Study protocol for a group-based motivational interviewing brief intervention to reduce substance use and sexual risk behavior among young adults experiencing homelessness

The effectiveness of abstinence-based and harm reduction-based interventions in reducing problematic substance use in adults who are experiencing homelessness in high income countries: A systematic review and meta-analysis: A systematic review

Background

Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing.

Objectives

To understand the effectiveness of different substance use interventions for adults experiencing homelessness.

Search Methods

The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand-searching key journals, and unpacking relevant systematic reviews.

Selection Criteria

Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries.

Data Collection and Analysis

Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta-analysis, we have provided a narrative synthesis of the study and its findings.

Main Results

We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of -0.11 SD (95% confidence interval [CI], -0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (-0.21 SD, 95% CI [-0.59, 0.17] - 6 studies, 17 effect sizes), the removal of quasi-experimental studies (-0.14 SD, 95% CI [-0.30, 0.02] - 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (-0.08 SD, 95% CI [-0.31, 0.15] - 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence-based interventions compared to treatment-as-usual (TAU) service provision was -0.28 SD (95% CI, -0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, -0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence-based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [-0.07, 0.13] and -0.47 SD, 95% CI [-0.72, -0.21] 0.05 SD, 95% CI [-0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of -0.47 SD, 95% CI (-0.72, -0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest.

Authors' Conclusions

Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.

In flux: Associations of substance use with instability in housing, employment, and income among young adults experiencing homelessness

Young adults experiencing homelessness (YAEH) are faced with instabilities in many areas of their lives, including their living situation, employment, and income. Little is known about how the experience of instability in these different domains might be associated with substance use. Leveraging data collected on 276 YAEH in Los Angeles County, regression analyses examine associations between three distinct types of instability (housing, employment, income) and participants' self-reported alcohol use, alcohol consequences, non-cannabis drug use, and substance use symptoms. Results indicated that recent instability in income, employment, and secure housing for those with access to it (but not housing in general or non-secure housing) were significantly associated with greater alcohol/drug use or substance use symptoms. Depression was also found to moderate the association between employment instability and alcohol use. Our findings suggest that efforts to reduce instability in income, employment, and secure housing may have positive benefits for substance using YAEH, especially those with depressive symptoms.

A randomized controlled trial of a brief motivational interviewing-based group intervention for emerging adults experiencing homelessness: 24-month effects on alcohol use

OBJECTIVE

Despite rates of alcohol misuse being higher among emerging adults experiencing homelessness compared to those who are stably housed, there are few brief evidence-based risk reduction programs for this population that focus on alcohol use and assess outcomes for more than 1 year. This study examines alcohol outcomes from a 24-month evaluation of AWARE, a brief motivational interviewing-based group risk reduction intervention for emerging adults experiencing homelessness.

METHOD

In a cluster randomized crossover trial, 18- to 25- year-olds received AWARE (n = 132) or standard care (n = 144) at one of three drop-in centers serving young people experiencing homelessness in Los Angeles County. We evaluated intervention effects on past month alcohol use, consequences, and related cognitions such as motivation to change behavior.

RESULTS

AWARE participants showed significant reductions over 24 months in alcohol use and negative consequences from drinking and reported significant increases in their use of drinking protective strategies. Except for drinking frequency, control group participants did not show a significant change in these outcomes.

CONCLUSIONS

Findings build on earlier work by demonstrating that AWARE is effective in reducing alcohol use and related problems among emerging adults experiencing homelessness over a 2-year period. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sociodemographic and Behavioral Risk Correlates of PrEP Interest and Use Among Young Adults Experiencing Homelessness in Los Angeles

Young adults experiencing homelessness (YAEH) are at elevated risk for HIV compared to their stably housed peers. Preexposure prophylaxis (PrEP) is highly effective at preventing HIV infection, yet YAEH have been largely overlooked in PrEP efforts to date despite YAEH reporting high overall interest in PrEP. We assessed individual, social, and structural variables associated with PrEP interest and use among a sample of 195 YAEH (ages 18-25) recruited from drop-in centers across Los Angeles County who met criteria for HIV risk. In the current sample, though most had heard of PrEP (81.0%), the majority were not interested in taking PrEP (68.2%) and only a minority had used/were using PrEP (11.8%). YAEH who identified as sexual and/or gender minority, reported knowing someone who had used PrEP, or recently accessed sexual health services were more likely to have used and/or reported interest in using PrEP. Those who reported more episodes of heavy drinking were less likely to report having used PrEP. Suggestions are provided for better integrating PrEP-related services into existing behavioral and health service programs for YAEH, as well as leveraging peers and fostering positive social norms to reduce PrEP-related stigma and increase interest and use of PrEP among YAEH.

