Health Care Needs of Young Adults Who Have Experienced Homelessness

INTRODUCTION

Young adults experiencing homelessness have poorer overall health compared with the general population. However, not much is known about how health care needs may change in the transition from homelessness to supportive housing. This study utilizes the Gelberg-Andersen Behavioral Model for Vulnerable Populations to examine unmet health care needs among young adults currently experiencing homelessness and formerly homeless young adults living in supportive housing.

METHODS

This study includes data from 192 young adults who were either residing in a supportive housing program (n=103) or were "unhoused" (eg, residing on the street, staying in emergency shelters; n=89) in Los Angeles, CA, between 2017 and 2019. Hierarchical modeling examined unmet health care needs and factors that may enable those needs to be met, controlling for predisposing and other need factors.

RESULTS

Controlling for predisposing and other need characteristics, this study identified increased enabling factors among those residing in supportive housing, the most widely applied intervention for homelessness. Participants who resided in supportive housing were more likely to report at least 1 type of unmet need than youth who did not have access to housing. Additional findings regarding the association of enabling factors and unmet need yield mixed results based on the type of unmet need.

DISCUSSION

The acknowledgment of unmet needs may, in fact, be a byproduct of shifting priorities, which often occurs in the transition from homelessness to housing. Understanding the unmet need and health implications of this transition has relevance for practice as we work to better support formerly homeless young adults in meeting the needs that they identify.

Feasibility and Acceptability of Ecological Momentary Assessment With Young Adults Who Are Currently or Were Formerly Homeless: Mixed Methods Study

Background

Ecological momentary assessment (EMA) has been used with young people experiencing homelessness to gather information on contexts associated with homelessness and risk behavior in real time and has proven feasible in this population. However, the extent to which EMA may affect the attitudes or behaviors of young adults who are currently or were formerly homeless and are residing in supportive housing has not been well investigated.

Objective

This study aims to describe the feedback regarding EMA study participation from young adults who are currently or were formerly homeless and examine the reactivity to EMA participation and compliance.

Methods

This mixed methods study used cross-sectional data collected before and after EMA, intensive longitudinal data from a 7-day EMA prompting period, and focus groups of young adults who are currently or were formerly homeless in Los Angeles, California, between 2017 and 2019.

Results

Qualitative data confirmed the quantitative findings. Differences in the experience of EMA between young adults who are currently or were formerly homeless were found to be related to stress or anxiety, interference with daily life, difficulty charging, behavior change, and honesty in responses. Anxiety and depression symptomatology decreased from before to after EMA; however, compliance was not significantly associated with this decrease.

Conclusions

The results point to special considerations when administering EMA to young adults who are currently or were formerly homeless. EMA appears to be slightly more burdensome for young adults who are currently homeless than for those residing in supportive housing, which are nuances to consider in the study design. The lack of a relationship between study compliance and symptomatology suggests low levels of reactivity.

Housing interventions for emerging adults experiencing homelessness: A scoping review

INTRODUCTION

This review aims to identify and synthesize literature focused on housing interventions for young adults experiencing homelessness.

METHODS

Following a five-stage approach to scoping reviews, a computerized search was conducted between February 4-8, 2019 to include peer-reviewed articles from a total of eight electronic databases: PsychINFO, Google Scholar, PubMed, Web of Science, Social Work Abstracts, Cochrane, Clinicaltrials.gov, and CINAHL. The search was limited to include literature published between January 1, 1987 and December 31, 2018. Search parameters included three domains: homelessness, housing intervention, and age.

RESULTS

Of the initial 7,344 sources identified, 29 articles met the search criteria and were included in the final sample. Housing models discussed in the reviewed literature include Permanent Supportive Housing, Transitional and Independent Housing and Living Programs, the Foyer model, Housing First, and general Supportive Housing. Housing models were discussed in the context of outcome domains including quality of life, education, employment, housing tenure, cost of intervention, systems and service use, HIV, and social network and relationships.

