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1007/s12147-008-9057-5 ORIGINAL ARTICLE
Subjective Versus Objective Deﬁnitions of Homelessness: Are there Differences in Risk Factors among Heavy-Drinking Women?
Karin M. Eyrich-Garg Æ Catina Callahan O’Leary Æ Linda B. Cottler
Published online: 27 September 2008 Ó Springer Science+Business Media, LLC 2008
Abstract Investigations with homeless populations have focused on those living on the streets or in shelters; few have examined phenomena based on respondents’ self-deﬁnitions as homeless or not. This investigation examined similarities and differences among risk factors (including mental health, substance abuse, religion/ spirituality, social support, and risky sexual behaviors) using two deﬁnitions of homelessness: one where place of residence deﬁned individuals as homeless (the ‘objective’ or traditional, deﬁnition) and another where respondents deﬁned themselves as homeless (the ‘subjective’ deﬁnition). Data come from the baseline survey of the NIAAA-funded ‘‘Sister-to-Sister’’ study (n = 339) of heavy-drinking women. Subjectively deﬁned homelessness was associated with higher rates of mental health and substance use disorders, lower rates of condom use, higher rates of trading sex for food, and less social support. Objectively deﬁned homelessness was associated with higher rates of drinking in abandoned buildings, on the streets, and in public restrooms, more new sexual partners, and higher rates of trading sex for heroin and speedballs. Investigations failing to ask for subjective information may misattribute some factors to homelessness which may overestimate the effect
K. M. Eyrich-Garg (&) Department of Social Work, Temple University School of Social Administration, Ritter Annex, 5th Floor, 1301 Cecil B. Moore Ave., Philadelphia, PA 19122, USA e-mail: firstname.lastname@example.org K. M. Eyrich-Garg Department of Public Health, Temple University College of Health Professions, Philadelphia, USA C. C. O’Leary Á L. B. Cottler Department of Psychiatry, Washington University School of Medicine, 40 N. Kingshighway, Suite 4, St. Louis, MO 63108, USA e-mail: email@example.com L. B. Cottler e-mail: firstname.lastname@example.org
Gend. Issues (2008) 25:173–192
of various factors on homelessness. Investigators should ask respondents to deﬁne their homelessness, or they lose an important dimension of the concept of homelessness. Keywords Methods Homelessness Á Women Á Alcohol Á Substance use Á Risky behaviors Á
Introduction According to the Merriam-Webster dictionary , homelessness refers to ‘‘having no home or permanent place of residence.’’ The misleadingly simple concept is challenging to operationalize. Many policies and social service programs deﬁne homelessness using the deﬁnition outlined in the ‘‘McKinney Act’’—originally passed in 1983 and renamed to the Stewart B. McKinney Homeless Assistance Act in 1987. The McKinney Act deﬁnes a homeless person as: ‘‘(1) an individual who lacks a ﬁxed, regular, and adequate nighttime residence and (2) an individual who has a primary nighttime residence that is (a) a supervised, publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill), (b) an institution that provides a temporary residence for individuals intended to be institutionalized, or (c) a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings’’ . Most commonly in the scientiﬁc literature homelessness is deﬁned by either a request for  or a stay at [3, 20] an overnight shelter. However, one night in a shelter may not be sufﬁcient to classify someone as homeless, so this deﬁnition would capture only a segment of the homeless population. Literal homelessness expands this deﬁnition by including individuals sleeping on the streets, in cars, abandoned buildings, tunnels, bus stations, parks, and similar places [2, 18, 25]. Deﬁnitions of literal homelessness vary in duration by nights, weeks, or years. Rates based on literal homelessness are generally higher than those based on shelter stays alone because they are more likely to include those who have been homeless for longer periods of time. Investigators sometimes use an even broader deﬁnition of homelessness, including individuals who are marginally housed , which refers to individuals living in transitional living programs, living with relatives or friends (i.e., ‘‘doubledup’’), and living in cheap hotels and motels, or single room occupancy units (SROs). Others disagree and argue that individuals who are doubling-up or are renting rooms in hotels, motels, or SROs are not yet homeless because they currently have a place to stay even though they may be on the cusp of homelessness. Only a few studies have taken the respondents’ own perspectives of homelessness into account, counting someone as homeless if he/she self-identiﬁes as experiencing homelessness. For instance Link et al.  classiﬁed respondents as being homeless if they ever considered themselves homeless. However, many individuals, especially in the beginning months of homelessness, do not identify themselves as homeless . If investigators require individuals to subjectively rate
