1
|
Rosenblad AK, Klarare A, Rapaport P, Mattsson E, Gaber SN. Health literacy and its association with mental and spiritual well-being among women experiencing homelessness. Health Promot Int 2024; 39:daae019. [PMID: 38430507 PMCID: PMC10908353 DOI: 10.1093/heapro/daae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2024] Open
Abstract
Low health literacy (HL) has been linked to low self-rated health, reduced efficacy of behaviour change, and challenges in preventing, treating, or managing health conditions. People experiencing homelessness are at risk of poor HL; however, few studies have investigated HL in relation to mental and spiritual well-being among people experiencing homelessness in general, or women experiencing homelessness specifically. This cross-sectional study of 46 women experiencing homelessness in Stockholm, Sweden, recruited during the period October 2019-December 2020, aimed to examine how HL was associated with mental and spiritual well-being among women experiencing homelessness. Participants answered questions about socio-demographic characteristics (age, length of homelessness, education) and digital technology (mobile phone/the Internet) use, in addition to Swedish language versions of three questionnaires administered through structured, face-to-face interviews: the Communicative and Critical Health Literacy Scale, the General Health Questionnaire 12 and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being. Data were analysed using linear regression, which revealed statistically significant associations between HL and mental well-being (p = .009), and between HL and spiritual well-being (p = .022). However, neither socio-demographic characteristics nor digital technology use were significantly associated with HL. In conclusion, promoting HL may improve mental and spiritual well-being in this vulnerable population. An advisory board of women with lived experiences of homelessness (n = 5) supported the interpretation of the findings and emphasised the need to consider HL in relation to basic needs such as 'housing first'. Moreover, health information and services should be accessible to people with different degrees of HL.
Collapse
Affiliation(s)
- Andreas Karlsson Rosenblad
- Department of Statistics, Uppsala University, Box 513, 751 20, Uppsala, Sweden
- Department of Medical Sciences, Division of Clinical Diabetology and Metabolism, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Anna Klarare
- Department of Women’s and Children’s Health, Healthcare Services and e-Health, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
- Department of Healthcare Sciences, Marie Cederschiöld University, Box 11189, 100 61, Stockholm, Sweden
| | - Penny Rapaport
- Division of Psychiatry, Faculty of Brain Sciences, University College London, Maple House, W1T 7BN, London, UK
| | - Elisabet Mattsson
- Department of Women’s and Children’s Health, Healthcare Services and e-Health, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
- Department of Healthcare Sciences, Marie Cederschiöld University, Box 11189, 100 61, Stockholm, Sweden
| | - Sophie Nadia Gaber
- Department of Women’s and Children’s Health, Healthcare Services and e-Health, Uppsala University, Akademiska sjukhuset, 751 85, Uppsala, Sweden
- Department of Healthcare Sciences, Marie Cederschiöld University, Box 11189, 100 61, Stockholm, Sweden
| | | |
Collapse
|
2
|
Greene A, Korchmaros JD, Frank F. Trauma Experience Among Women Who Have Substance Use Disorders and are Homeless or Near Homeless. Community Ment Health J 2024; 60:233-243. [PMID: 37462795 PMCID: PMC10821823 DOI: 10.1007/s10597-023-01162-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/18/2023] [Indexed: 01/28/2024]
Abstract
Women with substance use disorders (SUDs) who are homeless or near homeless have high rates of mental health, behavioral health, and SUD treatment needs. To effectively respond to these needs, it is critical to understand the population-specific trauma experiences of these women. This descriptive study examined the extent and nature of trauma experience among women who have an SUD and are homeless or near homeless. Results (n = 851 women) indicated high rates of trauma experience. All participants (100%) reported at least one type of trauma experience in their lifetime, with the majority (75.3%) having experienced five to seven of the seven types of trauma experiences assessed. Participants reported high levels of emotional severity related to the majority of traumatic events experienced. The pervasiveness of the trauma experiences and the related emotional impact among women with SUDs who are homeless or near homeless reinforce the necessity for trauma-informed care in treatment settings.
Collapse
Affiliation(s)
- Alison Greene
- University of Arizona, Southwest Institute for Research on Women, 925 N Tyndall Avenue, P.O. Box 210438, Tucson, AZ, 85721-0438, USA.
- School of Public Health-Bloomington, Indiana University, 1025 East 7th Street, Bloomington, IN, 47405-7109, USA.
| | - Josephine D Korchmaros
- University of Arizona, Southwest Institute for Research on Women, 925 N Tyndall Avenue, P.O. Box 210438, Tucson, AZ, 85721-0438, USA
| | - Franziska Frank
- School of Sociology, University of Arizona, 1145 E. South Campus Drive, Tucson, AZ, 85721-0438, USA
| |
Collapse
|
3
|
Greene A, Korchmaros JD. A Research-Informed Approach to Providing Behavioral Healthcare to Women with Extensive Trauma Histories. Community Ment Health J 2024; 60:203-207. [PMID: 37439969 PMCID: PMC10821824 DOI: 10.1007/s10597-023-01159-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/18/2023] [Indexed: 07/14/2023]
Abstract
Translating research to behavioral healthcare practice is vital for improving treatment impact but can be challenging. Current and lifetime histories of trauma need to be considered in behavioral healthcare provision as they can significantly affect an individual's treatment experience. This article provides guidance on how to utilize research findings regarding trauma prevalence and experiences of women who have substance use disorder and who are homeless or near homeless to help guide responsive healthcare and treatment in practice.