DISCUSSION

Housing interventions for young adults experiencing homelessness remains a relatively new intervention to combat homelessness among younger demographics. While the evidence base continues to grow, there remains a need for quality research to generate empirical evidence in this area, though studies included in this review showed promise for the development of best housing practices with this population.

COVID-19 vaccine access and attitudes among people experiencing homelessness from pilot mobile phone survey in Los Angeles, CA

People experiencing homelessness (PEH) are at high risk for COVID-19 complications and fatality, and have been prioritized for vaccination in many areas. Yet little is known about vaccine acceptance in this population. The objective of this study was to determine the level of vaccine hesitancy among PEH in Los Angeles, CA and to understand the covariates of hesitancy in relation to COVID-19 risk, threat perception, self-protection and information sources. A novel mobile survey platform was deployed to recruit PEH from a federally qualified health center (FQHC) in Los Angeles to participate in a monthly rapid response study of COVID-19 attitudes, behaviors, and risks. Of 90 PEH surveyed, 43 (48%) expressed some level of vaccine hesitancy based either on actual vaccine offers (17/90 = 19%) or a hypothetical offer (73/90 = 81%). In bivariate analysis, those with high COVID-19 threat perception were less likely to be vaccine hesitant (OR = 0.34, P = 0.03), while those who frequently practiced COVID-19 protective behaviors were more likely to be vaccine hesitant (OR = 2.21, P = 0.08). In a multivariate model, those with high threat perception (AOR = 0.25, P = 0.02) were less likely to be hesitant, while those engaging in COVID-19 protective behaviors were more hesitant (AOR = 3.63, P = 0.02). Those who trusted official sources were less hesitant (AOR = 0.37, P = 0.08) while those who trusted friends and family for COVID-19 information (AOR = 2.70, P = 0.07) were more likely to be hesitant. Findings suggest that targeted educational and social influence interventions are needed to address high levels of vaccine hesitancy among PEH.

A Mixed-method Evaluation of the Behavioral Health Integration and Complex Care Initiative Using the Consolidated Framework for Implementation Research

BACKGROUND

Integrated behavioral health and primary care can improve the health of persons with complex chronic conditions. The Behavioral Health Integration and Complex Care Initiative (BHICCI) implemented integrated care across a large health system. Whether Behavioral Health Organizations (BHOs) and Federally Qualified Health Centers (FQHCs) implemented the BHICCI differently is unclear.

OBJECTIVES

The objective of this study was to evaluate integration under the BHICCI and to understand implementation differences between BHOs and FQHCs.

METHODS

We used a convergent parallel mixed-method design. Integration was measured quantitatively using the Maine Health Access Site Self-Assessment (SSA), which was completed by clinic teams at baseline and 24 months, and through n=70 qualitative interviews with initiative stakeholders, which were organized using the Consolidated Framework for Implementation Research. Results were compared to understand how qualitative findings explained quantitative results.

RESULTS

Data were collected in 7 clinics (n=2 FQHC; n=5 BHOs). FQHCs reported greatest improvement in the client centered subscale, with a baseline score of 4.6 (SD=0.64) and 7.8 (SD=0.89) at 24 months. BHOs reported greatest improvement in the organizational supports for integration subscale, with a baseline score of 4.8 (SD=1.07) and 7.9 (SD=1.1) at 24 months. Our Consolidated Framework for Implementation Research analysis illustrates contextual factors, such as insurance plan supports and clinic-level challenges, that explain these scores.

CONCLUSIONS

All clinical settings received support from the health plan, but differences between BHOs and FQHCs affected integration progress. Study results can help identify organizational practices that advance or undermine the delivery of integrated care across multiple clinical settings.