(4) being drug negative for cocaine. 5. Louis was mapped and coded for documentation of outreach efforts.272 women reported being at least 18 years old. Fifty-ﬁve percent of these women (n = 1. Staff introduced themselves and the study and administered a ﬁve-item questionnaire to assess eligibility. Interestingly. Women were also asked to recruit friends from the same geographic locations. classifying individuals as homeless if they both considered themselves homeless and spent at least one night in a shelter or nonsleeping space because they had nowhere else to go.  used a hybrid deﬁnition of homelessness. Women who met the eligibility criteria were given an identiﬁcation code. Recruitment Each area of St. We had the opportunity to explore deﬁnitions of homelessness with data from a study that was not focused on homelessness. Those who scored a 4 or higher were invited to make an appointment to come to one of the study’s storefront clinics. in which respondents were not biased towards stating they were homeless. which tested a peer-delivered intervention based on holistic health concepts adapted from Cottler and colleagues’ work .Gend. Methods This investigation used baseline data from the NIAAA-funded ‘‘Sister to Sister’’ study. Issues (2008) 25:173–192 175 themselves. and voucher and asked to call one of the study’s two storefront ofﬁces within 30 days for further screening with the alcohol use disorders identiﬁcation test (AUDIT. a bias could result because these individuals may not be ready to ‘subjectively’ label themselves as homeless. Referrals were also made to the study from the St. (2) reporting sexual activity in the past 4 months. and using alcohol but not drugs in the past 30 days. Herman et al. To our knowledge. which was aimed at reducing high risk HIV behaviors among heavy drinking women. and amphetamines. heroin. During the ﬁeld period. ). (3) reporting problem use of alcohol (AUDIT score of 4?). Women with drug-negative urines were eligible to participate in the ‘‘Sister to Sister’’ study.012) later called for more information or came immediately to the ofﬁce for an AUDIT. and beauty salons and on the streets. For this study. 98% (n = 990) scored 4? and were asked to make an appointment to 123 . Outreach personnel were assigned to recruit in these different geographic locations each day. 2. indicating their recruitment source. complete an informed consent. laundromats. Louis City Female Drug Court. eligibility criteria included (1) being female and over the age of 18. bus stops.551 women were approached by study personnel. The purpose of this investigation was to explore how differing deﬁnitions of homelessness are associated with various factors. This was one of the ﬁrst community-based NIH NIAAA-funded HIV intervention studies. Women were systematically approached in these geographic locations in grocery stores. sexually active in the prior 4 months. and provide a urine sample. no one has examined this particular issue. and (5) living in the St. Louis Area.
club drugs. conduct disorder. ) were administered to assess DSM-IV depression. extensive baseline tracking of women was not allowed. abuse. The original version underwent extensive psychometric testing [8. post-traumatic stress disorder. hallucinogens. amphetamines.176 Gend. and completed the baseline interviews. it was determined that no signiﬁcant differences were found between the women who enrolled and those who did not. nicotine. has undergone psychometric testing [11. 21]. inhalants. Issues (2008) 25:173–192 participate in the study. cocaine. were negative for drugs. 17. and dependence (alcohol. were eligible for the study. Interview Protocol Interviewers underwent 2 weeks of training and were permitted to conduct interviews only after becoming certiﬁed by the quality control manager. and treatment history. The SAM has undergone psychometric testing in the United States and in other countries . The SAM assesses lifetime and current patterns of substance use. insurance status. other than transportation and other enrollment barriers. 27]. The DIS assesses lifetime and current patterns of psychiatric symptoms and has been used widely in psychiatric research since its creation in 1980. [4. and sedatives). DSM-III-R. 11]) and the Washington University risk behavior assessment for women (RBA. and pathological gambling. a partial version of the substance abuse module (SAM. The RBA. originally developed by NIDA for use in its cooperative agreement study in the 1990s. assesses lifetime and recent sexual activity and use of protection against HIV and other sexually transmitted diseases. It was modiﬁed to be more relevant to women and to cover additional risk and protective behaviors such as perceptions and attitudes towards sex. consented to urine screens. Variables Residential Status Residential status was deﬁned in two ways: the self (or ‘subjective’) deﬁnition and the traditional (or ‘objective’) deﬁnition. During the ﬁrst session. Based on the minimal demographics women provided at the time of contact. 123 . cannabis. Of these 990 women. antisocial personality disorder. in the second session. Ongoing quality control was conducted throughout the study for every interviewer via reviews of audiotaped interviews. It. Participants received $10 remuneration for each of the two baseline interviews. nutritional risk factors. The baseline assessment was completed in two sessions. PCP. and ICD-10. several sections of the diagnostic interview schedule version IV (DIS. opioids. These patterns are mapped to diagnostic criteria outlined in the DSM-III. medical illnesses. DSM-IV. Baseline interviews for this study were conducted between May 2000 and September 2003. ) were administered. recent use of health care services. 339 AUDIT? women came to the site. too. Two weeks later. Because one of the aims of the study was to understand how feasible it was to use street-based methods for heavy drinking women.
