Finding safety: a pilot study of managed alcohol program participants’ perceptions of housing and quality of life
Tóm tắt
There is a higher prevalence of alcohol use and severe alcohol dependence among homeless populations. The combination of alcohol use and lack of housing contributes to increased vulnerability to the harms of substance use including stigma, injury, illness, and death. Managed alcohol programs (MAPs) administer prescribed doses of alcohol at regular intervals to people with severe and chronic alcohol dependence and homelessness. As a pilot for a larger national study of MAPs, we conducted an in-depth evaluation of one program in Ontario, Canada. In this paper, we report on housing and quality of life outcomes and experiences of the MAP participants and staff. We conducted a pilot study using mixed methods. The sample consisted of 38 people enrolled in or eligible for entry into a MAP who completed a structured quantitative survey that included measures related to their housing and quality of life. All of the participants self-identified as Indigenous. In addition, we conducted 11 in-depth qualitative interviews with seven MAP residents and four program staff and analyzed the interviews using constant comparative analysis. The qualitative analysis was informed by Rhodes’ risk environment framework. When compared to controls, MAP participants were more likely to retain their housing and experienced increased safety and improved quality of life compared to life on the streets, in jails, shelters, or hospitals. They described the MAP as a safe place characterized by caring, respect, trust and a nonjudgmental approach with a sense of family and home as well as opportunities to reconnect with family members. The MAP was, as described by participants, a safer environment and a home with feelings of family and a sense of community that countered stigma, loss, and dislocation with potential for healing and recovery. The MAP environment characterized by caring, respect, trust, a sense of home, “feeling like family”, and the opportunities for family and cultural reconnections is consistent with First Nations principles for healing and recovery and principles of harm reduction.
Tài liệu tham khảo
Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in Western countries: systematic review and meta-regression analysis. PLOS Medicine. 2008;5(12):e225. doi:1-.1371/journal.pmed.0050225.
Fazel S, Geddes JR, Kushel M. The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations. Lancet. 2014;384(9953):1529–40.
Turnbull J, Muckle W, Masters C. Homelessness and health. Can Med Assoc J. 2007;177(9):1065–6.
Williams N. Waiting and working: coping responses of individuals enduring homelessness when accessing alcohol and shelter accommodation. 2011.
Svoboda T. Message in a bottle: wet shelters embody true harm reduction approach. Crosscurrents. 2009.
Muckle W, Oyewumi L, Robinson V, Tugwell P, Ter Kuile A. Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse: the Cochrane Library. 2008.
Lehman AF, Cordray DS. Prevalence of alcohol, drug and mental disorders among the homeless: one more time. Contemp Drug Probs. 1993;20:355.
World Health Organization. Management of substance abuse program. 2007. http://www.who.int/substance_abuse/facts/en/.
Pauly BM, Reist D, Belle-Isle L, Schactman C. Housing and harm reduction: what is the role of harm reduction in addressing homelessness? International Journal of Drug Policy. 2013;24(4):284–90. doi:http://dx.doi.org/10.1016/j.drugpo.2013.03.008.
Marlatt GA, Witkiewitz K. Update on harm-reduction policy and intervention research. Annu Rev Clin Psychol. 2010;6(20):1–16.
Collins SE, Clifasefi SL, Dana EA, Andrasik MP, Stahl N, Kirouac M, et al. Where harm reduction meets housing first: exploring alcohol’s role in a project-based housing first setting. Int J Drug Policy. 2012;23(2):111–9. doi:10.1016/j.drugpo.2011.07.010.
Larimer M, Malone D, Garner M, Atkins D, Burlingham B, Lonczak H, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009;301(13):1349–57.
Collins SE, Malone DK, Clifasefi SL, Ginzler JA, Garner MD, Burlingham B, et al. Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012;102(3):511–9. doi:10.2105/ajph.2011.300403.
Collins SE, Malone DK, Larimer ME. Motivation to change and treatment attendance as predictors of alcohol-use outcomes among project-based Housing First residents. Addict Behav. 2012;37(8):931–9. doi:10.1016/j.addbeh.2012.03.029.
Kirst M, Zerger S, Misir V, Hwang S, Stergiopoulos V. The impact of a Housing First randomized controlled trial on substance use problems among homeless individuals with mental illness. Drug Alcohol Depend. 2015;146:24–9.
Clifasefi SL, Malone DK, Collins SE. Associations between criminal history, Housing First exposure and jail outcomes among chronically homeless individuals with alcohol problems. Alcoholism. 2012;36:360A.
Podymow T, Turnbull J, Coyle D. Shelter-based palliative care for the homeless terminally ill. Palliat Med. 2006;20(2):81–6.
Pauly BM, Stockwell T, Chow C, Gray E, Krysowaty B, Vallance K, et al. Towards alcohol harm reduction: preliminary results from an evaluation of a Canadian managed alcohol program. Victoria, BC: Centre for Additions Research of British Columbia; 2013.
Stockwell T, Pauly BM, Chow C, Vallance K, Perkin K. Evaluation of a managed alcohol program in Vancouver, BC: early findings and reflections on alcohol harm reduction. Victoria, British Columbia: University of Victoria; 2013.
Vallance K, Stockwell T, Pauly B, Chow C, Gray E, Krysowaty B et al. Do managed alcohol programs change patterns of alcohol consumption and reduce related harm? A pilot study. Harm Reduction Journal. In press 2016.
