Implementing a trauma-informed intervention for homeless female survivors of gender-based violence: Lessons learned in a large Canadian urban centre

Interventions to improve the mental health of women experiencing homelessness: A systematic review of the literature

BACKGROUND

Homelessness is a growing public health challenge in the United Kingdom and internationally, with major consequences for physical and mental health. Women represent a particularly vulnerable subgroup of the homeless population, with some evidence suggesting that they suffer worse mental health outcomes than their male counterparts. Interventions aimed at improving the lives of homeless women have the potential to enhance mental health and reduce the burden of mental illness in this population. This review synthesised the evidence on the effectiveness and acceptability of interventions which aim to improve mental health outcomes in homeless women.

METHODS

Five electronic bibliographic databases: MEDLINE, PsycInfo, CINAHL, ASSIA and EMBASE, were searched. Studies were included if they measured the effectiveness or acceptability of any intervention in improving mental health outcomes in homeless women. Study quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. A narrative summary of the study findings in relation to the research questions was produced.

RESULTS

Thirty-nine studies met inclusion criteria. Overall, there was moderate evidence of the effectiveness of interventions in improving mental health outcomes in homeless women, both immediately post-intervention and at later follow-up. The strongest evidence was for the effectiveness of psychotherapy interventions. There was also evidence that homeless women find interventions aimed at improving mental health outcomes acceptable and helpful.

CONCLUSIONS

Heterogeneity in intervention and study methodology limits the ability to draw definitive conclusions about the extent to which different categories of intervention improve mental health outcomes in homeless women. Future research should focus on lesser-studied intervention categories, subgroups of homeless women and mental health outcomes. More in-depth qualitative research of factors that enhance or diminish the acceptability of mental health interventions to homeless women is also required.

How Social Responses to Child Sexual Abuse and Intimate Partner Violence Affect Homelessness Among Women in Two Rural Regions With Resource-Based Economies in Eastern Quebec

This study presents findings from a qualitative study conducted in two relatively remote, primarily rural regions of the Canadian province of Quebec whose resource-based economic structures exacerbate inequalities between men and women. The purpose of this study was to understand how violence and homelessness intertwine in women's life courses in such regions. On the basis of past research showing that gender socialization around traditional roles and conservative values is particularly tenacious in non-urban areas, we conducted life-course interviews with 22 women in 13 different towns and villages of these two regions. Our content analysis of these interviews showed that specific social responses have forced women to maintain relationships with their aggressors or with people who have protected them, thus relegating these women's lives to the private sphere while reducing their opportunities for social participation in the public sphere. These social responses, together with women's economic and social disadvantages in these regions, were also the main factors that explain homelessness experienced by the participants in this study. Our analysis of these responses illustrates the patriarchal social structure of power in these regions, which is perpetuated in the interpersonal, institutional, and representational dimensions and keeps women in precarious, subordinate social positions, while ostracizing or punishing women who try to resist.

Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches

Alcohol is legalized and used for a variety of reasons, including socially or as self-medication for trauma in the absence of accessible and safe supports. Trauma-informed approaches can help address the root causes of alcohol use, as well as the stigma around women's alcohol use during pregnancy. However, it is unclear how these approaches are used in contexts where pregnant and/or parenting women access care. Our objective was to synthesize existing literature and identify promising trauma-informed approaches to working with pregnant and/or parenting women who use alcohol. A multidisciplinary team of scholars with complementary expertise worked collaboratively to conduct a rigorous scoping review. All screening, extraction, and analysis was independently conducted by at least two authors before any differences were discussed and resolved through team consensus. The Joanna Briggs Institute method was used to map existing evidence from peer-reviewed articles found in PubMed, CINAHL, PsycINFO, Social Work Abstracts, and Web of Science. Data were extracted to describe study demographics, articulate trauma-informed principles in practice, and gather practice recommendations. Thirty-six studies, mostly from the United States and Canada, were included for analysis. Studies reported on findings of trauma-informed practice in different models of care, including live-in treatment centers, case coordination/management, integrated and wraparound supports, and outreach-for pregnant women, mothers, or both. We report on how the following four principles of trauma-informed practices were applied and articulated in the included studies: (1) trauma awareness; (2) safety and trustworthiness; (3) choice, collaboration, and connection; and (4) strengths-based approach and skill building. This review advances and highlights the importance of understanding trauma and applying trauma-informed practice and principles to better support women who use alcohol to reduce the risk of alcohol-exposed pregnancies. Relationships and trust are central to trauma-informed care. Moreover, when applying trauma-informed practices with pregnant and parenting women who use alcohol, we must consider the unique stigma attached to alcohol use.