a place to stay. hallucinogen. Religiosity/spirituality and social support were assessed by asking how often women attended religious services in the past 12 months. rabbi.e. They were also asked how satisﬁed they were with this support. ‘Objective’ Traditional Deﬁnition. Those who reported staying in their own house or apartment were classiﬁed as not homeless (n = 152. minister.Gend. and individual substance abuse/dependence disorders (alcohol. all women reported having sex in the past 123 . opioid. and anal sex. psychic. or clothing was assessed.e. Issues (2008) 25:173–192 177 ‘Subjective’ Self Deﬁnition. without exclusions. spiritual adviser. or other member of the religious community’’) or from a nontraditional spiritual ﬁgure (i. Regarding other social support. level of education (dichotomized into graduated from high school or attained a general equivalency diploma (GED) versus not). and club drug). Because satisfaction with support is conditional on having support. the number of times respondents had vaginal. Race was dichotomized because three-quarters of the sample identiﬁed as African American. Women who reported staying on the streets or in a shelter were classiﬁed as literally homeless (n = 31. Level of education was dichotomized because a high school diploma or GED is a minimal requirement for many jobs. adult antisocial behaviors. During the initial screening. 46%). oral. Those who responded negatively were classiﬁed as not homeless (n = 255. Disorders were coded as met criteria versus did not meet criteria. ‘‘priest. the gender of sexual partners. PTSD. Sexual risk-taking in the past 4 months was characterized by assessing the number of sexual partners. ‘‘Do you consider yourself to be homeless?’’ were classiﬁed as homeless (n = 84. ‘‘Where are you living or staying now?’’ Response categories were provided. 45%). money. Those who reported staying in a rooming/boarding house or halfway house or in someone else’s apartment were classiﬁed as marginally housed (n = 156. Substance use diagnoses were not calculated for women who never used because substance abuse and dependence are conditional on the substances used. 21% identiﬁed as Caucasian. ‘‘prophet. and if they sought help from a traditional religious ﬁgure (i. the number of new sexual partners. how important religion/ spirituality is to them. Women who responded afﬁrmatively to the question. food.. or tarot card reader’’). Women were also asked. Abuse and dependence for each substance were combined for these analyses. 75%). Other Variables Other demographic variables included age (a continuous variable). women were asked if they had someone they could talk to about things that were important. cocaine. ASPD. 9%). and 4% identiﬁed as other.. to count on for understanding and advice. the number of IDU partners. Sex trading in the past 4 months for alcohol/drugs. and the percent of time it was protected by condoms. cannabis. amphetamine. Psychiatric diagnostic variables included DSM-IV lifetime major depression. 25%). including living on the streets or in a shelter. sedative. palmist. and race (dichotomized into Caucasian versus of color). women reporting no support were omitted from the analyses for the satisfaction variable. and to rely on for practical things. PCP.
Descriptive data are summarized with percentage rates and means with standard deviations. p \ . marginally housed. there was not a perfect agreement between the subjective and objective deﬁnitions of homelessness. Results Respondent Classiﬁcation versus Traditional Classiﬁcation as Homeless To understand the overlap in classiﬁcation status. we compared women who classiﬁed themselves as homeless with those who were classiﬁed as homeless by the traditional deﬁnition. Because multiple tests were run. The number of days in the past month women spent drinking at a bar. Women who reported not drinking in any of these locations were coded 0. Issues (2008) 25:173–192 4 months (which was a study inclusion criterion). df = 1.. Every respondent who was objectively deﬁned as not homeless subjectively deﬁned themselves as not homeless (i. this test was selected because the two variables (subjective and objective) were not independent .01.20. a small number of women (n = 48) reported not having sex in the past 4 months at the time of the interview. Chi-square and Fisher’s exact tests were performed with categorical variables.178 Gend. or in a public restroom were also elicited. McNemar’s test for correlated proportions was used to compare respondents’ subjective classiﬁcation (as homeless versus not homeless) with the objective classiﬁcation (as literally homeless. These women were coded 0 for these sex questions. the p-value for statistical signiﬁcance was set at . only three respondents who were living in shelters or on the streets did not consider themselves homeless. 90% considered themselves homeless. However. perfect agreement). this scenario is plausible because some women were interviewed 30 days after their initial screening. of Table 1 Residential classiﬁcation ‘Subjective’ self deﬁnition of homelessness ‘Objective’ traditional deﬁnition of homelessness Literally homeless (n = 31) n Homeless (n = 84) Not homeless (n = 255) 28 3 % 90 10 Marginally housed (n = 156) n 56 100 % 36 64 Not homeless (n = 152) n 0 152 % 0 100 McNemar = 179. Among the 31 persons who were objectively classiﬁed as literally homeless.e. As shown in Table 1. However. because condom use is conditional on sexual activity. Data Analysis Data were analyzed using SAS 9. or not homeless). Additionally. in an abandoned building. the percent of time sex was protected by condoms was calculated only for those reporting sexual activity.0001 123 . t-tests and ANOVAs were used for continuous variables.1 . on the streets.
