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PubMed2000

Narratives of identity: re-presentation of self in people who are homeless.

The problem of homelessness is a pressing social and health concern ascribed to the interaction between personal, social, economic, and service system resources. The article is based on a qualitative study of the experiences of 29 homeless individuals. In-depth interviews were conducted with single adult shelter users. Analysis revealed the self to be a process that was continually developing. Participants tacitly locate their self-concepts in the past, present, and future. These time frames reflect the form and content of self. They also reveal hopes, dreams, beliefs, and understandings about self. The ways in which homelessness discredits notions of self and personal identity, and the hierarchy of identify with which homeless individuals use to cope are also examined.

Adaptation, Psychological↗
PubMed2003

Ethical issues in qualitative health research with homeless youths.

BACKGROUND: There is a need for increased guidance for the ethical conduct of qualitative research with vulnerable populations such as homeless youths. AIM: The purpose of this paper is to provide an overview of the main ethical challenges of conducting qualitative research with homeless youths and to propose possible solutions to these challenges. METHODS: This paper was informed by a review of professional guidelines for the ethical conduct of adolescent health research, national (US) and international bioethics bibliographical searches, and personal experience with qualitative research with homeless youths. FINDINGS: The main ethical challenges of conducting qualitative research with homeless youths include establishing and maintaining healthy researcher roles and boundaries, addressing the risks of researcher burn-out and safety issues, assuring optimal confidentiality, and avoiding sensationalism and voyeurism. CONCLUSION: It is important for qualitative researchers who work with vulnerable populations to ensure that research is conducted in the most ethical way possible.

Adolescent↗
PubMed2003

Assisted living and use of health services among medicaid beneficiaries with schizophrenia.

BACKGROUND: Considerable attention has been given to the appropriateness of mental and medical health care provided to residents of certain assisted living facilities specialized for the severely mentally ill. However, there exists little objective evidence regarding the level of services provided by these facilities in general. AIMS OF THE STUDY: To compare the use of mental and medical health services among persons with schizophrenia who were residing in assisted living facilities compared to those received by patients living independently and those who were homeless. METHODS: Medicaid claims were combined with person level data on living situation and psychological and social functioning for 1998-2000. Regression models were used to analyze whether living in a board-and-care facility was related to use of outpatient mental health services including case management, therapy, crisis stabilization, medication supervision, day treatment, and drug treatment, the probability of acute psychiatric hospitalization, the probability of hospitalization for physical health, and costs. RESULTS: Residents of board-and-care facilities had greater use of outpatient mental health services and lower rates of psychiatric and medical hospitalization. Pharmacy costs and total health care costs were highest in assisted living. DISCUSSION: Our data was observational, and selection processes related to illness severity likely affect living arrangement. Our analysis suggests that assisted living was related to greater use of outpatient mental health services and lower rates of hospitalization. IMPLICATIONS FOR HEALTH POLICIES: Assisted living facilities may provide a suitable environment though which to provide outpatient mental health services. Policy makers interested in reducing homelessness through interventions might consider subsidizing these facilities. IMPLICATIONS FOR FURTHER RESEARCH: Research studies should be designed to evaluate characteristics of assisted living facilities that lead to improved function and outcomes among residents.

Activities of Daily Living↗
PubMedDate not supplied

Taking it to the streets: recording medical outreach data on personal digital assistants.

Carrying hundreds of patient files in a suitcase makes medical street outreach to the homeless clumsy and difficult. Healthcare for the Homeless--Houston (HHH) began a case study under the assumption that tracking patient information with a personal digital assistant (PDA) would greatly simplify the process. Equipping clinicians with custom-designed software loaded onto Palm V Handheld Computers (palmOne, Inc, Milpitas, CA), Healthcare for the Homeless--Houston assessed how this type of technology augmented medical care during street outreach to the homeless in a major metropolitan area. Preliminary evidence suggests that personal digital assistants free clinicians to focus on building relationships instead of recreating documentation during patient encounters. However, the limits of the PDA for storing and retrieving data made it impractical long-term. This outcome precipitated a new study to test the feasibility of tablet personal computers loaded with a custom-designed software application specific to the needs of homeless street patients.

Community-Institutional Relations↗
PubMedDate not supplied

Dental health of homeless adults.

As part of a community-based study, we were able to assess the number of grossly decayed and missing teeth, as well as recent use of dental services, among 529 homeless adults. We found that 27% reported having had a toothache during the previous month (only one-tenth of these individuals had sought help from a dentist for their toothache). Homeless adults, as compared with a general population, were half as likely to have made a dental visit within the preceding year (26.7% versus 55.0%) and had more grossly decayed teeth (means = 2.3 versus means = 1.4). Individuals with more tooth decay and missing teeth were more likely to be older, have physical health problems, smoke more cigarettes, use more alcohol, and have worse personal hygiene. Age, not length of homelessness, was the most important predictor variable of missing teeth. Thus, homeless adults have a higher degree of dental pathosis as well as a lower use of dental services than the general population. On the basis of these findings, more accessible dental services need to be designed for the homeless population.