Rhodes T, Singer M, Bourgois P, Friedman S, Strathdee S. The social structural production of HIV risk among injecting drug users. Social Science & Medicine. 2005;61(5):1026–44. doi:http://dx.doi.org/10.1016/j.socscimed.2004.12.024.
Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. International Journal of Drug Policy. 2009;20(3):193–201. doi:http://dx.doi.org/10.1016/j.drugpo.2008.10.003.
Rhodes T. The ‘risk environment’: a framework for understanding and reducing drug-related harm. Int J Drug Policy. 2002;13(2):85–94.
Rhodes T, Singer M, Bourgois P, Friedman S, Strathdee S. The social structural production of HIV risk among injecting drug users. Soc Sci Med. 2005;61:1026–44.
Goering P, Veldhuizen S, Watson A, Adair C, Kopp B, Latimer E, et al. National at Home/Chez Soi final report. Calgary, AB: Mental Health Commission of Canada; 2014.
Tsemberis S, Kent D, Respress C. Housing stability and recovery among chronically homeless persons with co-occuring disorders in Washington, DC. Am J Public Health. 2011;102(1):13–6. doi:10.2105/ajph.2011.300320.
Nelson G, Stefancic A, Rae J, Townley G, Tsemberis S, Macnaughton E, et al. Early implementation evaluation of a multi-site housing first intervention for homeless people with mental illness: a mixed methods approach. Eval Program Plann. 2014;43:16–26.
Stefancic A, Tsemberis S. Housing first for long-term shelter dwellers with psychiatric disabilities in a suburban country: a four-year study of housing access and retention. J Prim Prev. 2007;28:265–79.
Greene J, Caracelli V, Graham W. Toward a conceptual framework for mixed-method evaluation designs. EducEval Policy Anal. 1989;11(3):255–74.
Caracelli V, Greene J. Crafting mixed-method evaluation designs. N Dir Eval. 1997;74:19–32.
Babor T, Higgins-Biddle J, Saunders J, Monteiro M. The alcohol use disorders identification test: guidelines for use in primary care. 2nd ed. Geneva: World Health Organization; 2001.
Toro P, Bellavia C, Daseschler C, Wall D, Smith S. Evaluating an intervention for homeless person: results of a field experiment. Journal of Consulting and Clin Psychol. 1997;65(3):475–84.
Tsemberis S, Rogers E, Rodis E, Dushuttle P, Skryha V. Housing satisfaction for persons with psychiatric disabilities. J Community Psychol. 2003;31(6):581–90.
World Health Organization. WHOQOL-Bref. Geneva: World Health Organization; 1996.
Boeije H. A purposeful approach to the constant comparative method in the analysis of qualitative interviews. Qual Quant. 2002;36(4):391–409.
Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd ed. Thousand Oaks, CA: Sage Publications; 2008.
Fram SM. The constant comparative analysis method outside of grounded theory. Qual Rep. 2013;18:1.
Miles MB, Huberman AM. Qualitative data analysis: an expanded sourcebook. 2nd ed. London: Sage; 1994.
Pauly B, McCall J, Brown A, Parker J, Mollison A. Toward cultural safety: nurses’ and patients perceptions of substance use in hospitals. Adv Nurs Sci. 2015;38(2):121–35.
International Harm Reduction Association. What is harm reduction? 2006.
MacNeil J, Pauly BM. Needle exchange as a safe haven in an unsafe world. Drug & Alcohol Review. 2011;30(1). doi:10.1111/j.1465-3362.2010.00188.x.
McNeil R, Small W. ‘Safer environment interventions’: a qualitative synthesis of the experiences and perceptions of people ho inject drugs. Soc Sci Med. 2014;106:151–8.
Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. Int J Drug Policy. 2009;20:193–201.
Dell C, Lyons T, Cayer K. The role of ‘Kijigabandan’ and ‘Manadjitowin’ in understanding harm reduction policies and programs for Aboriginal peoples. Native Social Work J. 2010;7:109–37.
Reading CL, Wien F. Health inequities and social determinants of Aboriginal peoples’ health. Prince George, BC: National Collaborating Centre for Aboriginal Health; 2009.
Hwang SW. Homelessness and health. Can Med Assoc J. 2001;164(2):229–33.
Loppie Reading C, Wein F. Health inequities and social determinants of Aboriginal peoples’ health. Prince George, BC: National Collaborating Centre for Aboriginal Health; 2009.
Blackstock C. The Canadian Human Rights Tribunal on First Nations child welfare: why if Canada wins, equality and justice lose. Child Youth Serv Rev. 2011;33(1):187–94.
Gone JP. Redressing First Nations historical trauma: theorizing mechanisms for indigenous culture as mental health treatment. Transcult Psychiatry. 2013;50(5):683–706.
Dell CA, Lyons T. Harm reduction policies and programs for persons of Aboriginal descent. Ottawa: Canadian Centre on Substance Abuse; 2007.
First Nations Addictions Advisory Panel. Honouring our strengths: a renewed framework to address substance abuse issues among First Nations people in Canada. 2011.
Pauly BM. Close to the street: nursing practice with people marginalized by homelessness and substance use. In: Hwang S, Younger M, editors. Homelessness and health in Canada. Ottawa: University of Ottawa Press; 2014.
Pauly B. Shifting moral values to enhance access to health care: harm reduction as a context for ethical nursing practice. Int J Drug Policy. 2008;19:195–204.
Evans J, Semogas D, Smalley J, Lohfeld L. “This place has given me a reason to care”: understanding ‘managed alcohol programs’ as enabling places in Canada. Health Place. 2015;33:118–24.