Almost three quarters (73%) of the sample had children. Those who labeled themselves as homeless were older than those who did not. rates of adult antisocial behaviors were higher among the homeless (and the marginally housed). and in public restrooms were reported more often by persons who were objectively deﬁned as literally homeless. Religion/Spirituality No differences in religious/spiritual variables were detected by either subjective or objective deﬁnitions of homelessness (Table 4). rates of ever trading sex for alcohol/ drugs. 123 . on the streets. No differences were detected using the objective deﬁnition of homelessness. Sample Demographics Over half (53%) of the sample had at least a high school education or GED. Seventy-nine percent of the sample identiﬁed as being of color. Drinking in abandoned buildings. Demographics are presented in Table 2 by deﬁnitions of homelessness. money. Rates of cocaine and opioid abuse/dependence were higher among the homeless regardless of subjective or objective deﬁnitions. only 36% considered themselves to be homeless. They also reported a lower rate of satisfaction with their social support. Women who subjectively classiﬁed themselves as homeless were more likely to meet criteria for ASPD and PTSD than those who subjectively classiﬁed themselves as housed. Issues (2008) 25:173–192 179 those objectively classiﬁed as marginally housed. The average age was 31. No other signiﬁcant differences were detected between the groups. and a place to stay were higher among the homeless (Table 5). although both groups had considerably high rates of support. Social Support Those who subjectively deﬁned themselves as homeless had less social support in the form of having someone provide them with advice and understanding compared to those who did not deﬁne themselves as homeless.999 and 87% earning under $15. Psychiatric Diagnostics Rates of psychiatric disorders by deﬁnitions of homelessness are presented in Table 3. The personal incomes of these women were quite low. with 44% of the sample earning under $3.000 in the past 12 months. Regardless of subjective or objective deﬁnition.Gend.07 years. Those who subjectively deﬁned themselves as homeless had higher rates of alcohol and sedative abuse/dependence than those who deﬁned themselves as housed.95 ± 10. Risky Sexual Behaviors Regardless of subjective or objective deﬁnition.
14 ± 10.60 ± 1513.89 # Days living at current place 650.0098 ns ns ns ns ns 60.23 ± 10.20 ± 9. Issues (2008) 25:173–192 .15 ± 1.47 ± 2.20A % Nonwhite 83 77 % HS Grad 50 57 % With children 83 69 # Children 3.94 ± 1. B ns p = .70 31.58 3.29 ± 135.87 ± 1798.20 2.84 Gend. E ns ns ns ns ns ns ns Table 2 Demographics Item ‘Subjective’ self deﬁnition Homeless (A) Not homeless (B) N 84 255 Age 34.87 835.40 ± 9. D ns ns ns ns ns ns ns p-value C vs. E ns ns ns ns ns ns ns p-value D vs.01 34.42 31 156 152 32.58 ± 3.92 Literally homeless (C) Marginally housed (D) Not homeless (E) p-value C vs.27B 31.06 ± 2287.13 937.32 ± 8.180 123 ‘Objective’ traditional deﬁnition p-value A vs.87 77 76 42 50 67 83 76 64 69 3.93 ± 2.00 1057.30 ± 2072.50 2.
E Item Not homeless p-value (B) A vs. % with 74A p = .D 17 11 ns 71A 20 A Depression ns 52 ns 48 18 43 ns ns p = . E p-value D vs.0004 ns ns ns p = .0003 ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns 181 Cannabis abuse/ dependence 13 36 39 Amphetamine abuse/dependence 8 Sedative abuse/dependence 14B Cocaine abuse/dependence 48B Opioid abuse/dependence 18 B PCP abuse/dependence 8 Hallucinogen abuse/ dependence 1 Club drug abuse/dependence 1 % Mostly drinks with Partner 34 Relative/friend 35 Stranger/acquaintance 3 123 Alone 20 .E p = . D p-value C vs.0005 p = .0005 p = .0037 87 ns ns p = .0001 ns ns p = .Table 3 Mental health and substance use ‘Objective’ traditional deﬁnition Literally homeless (C) Marginally housed (D) Not homeless p-value (E) C vs. B ‘Subjective’ self deﬁnition Homeless (A) % With DSM IV 39 12A p = .0006 29 p \ .0003 61D.0072 35 22 23 90E 83E 66C.E Alcohol abuse/dependence 79 33 6 6 31C 6 C 89B 75 30 11 5 26C 8C 3 7 4 26 47 4 22 31 9 4A 2A 6 4 6 3 29 47 4 19 A ns ns ns ns ns ns ns ns p = .0003 p = .0016 19 p = .0004 ns Gend.0014 29 ns ns ns ns ns ns ns 27 42 9 14 3 3 3 7 3 1 34 42 3 18 D. Issues (2008) 25:173–192 ASPD 27B Adult antisocial behaviors 92B PTSD 35 B Of those using the substance.