"A right place for everybody": Supporting aging in the right place for older people experiencing homelessness

While policies and practices that promote aging in place have risen in prominence over the last two decades, marginalised older adults have largely been overlooked. 'Aging in the right place' is a concept that recognises the importance of adequate and appropriate age-related health and psychosocial supports in shelter/housing settings and their impact on the ability of older people to age optimally. To understand the unique shelter/housing challenges and solutions that affect aging in the right place for older people experiencing homelessness (OPEH), we conducted three World Café workshops in three Canadian cities-Montreal, Calgary, and Vancouver. In total, 89 service providers and OPEH engaged in the workshops, which involved guided, small-table discussions with the goal of stimulating creative ideas and fostering a productive atmosphere. Findings revealed two overarching themes 1) Discrepancies, between the need and availability of housing options and community supports for OPEH, such as affordable transportation, case management, access to healthcare, and system navigation; and 2) Desires, for more peer support, participatory planning, service-enriched housing, social programming, and policies that promote agency, independence, and choice for OPEH. These findings provide evidence to inform the development or modification of housing and supports for OPEH that promote aging in the right place.

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis

BACKGROUND

It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability.

OBJECTIVES

This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes.

SEARCH METHODS

In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations.

DATA COLLECTION AND ANALYSIS

Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings.

MAIN RESULTS

We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Explaining the Help-Seeking Intentions of Adolescents Subject to Sexual Exploitation in Tanzania: An Application of the Theory of Planned Behavior

The sexual exploitation (SE) of children and adolescents is a universal concern. Numerous empirical studies have examined the prevalence and consequences of this phenomenon worldwide, but there is little information on the factors that determine the help-seeking intentions of adolescents subject to SE in Tanzania. We drew on the theory of planned behavior (TPB) to address this knowledge gap. The study had two main objectives. First, we examined four TPB variables (attitudes toward seeking help, perceived social support, perceived social stigma, and generalized self-efficacy) as determinants of the Tanzanian adolescents' help-seeking intentions. Second, we explored the moderating effects of social stigma on the relationship between the examined TPB factors and the adolescents' help-seeking intentions. A cross-sectional survey design was used to collect data from a stratified random sample of 1,116 secondary school adolescents aged 13-17 (M = 15.66; SD = 1.09). The participants were recruited from two regions in the east and northwest of Tanzania and data were analyzed using hierarchical multiple regression. The results indicate that the TPB variables of attitude toward seeking help, perceived social support, and generalized self-efficacy were positively associated with the help-seeking intentions of adolescents subject to SE, but not social stigma. Through moderation analyses, we found that social stigma significantly weakened the explanatory power of the attitude toward seeking help. The findings of this study in the context of Tanzania were discussed and implications for policy, practice, and future research were suggested.

More than a house: Women's recovery from homelessness in Australia

Recovery from homelessness for women is often a long, complex and highly individualised journey. This study investigated women's experiences of exiting homelessness and examined the factors that influenced recovery. The qualitative interpretive study involved auto-driven photo elicitation and in-depth interviews with 11 women who had previously been homeless. It took place in Australia between August 2018 and August 2019. Women took photographs that represented their experiences of exiting homelessness to guide discussion during interviews. Data were analysed using thematic analysis. Findings indicate that recovery from homelessness involves more than becoming housed. Recovery from homelessness is the overarching theme being presented, described using five subthemes: Finding the right house, Making a house a home, Connection, Building confidence and Helping others. Housing was only the starting point for recovery from homelessness for women. The women drew on their own self determination to create factors necessary for recovery from the experience of homelessness. We conclude that ongoing support is necessary to empower and assist women recovering from the traumatic experiences of homelessness. Trauma-informed care offers service providers a framework for supporting women who have lived through homelessness. Services can draw on this framework to provide support beyond the point of securing a house and assist women to create a home environment, build confidence in themselves and form connections to their community as they transition out of homelessness.