Collapse
Affiliation(s)
- Alison Greene
- University of Arizona, Southwest Institute for Research on Women, 925 N Tyndall Avenue, P.O. Box 210438, Tucson, AZ, 85721-0438, USA.
- School of Public Health-Bloomington, Indiana University, 1025 East 7th Street, Bloomington, IN, 47405-7109, USA.
| | - Josephine D Korchmaros
- University of Arizona, Southwest Institute for Research on Women, 925 N Tyndall Avenue, P.O. Box 210438, Tucson, AZ, 85721-0438, USA
| |
Collapse
|
4
|
Foley K, Freeman T, Wood L, Flavel J, Parry Y, Baum F. Logic modelling as hermeneutic praxis: Bringing knowledge systems into view during comprehensive primary health care planning for homelessness in Australia. Health (London) 2023:13634593231200129. [PMID: 37747045 DOI: 10.1177/13634593231200129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Logic modelling is used widely in health promotion planning for complex health and social problems. It is often undertaken collaboratively with stakeholders across sectors that hold and enact different institutional approaches. We use hermeneutic philosophy to explore how knowledge is 'lived' by - and unfolds differently for - cross-sectoral stakeholders during comprehensive primary healthcare service planning. An Organisational Action Research partnership was established with a non-government organisation designing comprehensive primary health care for individuals experiencing homelessness in Adelaide, Australia. Grey literature, stakeholder input, academic feedback, a targeted literature review and evidence synthesis were integrated in iterative cycles to inform and refine the logic model. Diverse knowledge systems are active when cross-sectoral stakeholders collaborate on logic models for comprehensive primary health care planning. Considering logic modelling as a hermeneutic praxis helps to foreground and explore these differences. In our case, divergent ideas emerged in how health/wellbeing and trust were conceptualised; language had different meanings across sectors; and the outcomes and data sought were nuanced for various collaborators. We explicate these methodological insights and also contribute our evidence-informed, collaboratively-derived model for design of a comprehensive primary health care service with populations experiencing homelessness. We outline the value of considering cross-sectoral logic modelling as hermeneutic praxis. Engaging with points of difference in cross-sectoral knowledge systems can strengthen logic modelling processes, partnerships and potential outcomes for complex and comprehensive primary health care services.
Collapse
|
5
|
Motta-Ochoa R, Incio-Serra N, Brulotte A, Flores-Aranda J. Motives for alcohol use, risky drinking patterns and harm reduction practices among people who experience homelessness and alcohol dependence in Montreal. Harm Reduct J 2023; 20:22. [PMID: 36829166 PMCID: PMC9955533 DOI: 10.1186/s12954-023-00757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND People experiencing homelessness are disproportionately affected by harms related to alcohol use. Indeed, their alcohol dependence is associated with numerous physical and mental health problems along with strikingly high rates of alcohol-related mortality. Recent research has extensively examined alcohol use patterns among people experiencing homelessness in an effort to develop interventions and treatments for this problem. However, only a few studies have incorporated the perspectives of the individuals under study about their drinking or examined the ways in which they manage the associated harms. To bridge this gap, we conducted a qualitative study exploring the relation between the drinking motives, risky drinking patterns and harm reduction practices of a group of people (n = 34) experiencing homelessness in Montreal, Canada. METHODS The qualitative methods we used consisted of semi-structured interviews (n = 12) and focus groups (n = 2, with a total of 22 participants). The content of the collected data was then analyzed. RESULTS Participants identified their various motives for alcohol use (coping with painful memories, dealing with harsh living conditions, socializing/seeking a sense of belonging, enjoying themselves/having fun); their risky drinking patterns (binge drinking, mixing alcohol with drugs, non-beverage alcohol drinking, failing to keep sufficient alcohol on hand to prevent acute withdrawal, drinking in public settings); their harm reduction practices (planning how much to drink, keeping a supply of alcohol to prevent acute withdrawal, hiding to drink, concealing alcohol, drinking alone, drinking/hanging out with others, drinking non-beverage alcohol, and taking benzodiazepines, cocaine or other stimulant drugs); and the rationales underpinning their alcohol use and harm reduction practices. CONCLUSION Associating the drinking motives of a group of study participants with their risky drinking patterns and harm reduction practices shed light on their rationales for alcohol use, yielding insights that could be used to better tailor policies and interventions to their needs.