Predictors of Housing Trajectories Among Young Adults Experiencing Homelessness in Los Angeles

Experiencing homelessness during young adulthood is associated with negative health outcomes and understanding housing trajectories of young adults experiencing homelessness may aid in the development of evidence-based public health programs designed to serve this at-risk age group. In the present study, the authors examined baseline predictors of 24-month trajectories of housing stability and unsheltered housing among a sample of 271 young adults aged 18 to 25 recruited from drop-in centers in Los Angeles. In multivariate models, the authors found that identifying as multi-racial/other and better friendship quality at baseline were associated with less steep increases in the likelihood of stable housing over time. Being employed at baseline was associated with a less steep decrease in the probability of being unsheltered over time, while illicit drug use days associated with a steeper decrease in the probability of being unsheltered over time. Continued research is needed to establish important factors determining young adults' long-term housing trajectories in the effort to promote greater access and engagement with housing services.

A randomized controlled trial of a brief motivational interviewing-based group intervention for emerging adults experiencing homelessness: 12-Month effects on substance use and sexual risk behavior

INTRODUCTION

Few brief evidence-based risk reduction programs for emerging adults experiencing homelessness focus on the interrelated problems of substance use and sexual risk behavior. This study examines outcomes from a 12-month evaluation of AWARE, a brief Motivational Interviewing (MI)-based group risk reduction intervention for this population.

METHODS

In a cluster randomized crossover trial, N = 276 18-25-year-olds received AWARE or usual care at drop-in centers serving homeless youth in Los Angeles County. We evaluated intervention effects on substance use and condomless sex (primary outcomes), as well as drinking consequences and protective strategies, number of casual partners, self-efficacy, and motivation for change (secondary outcomes).

RESULTS

AWARE participants self-reported reductions in their alcohol use and negative consequences from drinking, and an increase in use of drinking protective strategies. AWARE participants also reported an initial decrease in drug use other than marijuana, followed by a slight uptake later on, as well as an initial increase in importance of cutting down on other drug use followed by a decrease. Control group participants did not show change in these outcomes. Among those who reported casual sex partners at both baseline and 12-month surveys, exploratory analyses indicated that AWARE participants had a 29 % decline in condomless sex with casual partners compared to a 6 % decline for control group participants.

CONCLUSIONS

Findings build on our pilot work by demonstrating that AWARE has long-term benefits on drinking among emerging adults experiencing homelessness. Further work should seek to strengthen its long-term effectiveness in reducing drug use in this population.

A Qualitative Study of the Benefits and Utility of Brief Motivational Interviewing to Reduce Sexually Transmitted Infections among Men Who Have Sex with Men

Several studies have demonstrated the effectiveness of motivational interviewing (MI) in reducing sexual risk behaviors. However, limited information is available on the acceptability of brief MI among men who have sex with men (MSM) in poor resource settings like sub-Saharan Africa. The objective of this study was to assess the views of MSM about the benefits and utility of brief MI (bMI) in changing their risky behavior. A qualitative study among men who have sex with men (MSM) who were enrolled in a longitudinal observational study between December 2021 and May 2023. The setting was in Tshwane North and participants were scheduled for baseline, 6-month, and 12-month visits. All participants received 20 min one-on-one face-to-face brief motivational interview (bMI) sessions during their follow-up visits. At month 12, an exit interview was conducted with consenting conveniently sampled participants (n = 23) who had completed all scheduled visits and received three bMI sessions. The findings indicated that the most recalled conversation was related to multiple sexual partners, having sex under the influence of alcohol, and MSM learned more about sexually transmitted diseases. Many expressed being comfortable with the sessions because the counselor was respectful and non-judgmental. Most found the bMI sessions to have a positive impact on changing and reducing risky sexual behaviors, particularly it reportedly increased their use of condoms and reduced the number of multiple partners. MSM found the bMI to be useful and acceptable in reducing sexual risk behaviors among MSM.

Secondary Outcomes of a Brief Group Alcohol and Risky Sex Intervention for Emerging Adults Experiencing Homelessness

AWARE is a four-session group-based motivational enhancement intervention designed to reduce substance use and sexual risk behavior among emerging adults experiencing homelessness. Expanding on promising intervention effects on substance use and risky sex outcomes, this study explored intervention effects on changes in secondary outcomes from baseline to 12-month post-intervention: depression, physical health (general health ratings, physical symptoms), social functioning (satisfaction, quality of friendships), and housing stability. Among the 240 participants with baseline and 12-month follow-up data, we found small effect sizes generally favoring the intervention over usual care for all outcomes. Findings show promise that addressing substance use and risky sexual behavior through interventions in drop-in centers could benefit emerging adults experiencing homelessness in additional areas of their lives. More work is needed to understand how interventions could be tailored to more directly address these outcomes and sustain changes in the long-term.