10 ns ns \1 ns 23 33 45 ns ns ns ns ns p = \.182 Table 3 continued ‘Objective’ traditional deﬁnition Literally homeless (C) Marginally housed (D) Not homeless p-value (E) C vs.41E 32E 28E 14C.93 ± 4.84 % Drank in abandoned building 4 # Days drank in abandoned building 0.00C ns ns ns 9D.15 ± 0.64 ± 2.44C 0.07 ± 5.49 ± 5.96 ± 5.0020 p \ .19 0.97 3 2 ns ns 9 4.D 0.0001 ns p = .0020 p = .43 2.64 ± 1.0058 p = .26 % Drank in public restroom 7 # Days drank in public restroom 0.73 2.23 ± 4.0001 20 2 0.E 0. B 40 ns ns ns ns ns 1.33 ± 4.0003 p = .27 ± 8.08D.07 ± 0.0058 ns ns ns p = .94 ± 5. E p-value D vs.31 2.0003 ns p = .79 0.24 ± 1.03 ± 0.05 ± 0.41 ± 1.03 ± 0.30C 0.E 1C 0C 0. E 123 Not homeless p-value (B) A vs.E 0.01 ± 0.59 ± 2.19 % Drank on streets 28 # Days drank on streets 1.22C 0.48C Item ‘Subjective’ self deﬁnition Homeless (A) In past month % Drank at bar 30 # Days drank at bar 1.00 ± 0.33D.12 1.40 Gend. D p-value C vs. Issues (2008) 25:173–192 .0003 p = .
0073 ns ns ns ns 22 3 \1 25 14 A 76 % Satisﬁed with current support 54 42 0 4 35 6 67 28 4 2 25 11 75 21 4 0 29 24 ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns 183 ns % Very satisﬁed 53B % Somewhat satisﬁed 39 B % Somewhat dissatisﬁed 5 % Very dissatisﬁed 3 % Sought help from religious community 36 123 % Sought help from spiritual person 7 . B Literally homeless (C) Marginally housed (D) Not homeless (E) p-value C vs.Table 4 Religion/spirituality & social support ‘Objective’ traditional deﬁnition p-value A vs. E p-value D vs. E Item Not homeless (B) ‘Subjective’ self deﬁnition Homeless (A) % Attended religious services 32 29 23 16 9 26 65 91 92A p = .0073 p = . D p-value C vs.0016 ns 77 90 85 85 84 ns 94 89 ns 71 69 ns 23 24 24 67 89 93 84 ns 6 8 9 ns 19 17 18 ns 26 25 22 ns ns ns ns ns ns ns ns ns 32 27 26 ns ns 23 31 34 ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns ns Never 30 Gend. Issues (2008) 25:173–192 Rarely 20 1–2 times per month 26 1? times per week 24 % Religion/spirituality important Not at all 6 Somewhat 17 Very 77 % With someone to tell about important things 87 % With someone who provides understanding & advice 80B % With someone to rely on for practical things (favors) 74A p = .
71 ± 7. D p-value C vs.51 ± 59.11 ± 0.38 3.0005 ns ns ns ns ns ns ns ns ns ns 15 0.45 ± 8.89 8.17 ± 0.45 ± 1.74 0.51 18 0.56 # Female sexual partners 0.86 # New sexual partners 1.77 ns 40 ns ns ns ns ns 3.09 ± 0.0001 ns p = .76 ns ns ns ns 24.0016 19 .43 % Times used male condom during anal sex p = .23 D.17 ± 0.22 ± 3.57 ± 5.10 ± 0. B ns ns p = .28 19 1.85 ± 4.83 ± 2.75 0.01 ± 67.25 ± 81.0001 58 D.50 4 1.22 ± 97.65 0.E p \ .0003 55D. E p-value D vs.75 ± 8.33 3.94 0.29 ± 2.46 36.4 ± 68.93 24 30.79 ± 5.64 % Times used male condom performing oral sex 12 # Times anal sex 0.21 ± 8.10 ± 11.17 ± 0.36 1.86 # Sex partners who probably inject drugs 0.0005 p = .56 ± 16.39 ns ns ns 47.74 ± 87.34 2.51 # Times vaginal sex 37.22 0.49 ± 2.56 ± 1.17 ± 53.75 0.E 11 Ever traded sex 22C 31 C % For alcohol/drugs 36B 14C 22C 12 9 p = .66 39 10.84 ± 8.0002 p \ .82 ± 5.41 # Male sexual partners 2.83 % Times used male condom during vaginal sex 28 # Times performed oral sex 14.28 13 0.0047 p \ .70 ± 47.0029 0 ns ns 0.09 ± 0.95 14 1. E ns ns ns ns p = .22 ± 39.94 30.16 ± 6.58 ± 1.0001 ns ns ns ns % For money 48 B Gend.44 ns 37 5.26 ± 6.33 1.33 0.29 81 88 91 ns ns ns ns ns ns ns ns ns ns ns ns ns 71 81 74 ns ns Literally homeless (C) Marginally housed (D) Not homeless (E) p-value C vs.22 ± 1.21 1.99 28 17A 24 8A A Item ‘Subjective’ self deﬁnition Homeless (A) % Consented to sex ﬁrst time 77 In past 4 months % Had sex 86 % Always used condom 5B # Sexual partners 2.E C C 123 Not homeless (B) 77 90 18A 17 2.65 ± 1.83 32 ns ns ns ns ns 16 ns 1. Issues (2008) 25:173–192 % For food 20B p = .76 ± 4.65 ± 4.27 0.184 Table 5 Risky sexual behaviors ‘Objective’ traditional deﬁnition p-value A vs.