Collapse
Affiliation(s)
- Rossio Motta-Ochoa
- grid.38678.320000 0001 2181 0211École de travail social, Université du Québec à Montréal, 455 René-Lévesque Blvd. Est Local W-4020, Montreal, QC H2L 4Y2 Canada ,grid.14848.310000 0001 2292 3357École de travail social, Université de Montréal, Pavillon Lionel-Groulx, 3150 Jean-Brillant Street (C-7075), Montreal, QC H3T 1J7 Canada ,Canada Research Chair in Sexually and Gender Diverse Individuals (SGD) and Their Psychoactive Substance Use Trajectories (TRADIS Chair), Montreal, Canada
| | - Natalia Incio-Serra
- grid.14709.3b0000 0004 1936 8649Faculty of Education, McGill University, 3700 McTavish Street, Montreal, QC H3A 1Y2 Canada
| | - Alexandre Brulotte
- grid.38678.320000 0001 2181 0211École de travail social, Université du Québec à Montréal, 455 René-Lévesque Blvd. Est Local W-4020, Montreal, QC H2L 4Y2 Canada ,Canada Research Chair in Sexually and Gender Diverse Individuals (SGD) and Their Psychoactive Substance Use Trajectories (TRADIS Chair), Montreal, Canada
| | - Jorge Flores-Aranda
- École de travail social, Université du Québec à Montréal, 455 René-Lévesque Blvd. Est Local W-4020, Montreal, QC, H2L 4Y2, Canada. .,Canada Research Chair in Sexually and Gender Diverse Individuals (SGD) and Their Psychoactive Substance Use Trajectories (TRADIS Chair), Montreal, Canada.
| |
Collapse
|
6
|
Jones AA, Schneider KE, Tobin KE, O'Sullivan D, Latkin CA. Daily opioid and stimulant co-use and nonfatal overdoses in the context of social disadvantage: Findings on marginalized populations. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023:208986. [PMID: 36822268 DOI: 10.1016/j.josat.2023.208986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 11/28/2022] [Accepted: 02/12/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE Opioids and stimulants are increasingly implicated in overdose deaths, particularly among minoritized groups. We examined daily opioid and cocaine co-use, nonfatal overdoses, and naloxone carrying among minoritized people who inject drugs (PWID). METHODS The study derived data from 499 PWID in Baltimore City, MD, recruited using street-based outreach between 2016 and 2019. Participants reported overdoses; sociodemographic characteristics; and use of nonmedical prescription opioids, heroin, cocaine, and naloxone. RESULTS Among the participants, the mean age was 46, 34 % were female, 64 % self-identified as Black, and 53 % experienced recent homelessness. Black PWID, compared to White PWID, were as likely to use opioids and cocaine daily but were 61 % less likely to have naloxone. After controlling for sociodemographic characteristics, women (aOR:1.88, 95%CI: 1.14, 3.11), persons experiencing homelessness (aOR:3.07, 95%CI: 1.79, 5.24), and those who experienced a recent overdose (aOR:2.14, 95%CI: 1.29, 3.58) were significantly more likely to use opioids and any form of cocaine every day. In a subanalysis of only female PWID, females engaged in sex work (aOR:2.27, 95%CI: 1.02, 5.07) and females experiencing recent homelessness (aOR:5.82, 95%CI: 2.50, 13.52) were significantly more likely to use opioids and cocaine daily. Furthermore, females (aOR:1.69, 95%CI:1.03, 2.77), persons experiencing homelessness (aOR:1.94, 95%CI:1.16, 3.24), and those with higher educational attainment (aOR:2.06, 95%CI:1.09, 3.91) were more likely to often/always carry naloxone, while Black PWID were less likely to have naloxone (aOR:0.39, 95%CI:0.22, 0.69). CONCLUSIONS These findings highlight the need for targeted naloxone distribution and other harm-reduction interventions among minoritized groups in urban areas.
Collapse
Affiliation(s)
- A A Jones
- Department of Human Development and Family Studies, The Pennsylvania State University, USA.
| | - K E Schneider
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, USA
| | - K E Tobin
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, USA
| | - D O'Sullivan
- Department of Educational Psychology, Counseling, and Special Education, The Pennsylvania State University, USA
| | - C A Latkin
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, John Hopkins University, USA
| |
Collapse
|
7
|
Schmidt CN, Wingo EE, Newmann SJ, Borne DE, Shapiro BJ, Seidman DL. Patient and provider perspectives on barriers and facilitators to reproductive healthcare access for women experiencing homelessness with substance use disorders in San Francisco. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231152374. [PMID: 36939096 PMCID: PMC9947686 DOI: 10.1177/17455057231152374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND Women experiencing homelessness with substance use disorders face unique and intersecting barriers to realizing their reproductive goals. OBJECTIVE This study explored the reproductive aspirations of this population, as well as the barriers to accessing reproductive services from the perspectives of affected individuals, and the healthcare providers who serve them. DESIGN This mixed-methods study included surveys and interviews with women experiencing homelessness with substance use disorders and healthcare providers. METHODS We conducted surveys and semi-structured interviews with women recruited from opiate treatment programs and homeless encampments in San Francisco, California in 2018. We also conducted interviews and focus groups with healthcare providers in reproductive health and substance use treatment settings. Interviews were recorded, transcribed, and coded. Descriptive statistics of survey results were performed. RESULTS Twenty-eight women completed surveys, 96% of whom reported current substance use. Ten women participated in interviews. One-third (9/28) reported desiring pregnancy in the next year; over half (16/28) reported they would be somewhat or very happy to learn they were pregnant. A majority used no contraception at last intercourse (14/28). Twenty-six healthcare providers participated in interviews (n = 15) and focus groups (n = 2). Patients and providers identified similar barriers to care access, including discrimination, logistical and financial challenges, and delayed pregnancy awareness. While providers proposed solutions focused on overcoming logistical challenges, patients emphasized the importance of transforming the healthcare environment to treat patients affected by substance use and homelessness with dignity and respect. CONCLUSION Women experiencing homelessness with substance use disorders face intersecting and compounding barriers to accessing reproductive health services. For patients, the impact of stigma and bias on treatment experiences are particularly salient, in contrast to logistical barriers emphasized by providers. Improving access will require structural and individual-level solutions to address stigma and create person-centered, trauma-informed, and respectful care environments.