Construct, concurrent, and real-world predictive validity of the Difficulties in Emotion Regulation (DERS-18) among young adults with history of homelessness

Skills in emotional regulation are vitally important for enabling homeless young adults to navigate the complex and chaotic settings associated with homelessness. The current study seeks to test the construct, concurrent, and predictive validity of the Difficulties in Emotional Regulation Scale (DERS-18) in a sample of formerly and currently homeless young adults. Data come from a study of HIV risk among young adults who have experienced homelessness, including both those currently experiencing homelessness (n = 99) and in permanent housing (n = 120), collected between 2017 and 2019 in Los Angeles, CA. Structural Equation Modeling was used to complete Confirmatory Factor Analysis and Path Models focused on the relationship between mental health symptomatology and emotional regulation. Linear regression models tested the link between affective intensity and instability and the DERS-18. Model fit indices pointed to the five-factor solution of the DERS-18, excluding the Awareness subscale. Clinical scores of anxiety, depression, and PTSD were found to have a significant, positive correlation with DERS. Both intensity and instability of negative affect were associated with greater difficulty in emotional regulation, while the increased intensity of positive affect was associated with increased skills in emotional regulation. This study addressed several gaps in both homelessness and emotional regulation literature. The DERS-18 was found to have construct, concurrent, and predictive validity in our sample. Future work should consider the use of the DERS-18 to assess skills in emotional regulation, understand outcomes, and better tailor interventions for young adults who have experienced homelessness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Social Network Change after Moving into Permanent Supportive Housing: Who Stays and Who Goes?

Social relationships are important among persons experiencing homelessness, but there is little research on changes in social networks among persons moving into permanent supportive housing (PSH). Using data collected as part of a longitudinal study of 405 adults (aged 39+) moving into PSH, this study describes network upheaval during this critical time of transition. Interviews conducted prior to and after three months of living in PSH assessed individual-level characteristics (demographics, homelessness history, health and mental health) and included a social network component that assessed network size and composition (demographics, relationship type, social support); interviewers utilized network member characteristics to assess whether network members were new or sustained between baseline and 3 months post-housing. Multilevel logistic regression models assessed what characteristics of network members were associated with being newly-gained or persisting in networks 3 months after moving into PSH. We found that only one-third of social networks were retained during the transition to PSH, and that veterans, African Americans and other persons of racial/ethnic minorities, and those living in scattered-site housing were more likely to experience network disruption. Relatives, romantic partners, and service providers were most likely to be retained after move-in. Some network change was moderated by tie strength, including the retention of street-met persons. Implications are discussed.

Real-Time Data Collection to Examine Relations Between Physical Activity and Affect in Adults With Mental Illness

Adults with serious mental illness engage in limited physical activity, which contributes to significant health disparities. This study explored the use of both ecological momentary assessments (EMAs) and activity trackers in adults with serious mental illness to examine the bidirectional relationship between activity and affect with multilevel modeling. Affective states were assessed up to seven times per day using EMA across 4 days. The participants (n = 20) were equipped with a waist-worn accelerometer to measure moderate to vigorous physical activity. The participants had a mean EMA compliance rate of 88.3%, and over 90% of completed EMAs were matched with 30-min windows of accelerometer wear. The participants who reported more positive affect than others had a higher probability of engaging in moderate to vigorous physical activity. Engaging in more moderate to vigorous physical activity than one's usual was associated with more negative affect. This study begins to address the effect of momentary mood on physical activity in a population of adults that is typically difficult to reach.

Exploring the Association of Community Integration in Mental Health among Formerly Homeless Individuals Living in Permanent Supportive Housing

Supportive housing has been widely used among persons experiencing chronic homelessness and/or mental health conditions. While it has been demonstrated to be effective in addressing homelessness among populations with complex needs, community integration remains a challenge. Community integration is the extent to which individuals live, participate, and socialize in their community and consists of three aspects: physical, social, and psychological. The study utilized data from the Transitions to Housing project that followed formerly homeless individuals (N = 383) throughout their first year of residence in permanent supportive housing (PSH). The study set out to examine which aspects of community integration are associated with mental health symptoms in this population. Five nested multivariate linear regression models were conducted and then compared. The model that accounted for demographics, substance use, neighborhood quality, and all three aspects of community integration simultaneously was the best fit and explained the most variance in mental health symptoms (24%). The complete model suggested higher levels of psychological integration were significantly associated with decreased mental health symptoms in this sample. This finding suggests fostering a sense of belonging among PSH residents could improve mental health outcomes. Implications for practice and future research are discussed.