0086 ns p = .39 ± 42. B p = .35 ± 20.0020 25E 9 0C 0 1 1 1 C 8.0001 ns ns ns ns % For clothing 7 Gend. Issues (2008) 25:173–192 In the past four months # Times traded sex for money.0017 20D.46 ns 4 ns ns ns ns ns ns ns ns 6. place to stay.77 5.0089 p = .76 ± 12.09 ± 8. E Item Not homeless (B) 8A 3 ‘Subjective’ self deﬁnition Homeless (A) % For place to stay 19B p \ .51 1.Table 5 continued ‘Objective’ traditional deﬁnition p-value A vs.0086 ns ns ns ns ns ns ns ns ns ns Cannabis 0 Cocaine 16B Heroin 1 Speedball 1 Amphetamines 0 Club drugs 1 Other drugs 0 185 123 .E 5 0 5 0 D.E 0 5D. E p-value D vs.55 # Times traded sex for alcohol/drugs 1A \1 ns p = .80 10 6C Literally homeless (C) Marginally housed (D) Not homeless (E) p-value C vs.24 ± 1.49 ± 35.03 ± 90.74 13.0038 29E 12 3 4.45 % Traded sex for p = .94 ± 32.61 21. clothing 1.51 ± 14.20 0.0003 ns p = .0001 ns ns ns ns ns p = . D p-value C vs.E Alcohol 0 1 4C 0C 0C 0 0 0 5A 0 0 \1 ns ns ns \1 \1 ns ns 9B 3C 1C p = .0012 p \ .0089 p = . food.67 ± 68.74 ns 1.
Women staying in a rooming/boarding home or halfway house were more similar to the literally homeless than to the not homeless on all variables: presence of major depression. Those staying in a rooming/boarding home or halfway house were older than those staying in someone else’s home. the key classiﬁcation disagreement (subjective versus objective) occurred among the marginally housed. they were more similar to the not homeless than to the literally homeless on three variables: presence of cocaine use disorder.001 123 . Literal homelessness was associated with more new sexual partners and higher rates of trading sex for heroin and speedballs in the past 4 months than the marginally housed and not homeless groups. Only 17 respondents reported staying in a rooming/boarding home or halfway house. rates of trading sex for alcohol and cocaine in the past 4 months were higher among the homeless. ever trading sex for alcohol/ drugs. They were also more similar to the literally homeless than to the not homeless for adult antisocial behaviors. mental health and substance use. those staying in someone else’s home were more likely than all other groups to identify as being of color. Issues (2008) 25:173–192 Similarly.186 Gend. they also reported higher rates of ever trading sex for a basic necessity of life—food. p \ . however. Additional Investigation As previously noted. Further analysis (Table 6) determined that the marginally housed who were staying in someone else’s home were less likely than the marginally housed who were staying in a rooming/boarding home or halfway house to consider themselves homeless (33% vs. We detected differences on seven variables (Table 7). regardless of deﬁnition. Women who considered themselves homeless also were less likely than those who did not consider themselves homeless to report always using a condom. Additionally. Because we thought this deserved further exploration. we examined differences between those staying in someone else’s home and those staying in a rooming/boarding home or halfway house on all demographic. we altered our threshold for statistical signiﬁcance to p B .70. and risky sexual behavior variables.05 when examining the marginally housed subgroups to decrease the chance of making Type II errors. religion/spirituality and social support. and trading sex for cocaine in the past 4 months. 59%). Table 6 Breakdown of marginally housed classiﬁcation ‘Subjective’ self deﬁnition of homelessness Where are you living or staying now? In someone else’s home (n = 139) n Homeless Not homeless 46 93 % 33 67 In rooming/boarding home or hotel (n = 17) n 10 7 % 59 41 McNemar = 28. therefore. df = 1.