Collapse
Affiliation(s)
- Christina N Schmidt
- School of Medicine, University of
California San Francisco, San Francisco, CA, USA
| | - Erin E Wingo
- Department of Obstetrics, Gynecology
& Reproductive Services, University of California San Francisco and San
Francisco General Hospital, San Francisco, CA, USA
| | - Sara J Newmann
- Department of Obstetrics, Gynecology
& Reproductive Services, University of California San Francisco and San
Francisco General Hospital, San Francisco, CA, USA
| | - Deborah E Borne
- San Francisco Department of Public
Health, San Francisco, CA, USA
| | - Brad J Shapiro
- Department of Psychiatry, University of
California San Francisco, San Francisco, CA, USA
| | - Dominika L Seidman
- Department of Obstetrics, Gynecology
& Reproductive Services, University of California San Francisco and San
Francisco General Hospital, San Francisco, CA, USA
- Dominika L Seidman, Department of
Obstetrics, Gynecology & Reproductive Services, University of California San
Francisco and San Francisco General Hospital, 1001 Potrero Avenue Ward 6D, San
Francisco, CA 94110, USA.
| |
Collapse
|
8
|
Garfin DR, Amador A, Osorio J, Ruivivar KS, Torres A, Nyamathi AM. A multi-method exploration of mindfulness as a coping tool: Perspectives from trauma-exposed, unhoused women residing at a drug treatment facility. Stress Health 2022; 39:347-360. [PMID: 35933124 PMCID: PMC9899869 DOI: 10.1002/smi.3188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/24/2022] [Accepted: 07/27/2022] [Indexed: 02/07/2023]
Abstract
This multi-method study examined perspectives on mindfulness and coping strategies used by trauma-exposed women experiencing homelessness (WEH), residing in a state-funded residential drug treatment site in Southern California (United States). Questionnaires and in-depth focus group interviews were utilised to examine traumatic experiences over the lifespan, probable-posttraumatic stress disorder (PTSD), and coping strategies. Mindfulness was explored as a potential way to improve coping; potential benefits and challenges associated with implementing a mindfulness-based intervention (MBI) with trauma-exposed WEH were also investigated. A Community Advisory Board (CAB) was formed to identify key issues experienced by WEH and to develop a semi structured interview guide (SSIG). Using the SSIG, women participated in one of four focus groups (total N = 28; n = 7 per group). Quantitative data on demographic indicators, probable-PTSD, and trauma exposure were collected. Almost 90% of women met criteria for probable-PTSD; trauma exposure was exceedingly high; most women had experienced multiple traumas throughout their lives. Four main themes emerged from qualitative analyses, which drew from Grounded Theory and used open, selective, and axial coding: (1) ways of coping with trauma; (2) perspectives on mindfulness; (3) prior experiences with mindfulness; and (4) challenges for conducting a mindfulness programme. Overall, WEH used a variety of coping techniques to deal with their trauma, had some familiarity with mindfulness, and were optimistic an MBI would be helpful, despite identifying several challenges to implementation. MBIs may be helpful adjuncts to traditional care for trauma-exposed, WEH, recovering from substance use disorder. Population-specific considerations may improve implementation and participation.
Collapse
Affiliation(s)
- Dana Rose Garfin
- Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles
| | - Alexandra Amador
- Department of Psychological Science, University of California, Irvine
| | - Jessica Osorio
- Sue & Bill Gross School of Nursing, University of California, Irvine
| | | | | | | |
Collapse
|
9
|
The Health Needs of Regionally Based Individuals Who Experience Homelessness: Perspectives of Service Providers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148368. [PMID: 35886228 PMCID: PMC9316847 DOI: 10.3390/ijerph19148368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/07/2022]
Abstract
The bidirectional relationship between homelessness and poor health and the barriers that individuals who experience homelessness face when trying to access healthcare are well documented. There is, however, little Australian research exploring the situation of individuals who experience homelessness in regional contexts and, moreover, from the perspective of service providers. A qualitative descriptive methodology underpinned this study, with in-depth semi-structured interviews being conducted with 11 service providers to identify barriers to care faced by people who experience homelessness and barriers that service providers themselves experience in supporting this population. The key barriers identified were client-level barriers: living day-by-day, financial, health literacy, mental health conditions, behaviour, safety and stigma; provider-level barriers: few bulk-billing doctors, fragmented services, limited resources, negative past experiences with healthcare; and system level barriers: transportation, over-stretched healthcare services. The combined impact of these barriers has significantly contributed to the desperate situation of people experiencing homelessness in Launceston. This situation is likely replicated in other regional populations in Australia. Given that individuals experiencing homelessness have higher rates of every measure in health inequality, steps need to be taken to reduce barriers, and a standardised approach to health care urgently needs to be implemented by governments at the state and national level to improve the health of regionally based individuals experiencing homelessness.