Provider perspectives of housing programs for young adults experiencing homelessness

OBJECTIVE

Qualitative methods were used to investigate the perspectives of service providers working in Permanent Supportive Housing, Transitional Living Programs, and Rapid Rehousing for young adults who have experienced homelessness. The primary aim was to explore how housing models were designed, implemented, and the extent to which there is variability in how providers approach their work with young adults.

METHODS

Data come from 26 housing service providers purposively sampled from supportive housing providers across the United States between October 2017 and July 2018. Interview transcripts were analyzed using a comparative case summary approach, grouped by program model.

RESULTS

Three themes emerged from the qualitative analysis related to how specific housing models were developed (Stranded between systems: "No model to follow"), the strategies that providers took to support residents toward independence and self-sufficiency (Working toward independence and self-sufficiency: "No one-sized approach"), and the various roles that individual providers discussed fulfilling in their work with young adults (Shifting roles: "Whatever type of figure is needed").

DISCUSSION

While the overarching goals of supportive housing span across housing models, the methods and philosophies of service delivery differ, mirroring the programmatic structure of the model. Results point to a competing philosophies approach to housing as it delivers different philosophically oriented programming models for similar youth through Transitional Living Programs, Permanent Supportive Housing, and Rapid Rehousing models.

DOES THE TIMING OF INCARCERATION IMPACT THE TIMING AND DURATION OF HOMELESSNESS? EVIDENCE FROM "THE TRANSITIONS TO HOUSING" STUDY

Compared to their non-homeless peers, chronically homeless adults are much more likely to have a history of incarceration. In turn, homelessness is associated with increased morbidity, lack of access to adequate healthcare services, and decreased life expectancy. This study investigates whether age at first incarceration is associated with age at first homeless experience and with lifetime duration of literal homelessness. Study participants are homeless adults entering permanent supportive housing (PSH) in Los Angeles County, California, that have experienced incarceration prior to their first experience of homelessness (n=230). Multivariate linear regressions were conducted to determine association between age at first incarceration with: 1) age at first literal homelessness and 2) lifetime duration of literal homelessness. Results indicate that incarceration as a juvenile and young adult is significantly associated with earlier literal homelessness experiences and may be associated with longer durations of literal homelessness, for adults entering PSH. Moreover, women incarcerated as juveniles and entering PSH first experienced literal homelessness earlier than comparable men. Our findings suggest the need for long-term supportive services for persons incarcerated before 25 years old, especially for women. Moreover, these findings refine the working knowledge that prior incarceration increases risk for prolonged homelessness and can help agencies complete more accurate risk assessments.

Understanding pathways between PTSD, homelessness, and substance use among adolescents

Youth experiencing homelessness have been shown to experience high levels of both trauma and substance use. However, prior work has yet to consider how substance use, posttraumatic stress disorder (PTSD) symptoms, and homelessness are temporally, or reciprocally, associated over time. The current study uses symptom-driven and experience-driven models to examine the reciprocal relationships between substance use, PTSD symptoms, and homelessness among a large sample of adolescents receiving substance use treatment in the United States. Adolescents (n = 20,069; M_age = 15.6; 74% male) completed baseline, 3-, 6-, and 12-month assessments. Autoregressive latent trajectory with structured residual (ALT-SR) models were used to examine within- and between-person relationships. We found continued support for prior work at the between-person level of analysis. At the within-person level, during the treatment phase, PTSD emerged as a key mechanism predicting both return to use and increased days of homelessness posttreatment. Further, greater substance use at treatment completion was associated with greater PTSD symptoms and homelessness, prospectively. The current study extends the previous work to consider individual level processes in conjunction with overarching event level predictors of homelessness. We found that PTSD symptomology is a driving factor that influences, both directly and indirectly, experiences of homelessness posttreatment. Interventions may wish to incorporate trauma informed approaches for youth entering treatment as this may mitigate long-term experiences of homelessness and return to substance use. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Where do Peer Providers Fit into Newly Integrated Mental Health and Primary Care Teams? A Mixed Method Study

Little is known about the involvement of peer providers in integrated behavioral health teams. This study asks where peer providers fit within integrated care teams in Los Angeles County. Social network analysis combined with qualitative fieldwork was used to understand the network positions of peer providers in 14 integrated pilot programs. Four programs' peer providers were highly central, while 3 programs' were on the network's periphery. Positional variation appeared to be related to the peers' mental health status. Targeted efforts are needed to support the implementation of peer providers on integrated teams at the program and system levels.

