is located, increased the likelihood of patients continuing with treatment in the community. Discharge to the preadmission address, a chief complaint of bizarre behavior, close proximity of two or more liquor and/or beer stores, a high density of narcotics anonymous (NA) and/or alcoholics anonymous (AA) meetings within the neighborhood, an axis I diagnosis of substance-induced mood disorder, and a urine drug screen positive for heroin reduced the likelihood of attending outpatient treatment. We conclude that geographic and community variables as they relate to substance abuse may add an important dimension to our understanding of patient functioning and well being in the community following inpatient treatment.