Collapse
|
10
|
Chun SY, Yoo JW, Park H, Hwang J, Kim PC, Park S, Shen JJ. Trends and age-related characteristics of substance use in the hospitalized homeless population. Medicine (Baltimore) 2022; 101:e28917. [PMID: 35212298 PMCID: PMC8878700 DOI: 10.1097/md.0000000000028917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/24/2022] [Indexed: 01/04/2023] Open
Abstract
We aimed to examine trends and characteristics of substance use (opioid, cocaine, marijuana, and heroin) among hospitalized homeless patients in comparison with other hospitalized patients in 3 states.This was a cross-sectional study, based on the 2007 to 2015 State Inpatient Data of Arizona, Florida, and Washington (n = 32,162,939). Use of opioid, cocaine, marijuana, heroin, respectively, was identified by the International Classification of Diseases, 9th Revision. Multi-level multivariable regressions were performed to estimate relative risk (RR) and 95% confidence intervals (CI). Dependent variables were the use of substances (opioid, cocaine, marijuana, and heroin), respectively. The main independent variable was homeless status. The subgroup analysis by age group was also conducted.Homeless patients were associated with more use of opioid (RR [CI]), 1.23 [1.20-1.26], cocaine 2.55 [2.50-2.60], marijuana 1.43 [1.40-1.46], and heroin 1.57 [1.29-1.91] compared to other hospitalized patients. All hospitalized patients including those who were homeless increased substance use except the use of cocaine (RR [CI]), 0.57 [0.55-0.58] for other patients and 0.60 [0.50-0.74] for homeless patients. In all age subgroups, homeless patients 60 years old or older were more likely to be hospitalized with all 4 types of substance use, especially, cocaine (RR [CI]), 6.33 [5.81-6.90] and heroin 5.86 [2.08-16.52] in comparison with other hospitalized patients.Homeless status is associated with high risks of substance use among hospitalized patients. Homeless elderly are particularly vulnerable to use of hard drugs including cocaine and heroin during the opioid epidemics.
Collapse
Affiliation(s)
- Sung-youn Chun
- Research and Analysis Team, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Ji W. Yoo
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV
| | - Hyeki Park
- Department of International Cooperation, Health Insurance Review & Assessment Service, Wonju, Republic of Korea
| | - Jinwook Hwang
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Pearl C. Kim
- Department of Healthcare Administration and Policy, University of Nevada Las Vegas School of Public Health, Las Vegas, NV
| | - Seong Park
- Department of Criminal Justice, University of Nevada Greenspun College of Urban Affairs, Las Vegas, NV
| | - Jay J. Shen
- Department of Criminal Justice, University of Nevada Greenspun College of Urban Affairs, Las Vegas, NV
| |
Collapse
|
11
|
Alexander AC, Waring JJ, Olurotimi O, Kurien J, Noble B, Businelle MS, Ra CK, Ehlke SJ, Boozary LK, Cohn AM, Kendzor DE. The relations between discrimination, stressful life events, and substance use among adults experiencing homelessness. Stress Health 2022; 38:79-89. [PMID: 34137166 PMCID: PMC9629914 DOI: 10.1002/smi.3073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 02/03/2023]
Abstract
The current study investigated whether stressful life events and everyday discrimination experiences were associated with using one or more substances in the past 30-days and substance use disorder (SUD) among adults experiencing homelessness. We obtained survey data from adults (N = 501) seeking services at a day shelter. Participants self-reported whether they used cigarettes, other tobacco products, cannabis, alcohol, opioids, amphetamine, and cocaine/crack in the past 30-days, and the total number of substances used were also calculated. We measured stressful life events and everyday discrimination using validated scales. We used multivariable logistic and negative binomial regression analyses to evaluate hypothesised associations. Results indicated that reporting a higher number of stressful life events was associated with past 30-days cannabis, tobacco, alcohol, and other substance use, screening positive for a SUD, and using a greater number of substances in the past 30 days. After accounting for stressful life events, everyday discrimination was associated with only past 30-days cannabis use. Overall, we found that reporting stressful life events was related to current substance use and screening positive for a SUD. Findings suggest that life stressors, and discrimination to a lesser extent, were associated with substance use and SUD among adults experiencing homelessness.