A Qualitative Study of Caregiving for Adolescents and Young Adults With Spinal Cord Injuries: Lessons From Lived Experiences

Objective: To examine characteristics of caregiving from the perspectives of adolescents and young adults (AYAs) with spinal cord injuries (SCIs) and their informal caregivers to address outstanding gaps in knowledge relating to definitions of caregiving and its associated practices for this population. Methods: A multiphase qualitative design was applied, using phenomenological and narrative methods to capture data in participants' homes and communities. Participants were recruited from rehabilitation hospitals and community organizations throughout Los Angeles County, California. Inclusion criteria for AYAs included being 15-22 years old, having acquired an SCI within the previous 5 years, and using a wheelchair for mobility. The AYAs nominated persons they identified as primary caregivers to also participate. Data were collected through individual and group interviews as well as activity observations. Results: Data from the 17 participants (9 AYAs and 8 informal, primary caregivers) revealed ways in which the meaning of caregiving varied among dyads. Caregiving practices extended beyond physical assistance to include support for a range of day-to-day activities spanning from practical needs to facilitating developmental trajectories. Although AYAs expressed ideas about preferred caregiver characteristics, care partnerships appeared to be guided more by availability than preference. Conclusion: Phenomenological analysis revealed that the meaning of "caregiving" and its associated practices are highly individualized for AYAs with SCIs. Caregiving is rooted in personal needs related to effects of SCI and developmental goals. Everyday practices are shaped by individual relationships and the beliefs of AYAs and their caregivers. Addressing influences of caregiving on long-term health and function may require attention to developmental processes, caregiver "fit," and ways care is, or can be, distributed throughout broader networks according to personal needs and preferences.

From Physical Wellness to Cultural Brokering: Unpacking the Roles of Peer Providers in Integrated Health Care Settings

This qualitative study explored peer provider experiences working in newly integrated mental health and primary care pilot programs within a large public mental health system. Nineteen peer providers participated in semistructured interviews that focused on experiences delivering care within integrated teams. Interviews were analyzed using constant comparative methods informed by grounded theory. Findings were organized into three themes that speak to variation in the definition and function of peers; lack of clarity in the peer role; and relating to other providers. Integrated settings need ongoing support to ensure clarity in the peer role and an inclusive work environment.

Social networks and substance use after transitioning into permanentsupportive housing

BACKGROUND

Substance use disorders are common among persons experiencing homelessness, and research has identified social networks as important correlates of substance use in this population. Permanent supportive housing (PSH), particularly Housing First, which uses a harm reduction model not requiring substance abstinence, is a key solution for ending homelessness. However, conflicting evidence exists regarding the associations between moving into PSH and changes in substance use, and there is limited understanding of how networks may influence such changes.

METHODS

Using observational, longitudinal data from 421 persons before they moved in and over their first year in PSH (collected as part of a HIV-risk study), this paper assesses substance use change (alcohol, marijuana, and illicit drugs) and associations between perceived network characteristics and individual substance use.

RESULTS

Substance use remained relatively stable among participants over their first year living in PSH, although illicit substance use reduced somewhat at six months compared to baseline levels (from 18.5%-14.5%) and marijuana use increased slightly at 12 months (from 26.6% at baseline to 32.9%). Substance use among social network members was consistently associated with individual-level substance use, both cross-sectionally and longitudinally. Specific network substance use characteristics, such as proximity, location met, and social support, had differential relationships with particular substance types.