Adolescent↗
PubMed2006

The relationship between childhood sexual abuse and sexual health practices of homeless adolescents.

This study explored the gender differences in sexual self-concept, personal resources for sexual health, safe sex behaviors, and risky sexual behaviors among homeless adolescents with and without histories of sexual abuse. Data for this secondary analysis were collected in 2003 to 2004 in the first phase of a larger repeated-measures sexual health intervention study; 371 homeless youth between 16 and 23 years of age (M = 19.26, SD = 1.83) were recruited from a street outreach center. The majority (64.6%) of participants were males. Self-report instruments were completed at the outreach center via audio computer-assisted self-interview (A-CASI) format. It was found that female participants were better off than males on numerous measures of sexual health behaviors and attitudes. Sexually abused participants had significantly less future time perspective (p = .05), fewer sexual self-care behaviors (p = .04), and less social support than nonabused participants (p = .01) and almost significantly more sexual risk-taking (p = .08). However, no significant differences were found between abused and nonabused participants on sexual self-concept, self-efficacy or intention to use condoms, safe sex behaviors, AIDS knowledge, assertive communication, or self-efficacy to perform testicular/ breast self-exams. Overall, participants who did not report a history of sexual abuse had significantly more sexual health resources and engaged in fewer sex-risk behaviors than those who reported having been abused. These differences have notable implications for screening adolescents for a history of sexual abuse. Adolescents who report sexual abuse should receive risk counseling and be screened regularly for the development of sexual risk behaviors.

Adolescent↗
PubMed1993

Homelessness and mental illness.

In Great Britain 1-2 million people may be homeless. Most homeless people are men, but about 10-25% are women, of whom about half are accompanied by children. Significant mental illness is present in 30-50% of the homeless: functional psychoses predominate; acute distress and personality dysfunction are also prevalent. Co-morbidity of mental illness and substance abuse occurs in 20%, and physical morbidity rates exceed those of domiciled populations. The homeless mentally ill also have many social needs. Pathways to homelessness are complex; deinstitutionalization may be only one possible cause of the increase in the number of homeless people. There is much recent research estimating the extent of mental illness and the characteristics of selected subgroups of accessible homeless people. The evaluation of potential service solutions has received less attention. This review outlines the research, highlights current views on the definition and classification of homeless populations, and offers some guidelines on avenues which need to be explored.

Cross-Cultural Comparison↗
PubMed1998

Health promotion lifestyles of women experiencing crises.

Women who are experiencing crisis situations, including homelessness, are often perceived as passive victims of their social, economic, and personal circumstances. A few studies have challenged the stereotype of homeless women as passive victims and demonstrated that they are active in seeking solutions to their problems (Hodnicki, Horner, & Boyle, 1992; Montgomery, 1994; Thrasher & Mowbray, 1995). This study surveyed women receiving assistance at a nurse-managed clinic that serves a homeless population to determine their health promotion strategies. On the basis of this study's findings, health care providers are encouraged to recognize and build on the strengths of women in crises at both the individual and community levels of care.

Adult↗
PubMedDate not supplied

Poverty and procreation among women. An anthropologic study with implications for health care providers.

In this article, select findings from a 5-year ethnographic study of homeless, pregnant women in Southern California pin-pointed the contextual constraints, along with individual factors, that framed the women's reproductive options and actions. The women had very little choice in the timing, the place, the partner, and the circumstances surrounding conception. Factors contributing to their becoming pregnant were the woman's victimization, economic survival, lack of access to contraceptives, uncertain fertility, desire for intimacy, and hope for the future. Findings suggest that even if the women were able to establish reproductive goals and had the wherewithal to acquire and effectively use contraceptives, situational constraints (homelessness, pregnancy, poverty, contraception, fertility patterns) might still prevent their success.

Adolescent↗
PubMed1996

Self-reported risk factors for AIDS among homeless youth.

This study assessed HIV risk behaviors in a sample of homeless youth in a large urban area and examined factors associated with these behaviors. Self-reported behaviors were assessed via interviews with 196 homeless youth in Chicago in all 10 urban shelters serving this group and in 5 street locations. Overall, 83.7% reported at least one of these risk factors: multiple sex partners; high-risk partners; inconsistent condom use; history of sexually transmitted disease; anal sex; prostitution; and/or intravenous drug use. An index of these behaviors was associated with being male, having unmet personal needs, being interviewed in street locations, and having a history of sexual abuse. Findings suggest that strategies that may decrease risk behaviors among homeless youth include the elimination of their need to rely on illicit activities for income, provision of basic needs, education regarding existing services, increased outreach efforts, and early identification of and protection from childhood sexual abuse.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Correlates of codisorders in homeless and never homeless indigent schizophrenic men.