Collapse
Affiliation(s)
- Adam C. Alexander
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.,Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joseph J.C. Waring
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Oluwakemi Olurotimi
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Jasmin Kurien
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Bishop Noble
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Michael S. Businelle
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.,Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Chaelin K. Ra
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Sarah J. Ehlke
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Laili K. Boozary
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.,Department of Psychology, Cellular and Behavioral Neurobiology, The University of Oklahoma, Norman, OK
| | - Amy M. Cohn
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.,Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Darla E. Kendzor
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.,Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| |
Collapse
|
12
|
Song A, Wenzel SL, Cho Y. Child Abuse Victimization, Depression, and Substance Use Among Homeless Women: Application of General Strain Theory. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:8852-8873. [PMID: 31179812 DOI: 10.1177/0886260519853410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The main purpose of this study was to investigate the association between child abuse and substance use among homeless women based on a framework of General Strain Theory, which emphasizes the strong relationship between deviant behaviors and personally experienced strain. In this study, as the strain associated with substance use, child abuse experience in the past was assessed. This research tested three hypotheses about (a) the association between physical and sexual abuse during childhood and substance use (heavy drinking, marijuana use, and crack cocaine use), (b) the mediating effect of depressive symptoms, and (c) the moderating effect of positive social supports on the relationship between abuse during childhood and substance use with a survey and interview data of a randomly selected sample of 445 homeless women in a temporary shelter setting in Los Angeles County between June 2007 and March 2008. Although the results indicated that abuse during childhood was not significantly associated with any form of substance use, the results of multivariate analyses indicated that depressive symptoms fully mediated the four relationships (p < .01; physical abuse and heavy drinking, physical abuse and crack cocaine use, sexual abuse and heavy drinking, and sexual abuse and crack cocaine use). The results of this study also indicated that positive social supports significantly moderate the effect of physical (p < .01) and sexual (p < .05) abuse experience on heavy drinking, which implies that positive social supports would be significant to reduce substance use among homeless women who had a history of physical and sexual abuse during childhood.
Collapse
Affiliation(s)
| | | | - Yusun Cho
- Korea University, Seoul, South Korea
| |
Collapse
|
13
|
Salameh TN, Hall LA, Crawford TN, Staten RR, Hall MT. Trends in mental health and substance use disorders and treatment receipt among pregnant and nonpregnant women in the United States, 2008-2014. J Psychosom Obstet Gynaecol 2020; 41:298-307. [PMID: 31718367 DOI: 10.1080/0167482x.2019.1689949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To compare trends in mental health and substance use disorders and treatment receipt of pregnant and nonpregnant women from 2008 to 2014. METHODS Using data from the 2008-2014 National Survey on Drug Use and Health, logistic regression was used to compare trends in mental health and substance use disorders and treatment receipt for mental health and substance use disorders among propensity score-matched groups of pregnant (n = 5520) and nonpregnant women (n = 11,040). Among women in the matched sample who met criteria for at least one mental illness, trends in mental health treatment receipt of pregnant (n = 1003) and nonpregnant women (n = 2634) were compared. RESULTS There were no differences in the trends by pregnancy status from 2008 to 2014. Past-year anxiety disorder, past-month psychological distress and illicit drug use disorder increased in the total sample from 2008 to 2014, yet trends in mental health treatment and unmet need for substance use treatment did not change over time. Pregnant women had lower odds of mental illness, but those who had mental illness were less likely to receive mental health treatment than their nonpregnant counterparts. CONCLUSIONS There is a need for preventive strategies addressing anxiety disorder, psychological distress and illicit drug use among women of childbearing age as well as initiatives to increase access to mental health treatment among pregnant women.
Collapse
Affiliation(s)
| | - Lynne A Hall
- School of Nursing, University of Louisville, Louisville, KY, USA
| | - Timothy N Crawford
- Department of Population and Public Health Sciences, Wright State University, Dayton, OH, USA
| | - Ruth R Staten
- School of Nursing, University of Louisville, Louisville, KY, USA
| | - Martin T Hall
- Kent School of Social Work, University of Louisville, Louisville, KY, USA
| |
Collapse
|
14
|
Iwundu CN, Agrawal P, Businelle MS, Kendzor DE, Reitzel LR. Predictors of Overnight and Emergency Treatment among Homeless Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4271. [PMID: 32549281 PMCID: PMC7345623 DOI: 10.3390/ijerph17124271] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/31/2020] [Accepted: 06/10/2020] [Indexed: 12/02/2022]
Abstract
High usage of emergency treatment and hospitalization has been reported among homeless individuals. Hence, this study aimed to identify the sociodemographic predictors associated with overnight and emergency hospital treatment among a sample of homeless adults. Participants were recruited from a shelter in Dallas, Texas (N = 354; Mage = 43.7 ± 11.7) and were predominantly uninsured, low-income men from various racial groups. The outcome variables were: (a) stayed overnight for treatment in a hospital; and (b) treated in a hospital emergency room. In logistic regression models, sex emerged as the only predictor of overnight treatment in a hospital (OR = 2.68, 95% CI = 1.61-4.47), and treatment in an emergency room (OR = 2.21, 95% CI = 1.34-3.65), such that women were more likely than men to be treated overnight and use emergency care. Targeted interventions and policies are needed to address homeless women's primary care needs and reduce costlier treatment.