CONCLUSIONS

These findings provide longitudinal evidence that changes within substance-using social networks are associated with subsequent changes in individual use and underscore the importance of interventions aimed at promoting positive social relationships for formerly homeless persons and improving PSH's social environments.

Health Outcomes and Costs Associated with the Provision of Culturally Competent Services for Underrepresented Ethnic Populations with Severe Mental Illness

Underrepresented racial/ethnic populations (UREPs) face disparities in their use of behavioral health services for multiple reasons including lack of culturally competent services and stigma. This paper employs mixed methods to compare health outcomes and costs among clients in 14 culturally competent behavioral health programs targeting specific UREPs to five programs without a specific racial or ethnic focus. We found that UREP-focused programs were associated with similar improvements in health outcomes, but greater costs relative to the comparison programs. Main themes from the qualitative analysis included: addressing stigma, building trust and understanding confidentiality, looking for a cure, and moving beyond linguistic competency.

Life Goals Over Time Among Homeless Adults in Permanent Supportive Housing

Permanent supportive housing (PSH) is a widely-accepted solution to the challenge of chronic homelessness. While housing support and retention, physical health, and healthcare continue to be important for formerly homeless persons in PSH, "higher-order" and humanistic needs such as thriving have received less attention and as a result are less well understood in this population. One important indicator of thriving is the ability to establish and articulate life goals. This study utilizes longitudinal data from 421 formerly homeless adults prior to their move into PSH, and at 3-, 6- and 12-months after move-in (369 respondents completed all four interviews), to examine what life goals are articulated by this population and how those goals change over time. Prior to housing, most respondents articulated housing attainment as their primary life goal, whereas at follow-up interviews health goals, housing relocation, and financial goals became more prevalent. Aspirational goals (e.g., independence, self-improvement, artistic pursuits) were also common, but demonstrated a decrease over time in housing. Relationship goals remained common and consistent over time. Findings indicate that housing is a necessary, but perhaps not sufficient, step for improving thriving among formerly homeless adults. Implications for practice and future research are discussed.

Response to culturally competent drug treatment among homeless persons with different living arrangements

This study investigated the association between program cultural competence and homeless individuals' drug use after treatment in Los Angeles County, California. Los Angeles County has the largest and most diverse population of homeless individuals in the nation. We randomly selected for analysis 52 drug-treatment programs and 2158 participants who identified as homeless in the Los Angeles County Participant Reporting System in 2011. We included their living arrangements (indoors and stable, indoors and unstable, and outdoors) and individual and program characteristics (particularly whether their programs used six culturally competent practices) in multilevel regression analyses. The outcome was days of primary drug use at discharge.Results showed that higher levels of staff personal involvement in minority communities (IRR=0.437; 95% CI=0.222, 0.861) and outreach to minority communities (IRR = 0.406; 95% CI=0.213, 0.771) were associated with fewer days of drug use at discharge. Homeless individuals living outdoors used their primary drug more often than any other group. Yet, compared to individuals with other living arrangements, when outdoor homeless individuals were treated by programs with the highest community resources and linkages (IRR=0.364; 95% CI=0.157, 0.844), they reported the fewest days of drug use. We discuss implications for program evaluation and community engagement policies and practices.

Peer Support in Full-Service Partnerships: A Multiple Case Study Analysis

Peer providers are integral to Full Service Partnerships (FSPs), which are team-based mental health service models. Peer providers use principles of recovery to engage clients, but FSPs can vary in their recovery orientation. Whether and how peer recovery orientation reflects the organizational environments of FSPs is unclear. This qualitative study explored peer provider attitudes towards recovery within the organizational contexts of FSPs where they are employed. Case study analysis was conducted on eight purposively sampled FSPs using qualitative interviews with peer providers and program directors. In two cases, peer recovery attitudes diverged from those of their organizational context. In these cases, peer providers were champions for recovery, and used practice-based strategies to promote client autonomy despite working in settings with lower recovery orientation. Peer providers could be uniquely positioned to promote client autonomy in settings where organizational factors limit consumer choice.