We recently completed a case-control study of 100 literally homeless and 100 never homeless indigent schizophrenic men in New York City, in which concurrent substance abuse and antisocial personality disorder were widespread. In this paper we probe the correlates of 'pure' schizophrenia (single disorder, N = 60), schizophrenia and substance abuse (double disorder, N = 89), and schizophrenia, substance abuse, and antisocial personality disorder (triple disorder, N = 50), across the homeless/never homeless distinction. Subjects were recruited from a homeless shelter and mental health service programmes in Upper Manhattan. Psychologist and social worker interviewers administered the Structured Clinical Interview for DSM-III-R, I, and II and other structured instruments to explore social, family and illness history, the current illness, and aspects of treatment and family support. Codisorder subjects emerged from more disadvantaged family backgrounds, experienced greater school difficulties, began drug use in early adolescence, were more prone to hyperactivity in childhood, and were more likely to have spent time in jail. While codisorder groups did not differ on key aspects of schizophrenia, the triple disorder group was found to suffer from a more severe form of substance abuse than double disorder subjects, associated with an earlier age of onset and abuse of a wider array of substances. The widespread prevalence of codisorders among indigent schizophrenic men has major significance for clinical psychiatry. Study of the correlates of codisorders has revealed important differences in social, family, and illness history which may guide the development of more effective treatments and improved service delivery.

Adolescent↗
PubMed2006

In-house work opportunities: implications for housing organizations serving persons living With HIV/AIDS.

Finding work and/or re-entering the workforce can be extremely challenging for persons living with HIV/AIDS. Also difficult is assisting them in the process, mostly because there is little documentation or resources about programs that provide vocational services specifically for this population. In response to this dilemma and because it was perceived as a win/win situation, three urban residential community organizations serving the HIV/AIDS population, decided independently to create in-house work opportunities for their clients. All of these organizations are a variation of the same theme: transitional/supportive housing for persons with HIV/AIDS that were formerly homeless and are now interested in becoming increasingly self-sufficient. This article will present a program description that addresses unique manner in which these three sites created in-house job programs in the areas of receptionist, kitchen, and maintenance work. More specifically, this paper will address the strengths, limitations, and ethical considerations that guided program development.

HIV Seropositivity↗
PubMed1998

The prevalence of homelessness among adolescents in the United States.

OBJECTIVES: Homeless adolescents represent one of the nation's most vulnerable populations. This study reports the 12-month prevalence of homeless episodes among US adolescents. METHODS: Personal, audiotaped interviews were conducted in 1992 and 1993 with a representative household sample of 6496 adolescents aged 12 to 17 as part of the Youth Risk behavior Survey sponsored by the Centers for Disease Control and Prevention. Respondents reported whether they had spent the night in any of a variety of locations other than home during the previous 12 months. RESULTS: Altogether, 7.6% of the youths questioned reported that they had spent at least 1 night in youth or adult shelter (3.3%), public place (2.2%), an abandoned building (1.0%), outside 2.2%), underground (0.4%), or with a stranger (1.1%). Boys were much more likely than girls to report having experienced a homeless episode. CONCLUSIONS: This study suggests that homelessness among adolescents is not simply an urban problem and that prevention programs targeting homeless youths should be implemented nationwide. Additional research is needed to assess the frequency and duration of homeless experiences. Future studies of homelessness in the general population should include questions pertinent to adolescents.

Adolescent↗
PubMed2006

[Quality of life, social deprivation and mental disorders--is there an association in populations at risk?].

OBJECTIVE: The study aims at assessing the psychiatric morbidity and the quality of life of persons at immediate risk for getting homeless as well as identifying risk factors and correlations between quality of life, threatening homelessness and mental disorders. METHODS: The sample included 101 citizens of Mannheim, Germany, which were immediately threatened to be thrown out of their apartment due to not paying their rent or other causes. In a cross-sectional study, mental disorders were diagnosed by SKID-interview, quality of life was determined by using the Münchener Lebensqualitäts-Dimensionen Liste (MLDL). Other factors of potential influence were assessed. Multiple regression analyses were conducted. RESULTS: Acute mental disorders requiring treatment were determined in 79,3 % of the study sample. Addiction disorders (alcoholism) played a major role. This psychiatric morbidity was even higher in some disorders than in a sample of homeless people from the same region. Quality of life was low and also showed a similar pattern to the homeless sample. Regression analyses confirmed a high association of mental disorders and quality of life, which was adversely affected by former episodes of homelessness, the length of instable social conditions and a lack of social support. CONCLUSIONS: Specific psychiatric services or programs for the population at risk were not available, although their help seeking behaviour offers good opportunities for taking primary or secondary preventive action, which is likely to reduce the subjective burden on quality of life and lower the payments provided by local welfare agencies.

