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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: email@example.com 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: firstname.lastname@example.org L. B. Cottler e-mail: email@example.com
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
To our knowledge. complete an informed consent. laundromats. Women with drug-negative urines were eligible to participate in the ‘‘Sister to Sister’’ study. indicating their recruitment source. (4) being drug negative for cocaine.Gend. Recruitment Each area of St.  used a hybrid deﬁnition of homelessness.551 women were approached by study personnel. and beauty salons and on the streets. 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.012) later called for more information or came immediately to the ofﬁce for an AUDIT. Outreach personnel were assigned to recruit in these different geographic locations each day. Methods This investigation used baseline data from the NIAAA-funded ‘‘Sister to Sister’’ study. eligibility criteria included (1) being female and over the age of 18. Staff introduced themselves and the study and administered a ﬁve-item questionnaire to assess eligibility. which was aimed at reducing high risk HIV behaviors among heavy drinking women. and (5) living in the St. Women were systematically approached in these geographic locations in grocery stores. Louis City Female Drug Court. Women were also asked to recruit friends from the same geographic locations. Louis Area. in which respondents were not biased towards stating they were homeless. and amphetamines. 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. 5. (3) reporting problem use of alcohol (AUDIT score of 4?). heroin. We had the opportunity to explore deﬁnitions of homelessness with data from a study that was not focused on homelessness. sexually active in the prior 4 months. Women who met the eligibility criteria were given an identiﬁcation code. Referrals were also made to the study from the St. This was one of the ﬁrst community-based NIH NIAAA-funded HIV intervention studies. (2) reporting sexual activity in the past 4 months. Herman et al. Interestingly. which tested a peer-delivered intervention based on holistic health concepts adapted from Cottler and colleagues’ work .272 women reported being at least 18 years old. and provide a urine sample. Issues (2008) 25:173–192 175 themselves. For this study. 98% (n = 990) scored 4? and were asked to make an appointment to 123 . Those who scored a 4 or higher were invited to make an appointment to come to one of the study’s storefront clinics. and using alcohol but not drugs in the past 30 days. During the ﬁeld period. 2. Fifty-ﬁve percent of these women (n = 1. ). no one has examined this particular issue. bus stops. Louis was mapped and coded for documentation of outreach efforts. The purpose of this investigation was to explore how differing deﬁnitions of homelessness are associated with various factors.
and pathological gambling. 11]) and the Washington University risk behavior assessment for women (RBA. several sections of the diagnostic interview schedule version IV (DIS. The SAM has undergone psychometric testing in the United States and in other countries . 27]. PCP. The SAM assesses lifetime and current patterns of substance use. opioids. ) were administered to assess DSM-IV depression. recent use of health care services. 339 AUDIT? women came to the site. It was modiﬁed to be more relevant to women and to cover additional risk and protective behaviors such as perceptions and attitudes towards sex. The DIS assesses lifetime and current patterns of psychiatric symptoms and has been used widely in psychiatric research since its creation in 1980. 123 . DSM-III-R. too. DSM-IV. and sedatives). has undergone psychometric testing [11. Baseline interviews for this study were conducted between May 2000 and September 2003. other than transportation and other enrollment barriers. consented to urine screens. it was determined that no signiﬁcant differences were found between the women who enrolled and those who did not. [4. and completed the baseline interviews. The RBA. insurance status. cannabis. 21]. Of these 990 women. nicotine. Ongoing quality control was conducted throughout the study for every interviewer via reviews of audiotaped interviews. The baseline assessment was completed in two sessions. Interview Protocol Interviewers underwent 2 weeks of training and were permitted to conduct interviews only after becoming certiﬁed by the quality control manager. cocaine. hallucinogens. and ICD-10. During the ﬁrst session. conduct disorder.176 Gend. These patterns are mapped to diagnostic criteria outlined in the DSM-III. antisocial personality disorder. extensive baseline tracking of women was not allowed. post-traumatic stress disorder. Issues (2008) 25:173–192 participate in the study. and dependence (alcohol. in the second session. assesses lifetime and recent sexual activity and use of protection against HIV and other sexually transmitted diseases. were negative for drugs. ) were administered. 17. club drugs. medical illnesses. originally developed by NIDA for use in its cooperative agreement study in the 1990s. It. and treatment history. were eligible for the study. Participants received $10 remuneration for each of the two baseline interviews. abuse. Based on the minimal demographics women provided at the time of contact. nutritional risk factors. Two weeks later. The original version underwent extensive psychometric testing [8. amphetamines. Variables Residential Status Residential status was deﬁned in two ways: the self (or ‘subjective’) deﬁnition and the traditional (or ‘objective’) deﬁnition. 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 partial version of the substance abuse module (SAM. inhalants.