Provider perceptions on HIV risk and prevention services within permanent supportive housing

Permanent supportive housing (PSH) is an evidence-based solution to homelessness for persons experiencing chronic or long-term homelessness and one or more physical or behavioral health problems. Health services through PSH typically focus on physical and behavioral health. With the exception of programs specifically designed for persons living with HIV/AIDS, little attention has focused on services through PSH to prevent transmission of HIV or other sexually transmitted infections (STIs), yet sexual risk behavior continues after homeless persons move into PSH. The purpose of this study was to investigate how PSH providers approach HIV prevention and the challenges they perceive surrounding HIV prevention in PSH. Results serve as a critical first step toward addressing the acceptability and feasibility of providing HIV/STI prevention services to PSH residents. As part of a longitudinal mixed methods study examining HIV risk and prevention behavior among homeless unaccompanied adults moving into PSH in Los Angeles, we conducted eleven focus groups with a total of 60 frontline staff across 10 PSH agencies. Thirty-three percent of focus group participants were African American, 32% were Hispanic, and 55% were women. Results suggest that provider awareness and knowledge of PrEP is very limited, and provision of formal HIV prevention programing for residents is perceived as challenging. Informal, ad hoc conversations with residents about sexual risk and HIV prevention do occur when providers have rapport with clients and perceive risk. There are significant gaps in HIV prevention services through PSH but also opportunities to enhance providers' efforts to promote the health of residents through prevention.

Health Care Decisions among Mental Health Services Consumers in San Diego County: Implications for Integrated Care

People living with serious mental illness are at elevated risk for chronic diseases compared with those in the general population. Whether integrated care for this population would be most accessible in primary care or mental health settings is unclear. The cross-sectional study described in this article used descriptive analyses and multinomial logistic regression to assess factors associated with using physical health services from primary or mental health providers. Data were drawn from a large-scale assessment of client-reported use of primary care services in a large and ethnically diverse public mental health system. Most people (80.4 percent) reported accessing primary care services from one or more service settings. Having chronic conditions was associated with accessing physical health care from multiple service settings, whereas having poor self-rated emotional health decreased health services use from any setting. It was concluded that mental health services consumers access health care from various service settings. Social workers can play a critical role in enhancing care coordination across the mental health and primary care systems.

Differences in Health and Social Support between Homeless Men and Women Entering Permanent Supportive Housing

BACKGROUND

Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH.

METHODS

This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area.

RESULTS

Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict.

CONCLUSIONS

There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.

No Digital Divide? Technology Use among Homeless Adults

Homeless adults experience increased risk of negative health outcomes, and technology-based interventions may provide an opportunity for improving health in this population. However, little is known about homeless adults' technology access and use. Utilizing data from a study of 421 homeless adults moving into PSH, this paper presents descriptive technology findings, and compares results to age-matched general population data. The vast majority (94%) currently owned a cell phone, although there was considerable past 3-month turnover in phones (56%) and phone numbers (55%). More than half currently owned a smartphone, and 86% of those used Android operating systems. Most (85%) used a cell phone daily, 76% used text messaging, and 51% accessed the Internet on their cell phone. One-third reported no past 3-month Internet use. These findings suggest that digital technology may be a feasible means of disseminating health and wellness programs to this at-risk population, though important caveats are discussed.

Reevaluating the Self-Medication Hypothesis among the Dually Diagnosed

The self-medication hypothesis (SMH) is an intuitively appealing explanation for substance use. Conceptually, however, it is not always clear what the hypothesis entails, particularly when applied to persons with mental and substance use disorders. This makes empirical support for SMH difficult to evaluate. By classifying the self-reported reasons for substance use from 33 participants in a NIMH-funded qualitative study of dual diagnosis and homelessness, this study aims to evaluate the applicability of SMH. How one conceptualizes SMH will determine whether SMH is empirically supported. When SMH refers to using substances strictly to cope with symptoms of mental disorders, only 11 out of 72 attributions support it. When SMH refers to using substances to cope with painful feelings in general, more than half of all attributions support SMH. The significance of accurately understanding the various reasons people give for why they use substances is discussed.