D C vs.D 7A.32 ± 8. B A vs.0012 ns ns ns ns p = .D 31B.D Mental health & substance use 71B.40 ± 10.D 35A.18C 38.0005 ns p = . D B vs.D 26A.0001 p = . C B vs.0001 ns ns ns ns 100B. % with cocaine abuse/ dependence 47B.92 ns 76B p = .Table 7 Variables with signiﬁcant differences between marginally housed subgroups Staying in rooming/ boarding home or halfway house (C) Not homeless (D) A vs.0001 p = .C 66A.0095 ns ns 59B p = .C Risky sexual behaviors p \ .D 19A.D 4A. D Literally Staying in homeless (A) someone else’s home (B) Gend. C A vs.C 43C p = .D p = .C 14A.B.0064 ns p = .0001 % Ever traded sex for alcohol/drugs 55B.0076 ns p \ .0038 p \ .20 ± 9.0009 p \ .0005 Of those using cocaine.0307 % With DSM IV major depression 48 36C % With adult 90D antisocial behaviors 80C.D ns ns p \ .0075 ns p = . Issues (2008) 25:173–192 Demographics 32.0054 p = .46B % Nonwhite 67B 84C.C 187 123 .C 61B.D 85B.C % Traded sex for cocaine in past 4 months 25B.0034 ns p = .0003 p = .70 30.0448 p = .0112 p = .0001 ns p = .06 ± 10.0067 p = .0053 ns Age 34.
the marginally housed were more similar to the literally homeless than to the not homeless. This is an area that has received little scientiﬁc attention (an exception is Link and colleagues ). for these variables. ever trading sex. This deﬁnition also detected higher numbers of new sexual partners and higher rates of trading sex for heroin and speedballs in the past 4 months among the homeless. The objective deﬁnition of homelessness captured some risk factors that were undetected using the subjective deﬁnition. Investigators should consider adding this one question of homelessness to their studies to avoid the risk of underestimating these conditions. PTSD. The self-deﬁned homeless reported lower rates of always using condoms and higher rates of ever trading sex for food. Discussion The purpose of this investigation was to examine differences in characteristics of persons deﬁned as homeless either by themselves or based on traditional methods. for mental health diagnoses. indicating that investigators should continue using the objective method of deﬁning homelessness when studying these risk factors. cheap hotels/ motels. Speciﬁcally. It was surprising that a majority (64%) of women whom we classiﬁed as marginally housed classiﬁed themselves as housed. and alcohol and sedative abuse/dependence) than those who did not. cocaine and opioid abuse/dependence. those who thought they were homeless reported higher rates of psychiatric disorders (ASPD. it captured some risk factors that were undetected using the objective deﬁnition.188 Gend.’’ among the literally homeless for drinking more in abandoned buildings. it makes sense that they would be associated. Investigators studying social support should consider adding this deﬁnition to their studies as well. and risky sexual behaviors (number of sexual partners and trading sex). on the streets. or in halfway houses be considered homeless? In this investigation. and trading sex for alcohol and cocaine in the past 4 months. they were more similar to the not homeless than to the literally homeless for location of drinking. Should people who are living with others because they have nowhere else to stay be considered homeless? Should people who are living in single room occupancies. The subjective deﬁnition of homelessness provided additional value. Thus. Issues (2008) 25:173–192 adult antisocial behaviors. The homeless by both deﬁnitions had higher rates of adult antisocial behaviors. increased rates of risky sexual behaviors were not found with the use of the subjective deﬁnition of homelessness. In general. substance use diagnoses. When the marginally housed group was broken into subgroups—those staying in someone else’s home and those staying in rooming/boarding homes or halfway 123 . Social support was also underreported when women self disclosed their homelessness. However. Because both social support and self deﬁned homelessness are perceived concepts. and in public restrooms. and cocaine use disorder as well as ever trading sex for alcohol/drugs and trading sex for cocaine in the past 4 months. This deﬁnition detected ‘‘undesirable behaviors. Both the objective and subjective deﬁnitions captured differences in several risk factors. it does not appear to matter which deﬁnition of homelessness investigators use in their studies.