During the initial screening. the number of new sexual partners. 25%). sedative. and the percent of time it was protected by condoms. or tarot card reader’’). 46%). ‘‘Do you consider yourself to be homeless?’’ were classiﬁed as homeless (n = 84. They were also asked how satisﬁed they were with this support. Women who reported staying on the streets or in a shelter were classiﬁed as literally homeless (n = 31. Religiosity/spirituality and social support were assessed by asking how often women attended religious services in the past 12 months. the gender of sexual partners. how important religion/ spirituality is to them. Regarding other social support. Sex trading in the past 4 months for alcohol/drugs. ASPD. oral. the number of IDU partners. Women were also asked. Because satisfaction with support is conditional on having support. all women reported having sex in the past 123 . Other Variables Other demographic variables included age (a continuous variable). minister. without exclusions. and if they sought help from a traditional religious ﬁgure (i. Substance use diagnoses were not calculated for women who never used because substance abuse and dependence are conditional on the substances used.. Abuse and dependence for each substance were combined for these analyses. money. and race (dichotomized into Caucasian versus of color). Issues (2008) 25:173–192 177 ‘Subjective’ Self Deﬁnition. 45%). Sexual risk-taking in the past 4 months was characterized by assessing the number of sexual partners. and anal sex. Women who responded afﬁrmatively to the question. 9%). or other member of the religious community’’) or from a nontraditional spiritual ﬁgure (i. Those who responded negatively were classiﬁed as not homeless (n = 255. women reporting no support were omitted from the analyses for the satisfaction variable. Those who reported staying in their own house or apartment were classiﬁed as not homeless (n = 152.Gend. food. Level of education was dichotomized because a high school diploma or GED is a minimal requirement for many jobs. Disorders were coded as met criteria versus did not meet criteria. ‘‘Where are you living or staying now?’’ Response categories were provided. cannabis. rabbi. Psychiatric diagnostic variables included DSM-IV lifetime major depression. 75%). 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. psychic. palmist. level of education (dichotomized into graduated from high school or attained a general equivalency diploma (GED) versus not). to count on for understanding and advice.. and individual substance abuse/dependence disorders (alcohol. hallucinogen. ‘Objective’ Traditional Deﬁnition.e. opioid. the number of times respondents had vaginal. ‘‘priest. including living on the streets or in a shelter. PCP. ‘‘prophet. amphetamine. adult antisocial behaviors. cocaine. or clothing was assessed.e. and to rely on for practical things. and club drug). PTSD. a place to stay. and 4% identiﬁed as other. women were asked if they had someone they could talk to about things that were important. Race was dichotomized because three-quarters of the sample identiﬁed as African American. spiritual adviser. 21% identiﬁed as Caucasian.
As shown in Table 1. 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. this test was selected because the two variables (subjective and objective) were not independent . Issues (2008) 25:173–192 4 months (which was a study inclusion criterion).01. Among the 31 persons who were objectively classiﬁed as literally homeless. on the streets. only three respondents who were living in shelters or on the streets did not consider themselves homeless. p \ . Women who reported not drinking in any of these locations were coded 0.e. Chi-square and Fisher’s exact tests were performed with categorical variables. or not homeless). Every respondent who was objectively deﬁned as not homeless subjectively deﬁned themselves as not homeless (i. 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.178 Gend. the percent of time sex was protected by condoms was calculated only for those reporting sexual activity. there was not a perfect agreement between the subjective and objective deﬁnitions of homelessness.20. the p-value for statistical signiﬁcance was set at . a small number of women (n = 48) reported not having sex in the past 4 months at the time of the interview. Additionally. 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. df = 1. Descriptive data are summarized with percentage rates and means with standard deviations. However. in an abandoned building. Because multiple tests were run. perfect agreement). 90% considered themselves homeless. t-tests and ANOVAs were used for continuous variables.1 . Data Analysis Data were analyzed using SAS 9.. marginally housed. because condom use is conditional on sexual activity. or in a public restroom were also elicited. These women were coded 0 for these sex questions. However. The number of days in the past month women spent drinking at a bar. this scenario is plausible because some women were interviewed 30 days after their initial screening.0001 123 .