Adult↗
PubMed2004

Adherence to highly active antiretroviral therapy in the homeless population in San Francisco: a prospective study.

BACKGROUND: We examined adherence to highly active antiretroviral therapy (HAART) in the homeless population, a population thought to be at high risk for poor adherence to therapy and for development of drug-resistant strains of human immunodeficiency virus (HIV). METHODS: We performed a 12-month prospective study of 148 persons receiving HAART who were identified in a stratified screening of the homeless and marginally housed. We sampled in lunch lines, shelters, and hotels in 3 neighborhoods of San Francisco, California. We used pill counts at unannounced home visits as the primary measure of adherence. RESULTS: Of 148 individuals sampled, 46 (31%) discontinued HAART during the study. Average adherence in the group of those who discontinued HAART was 51%, and 9% of these subjects had undetectable virus loads (i.e., <400 copies/mL) at the last follow-up visit. Predictors of discontinuation of therapy were depressive symptoms, injection drug use, African American ethnicity, and early poor adherence. Of 148 subjects, 102 (69%) continued to receive HAART throughout the study period. Average adherence in the group of those who continued to receive HAART was 74%, and 55% of these subjects had undetectable virus loads at the last follow-up visit. Predictors of lower average adherence in this group were African American ethnicity and use of crack cocaine; men who had sex with men had higher adherence. CONCLUSIONS: One-third of homeless and marginally housed persons receiving HAART discontinued therapy during the follow-up period and would benefit from adherence interventions directed at sustaining therapy; two-thirds continued to receive therapy at adherence levels comparable to those found with other clinical populations.

Adult↗
PubMed2001

The epidemiology of the homeless population and its impact on an urban emergency department.

OBJECTIVES: To characterize the homeless adult population of an urban emergency department (ED) and study the medical, psychiatric, and social factors that contribute to homelessness. METHODS: A prospective, case-control survey of all homeless adult patients presenting to an urban, tertiary care ED and a random set of non-homeless controls over an eight-week period during summer 1999. Research assistants administered a 50-item questionnaire and were trained in assessing dentition and triceps skin-fold thickness. INCLUSION CRITERIA: all homeless adults who consented to participate. Homelessness was defined as being present for any person not residing at a private address, group home, or drug treatment program. Randomly selected controls were concurrently enrolled with a 3:1 homeless:control rate. EXCLUSION CRITERIA: critically ill, injured, or incapacitated patients, or patients <21 years of age. Univariate analysis with appropriate statistical tests was used. The Mantel-Haenszel test was used to adjust for population differences. RESULTS: Two hundred fifty-two homeless subjects and 88 controls were enrolled. Data are presented for homeless vs control patients, and all p-values were <0.01. Odds ratios (ORs) with 95% confidence intervals (95% CIs) are given where appropriate: mean age (+/-SD) = 42 +/- 10 vs 48 +/- 13; male gender 95% vs 54% (OR = 17; 95% CI = 8 to 37); history of (hx) tuberculosis 49% vs 15% (OR = 2.5; 95% CI = 1.2 to 3); hx HIV infection 35% vs 13% (OR = 3.8; 95% CI = 1.8 to 8); hx penetrating trauma 62% vs 16% (OR = 8.62; 95% CI = 4.4 to 17.1); hx depression 70% vs 15% (OR = 13.4; 95% CI = 6.7 to 27); hx schizophrenia 27% vs 7% (OR = 5.1; 95% CI = 2.0 to 14); hx alcoholism 81% vs 15% (OR = 24; 95% CI = 12 to 49); significant tooth loss (>3) 43% vs 18% (OR = 3.3; 95% CI = 1.8 to 6.4); percentage of body fat 16.5% vs 19.7%; hx social isolation (no weekly social contacts) 81% vs 11% (OR = 33.3; 95% CI = 14 to 100); mean number of ED visits/year 6.0 vs 1.6. CONCLUSIONS: In the study population homelessness was associated with a history of significantly higher rates of infectious disease, ethanol and substance use, psychiatric illness, social isolation, and rates of ED utilization.

Adult↗
PubMed1991

Homelessness in the United States. An ecological perspective.

This article presents an ecological perspective on homelessness that emphasizes the context in which homeless people live and the complex interactions between personal, social, economic, and service system resources that affect their well-being. The ecological perspective encourages researchers and program developers to assess the problems of homelessness at multiple levels of analysis, to view homelessness as a result of contextual factors that interact with individual and family vulnerabilities, and to assess carefully the social contexts in which researchers and program developers operate. Four ecological principles are described as a heuristic for research, intervention, and policy development. The implications of an ecological perspective for psychologists who wish to get involved in dealing with homelessness are discussed.

Adaptation, Psychological↗