'Don't Leave Me Hanging': Homeless Mothers' Perceptions of Service Providers

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

Trauma-Disclosure, Meaning-Making, and Help-Seeking in Mothers Experiencing Homelessness: Results From a Trauma-Focused, Clinical Ethnographic Narrative Intervention

Mothers experiencing homelessness are seldom asked about past trauma that may be causal to housing instability and poor health. There are also few validated trauma-focused interventions in family shelters. To address this gap, we tested the feasibility and acceptability of the trauma-focused clinical ethnographic narrative intervention (CENI-TF) in increasing mothers' trauma disclosure, appraisal of its meaning in their lives, and help-seeking behaviors. We also present the qualitative findings to contextualize the intervention. Findings are organized under three major domains and nine subthemes that capture participants' voices and experiences. The CENI-TF has the potential to promote help-seeking behaviors and interrupt recurring cycles of trauma and housing instability in this at-risk population.

Perceptions of support in shelter environments for caregivers and young children experiencing family homelessness

BACKGROUND

Young children who stay with their families in homeless shelters face chronic challenges related to extreme poverty and acute risks from stressful events surrounding the loss of housing and move to shelter. These adversities increase the likelihood of a range of poor developmental outcomes. Consistent with the risk and resilience perspective, however, many children who experience family homelessness succeed, functioning as well or better than their non-homeless peers. As such, efforts to support resilience should consider how best to enhance protective factors, such as supportive environments within shelter settings.

METHODS

With data from 60 caregivers of children ages birth to 5 years recruited from family shelters, we assessed caregivers' perceptions of community support as well as child and family well-being in terms of recent adverse experiences, parenting stress, access to social support, and child social-emotional functioning.

RESULTS

Many caregivers experiencing family homelessness perceived negative aspects of the shelters where they were staying with their children. Furthermore, children whose caregivers had more negative perceptions of the shelter environment displayed worse social-emotional functioning, even when accounting for differences in parenting stress, recent family adversity, and other sources of social support.

CONCLUSIONS

Because young children rely on their caregivers as primary resources for nurturance and support, we encourage family homelessness service providers to work in partnership with caregivers to create more inclusive and empowering practices within the shelter context. Doing so is likely to improve children's developmental outcomes and the overall well-being of the families.

Perspectives of homeless service providers on their work, their clients, and the healthcare system

PURPOSE

To describe the perspectives of homeless service providers who work for Chicago organizations that primarily serve persons experiencing homelessness.

METHODS

A qualitative, cross-sectional study of Chicago homeless service providers (n = 17) consisting of a semi-structured interview and the Attitudes Toward the Homeless Inventory (ATHI). Interviews were analyzed for themes and patterns using inductive approach.

RESULTS

Four categories of 16 themes describing homeless service providers' perspectives and perceptions: 1) perspectives on work, 2) perspectives on the general population of those experiencing homelessness at large, 3) perceptions of the population of those experiencing homelessness based on client interactions, and 4) perceptions of hospitals and healthcare.

CONCLUSIONS

A richer understanding of the perspectives of homeless service may provide guidance in recruitment and training of workers in this area and offer insight into caring for persons experiencing homelessness in hospital settings.

A culture of care: How Lotus House Women's Shelter heals program participants through genuineness, space, high expectations, dignity, individualized attention, and community

The present study was designed to examine perceptions of Lotus House Women's Shelter from the perspective of former program participants, for the purpose of informing shelter programming and policies. Our qualitative research followed a community-based participatory research framework. Fifty diverse women graduates of Lotus House Women's Shelter participated in eight focus groups to discuss their experiences with Lotus House and other shelters. Findings from this study highlight the elements that create a "culture of care" within an organization. Participants described Lotus House shelter culture as genuine, defined by dignity and respect, having high expectations for guest independence and accountability, giving space to rest and recuperate, recognizing and accommodating individual needs and experiences, and fostering a sense of community. Creating an organizational "culture of care" is an avenue by which any shelter or related organization can enhance the experience of program participants.

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Background

People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need to be synthesised to generate further practice-relevant insights from the perspective of this group.

Methods

Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model.