07 years.Gend. with 44% of the sample earning under $3. No other signiﬁcant differences were detected between the groups. They also reported a lower rate of satisfaction with their social support. The average age was 31. Seventy-nine percent of the sample identiﬁed as being of color. 123 . Almost three quarters (73%) of the sample had children. Demographics are presented in Table 2 by deﬁnitions of homelessness. The personal incomes of these women were quite low. rates of ever trading sex for alcohol/ drugs. on the streets.000 in the past 12 months. money. although both groups had considerably high rates of support. and a place to stay were higher among the homeless (Table 5). Those who labeled themselves as homeless were older than those who did not. Sample Demographics Over half (53%) of the sample had at least a high school education or GED. and in public restrooms were reported more often by persons who were objectively deﬁned as literally homeless. Rates of cocaine and opioid abuse/dependence were higher among the homeless regardless of subjective or objective deﬁnitions. Religion/Spirituality No differences in religious/spiritual variables were detected by either subjective or objective deﬁnitions of homelessness (Table 4). 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. Drinking in abandoned buildings. 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.95 ± 10. Issues (2008) 25:173–192 179 those objectively classiﬁed as marginally housed. No differences were detected using the objective deﬁnition of homelessness. rates of adult antisocial behaviors were higher among the homeless (and the marginally housed). Risky Sexual Behaviors Regardless of subjective or objective deﬁnition. Those who subjectively deﬁned themselves as homeless had higher rates of alcohol and sedative abuse/dependence than those who deﬁned themselves as housed. only 36% considered themselves to be homeless. Regardless of subjective or objective deﬁnition. Psychiatric Diagnostics Rates of psychiatric disorders by deﬁnitions of homelessness are presented in Table 3.999 and 87% earning under $15.
13 937.15 ± 1. E ns ns ns ns ns ns ns Table 2 Demographics Item ‘Subjective’ self deﬁnition Homeless (A) Not homeless (B) N 84 255 Age 34.30 ± 2072.20 2.0098 ns ns ns ns ns 60.70 31.50 2.92 Literally homeless (C) Marginally housed (D) Not homeless (E) p-value C vs.32 ± 8.42 31 156 152 32.93 ± 2.06 ± 2287.87 835.87 ± 1798.89 # Days living at current place 650.58 3.29 ± 135.58 ± 3.94 ± 1. E ns ns ns ns ns ns ns p-value D vs.84 Gend.87 77 76 42 50 67 83 76 64 69 3.23 ± 10.14 ± 10.60 ± 1513.40 ± 9.47 ± 2.20 ± 9. D ns ns ns ns ns ns ns p-value C vs. B ns p = .27B 31.180 123 ‘Objective’ traditional deﬁnition p-value A vs.00 1057. Issues (2008) 25:173–192 .01 34.20A % Nonwhite 83 77 % HS Grad 50 57 % With children 83 69 # Children 3.
D 17 11 ns 71A 20 A Depression ns 52 ns 48 18 43 ns ns p = .0004 ns Gend.0072 35 22 23 90E 83E 66C.Table 3 Mental health and substance use ‘Objective’ traditional deﬁnition Literally homeless (C) Marginally housed (D) Not homeless p-value (E) C vs.0004 ns ns ns p = .0001 ns ns p = . E p-value D vs. E Item Not homeless p-value (B) A vs.0005 p = . B ‘Subjective’ self deﬁnition Homeless (A) % With DSM IV 39 12A p = . % with 74A p = .0005 p = .E p = . D p-value C vs.0016 19 p = .0037 87 ns ns p = .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.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 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 61D.0003 p = .0006 29 p \ .