The association between housing stability and perceived quality of life among emerging adults with a history of homelessness

Many cities across the United States are experiencing homelessness at crisis levels, including rises in the numbers of unhoused emerging adults (18-25). Emerging adults experiencing homelessness may be at higher risk of experiencing negative outcomes, given that being unhoused increases risk for a variety of behaviors. To better understand the current living circumstances of emerging adults with a history of homelessness, as well as their perceptions about associations between housing stability and quality of life (QOL), we conducted 30 semi-structured in-depth interviews with individuals recruited from drop-in centers for youth experiencing homelessness. At the time of recruitment n=19 were stably housed and n=11 were unstably housed. Two coders analyzed these data inductively and deductively, using pre-identified domains and open coding. Coding reliability was assessed. Three main themes emerged, each with subthemes: 1) Housing quality (neighborhood safety, convenience, housing unit characteristics); 2) QOL before stable housing (physical and mental wellbeing, social wellbeing, and other determinants of QOL, such as encounters with law enforcement); and 3) Changes in QOL after stable housing (same subthemes as for pre-housing stability QOL). Findings indicated a pattern of perceived relationships between housing stability, housing quality, built and social environments, and QOL in the context of emerging adults who experienced or continued to experience homelessness. However, results were mixed with regards to the perceived effects of housing stability on alcohol and other drug use. Taken together, results indicate several areas of challenge, but also highlight opportunities to facilitate improvements in QOL among vulnerable emerging adults who experience homelessness.

COVID-19 Vaccination Rates and Attitudes Among Young Adults With Recent Experiences of Homelessness

PURPOSE

This study provides information on COVID-19 vaccination and attitudes among young adults with recent experiences of homelessness.

METHODS

Participants (n = 134) from a clinical trial of a risk reduction program for youth experiencing homelessness in Los Angeles completed survey items about COVID-19 vaccinations between March and October 2021.

RESULTS

A total of 29% of respondents were vaccinated, and 50% were not interested in getting vaccinated. Among the unvaccinated, 58% had not been offered the vaccine; furthermore, 38%-45% had strong distrust of the vaccine and were worried about its harmfulness. Vaccination status was generally unrelated to demographics, housing instability, service use, substance use, or mental health.

DISCUSSION

Our data suggest that vaccination rates are lower among young adults with recent experiences of homelessness than those in the general US population. The results suggest a need for greater direct outreach that includes both offering the vaccine and addressing misconceptions about its safety to increase vaccination rates in this population.

A pilot study on the efficacy of motivational interviewing groups in alcohol use disorders

OBJECTIVES

The present pilot study was designed to measure the feasibility and efficacy of motivational interviewing (MI) in groups in France, using the Wagner and Ingersoll's method.

METHOD

Participants (N = 85) were people with an alcohol use disorder (AUD) recruited from addiction consultation centers: 37 received five sessions of 2-h MI groups and 48 were assigned to treatment-as-usual condition (TAU). The sample was middle-aged (M = 43.95, SD = 12.96).

RESULTS

MI in groups seems to lead to a significant decrease in alcohol use and anxiety and depressive symptoms of participants in the MI condition. Moreover, there seems to be an increase in subjective happiness scores after the MI groups. In addition, participants' reactions were very positive.

CONCLUSIONS

This study provides encouraging results in favor of the feasibility and efficacy of MI in groups. The use of MI in groups has many advantages in clinical settings.

Behavioral Health and Service Usage During the COVID-19 Pandemic Among Emerging Adults Currently or Recently Experiencing Homelessness

PURPOSE

This study provides information on how the coronavirus disease 2019 (COVID-19) outbreak is affecting emerging adults currently or recently homeless in terms of engagement in protective behaviors, mental health, substance use, and access to services.

METHODS

Ninety participants in an ongoing clinical trial of a risk reduction program for homeless, aged 18-25 years, were administered items about COVID-19 between April 10 and July 9, 2020.

RESULTS

Most participants reported engaging in COVID-19 protective behaviors. Past week mental health symptoms were reported by 38%-48% of participants, depending on symptoms. Among those who used substances before the outbreak, 16%-28% reported increased use of alcohol, tobacco, and marijuana. More than half of the participants reported increased difficulty meeting basic needs (e.g., food), and approximately 32%-44% reported more difficulty getting behavioral health services since the outbreak.

CONCLUSIONS

Innovative strategies are needed to address the increased behavioral health needs of young people experiencing homelessness during events such as the COVID-19 outbreak.