Results

Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis, a new model was developed highlighting critical components of effective substance use treatment from the service user’s perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people’s lives.

Conclusion

This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted. The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals’ complex lives.

Youth Growing Up in Families Experiencing Parental Substance Use Disorders and Homelessness: A High-Risk Population

Objectives: We sought to understand the stressors, the parent-child relationship and family processes, and experiences with services among families experiencing parental substance use disorders (SUDs) and homelessness. Methods: We conducted a total of 41 in-depth semistructured interviews with parents with a history of SUDs and homelessness (n = 16) and housing support staff (n = 25) from May 2017 until January 2018. Participants were recruited from transitional housing facilities across the Los Angeles metropolitan area, which served families experiencing homelessness and parental SUDs. The interviews were audio-recorded, transcribed, and themes coded with Dedoose. Results: We found a high burden of trauma and guilt among parents, and a fear of SUD disclosure. We found challenges with family processes important for SUD prevention, including communication, discussion of substance use, and family and youth goal setting. We also discovered unique stressors related to navigating housing and services within the community. Conclusion: Our findings demonstrate the need for a family-based SUD-preventive intervention for youth growing up in families with parental SUDs and experiencing homelessness, to address the heightened SUD risk. In addition, findings from our study can inform clinical and housing services for this important population.

Social Services Professionals' Views of Barriers to Supporting Homeless Noncustodial Fathers

OBJECTIVE

To investigate barriers to service for homeless non-custodial fathers from the perspective of social service professionals who work directly to assist men with securing housing while meeting the demands of fatherhood.

BACKGROUND

The population of homeless fathers in the United States is increasing. Longitudinal studies show that although homeless noncustodial fathers and mothers face similar risk factors and barriers to services, research on minimizing risk factors and barriers for noncustodial fathers is limited compared with that for noncustodial mothers.

METHOD

The sample included 7 administrators and 12 direct service professionals engaged with fathers transitioning from homelessness. Data were collected via face-to-face, semi-structured interviews and analyzed using a qualitative inductive approach. Multiple cycle coding was employed to capture emerging themes.

RESULTS

Three major themes, encompassing emotional, relational, and systemic factors, emerged regarding participants' experiences serving homeless noncustodial fathers.

CONCLUSION

Effective approaches to supporting fathers require empathy, relationship building, and collaboration between service providers and policymakers.

IMPLICATIONS

Future policies and interventions should be based on input from direct service professionals and homeless noncustodial fathers themselves, with the aim of best supporting their efforts toward securing housing while meeting the demands of fatherhood.

Health interventions for people who are homeless

Homelessness has serious implications for the health of individuals and populations. Primary health-care programmes specifically tailored to homeless individuals might be more effective than standard primary health care. Standard case management, assertive community treatment, and critical time intervention are effective models of mental health-care delivery. Housing First, with immediate provision of housing in independent units with support, improves outcomes for individuals with serious mental illnesses. Many different types of interventions, including case management, are effective in the reduction of substance misuse. Interventions that provide case management and supportive housing have the greatest effect when they target individuals who are the most intensive users of services. Medical respite programmes are an effective intervention for homeless patients leaving the hospital. Although the scientific literature provides guidance on interventions to improve the health of homeless individuals, health-care providers should also seek to address social policies and structural factors that result in homelessness.

Efficacy of ecologically-based treatment with substance-abusing homeless mothers: substance use and housing outcomes

This randomized pilot study tested the efficacy of an integrative treatment targeting homeless substance abusing mothers with young children in their care. Sixty mothers with 2-6 year old children were recruited from a local family shelter. The mothers were randomly assigned to Ecologically-Based Treatment (n=30) or treatment as usual (n=30). The intervention group received 3 months of rental and utility assistance up to $600 per month, case management services, and substance abuse counseling (referred to as supportive services). The treatment as usual group received housing and services through the family shelter and community housing programs. All participants completed follow-up assessments at 3, 6, and 9 months post-baseline. Mothers receiving Ecologically-Based Treatment showed a quicker decline in alcohol frequency and a quicker increase in housing stability. Furthermore, with supportive services, two-thirds of women were successful in maintaining their apartments 6 months after rental assistance ended.