84 % Drank in abandoned building 4 # Days drank in abandoned building 0.93 ± 4.0001 20 2 0.97 3 2 ns ns 9 4.00 ± 0.33 ± 4.10 ns ns \1 ns 23 33 45 ns ns ns ns ns p = \.07 ± 0.15 ± 0.73 2.E 0.0003 p = . B 40 ns ns ns ns ns 1.0001 ns p = .40 Gend.0003 p = .0003 ns p = .00C ns ns ns 9D.79 0.23 ± 4.33D.59 ± 2.182 Table 3 continued ‘Objective’ traditional deﬁnition Literally homeless (C) Marginally housed (D) Not homeless p-value (E) C vs.24 ± 1.03 ± 0.44C 0.12 1.0058 ns ns ns p = .49 ± 5.19 % Drank on streets 28 # Days drank on streets 1.0020 p = .E 1C 0C 0.94 ± 5.41E 32E 28E 14C.19 0. D p-value C vs.64 ± 1.07 ± 5.43 2.96 ± 5.D 0.0020 p \ . E p-value D vs.22C 0.41 ± 1.03 ± 0.01 ± 0.E 0.05 ± 0. E 123 Not homeless p-value (B) A vs.0058 p = .64 ± 2.26 % Drank in public restroom 7 # Days drank in public restroom 0.31 2.08D.48C Item ‘Subjective’ self deﬁnition Homeless (A) In past month % Drank at bar 30 # Days drank at bar 1.30C 0.27 ± 8. Issues (2008) 25:173–192 .
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. E Item Not homeless (B) ‘Subjective’ self deﬁnition Homeless (A) % Attended religious services 32 29 23 16 9 26 65 91 92A 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 . E p-value D vs.0073 p = . 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 = . B Literally homeless (C) Marginally housed (D) Not homeless (E) p-value C vs. D p-value C vs.Table 4 Religion/spirituality & social support ‘Objective’ traditional deﬁnition p-value A vs.
0047 p \ .76 ± 4.70 ± 47.34 2.09 ± 0.79 ± 5.26 ± 6.50 4 1.25 ± 81.4 ± 68.29 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.28 19 1.83 32 ns ns ns ns ns 16 ns 1.56 ± 1.17 ± 53.22 0.77 ns 40 ns ns ns ns ns 3.74 0.66 39 10.0002 p \ .21 1.84 ± 8.76 ns ns ns ns 24.36 1.82 ± 5.33 3.10 ± 0.94 30.0005 ns ns ns ns ns ns ns ns ns ns 15 0.89 8.83 % Times used male condom during vaginal sex 28 # Times performed oral sex 14.93 24 30.01 ± 67.85 ± 4.38 3.56 # Female sexual partners 0.27 0.33 1.0001 ns ns ns ns % For money 48 B Gend.83 ± 2.56 ± 16.0029 0 ns ns 0.65 ± 4.71 ± 7.17 ± 0.22 ± 39.51 ± 59.0001 58 D. Issues (2008) 25:173–192 % For food 20B p = .16 ± 6.49 ± 2.23 D.10 ± 11.57 ± 5.86 # Sex partners who probably inject drugs 0.75 ± 8.86 # New sexual partners 1.22 ± 1.65 ± 1.0005 p = .95 14 1.64 % Times used male condom performing oral sex 12 # Times anal sex 0.184 Table 5 Risky sexual behaviors ‘Objective’ traditional deﬁnition p-value A vs.45 ± 8. E ns ns ns ns p = .22 ± 3.58 ± 1.94 0. D p-value C vs.0001 ns p = .0016 19 .E C C 123 Not homeless (B) 77 90 18A 17 2.21 ± 8.E p \ .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. B ns ns p = .17 ± 0.65 0.75 0.28 13 0.39 ns ns ns 47. E p-value D vs.45 ± 1.22 ± 97.29 ± 2.74 ± 87.33 0.11 ± 0.17 ± 0.0003 55D.51 18 0.43 % Times used male condom during anal sex p = .46 36.44 ns 37 5.41 # Male sexual partners 2.51 # Times vaginal sex 37.09 ± 0.75 0.E 11 Ever traded sex 22C 31 C % For alcohol/drugs 36B 14C 22C 12 9 p = .