Collapse
Affiliation(s)
- Chisom N. Iwundu
- Department of Rehabilitation and Health Services, College of Public and Health, University of North Texas Services, Denton, TX 76203, USA
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
| | - Pooja Agrawal
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
- School of Medicine, University of Texas Medical Branch, Galveston, TX 78701, USA
| | - Michael S. Businelle
- Oklahoma Tobacco Research Center, The University of Oklahoma Health Sciences Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104, USA; (M.S.B.); (D.E.K.)
| | - Darla E. Kendzor
- Oklahoma Tobacco Research Center, The University of Oklahoma Health Sciences Center, 655 Research Parkway, Suite 400, Oklahoma City, OK 73104, USA; (M.S.B.); (D.E.K.)
| | - Lorraine R. Reitzel
- Department of Psychological, Health, and Learning Sciences, College of Education, University of Houston, Houston, TX 77204, USA; (P.A.); (L.R.R.)
- HEALTH Research Institute, University of Houston, 4849 Calhoun Rd., Houston, TX 77204, USA
| |
Collapse
|
15
|
Guillén AI, Marín C, Panadero S, Vázquez JJ. Substance use, stressful life events and mental health: A longitudinal study among homeless women in Madrid (Spain). Addict Behav 2020; 103:106246. [PMID: 31838444 DOI: 10.1016/j.addbeh.2019.106246] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/23/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
The objectives of this study were: (1) to assess the prevalence of substance use among homeless women; (2) to examine the correlates for drug abuse; (3) to analyze paths between early stressful life events, drug abuse and mental health. The methodology was a longitudinal study of women homeless in Madrid (Spain), who were followed for a 24 months period. There were 138 participants interviewed at baseline and 73 participants interviewed at follow-up. We ran bivariate and multivariate analysis to examine the correlates for drug abuse. We also performed path analysis to test the interconnections between stressful life events, drug abuse and mental health. Results at baseline showed that 83.3% of participants had consumed at least one substance in the previous month. Tobacco was the most common substance consumed (70.1%), followed by sedatives (48.6%), alcohol (36.2%), methadone (13.7%), cocaine (7.2%), cannabis (6.5%) and heroin (5.1%). In addition, women who met criteria for drug abuse (19.6% of the sample) were more likely to be younger, have suffered adverse experiences during childhood, have engaged in prostitution, and have ever attempted suicide, in comparison with women who did not meet criteria for drug abuse. Path analysis supported that early stressful life events increased the vulnerability for subsequent negative outcomes among homeless women. These findings have significant implications for understanding how to implement programs for homeless women in Spain.
Collapse
|
16
|
Smith L, Veronese N, López-Sánchez GF, Moller E, Johnstone J, Firth J, Grabovac I, Yang L, Soysal P, Jackson SE. Health behaviours and mental and physical health status in older adults with a history of homelessness: a cross-sectional population-based study in England. BMJ Open 2019; 9:e028003. [PMID: 31203244 PMCID: PMC6585828 DOI: 10.1136/bmjopen-2018-028003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES This study compared (1) levels of engagement in lifestyle risk behaviours and (2) mental and physical health status in individuals who have previously been homeless to those of individuals who have not. DESIGN Cross-sectional. PARTICIPANTS Data were from participants (n=6931) of the English Longitudinal Study of Ageing. : Measures : Participants reported whether they had ever been homeless. We used regression models to analyse associations between homelessness and (1) cigarette smoking, daily alcohol consumption and physical inactivity, adjusting for sociodemographic covariates (age, sex, ethnicity, highest level of education, marital status and household non-pension wealth) and (2) self-rated health, limiting long-standing illness, depressive symptoms, life satisfaction, quality of life and loneliness, adjusting for sociodemographics and health behaviours. RESULTS 104 participants (1.5%) reported having been homeless. Individuals who had been homeless were significantly more likely to be physically inactive (OR 1.62, 95% CI 1.44 to 2.52), report fair/bad/very bad self-rated health (OR 1.75, 95% CI 1.07 to 2.86), have a limiting long-standing illness (OR 2.66, 95% CI 1.65 to 4.30) and be depressed (OR 3.06, 95% CI 1.85 to 5.05) and scored lower on measures of life satisfaction (17.34 vs 19.96, p<0.001) and quality of life (39.02 vs 41.21, p=0.013). Rates of smoking (20.2% vs 15.4%, p=0.436), daily drinking (27.6% vs 22.8%, p=0.385) and loneliness (27.1% vs 21.0%, p=0.080) were also elevated. CONCLUSIONS Those who were once homeless have poorer mental and physical health outcomes and are more likely to be physically inactive. Interventions to improve their health and quality of life are required.