A qualitative exploration of women's resilience in the face of homelessness

The aim of this study was to examine the experiential perspectives of women becoming and experiencing homelessness. Situated in the qualitative interpretative tradition, data were collected using auto-driven photo-elicitation and in-depth face-to-face interviews. Eleven Australian women used photographs that represented their experiences of being homeless to guide their interview discussion. The findings revealed that homelessness for women is a period often preceded by a series of adverse incidents in their lives, characterised by progressive resilience building in the face of trauma, finding hope and building strength to work towards exiting homelessness. After becoming homeless, five stages of resilience transition emerged: The trauma of homelessness, Finding hope and surviving, Finding help, Finding connection and Taking control. Women experiencing homelessness are resilient and capable of enacting competence and autonomy in seeking help to exit homelessness. Changes to service delivery are recommended to improve trauma-informed, person-centred housing and social services that are integrated and easy to navigate.

Benefits of Digital Health Resources for Substance Use Concerns in Women: Scoping Review

BACKGROUND

Digital health resources are being increasingly used to support women with substance use concerns. Although empirical research has demonstrated that these resources have promise, the available evidence for their benefit in women requires further investigation. Evidence supports the capacity of interventions that are sex-, gender-, and trauma-informed to improve treatment access and outcomes and to reduce health system challenges and disparities. Indeed, both sex- and gender-specific approaches are critical to improve health and gender equity. Violence and trauma are frequent among those with substance use concerns, but they disproportionately affect those who identify as female or women, further underscoring the need for trauma-informed care as well.

OBJECTIVE

The objective of this investigation was to evaluate the evidence supporting the efficacy or effectiveness of online or mobile interventions for risky or harmful substance use in adults who identify as female or women, or who report a history of trauma.

METHODS

This scoping review is based on an academic search in MEDLINE, APA PsycINFO, Embase, Cochrane Central, and CINAHL, as well as a grey literature search in US and Canadian government and funding agency websites. Of the 7807 records identified, 465 remained following title and abstract screening. Of these, 159 met all eligibility criteria and were reviewed and synthesized.

RESULTS

The 159 records reflected 141 distinct studies and 125 distinct interventions. Investigations and the interventions evaluated predominantly focused on alcohol use or general substance use. Evaluated digital health resources included multisession and brief-session interventions, with a wide range of therapeutic elements. Multisession online and mobile interventions exhibited beneficial effects in 86.1% (105/122) of studies. Single-session interventions similarly demonstrated beneficial effects in 64.2% (43/67) of study conditions. Most investigations did not assess gender identity or conduct sex- or gender-based analyses. Only 13 investigations that included trauma were identified.

CONCLUSIONS

Despite the overall promise of digital health interventions for substance use concerns, direct or quantitative evidence on the efficacy or effectiveness of interventions in females or women specifically is weak.

Quality of Life and Mental Well-Being: A Gendered Analysis of Persons Experiencing Homelessness in Canada

Homelessness has negative implications for mental well-being and quality of life. This paper identifies the quality of life variables that contribute to positive or negative wellbeing, reporting on a regression analysis from 343 individuals experiencing homelessness in Canada. Results indicate that a lack of sleep duration and quality reduced mental well-being for both genders, not having access to food and/or hygiene facilities decreased men's well-being, and engaging in illegal subsistence strategies, such as selling drugs, negatively impacted women's mental well-being. For persons experiencing homelessness, mental well-being and quality-of-life are gendered outcomes of their limited access to social determinants of health.

Supporting Female Survivors of Gender-Based Violence Experiencing Homelessness: Outcomes of a Health Promotion Psychoeducation Group Intervention

Homelessness is an important risk factor for gender-based violence (GBV), particularly among youth, and disproportionally affects women and girls. Survivors of GBV experience enduring and severe physical, psychological, and sexual health problems. Although key elements in service delivery for survivors of GBV have been identified, little is known about outcomes of community-based programs aiming to assist homeless and unstably housed youth experiencing GBV. This longitudinal study aimed to quantitatively evaluate changes in mental health and well-being outcomes in female identified youth experiencing GBV and homelessness, 12 months after enrolment in a community-based, trauma-informed, brief group psychoeducation intervention. Standardized survey measures were administered at baseline, 6 and 12 months for 70 participants, recruited between February 2017 and April 2019, assessing quality of life, psychological distress, traumatic symptoms, substance use, resilience, victimization, and sense of mastery. Linear mixed models were used to examine longitudinal changes in quality of life as well as secondary outcomes among study participants. After 12 months, quality of life increased significantly among participants (p = 0.009), and the 12-month victimization score was significantly decreased relative to baseline (p = 0.05). Changes in other outcomes were not statistically significant. Findings suggest that community-based brief group psychoeducation interventions may be a promising approach to improving outcomes for this disadvantaged population.