03 ± 90. D p-value C vs.0001 ns ns ns ns % For clothing 7 Gend. clothing 1.24 ± 1.51 1.0017 20D.51 ± 14.0089 p = . E p-value D vs.67 ± 68. food. place to stay.0086 ns p = .49 ± 35.77 5.0089 p = .0020 25E 9 0C 0 1 1 1 C 8. E Item Not homeless (B) 8A 3 ‘Subjective’ self deﬁnition Homeless (A) % For place to stay 19B p \ . B p = .45 % Traded sex for p = .20 0.35 ± 20.0086 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 .0003 ns p = .0012 p \ .0038 29E 12 3 4.74 ns 1.09 ± 8.46 ns 4 ns ns ns ns ns ns ns ns 6.94 ± 32.0001 ns ns ns ns ns p = .E 0 5D.55 # Times traded sex for alcohol/drugs 1A \1 ns p = .Table 5 continued ‘Objective’ traditional deﬁnition p-value A vs.39 ± 42.E 5 0 5 0 D.80 10 6C Literally homeless (C) Marginally housed (D) Not homeless (E) p-value C vs.74 13.61 21. Issues (2008) 25:173–192 In the past four months # Times traded sex for money.76 ± 12.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 = .
those staying in someone else’s home were more likely than all other groups to identify as being of color. and risky sexual behavior variables. 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. regardless of deﬁnition. They were also more similar to the literally homeless than to the not homeless for adult antisocial behaviors. rates of trading sex for alcohol and cocaine in the past 4 months were higher among the homeless.186 Gend. ever trading sex for alcohol/ drugs. df = 1. Additionally. 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. Women who considered themselves homeless also were less likely than those who did not consider themselves homeless to report always using a condom. Those staying in a rooming/boarding home or halfway house were older than those staying in someone else’s home. 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. Additional Investigation As previously noted. We detected differences on seven variables (Table 7). p \ . the key classiﬁcation disagreement (subjective versus objective) occurred among the marginally housed. 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 = 28.001 123 . 59%). Only 17 respondents reported staying in a rooming/boarding home or halfway house. Because we thought this deserved further exploration. and trading sex for cocaine in the past 4 months. therefore. they also reported higher rates of ever trading sex for a basic necessity of life—food. 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.05 when examining the marginally housed subgroups to decrease the chance of making Type II errors.70. religion/spirituality and social support. they were more similar to the not homeless than to the literally homeless on three variables: presence of cocaine use disorder. Issues (2008) 25:173–192 Similarly. however. we altered our threshold for statistical signiﬁcance to p B . mental health and substance use.
D Literally Staying in homeless (A) someone else’s home (B) Gend.0001 p = .0448 p = .C Risky sexual behaviors p \ .0005 ns p = .0053 ns Age 34.Table 7 Variables with signiﬁcant differences between marginally housed subgroups Staying in rooming/ boarding home or halfway house (C) Not homeless (D) A vs.D ns ns p \ .0001 ns p = .D 19A.C 14A.0112 p = .06 ± 10.46B % Nonwhite 67B 84C.D Mental health & substance use 71B. B A vs.0075 ns p = .C 187 123 .B.0067 p = . C A vs.20 ± 9.D 85B.0003 p = .92 ns 76B p = .C 61B. Issues (2008) 25:173–192 Demographics 32.D p = .C 43C p = .32 ± 8.0005 Of those using cocaine.D 35A.D 4A. D B vs.0009 p \ .0034 ns p = .0095 ns ns 59B p = .D 31B. C B vs.0076 ns p \ .0012 ns ns ns ns p = .0001 % Ever traded sex for alcohol/drugs 55B.70 30.C 66A.0054 p = .0064 ns p = .0001 p = . D C vs.D 26A.40 ± 10.C % Traded sex for cocaine in past 4 months 25B.0307 % With DSM IV major depression 48 36C % With adult 90D antisocial behaviors 80C.18C 38.0001 ns ns ns ns 100B.0038 p \ .D 7A. % with cocaine abuse/ dependence 47B.