however.Gend. Thus. from those who do not choose this. and other direct-service professionals may place more weight on clients’ perceptions of their living arrangements than on the technicalities of their living arrangements. and the self-deﬁned homeless reported higher rates of psychiatric diagnoses and less social support than the self-deﬁned not homeless. 10. our data indicate that considerable data about psychiatric diagnoses and social support are lost without the additional question about perceived homelessness. Women staying in rooming/boarding homes or halfway houses were more similar to the literally homeless than to the not homeless. At ﬁrst glance these data suggest that. Those studying mental health disorders. Because these two categories of factors are commonly hypothesized (both implicitly and explicitly) to be critical elements in the entry into. The data on women staying in someone else’s apartment or home were more complicated—sometimes more similar to the literally homeless. we suspect not. Additionally. respondents had no reason to 123 .’’ Strengths and Limitations Although the ‘‘Sister to Sister’’ study was not a study of homelessness and did not target homeless women. they capture one dimension of the homeless condition. in general. In fact. maintenance of. Regardless of the reasons for the differences in self-perception. The next question is whether the marginally housed group should be subdivided. 25]. including this aspect of homeless self-deﬁnition in scientiﬁc investigations might extend more applicability to ‘‘real world practice. Issues (2008) 25:173–192 189 houses—very few differences emerged. should consider including them. investigators should continue to do so to compare results across studies in different cities. over one-third (36%) of the women we classiﬁed as marginally housed with the traditional deﬁnition (whom are almost always omitted from homelessness studies) classiﬁed themselves as homeless. Future studies could separate those who live in a halfway house from those who live in a rooming/boarding home. people who choose to consider themselves as homeless are different. 18. Psychiatrists. sometimes more similar to the not homeless. investigators studying these elements should consider including the marginally housed as a homeless group as well. and sometimes in between the two groups. Too few differences emerged to warrant such bifurcation. which could yield greater clarity on this issue. ‘‘Do you consider yourself to be homeless?’’ This question allowed us to examine results using two independent deﬁnitions of homelessness. Use of a subjective deﬁnition of homelessness may also prove more valuable for service providers working with this population. the investigators did ask the question. in some ways. those studying psychiatric disorders and social support may be inadvertently misclassifying people and creating bias. More than one-third of the marginally housed considered themselves homeless. social workers. Because most investigations to date have relied on objective measures of homelessness (number of nights on the streets or in shelters). However. However. the marginally housed should not be considered a homeless group. and exit from the homeless condition [2. 20. Although we had fairly little power (with only 17 participants in one subgroup). When investigators classify individuals by where they live.
g. 423–432.. or amphetamines. Babor. However. demographics of the homeless women in this study are not unlike those of homeless women in other studies [12. (1995). M. 24. J.. 56. References 1. R. and women who considered themselves to be living in someone else’s home were coded accordingly. Susan Bradford for assistance with the data analysis. women who considered themselves to be living in their own home were coded as such. These women are most likely underrepresented in the scientiﬁc literature in general. The ‘‘Sister to Sister’’ study was conducted in one city. The ﬁndings of this study should be generalized with some caution. 123 . G. no explicit distinction could be made between the women who lived with others because they had nowhere else to stay (truly doubled-up) and the women who lived with others because they wanted to do so (e. results could be different for women who urine-test positive for drugs. caring for elders). identiﬁcation. Grant #AA12111. H. Issues (2008) 25:173–192 falsely report whether they were homeless or not. Another strength of this study is that the women were recruited from the community (not from shelters or through service providers). Transportation barriers were real. Such data could be useful for assessment. Nick Garg for assistance with the conceptualization of this manuscript and Ms. there are a substantial number of differences between those who were classiﬁed as literally homeless and not homeless. The authors would like to thank Dr. The marginally housed group was not operationalized as precisely as was desirable. Conclusions Researchers conducting investigations with homeless individuals—especially those studying psychiatric disorders and social support—should consider including one simple question about self-disclosed homelessness in addition to the usual questions on housing status. However. Thus. 19. Bohn. Regardless of who owned or leased the residence. Acknowledgments Research was supported by NIAAA. even if one ignores the ﬁndings involving the marginally housed group (who are usually not included in homelessness studies). & Kranzler. among a sample of women who were asked to report to a research site. The addition of one question could provide investigators with more useful information about the histories of individuals who live in unstable conditions. Women were recruited because they were heavy drinkers and did not use cocaine. Journal of Studies on Alcohol. 20. the interviews were not conducted by treatment providers who could assist them with accessing the shelter system or other services. and for other populations.. The alcohol use disorders identiﬁcation test (AUDIT): Validation of a screening instrument for use in medical settings. and treatment of the homeless condition. heroin. for men.190 Gend. 26].
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et al.. She is Director of two NIH Post Doc training programs and the Epidemiology and Prevention Research Group. Validity of self-reported drug use among injection drug users and crack cocaine users recruited through street outreach. She is an author on over 150 scientiﬁc papers and chapters. Needle. Dr. she holds a secondary appointment in the College of Health Professions. N. Dr. 123 . Cottler is Professor of Epidemiology in the Department of Psychiatry at Washington University School of Medicine. Cesari. Watters. R. She runs several national and international HIV prevention studies and is an author of several articles. Department of Public Health.. (1994). Weatherby. Her work focuses on reducing substance abuse and HIV risk behaviors among underrepresented populations. Karin M. Cottler holds memberships in academic societies and is on the editorial board of many highimpact journals. She has most recently been elected to serve as President of the American Psychopathological Association for 2010-its centennial celebratory year. Evaluation and Program Planning. Issues (2008) 25:173–192 27.. Department of Psychiatry. Booth. J. Department of Social Work..192 Gend. Dr. H. Author Biographies Dr. Catina Callahan O’Leary is the lead project manager in the Epidemiology and Prevention Research Group at Washington University School of Medicine. School of Social Administration. R. McCoy. Eyrich-Garg is an Assistant Professor at Temple University.. 347–355. 17. C.. Linda B. She is an author of several articles examining homeless and marginally-housed populations.
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