Collapse
Affiliation(s)
- Lee Smith
- The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padova, Italy
| | | | | | - James Johnstone
- The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, UK
| | - Joseph Firth
- NICM Health Research Institute, Western Sydney University, Sydney, Australia
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Vienna, Austria
| | - Lin Yang
- Cancer Epidemiology and Prevention Research, Alberta Health Services, Calgary, Canada
| | - Pinar Soysal
- Department of Geriatric Medicine, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Sarah E Jackson
- Department of Behavioural Science and Health, University College London, London, UK
| |
Collapse
|
17
|
Neisler J, Shree S, Reitzel LR, Chen TA, Kendzor DE, Obasi EM, Wrighting Q, Businelle MS. Characterizing Alcohol Use Behaviors among Homeless Men and Women. Am J Health Behav 2019; 43:37-49. [PMID: 30522565 PMCID: PMC6296245 DOI: 10.5993/ajhb.43.1.4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives: In this study, we characterized alcohol use behaviors by sex among sheltered homeless adults and explored associations with health and readiness to change drinking behaviors. Methods: Participants (N = 581; 63.7% men; Mage = 43.6, 29.4% white) self-reported alcohol use and readiness to change drinking behaviors. Sex differences were analyzed via Wilcoxon ranksum, chi-square tests, logistic regression, and ANCOVAs. Results: Overall, 38.5% of the sample met criteria for current at-risk drinking, 39.7% self-reported a history of alcohol problems, and 22.9% reported having a formal alcohol use disorder (AUD) diagnosis. Among current alcohol users, 83.8% reported at-risk drinking. Men had more drinks per drinking day, more drinks per week, and more drinking days per week when compared to women. No sex differences were found for at-risk drinking, self-reported alcohol problems, probable alcohol abuse/dependence, AUD diagnosis, readiness to change drinking, or recent alcohol/substance abuse counseling. Conclusions: High rates of at-risk drinking were found among alcohol users. Homeless men and women did not exhibit differences in several manifestations of problematic alcohol use. Alcohol use interventions might be equally appealing to both sexes given equivalent readiness to change drinking; however, rates of recent treatment receipt were low.
Collapse
Affiliation(s)
- Julie Neisler
- Graduate Student, University of Houston, Department of Psychological, Health, & Learning Sciences, Houston, TX
| | - Sonakshee Shree
- Research Assistant, University of Houston, Department of Psychological, Health, & Learning Sciences, Houston, TX
| | - Lorraine R Reitzel
- Associate Professor, University of Houston, Department of Psychological, Health, & Learning Sciences, Houston, TX;,
| | - Tzu-An Chen
- Assistant Professor, University of Houston HEALTH Research Institute, Houston, TX
| | - Darla E Kendzor
- Associate Professor, University of Oklahoma Health Sciences Center, Oklahoma Tobacco Research Center, Oklahoma City, OK
| | - Ezemenari M Obasi
- Professor, University of Houston, Department of Psychological, Health, & Learning Sciences, Houston, TX
| | - Quentaxia Wrighting
- Research Data Coordinator, MD Anderson Cancer Center, Department of Behavioral Sciences, Houston, TX
| | - Michael S Businelle
- Associate Professor, University of Oklahoma Health Sciences Center, Oklahoma Tobacco Research Center, Oklahoma City, OK
| |
Collapse
|
18
|
Upshur CC, Jenkins D, Weinreb L, Gelberg L, Orvek EA. Homeless women's service use, barriers, and motivation for participating in substance use treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:252-262. [PMID: 28806101 PMCID: PMC6088786 DOI: 10.1080/00952990.2017.1357183] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/16/2017] [Accepted: 07/14/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Homeless women are at high risk for substance use disorder (SUD), and are a growing proportion of the homeless population. However, homeless women experience barriers to engaging in substance use services. OBJECTIVES Among homeless women with SUD, to explore service use, motivation to change, service barriers, and willingness to have substance use and mental health problems addressed in primary health care. METHODS Women with SUD were sampled from 11 Health Care for the Homeless (HCH) primary care clinics in 9 states, yielding 241 with either an alcohol or drug use disorder who then completed questions about SUD services. RESULTS Over 60% of women with dual alcohol and drug use disorders used some type of SUD service in the past year, while 52% with a drug only disorder, and 44% with an alcohol only disorder used services. The most mentioned barrier to service use was depression, but cost, wait time, where to find treatment, and facilities located too far away, were also frequently noted. A large proportion across all groups indicated high motivation for treatment and willingness to discuss their SUD in a primary care setting. CONCLUSION There are continued barriers to SUD service use for homeless women despite high motivation for treatment, and willingness to be asked about SUD and mental health problems in primary care. HCH primary care sites should more systematically ask about SUD and mental health issues and address women's expressed need for support groups and alternative therapies to more holistically address their SUD needs.
Collapse
Affiliation(s)
- Carole C. Upshur
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester MA 01655 USA
- Department of Quantitative Methods, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester MA 01655 USA
| | - Darlene Jenkins
- National Health Care for the Homeless Council, 604 Gallating Ave. Suite 106, Nashville, TN 37206 USA
| | - Linda Weinreb
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester MA 01655 USA
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine, and Department of Health Policy and Management, Fielding School of Public Health, University of California at Los Angeles, 10880 Wilshire Blvd, Suite 1800, Los Angeles, CA 90024 USA
| | - Elizabeth Aaker Orvek
- Department of Quantitative Methods, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester MA 01655 USA
| |
Collapse
|