Because both social support and self deﬁned homelessness are perceived concepts. 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 . it makes sense that they would be associated. 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. However. it does not appear to matter which deﬁnition of homelessness investigators use in their studies. This is an area that has received little scientiﬁc attention (an exception is Link and colleagues ). Speciﬁcally. In general. 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. and in public restrooms. increased rates of risky sexual behaviors were not found with the use of the subjective deﬁnition of homelessness. The self-deﬁned homeless reported lower rates of always using condoms and higher rates of ever trading sex for food. PTSD. The homeless by both deﬁnitions had higher rates of adult antisocial behaviors. the marginally housed were more similar to the literally homeless than to the not homeless. it captured some risk factors that were undetected using the objective deﬁnition. and alcohol and sedative abuse/dependence) than those who did not. The objective deﬁnition of homelessness captured some risk factors that were undetected using the subjective deﬁnition. substance use diagnoses. for these variables. Social support was also underreported when women self disclosed their homelessness. indicating that investigators should continue using the objective method of deﬁning homelessness when studying these risk factors. It was surprising that a majority (64%) of women whom we classiﬁed as marginally housed classiﬁed themselves as housed. ever trading sex.188 Gend. This deﬁnition detected ‘‘undesirable behaviors. or in halfway houses be considered homeless? In this investigation. Both the objective and subjective deﬁnitions captured differences in several risk factors. Investigators should consider adding this one question of homelessness to their studies to avoid the risk of underestimating these conditions. on the streets. those who thought they were homeless reported higher rates of psychiatric disorders (ASPD. they were more similar to the not homeless than to the literally homeless for location of drinking. for mental health diagnoses. and cocaine use disorder as well as ever trading sex for alcohol/drugs and trading sex for cocaine in the past 4 months.’’ among the literally homeless for drinking more in abandoned buildings. 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. Issues (2008) 25:173–192 adult antisocial behaviors. and risky sexual behaviors (number of sexual partners and trading sex). Investigators studying social support should consider adding this deﬁnition to their studies as well. Thus. cheap hotels/ motels. The subjective deﬁnition of homelessness provided additional value. cocaine and opioid abuse/dependence. and trading sex for alcohol and cocaine in the past 4 months.
‘‘Do you consider yourself to be homeless?’’ This question allowed us to examine results using two independent deﬁnitions of homelessness. respondents had no reason to 123 . however. At ﬁrst glance these data suggest that. we suspect not. in some ways. Future studies could separate those who live in a halfway house from those who live in a rooming/boarding home. Use of a subjective deﬁnition of homelessness may also prove more valuable for service providers working with this population. However. and exit from the homeless condition [2. Women staying in rooming/boarding homes or halfway houses were more similar to the literally homeless than to the not homeless. the investigators did ask the question. Too few differences emerged to warrant such bifurcation. 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. Thus. Those studying mental health disorders.Gend. Psychiatrists. 25]. and the self-deﬁned homeless reported higher rates of psychiatric diagnoses and less social support than the self-deﬁned not homeless.’’ Strengths and Limitations Although the ‘‘Sister to Sister’’ study was not a study of homelessness and did not target homeless women. In fact. investigators studying these elements should consider including the marginally housed as a homeless group as well. and other direct-service professionals may place more weight on clients’ perceptions of their living arrangements than on the technicalities of their living arrangements. 10. which could yield greater clarity on this issue. 20. sometimes more similar to the not homeless. Because these two categories of factors are commonly hypothesized (both implicitly and explicitly) to be critical elements in the entry into. including this aspect of homeless self-deﬁnition in scientiﬁc investigations might extend more applicability to ‘‘real world practice. The data on women staying in someone else’s apartment or home were more complicated—sometimes more similar to the literally homeless. Additionally. in general. 18. maintenance of. should consider including them. people who choose to consider themselves as homeless are different. investigators should continue to do so to compare results across studies in different cities. When investigators classify individuals by where they live. they capture one dimension of the homeless condition. from those who do not choose this. However. Issues (2008) 25:173–192 189 houses—very few differences emerged. More than one-third of the marginally housed considered themselves homeless. Although we had fairly little power (with only 17 participants in one subgroup). Regardless of the reasons for the differences in self-perception. our data indicate that considerable data about psychiatric diagnoses and social support are lost without the additional question about perceived homelessness. those studying psychiatric disorders and social support may be inadvertently misclassifying people and creating bias. Because most investigations to date have relied on objective measures of homelessness (number of nights on the streets or in shelters). The next question is whether the marginally housed group should be subdivided. the marginally housed should not be considered a homeless group. and sometimes in between the two groups. social workers.
Women were recruited because they were heavy drinkers and did not use cocaine. J. Nick Garg for assistance with the conceptualization of this manuscript and Ms. 20. women who considered themselves to be living in their own home were coded as such. Regardless of who owned or leased the residence.. M. 26]. Journal of Studies on Alcohol. The authors would like to thank Dr. The marginally housed group was not operationalized as precisely as was desirable. Transportation barriers were real. results could be different for women who urine-test positive for drugs.. Bohn.. 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. among a sample of women who were asked to report to a research site.190 Gend. even if one ignores the ﬁndings involving the marginally housed group (who are usually not included in homelessness studies). the interviews were not conducted by treatment providers who could assist them with accessing the shelter system or other services. The addition of one question could provide investigators with more useful information about the histories of individuals who live in unstable conditions. The ‘‘Sister to Sister’’ study was conducted in one city. The alcohol use disorders identiﬁcation test (AUDIT): Validation of a screening instrument for use in medical settings. Thus. Grant #AA12111. G. However. (1995). demographics of the homeless women in this study are not unlike those of homeless women in other studies [12. identiﬁcation. caring for elders). Issues (2008) 25:173–192 falsely report whether they were homeless or not. References 1. 19. there are a substantial number of differences between those who were classiﬁed as literally homeless and not homeless. for men. Susan Bradford for assistance with the data analysis. H. Acknowledgments Research was supported by NIAAA. The ﬁndings of this study should be generalized with some caution. Babor. Such data could be useful for assessment. 123 . These women are most likely underrepresented in the scientiﬁc literature in general. 56. heroin. and treatment of the homeless condition. 24. 423–432. R. and women who considered themselves to be living in someone else’s home were coded accordingly. and for other populations. 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. Another strength of this study is that the women were recruited from the community (not from shelters or through service providers). & Kranzler. or amphetamines.g.
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Karin M. Author Biographies Dr.. Dr. She is an author on over 150 scientiﬁc papers and chapters. Issues (2008) 25:173–192 27.. N. 123 . Linda B. McCoy. Dr. C. School of Social Administration. Needle. (1994). Dr. et al. Watters. R. Booth. Evaluation and Program Planning. Weatherby. Her work focuses on reducing substance abuse and HIV risk behaviors among underrepresented populations.. Cottler is Professor of Epidemiology in the Department of Psychiatry at Washington University School of Medicine. Catina Callahan O’Leary is the lead project manager in the Epidemiology and Prevention Research Group at Washington University School of Medicine. Cesari. H.. She is Director of two NIH Post Doc training programs and the Epidemiology and Prevention Research Group.192 Gend. Cottler holds memberships in academic societies and is on the editorial board of many highimpact journals. Validity of self-reported drug use among injection drug users and crack cocaine users recruited through street outreach. She has most recently been elected to serve as President of the American Psychopathological Association for 2010-its centennial celebratory year. 17.. 347–355. Department of Social Work. She runs several national and international HIV prevention studies and is an author of several articles. Department of Psychiatry. R. Eyrich-Garg is an Assistant Professor at Temple University.. She is an author of several articles examining homeless and marginally-housed populations. she holds a secondary appointment in the College of Health Professions. Department of Public Health. J.
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